This Week in The New England Journal of Medicine

April 26, 2001

The Efficacy of a Conjugate Typhoid Vaccine in Young Children

A conjugate typhoid vaccine has been made with Salmonella typhi capsular polysaccharide (Vi) bound to nontoxic recombinant Pseudomonas aeruginosa exotoxin A. In a randomized, double-blind trial, this new vaccine was evaluated in 11,091 Vietnamese children two to five years old. Over a period of 27 months the efficacy of the vaccine was found to be 91.5 percent.

In developing countries, typhoid fever is common, serious, and increasingly difficult to treat. This conjugate vaccine is an advance over the currently licensed typhoid vaccines, which confer only about 70 percent immunity and do not protect young children. However, its immunogenicity in infants is not yet known.

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Biopsy Specimen: Moderate Dysplasia.

DNA Content as a Prognostic Marker in Patients with Oral Leukoplakia

The potential of a given patch of oral leukoplakia to undergo malignant transformation cannot be ascertained by its clinical or histologic appearance. In this study of the DNA content (ploidy) of lesions, the proportion of aneuploid lesions that evolved into carcinoma was high (84 percent), whereas only 3 percent of the diploid lesions became malignant.

These findings provide a potential solution to the puzzle of the malignant potential of oral leukoplakia. The immediate clinical value is that quantitative analysis of nuclear DNA, which is feasible in many pathology laboratories, appears to provide prognostic information that is not available through clinical or microscopical analysis.

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Fluvoxamine for the Treatment of Anxiety Disorders in Children and Adolescents

Drugs that selectively inhibit serotonin reuptake are effective in the treatment of anxiety and mood disorders in adults. In this study of 128 children and adolescents with social phobia, separation anxiety disorder, or generalized anxiety disorder, treatment with fluvoxamine resulted in greater improvement on a global assessment scale and a greater reduction in symptoms of anxiety than did placebo, and it had few adverse effects.

Anxiety disorders can have negative effects on behavior and academic and social development in children, and many affected children are not treated or are undertreated. This study represents a small step toward reversing that situation. The results demonstrate that it is possible to carry out controlled trials of drugs that act on the central nervous system both successfully and safely in children and that fluvoxamine is an effective treatment for children with anxiety disorders.

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Heparin-Induced Thrombocytopenia

In heparin-induced thrombocytopenia, the platelet count usually begins to fall 5 to 10 days after the start of heparin therapy. This study identified a group of patients in whom the platelet count began to decrease within hours after the start of heparin administration. All of these patients had previously received heparin. Heparin-dependent antibodies can persist in the circulation for three months or more. Even so, some patients with a history of heparin-induced thrombocytopenia can tolerate a brief subsequent course of heparin during cardiac or vascular surgery.

Heparin-induced thrombocytopenia is a common and troublesome drug reaction resulting from the presence of antibodies against a complex of heparin and platelet factor 4. This study underlines the risk of heparin treatment in patients with a history of such a reaction but also points out that a history of heparin-induced thrombocytopenia is not an absolute contraindication to the use of heparin.

Global Trends in Resistance to Antituberculosis Drugs

The World Health Organization and the International Union against Tuberculosis and Lung Disease have gathered data from 58 geographic sites on 6 continents. The median prevalence of multidrug resistance among newly diagnosed cases was only 1 percent, but the prevalence was much higher in regions such as Estonia (14 percent), Henan Province, China (11 percent), Latvia (9 percent), and the two Russian oblasts surveyed. In Estonia and Denmark, the prevalence of drug resistance has increased significantly over time.

This report uses standardized methods to present a global profile of trends in the resistance to antituberculosis drugs. The problem is especially severe among some of the countries of eastern Europe. The increasing prevalence of multidrug-resistant disease is evidence of inadequate control of primary tuberculosis.

Primary Care: Cardiac Resuscitation

This review is based on recently revised recommendations for the management of ventricular fibrillation and pulseless ventricular tachycardia. It includes a summary of the use of medications, as well as a discussion of controversies, recent developments, and common errors made in cardiac resuscitation.

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