This Week in the Journal

November 29, 2001

Simvastatin plus Niacin, Antioxidant Vitamins, or the Combination for Prevention of Coronary Disease

Patients with coronary disease and low high-density lipoprotein(HDL) cholesterol levels are at risk for coronary events. Thisstudy found that a combination of niacin and simvastatin wasvery effective over a period of three years in reducing thefrequency of coronary events and causing a slight regressionof coronary lesions, as measured by angiography. By contrast,antioxidant vitamins had no benefit, and the addition of antioxidantvitamins to niacin and simvastatin attenuated their beneficialeffect.

The combination of niacin and simvastatin, which concurrentlylowers the low-density lipoprotein cholesterol level and raisesthe HDL cholesterol level, has important clinical benefits inpatients with coronary disease and low HDL levels. Antioxidantsare not recommended.

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Decreased Rate of Restenosis after Coronary Angioplasty with Vitamin Therapy

In this double-blind study, a combination of folate, vitaminB₁₂, and pyridoxine was found to reduce the rate of restenosisin patients who had undergone coronary angioplasty. There wasless benefit in patients who had received stents than in thosewho had not. Vitamin therapy also resulted in lower plasma homocysteinelevels, a potential mechanism of the clinical effect.

These findings suggest that a relatively simple and inexpensiveintervention, vitamin supplementation, may reduce the risk ofrestenosis after coronary angioplasty. It is plausible thatthe beneficial effect is mediated by a reduction in plasma homocysteinelevels, but other effects of vitamin therapy may also be involved.

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An Outbreak of Primary Pneumonic Tularemia

In the summer of 2000, there was an outbreak of tularemia onthe island of Martha's Vineyard in Massachusetts. This case–controlstudy identified 15 patients with Francisella tularensis infection,including 11 with primary pneumonic tularemia. One patient died.The patients were more likely than controls to have used a lawnmower or brush cutter in the two weeks before the illness.

Primary pneumonic tularemia results from inhalation of the organismand is the most severe form of tularemia. Analysis of this outbreaksuggests that mowing and cutting brush led to aerosolizationof the organism.

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Index Case of Fatal Inhalational Anthrax Due to Bioterrorism in the United States

This case report provides a description of the first case offatal inhalational anthrax in the United States in 25 years.This 63-year-old newspaper photo editor had a rapidly progressivefebrile illness, and lumbar puncture showed cloudy cerebrospinalfluid with numerous polymorphonuclear leukocytes and many largegram-positive bacilli, singly and in chains. A diagnosis ofinhalational anthrax was made, and despite aggressive treatmentthe patient died soon thereafter. The infection appeared tohave been transmitted through mail contaminated with anthraxspores as a result of biologic terrorism.

Special Article: Shattuck Lecture — Hidden Barriers to Quality Improvement

The Shattuck Lecture is delivered at the Annual Meeting of theMassachusetts Medical Society. In the 111th lecture, Dr. BarbaraMcNeil discusses a core problem in health policy, the barriersto improvement in the quality of medical care. She focuses ontwo key impediments: uncertainty about which therapeutic anddiagnostic interventions are actually effective, and cost pressures,which may result in the underuse of potentially valuable medicaltreatments and techniques.

Current Concepts: Recognition and Management of Anthrax

Infection with Bacillus anthracis, commonly known as anthrax,has reemerged as a weapon of bioterrorism. This review articlerevisits and updates our 1999 review of anthrax and containspractical information for the physician faced with a possiblecase of this dangerous infection.

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