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Screening for Colorectal Cancer
More than 2800 adults who were 50 to 75 years of age and had no symptoms of colorectal cancer participated in a screening program for the disease in which a fecal occult-blood test and colonoscopy were performed. About 30 percent of the participants with a positive test for fecal occult blood had a colonic neoplasm. Combined screening with the fecal occult-blood test plus examination of the sigmoid colon was not substantially more accurate than sigmoidoscopy alone.
Screening for colorectal cancer can save lives, but there is no general agreement about the best method of screening. A one-time screening with occult-blood testing and sigmoidoscopy will fail to identify about 25 percent of patients with colonic neoplasia. When adequate resources are available, colonoscopy is a better one-time screening test.
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Use of the Copper IUD and Tubal Infertility
The concern that intrauterine devices (IUDs) containing copper may increase the risk of tubal infertility has limited the use of this very effective method of birth control. Using a case–control design, the authors compared nulligravid women with infertility due to tubal occlusion (documented by hysterosalpingography) with infertile women without tubal occlusion and with primigravid women in terms of previous contraceptive use and other characteristics. The odds ratio for tubal occlusion associated with IUD use was 1.0 in analyses involving infertile controls, and 0.9 in analyses involving pregnant controls.
In this large case–control study, the previous use of an IUD containing copper was not associated with an increased risk of tubal occlusion among nulligravid women. These results support greater use of this effective birth-control method among nulliparous women who are not at increased risk for pelvic inflammatory disease.
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Prone Positioning for Acute Respiratory Failure
Critically ill patients with acute respiratory failure are sometimes placed in a prone (face-down) position to improve their oxygenation. This study of 304 patients evaluated whether this approach, which requires considerable nursing effort, improves survival as compared with the conventional practice of treating patients in the supine position. Although confirming that the practice improves oxygenation, the investigators found no effect on survival, when assessed at 10 days, the time of discharge from the intensive care unit, or 6 months.
These findings suggest that use of the prone position in patients with acute respiratory failure is not justified. Although it improves oxygenation, it does not prevent death. Patients with severe hypoxemia may benefit from this approach, but the trial did not have adequate power to assess the possibility.
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Prognostic Importance of Elevated Jugular Venous Pressure or a Third Heart Sound in Patients with Heart Failure
Whether common physical findings in patients with heart failure have independent prognostic value is unknown. In this retrospective study of a large population of patients with heart failure, multivariate analyses showed that elevated jugular venous pressure and a third heart sound were each independently associated with adverse outcomes, including death from pump failure.
The physical examination has been deemphasized in recent years as diagnostic technology has advanced. This study indicates that common physical findings in patients with heart failure are valuable prognostic markers, reaffirming the importance of bedside clinical assessment.
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Human Infection with Recombinant Vaccinia–Rabies Virus from an Oral Vaccine
After sustaining mild abrasions and a puncture wound when bitten by her dog, a 28-year-old pregnant woman was hospitalized for cellulitis of the arm. Necrotic lesions developed, requiring fasciotomy. She then had generalized erythroderma with exfoliation. The bites occurred when the woman removed a bait containing an oral rabies vaccine intended for carnivores in the wild from her dog's mouth. This live, attenuated vaccine consists of a recombinant vaccinia–rabies glycoprotein virus. The woman recovered completely.
This report documents an infection in a human with the live, recombinant rabies virus that is used as an oral vaccine and widely distributed in bait in order to reduce the incidence of rabies in raccoons and foxes in the wild. Both the patient's antibody response and studies of samples from her wound document infection with the vaccinia–rabies virus.
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Mechanisms of Disease: The Pathogenesis of Vasodilatory Shock
Vasodilatory shock results from the failure of vascular smooth muscle to constrict and is caused most often by sepsis. The mechanisms that underlie this failure — activation of potassium channels, increased nitric oxide synthesis, and vasopressin deficiency — are described in this review.
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