February 14, 2002
Pure Red-Cell Aplasia after Treatment with Recombinant Erythropoietin
Within three years, 13 cases of pure red-cell aplasia, a rare disease, were identified in patients with chronic renal failure who were receiving recombinant human erythropoietin (epoetin): 12 in France and 1 in Britain. All patients had antibodies that inhibited erythropoiesis in vitro and bound to epoetin with high affinity. Despite the discontinuation of epoetin treatment, most of the patients remain transfusion-dependent. An autoimmune response engendered by epoetin against endogenous erythropoietin is the most likely reason for the development of pure red-cell aplasia in these 13 patients. Such a response should be considered in any patient being treated with epoetin in whom anemia suddenly develops in the absence of the usual causes.
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Plasma Homocysteine and Alzheimer's Disease
A cohort of 1092 elderly subjects who were free of dementia were studied prospectively. After a median of eight years of follow-up, dementia had developed in 111 subjects. Even after adjustment for other known risk factors, an elevated plasma total homocysteine level at base line was an independent predictor of the development of clinical dementia, most cases of which were caused by Alzheimer's disease. The risk of Alzheimer's disease was nearly doubled for those with the highest plasma homocysteine levels. This prospective, observational study greatly strengthens the evidence for an association between the plasma homocysteine level and the risk of dementia. Since folic acid supplementation can reduce plasma homocysteine levels, this report suggests an intervention that may help prevent dementia.
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Clinical Outcomes of Pulmonary Langerhans'-Cell Histiocytosis in Adults
Pulmonary Langerhans'-cell histiocytosis in adults is a rare interstitial lung disease, and its course and outcome have not been well defined. In this study, the records of 102 adults with clearly established disease were reviewed. Over a median follow-up period of four years, 33 deaths occurred, about half of which were attributable to respiratory failure. The overall survival was significantly shorter than that expected for persons matched for sex and calendar year of birth. This study of a large series of patients with the adult form of pulmonary Langerhans'-cell histiocytosis defines the course of this rare condition and the prognosis for affected persons.
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Staphylococcus aureus Conjugate Vaccine in Patients Receiving Hemodialysis
This double-blind, placebo-controlled study evaluated the use of a conjugate vaccine containing the two most common capsular polysaccharides that confer virulence on S. aureus. Among adults receiving long-term hemodialysis, a single dose of the vaccine had an efficacy of 57 percent against S. aureus bacteremia from week 3 to week 40 after vaccination. This encouraging study in a high-risk population shows that an S. aureus conjugate vaccine is safe and immunogenic and provides some protection against a dangerous type of bacteremia. However, protection declined about 40 weeks after vaccination and was not significant over the full 54 weeks of the trial.
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Special Article: Direct-to-Consumer Drug Advertising
Spending on direct-to-consumer advertising of drugs tripled between 1996 and 2000, when it reached $2.5 billion. The majority of this advertising is on television. Highly selected drugs are targeted for this form of advertising, and the intensity of such advertising may fluctuate markedly over time (antihistamines, for example, are advertised seasonally). Although spending for direct-to-consumer advertising accounts for only 15 percent of total expenditures on drug promotion, its substantial growth means that physicians must spend more of their limited time assisting patients in interpreting the information targeted to them through advertising.
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Clinical Practice: Treating Tobacco Use and Dependence
A 66-year-old woman with stable angina and a history of depression smokes 25 cigarettes daily. She would like to stop smoking but is concerned about weight gain. She has made several unsuccessful attempts at quitting on her own. How should she be treated? This article reviews approaches to facilitate smoking cessation.
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Sounding Board: Direct-to-Consumer Marketing of High-Technology Screening Tests
The authors sharply criticize the now-common practice of marketing high-technology medical screening tests directly to the consumer. As a prominent example, they select electron-beam computed tomography to screen for lung cancer. The authors voice concern about the validity of such screening, the financial consequences, and potential ethical problems.
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