November 14, 2002
Dexamethasone Treatment to Improve Outcomes in Bacterial Meningitis
Can adjuvant treatment with dexamethasone reduce morbidity and mortality in adults with acute bacterial meningitis? In this randomized, double-blind trial, which involved 301 patients, the outcomes were clearly better in the group that received dexamethasone for four days, in addition to antibiotics, than in the group that received placebo and antibiotics. With dexamethasone treatment, the risk of an unfavorable outcome was greatly reduced (relative risk, 0.59), and mortality was reduced from 15 percent to 7 percent. This carefully controlled trial will have an important effect on the treatment of adults with bacterial meningitis. The greatest benefits were in patients with pneumococcal meningitis. There was no significant increase in the risk of gastrointestinal bleeding among patients treated with dexamethasone.
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C-Reactive Protein in the Prediction of First Cardiovascular Events
Studies have suggested that C-reactive protein, a marker of inflammation, may predict the risk of cardiovascular events, including coronary events. In this study of nearly 28,000 women, C-reactive protein levels were found to predict the risk of subsequent cardiovascular events independently of other known coronary risk factors. C-reactive protein and low-density lipoprotein cholesterol levels were found to be complementary in the prediction of risk. The prediction of cardiovascular risk is an important goal. The use of C-reactive protein measurement as a screening test for this risk is under discussion.
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Cyclin E and Survival in Breast Cancer
The level of cyclin E, part of a molecular network that controls the cell cycle, is increased in breast-cancer cell lines. In breast-cancer tissue, high levels of cyclin E correlated with a poor outcome, whereas low levels correlated with a good outcome. If this work is substantiated, measurement of cyclin E will be used to obtain prognostic information in patients with breast cancer. An obvious clinical reason to measure cyclin E will be to stratify patients with breast cancer who are enrolled in therapeutic trials.
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Asymptomatic Bacteriuria in Women with Diabetes
In women with diabetes, treatment of asymptomatic bacteriuria has been recommended to prevent complications. In this trial, 55 women with diabetes and asymptomatic bacteriuria were randomly assigned to receive antimicrobial therapy and 50 to receive placebo. After a mean follow-up of 27 months, the rates of symptomatic urinary tract infection were similar: 42 percent in the treated group and 40 percent in the placebo group. There were also no significant differences between the two groups in the rates of pyelonephritis or hospitalization for urinary tract infection, although the 95 percent confidence intervals for these differences were wide. Among women with diabetes, a policy of screening for and treating asymptomatic bacteriuria leads to many courses of antibiotics but does not appear to prevent complications. The findings of this controlled study call such a policy into question.
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Special Article: Contribution of Major Diseases to Disparities in Mortality
Mortality from all causes is higher for persons with less education and for black persons. This study examined cause-specific mortality to estimate the relative contribution of major health problems to these educational and racial disparities in life expectancy. The diseases that contributed most to the educational disparity were smoking-related diseases. Ischemic heart disease accounted for 12 percent of the disparity, lung cancer 8 percent, stroke 6 percent, congestive heart failure 5 percent, and lung disease 5 percent. The racial disparity was not driven by mortality from smoking-related illness but by hypertension, human immunodeficiency virus infection, diabetes, and trauma. Public health and educational efforts to eliminate health disparities should focus on the specific diseases that contribute most to racial and educational differences in health outcomes.
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Mechanisms of Disease: Human Tumor Cells
The apparent complexity of the genetic, biochemical, and physiological changes in cancer cells threatens to stall the elucidation of the origins of cancer and the development of new treatments for malignant diseases. The authors propose a considerably simplified scheme in which only five alterations are required to transform cells from a normal to a malignant phenotype.
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Health Policy Report in the Patient Safety Series: Reporting of Adverse Events
Systems for reporting adverse events can reduce medical errors by uncovering remediable problems in processes of care; however, current reporting systems are neither widely used nor highly effective. Reporting systems work best when they are confidential and easy to use, provide expert analysis of reports, and give timely feedback. If voluntary reporting systems are modified and expanded, they have the potential to improve patient safety.
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