November 21, 2002
A Vaccine against Human Papillomavirus Type 16
Human papillomavirus type 16 (HPV-16) is sexually transmitted and is present in 50 percent of cervical cancers. This randomized, double-blind trial assessed the effectiveness of a vaccine that consists of HPV-16 L1 virus-like particles in women who were seronegative for HPV-16. The vaccine was highly effective in preventing HPV-16 infection. This study may have important public health implications, since immunization of uninfected women against HPV-16 infection should reduce the incidence of cervical cancer. Of the women who received the vaccine, 99.7 percent had seroconversion and none became infected with HPV-16 after a median follow-up of 17.4 months.
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A Vaccine against Genital Herpes
Two double-blind, controlled trials assessed the efficacy of a glycoprotein-D–subunit vaccine to prevent genital herpes disease. The vaccine elicited humoral and cellular responses, but efficacy was found only in women who were seronegative for both herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) (efficacy in the two studies was 73 and 74 percent). The vaccine was not efficacious in women who were seronegative for HSV-2 if they were seropositive for HSV-1, nor was it efficacious in men. Genital herpes is epidemic, and a vaccine is needed that can prevent both symptomatic disease and transmission of the virus. These trials find some efficacy for this vaccine, but only in women who are seronegative for both HSV-1 and HSV-2. We do not yet know whether this vaccine can prevent asymptomatic infection and reduce the transmission of HSV.
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Transthoracic versus Transhiatal Esophagectomy for Adenocarcinoma
This study compared extended transthoracic resection with limited transhiatal resection for adenocarcinoma of the esophagus or gastric cardia. The five-year survival rates in the two groups were not significantly different, but a nonsignificant trend in overall survival favored transthoracic resection in later years. Is a more extensive, more invasive operation for cancer better than a more limited, less invasive procedure? The choice between extended surgery with its associated morbidity and a more limited operation still depends on individual preference and on the presence or absence of coexisting conditions.
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Narrowing of the Optic Canal in Fibrous Dysplasia
In patients with fibrous dysplasia, the optic canals may become encased by abnormal bone. Loss of vision is a complication, but there is controversy about whether prophylactic surgical decompression of the optic nerve can be helpful. Careful analysis of computed tomographic studies in 38 patients with polyostotic fibrous dysplasia or the McCune–Albright syndrome showed that most had complete encasement of the optic canal, but there was no clear relation between the size of the canals and visual function. The data in this study are cross-sectional, and a longitudinal study is needed. But the findings indicate that narrowing of the optic canals does not in itself result in loss of vision. Therefore, prophylactic surgical decompression may not be indicated in patients with these abnormalities.
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Special Article: Ambulatory Care and Mortality after Myocardial Infarction
The investigators used Medicare data to assess associations between the type of physician providing ambulatory care and mortality after myocardial infarction among 35,520 patients 65 years of age or older. After adjustment for multiple potential confounders, patients who saw a cardiologist in the three months after discharge from the hospital had lower mortality at two years than similar patients who saw only an internist or a family practitioner (14.6 percent vs. 18.3 percent, P<0.001). Patients who saw both a cardiologist and an internist or a family practitioner had the lowest mortality rates. Although the possibility of some residual confounding cannot be dismissed, these results suggest that survival after myocardial infarction is improved when a cardiologist is involved in ambulatory care, preferably together with an internist or a family practitioner.
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Clinical Practice: Transient Ischemic Attack
A 72-year-old woman telephones her physician immediately after recovering from a 30-minute episode of difficulty speaking and weakness of the right side of the face and right arm. Her medical history is unremarkable. How should she be treated?
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