December 12, 2002
An Outbreak of Varicella among Vaccinated Children
At a day-care center in New Hampshire, an outbreak of varicella affected 25 healthy young children, including 17 who had been vaccinated against varicella. The index patient was a four-year-old who had been vaccinated three years earlier. In this outbreak, the effectiveness of previous varicella vaccination was only 44 percent against disease of any severity, but it was 86 percent against moderate or severe disease. This outbreak in a population with good vaccination coverage shows that varicella can be highly infectious among vaccinated, healthy children. The effectiveness of the vaccine was well below the estimates of 71 to 100 percent from earlier investigations.
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Risk of Myocardial Infarction and Polymorphisms in Candidate Genes
The risk of myocardial infarction is known to be influenced by genetic factors, but few such factors have been identified. This study found that a polymorphism in the connexin 37 gene in men and polymorphisms in the plasminogen-activator inhibitor type 1 gene and the stromelysin-1 gene in women were associated with an increased risk of myocardial infarction. On the basis of their cellular functions, mutations in each of these proteins could be anticipated to affect the risk of myocardial infarction. The delineation of such genetic risk factors may lead to an improvement in primary-prevention efforts.
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Reconstruction versus Amputation after Leg-Threatening Injuries
This observational study compared two-year outcomes of patients with severe leg injuries who underwent reconstruction or amputation. The health status (as measured by a multidimensional instrument) of patients who had undergone reconstruction was similar to that of patients who had undergone amputation. Although the nonrandomized design of this study leaves open the possibility of residual confounding, the results suggest that the health and other functional outcomes of patients who have undergone limb reconstruction are likely to be similar to those of patients who have undergone amputation.
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Special Article in the Patient Safety Series: Views of Practicing Physicians and the Public on Medical Errors
According to this national survey, neither the public nor physicians view medical errors as one of the most important problems of the U.S. health care system. Practicing physicians and the public believe individual health care professionals are responsible for most errors. These findings are in sharp contrast to the Institute of Medicine's report that medical errors are widespread and the result of failures in systems, not individuals. The discrepancy between these views is likely to impede the success of efforts to reduce medical errors.
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Medical Progress: Exercise Training for Claudication
Claudication, a manifestation of systemic atherosclerosis and accompanying peripheral vascular disease, is characterized by pain induced by walking in one or both legs; it primarily affects the calves. Claudication usually does not abate with continued walking and is relieved only by rest. Since the effects of approved medication are usually limited, exercise programs have been developed to treat this painful condition. This review discusses the rationale for an exercise program for the patient with claudication, with a focus on pathophysiology and the effect of training.
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Clinical Implications of Basic Research: Erythropoietin
Apoptosis causes the death of photoreceptors in macular degeneration and retinitis pigmentosa and the death of retinal ganglion cells in glaucoma. Receptors for erythropoietin are present in both types of cells, and in mice, erythropoietin blocks light-induced apoptosis of these cells. Erythropoietin has potential as a treatment for degenerative retinal diseases.
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Sounding Board: Homeostasis without Reserve — The Risk of Health System Collapse
In this Sounding Board article, the author describes the changes in public policy and in the marketplace that have placed stress on the U.S. health care system over the past decade. The system has showed considerable homeostasis, and its structure has not changed dramatically. The author contends, however, that we have not addressed the underlying problems and that the turbulence of the past 10 years has left our health care system with little reserve and vulnerable to collapse.
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