This Week in the Journal

This Week in the Journal

May 1, 2003

Effects of the Conjugate Vaccine on Invasive Pneumococcal Disease

In 2000, a protein–polysaccharide pneumococcal conjugatevaccine was recommended for use in infants and young children.Surveillance data show that from 1998 to 2001 the rate of invasivedisease declined by 69 percent among children less than twoyears of age. There were also smaller but significant reductionsin pneumococcal disease in adults.

The use of the conjugate vaccine is reducing the frequency ofpneumococcal sepsis and meningitis in infants and young children,for whom it is recommended. A side benefit appears to be theprevention of disease in adults because of reduced transmissionof pneumococci from young children.

Effectiveness of Pneumococcal Vaccine in Older Adults

This population-based, retrospective study of more than 47,000older persons assessed the effectiveness of pneumococcal vaccination.Vaccination was associated with a significant reduction in therisk of pneumococcal bacteremia, but over three years of follow-upthere was no reduction in the risk of community-acquired pneumonia(hazard ratio, 1.07).

Although pneumococcal vaccination helps protect older personsagainst life-threatening bacteremia, it provides little if anyprotection against pneumonia. Other strategies are needed toprevent the nonbacteremic manifestations of pneumococcal infection.

Nitroprusside in Severe Aortic Stenosis and Heart Failure

In critically ill patients with aortic stenosis and left ventriculardysfunction, vasodilator therapy has been considered to be contraindicatedbecause of concern that it could cause hypotension. In thisstudy, nitroprusside was administered to 25 such patients undercarefully monitored conditions and, contrary to traditionalteaching, was found to cause substantial improvement in thecardiac index and other hemodynamic variables.

These findings will change the standard approach to the treatmentof these severely ill patients. Nitroprusside therapy can beused as a bridge to aortic-valve replacement or to maintenancetherapy with oral vasodilators.

Related Perspective

ZAP-70 Expression and Prognosis in Chronic Lymphocytic Leukemia

Mutations of immunoglobulin genes in chronic-lymphocytic-leukemia(CLL) cells augur a good outcome, whereas the absence of mutationsindicates a poor prognosis. The presence of ZAP-70 on CLL cellscorrelated with unmutated immunoglobulin genes and a poor prognosis,whereas its absence indicated the presence of mutated genesand a good outcome.

Discovery of the prognostic importance of immunoglobulin-chainmutations, a major advance in CLL, has been slow to change clinicalpractice, because finding mutations is complex and expensive.However, any laboratory with a flow cytometer can measure ZAP-70.

Related Editorial

Genomic Medicine: Hematologic Cancers

Hematologic cancers — that is, leukemias and lymphomas— usually result from somatic mutations in hematopoieticcells rather than heritable mutations. Many of these cancershave been classified on the basis of their morphology and thepresence of tumor marker antigens. This review explains complementaryDNA expression profiling, a genomic approach to the diagnosisof such tumors, with certain leukemias and lymphomas used asexamples.

Current Concepts: Management of Drug Withdrawal

This review summarizes the current approaches to the managementof withdrawal in patients addicted to sedatives such as alcoholor benzodiazepines, opioids, or stimulants such as amphetaminesor cocaine. Included are details of detoxification regimensand guidelines for recognizing and managing the most commoncomplications.

Environmental Lead Exposure and Chronic Renal Disease
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Imaging Studies after a First Febrile Urinary Tract Infection in Young Children
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T Cells in Ovarian Cancer
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Hypertrophic Cardiomyopathy and Outflow Tract Obstruction
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Preventing Falls in Elderly Persons
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Regional Anesthesia and Analgesia for Labor and Delivery
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Vesicoileal Fistula in a Patient with Hematochezia and Hematuria
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Reversible Dementia Due to Thalidomide Therapy for Multiple Myeloma
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