The finding of shortened telomeres in leukocytes from patients with aplastic anemia prompted a search for mutations in genes that maintain the structure of the telomerase complex. Mutations in TERT, the gene encoding telomerase reverse transcriptase, were found in seven unrelated patients.

The finding of TERT mutations in leukocytes and buccal mucosa indicates that these patients, who presented with acquired aplastic anemia, had germ-line mutations of TERT. The mutations probably contribute to the cause of aplastic anemia by acting in concert with other, unidentified genes, or environmental factors.

Patients with stable coronary artery disease may benefit from therapy to lower low-density lipoprotein (LDL) cholesterol levels, but optimal target levels are unknown. This study showed that intensive lowering of LDL cholesterol levels to a mean of 77 mg per deciliter (2.0 mmol per liter) with 80 mg of atorvastatin per day produced greater clinical benefit than lowering levels to a mean of 101 mg per deciliter (2.6 mmol per liter) with 10 mg of atorvastatin per day. These results could affect practice patterns by redefining target levels of LDL cholesterol in patients with stable coronary disease.

Data on community-acquired methicillin-resistant Staphylococcus aureus infections were obtained by population-based surveillance in Baltimore and Atlanta and by laboratory-based surveillance in Minnesota. From 2001 through 2002, between 8 and 20 percent of all staphylococcal infections were with methicillin-resistant organisms. Most infections involved the skin. A quarter of the patients were hospitalized because of their infections.

Methicillin-resistant S. aureus infections have become an important clinical problem in the community in patients with no identified risk factors.

Over a 15-month period at one center, 14 patients were identified who presented with community-acquired necrotizing fasciitis due to Staphylococcus aureus infection. Their median age was 46 years, and risk factors included current or past injection-drug use (six patients) and previous methicillin-resistant infections. Four patients had no serious coexisting conditions or risk factors.

All these patients survived, but most required wide surgical excision and intensive care. Necrotizing fasciitis appears to be a new, virulent form of methicillin-resistant S. aureus infection.

This study showed that Medicare patients who underwent cardiac revascularization in specialty cardiac hospitals were less severely ill than similar patients who were treated in general hospitals. Cardiac hospitals had lower unadjusted mortality rates, but the rates were similar after adjustment for the severity of illness and procedural volume.

The lower mortality rates at cardiac hospitals appear to result from their healthier patient populations and higher procedural volumes.

A 17-year-old boy with a six-month history of acne presents for initial evaluation and treatment. Physical examination reveals closed and open comedones and a large number of erythematous papules and pustules (50 or more) on the face and upper trunk. How should he be treated?

A previously healthy, 22-year-old man presented to an emergency department reporting three days of intermittent abdominal pain. Although the pain was initially mild and crampy and was relieved with bismuth subsalicylate, on the day he went to the hospital the patient awoke with severe, midepigastric pain and had two episodes of diarrhea. During the preceding week, he had had a productive cough and had noticed a slight decrease in exercise tolerance.