Annals of internal medicine
-
This paper provides the clinician with an understanding of the epidemiologic and biological characteristics of West Nile virus in North America, as well as useful information on the diagnosis, reporting, and management of patients with suspected West Nile virus infection and on advising patients about prevention. Information was gathered from the medical literature and from national surveillance data through May 2002. Since the identification of West Nile virus in New York City in 1999, enzootic activity has been documented in 27 states and the District of Columbia. ⋯ Immunoglobulin M antibody testing of serum specimens and cerebrospinal fluid is the most efficient method of diagnosis, although cross-reactions are possible in patients recently vaccinated against or recently infected with related flaviviruses. Testing can be arranged through local, state, or provincial (in Canada) health departments. Prevention rests on elimination of mosquito breeding sites; judicious use of pesticides; and avoidance of mosquito bites, including mosquito repellent use.
-
Human growth hormone is now readily available and approved for treatment of the growth hormone deficiency syndrome in adults. However, physicians have been slow to adopt this therapeutic modality. Reasons for skepticism about the use of growth hormone for the growth hormone deficiency syndrome include doubts about whether growth hormone deficiency causes increased morbidity and mortality in patients with hypopituitarism; availability of highly efficacious, easier to use, and less expensive agents for certain aspects of the growth hormone deficiency syndrome, especially cardiovascular disease; and concerns about possible toxicity in adults. Long-term studies in patients receiving appropriate comprehensive management for other hormonal deficiencies and for concomitant abnormalities will be required to convince physicians of the utility and safety of growth hormone replacement therapy.
-
Chemoprevention offers promise as a strategy for reducing morbidity and mortality from breast cancer in women. This review examined the evidence for the effectiveness of chemoprevention in women without a history of breast cancer. ⋯ Tamoxifen and raloxifene reduce the incidence of estrogen receptor-positive breast cancer in women. The relative risk reduction seems similar across all breast cancer risk groups. The absolute risk reduction varies by risk factors for breast cancer, however, and must be balanced against the potential harms to judge the appropriateness of treatment for individual women.
-
Recent years have witnessed a rapidly growing crisis in antimicrobial resistance, especially among microorganisms that cause nosocomial infection. To better understand common risk factors among multiresistant organisms, this review explores risk factors for nosocomial infection with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, Clostridium difficile, extended-spectrum beta-lactamase-producing gram-negative bacilli, and Candida. This review comprises data from 74 published studies; 53 (71%) were retrospective studies and addressed few risk factors or did not quantify risk. ⋯ Preemptive isolation of all patients with risk factors for infection by resistant organisms would very likely reduce secondary spread within the hospital. Conversely, programs that focus on only one organism or one antimicrobial drug are unlikely to succeed. Prospective studies of sufficient size that address all potential risk factors, especially individual anti-infective agents, and that use matched controls who are shown by surveillance cultures to be free of colonization by resistant organisms would enhance understanding of the epidemiology of antimicrobial resistance in institutions and guide efforts to develop more effective strategies for prevention.
-
Echocardiography is not recommended as a routine imaging test to diagnose suspected pulmonary embolism. However, it is useful for identifying patients with pulmonary embolism who may have a poor prognosis. It can be used for rapid and accurate risk assessment. ⋯ Such patients warrant consideration for thrombolysis or embolectomy. Serial imaging of right ventricular function can help physicians monitor the effect of treatment and judge whether the selected management strategy is successful. Further research will clarify and define more precisely the utility and limitations of echocardiography in the management of pulmonary embolism.