Vaccines have substantially reduced the incidence ofpediatric pneumonias caused by Haemophilus influenzae type band certain serotypes of Streptococcus pneumoniae. However,other organisms are being identified more frequently, includingmethicillin-resistant Staphylococcus aureus (MRSA) and serotypesof S pneumoniae that are not covered by the pneumococcalvaccine. Although chest radiographs are still a basic componentof the assessment of pneumonia, CT scans are increasinglybeing used to differentiate effusion from empyema and consolidationand to evaluate for pleural fluid loculations, lung abscesses,and lung necrosis. ß-Lactams, particularly extendedspectrumcephalosporins, remain an important cornerstone ofthe treatment of complicated pneumonia. In areas where community-acquired MRSA is a concern, empirical coverage for thispathogen should be considered in patients with a severe ornecrotizing pneumonia. (J Respir Dis. 2008;29(2):85-92)

Methicillin-resistant Staphylococcus aureus (MRSA) first came to the attention of health care providers as a nosocomial pathogen.1 More recently, MSRA has emerged as an important community-acquired pathogen2 and has been a cause of infection in men who have sex with men (MSM)3,4 and in persons with HIV-1 infection.5-7 Other reports include clusters of MRSA infection in prison inmates,8 military recruits,9 and athletes.10

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. Although immunocompetent persons with H capsulatum infections are usually asymptomatic, several clinical syndromes can manifest in immunocompromised patients.

How best to reduce the risk of osteonecrosis of the mandible in patients who take bisphosphonates? Bisphosphonates have a profound effect on osteoclast function: they inhibit bone remodeling, and then cellular apoptosis occurs. These drugs have been remarkably effective in the management of diverse diseases.

A 39-year-old woman complained of excruciating pain that radiated from a chronic lesion on the left upper lip to the entire left side of the face. She had AIDS (CD4+ cell count, 68/µL; HIV RNA level, greater than 750,000 copies/mL) but was not receiving antiretroviral therapy. The lesion first appeared as a blister, which ruptured after it was struck by a toy thrown by her son. It enlarged and became more painful despite antibiotic therapy and a 1-month course of valacyclovir. During this period, she had no fever. She used marijuana and alcohol for pain control.

Case 1: During the past few weeks, a 14-year-old boy has noticed blood on the proximal nail folds of the second and third fingers of his dominant hand. He denies any pain or pruritus. The patient is otherwise healthy and takes no prescription medications.Which of these questions do you ask the patient?A. What sports do you play?B. What are your extracurricular activities?C. Do you bite your nails?D. Do you take any over-the-counter medications or alternative remedies?E. All of the above. (Answer on next page.)

Cancer of the anal canal is a relatively uncommon disease in the United States. It accounts for about 2% of the cancers of the GI tract; about 5000 cases will be diagnosed this year. Squamous cell carcinoma of the anus (anal SCC) is of particular interest to the infectious disease specialist because it is one of the cancers associated with HIV infection in men who have sex with men (MSM).

Although adenoviruses are a recognized cause of serious pulmonary and disseminated disease among stem cell transplant recipients, their importance in other immunocompromised patient populations is less clearly documented.

Mr D is a 38-year-old African American man in whom AIDS had been diagnosed in 2001; he had responded well to antiretroviral therapy, with a recent CD4+ cell count of 376/µL and an HIV RNA level less than 50 copies/mL. He presented to our clinic complaining of a mildly tender "lump" on the left side of his neck, which he first noticed a week ago. He denied fever, chills, sweats, cough, anorexia, weight loss, and urinary symptoms but had a sore throat for 2 days.

Study Finds Antiretroviral Drugs May Prevent HIV Infection A study involving monkeys found that the use of 2 antiretroviral drugs, emtricitabine (FTC) and tenofovir, prevented transmission of a primate version of HIV (Berman J. Voice of America. February 5, 2008).

Little of promise in terms of HIV prevention science was reported at the 15th annual Conference on Retroviruses and Opportunistic Infections (CROI), held from February 3 to 6, 2008, in Boston. Coupled with several other pieces of disappointing news related to early HIV diagnosis and efficacy of vaginal microbicides, most hope continued to relate to disease treatment.

Currently, an estimated 26 million persons in the United States have a urological disorder, according to a newly released government-funded report. Bladder, prostate, and other urinary tract diseases in US adults cost almost $11 billion annually (2000 data), with Medicare's share exceeding $5.4 billion, according to the study by Litwin and colleagues funded by the NIH.

Complete insurance coverage of cardiovascular medications may lower health care costs as well as increase adherence and improve patient outcomes. Researchers led by Niteesh K. Choudhry, MD, PhD, assistant professor at Harvard University and in the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital, Boston, analyzed the cost-effectiveness of providing full prescription drug coverage for post-myocardial infarction (MI) Medicare beneficiaries 65 years and older enrolled in the Part D program. Study results were published in the March 11 issue of Circulation.

The practice of academic detailing is gaining interest and momentum in some health care circles. The primary aim of academic detailing is to prevent the overuse and misuse of certain medications. This is done by educating prescribers on the therapies that are clinically appropriate as well as the costs of therapeutically similar choices. It is less an issue of switching to generics than it is of favoring step therapy or moving toward cost-effective therapeutically equivalent options. A well-designed program should maintain prescriber autonomy and quality of care while helping manage drug costs for both health plans and patients.

A report from the Government Accountability Office (GAO) has led to new questions about the way health care for seniors covered under Medicare Advantage (MA) plans is paid for-and has prompted Centers for Medicare & Medicaid Services (CMS) acting administrator Kerry N. Weems to promise to collect more data from plans.

The highest rate of nonspecific serious psychological distress (SPD) (14.4%) among persons aged 18 and older in 2005 and 2006 was found in Utah, but overall, national SPD rates declined slightly. The rates of major depressive episodes (MDEs) among youths aged 12 to 17 years in Utah decreased significantly, from 10.1% in 2004 to 2005 to 8.2% from 2005 to 2006, according to a report released on March 6 by the Substance Abuse and Mental Health Services Administration (SAMHSA). MDE and SPD rates across all age groups were highest in the Midwest (7.8% and 11.8%, respectively) and lowest in the Northeast (7% and 10.8%, respectively). The study is based on data from 136,110 respondents collected for the 2005-2006 National Survey on Drug Use and Health.

Last month I wrote about how patients-or rather consumers-were taking on greater responsibility for decisions affecting their own health, largely because of the Internet and the ability to research and form opinions about individual treatments. That was only scratching the surface of how the Internet is revolutionizing health care.

Once a person reaches age 65 years, his or her prescription drug costs typically increase dramatically, according to results of a meta-analysis published in the March issue of the British Journal of Clinical Pharmacology. Researchers from the faculty of pharmacy at the University of Barcelona, Spain, led by Eduardo L. Marino, PharmD, PhD, examined the computerized pharmacy dispensing records of 5.47 million patients in Catalonia from January 1, 2002, to December 31, 2002. The team established 20 age-sex categories and analyzed the participants' use of 15 therapeutic classes of prescription drugs.

A new FDA policy requires pharmaceutical manufacturers to examine whether study participants become suicidal during clinical trials of new medications.1 The policy derives from the belated recognition that antidepressants seem to slightly increase suicidality in children, adolescents, and young adults early in the course of treatment. This is not the only news about medications linked to possible increases in suicidal ideation or behavior.

As dermatologists' use of biologic drugs for psoriasis grows, MCOs must take an increasingly active role in managing the near-term utilization of these high-cost agents while also taking into account that some of the "payback" for these drugs comes in the form of long-term costs avoided. Meanwhile, physicians, insurers, and employers continue to wrestle with issues such as step-down dosing; step therapy; patient-administration versus physician-administration; and whether biologic drugs should be covered under a plan's pharmacy benefit, medical benefit, or some combination. (Drug Benefit Trends. 2008;20:143-147).