Infective endocarditis is a complex and challenging illness. Successful management often requires expertise in cardiology, cardiac surgery, infectious disease, neurology and nephrology.1.Alpert JS Klotz SA Infective endocarditis, in Hurst.The Heart. 14th edition. McGraw Hill Publishers, 2017: 1621-1648Google Scholar Indeed, many institutions have formed multidisciplinary teams with members from each of these specialties to collaborate on the management of infective endocarditis patients. Because large randomized clinical trials examining therapy for infective endocarditis are lacking, management depends on the interpretation of retrospective series of patients treated in various ways. An additional problem with infective endocarditis involves difficulty in confirming the diagnosis. A review of recent reports involving patients with infective endocarditis resulted in 9 interesting new directions for clinicians who manage these patients. What follows is our interpretation of new frontiers in the world of infective endocarditis.1.The time-honored Duke criteria for establishing the diagnosis of infective endocarditis have been recently revised with new material added,2Otto CM Nishimura RA Bonow RO et al.2020 ACC/AHA Guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. 2021; 77: e25-e197https://doi.org/10.1016/j.jacc.2020.11.018Crossref PubMed Scopus (904) Google Scholar,3Fowler VG Durack DT Selton-Suty C Athan E Bayer AS Chamis AL Dahl A DiBernardo L Durante-Mangoni E Duval X Fortes CQ Fosbøl E Hannan MM Hasse B Hoen B Karchmer AW Mestres CA Petti CA Pizzi MN Preston SD Roque A Vandenesch F van der Meer JTM van der Vaart TW Miro JM. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria.Clin Infect Dis. 2023 Aug 22; 77 (Erratum in: Clin Infect Dis. 2023 Oct 13;77(8):1222): 518-526https://doi.org/10.1093/cid/ciad271Crossref PubMed Scopus (112) Google Scholar including new biomarkers to assist making the diagnosis in patients with less commonly encountered organisms: blood sample based polymerase chain reaction (PCR) or other nucleic acid-based techniques for Coxiella burnetii, Bartonella species, or Tropheryma whipplei ; C. burnetii antiphase I IgG antibody titer >1:800 or C. burnetii isolated from a single blood culture; and indirect immunofluorescence assays for detection of henselae or Bartonella quintana, with IgG titer ≥1:800. In addition, imaging studies that detect endocardial involvement by echocardiography, cardiac CT, or 18F-fluorodeoxyglucose (18F-FDG) PET/CT scanning are now considered an important adjunct for establishing the diagnosis of infective endocarditis.2.The epidemiology of infective endocarditis has changed in recent decades. Healthcare-associated disease now accounts for 25%-30% of cases because of greater use of intravenous lines and cardiac devices. The incidence of infective endocarditis in the United States is increasing, with approximately 15 cases per 100,000 people.4Chen H Zhan Y Zhang K Gao Y Chen L Zhan L Chen, Zeng Z The Global, Regional, and National Burden and Trends of Infective Endocarditis From 1990 to 2019: Results From the Global Burden of Disease Study.Front. Med.,. 09 March 2022; (Sec. Infectious Diseases: Pathogenesis and Therapy 2022Accessed June 4, 2024)https://doi.org/10.3389/fmed.2022.77422Crossref Google Scholar Moreover, the world-wide incidence of infective endocarditis is also increasing.5Sebastian SA Co EL Mehendale M Sudan S Manchanda K Khan S. Challenges and Updates in the Diagnosis and Treatment of Infective Endocarditis.Curr Probl Cardiol. 2022 Sep; 47 (Epub 2022 May 28. PMID: 35636519)101267https://doi.org/10.1016/j.cpcardiol.2022.101267Crossref Scopus (9) Google Scholar Infectious endocarditis in individuals who inject drugs has become common in US hospitals.3.Complex cases of infective endocarditis are also increasing in number. These challenging patients often present with or develop complications such as heart failure, severe valvular incompetence, and structural complications including abscess, valve perforation, and fistula formation. These patients are best managed at tertiary care centers with a dedicated endocarditis team.6Rajani R Klein JL. Infective endocarditis: A contemporary update.Clin Med (Lond). 2020 Jan; 20: 31-35https://doi.org/10.7861/clinmed.cme.20.1.1Crossref Scopus (109) Google Scholar4.Culture-negative infective endocarditis is not uncommon and can result from prior antibiotic therapy. Intravenous antibiotic management of culture-negative infective endocarditis is complex, and the choice of regimens should be decided by the infectious disease specialist who is a member of the infective endocarditis team.5.Antibiotic prophylaxis to prevent infective endocarditis remains controversial. Many countries no longer recommend this for individuals at low risk, for example, patients with a patent foramen ovale or mild valvular abnormalities. However, antibiotic prophylaxis is still advised for individuals at high risk for developing endocarditis, such as those with prosthetic or surgically repaired heart valves, previous infective endocarditis, and patients with unrepaired cyanotic congenital heart disease or an unrepaired shunt. Procedures that require antibiotic prophylaxis include dental extractions, and subgingival scaling or manipulation of the gums, teeth, or oral mucosa.6Rajani R Klein JL. Infective endocarditis: A contemporary update.Clin Med (Lond). 2020 Jan; 20: 31-35https://doi.org/10.7861/clinmed.cme.20.1.1Crossref Scopus (109) Google Scholar6.Staphylococcus aureus is now the most common cause of infective endocarditis, especially in individuals who self-inject drugs. This organism can cause severe damage to the infected valve, resulting in acute valvular incompetence, heart failure, and shock.7.Patients with infective endocarditis often develop highly variable signs and symptoms. The disease may present as an acute, subacute, or even chronic entity, depending on causative microorganisms, underlying cardiac conditions, and pre-existing comorbidities. Ninety percent of patients with infective endocarditis will have fever, often accompanied by night sweats, malaise, fatigue, anorexia, and weight loss. Approximately a quarter of infective endocarditis patients present with embolic phenomena such as sudden onset of blindness, abdominal pain from splenic or renal infarction, or stroke. The diagnosis of infective endocarditis should be entertained in individuals with predisposing conditions who present with fever, a heart murmur, and embolic events. Antibiotics should not be administered until three sets of blood cultures have been obtained. Earlier administration of antibiotic therapy is the most common reason for culture-negative endocarditis and complicates diagnosis and therapy.8.For decades, prolonged intravenous (IV) antibiotic therapy, typically lasting 6 weeks, has been the standard of care for infective endocarditis. Recent studies have demonstrated that stepping down from IV to oral therapy can be safe and effective7Wald-Dickler N Holtom PD Phillips MC Centor RM Lee RA Baden R Spellberg B. Oral Is The New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review.Am J Med. 2022; 135 (-37): 369Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar. Patients who may benefit from stepdown therapy include those who are afebrile and clinically stable, those who do not require surgical intervention, those infected with an organism that is susceptible to an antibiotic with good oral bioavailability, and those with functioning gastrointestinal tracts. Further studies will be needed to determine the best timing for the transition to oral therapy as well as the optimal duration of treatment.9.The timing of surgical valve replacement for patients with infective endocarditis remains controversial, with some authorities arguing for early intervention while others prefer later surgery as long as the patient is stable and responding to antibiotic therapy. The infective endocarditis team approach is useful in determining the best timing for invasive intervention.8El-Dalati S Cronin D Riddell 4th, J Shea M Weinberg RL Washer L Stoneman E Perry DA Bradley S Burke J Murali S Fagan C Chanderraj R Christine P Patel T Ressler K Fukuhara S Romano M Yang B Deeb GM The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team.Ann Thorac Surg. 2022 Jan; 113 (Epub 2021 Mar 1): 118-124https://doi.org/10.1016/j.athoracsur.2021.02.027Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Joseph S. Alpert: Writing – review & editing. Steven Klotz: Writing – review & editing. Harvey B. Simon: Writing – review & editing. There are no conflicts of interest for any of the authors. None

The Editors of The American Journal of Medicine (AJM) are grateful to Dr. Heslley Machado Silva for calling our attention to the Brazilian government's misinterpretation and misuse of an article published in The American Journal of Medicine.1Silva HM The Brazilian scientific denialism through The American Journal of Medicine.Am J Med. 2021; ([e-pub ahead of print]) (Feb 6)https://doi.org/10.1016/j.amjmed.2021.01.003Abstract Full Text Full Text PDF Scopus (14) Google Scholar As noted in Dr. Silva's commentary, the Brazilian government continues to tout hydroxychloroquine (HCQ) as a cure-all and preventive for Coronavirus disease 2019 (COVID-19) infections. The government quotes an article printed in the AJM in January 2021 but written and accepted more than 6 months earlier and posted on the PubMed website2McCullough PA Kelly RJ Ruocco G et al.Pathophysiological basis and rationale for early outpatient treatment of SARS-CoV-2 (COVID-19) infection.Am J Med. 2021; 134: 16-22Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar at that time. This article was accepted for publication at a time when scientific information concerning prevention and management of COVID-19 was rapidly evolving. The article begins by emphasizing the importance of preventive measures including facial coverings, sanitization, and quarantining. The authors then discuss 8 agents or groups of agents that have shown in vitro or possible clinical activity against various coronaviruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Subsequently, a number of these agents, including HCQ, have been shown to be ineffective or harmful in preventing or treating infection with SARS-CoV-2. The AJM is one of many publications to call attention to this evolving scientific information.3Shih RD Johnson HM Maki DG Hennekens CH Hydroxychloroquine for Coronavirus: the urgent need for a moratorium on prescriptions.Am J Med. 2021; 133: 1007-1008Abstract Full Text Full Text PDF Scopus (5) Google Scholar Despite these new data, the government of Brazil continues to cite "the prestigious American Journal of Medicine" as proof that hydroxychloroquine can prevent or treat COVID-19. In other words, the Brazilian government claims that the AJM had given a seal of approval to the use of HCQ. Nothing could be further from the truth. The AJM is neither a regulatory agency nor an arbiter of political and scientific disputes. The AJM is a vehicle of communication employed by scientists and clinicians to report information that is potentially useful to physicians throughout the world. It is completely inaccurate to claim that the AJM has endorsed a therapeutic intervention. The article that the Brazilian government quotes as "proof" of the efficacy of HCQ was posted in PubMed before studies demonstrated that HCQ does more harm than good. The results of scientific studies are always open to review and revision by later investigation. This was the case with some of the hopeful speculations in the article by McCullough et al.2McCullough PA Kelly RJ Ruocco G et al.Pathophysiological basis and rationale for early outpatient treatment of SARS-CoV-2 (COVID-19) infection.Am J Med. 2021; 134: 16-22Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar What seemed reasonable last summer based on laboratory experiments has subsequently been shown to be untrue, but the Brazilian government does not seem to have taken account of this widely available new information, as well as the crucial role of face covering, social distancing, and sanitization that are the first recommendations of McCullough et al.2McCullough PA Kelly RJ Ruocco G et al.Pathophysiological basis and rationale for early outpatient treatment of SARS-CoV-2 (COVID-19) infection.Am J Med. 2021; 134: 16-22Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Based on the US experience in 2020, this politicization of science should not be surprising.

Faulkner famously said that the past is never dead. It's not even past. It's true of our personal lives because our memories, accurate or not, conscious or not, strongly color our view of the present and our plans for the future. It's true of the body politic, as we seem doomed to endure cycles of peace and war, liberalism and conservatism, and boom or bust as history repeats itself. And it's also true of medicine, as we are inspired by breakthroughs from the past and humbled as new discoveries overturn long-established beliefs.

As classmate and former running mate, I seek Simon's critique of my contrary interpretation to his “Pheidippides Redux” exonerating strenuous exercise as a cause of acute cardiac events.1Simon H.B. Exercise and health: dose and response, considering both ends of the curve.Am J Med. 2015; 128: 1171-1177Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 2Siegel A.J. Pheidippides redux: reducing acute cardiac risk during marathon running.Am J Med. 2012; 125: 630-635Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The same 10-year prospective registry citing low overall cardiovascular risk in US road races since 2000 identified the marathon and male gender as significant risk factors for cardiac arrest.3Kim J.H. Malhotra R. Chiampas G. et al.Cardiac arrest during long-distance running races; for the race-associated cardiac arrest event registry [RACER] Study Group.N Engl J Med. 2012; 36: 130-140Crossref Scopus (422) Google Scholar Reporting 59 cases in runners averaging age 42 years, cardiac arrests increased 2.3-fold in middle-aged men after 2005. Atherosclerotic heart disease has been shown elsewhere to be the main cause of race-related sudden cardiac death in men aged more than 40 years,4Mathews S.C. Narotsky D.L. Berbholt D.L. et al.Mortality among marathon runners in the United States, 2000-2009.Am J Sports Med. 2012; 40: 1495-5000Crossref PubMed Scopus (65) Google Scholar which is potentially preventable in contrast to underlying cardiac conditions in younger athletes. Use of prerace aspirin for susceptible men on approval by their physicians has been recommended by a group of international marathon medical directors beginning at the Rio de Janeiro marathon in 2014.5Siegel AJ. IMMDA advisory statement, 2015: pre-race aspirin to prevent heart attack and/or cardiac arrest during long distance running. Available at: http://immda.org/wp-content/uploads/2015/08/Spring-2015-Pre-race-ASA.pdf. Accessed December 21, 2015.Google Scholar The rationale rests on the final report on aspirin in the prospective randomized Physicians Health Study, which found conclusive evidence for protection of healthy middle-aged male physicians from first myocardial infarctions.6Steering Committee of the Physicians' Health Study Research GroupFinal report on the aspirin component of the ongoing Physicians' Health Study.N Engl J Med. 1989; 321: 129-135Crossref PubMed Scopus (2515) Google Scholar Transient high cardiac risk was subsequently identified in same-aged, asymptomatic, male physician-runners during races by stratification of validated biomarkers.7Siegel A.J. Aspirin usage pre-race to prevent cardiac arrest in marathon runners during races.Am J Med. 2013; 126: e47Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The use of aspirin was not considered by Simon in his “simple precautions” to make the sport safer. As a remedy known to Hippocrates in the time of Pheidippides, aspirin is a class 1A recommendation for prehospital treatment of acute coronary syndromes. The efficacy of this strategy to mitigate the increasing frequency of cardiac arrests in susceptible men warrants prospective study by the marathon medical community once accepted by runners. Deconstructing Pheidippides Redux, what's not to embrace about primary prevention of marathon-related cardiac arrests mediated by atherothrombosis in men identified at high risk during races?8Siegel A.J. Prerace aspirin to protect susceptible runners from cardiac arrest during marathons: is opportunity knocking?.Open Heart. 2015; 2: e000102Crossref Google Scholar Exercise and Health: Dose and Response, Considering Both Ends of the CurveThe American Journal of MedicineVol. 128Issue 11PreviewOver the past 60 years, an enormous body of data has demonstrated that exercise is good for health. Recently, however, there has been concern that repetitive intense exercise may have deleterious cardiovascular effects. To evaluate this possibility, I have reviewed the health response to exercise, with particular attention to the body's minimum daily requirement and to the maximum amount that is safe and effective. Full-Text PDF The ReplyThe American Journal of MedicineVol. 129Issue 6PreviewAlthough aspirin is safe and effective for the secondary prevention of myocardial infarction, its role in primary prevention is less clear. As aptly cited by Siegel, a 1989 report by the Physicians' Health Study noted an impressive 44% reduction in the risk of a first heart attack in male physicians. But even in this population, the benefit was restricted to men age 50 years and older, and aspirin did not lower the overall risk of cardiovascular death.1 Unfortunately, more recent studies have reported that aspirin is not effective for primary prevention of cardiovascular disease in women2 or even in people at high risk, including those with peripheral artery disease,3 diabetes,4 hypertension,5 and people with cardiovascular risk factors age 60 years and above. Full-Text PDF

Over the past 60 years, an enormous body of data has demonstrated that exercise is good for health. Recently, however, there has been concern that repetitive intense exercise may have deleterious cardiovascular effects. To evaluate this possibility, I have reviewed the health response to exercise, with particular attention to the body's minimum daily requirement and to the maximum amount that is safe and effective.

Earlier this year, The American Journal of Medicine published 2 articles that discussed how doctors can benefit from nonmedical reading. In February, our Editor-in-Chief, Dr Joseph Alpert, explained how reading helps him deal with the pressures of medical practice and administration. 1 Alpert J.S. My recent reading list of nonmedical books. Am J Med. 2014; 127: 101-102 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In April, I suggested that reading fiction can function as a virtual house call, introducing practitioners to a wide array of personalities and situations before they are encountered in a clinical setting. 2 Simon H.B. Reading fiction. Am J Med. 2014; 127: 356-357 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar I also argued that literary fiction has the ability to enhance clinically important skills, such as empathy, sensitivity, and understanding. This special role of literary fiction depends on its complexities and ambiguities, which disrupt expectations and force the reader to actively and creatively interpret the inner thoughts, feelings, and beliefs of fictional characters. At that time, I presented empiric data by Kidd and Castano 3 Kidd D.C. Castano A. Reading literary fiction improves theory of mind. Science. 2013; 342: 377-380 Crossref PubMed Scopus (666) Google Scholar that support the specific benefits of literary fiction. Now, I will call attention to a wonderful new novel that demonstrates the power of literary fiction.

Sir William Osler said that books are the tools of the mind. To master the science of medicine, doctors must read textbooks and journals that constitute “the literature” of medicine. Reading history, politics, and economics can make doctors better citizens and help them become leaders. Reading about sports and popular culture can help practitioners relate to patients. But can reading fiction improve evidence-based, data-driven medical practice? I think it can, and so did Osler, who cautioned that by the neglect of the humanities, which is far too general, the profession loses a very precious quality.

Music is a fundamental attribute of the human species. Virtually all cultures, from the most primitive to the most advanced, make music. It's been true through history, and it's true throughout an individual's lifespan. In tune or not, we humans sing and hum; in time or not, we clap and sway; in step or not, we dance and bounce. The human brain is hardwired to distinguish music from noise and to respond to rhythm and repetition, tones, and tunes. The auditory nerve transmits the electrical signals of music and other sounds to the auditory cortex in the temporal lobe. Studies using magnetic resonance imaging and positron emission tomography scans suggest that nerve networks in different parts of the brain bear primary responsibility for decoding and interpreting different properties of music.1Stewart L. von Kriegstein K. Warren J.D. et al.Music and the brain: disorders of music listening.Brain. 2006; 129: 2533-2553Crossref PubMed Scopus (239) Google Scholar For example, a small area in the right temporal lobe is essential to perceive pitch, which forms the basis of melody (patterns of pitch over time), chords (multiple pitches that sound at the same time), and harmony (2 or more melodies at the same time). Another nearby center is responsible for decoding timbre, the quality that allows the brain to distinguish between different instruments that are playing the same note. The cerebellum processes rhythm, and the frontal lobes interpret the emotional content of music. And music that's powerful enough to be "spine tingling" can light up the brain's reward center, much like pleasurable stimuli ranging from alcohol to chocolate. Although every healthy human brain can perform all the complex tasks needed to perceive music, musicians' brains are, so to speak, more finely attuned to these tasks.2Munte T.F. Kohlmetz C. Nagert W. et al.Superior auditory spatial tuning in conductors.Nature. 2001; 409: 580Crossref PubMed Scopus (102) Google Scholar Physicians, too, may have a particular affinity for music. Notable physician-musicians include Hector Berlioz, Fritz Kreisler, Aleksandr Borodin, Theodor Billroth, Albert Schweitzer,3Cerda J.J. Art in medicine: musicians, physicians and physician-musician.Trans Am Clin Climatol Assoc. 1993; 104: 228-234PubMed Google Scholar and Jeffrey Tate. Classical orchestras composed of doctors and medical students perform regularly in Boston, Los Angeles, Philadelphia, and Houston.4Ofri D. Thoughts on a G string.Lancet. 2009; 373: 116-117Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Many surgeons play music in their operating rooms to enhance concentration and focus, and many practitioners rely on music for relaxation, stimulation, and pleasure. Music is important for many physicians—but can doctors use music to promote the health and well-being of their patients? A variety of studies suggest the answer may be yes. Some are blinded, randomized trials, but most are relatively small and brief. Still, they present an interesting group of observations. The most highly publicized influence of music on the brain is the so-called Mozart effect. A 1995 report found that listening to Mozart improved performance on IQ tests.5Rauscher F.H. Shaw G.L. Ky K.N. Listening to Mozart enhances spatial-temporal reasoning: towards a neurophysiological basis.Neurosci Lett. 1995; 185: 44-47Crossref PubMed Scopus (314) Google Scholar Unfortunately, subsequent research found that the purported benefit was minimal and short-lived.6Steele K.M. Dalla Bella S. Peretz I. et al.Prelude or requiem for the "Mozart effect".Nature. 1999; 400: 826-827Crossref PubMed Scopus (142) Google Scholar Still, learning to play music in childhood enhances neuroplasticity, resulting in certain structural changes and functional improvements that persist into adulthood.7Hyde K.L. Lerch J. Norton A. Musical training shapes structural brain development.J Neurosci. 2009; 29: 3019-3025Crossref PubMed Scopus (585) Google Scholar, 8Skoe E. Kraus N. A little goes a long way: how the adult brain is shaped by musical training in childhood.J Neurosci. 2012; 32: 11507-11510Crossref PubMed Scopus (102) Google Scholar, 9Zuk J. Benjamin C. Kenyon A. et al.Behavioral and neural correlates of executive functioning in musicians and non-musicians.PLOS One. 2014; 9: e99868Google Scholar Playing music is more complex and demanding than simply listening, but listening may enhance cognitive function in the elderly10Hars M. Herrmann F.R. Gold G. et al.Effect of music-based multitask training on cognition and mood in older adults.Age Ageing. 2014; 43: 196-200Crossref PubMed Scopus (72) Google Scholar, 11Satoh M. Ogawa J. Tokita T. The effects of physical exercise with music on cognitive function of elderly people: Mihama-Kiho project.PLOS One. 2014; 9: e25230Google Scholar and improve quality of life and possibly cognition in dementia.12Vasionte I. Madison G. Musical intervention for patients with dementia: a meta-analysis.J Clin Nurs. 2013; 22: 1203-1216Crossref PubMed Scopus (93) Google Scholar Music listening can assist cognitive recovery, elevate mood,13Sarkamo T. Tervaniemi M. Laitinen S. et al.Music listening enhances cognitive recovery and mood after middle cerebral artery stroke.Brain. 2008; 131: 866-876Crossref PubMed Scopus (563) Google Scholar and boost muscular function14Colfrancesco E.M. The effect of music therapy on hand grasp strength and functional task performance in stroke patients.J Music Ther. 1985; 22: 129-145Crossref Scopus (17) Google Scholar after certain strokes. Singing has been used to help aphasic patients recover speech.15Schlaug G. Marchina S. Norton A. From singing to speaking: why singing may lead to recovery of expressive language function in patients with Broca's aphasia.Music Percept. 2008; 25: 315-323Crossref PubMed Scopus (163) Google Scholar Music-based training can improve gait and balance in elderly people at risk for falling16Trombetti A. Hars M. Herrmann F.R. et al.Effect of music-based multitask training on gait, balance, and fall risk in elderly people.Arch Intern Med. 2011; 171: 525-533Crossref PubMed Scopus (194) Google Scholar; brisk, rhythmic music enhances gait velocity, cadence, and stride length in patients with Parkinson's disease.17McIntosh G.C. Brown S.H. Rice R.R. et al.Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson's disease.J Neurol Neurosurg Psychiatry. 1997; 62: 22-26Crossref PubMed Scopus (508) Google Scholar Music allows people to express their feelings and communicate with others. More than simply expressing emotions, music can alter them; indeed, Tolstoy said that music is the shorthand of emotion, and Congreve explained that music has charms to soothe a savage breast. Few things are more stressful than illness and surgery. Music can reduce stress in these circumstances. Listening to music during cataract surgery reduces intraoperative and postoperative blood pressures and heart rates.18Allen K. Golden L.H. Izzo J.L. et al.Normalization of hypertensive responses during ambulatory surgical stress by perioperative music.Psychosom Med. 2001; 63: 487-492Crossref PubMed Scopus (91) Google Scholar Music also reduces sedative requirements in patients undergoing urologic procedures under spinal anesthesia19Ayoub C.M. Rizk L.B. Yaacoub C.I. et al.Music and ambient operating room noise in patients undergoing spinal anesthesia.Anesth Analg. 2000; 100: 1316-1319Crossref Scopus (79) Google Scholar and in intensive care unit patients.20Chalan L.L. Weinert C.R. Heiderscheit A. et al.Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support.JAMA. 2013; 309: 2335-2344Crossref PubMed Scopus (188) Google Scholar, 21Conrad C. Niess H. Jauch K.-W. et al.Overture for growth hormone: requiem for interleukin-6.Crit Care Med. 2007; 35: 2709-2713Crossref PubMed Scopus (119) Google Scholar Reduced levels of interleukin-6 and epinephrine may account for this benefit, as well as the lower blood pressures and heart rates associated with some types of music.21Conrad C. Niess H. Jauch K.-W. et al.Overture for growth hormone: requiem for interleukin-6.Crit Care Med. 2007; 35: 2709-2713Crossref PubMed Scopus (119) Google Scholar The body's response to music is influenced by the type of music used. Rapid, march-like rhythms improve the gait of patients with Parkinson's disease.17McIntosh G.C. Brown S.H. Rice R.R. et al.Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson's disease.J Neurol Neurosurg Psychiatry. 1997; 62: 22-26Crossref PubMed Scopus (508) Google Scholar Tempos that are slow, relaxing, or joyful appear to reduce blood pressure and heart rate and promote vasodilatation, whereas fast, tension-producing music has the opposite effect.21Conrad C. Niess H. Jauch K.-W. et al.Overture for growth hormone: requiem for interleukin-6.Crit Care Med. 2007; 35: 2709-2713Crossref PubMed Scopus (119) Google Scholar, 22Miller M. Mangano C.C. Beach V. et al.Divergent effects of joyful and anxiety-provoking music on endothelial vasoreactivity.Psychosom Med. 2010; 72: 354-356Crossref PubMed Scopus (29) Google Scholar, 23White J. Effects of relaxing music on cardiac autonomic balance and anxiety after acute myocardial infarction.Am J Crit Care. 1999; 8: 220-230PubMed Google Scholar, 24Bernardi L. Porta C. Sleight P. Cardiovascular, cerebrovascular, and respiratory changes induced by different types of music in musicians and non-musicians: the importance of silence.Heart. 2006; 92: 445-452Crossref PubMed Scopus (347) Google Scholar, 25Bernardi L. Porta C. Casucci G. et al.Dynamic interactions between musical, cardiovascular, and cerebral rhythms in humans.Circulation. 2009; 119: 3171-3180Crossref PubMed Scopus (190) Google Scholar These changes are short-lived, but daily sessions of music-guided slow breathing may produce a sustained reduction in blood pressure not seen with music alone.26Modesti P.A. Ferrari A. Bazzini C. et al.Psychological predictors of the antihypertensive effects of music-guided slow breathing.J Hypertension. 2010; 26: 1097-1103Crossref Scopus (33) Google Scholar Plato believed that music gives soul to the universe, wings to the imagination, and charm and gaiety to life. Gaiety may be beyond the reach of patients with depression, cancer, chronic pain, and terminal illnesses, but music therapy has been able to improve mood and quality of life in these circumstances.27Marantos A.S. Gold C. Wang X. et al.Music therapy for depression.Cochrane Database Syst Rev. 2008; 1: CD004517Google Scholar, 28Siedliecki S.L. Good M. Effects of music on power, pain, depression and disability.J Adv Nurs. 2006; 54: 553-562Crossref PubMed Scopus (127) Google Scholar, 29Bradt J. Dileo C. Groke D. et al.Music interventions for improving psychological and physical outcomes in cancer patients.Cochrane Database Syst Rev. 2011; 8: CD006911PubMed Google Scholar, 30Puetz T.W. Morley C.A. Herring M.P. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.JAMA Intern Med. 2013; 173: 960-969Google Scholar, 31Tsai H.F. Chen Y.R. Chung M.H. et al.Effectiveness of music intervention in ameliorating cancer patients' anxiety, depression, pain, and fatigue: a meta-analysis.Cancer Nurs. 2014; 37: E35-E50Google Scholar, 32Dileo C. Music therapy for end of life care.Cochrane Database Syst Rev. 2010; 1: CD007169Google Scholar Additional research is needed to confirm these apparent benefits and elucidate their mechanisms, but Browning may have provided a clue when he observed that a person who hears music feels his solitude peopled all at once. The ancient Greeks put one god, Apollo, in charge of both medicine and music. Contemporary scientists tell us that music can enhance the function of neural networks, slow the heart rate, lower blood pressure, reduce levels of stress hormones and inflammatory cytokines, and provide some relief to patients undergoing surgery and to those with Parkinson's disease, strokes, heart attacks, depression, and painful chronic illnesses. Arnold Steinhardt, the founding first violinist of the Guarneri String Quartet, said that there seems to be a mysterious and powerful underground railroad linking medicine and music. He wondered if perhaps music is an equally effective agent of healing, and doctors and musicians are part of a larger order serving the needs of mankind.

Life is short, said Hippocrates, the art long. Human lifespan has lengthened substantially in the 2400 years since the Father of Medicine wrote, but these gains have been dwarfed by the explosive discoveries that have revolutionized the art and science of medicine. Faced with the need to master so much scientific data, it's not surprising that medical educators and clinicians pay scant attention to verbal and written communication skills. But while writing will never displace molecular biology, it does deserve attention and respect. I believe writing is important for patient care, for professional communication, for educating the public, and for personal growth and satisfaction. The time-honored first step in patient care is the history and physical. Listening to the patient, itself an acquired skill, is the first step. It is necessary but not sufficient.1Alpert J.S. Some simple rules for effective communication in clinical teaching and practice environments.Am J Med. 2011; 124: 381-382Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The next step is to reflect on the patient's story, organize relevant information, and construct a coherent narrative. Writing a narrative history is an active process. A good narrative should be complete but compact, organizing important medical events and their personal impact into a coherent story. It should be dispassionate and nonjudgmental while still capturing something of the personality and characteristics that make your patient unique. A coherent narrative can bring your patients back to life when you return to their charts after months or years. It can communicate your findings to consultants and other providers. Above all, the act of writing will help you understand your patients and plan an approach to their clinical problems. You don't have to be a great novelist to agree with Flannery O'Connor, who said “I never know what I think until I read what I wrote.” Indeed, writing is learning. A well-written narrative has always been important for patient care, but it has gained urgency as patients seek access to their medical records.2Zulman D.M. Nazi K.M. Turvey C.L. et al.Patient interest in sharing personal health record information.Ann Intern Med. 2011; 155: 805-810Crossref PubMed Scopus (119) Google Scholar Sharing medical records can bolster patient-centered care3Barry M.J. Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care.N Engl J Med. 2012; 366: 780-781Crossref PubMed Scopus (2172) Google Scholar by building trust and transparency and by allowing patients to add personal perspectives and call attention to errors. But medical records also can spark confusion, fear, or anger.4Walker J. Levelle S.G. Ngo L. et al.Inviting patients to read their doctors' notes: patients and doctors look ahead.Ann Intern Med. 2011; 155: 811-819Crossref PubMed Scopus (162) Google Scholar Good writing can help minimize the risks and maximize the benefits of information sharing. Electronic medical records make information sharing easy and efficient, but they also introduce new barriers to good communication.5Hartzband P. Groopman J. Off the record—avoiding the pitfalls of going electronic.N Engl J Med. 2008; 358: 1656-1658Crossref PubMed Scopus (141) Google Scholar A new patient's record begins with a blank page; that can be daunting, but it forces the clinician to create an original narrative. After that, though, the ability to copy and paste presents an almost irresistible temptation to cut corners by importing another person's narrative. I understand the time pressures that lead so many doctors to copy and paste existing narratives. Still, I urge you to resist shortcuts that will prevent you from digesting and synthesizing your patient's story and also may enshrine errors that have crept into the record. The pitfalls of digital technology are not limited to copy-and-paste applications. Templates make it easy to comply with the mandates of third-party payers, but they introduce observations that may not be credible. When I read that a cardiac consultant finds our mutual patient's pupils equal, round, and reactive to light and accommodation, I suspect a waste of time and brainpower or a minor mendacity; neither builds confidence. Because we can import reams of laboratory data with a few clicks of a mouse, many electronic records become burdened with reports that are irrelevant or distracting. And while we're thinking about laboratory results and radiology reports, our colleagues in clinical pathology and radiology could enhance patient care by presenting their findings in patient-friendly formats. Consult notes, whether digital or hand-written, present particular challenges to effective clinical communication.1Alpert J.S. Some simple rules for effective communication in clinical teaching and practice environments.Am J Med. 2011; 124: 381-382Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Doctors request consultations to get varying degrees of practical help, specialty education, and reassurance. A good consultant will provide all 3 in proportion to the needs and desires of the requesting physician. In every case, though, a consultant should strive for clarity and brevity instead of dazzling erudition. One of the most important things I learned as an infectious disease fellow came from an attending who told me, “Keep it simple, Simon.” And another infectious disease attending set a benchmark that would be impossible to duplicate in today's highly regulated environment. A crusty senior internist asked us for a nonacademic consultation to answer 3 questions: What does my patient have? What tests should I order? And what antibiotics should I give? In reply, my colleague wrote simply “1. Virus. 2. None. 3. None.” Those were the days … Good writing can promote good patient care, but it's an acquired skill. Table 1 offers some tips that may help.Table 1Tips for Clinical CommunicationWrite with pride. Write as if your patients will read their charts; sooner or later, they will.Be concise and clear, complete but not exhaustive.Use everyday language. Avoid acronyms, abbreviations, jargon, and unnecessary technical terms.Avoid stilted, formulaic words and phrases. Your patients are men and women, not males and females. Your patient is not a good or poor historian; you are the historian, for better or worse.Get personal. Your patient has a name; use it: “Mrs. Jones tells me,” not “the patient claims.”When appropriate, incorporate direct quotes from your patient.Be descriptive but discreet. Note that Mr. Smith is forceful, not aggressive; forgetful, not demented. If a patient displays seductive behavior, you can capture it simply by noting that a chaperone was present throughout your examination.Make electronic records useful. Do not copy and paste to create a narrative. Use templates honestly and sparingly. Defeat digital diarrhea by editing reports and deleting obsolete or irrelevant data.Proofread and edit. It's particularly important for dictations that use voice recognition software; errors are sometimes amusing but are always distracting and sometimes dangerous.Focus on the essentials, especially for consult notes and letters.Use relevant communication tips from Table 2. Open table in a new tab Good writing can promote good care by helping physicians understand their patients, organize clinical information, and communicate effectively with other providers. I believe that writing also can help patients by allowing them to express feelings, which may enhance well-being. This belief is based on personal experience with psychological distress and a randomized clinical trial focusing on physical symptoms.6Smyth J.M. Stone A.A. Hurewitz A. Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis.JAMA. 1999; 281: 1304-1309Crossref PubMed Scopus (623) Google Scholar I first witnessed the healing potential of writing after my father died. My stepmother was shattered, but she was a brilliant and articulate woman. Within a matter of weeks, Mom began to deal with loneliness and loss by writing letters to Dad. She knew full well that her letters would never be read, much less answered, but the act of expressing feelings in writing helped enormously. Over the past 25 years, I've recommended a similar strategy to many bereaved patients. I've never tallied the results, but a substantial number of people who accept the idea appear to benefit. And my anecdotal experience suggests that writing letters or keeping journals can help people across a wide educational and socioeconomic spectrum. A 1999 trial conducted a systematic evaluation of emotionally expressive writing.6Smyth J.M. Stone A.A. Hurewitz A. Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis.JAMA. 1999; 281: 1304-1309Crossref PubMed Scopus (623) Google Scholar The study evaluated community-dwelling patients with well-documented asthma (n=61) or rheumatoid arthritis (n=51). After undergoing medical and psychological evaluations, volunteers were randomly assigned to spend 20 minutes on 3 consecutive days writing, either about the most stressful experience of their lives (the experimental group; n=71) or about emotionally neutral topics (the control group; n=41). Disease activity was evaluated before the intervention and at 2, 8, and 16 weeks afterwards. At each interval, the participants rated their own health status; patients with asthma underwent spirometry, and patients with rheumatoid arthritis were evaluated by rheumatologists who did not know whether the patient was in the experimental or control group. As compared with patients who wrote about mundane topics, those who wrote about stress demonstrated statistically significant improvements in asthma at 2, 4, and 16 weeks. In contrast, emotionally expressive writing appeared to reduce rheumatoid arthritis activity only at 16 weeks. In all, 47.1% of experimental patients versus 24.2% of control patients met criteria for clinically relevant improvement (P=.001). It's a relatively small and brief study, and it's naïve to hope that expressive writing could ever replace beta-agonists or disease-modifying antirheumatic drugs. More study is needed, but writing may have benefits similar to other forms of emotional expression for patients, and with medical as well as psychological problems. Department chairs and medical school deans may roll their eyes in denial, but the academic imperative does contain a germ of truth. Whether you are writing a grant or preparing a manuscript, good writing is important for success. And communication skills also are crucial for oral presentations. Each of us should develop a personal style and voice, but all of us can benefit from simple guidelines that apply in settings as diverse as international meetings, patient care conferences, talks to community groups, and writing for publication in elite scientific journals or mass circulation magazines. Table 2 offers some tips that may help.Table 2Tips for Professional CommunicationWhen you have a choice, pick a topic that interests you. Even if the subject is assigned, find an aspect that excites you. Enthusiasm is infectious. So is boredom.Know your audience. Physician-scientists speak to each other, but they also communicate with students, patients, community groups, and even children. Tailor your tone, language, and level of detail to your readers or listeners.Respect your audience. Never talk down to people, however unsophisticated or young. If you try to show how smart you are, you're likely to seem stuffy at best, arrogant at worst.Tell a story. Every communication should have a beginning, middle, and end. Use the beginning to explain why the topic is important and interesting, both to you and your audience. Outline your plan before you get started; if your material is complex or lengthy, remind your audience of where you're taking them as you go along. Conclude with a brief summary of key points, then note areas that deserve more study.Use direct, clear language and a conversational tone. Avoid jargon, inflated language, and 10-dollar words; a cleverly-titled paper documents the pitfalls of inflated language.7Oppenheimer D.M. Consequences of erudite vernacular utilized irrespective of necessity Problems with using long words needlessly.Behav Sci. 1985; 77: 199-214Google ScholarUse the active voice: “we obtained samples from all the patients,” not “samples were obtained from all the patients.”Vary your sentence structure. Beginning writers always put the subject first. Variety, however, is the hallmark of engaging writers.Avoid redundancy. It is useful, even important, to emphasize key points by restating them at appropriate places, but it's never wise to repeat minor or obvious information. So avoid repetition and redundancy. Do not repeat yourself, either.Minimize echoes. Refer to people who advance medical knowledge as scientists, investigators, workers, or researchers instead of repeating a single identifier. Clinicians, too, can be called physicians, doctors, or clinicians.Think of how your manuscript will look. Use subheads, short paragraphs, bulleted lists, graphs, and illustrations when appropriate. Be as concise as possible.Use visual aids for oral presentations—but make them clear and legible.Use humor when it suits your voice and style, but only if it's appropriate and tasteful. The gonococcus may be worth a chuckle, but the meningococcus may not.Proofread and use software to check spelling and grammar. It's true that errors may still crop up, but sloppiness is a dagger in the heart of credibility.Acknowledge others. You do not have to thank your mom every time you boot up, nor should you hide your own achievements under a rock. Still, we've all learned from mentors and have benefited from collaborators. Whenever appropriate, use a humble “we” instead of a self-aggrandizing “I.”Practice your oral presentation, seek editing for your writing, and ask for feedback whenever possible. No matter how good you are, you can be better next time. Open table in a new tab When I finished my fellowships, I knew that clinical medicine would be challenging, but I thought my major tasks would be diagnosis and therapy. After just a few weeks in practice, though, I recognized a third challenge: informing and motivating my patients. It's always been a crucial element of good care, but it's more important than ever in the era of shared decision-making.8Stiggelbout A.M. Van der Weijden T. De Wit M.P.T. et al.Shared decision making: really putting patients at the centre of healthcare.BMJ. 2012; 344: e256Crossref PubMed Scopus (650) Google Scholar Whether you call it compliance, adherence, or cooperation, good clinical outcomes depend on active participation by patients, often in concert with family members. Multiple interventions are needed to enhance adherence,9Steiner JF. Rethinking adherence. Ann Intern Med. 2102:157:580-585.Google Scholar but many patients will benefit from clear, specific written information. Low health literacy presents a barrier to understanding medical instructions and drug information, which is one reason low literacy is associated with increased mortality.10Bostock S. Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study.BMJ. 2012; 344: e1602Crossref PubMed Scopus (390) Google Scholar Individual practitioners cannot correct the educational and socioeconomic problems that limit literacy, but we can and should tailor our communications to our patients' abilities.11Raynor D.K. Health literacy.BMJ. 2012; 344: e2188Crossref PubMed Scopus (11) Google Scholar Now that doctors have been transformed from gods to guides, a growing number of physicians strive to provide medical guidance to the public at large. When I first embarked on consumer health writing in the 1970s, there was a dearth of physician-authored material and it was relatively easy to reach readers. In the digital age, it's easier to get a platform but much harder to cut through the blizzard of medical chatter to connect with the community. But because so many web-based sources are incomplete, frightening, or misleading, responsible consumer health information is more important than ever. Because they are trained to read and understand scientific literature, physicians should be in an ideal position to interpret data for the public. Media reports written by journalists often rely on press releases issued by health care organizations and medical journals; incomplete press releases contribute to inaccurate articles in the lay press.12Schwartz L.M. Woloshin S. Andrews A. Stukel T.A. Influence of medical journal press releases on the quality of associated newspaper coverage: retrospective cohort study.BMJ. 2012; 344: d8164Crossref PubMed Scopus (109) Google Scholar In turn, “spin” in press releases can often be traced back to “spin” in the conclusions presented in the abstract section of medical journal articles.13Yavchitz A. Boutron I. Bafeta A. et al.Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study.PLoS Med. 2012; 9: e1001308Crossref PubMed Scopus (189) Google Scholar Physicians who write for scholarly publications should be sure their abstracts and articles contain balanced, responsible conclusions. And doctors who write for the public should read and digest the medical literature as carefully as they would in writing for peer-reviewed journals or scholarly texts. Table 3 lists some common pitfalls to avoid.Table 3Writing for the Public: Common PitfallsNot identifying the duration of a study and the composition and size of the study population.Inferring causality from observational studies.Reporting relative risks but not absolute risks.Reporting statistical significance without clinical significance (or insignificance).Omitting side effects and other negative aspects.Omitting context, including previous research.Omitting conflicts of interest and other potential biases (including your own). Open table in a new tab In writing for the public, as in writing for peers, accuracy is necessary but not sufficient. The tips in Table 2 apply to writing for all audiences, but successful consumer health writing requires additional techniques. The first task is to capture the attention of your readers. An article that's engaging but not instructive is still engaging; an article that's instructive but not engaging is algebra. Table 4 offers some tips for consumer health writing.Table 4Tips for Consumer Health WritingTell a story. Begin with a lead that will capture attention and explain why your topic is important and relevant. Try not to rely on “XXX is the leading cause of YYY.” Construct a clear narrative arc for the middle of your story. End with a clincher; try not to rely on “In conclusion …”Find your voice. Be authentic, conversational, and direct.Identify your readers. Tailor your tone and medical sophistication to your target audience.Respect your readers. Don't talk down to them or inflate your own importance.Use shorthand with care. Does exercise actually prevent heart disease or does it simply reduce the risk of cardiac events?Don't sensationalize or oversimplify. Don't hype your article by proclaiming “New hope” or “No hope.”Use personal anecdotes but objective data.Eliminate weasel words (such as “essentially”) and use adverbs very sparingly (such as “very”).Favor short paragraphs and bulleted lists but don't fear compound sentences; semicolons are your friends.Don't be snarky; chiropractors are people (and readers) too.Sprinkle in quotes when appropriate. Shakespeare and Yogi Berra are among many notable quotables.Remember that words have power. “Dr. Alpert claims” and “Dr. Alpert says” both refer to a doctor's statement but have different connotations.Allow yourself to break any of these “rules” as long as it's intentional. Fragments, clichés, and other infractions can serve a purpose. Open table in a new tab Every practitioner writes in the course of providing clinical care, many physicians write for scholarly publications, and some doctors engage in consumer health writing. A smaller number of physicians have made writing a major part of their careers; Table 5 lists some notable examples.Table 5Select Physician-WritersClinical and scientific writing Lewis Thomas, Sir William Osler, HippocratesWriting about medicine for the public Jerome Groopman, Atul Gawande, Siddhartha Mukherjee, Oliver Sacks, Sherwin NulandLiterary fiction and drama Abraham Verghese, Ethan Canin, Daniel Mason, Walker Percy, Somerset Maugham, Anton ChekovPopular fiction Michael Crichton, Michael Palmer, Robin Cook, Sir Arthur Conan DoylePoetry William Carlos Williams, John Keats Open table in a new tab It's an inspiring list, but an intimidating one. Few writers can achieve this level of success, and physicians generally face even greater challenges than people who choose writing as their primary careers. Before you embark on a major writing project, understand that literary fame and fortune are long shots at best. Remember, too, that serious writing can add stress to a busy professional life. Winston Churchill, one of the most brilliant and successful writers of the 20th century, said that writing a book begins as an adventure and amusement that soon becomes a mistress, then a master, and finally a monster. Still, if you have something to say and the need to say it, writing can add an important dimension to your life. Writing is teaching, and teaching is learning. I am grateful to Dr Robert Leibowitz for reviewing this manuscript and offering helpful suggestions.

As usual, the Bard got it right—at least when it comes to flowers. But when it comes to medicine, things are more complex. Medical language has evolved over some 2 1/2 millennia. Many terms originated with the ancient Greeks and Romans, but various cultures have enriched medical nomenclature over the years. Add the diagnoses that honor distinguished physicians of yore and the explosion of scientific knowledge during recent decades, and it is easy to see how we have arrived at our current hodgepodge of obscure and confusing terms.

Over the past decade, it has become clear that atherosclerosis is an inflammatory disease. T-lymphocytes and macrophages present in atheromatous plaques secrete cytokines and other proinflammatory mediators [1]. Patients with atherosclerosis involving coronary, carotid, or peripheral arteries often have elevated serum levels of these mediators. They may also have high levels of C-reactive protein, fibrinogen, and other acute-phase reactants produced by the liver in response to circulating cytokines [2, 3].What fuels the flames of inflammation? Oxidized LDL cholesterol appears to be the culprit, but although necessary, it may not be sufficient to produce vascular damage. In some patients, infectious agents such as Chlamydia pneumoniae may also provoke or perpetuate inflammation. In addition, acute phase reactants themselves, especially C-reactive protein, may play a role [4, 5].These insights, gleaned from many laboratories, are already finding practical clinical applications. The statin drugs appear to have anti-inflammatory activity independent of their ability to reduce LDL levels [6]. The anti-inflammatory action of aspirin may add to its therapeutically crucial anti-platelet properties [7]. Trials of non-steroidal anti-inflammatory drugs and macrolides are in progress, but it is premature to recommend these agents in advance of new data. Even now, however, C-reactive protein levels can help determine the risk for cardiac [8]and cerebrovascular [9]events, both for patients with known coronary artery disease [10]and for apparently healthy individuals [11]. Elevated C-reactive protein levels may also identify patients with borderline cholesterol profiles who are likely to benefit from statin therapy [12]. In addition, the surprising failure of post-menopausal hormone replacement therapy to reduce cardiac and cerebrovascular events may be explained by the recent observation that estrogen increases C-reactive protein levels [13].The term atherosclerosis is derived from two Greek roots: athéré means gruel or porridge and sclerosis signifies hardening. It is an improvement over the older designation arteriosclerosis, which recognizes the calcific hardening of advanced disease but overlooks the fatty debris of active plaques. But in light of the new understanding that inflammation is an intrinsic part of the process, I propose a further change of nomenclature, calling the disease atheroscleritis.

Presentation of CaseA 32-year-old man was admitted to the hospital because of meningitis.He was well until five years previously, when fatigue, weight loss, sweats and fever developed. A lymph-node biopsy disclosed Hodgkin's disease, nodular-sclerosis type. An x-ray film of the chest demonstrated hilar and paratracheal lymphadenopathy; a lymphangiographic examination was negative. A staging laparotomy revealed involved celiac-axis lymph nodes and gross evidence of disease in the spleen, which was removed; a liver biopsy was negative. A diagnosis of Hodgkin's disease, Stage IIIB, was made. A course of MOPP (nitrogen mustard, Oncovin [vinblastine], procarbazine and prednisone) was given, without . . .

Presentation or CaseA 58-year-old man was admitted to the hospital because of weakness.He had enjoyed excellent health until 11 months previously, when fatigue, anorexia and abdominal bloating developed, with loss of 12 kg in weight during the ensuing three months. Four months before entry iron was prescribed because of anemia. The patient did not improve and was referred to this hospital. Examination disclosed marked splenomegaly, without lymphadenopathy. The hematocrit was 26.9 per cent, and the white-cell count 3800. The bilirubin was 0.9 mg, and the protein 4.5 g (the albumin 2.8 g, and the globulin 1.7 g) per . . .

From the Laboratory of Clinical Investigation. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20014.

Pneumocystis carinii is recognized widely as a cause of rapidly lethal diffuse bilateral pneumonitis in immunologically compromised adults and debilitated infants. We describe the clinical course and pathologic features of a 20 year old man with classic allergic bronchopulmonary aspergillosis and chronic localized pulmonary pneumocystosis in the absence of demonstrable immunologic deficiency. Marked roentgenologic and clinical improvement occurred following pentamidine therapy. This unusual presentation reinforces earlier observations that Pneumocystis carinii is a true opportunist, with low virulence for the intact host.

The ability of antigenically stimulated immune lymphocytes to influence the bactericidal capacity of normal macrophages was studied in vitro. Purified lymphocytes were obtained from the lymph nodes and peritoneal exudates of guinea pigs immunized with bovine gamma globulin (BGG) and from control animals. Immune and control lymphocytes were added to normal macrophages and incubated overnight in the presence or absence of BGG. After washing, the macrophage monolayers were infected with Listeria monocytogenes; 4 hr later, the cells were lysed and the surviving intracellular bacteria quantitated. The macrophages which had been incubated with BGG-immune lymphocytes in the presence of BGG displayed a markedly enhanced listericidal capacity. In parallel experiments, these same antigen-stimulated lymphocytes were shown to inhibit the migration of normal macrophages. Lymphocytes derived from peritoneal exudates were more active than lymph node lymphocytes in both assays.