The New England Journal of Medicine

Staszewski, Schlomo; Morales-Ramirez, Javier; Tashima, Karen T.; Rachlis, Anita; Skiest, Daniel; Stanford, James; Stryker, Richard; Johnson, Philip; Labriola, Dominic F.; Farina, Dianne; Manion, Douglas J.; Ruiz, Nancy M.

doi: 10.1056/NEJM199912163412501pmid: 10601505

BackgroundEfavirenz is a nonnucleoside reverse-transcriptase inhibitor of human immunodeficiency virus type 1 (HIV-1). We compared two regimens containing efavirenz, one with a protease inhibitor and the other with two nucleoside reverse-transcriptase inhibitors, with a standard three-drug regimen.MethodsThe study subjects were 450 patients who had not previously been treated with lamivudine or any nonnucleoside reverse-transcriptase inhibitor or protease inhibitor. In this open-label study, patients were randomly assigned to one of three regimens: efavirenz (600 mg daily) plus zidovudine (300 mg twice daily) and lamivudine (150 mg twice daily); the protease inhibitor indinavir (800 mg every eight hours) plus zidovudine and lamivudine; or efavirenz plus indinavir (1000 mg every eight hours).ResultsSuppression of plasma HIV-1 RNA to undetectable levels was achieved in more patients in the group given efavirenz plus nucleoside reverse-transcriptase inhibitors than in the group given indinavir plus nucleoside reverse-transcriptase inhibitors (70 percent vs. 48 percent, P<0.001). The efficacy of the regimen of efavirenz plus indinavir was similar (53 percent) to that of the regimen of indinavir, zidovudine, and lamivudine. CD4 cell counts increased significantly with all combinations (range of increases, 180 to 201 cells per cubic millimeter). More patients discontinued treatment because of adverse events in the group given indinavir and two nucleoside reverse-transcriptase inhibitors than in the group given efavirenz and two nucleoside reverse-transcriptase inhibitors (43 percent vs. 27 percent, P=0.005).ConclusionsAs antiretroviral therapy in HIV-1–infected adults, the combination of efavirenz, zidovudine, and lamivudine has greater antiviral activity and is better tolerated than the combination of indinavir, zidovudine, and lamivudine.

Starr, Stuart E.; Fletcher, Courtney V.; Spector, Stephen A.; Yong, Florence H.; Fenton, Terence; Brundage, Richard C.; Manion, Douglas; Ruiz, Nancy M.; Gersten, Merril; Becker, Mark; McNamara, James; Purdue, Lynette; Siminski, Suzanne; Graham, Bobbie;

Buxton, Alfred E.; Lee, Kerry L.; Fisher, John D.; Josephson, Mark E.; Prystowsky, Eric N.; Hafley, Gail

doi: 10.1056/NEJM199912163412503pmid: 10601507

BackgroundEmpirical antiarrhythmic therapy has not reduced mortality among patients with coronary artery disease and asymptomatic ventricular arrhythmias. Previous studies have suggested that antiarrhythmic therapy guided by electrophysiologic testing might reduce the risk of sudden death.MethodsWe conducted a randomized, controlled trial to test the hypothesis that electrophysiologically guided antiarrhythmic therapy would reduce the risk of sudden death among patients with coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias were induced by programmed stimulation were randomly assigned to receive either antiarrhythmic therapy, including drugs and implantable defibrillators, as indicated by the results of electrophysiologic testing, or no antiarrhythmic therapy. Angiotensin-converting–enzyme inhibitors and beta-adrenergic–blocking agents were administered if the patients could tolerate them.ResultsA total of 704 patients with inducible, sustained ventricular tachyarrhythmias were randomly assigned to treatment groups. Five-year Kaplan–Meier estimates of the incidence of the primary end point of cardiac arrest or death from arrhythmia were 25 percent among those receiving electrophysiologically guided therapy and 32 percent among the patients assigned to no antiarrhythmic therapy (relative risk, 0.73; 95 percent confidence interval, 0.53 to 0.99), representing a reduction in risk of 27 percent. The five-year estimates of overall mortality were 42 percent and 48 percent, respectively (relative risk, 0.80; 95 percent confidence interval, 0.64 to 1.01). The risk of cardiac arrest or death from arrhythmia among the patients who received treatment with defibrillators was significantly lower than that among the patients discharged without receiving defibrillator treatment (relative risk, 0.24; 95 percent confidence interval, 0.13 to 0.45; P<0.001). Neither the rate of cardiac arrest or death from arrhythmia nor the overall mortality rate was lower among the patients assigned to electrophysiologically guided therapy and treated with antiarrhythmic drugs than among the patients assigned to no antiarrhythmic therapy.ConclusionsElectrophysiologically guided antiarrhythmic therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease.

Carpenter, Christopher F.; Subramanian, Aruna K.

doi: 10.1056/NEJM199912163412504pmid: 10601508

Figure 1. A 60-year-old man with diabetes mellitus and advanced cirrhosis underwent orthotopic liver transplantation that was complicated by an intraoperative myocardial infarction. His immunosuppressive regimen included tacrolimus and methylprednisolone, and his postoperative course was complicated by poor graft function with intrahepatic cholestasis, hyperglycemia, and progressive renal failure, as well as vancomycin-resistant Enterococcus faecium bacteremia and Candida parapsilosis fungemia. Laboratory studies revealed persistent leukocytosis with a leftward shift and low serum iron levels. At the end of the first postoperative week, a skin lesion developed above the patient's right eye; the lesion was initially erythematous and subsequently enlarged and became . . .

Kyriacou, Demetrios N.; Anglin, Deirdre; Taliaferro, Ellen; Stone, Susan; Tubb, Toni; Linden, Judith A.; Muelleman, Robert; Barton, Erik; Kraus, Jess F.

doi: 10.1056/NEJM199912163412505pmid: 10601509

BackgroundDomestic violence is the most common cause of nonfatal injury to women in the United States. To identify risk factors for such injuries, we examined the socioeconomic and behavioral characteristics of women who were victims of domestic violence and the men who injured them.MethodsWe conducted a case–control study at eight large, university-affiliated emergency departments. The 256 intentionally injured women had acute injuries resulting from a physical assault by a male partner. The 659 controls were women treated for other conditions in the emergency department. Information was collected with a standardized questionnaire; no information was obtained directly from the male partners.ResultsThe 256 intentionally injured women had a total of 434 contusions and abrasions, 89 lacerations, and 41 fractures and dislocations. In a multivariate analysis, the characteristics of the partners that were most closely associated with an increased risk of inflicting injury as a result of domestic violence were alcohol abuse (adjusted relative risk, 3.6; 95 percent confidence interval, 2.2 to 5.9); drug use (adjusted relative risk, 3.5; 95 percent confidence interval, 2.0 to 6.4); intermittent employment (adjusted relative risk, 3.1; 95 percent confidence interval, 1.1 to 8.8); recent unemployment (adjusted relative risk, 2.7; 95 percent confidence interval, 1.2 to 6.5); having less than a high-school education (adjusted relative risk, 2.5; 95 percent confidence interval, 1.4 to 4.4); and being a former husband, estranged husband, or former boyfriend (adjusted relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.3).ConclusionsWomen at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school education, and are former husbands, estranged husbands, or former boyfriends of the women.

Grisso, Jeane Ann; Schwarz, Donald F.; Hirschinger, Nancy; Sammel, Mary; Brensinger, Colleen; Santanna, Jill; Lowe, Robert A.; Anderson, Elijah; Shaw, Leslie M.; Bethel, Courtney A.; Teeple, Leslie

doi: 10.1056/NEJM199912163412506

Joshi, Nirmal; Caputo, Gregory M.; Weitekamp, Michael R.; Karchmer, A.W.

doi: 10.1056/NEJM199912163412507pmid: 10601511

Contrary to common belief, the association between diabetes mellitus and increased susceptibility to infection in general is not supported by strong evidence.1,2 However, many specific infections are more common in diabetic patients, and some occur almost exclusively in them. Other infections occur with increased severity and are associated with an increased risk of complications in patients with diabetes. Several aspects of immunity are altered in patients with diabetes. Polymorphonuclear leukocyte function is depressed, particularly when acidosis is also present. Leukocyte adherence, chemotaxis, and phagocytosis may be affected.3–5 Antioxidant systems involved in bactericidal activity may also be impaired.6 The . . .

Slaiby, Jeffrey M.; Fan, Chieh-Min; Aretz, H. Thomas

doi: 10.1056/NEJM199912163412508pmid: 10601512

Presentation of Case A 62-year-old woman was admitted to the hospital because of a foot infection. The patient's medical history included hypertension, hyperlipoproteinemia, and mild chronic renal failure, with a base-line creatinine level of 2 mg per deciliter (177 μmol per liter). Twelve years before admission, Takayasu's arteritis, severe aortic atherosclerosis, and peripheral vascular disease (central aortic systolic pressure, 130 mm Hg; systolic pressure in each arm, 80 mm Hg) were diagnosed, and prednisone was administered for two years. At approximately the same time, pulmonary hypertension was documented by a catheter study. During the year before the current admission, bilateral . . .

Angell, Marcia

doi: 10.1056/NEJM199912163412509pmid: 10601513

Five years ago, the citizens of Oregon voted by a narrow margin to legalize physician-assisted suicide for certain terminally ill patients. There followed a variety of efforts to nullify the decision, which culminated in a second referendum in 1997. This time Oregonians voted overwhelmingly to affirm their original decision, and Oregon is now the only state in which physician-assisted suicide is practiced legally.1 Surveys indicate that most Americans and their doctors believe it should be available in all states.2–4 Shortly before the second Oregon vote, the U.S. Supreme Court considered the issue of physician-assisted suicide. The cases before it . . .

Clumeck, Nathan

doi: 10.1056/NEJM199912163412510pmid: 10601514

Fifteen drugs are currently available for the treatment of patients with human immunodeficiency virus type 1 (HIV-1) infection, all of which target the virally encoded transcriptase or protease enzymes. Under development is a second generation of antiretroviral drugs that are more potent or that act at different sites of the viral replicative cycle. Theoretically, many combinations of drugs are possible. However, because of interactions between drugs, additive toxicity, and cross-resistance, the actual number of therapeutic options is limited in previously treated patients; this fact underscores the importance of initiating therapy for HIV-1 infection with the best possible regimen. After years . . .