Wilck, Marissa B.; Hamel, Mary Beth; Baden, Lindsey R.
doi: 10.1056/NEJMclde0902765pmid: 19494211
This interactive feature presented the case of a 25-year-old woman with incidentally identified HCV infection.
Gotoh, Shimpei; Chohnabayashi, Naohiko
doi: 10.1056/NEJMicm0707466pmid: 19494210
An 86-year-old man had repeated episodes of septic shock due to MRSA pneumonia. In 1948, he had undergone extrapleural pneumonolysis (plombage) with polymethyl methacrylate (Lucite) balls to treat pulmonary tuberculosis.
doi: 10.1056/NEJMp0903872pmid: 19439732
The Obama administration and its Democratic allies have made important strides in their aggressive pursuit of health care reform legislation. John Iglehart reports.
doi: 10.1056/NEJMp0809125pmid: 19494212
Dr. Arnold Milstein discusses a law that constrains hospitals' ability to bill Medicare for a higher-paid diagnosis-related group when complications occur. The complications chosen include some “never events” — serious complications that should never occur in a safe hospital.
Inouye, Sharon K.; Brown, Cynthia J.; Tinetti, Mary E.
doi: 10.1056/NEJMp0900963pmid: 19494213
Medicare will no longer reimburse hospitals for a higher-paying diagnosis-related group when one of eight selected hospital-acquired conditions develops during the hospital stay. Drs. Sharon Inouye, Cynthia Brown, and Mary Tinetti write that the inclusion of hospital falls and trauma may cause greater harm than the falls that the initiative is meant to prevent.
Donald, Peter R.; van Helden, Paul D.
doi: 10.1056/NEJMp0903806pmid: 19494214
Disturbingly, there were an estimated 500,000 cases of multidrug-resistant (MDR) tuberculosis in 2007, and 55 countries had reported cases of extensively drug-resistant (XDR) tuberculosis by the end of 2008. Dr. Peter Donald and Paul van Helden write that these figures highlight a potential threat to our ability to treat tuberculosis.
Diacon, Andreas H.; Pym, Alexander; Grobusch, Martin; Patientia, Ramonde; Rustomjee, Roxana; Page-Shipp, Liesl; Pistorius, Christoffel; Krause, Rene; Bogoshi, Mampedi; Churchyard, Gavin; Venter, Amour; Allen, Jenny; Palomino, Juan Carlos; De Marez, Tine; van Heeswijk, Rolf P.G.;
Liu, Yecai; Weinberg, Michelle S.; Ortega, Luis S.; Painter, John A.; Maloney, Susan A.
doi: 10.1056/NEJMoa0809497pmid: 19494216
BackgroundIn 2007, a total of 57.8% of the 13,293 new cases of tuberculosis in the United States were diagnosed in foreign-born persons, and the tuberculosis rate among foreign-born persons was 9.8 times as high as that among U.S.-born persons (20.6 vs. 2.1 cases per 100,000 population). Annual arrivals of approximately 400,000 immigrants and 50,000 to 70,000 refugees from overseas are likely to contribute substantially to the tuberculosis burden among foreign-born persons in the United States.MethodsThe Centers for Disease Control and Prevention (CDC) collects information on overseas screening for tuberculosis among U.S.-bound immigrants and refugees, along with follow-up evaluation after their arrival in the United States. We analyzed screening and follow-up data from the CDC to study the epidemiology of tuberculosis in these populations.ResultsFrom 1999 through 2005, a total of 26,075 smear-negative cases of tuberculosis (i.e., cases in which a chest radiograph was suggestive of active tuberculosis but sputum smears were negative for acid-fast bacilli on 3 consecutive days) and 22,716 cases of inactive tuberculosis (i.e., cases in which a chest radiograph was suggestive of tuberculosis that was no longer clinically active) were diagnosed by overseas medical screening of 2,714,223 U.S.-bound immigrants, representing prevalences of 961 cases per 100,000 persons (95% confidence interval [CI], 949 to 973) and 837 cases per 100,000 persons (95% CI, 826 to 848), respectively. Among 378,506 U.S.-bound refugees, smear-negative tuberculosis was diagnosed in 3923 and inactive tuberculosis in 10,743, representing prevalences of 1036 cases per 100,000 persons (95% CI, 1004 to 1068) and 2838 cases per 100,000 persons (95% CI, 2785 to 2891), respectively. Active pulmonary tuberculosis was diagnosed in the United States in 7.0% of immigrants and refugees with an overseas diagnosis of smear-negative tuberculosis and in 1.6% of those with an overseas diagnosis of inactive tuberculosis.ConclusionsOverseas screening for tuberculosis with follow-up evaluation after arrival in the United States is a high-yield intervention for identifying tuberculosis in U.S.-bound immigrants and refugees and could reduce the number of tuberculosis cases among foreign-born persons in the United States.
Showing 1 to 10 of 28 Articles
doi: 10.1056/NEJMoa0808427pmid: 19494215
BackgroundThe diarylquinoline TMC207 offers a new mechanism of antituberculosis action by inhibiting mycobacterial ATP synthase. TMC207 potently inhibits drug-sensitive and drug-resistant Mycobacterium tuberculosis in vitro and shows bactericidal activity in patients who have drug-susceptible pulmonary tuberculosis.MethodsIn the first stage of a two-stage, phase 2, randomized, controlled trial, we randomly assigned 47 patients who had newly diagnosed multidrug-resistant pulmonary tuberculosis to receive either TMC207 (400 mg daily for 2 weeks, followed by 200 mg three times a week for 6 weeks) (23 patients) or placebo (24 patients) in combination with a standard five-drug, second-line antituberculosis regimen. The primary efficacy end point was the conversion of sputum cultures, in liquid broth, from positive to negative.ResultsThe addition of TMC207 to standard therapy for multidrug-resistant tuberculosis reduced the time to conversion to a negative sputum culture, as compared with placebo (hazard ratio, 11.8; 95% confidence interval, 2.3 to 61.3; P=0.003 by Cox regression analysis) and increased the proportion of patients with conversion of sputum culture (48% vs. 9%). The mean log10 count of colony-forming units in the sputum declined more rapidly in the TMC207 group than in the placebo group. No significant differences in average plasma TMC207 concentrations were noted between patients with and those without culture conversion. Most adverse events were mild to moderate, and only nausea occurred significantly more frequently among patients in the TMC207 group than among patients in the placebo group (26% vs. 4%, P=0.04).ConclusionsThe clinical activity of TMC207 validates ATP synthase as a viable target for the treatment of tuberculosis. (ClinicalTrials.gov number, NCT00449644.)
BackgroundThe cryopyrin-associated periodic syndrome (CAPS) is a rare inherited inflammatory disease associated with overproduction of interleukin-1. Canakinumab is a human anti–interleukin-1β monoclonal antibody.MethodsWe performed a three-part, 48-week, double-blind, placebo-controlled, randomized withdrawal study of canakinumab in patients with CAPS. In part 1, 35 patients received 150 mg of canakinumab subcutaneously. Those with a complete response to treatment entered part 2 and were randomly assigned to receive either 150 mg of canakinumab or placebo every 8 weeks for up to 24 weeks. After the completion of part 2 or at the time of relapse, whichever occurred first, patients proceeded to part 3 and received at least two more doses of canakinumab. We evaluated therapeutic responses using disease-activity scores and analysis of levels of C-reactive protein (CRP) and serum amyloid A protein (SAA).ResultsIn part 1 of the study, 34 of the 35 patients (97%) had a complete response to canakinumab. Of these patients, 31 entered part 2, and all 15 patients receiving canakinumab remained in remission. Disease flares occurred in 13 of the 16 patients (81%) receiving placebo (P<0.001). At the end of part 2, median CRP and SAA values were normal (<10 mg per liter for both measures) in patients receiving canakinumab but were elevated in those receiving placebo (P<0.001 and P=0.002, respectively). Of the 31 patients, 28 (90%) completed part 3 in remission. In part 2, the incidence of suspected infections was greater in the canakinumab group than in the placebo group (P=0.03). Two serious adverse events occurred during treatment with canakinumab: one case of urosepsis and an episode of vertigo.ConclusionsTreatment with subcutaneous canakinumab once every 8 weeks was associated with a rapid remission of symptoms in most patients with CAPS. (ClinicalTrials.gov number, NCT00465985.)