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September 29, 2005 Vol. 353 No. 13
Treatment of hematologic malignant disease with allogeneic hematopoietic stem cells requires conditioning regimens that carry a substantial risk of acute graft-versus-host disease (GVHD). This study found that a regimen developed in a mouse model sharply reduces the incidence of acute GVHD yet retains potent antitumor activity.
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Drotrecogin alfa (activated) is approved for use in patients with sepsis who are at high risk for death. This controlled trial found no benefit in patients at a low risk for death (relative risk of death with drotrecogin alfa, 1.08). The rate of serious bleeding was higher with drotrecogin alfa. Drotrecogin alfa should not be used in patients with sepsis who have a low risk of death, such as those with single-organ failure or an APACHE II score below 25.
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In a study published over a decade ago, patients with severe aortic regurgitation who were treated with nifedipine as compared with digoxin had a delay in the need for aortic-valve replacement. A trial in this issue comparing nifedipine or enalapril with no treatment was not able to confirm such an effect.
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Congenital cytomegalovirus (CMV) infection is associated with a high rate of neurologic sequelae. In this study, intravenous CMV-specific hyperimmune globulin was given to 31 pregnant women who had evidence of recent primary CMV infection. Only one had an infant with symptomatic impairment, as compared with impairment in 7 of 14 infants born to women who did not receive hyperimmune globulin. Hyperimmune globulin was safe, and this nonrandomized study suggests that it may be effective in treating and preventing congenital CMV infections.
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A highly pathogenic avian influenza A (H5N1) virus has crossed the species barrier to cause deaths in humans in Asia and poses an increasing threat of a pandemic. These infections differ from human influenza in the routes of transmission, clinical severity, pathogenesis, and response to treatment. This article describes the features of influenza A (H5N1) infection and updates recommendations for prevention and clinical management.
A 56-year-old renal-transplant recipient presented with fever and axillary lymphadenopathy. There was no recent travel or exposure to ill persons. Examination disclosed a skin nodule on the dorsum of his hand and a tender mass of lymph nodes in the ipsilateral axilla. Clarithromycin was prescribed; within a day, the temperature rose to 39.4°C, with shaking chills.
The authors argue that despite the success of the patient-safety movement in attracting the attention of the public and the medical profession, the Institute of Medicine's goal of reducing deaths from medical errors by 50 percent has not been achieved. They believe the greatest promise will come not from a focus on preventing accidental deaths but from dedication to evidence-based interventions to deliver more effective medical care.
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