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Carvedilol and Survival in Chronic Heart Failure
Although beta-blockers are used to treat mild-to-moderate heart failure, they are usually avoided in patients with severe heart failure because of the concern that they may worsen the condition. In this randomized trial, the effects of carvedilol, which blocks  1-,  1-, and 2-receptors, were studied in patients with severe heart failure. As compared with placebo, carvedilol reduced the risk of death by 35 percent and the combined risk of death or hospitalization by 24 percent.
The results of this study support the use of carvedilol in patients with severe heart failure. However, the study excluded patients with marked fluid retention, clinically significant renal dysfunction, hypotension, or a need for intravenous vasodilators or inotropic drugs. Thus, whether the promising results apply to patients with these clinical characteristics is not known.
Related Editorial
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Bucindolol in Advanced Chronic Heart Failure
Beta-blockers have an established role in the treatment of mild-to-moderate chronic heart failure. In this study, the effects of a nonselective beta-blocker, bucindolol, were studied in 2708 patients with more advanced heart failure. There was no effect of treatment on overall mortality, except in nonblack patients. There were only small reductions in the risk of death from cardiovascular causes and the combined end point of heart transplantation or death.
In contrast to some previous studies, this clinical trial does not support the use of beta-blockade, in this case with bucindolol, in patients with advanced chronic heart failure -- except possibly in the subgroup of nonblack patients. These results with bucindolol may not apply to other beta-blockers.
Related Editorial
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Rapid Progression to AIDS.
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HLA-B*35 Subtypes and Progression to AIDS
The major-histocompatibility-complex class I HLA-B*35 and Cw*04 alleles are associated with an increased rate of progression to AIDS in patients infected with human immunodeficiency virus type 1 (HIV-1). This study examined the relation of HLA-B*35 subtypes to disease progression in a cohort of 850 patients. With the most common subtype, HLA-B*3501, there was no increase in the rate of progression, but there was a marked increase in progression to AIDS with the closely related HLA-B*35-Px subgroup.
This analysis shows that a single amino acid change in HLA molecules has a substantial effect on the rate of progression from HIV-1 infection to AIDS. The findings indicate that these HLA-B alleles have a clinically significant effect on the immune response to HIV-1.
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Donor Tissues (Left) and
Recipient (Right).
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Laryngeal Transplantation and 40-Month Follow-up
This report describes the results of transplantation of a cadaveric larynx and pharynx into a man whose larynx and pharynx had been crushed years earlier, leaving him aphonic. The patient was able to speak soon after transplantation, and at 36 months he had a normal-sounding voice with inflection and qualities unique to him, and he was able to swallow normally. Postoperative complications included one episode of rejection, three of tracheobronchitis, and one of Pneumocystis carinii pneumonia.
The list of organs that can be transplanted successfully continues to grow. However, the merits of the transplantation of nonessential organs, such as the larynx, must be carefully examined, given the short-term risks of surgical complications and the long-term risks of immunosuppression and rejection.
Related Editorial
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Stents in Duodenum and Bile Duct.
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Current Concepts: Expandable Metal Stents for Gastrointestinal Obstruction Due to Cancer
Obstruction is a common and serious complication of gastrointestinal cancer. This article reviews the use of expandable metal stents, which are a recent advance and an alternative to surgery for the treatment of obstructive tumors in the esophagus, the biliary system, and the small and large bowel. Future directions may include the use of biodegradable stents for benign disease, and for cancer, metal stents that emit radiation or chemotherapeutic agents.
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Upper Motor Neuron.
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Medical Progress: Amyotrophic Lateral Sclerosis
Also called "motor neuron disease" or, colloquially, "Lou Gehrig's disease," amyotrophic lateral sclerosis strikes adults, results in degeneration of lower and upper motor neurons, and is progressive, with a mean survival of only three to five years. This article presents current information about the disorder, including insights derived from the study of the familial form of the disease that results from mutations in the gene encoding superoxide dismutase 1.
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