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February 15, 2001
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Continuing Value of the Apgar Score
The determination of Apgar scores is a simple method of assessing the condition and prognosis of newborn infants. In this retrospective study, one-minute and five-minute Apgar scores and umbilical-artery blood pH values were determined in 145,627 newborn infants. In both preterm and term infants, the rate of survival increased as Apgar scores increased. The highest relative risk of neonatal death in both preterm and term infants was associated with five-minute Apgar scores of 0 to 3. The five-minute Apgar score was a better predictor of neonatal survival than were measurements of umbilical-blood pH values.
This large study demonstrates the continuing value of the Apgar score as an indicator of the condition of newborn infants and therefore its value for identifying infants who need more aggressive care. The finding that the Apgar score is superior to the "high-tech" measurement of umbilical-blood pH is reassuring.
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Consequences of Discontinuing Antiretroviral Therapy
Failure to achieve complete viral suppression with combination therapy with antiretroviral drugs is common in patients with HIV infection. In a randomized study of 16 patients, discontinuation of therapy resulted in a decrease in CD4 cell counts and an increase in plasma HIV RNA levels. The changes were associated with the emergence of wild-type virus with an increased replicative capacity but also increased susceptibility to antiretroviral drugs.
Discontinuation of antiretroviral-drug therapy in patients with persistent viremia has potential benefits and drawbacks, since it may increase drug susceptibility, but it may also increase plasma HIV RNA levels and viral replicative capacity and decrease CD4 cell counts. These disadvantages suggest that antiretroviral-drug therapy should be continued in this group of patients.
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Noninvasive Ventilation in Immunosuppressed Patients
In this randomized trial, 52 patients with fever, pneumonitis, and an early stage of acute respiratory failure received either intermittent noninvasive ventilation or standard nonventilatory treatment. The majority of the patients had immunosuppression as a result of hematologic cancers and neutropenia. Noninvasive ventilation resulted in a significantly lower rate of endotracheal intubation and death in the hospital.
This was a small trial in which blinding was not possible, but it provides evidence that the early use of noninvasive ventilation can improve outcomes in a high-risk group of patients with immunosuppression.
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Botulinum Toxin A for Axillary Hyperhidrosis
Primary hyperhidrosis is defined as excessive, uncontrollable sweating without any discernible cause. Treatment is often unsatisfactory. This randomized, double-blind, placebo-controlled study of 145 patients evaluated injections of botulinum toxin A for severe axillary hyperhidrosis. The botulinum toxin A injections significantly reduced the mean rate of sweat production, and much of the beneficial effect persisted for six months.
Botulinum toxin A can stop excessive sweating by blocking the release of acetylcholine, which mediates sympathetic innervation of the sweat glands. It has been used extensively for the treatment of other conditions, including focal dystonia, achalasia, and chronic anal fissures. This study suggests that botulinum toxin A is a safe and effective treatment for severe axillary hyperhidrosis as well.
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