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Resumption of Driving after Life-Threatening Ventricular Tachyarrhythmia
Patients with life-threatening ventricular arrhythmias may place themselves and others at risk when they drive. This study surveyed the driving histories of 758 patients whose ventricular arrhythmias had been treated with antiarrhythmic drugs or implantable defibrillators. Although symptoms possibly related to arrhythmias were common while the patients were driving, accidents were uncommon and occurred at a rate lower than that in the general driving population of the United States.
Whether patients with life-threatening ventricular arrhythmias treated with drugs or implantable defibrillators should be prohibited from driving is a matter of uncertainty and debate. The data reported here support a policy of allowing such patients to drive.
Related Editorial
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Treatment of HIV after Nucleoside Analogues Fail
For HIV-infected patients who have received extensive treatment with nucleoside analogues, there are many options for treatment with the newer classes of antiviral agents. This randomized trial assessed treatment with two nucleoside analogues plus a protease inhibitor, a nonnucleoside reverse-transcriptase inhibitor, or both. Over a 48-week period, the patients who received the quadruple therapy, which included nelfinavir and efavirenz, had the highest rate of suppression of plasma HIV RNA.
This multicenter clinical trial involved 195 patients who had been treated with antiviral therapies that had lost their effectiveness. Shifting to treatment with agents from three classes achieved the highest rate of viral suppression, but that strategy may limit future options and risk causing new toxic effects.
Related Editorial
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Endothelial Protein C Activation in Meningococcemia
Disruption of the endothelial protein C activation complex may be an early event in meningococcemia. Studies of skin-biopsy specimens from 21 children with severe meningococcal disease and purpura fulminans showed a marked reduction in the expression of thrombomodulin and the endothelial protein C receptor in both thrombosed and nonthrombosed vessels. Plasma levels of protein C, protein S, and antithrombin antigens were lower than those in healthy controls.
The local control of thrombosis involves a delicate balance of prothrombotic and antithrombotic mechanisms, and it is difficult to study. These results show an impairment of an endothelial anticoagulation pathway in severe meningococcal disease. Treatment with an activated form of protein C may be a way to control the destructive thrombosis of meningococcemia.
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Cerebral Sinovenous Thrombosis in Children
Thrombosis of the cerebral sinuses and veins is an uncommon but serious cause of neurologic deficits in children. In this study of data from a Canadian registry, neonates were the age group most commonly affected. Risk factors included hypoxic encephalopathy, head and neck infections, and prothrombotic disorders. Seizures and the presence of venous cerebral infarcts predicted a poor outcome.
This large registry study has provided valuable insight into the clinical features of a potentially debilitating disorder. The information will be particularly useful in identifying children at risk, clarifying the role of antithrombotic therapy, and developing methods of primary and secondary prevention.
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Current Concepts: Toxic Leukoencephalopathy
Toxic leukoencephalopathy primarily involves the white-matter tracts devoted to higher cerebral function, and its clinical features can range from inattention to personality changes to devastating dementia. This review summarizes the approach to the diagnosis and the many causes, which include cranial irradiation and exposure to several anticancer drugs, drugs of abuse, and industrial solvents.
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Drug Therapy: The Coxibs, Selective Inhibitors of Cyclooxygenase-2
Drugs that selectively inhibit cyclooxygenase-2 have antiinflammatory actions similar to those of drugs that inhibit both cyclooxygenase-1 and cyclooxygenase-2 but may have fewer gastrointestinal side effects. This review evaluates the effects of cyclooxygenase-2–inhibiting drugs in patients with arthritis as well as the gastrointestinal, cardiovascular, and renal effects of these agents.
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