Implantation of Defibrillators after Myocardial Infarction

Patients who have had a myocardial infarction resulting in a reduced left ventricular ejection fraction are at risk for ventricular arrhythmias and sudden death. In this large trial, patients were randomly assigned to receive an implantable defibrillator or conventional therapy. During the follow-up period, which lasted up to four years, the mortality rate was lower in the defibrillator group than in the conventional-therapy group (14.2 percent vs. 19.8 percent).

The clinical benefit of defibrillator therapy is convincing, and the implantation of a defibrillator should be considered as an alternative to antiarrhythmic drug therapy in patients similar to those in this study. However, widespread use of the approach will be very costly, and this matter must be addressed by manufacturers and insurers.

Related Editorial

Amiodarone versus Lidocaine for Shock-Resistant Ventricular Fibrillation

Ventricular fibrillation is the most common cause of cardiac arrest outside the hospital. In cases resistant to defibrillation, lidocaine is often given as adjunctive antiarrhythmic therapy. This randomized, controlled clinical trial compared intravenous lidocaine with intravenous amiodarone, both administered by emergency-response personnel, and found that amiodarone was superior, resulting in increased survival to hospital admission.

Amiodarone, not lidocaine, should now be the drug of choice as adjunctive therapy for shock-resistant ventricular fibrillation. However, despite improved survival to hospital admission with amiodarone, survival to hospital discharge is still low.

Fluconazole for the Treatment of Cutaneous Leishmaniasis

This randomized trial evaluated the efficacy of 200 mg of fluconazole taken orally every day for six weeks as a treatment for cutaneous leishmaniasis. There were follow-up data on 145 patients, and all the parasites isolated were confirmed to be Leishmania major. Three months after treatment ended, there was complete healing of the lesions in 79 percent of those in the fluconazole group, as compared with only 34 percent of those in the placebo group.

This double-blind study conducted in Saudi Arabia shows that fluconazole taken orally is a safe and effective treatment for cutaneous leishmaniasis. An effective oral agent is needed, since treatment with the pentavalent antimony compounds requires parenteral administration and often has major toxic effects.

Bosentan for Pulmonary Hypertension

Endothelin-1, a potent vasoconstrictor and smooth-muscle mitogen, may have a role in the pathogenesis of pulmonary hypertension. The therapeutic efficacy of bosentan, an endothelin-receptor antagonist, was evaluated in this randomized clinical trial. Bosentan at a dose of 125 mg twice daily improved exercise capacity and functional class.

Pulmonary hypertension is a serious disorder with substantial morbidity and mortality. Current therapy includes anticoagulants, calcium-channel blockers, and epoprostenol or its derivatives. The use of endothelin-receptor antagonists for pulmonary hypertension represents a new approach that merits further exploration.

Related Editorial

Special Article: Geriatric Evaluation and Management

A total of 1388 hospitalized older patients were randomly assigned to receive care in an inpatient geriatric unit or a conventional inpatient unit and at an outpatient geriatric clinic or a conventional outpatient clinic. Neither geriatric intervention had an effect on mortality at one year, which was 21 percent overall. Care in the special inpatient unit was associated with improvements at the time of discharge in several measures of functioning and quality of life.

Nearly 20 years ago, a randomized study of patients who received care in an inpatient geriatric unit showed a large reduction in mortality, as compared with the rate among those who received usual care. This more recent, multicenter study of geriatric services provided by Veterans Affairs medical centers shows some improvements in functioning but no reduction in mortality with geriatric evaluation and management.

Related Perspective

Mechanisms of Disease: Subtle Acquired Renal Injury as a Mechanism of Salt-Sensitive Hypertension

Salt sensitivity is present in about half of people with essential hypertension; decreasing salt intake ameliorates the hypertension. This review provides an explanation of how initially subtle renal injury promotes a tendency toward hypertension. The kidneys, initially normal in many persons with early primary hypertension, sustain subclinical injury over time, resulting in arteriolosclerosis and tubulointerstitial disease that lead to established hypertension.

Targets for future therapy might focus on reversing the arteriolar and tubulointerstitial injury that perpetuates salt-sensitive hypertension.

Case Records of the Massachusetts General Hospital

An 80-year-old woman had headache and severe pain in the left eye, followed by sudden complete blindness in the eye.

Sounding Board: The Future of the Global Tobacco Treaty Negotiations

The tobacco business is a global enterprise that has caused a worldwide public health crisis — by the year 2020 an estimated 8.4 million people will succumb annually to tobacco-related diseases. This week's Sounding Board article discusses the ongoing response of the World Health Assembly of the World Health Organization to this crisis — to draft and adopt an international treaty called the Framework Convention on Tobacco Control, which aims to establish worldwide standards for tobacco control.

Provisions that will mandate appropriate taxes and labeling and that will control trade, passive smoking, and advertising are necessary to an effective treaty. The United States has a crucial role in negotiating this treaty, which will be ready for ratification by individual nations by 2003.

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