Treatment of Ankylosing Spondylitis by Inhibition of Tumor Necrosis Factor

Ankylosing spondylitis is difficult to treat — those affected often have acute inflammation and discomfort even decades after the onset of the disease. Since tumor necrosis factor appears to have a role in spondyloarthritides, the authors used etanercept, a recombinant human tumor necrosis factor receptor:Fc fusion protein, in a randomized, placebo-controlled trial followed by an open-label extension study. Treatment with etanercept resulted in significant and sustained improvement; at four months, 80 percent of the patients treated with etanercept had reached the primary end point, a treatment response, as compared with 30 percent of the placebo group. The patients who initially received placebo had rapid improvement during the six-month extension study, when both groups received etanercept.

The results of this study support the concept that inhibition of tumor necrosis factor leads to clinical improvement in patients with ankylosing spondylitis. The long-term outcome of such treatment is not known.

Related Editorial

Myocardial Gene Expression in Dilated Cardiomyopathy

Beta-blocker therapy may benefit patients with dilated cardiomyopathy. In this study, the expression of myocardial genes affecting cardiac contractility and hypertrophy was studied before and after the initiation of beta-blocker therapy. A response to therapy was accompanied by increased expression of genes such as those encoding -myosin heavy chain and calcium ATPase in the sarcoplasmic reticulum.

Effective therapy for heart failure, in this case with beta-blockers, is accompanied by changes in the expression of key myocardial genes that are involved in the regulation of cardiac contractility.

Related Perspective

Mycobacterial Boils after Footbaths at a Nail Salon

A physician in northern California reported four women who had multiple, culture-negative furunculoses of the lower extremities after pedicures at the same nail salon. Investigation identified an additional 106 customers with similar, persistent skin infections. All had had whirlpool footbaths before pedicures. The same strain of Mycobacterium fortuitum was isolated from 14 patients and three footbaths.

For months this large outbreak was not recognized. At the nail salon, the source of contamination was traced to hair and skin debris that accumulated behind screens in the water inlets to the whirlpool footbaths. New regulations may be required to prevent infection in this setting.

Special Article: Access to Experimental Treatments for HIV Infection

There is concern that minority groups and women are underrepresented in research trials and are less likely to receive experimental treatments for human immunodeficiency virus (HIV) infection. This study of patients with HIV infection in the United States found that blacks and Hispanics were less likely to participate in trials than whites and to have received experimental medications. Women were not underrepresented in trials and were as likely as men to receive experimental treatments.

According to this study, an estimated 14 percent of adults receiving HIV care have participated in a medication trial and about one quarter have received experimental medications. Although these rates are higher than those for patients with other diseases, there are substantial differences in access among racial and ethnic groups.

Related Editorial

Medical Progress: Bronchiectasis

Although bronchiectasis (permanent dilatation of the bronchi) is now uncommon, it has the potential to cause devastating illness. Chronic infection has an important role in its pathogenesis, and immunodeficiency states, cystic fibrosis, and primary ciliary dyskinesia may predispose patients to the condition. Diagnosis has been greatly facilitated by high-resolution computed tomography. This review article covers all aspects of the disorder, including recent approaches to therapy.

Clinical Problem-Solving: One Foot Away

A 59-year-old woman with systemic lupus erythematosus, which was treated with 200 mg of hydroxychloroquine and 20 mg of prednisone per day, presents with fever, abdominal pain, and hematuria. She has received cyclophosphamide because of a history of lupus nephritis. Physical examination reveals a cushingoid appearance, a blood pressure of 90/50 mm Hg, suprapubic tenderness, and a mass on the dorsum of her left foot.

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