Cardiac Resynchronization in Heart Failure

About a third of patients with chronic heart failure have an intraventricular conduction delay, which may lead to dyssynchrony of cardiac contraction and further clinical impairment. The patients in this clinical trial were randomly assigned to a group receiving resynchronization therapy with an atrial–biventricular pacemaker or to a control group. As compared with the control group, the resynchronization group had improved functional capacity, quality of life, and ejection fraction over a six-month period.

Resynchronization therapy has considerable promise in patients with heart failure, but there are limitations. It is applicable to only about a third of patients, and it requires the insertion of a complex pacing device that may be associated with a variety of technical problems and complications. This technique should be reserved for experienced centers.

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Ventricular Pacing or Dual-Chamber Pacing for Sinus-Node Dysfunction

In patients with sinus-node dysfunction who require permanent pacing for bradycardia, single-chamber ventricular pacing and dual-chamber atrioventricular pacing are alternative options. In this randomized trial, the frequency of the primary end point (death or nonfatal stroke) was not significantly different in the two groups. However, the dual-chamber group had a lower incidence of atrial fibrillation and end points related to heart failure, as well as a slightly better quality of life.

Dual-chamber pacing is more expensive and more technically complex than single-chamber ventricular pacing. Nevertheless, the maintenance of atrioventricular synchrony with dual-chamber pacing provides enough additional clinical benefit to justify its use in patients with sinus-node dysfunction.

Antiretroviral Therapy during Pregnancy

This report describes an analysis of combined data from seven studies of pregnant women with human immunodeficiency virus type 1 (HIV-1) infection to assess whether antiretroviral therapy during pregnancy is associated with an increased risk of premature delivery (<37 weeks of gestation) and other adverse outcomes. Rates of premature delivery, low birth weight, low Apgar scores, and stillbirth were similar whether or not the women received antiretroviral therapy and whether the treated women received combination therapy or monotherapy. As compared with combination regimens that did not include protease inhibitors, regimens that included these medications were associated with a greater risk of very low birth weight, after adjustment for several confounding factors, but this finding was based on small numbers of women.

These data provide reassurance that the use of combination antiretroviral therapy is not associated with an increased risk of premature delivery or other adverse outcomes in late pregnancy. Although the risk of very low birth weight appears to be higher with combination therapy that includes protease inhibitors than with regimens that do not include them, this finding requires confirmation, and the overall risks appear to be small in relation to the recognized benefits of these agents.

Intranasal Mupirocin to Prevent Postoperative Infections

In this double-blind trial, the rate of Staphylococcus aureus wound infections was similar among patients treated with mupirocin ointment (2.3 percent) and those who received placebo (2.4 percent). However, 23.1 percent of 3864 patients were identified as having nasal carriage of S. aureus, and among these patients there were fewer nosocomial S. aureus infections in the mupirocin group than in the placebo group (4.0 percent vs. 7.7 percent, P=0.02).

Nasal carriage of S. aureus is common, and carriers have a higher risk of staphylococcal infection after invasive medical or surgical procedures than those who do not carry this organism. This large study found an effect of topical antibiotic treatment only in the subgroup of patients who were carriers.

Related Editorial

Drug Therapy: Management of HIV Infection in Pregnancy

Globally, more than 16 million women are living with human immunodeficiency virus (HIV) infection. Each year, 600,000 children are infected, most of them through mother-to-child transmission. This review focuses on the management of HIV infection during pregnancy in developed countries in which antiretroviral therapy, scheduled cesarean delivery, and alternatives to breast-feeding are available; it discusses strategies for obtaining the best possible outcomes.

Intrapartum and postpartum care of the mother and infant can reduce the risk of HIV transmission and improve maternal health.

Sounding Board: Supporting Community Efforts to Assist Orphans in Africa

As a result of the AIDS epidemic, an increasing number of children throughout the world have lost their parents. Africa has been hardest hit by the pandemic, and millions of children have been left orphaned. In this Sounding Board article, Foster, who works in a hospital in Zimbabwe, describes the scope of the problem and argues that external aid agencies must work with local communities to distribute resources effectively to assist children who have been orphaned.

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