October 31, 2002
Trends in the Incidence of and Survival with Heart Failure
Congestive heart failure has an extremely poor prognosis. This investigation from the Framingham Heart Study tracked trends over a 50-year period in the incidence of heart failure and in survival after its onset. During this period, the incidence of heart failure declined among women but not among men, whereas survival improved among both men and women. Despite substantial improvement during the study period, overall survival rates among patients with heart failure remained below 50 percent at five years, pointing to the urgent need for better means of preventing this serious health problem.
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Increased Mortality among Women with Heart Failure Treated with Digoxin
The Digitalis Investigation Group previously reported no difference in mortality between patients with heart failure who received digoxin and those who received placebo. In this post hoc analysis, men and women in the trial were analyzed separately. Digoxin therapy had no effect on mortality in men but was associated with an increase in overall mortality among women (33.1 percent in the digoxin group vs. 28.9 percent in the placebo group). Although derived from a post hoc analysis, the findings raise important questions about — and call for a reexamination of — the use of digoxin in the treatment of heart failure in women.
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Skin Ulcers Misdiagnosed as Pyoderma Gangrenosum
It can be difficult to distinguish pyoderma gangrenosum from other causes of cutaneous ulceration. In this study, the authors identified 95 patients with skin ulcers that resembled pyoderma gangrenosum. The ulcers were actually caused by vascular occlusive or venous disease, vasculitis, cancer, infection, drug-induced or exogenous tissue injury, or other inflammatory disorders. Most patients who received a diagnosis of pyoderma gangrenosum were treated, and 36 percent of those who were treated had exacerbation of their underlying condition or a delay in its diagnosis. Pyoderma gangrenosum is a diagnosis of exclusion. In patients in whom pyoderma gangrenosum is suspected, evaluation for alternative causes of cutaneous ulceration is important.
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Special Article: Tuberculosis Control in India
In India nearly 500,000 people die each year from tuberculosis. Recent improvements in the national tuberculosis-control program are standardizing treatment, follow-up, and mandated reporting. More than 200,000 new health workers have been trained, and about 3.4 million patients have been evaluated. Nearly 800,000 patients have been treated, with a success rate of approximately 83 percent. The cost is about $50 per patient treated. The tuberculosis-control program in India is one of the largest public health efforts in the world. The national program has become more effective, but it still reaches less than half the population. Continued expansion is important, since India accounts for roughly one third of all the cases of tuberculosis in the world.
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Current Concepts: Rupture of the Interventricular Septum
When ventricular septal rupture complicates acute myocardial infarction, the mortality rate is high and immediate operative intervention is indicated. This review explains that septal rupture has become less common with reperfusion therapy but that rapid diagnosis remains crucial. Doppler echocardiography is usually diagnostic and can be used to estimate the size of the left-to-right shunt.
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Health Policy Report: Testing Medications in Children
To stimulate more evaluation of the safety and efficacy of medications in children, two federal regulations were established. The pediatric exclusivity provision gives an additional six months of patent protection to companies that voluntarily test a medication in children, whereas the pediatric rule requires pediatric studies if a drug is important for children. More children are being enrolled in clinical trials. The long-term effect will depend on the ethical and effective conduct of the research and the government's continued commitment to assessing the safety and efficacy of drugs in children.
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