December 5, 2002
Rate Control or Rhythm Control for Atrial Fibrillation
There are two approaches to the treatment of atrial fibrillation: rate control, allowing atrial fibrillation to persist, and rhythm control, with cardioversion and antiarrhythmic drugs. This North American study found that, contrary to prevailing practice, rhythm control offered no survival advantage and was associated with higher rates of adverse drug effects than rate control. Atrial fibrillation is associated with substantial morbidity and mortality. This study, along with another, similar study in this issue of the Journal (see page 1834), will change the management of this common arrhythmia. As compared with rhythm control, rate control has advantages that have previously been underappreciated.
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Rate Control or Rhythm Control for Persistent Atrial Fibrillation
This study is the European counterpart of the North American study of atrial fibrillation reported in this issue of the Journal. Although the European study was smaller, the findings in the two studies were quite similar. Rate control was not inferior to rhythm control and should be regarded as appropriate for the management of persistent atrial fibrillation. The results of the European and North American studies are mutually confirmatory and together provide good evidence that rate control is an acceptable, and in some cases the preferred, approach to therapy for persistent atrial fibrillation. Anticoagulant therapy should be maintained with either strategy.
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Eliminating Lymphatic Filariasis
In Papua New Guinea, approximately 2500 residents participated in a prospective, four-year study of the effects of a single dose of antifilarial drugs given annually for four years. The proportion of microfilariae-positive infections decreased by 86 to 98 percent, and the frequency of hydrocele declined from 15 percent to 5 percent. This study demonstrates that annual mass treatment of a population can virtually eliminate the reservoir of microfilariae and greatly reduce lymphatic abnormalities due to infection with Wuchereria bancrofti, which is transmitted by mosquitoes. New infections in children nearly disappeared during the course of the study.
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Special Article: Improving the Management of Latent Tuberculosis in Immigrants
There is considerable variation in the patterns of resistance to antituberculosis drugs around the world. This decision-analysis study incorporated data on region-specific drug-resistance profiles. The results show that detecting and treating latent tuberculosis in new immigrants to the United States with the appropriate regimens was cost-saving in the case of immigrants from seven regions and was highly cost effective for immigrants from other developing nations. This analysis focuses on the United States, but the results have implications for other industrialized countries where many cases of tuberculosis occur in foreign-born persons. Optimal treatment decisions should reflect what is known about the pattern of drug resistance in the new immigrant's country of origin. Screening can lead to health benefits for the immigrants and cost savings for the health care system.
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Clinical Practice: Latent Tuberculosis Infection
A 44-year-old man who recently immigrated from Peru is found to have induration of 16 mm on a tuberculin skin test. He received bacille Calmette–Guérin vaccine as an infant and is asymptomatic. Chest radiography shows fibronodular opacities in the upper lobe. In another case, a 27-year-old schoolteacher born in the United States has induration of 17 mm on a tuberculin skin test, no symptoms, and a normal chest radiograph. How should these patients' cases be managed?
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Genomic Medicine: Genetic Testing
Classic genetic tests indicate, either directly or indirectly, the presence of DNA variants associated with rare but highly penetrant disorders such as Huntington's disease or multiple endocrine neoplasia type 2. This article not only reviews these classic tests but also shows how novel genetic tests can reveal the presence of DNA variants that are more logically considered risk factors for a given condition.
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Clinical Problem-Solving: The Unusual Suspect
A 17-year-old boy awakes with left-sided pleuritic chest pain. He also notes mild dyspnea during track-and-field practice. Over the ensuing months, symptoms progress to dyspnea when he is at rest, accompanied by three-pillow orthopnea.
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