December 19, 2002
Gene-Expression Signature as a Predictor of Survival in Breast Cancer
The patterns of expression of 70 genes in almost 300 breast-cancer specimens revealed two genetic signatures: one correlated with a good prognosis, and the other with a poor prognosis, as judged on the basis of overall survival and the development of distant metastases. These signatures correlated with outcome independently of the involvement of axillary lymph nodes and standard clinical and pathological prognostic indicators. This work represents a considerable advance in the clinical application of microarray technology. The finding that the genetic signature of a breast cancer correlates with outcome independently of the presence or absence of lymph-node involvement has important biologic and clinical implications.
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Effect of Dialysis Dose and Membrane Flux in Maintenance Hemodialysis
Both the amount of dialysis and the size of the molecules removed may influence morbidity and mortality among patients receiving long-term hemodialysis. The multicenter Hemodialysis Study randomly assigned 1846 patients, according to a two-by-two factorial design, either to the standard dialysis dose currently recommended in the United States or to a high dialysis dose, with either a high-flux or a low-flux dialyzer. Neither mortality from any cause nor morbidity differed between the groups during a mean follow-up of 2.84 years. These data suggest no major benefit from increasing the prescribed minimal dialysis dose from that in current U.S. guidelines or from switching from low-flux to high-flux dialysis membranes.
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A New Agent for the Treatment of Invasive Candidiasis
Caspofungin is a new echinocandin drug that has activity against the cell wall of candida species. This double-blind trial evaluated whether caspofungin is as effective as amphotericin B, which has substantial toxicity. Among 224 patients with invasive candidiasis, the outcomes were successful in 73.4 percent of those treated with caspofungin and in 61.7 percent of those treated with amphotericin B. The frequency of nephrotoxic effects was lower with caspofungin than with amphotericin B. Caspofungin appears to be at least as effective as amphotericin B, and it has considerably less toxicity. Few of the patients in this trial had neutropenia, so further evaluation of caspofungin therapy in this high-risk group will be required.
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Special Article: Effects of a Law against Early Postpartum Discharge
Examinations of newborns three or four days after birth occurred less frequently after a Massachusetts law requiring two-day postpartum hospitalizations eliminated the early-discharge program at a health maintenance organization (HMO), which had provided one postpartum night and one home visit. However, the HMO and state policies had little effect on the health outcomes of newborns or on HMO expenditures. Shorter hospital stays were not associated with adverse outcomes for newborns. Because hospitals' prices changed, the changes in hospital use had little effect on HMO expenditures.
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Clinical Practice: Community-Acquired Pneumonia
A 65-year old man with hypertension and degenerative joint disease presents to the emergency department with a three-day history of a productive cough and fever. His temperature is 38.3°C (101°F), his blood pressure is 144/92 mm Hg, his respiratory rate is 22 breaths per minute, his heart rate is 90 beats per minute, and his oxygen saturation is 92 percent while he is breathing room air. Physical examination reveals only crackles and egophony in the right lower lung field. The white-cell count is 14,000 per cubic millimeter, and routine chemical tests are normal. A chest radiograph shows an infiltrate in the right lower lobe. How should this patient be treated?
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Conservative estimates suggest that at least 12 percent of the U.S. population uses herbal medicines, and the number is increasing, yet these products are not regulated by the Food and Drug Administration. This review considers the evidence on the safety and efficacy of herbal medicines, focusing on four – Ginkgo biloba, hawthorn, saw palmetto, and St. John's wort – that have been evaluated in a sufficient number of randomized, controlled trials to permit an assessment. Controlled data that support or refute the use of herbal medications remain limited, at best. More research is required to support the claims currently being made.
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