ShortCuts-This Week in the Journals

July 28, 2008

summer.jpgCommentary by Michael Tanner MD, Section Editor, Clinical Correlations

This week in the Lancet, a study of the life expectancy of HIV-positive patients in affluent countries highlights the amazing gains made in this disease. The Antiretroviral Therapy Cohort Collaboration reports that a 20-year-old person starting combination antiretroviral therapy (cART) has an average life expectancy of 43 years. A 35-year-old starting cART can look forward to another 32 years of life. That adds up to half-price-Metro-Card eligibility! Life expectancy is 10 years shorter for intravenous drug users and 10-20 years shorter for patients who begin cART with CD4 counts less than 100. Only half of deaths in HIV-positive patients are now due to AIDS-defining conditions. The advent of the first reverse transcriptase inhibitor zidovudine (approved by the FDA in 1987) and the first protease inhibitor saquinavir (1995) transformed what was often a rapidly fatal disease into a treatable chronic illness. I remember as an AIDS-era Bellevue intern in 1989 admitting a breathless, cachectic man with fulminant Pneumocystis carinii pneumonia; having the DNR discussion with him while drawing his admission labs; and pronouncing him dead before midnight despite Bactrim, steroids, and AZT. The profound reduction in AIDS-related mortality is the most dramatic medical development I have seen during my career. Bellevue’s 17 West AIDS ward was opened in 1991, when five of six overnight admissions tended to be PCP. Its closing a couple of years ago due to low volume was thrilling to me. We have come a long way since the start of it all 26 years ago: “A cluster of Kaposi’s sarcoma and Pneumocystis carinii pneumonia among homosexual male residents of Los Angeles and Orange Counties, California” (Morbidity and Mortality Weekly Report, June 18, 1982). Increasing the use of triple antiretroviral combinations in developing countries is a major world health priority.

JAMA features an analysis of immigrants diagnosed with tuberculosis in the US between 2001 and 2006. In 2006, there were 13,779 cases of TB reported to the Centers for Disease Control; 57% of these were among foreign-born persons. At present, all immigrants and refugees over 15 who are bound for the United States are screened with a chest X-ray in their country of origin, with sputum culture for those with abnormal X-rays. However, 30% of the 37 million foreign-born people now living in the US are unscreened: students, visitors, workers, and illegal aliens. The highest rates of TB (greater than 250 cases per 100,000 persons) were in individuals from sub-Saharan Africa and Southeast Asia who immigrated within two years. The highest-risk countries were Somalia (889 cases per 100,000 individuals) and Eritrea (562 per 100,000). Of the 250 people per year diagnosed with smear-negative, culture-positive cases within three months of entry, 46% were from Vietnam and the Philippines. The study concludes that the yield of testing for TB can best be increased by focusing on the highest-risk populations first–namely recent immigrants from sub-Saharan Africa and Southeast Asia.

A study in the American Journal of Roentgenology suggests that the risk of contrast-induced nephropathy may be overestimated. Newhouse et al analyzed serial creatinines in over 32,000 inpatients who had not received recent contrast dye and found that five-day creatinine bumps of >25% occurred in over half of the patients for various reasons. This incidence is similar to those reported in contrast-exposed populations.

The Morbidity and Mortality Weekly Report chronicles the largest street fentanyl epidemic ever. Up to fifty times more potent than heroin, one gram of pure fentanyl can be cut into 7,000 doses, added to heroin or cocaine, and sold on the street for injection. From April 2005 to March 2007 a CDC/DEA surveillance system identified over 1,000 deaths from fentanyl overdose. The deaths were clustered in Philadelphia, Chicago, and Detroit–distribution points for an illegal factory in Toluca, Mexico. The deaths abruptly stopped in 2007 when the DEA raided the Toluca factory and began regulating access to N-phenethyl-4-piperidone, a key ingredient in the recipes readily available on the Internet.