Embargoed news from Annals of Internal Medicine

1. Chinese Herbal Remedy Shows Promise for Treating Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease that causes painful and debilitating swelling of the joints. Physicians often prescribe anti-inflammatory drugs such as sulfasalazine for the initial treatment of rheumatoid arthritis. Despite the clinical efficacy of these types of drugs, many patients discontinue treatment due to lack of improvement or adverse events. The Chinese herbal remedy Tripterygium wilfordii Hook F (TwHF) (also known as “lei gong teng” or “thunder god vine”) has shown promise in treating autoimmune and inflammatory conditions. Researchers randomly assigned 121 patients to take either TwHF root extract 60mg three times per day or sulfasalazine 1g two times per day for 24 weeks. The researchers used a standard measure of joint involvement to determine treatment outcomes. Many patients in both groups discontinued treatment. However, among those who continued treatment for 24 weeks, improvement was greater with TwHF (67%) than with sulfasalazine (36%) and adverse event rates were similar. The resulst were similar in analyses that adjusted for patient drop-out. Researchers conclude that the rapid improvement in joint symptoms may make TwHF extract an attractive and affordable alternative to anti-inflammatory drugs.

2. Elective Induction of Labor May Reduce Cesareans, Improve Fetal Outcomes

Elective induction of labor, or labor that is induced without medical necessity, is rapidly increasing in the United States. Pregnant women who are at term and their physicians may consider labor induction for several reasons including physical discomfort, scheduling issues, or concerns about maternal or fetal complications. However, many experts discourage the practice because of the widely held belief that it increases the risk for cesarean delivery and other complications. Researchers conducted a systematic review of 11 randomized trials and 25 observational studies to compare the benefits and harms of elective induction of labor and expectant management of pregnancy. The researchers found that elective induction of labor at 41 weeks of gestation and beyond was associated with an approximately 20 percent reduction in the rate of cesarean delivery and a 50 percent reduction in the presence of meconium in the amniotic fluid. These results suggest that outcomes may be better with elective induction of labor. More research should be conducted before elective induction of labor is routinely adopted.

3. China’s National Free Antiretroviral Program Has Limited Success, Shows Need for Improvement

In 2002, China began the National Free Antiretroviral Program to provide highly active antiretroviral therapy (HAART) to eligible patients with HIV. To determine the long-term outcomes of the program, researchers collected information on patient deaths and CD4 cell counts for the 48,785 program participants over five years. They found that mortality was highest within the first three months after HAART initiation. After about six months of treatment, death rates decreased to levels similar to those seen in HIV-infected patients who receive HAART in other developing countries. The lower death rates remained stable through year five. However, about half of the patients in the program had CD4 cell counts that suggested treatment failure after five years. The researchers believe that treatment failure may be due to the limited number of drug choices available to these patients. Once resistance developed, patients had few options for other drugs they could take.

4. Minor Epidemic May Have Led to Mozart’s Early Death

Wolfgang Amadeus Mozart died under mysterious circumstances on December 5, 1791 at the age of 35. For more than two centuries, the world has sought an answer to his cause of death. Theories range from poisoning, renal failure, Henoch-Schonlein purpura, and lethal trichinosis, among many others. In a recent attempt to solve the mystery, researchers evaluated the official daily register of deaths in Mozart’s Vienna for the period between November and December 1791 and January 1792. These records were analyzed with the corresponding periods in 1790/1 and 1792/3. The deaths of 3,442 adult men and 1,569 adult women were recorded over these periods. Tuberculosis and related conditions accounted for the highest number of deaths. Cachexia and malnutrition accounted for the second highest number of deaths, and edema was the third most common cause of death. According to eyewitnesses of Mozart’s final days, his body was severely swollen in the days preceding his death. In the weeks surrounding Mozart’s death, there was a marked increase in deaths from edema among younger men. This minor epidemic may have originated in the military hospital. The researchers’ analysis suggests that Mozzart may have died from acute nephritic syndrome, a complication that could stem from an epidemic of streptococcal infection.

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