Higher-dose rifampin for the treatment of pulmonary tuberculosis: a systematic review.

OBJECTIVE: To provide a descriptive synthesis of the evidence assessing the efficacy and safety of higher doses of rifampin (RMP) for the treatment of pulmonary tuberculosis (TB). METHODS: Systematic review of randomized controlled trials that evaluate a range of RMP doses, including doses higher than standard (>10 mg/kg or >600 mg), used as part of combination drug therapies for pulmonary TB. Two reviewers applied inclusion criteria, assessed trial quality and extracted data. Inclusion criteria were smear- or culture-confirmed pulmonary TB, and English and French language articles. Exclusion criteria were RMP monotherapy and smear-negative TB. Outcomes included were sputum culture conversion, treatment failure, recurrence and adverse events, including hepatotoxicity and flu-like syndrome. RESULTS: Of 14 trials (4256 participants) identified, 12 were conducted before 1980. Four trials were considered high quality according to published guidelines. Study characteristics, including history of prior TB treatment, dose of RMP, duration of treatment, timing of introduction of intervention treatment, concomitant drugs, and duration of follow-up, varied, making synthesis of efficacy data challenging. Several trials suggested an advantage in terms of likelihood of culture conversion among patients receiving at least 900 mg RMP. However, an increased incidence of flu-like syndrome was seen when RMP doses of 900 mg and higher were given intermittently. CONCLUSION: Historical trials suggest that higher than standard RMP dosing results in improved culture conversion rates. Phase 2 and 3 clinical trials evaluating higher doses of RMP and other rifamycins are needed to confirm efficacy and assure tolerability. Pharmacokinetic studies will be needed to inform the development of such trials.

Access to substance abuse treatment services under the Oregon Health Plan.

CONTEXT: The shift to Medicaid managed care has raised numerous concerns about access to publicly funded substance abuse treatment. The implementation of a capitated chemical dependency benefit within the Oregon Health Plan in 1995 provided an opportunity to study the impact of funding mechanisms on access. OBJECTIVES: To determine to what extent access to publicly funded substance abuse treatment changed following the shift to managed care in Oregon and to examine factors associated with that change. DESIGN: Analysis of statewide treatment and Medicaid eligibility data. SETTING AND PATIENTS: All Medicaid-eligible persons aged 12 to 64 years who were enrolled in the Oregon Health Plan during 1994 (88,320), 1996 (170,387), 1997 (160,929), or 1998 (149,877). MAIN OUTCOME MEASURES: Access rates (the number of unique individuals admitted to treatment during a calendar year divided by the average number of enrolled members) computed before (1994) and after (1997) implementation of the capitated benefit. Analyses were replicated with data for 1996 and 1998. RESULTS: The percentage of Medicaid-eligible persons admitted to substance abuse treatment programs during a calendar year increased from 5.5% of the average number of enrolled members per month in 1994 to 7.7% in 1997, following the shift to managed care. For 1996 and 1998, the rates were 6.9% and 7.7%, respectively. Access rates varied considerably among the 7 largest prepaid health plans after adjusting for case mix. Operating characteristics of these prepaid health plans, such as the method of reimbursing treatment providers, were significant predictors of access after controlling for member characteristics. CONCLUSION: According to our analyses, Medicaid-eligible persons in Oregon observed an increase in access to substance abuse treatment after a shift to managed care. JAMA. 2000;284:2093-2099.

[Lesions of the little finger in Dupuytren's disease]. / L'atteinte de l'auriculaire dans la maladie de Dupuytren.

One hundred and twenty six patients (148 hands) with Dupuytren's disease of the fifth finger were reviewed with an average follow-up of 5 years. Twenty-nine dermo-fasciectomies were performed on the palmar area of the fifth finger. The improvement in the MP joint was complete in all cases. A classification in to 4 grades according to the degree of pre- and postoperative retraction is proposed. The average improvement at the PIP joint was 50 degrees. 26 recurrences were observed. The recurrence rate was similar with or without a skin graft but the functional result was better with a digital graft, as recurrences were located away from the PIP joint.

Odontogenic sinus tracts.

Odontogenic sinus tracts are the most common cause of a chronically draining, fixed, nodulocystic papule of the face and neck. Injury or disease of a tooth may result in a periapical abscess that subsequently dissects along the path of least resistance and erupts through the skin. If recognized early, the sinus tract usually resolves after appropriate endodontic therapy or extraction.