Disseminated Mycobacterium tuberculosis infection due to interferon gamma deficiency. Response to replacement therapy.

The case of a previously healthy HIV seronegative woman with disseminated Mycobacterium tuberculosis infection and markedly reduced interferon gamma production is reported here. Complete healing of her disseminated lesions was seen only after addition of subcutaneous interferon gamma to her tuberculosis treatment.

Prospective study of anti-tumour necrosis factor receptor superfamily 1B fusion protein, and case study of anti-tumour necrosis factor receptor superfamily 1A fusion protein, in tumour necrosis factor receptor associated periodic syndrome (TRAPS): clinical and laboratory findings in a series of seven patients.

OBJECTIVE: To assess the effects prospectively of tumour necrosis factor (TNF) receptor superfamily (TNFRSF) fusion proteins TNFRSF1B (etanercept) and TNFRSF1A (p55TNFr-Ig) in patients with TNF receptor associated periodic syndrome (TRAPS). METHODS: Seven patients with a clinical and genetic diagnosis of TRAPS received subcutaneous etanercept for 24 weeks. One of these patients had previously received an intravenous infusion of p55TNFr-Ig. Therapeutic response was assessed by comparing corticosteroid requirement, acute-phase response and an established scoring system over 20 weeks, both on and off etanercept. RESULTS: Etanercept was well tolerated. The five corticosteroid-responsive patients required significantly less corticosteroids and demonstrated reductions in acute-phase reactants on etanercept. The two patients not requiring corticosteroids had small reductions in disease activity scores. The effect of p55TNFr-Ig in a single patient with TRAPS remains unclear. CONCLUSIONS: Etanercept does not abolish inflammatory attacks but improves disease activity allowing corticosteroid reduction. Etanercept may be clinically useful in replacing or reducing steroid requirements in the treatment of TRAPS. A formal trial of etanercept to establish its role in clinical management is indicated.

Can earnings decline cause a retirement flight of physicians? Financial compensation and the decision to stay in practice.

The authors analyze the historical correlation between annual change in the population of inactive physicians and annual change in the real net income earned by the average physician per hour of patient care. For a sample of nine census divisions across 8 years (1986-1989 and 1994-1997), two regression models conclude with 99% confidence that a fall in net income increases the outflow of physicians from active practice. Regression coefficients estimate that a $1.00 fall in hourly net income increases the population of inactive physicians by 1.46 percent after a 2-year period. Based on 1999 population data, the authors project that an earnings decline of $10.00 per patient care hour motivates 11,000 physicians to retire early. With projections of between 50,000 and 150,000 excess practitioners in the U.S. health care system, the analysis suggests that deterioration in financial compensation can erase part but not all of a physician surplus through early retirement.