Mother-to-Child Transmission ofBurkholderia pseudomallei

Abstract

1 report the results of a long-term, multicenter, randomized trial comparing fludarabine with chlorambucil in previously untreated patients with advanced chronic lymphocytic leukemia (CLL). In their study the treatments were repeated monthly for a maximum of 12 cycles unless patients had progressive disease, a complete remission, or a response that plateaued over two months of treatment. The hematologic toxicity of fludarabine is well established, and most prior studies have reported that fludarabine can be given for a maximum of six cycles. [2][3][4][5] In our experience, we have not been able to administer more than eight cycles of fludarabine therapy because of severe and prolonged myelosuppression. Rai et al. have not stated how many patients were able to receive 12 cycles of fludarabine, the median number of cycles of fludarabine administered, or the median number of courses of fludarabine needed to induce a complete remission. To the Editor: Rai et al. conclude that older patients with medical problems in addition to CLL should receive palliative treatment with chlorambucil and that fludarabine should be used in patients who can tolerate a more toxic treatment. Though this approach makes sense, the evidence underlying the decision is not presented. We believe that data concerning the rates of response and adverse effects stratified according to age would be invaluable to clinicians whose aim is to achieve the best risk-benefit ratio for their patients with CLL.Hacettepe University 06100 Ankara, TurkeyTo the Editor: The trial by Rai and colleagues demonstrates that fludarabine yields a higher rate of response as well as longer progression-free survival than chlorambucil in patients with CLL. However, the choice of therapy should also be considered from a health-policy perspective. Fludarabine is expensive; in Italy, a 40-mg dose of chlorambucil costs $8, whereas a 40-mg dose of fludarabine costs $296. In addition, fludarabine must be administered intravenously, and the cost for this procedure is $250 per day (charge based on diagnosis-related group code 473).We performed an economic comparison of fludarabine and chlorambucil as first-line therapy for CLL from the perspective of the Italian health care system. Using a Markov model, we followed the transition of treated patients from diagnosis (remission) to progression and death, according to the curves shown in the article by Rai et al. We calculated the incremental cost-effectiveness ratio of fludarabine as compared with chlorambucil by dividing the additional cost incurred by patients treated with fludarabine by theThe New England Journal of Medicine Downloaded from nejm.org on May 11, 2018. For personal use only. No other uses without permission.

Neonatal Melioidosis: A Case Report From India

“…[4,6] Neonatal cases have been reported from the United States of America, Thailand, Malaysia and United Kingdom. [1,[7][8][9][10][11] But, to the best of our knowledge, until now, there is no report of neonatal melioidosis from the Indian subcontinent.…”

“…[8] Very few are diagnosed by fine-needle aspiration/biopsy. [1,[6][7][8][9][10] Once the diagnosis has been established, the majority of the patients with TB respond favourably to ATT. [6] Our patient did not have a personal or family history of TB and was immunocompetent, with no evidence of any other foci of TB.…”

Fatal Melioidosis in a Newborn from Hainan, China

“…3,4 To our knowledge, this case of melioidosis is the youngest worldwide except for the maternal-neonatal vertical transmission case. 5 We postulate that transmission of B. pseudomallei from the father to the newborn might have occurred during close contact in the first couple of days after birth, probably through respiratory dissemination of B. pseudomallei-contaminated aerosols. There is a possibility that the real source of B. pseudomallei was from the environment or the father's clothes transiently, since B. pseudomallei can be transmitted through aerosols.…”

PCR-based Methodologies Used to Detect and Differentiate theBurkholderia pseudomalleicomplex:B. pseudomallei,B. mallei, andB. thailandensis

“…The disease is acquired through inhalation, contact with cuts/wounds, and occasionally through ingestion of contaminated water. Rare cases of person-to-person transmission have been documented (McCormick et al, 1975;Kunakorn et al, 1991;Abbink et al, 2001;Holland et al, 2002).…”