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DRUG INFORMATICS CENTER
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St. Anywhere Hospital
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QUESTION
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A young, adult male patient recently arrived from Japan and presented to the physician sparse medical records indicating he is suffering from tsutsugamushi disease. Because of the language difficulties, little is known about the patient, other than he is taking drug X for the illness. Physical examination reveals a patient in some discomfort with elevated temperature, swollen lymph glands, and red rash. All other findings appear to be normal. (Note: The person answering this question obtained as much background as possible about the patient.) The physician has little information on the disease and would like to know if that drug X is the most appropriate treatment.

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ANSWER
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Tsutsugamushi disease is an acute infectious disease seen in harvesters of hemp in Japan.1 It is caused by Rickettsia tsutsugamushi. Common symptoms of the disease include fever, painful swelling of the lymph glands, a small black scab in the genital region, neck or axilla, and large dark-red papules. The disease is known by a number of other names, including akamushi disease, flood fever, inundation fever, island disease, Japanese river fever, and scrub typhus.2-4 (Note: Background information presented.) The standard treatment of the disease includes either drug X or drug Y, although there are several other less effective treatments.5-7 In the remainder of this paper, a comparison of the two major drugs will be presented. (Note: Clear objective for paper is presented.)

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A thorough search of the available literature was conducted. Unfortunately, there were few textbooks available on this disease. A search of MEDLINE® (1966 to present) and EMBASE’s Drugs and Pharmacology (1980 to present) produced a number of articles that were obtained and are reviewed below. (Note: This documents the type of search and acts as a lead-in to the remainder of the body of the paper.)

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Smith and Jones8 performed a double-blind, randomized comparison of the effects of drug X and drug Y in patients with tsutsugamushi fever. Patients were required to be between 18 and 70 years old, and could not have any concurrent infection or disorder that would affect the immune response to the disease (e.g., neutropenia, AIDS). Twenty patients received 10 mg of drug X three times a day for 15 days. Eighteen patients received 250 mg of drug Y twice a day for 10 days. The two groups were comparable, except that the patients receiving drug X were an average of 5 years younger (p < 0.05). Drug X was shown to produce a cure, both in terms of symptoms and cultures in 85% of patients, whereas drug Y only produced a cure in 55.5% of patients. The difference was statistically significant (p < 0.01). No significant adverse effects were seen in either group. Although it appears that drug X was the better agent, it should be noted that drug Y was given at its minimally effective dose, and may have performed better in a somewhat higher dose or longer regimen. (Note: Evaluative comments made about article.)

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