Latest Articles Include:
- Buying Health Care, the Individual Mandate, and the Constitution
Rosenbaum S Gruber J - N Engl J Med 363(5) (2010)
In Rashomon, a classic film that explores the concept of truth, director Akira Kurosawa presents a story about a single incident retold by four narrators, leaving the audience to figure out what is real. Litigation has a Rashomon-like quality to it: two sides meet in a courtroom and each presents its case, arguing not only that abstract legal principles favor its cause, but equally important, that its version of the event that gave rise to the dispute should be the filter through which the court decides the matter. Three separate cases raising constitutional challenges to the Affordable Care Act .
- The SGR for Physician Payment â" An Indispensable Abomination
Aaron HJ - N Engl J Med 363(5) (2010)
Congress has just extended the life of the sustainable growth rate (SGR) â" the formula that Medicare uses to calculate physicians' fees â" for 6 more months. The SGR was enacted in 1998 to hold down the growth of these fees. It replaced a formula with the same objective that wasn't working. It ties the annual growth of Medicare fees to growth of the real gross domestic product, Medicare caseloads, and practice costs. But it ignores the principal reason that health care spending outpaces income growth: the increasing number and complexity of medical interventions. The SGR purports to control total .
- Geographic Variation in Medicare Drug Spending
Zhang Y Baicker K Newhouse JP - N Engl J Med 363(5) (2010)
The widespread geographic variation in Medicare spending has garnered a great deal of attention in the health care reform debate, both as a marker of inefficient resource use and as a window into potential strategies for improving the quality and value of U.S. health care. Analyses to date, however, have focused solely on inpatient and outpatient spending (Parts A and B) and have lacked information on pharmaceutical spending (Part D). With drug spending accounting for a rising share of total health care spending, these data limitations hinder interpretation of the variation in spending: do Medicare patients who spend more on .
- The Renaissance in HIV Vaccine Development â" Future Directions
Koff WC Berkley SF - N Engl J Med 363(5) (2010)
From July 18 through July 23, 2010, delegates from around the globe will convene for the biennial International AIDS Conference in Vienna. They will discuss our current risk of losing the war against the human immunodeficiency virus (HIV). Despite an unprecedented outpouring of resources and proliferation of programs, today, for every two patients who begin receiving treatment for HIV, five people are newly infected. Furthermore, new guidelines from the World Health Organization recommending that infected persons begin receiving treatment earlier will significantly increase the number of patients targeted for therapy. If we are to control this pandemic, we must recognize .
- Sipuleucel-T Immunotherapy for Castration-Resistant Prostate Cancer
- N Engl J Med 363(5):411-422 (2010)
Prostate cancer is the most common noncutaneous cancer among men in the United States and is the second leading cause of death from cancer in men.1 Localized prostate cancer may be cured with surgery or radiation therapy, but the disease recurs in approximately 20 to 30% of patients. Androgen-deprivation therapy, the most common treatment after recurrence, is effective, but the disease eventually progresses in most patients who receive such treatment.2 For men with metastatic castration-resistant prostate cancer, the median survival in recent phase 3 studies has ranged from 12.2 to 21.7 months.3â"9 A chemotherapeutic agent, docetaxel, is the only .
- CPR with Chest Compression Alone or with Rescue Breathing
- N Engl J Med 363(5):423-433 (2010)
Out-of-hospital cardiac arrest claims hundreds of thousands of lives each year worldwide.1,2 Successful resuscitation is challenging but achievable, requiring an interdependent set of actions that consist of early arrest recognition, early cardiopulmonary resuscitation (CPR), early defibrillation, expert advanced life support, and timely postresuscitation care.3 Early initiation of CPR by a layperson can increase the patient's chances of surviving and having a favorable long-term neurologic recovery.4,5 CPR performed by a layperson has traditionally consisted of chest compressions interspersed with rescue breathing, which allows some measure of both circulation and oxygenation.6 Interest in CPR that focuses on chest compressions and .
- Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest
- N Engl J Med 363(5):434-442 (2010)
Emergency medical dispatch centers are crucial in supporting and giving instructions to witnesses or bystanders who call for help for patients with cardiac arrest before the arrival of emergency medical services (EMS) personnel.1 Telephone instructions given for cardiopulmonary resuscitation (CPR) seem to be given predominantly for CPR involving chest compression.2 Using an animal model, Berg and colleagues3 found that compression-only CPR and standard CPR (i.e., CPR involving both compression and ventilation) have similar efficacy. In a clinical study in which dispatchers gave randomly assigned instructions to callers for aid to patients with cardiac arrest â" to attempt resuscitation with the .
- A School-Based Intervention for Diabetes Risk Reduction
The HEALTHY Study Group - N Engl J Med 363(5) (2010)
Recent data indicate that 16% of children 6 to 19 years of age in the United States are overweight, and 19% are obese.1 Rates are even higher in economically disadvantaged ethnic minority groups.2 Of all the consequences of childhood obesity,3â"5 the most serious is the development of type 2 diabetes. Children in whom type 2 diabetes develops are at risk for complications from the disease, including retinopathy, neuropathy, and cardiovascular and renal disease, that can be manifested when they are adults, if not earlier. Schools present opportunities for reducing the risk of diabetes, since no other institution has as .
- Acupuncture for Chronic Low Back Pain
- N Engl J Med 363(5):454-461 (2010)
Foreword This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the authors' clinical recommendations. Stage A 45-year-old construction worker with a 7-year history of intermittent low back pain is seen by his family physician. The pain has gradually increased over the past 4 months, despite pain medications, physical therapy, and two epidural corticosteroid injections. The pain is described as a dull ache in the lumbosacral area with episodic aching in the posterior aspect of both thighs; it worsens with prolonged standing and sitting. He is concerned about losing his job, while at the same time worried that continuing to work could cause further pain. The results of a neurologic examination and a straight-legâ"raising test .
- Pneumothorax â" An Uncommon Complication of a Common Procedure
- N Engl J Med 363(5):462-462 (2010)
A 92-year-old woman was admitted to the hospital with a severe left-sided ischemic stroke causing altered mental status (i.e., a score of 9 on the Glasgow Coma Scale, on which scores range from 3 to 15, with higher scores indicating increased consciousness), weakness on the right side, and dysphagia. An initial attempt to insert a small-caliber nasogastric tube for feeding was unsuccessful, with coiling of the tube in the mouth. A subsequent attempt with a stiff stylet resulted in easy insertion, without cough or respiratory distress. While awaiting radiography to confirm positioning of the tube, the patient had shortness of .
- Serpentine Supravenous Hyperpigmentation
- N Engl J Med 363(5) (2010)
A 61-year-old man with recently diagnosed, inoperable esophageal squamous-cell carcinoma was treated with induction chemotherapy combining cisplatin and fluorouracil and concurrent radiotherapy. Because of worsening renal function, the use of cisplatin was suspended, and the chemotherapy was shifted to weekly high-dose fluorouracil and leucovorin. After the seventh infusion of fluorouracilâ"leucovorin, thrombosis developed in the right jugular and subclavian veins. This venous thrombosis prohibited further use of the permanent tunneled central-infusion catheter. The eighth infusion of fluorouracilâ"leucovorin was administered continuously over a 24-hour period by means of a peripheral catheter in the left forearm. A day later, the patient noticed a .
- Case 23-2010
- N Engl J Med 363(5):463-475 (2010)
Presentation of Case Dr. David B. Sykes (Hematologyâ"Oncology): A 49-year-old man was admitted to this hospital because of erythrocytosis, perinephric collections of fluid, and acute renal failure. The patient had been well until 7 years earlier, when routine testing at another facility revealed a hematocrit of 58.1%; the level of erythropoietin was 16.2 mIU per milliliter (reference range, 4.1 to 19.5). Ultrasonography of the abdomen reportedly revealed normal-size kidneys, with no hydronephrosis or cysts, and several hepatic lesions (approximately 1 cm in diameter) that were consistent with hemangiomas. A presumptive diagnosis of polycythemia vera was made, and therapeutic phlebotomy was .
- Don't Mess with the DSMB
Drazen JM Wood AJ - N Engl J Med 363(5) (2010)
If the lyrics of the popular Jim Croce song from the early 1970s were adapted for a clinical trialist anthem, the refrain would likely be You don't tug on Superman's cape You don't spit into the wind You don't pull the mask off that old Lone Ranger And you don't mess around with the DSMB. Since the DSMB (data and safety monitoring board) is charged with ensuring that clinical equipoise is maintained as trial data are accrued, it is considered very bad, even self-destructive, behavior for people who are involved with the study to interact with DSMB members on trial-related .
- New Therapies for Castration-Resistant Prostate Cancer
- N Engl J Med 363(5):479-481 (2010)
On April 29, 2010, the Food and Drug Administration (FDA) approved a new immunotherapy, sipuleucel-T, for the treatment of patients with asymptomatic or minimally symptomatic castration-resistant prostate cancer. Traditionally, immune-based therapies have been categorized according to whether the agent has direct antitumor effects (so-called passive immunotherapy) or stimulates a host antitumor response (active immunotherapy) and whether the agent elicits a general increase in immune activation (nonspecific) or an immune response based on tumor recognition (specific). Sipuleucel-T is a form of active specific immunotherapy. The sipuleucel-T intervention involves harvesting the patient's peripheral-blood mononuclear cells (PBMCs), culturing them with a chimeric protein .
- In CPR, Less May Be Better
- N Engl J Med 363(5):481-483 (2010)
Fifty years have passed since Kouwenhoven, Jude, and Knickerbocker1 proposed external chest compression to provide circulation of blood to the brain and heart after cardiac arrest. Shortly thereafter, mouth-to-mouth rescue breathing was adopted as an essential addition to this lifesaving procedure. Since that time, there has been very little fundamental change in the method or manner of cardiopulmonary resuscitation (CPR). Decades of observational studies have shown that survival is improved if CPR is performed by bystanders rather than being provided only when emergency medical services (EMS) staff arrives. The use of automated external defibrillators by bystanders and the use of .
- Response to Dengue Fever â" The Good, the Bad, and the Ugly?
- N Engl J Med 363(5):484-487 (2010)
Dengue may be the most widespread arboviral illness worldwide. Most patients with dengue infection have only mild disease or classic dengue fever, with influenza-like symptoms, severe headache, and aching joints and muscles. However, in a small percentage of patients â" maybe half a million people every year â" potentially lethal forms of dengue called dengue hemorrhagic fever and dengue shock syndrome develop. It has been known for many years that antibodies directed against either of the two surface proteins of the dengue virus (the precursor membrane protein and the envelope protein) can neutralize infectivity and confer protection, although envelope protein .
- Duration of Clopidogrel Therapy with Drug-Eluting Stents
- N Engl J Med 363(5):488-490 (2010)
To the Editor: In their article about the duration of dual antiplatelet therapy after implantation of drug-eluting stents, Park and colleagues (April 15 issue)1 report that the use of extended dual antiplatelet therapy in patients who had received drug-eluting stents was not significantly more effective than aspirin monotherapy in reducing the rate of myocardial infarction or death from cardiac causes. Yet the rate of a composite of myocardial infarction, stroke, or death from any cause was nearly significantly higher in patients receiving extended dual antiplatelet therapy than in those receiving aspirin alone. These results are unpredictable and thus are difficult .
- Physician Cost Profiling
- N Engl J Med 363(5):491-493 (2010)
To the Editor: Adams et al. (March 18 issue)1 highlight problems in the use of claims data to profile physicians. We agree caution is necessary, but not all âprofilingâ is problematic. Three modifications can improve estimates: excluding infrequent and expensive items outside the physician's control, focusing on the primary care physician, and being condition-specific. For the profiling of resource use (i.e., cost) related to specific chronic illnesses, we recommend setting aside inpatient care. We evaluated data on 20,073 year-long episodes of care for patients with diabetes (excluding inpatient costs) in a large medical group in 2006, 2007, and 2008. Costs .
- Outpatient Management of Severe COPD
- N Engl J Med 363(5):493-495 (2010)
To the Editor: Niewoehner (April 15 issue)1 reports that there are no serious safety problems associated with inhaled bronchodilators. We disagree. First, the Towards a Revolution in COPD Health trial (TORCH; ClinicalTrials.gov number, NCT00268216) showed a significantly increased risk of serious pneumonia with the use of long-acting beta-agonist combinations (relative risk with inhaled corticosteroids plus long-acting beta-agonists vs. long-acting beta-agonists, 1.58; 95% confidence interval [CI], 1.24 to 2.01).2 Second, there was a significantly increased risk of intestinal obstruction (reported as adverse events) with the use of tiotropium (relative risk, 5.55; 95% CI, 1.24 to 24.8) in the Understanding Potential Long-Term .
- What's Keeping Us So Busy in Primary Care?
- N Engl J Med 363(5):495-496 (2010)
To the Editor: The article by Baron (April 29 issue)1 paints a fascinating picture of the reality of a five-member single-specialty primary care group practice. One interesting aspect of that practice is that although it employed four medical assistants, five front-desk staff, one business manager, and one billing manager, it did not have any nurse or midlevel practitioners on board at the time of the study. After the study, they hired a registered nurse (RN) to take on âinformation triageâ to reduce some of the physicians' workload. This is a good example of the value of an electronic health record, .
- PLA2R Autoantibodies and Recurrent Membranous Nephropathy after Transplantation
- N Engl J Med 363(5):496-498 (2010)
To the Editor: Membranous nephropathy is a leading cause of the nephrotic syndrome in adults. One third of patients have a progressive loss of renal function and reach end-stage renal disease.1 Membranous nephropathy recurs in up to 40% of patients after renal transplantation.2 Recently, Beck et al.3 found that patients with membranous nephropathy had circulating autoantibodies against M-type phospholipase A2 receptor (PLA2R), which in the kidney is exclusively expressed on glomerular podocytes. Binding of PLA2R autoantibodies to this receptor is responsible for the induction of idiopathic membranous nephropathy.4 We report findings regarding a 56-year-old female patient with biopsy-proven membranous .
- Pay-for-Performance System for English Physicians
- N Engl J Med 363(5):498-498 (2010)
Pay-for-Performance System for English Physicians Correspondence, N Engl J Med 2008:359;2176-2177. In Table 1 (page 2177), the Exception rate should have been equal to ân2/Ntotal, n3/Ntotal,â rather than ân1/Ntotal, n3/Ntotal.â We regret the error. The article has been corrected at NEJM.org.
- Low Diagnostic Yield of Elective Coronary Angiography
- N Engl J Med 363(5):498-498 (2010)
Low Diagnostic Yield of Elective Coronary Angiography Original Article, N Engl J Med 2010:362;886-895. In Table 2 (page 892), the value of the Adjusted Odds Ratio in the âNot requiring dialysisâ row under âRenal failureâ should have been â1.15,â rather than â1.45.â The article has been corrected at NEJM.org.
- Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis
- N Engl J Med 363(5):498-498 (2010)
Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis Original Article, N Engl J Med 2010:363;11-23. In the third paragraph of the Discussion section (page 21), the third sentence should have ended â.