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Correspondence
Sildenafil for Severe Lymphatic Malformations
To the Editor: Lymphatic malformations are uncommon congenital vascular anomalies that can cause complications including obstruction of vital organs and their function, recurrent infection, and disfigurement. Current procedural treatments are only partially successful, and lymphatic malformations…
- January 26, 2012
- N Engl J Med 2012; 366:384 - 386
- Free Full Text
Lymphatic malformations are rare but can cause significant clinical problems in addition to cosmetic disfigurement. Sildenafil was used in a child whose pulmonary hypertension was caused by lymphatic malformation; the result was a marked decrease in the lymphatic malformation.
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Original Article
Low-Molecular-Weight Heparin and Mortality in Acutely Ill Medical Patients
Venous thromboembolism is an important complication in hospitalized patients.– It is estimated that if thromboprophylaxis is not administered, objectively diagnosed deep-vein thrombosis — with the potential for fatal pulmonary embolism — will develop in 10 to 20% of medical patients and in 40…
- December 29, 2011
- Kakkar A.K., Cimminiello C., Goldhaber S.Z., et al.
- N Engl J Med 2011; 365:2463 - 2472
- CME
Thromboprophylaxis with low-molecular-weight heparin is known to prevent deep-vein thrombosis in acutely ill medical patients. This large trial showed no effect of enoxaparin on 30-day mortality, which was virtually identical in the active-treatment and placebo groups.
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Images in Clinical Medicine
Pneumopericardium Associated with a Peptic Ulcer
Figure 1.
- December 22, 2011
- Andrianov A. and Nissenbaum M.A.
- N Engl J Med 2011; 365:2412
- Free Full Text
A 63-year-old man with a history of peptic ulcer and recent use of NSAIDs presented to the emergency department with acute shortness of breath and chest pain. He had hypotension and tachycardia.
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Case Records of the Massachusetts General Hospital
Case 39-2011 — A Woman in Her 90s with Unilateral Ptosis
Presentation of Case. Dr. Xuemei Cai (Medicine): A woman in her 90s was seen in the emergency department at this hospital because of ptosis of the left eyelid. The patient had been in her usual health until 4 days earlier when, on awakening, she was unable to open her left eye. She reported no…
- December 22, 2011
- Venna N., Gonzalez R.G., Zukerberg L.R.
- N Engl J Med 2011; 365:2413 - 2422
A woman in her 90s came to the ER because of acute unilateral ptosis. During the next 8 weeks, weakness of the neck, fatigue, choking, and difficulty breathing developed, progressing to respiratory failure and death. An autopsy was performed.
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Case Records of the Massachusetts General Hospital
Case 38-2011 — A 34-Year-Old Man with Diarrhea and Weakness
Presentation of Case. Dr. Andrew Courtwright (Medicine): A 34-year-old man was admitted to this hospital because of diarrhea and weakness. Three days before admission, weakness developed in the patient's right hand, followed by increasing weakness in the left hand. During the next 2 days, weakness…
- December 15, 2011
- Ryan E.T., Cronin C.G., Branda J.A.
- N Engl J Med 2011; 365:2306 - 2316
- CME
A 34-year-old man was admitted to the hospital because of weakness, chronic diarrhea, and weight loss. Initial laboratory evaluation revealed a leukocytosis and hypokalemia. A diagnostic procedure was performed.
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Case Records of the Massachusetts General Hospital
Case 35-2011 — A 33-Year-Old Woman with Postpartum Leukocytosis and Gram-Positive Bacteremia
Presentation of Case. Dr. Edwin C. Huang (Obstetrics and Gynecology): A 33-year-old woman was admitted to the intensive care unit (ICU) at this hospital 16.5 hours post partum because of leukocytosis and gram-positive rods in the blood. The patient had received routine prenatal care at this…
- November 17, 2011
- Soper D.E., Lee S.I., Kim J.Y., McDonald A.G.
- N Engl J Med 2011; 365:1916 - 1924
- CME
A 33-year-old woman was admitted to the ICU 16.5 hours post partum because of leukocytosis and gram-positive rods in the blood. Diagnostic test results were received, and management decisions were made.
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Clinical Therapeutics
Extracorporeal Membrane Oxygenation for ARDS in Adults
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…
- November 17, 2011
- Brodie D. and Bacchetta M.
- N Engl J Med 2011; 365:1905 - 1914
- CME
A 41-year-old woman presents with severe pneumonia, and the acute respiratory distress syndrome (ARDS) develops. Despite mechanical ventilation, her oxygenation deteriorates. The use of extracorporeal membrane oxygenation (ECMO) is recommended.
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Images in Clinical Medicine
Traumatic Diaphragmatic Hernia
Figure 1.
- October 6, 2011
- Picetti E. and Mergoni M.
- N Engl J Med 2011; 365:e30
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A 6-year-old boy presented to the hospital after several hours of vomiting and dyspnea. He had been in a motor-vehicle accident 6 months earlier and had sustained a seatbelt injury that necessitated surgical repair of a right diaphragmatic hernia.
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Images in Clinical Medicine
Ortner's Syndrome
Figure 1.
- September 8, 2011
- Prada-Delgado O. and Barge-Caballero E.
- N Engl J Med 2011; 365:939
- Free Full Text
A 62-year-old woman presented with a 2-year history of progressive vocal hoarseness. She had had mitral-valve replacement for rheumatic mitral stenosis 21 years earlier, but her severe pulmonary hypertension had not resolved, and progressive clinical manifestations had developed.
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Original Article
Early versus Later Rhythm Analysis in Patients with Out-of-Hospital Cardiac Arrest
Out-of-hospital cardiac arrest is a common and lethal problem, leading to an estimated 330,000 deaths each year in the United States and Canada. Overall, the rate of survival to hospital discharge among patients with an out-of-hospital cardiac arrest who are treated by emergency medical services…
- September 1, 2011
- Stiell I.G., Nichol G., Leroux B.G., et al.
- N Engl J Med 2011; 365:787 - 797
- CME
Patients with cardiac arrest were assigned to either early analysis of cardiac rhythm (after 30 to 60 seconds of cardiopulmonary resuscitation) or later analysis (after 180 seconds). There was no significant difference between the groups in survival to hospital discharge.
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Original Article
A Trial of an Impedance Threshold Device in Out-of-Hospital Cardiac Arrest
Standard cardiopulmonary resuscitation (CPR), defined as manual chest compressions with rescue breathing, can be lifesaving but provides only a relatively small fraction of normal cardiac output, even when performed correctly. One proposed strategy to augment cardiac output during CPR is the use of…
- September 1, 2011
- Aufderheide T.P., Nichol G., Rea T.D., et al.
- N Engl J Med 2011; 365:798 - 806
Patients with out-of-hospital cardiac arrest were assigned to the use of either an impedance threshold device (ITD) or a sham ITD. There was no significant difference between the two groups in survival to hospital discharge with satisfactory functional status.
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Editorial
Cardiac Arrest and the Limitations of Clinical Trials
Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for more than 30 years. In this issue of the Journal, the…
- September 1, 2011
- Sanders A.B.
- N Engl J Med 2011; 365:850 - 851
Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for more than 30 ...
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Editorial
Nutrition Support in Critical Illness — Bridging the Evidence Gap
The modern field of specialized nutrition support began with seminal studies showing that parenteral nutrition could stimulate growth and development in infants, as well as wound healing and convalescence in adults with the severe short bowel syndrome, who until that time had been unable to survive…
- August 11, 2011
- Ziegler T.R.
- N Engl J Med 2011; 365:562 - 564
The modern field of specialized nutrition support began with seminal studies showing that parenteral nutrition could stimulate growth and development in infants, as well as wound healing and convalescence in adults with the severe short bowel syndrome, ...
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Original Article
Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection
Pleural infection affects more than 65,000 patients each year in the United States and the United Kingdom, and the incidence is increasing in both countries — in both children– and adults. The mortality rate from pleural infection is between 10% and 20%,,– and drainage through a chest tube…
- August 11, 2011
- Rahman N.M., Maskell N.A., West A., et al.
- N Engl J Med 2011; 365:518 - 526
- Free Full Text
- CME
Slowly clearing infections in the pleural space are a source of substantial morbidity. This study showed that instillation of recombinant DNase and tissue plasminogen activator (t-PA) is more effective than placebo in clearing radiographic pleural effusions.
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Original Article
Early versus Late Parenteral Nutrition in Critically Ill Adults
Critical illness induces anorexia and the inability to eat normally, predisposing patients to serious nutritional deficits, muscle wasting, weakness, and delayed recovery. Whether artificial nutritional support improves the outcome for critically ill patients is unclear. The administration route,…
- August 11, 2011
- Casaer M.P., Mesotten D., Hermans G., et al.
- N Engl J Med 2011; 365:506 - 517
- Free Full Text
This controlled, randomized, multicenter trial compared early initiation (<2 days) with late initiation (≥8 days) of parenteral nutrition in adults in the intensive care unit. Late initiation was associated with less morbidity and enhanced recovery.
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Clinical Problem-Solving
Looking at the Whole Picture
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 50-year-old woman presented with…
- August 4, 2011
- Donagh C., Bruzzi J., MacNeill B., et al.
- N Engl J Med 2011; 365:448 - 453
- CME
- Video
A 50-year-old woman presented with rapidly progressive shortness of breath. Five months earlier, she had received a diagnosis of invasive breast carcinoma and had undergone mastectomy. Her fifth cycle of chemotherapy was completed 10 days before presentation.
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Images in Clinical Medicine
“Thumb Sign” of Epiglottitis
Figure 1.
- August 4, 2011
- Grover C.
- N Engl J Med 2011; 365:447
- Free Full Text
A 58-year-old man presented to the ER after having had severe throat pain, hoarseness, and fever for 2 days. There was no stridor, respiratory distress, or drooling, and oropharyngeal examination was unremarkable. A lateral soft-tissue radiograph of the neck showed a “thumb sign.”
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Case Records of the Massachusetts General Hospital
Case 23-2011 — A 40-Year-Old Pregnant Woman with Placenta Accreta Who Declined Blood Products
Presentation of Case. Dr. Britta Panda (Obstetrics and Gynecology): A 40-year-old woman was seen by the maternal–fetal medicine service at this hospital at 22 weeks 2 days' gestation because of placenta previa and placenta accreta. Beginning at 12 weeks 1 day's gestation, the patient had received…
- July 28, 2011
- Barth W.H., Kwolek C.J., Abrams J.L., Ecker J.L., Roberts D.J.
- N Engl J Med 2011; 365:359 - 366
- CME
A 40-year-old woman was seen by the maternal–fetal medicine service of this hospital at 22 weeks 2 days' gestation because of placenta previa and placenta accreta. She declined transfusions of blood products because of her religious beliefs. Management decisions were made.
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Review Article
Current Concepts: Rapid-Response Teams
Rapid-response teams have been introduced to intervene in the care of patients with unexpected clinical deterioration. These teams are key components of rapid-response systems, which have been put in place because of evidence of "failure to rescue" with available clinical services, leading to…
- July 14, 2011
- Jones D.A., DeVita M.A., Bellomo R.
- N Engl J Med 2011; 365:139 - 146
Rapid-response teams aim to care for inpatients in whom acute respiratory, neurologic, or cardiac insufficiency is developing. This review describes the prevalence and consequences of sudden critical illness outside the ICU and discusses the rationale for rapid-response systems.
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Images in Clinical Medicine
Angioedema
Figure 1.
- July 14, 2011
- Bramante R.M. and Rand M.
- N Engl J Med 2011; 365:e4
- Free Full Text
A 71-year-old man presented to the ER with rapidly progressive tongue swelling. Examination revealed a swollen tongue and no hypotension, rash, bronchospasm, urticaria, or flushing. The patient had no recent exposures to known food allergens, new medications, or insect stings.
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Medical Meetings Conferences and Meetings

American Association for the Study of Liver Diseases

The following courses will be offered in Atlanta, unless otherwise indicated: "Hepatitis Single Topic Conference: HCV Direct Antiviral Agents (DAA): Concepts, Development and Optimal Use" (March 16 and 17); "The Henry M. and Lillian Stratton Basic Research Single Topic Conference: Mitochondria and Hepatotoxicity" (June 8 and 9); "Clinical Research Single Topic Conference: Acetaminophen Poisoning" (June 9 and 10); and "63rd Annual Meeting of the American Association for the Study of Liver Diseases: The Liver Meeting 2012" (Boston, Nov. 9-13).

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