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November 23, 2006  Vol. 355 No. 21

Audio Summary of this Issue

Perspective
2169-2171

On September 30, the New York Times reported that the FDA had issued a warning that the antifibrinolytic drug aprotinin could cause renal failure, congestive heart failure, stroke, and death. Dr. Jerry Avorn writes that many aspects of the aprotinin saga ...

2171-2173

Dr. William Hiatt writes that the recent discussions of aprotinin provide insight into the strengths and weaknesses of using observational data to assess drug safety and highlight the importance of using a transparent and open process when reviewing such ...

2174-2177

We don't know whether the next influenza pandemic will be caused by the H5N1 avian influenza virus. But Drs. Robert Webster and Elena Govorkova write that given the number of cases of H5N1 influenza that have occurred in humans to date (251) and the rate ...

Original Articles
2179-2185

Avian influenza A (H5N1) spread to Turkey in late 2005. These investigators report on the clinical characteristics of 8 of the 12 patients with WHO-confirmed H5N1 infection in Turkey in January 2006, including all the patients who died. Establishing the diagnosis of H5N1 infection was quite challenging and was successfully achieved with the use of a real-time polymerase-chain-reaction assay.

2186-2194

In 2005, multiple cases of avian influenza A (H5N1) virus infection were identified in Indonesia. Three case clusters are reported, involving eight patients with a 50% rate of death, although mild disease was also seen. The outbreak was caused by clade 2 H5N1 virus, and no antiviral resistance was identified.

2195-2202
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In this randomized trial of fetal pulse oximetry, there were no significant differences in the rates of cesarean delivery (overall or for the indication of a nonreassuring fetal heart rate) or in the conditions of infants at birth between women whose clinicians were made aware of the oximetry results and women whose clinicians were not. These findings do not support the use of fetal pulse oximetry in women in labor.

2203-2216

In this trial, patients with acute coronary syndromes undergoing an early invasive approach were randomly assigned to treatment with heparin or enoxaparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin alone. Rates of ischemic events at 30 days were similar for all three groups, whereas major bleeding was significantly reduced in the group receiving bivalirudin alone. The trial suggests that bivalirudin monotherapy may be similar in efficacy to standard therapy, although bivalirudin monotherapy is associated with a reduced risk of bleeding. Pretreatment with a thienopyridine seems to be necessary if bivalirudin monotherapy is used.

Review Articles
2217-2225

This article considers how doctors learn to reason in the clinical environment and recommends practical approaches that clinical teachers can use to promote the development of strong diagnostic reasoning skills in their students.

2226-2235

    This review surveys the data on the increase in the prevalence of asthma in recent decades and finds evidence of a plateau in many Western countries. The authors examine the evidence of possible causal relations to factors such as air pollution, obesity, diet, and exposure to infections, antibiotics, and allergens, including exposures at very young ages. The most strongly supported preventive measure is the avoidance of passive and active exposure to smoke.

    Images in Clinical Medicine
    2236
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    A 38-year-old man was scheduled to undergo invasive coronary angiography after cardiac scintigraphy revealed silent ischemia of the anterior myocardial wall. He was a smoker and had no other medical problems apart from occasional atypical chest pain. ...

    e24
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    This 78-year-old woman presented with dyspnea and a pleural effusion. She had a chronic decubitus ulcer with squamous-cell carcinoma adjacent to the ulcer.

    Case Records of the Massachusetts General Hospital
    2237-2245

      A 35-year-old woman in her second pregnancy was found to have hypertension and glycosuria at 17 weeks' gestation, which persisted despite medication. She was admitted to the hospital. She had had gestational diabetes during her first pregnancy. Serum electrolytes were normal except for a potassium level of 2.6 mmol per liter. Additional laboratory testing and a diagnostic procedure were performed.

      Editorials
      2247-2248

      Intrapartum electronic fetal heart-rate monitoring was introduced with great enthusiasm in the early 1970s. Most cases of cerebral palsy were thought to result from asphyxia during the intrapartum period, and it was hoped that the ability to recognize ...

      2249-2250

      The treatment of patients with acute coronary syndromes is straightforward in principle but complex in practice. With the increase in referrals of moderate- or high-risk patients for invasive cardiac procedures to improve clinical outcomes,1 there is a ...

      2251-2252

      As medical students become physicians, they need to learn to diagnose and manage clinical problems — a process often referred to as developing clinical reasoning skills. Researchers have been exploring the nature of clinical diagnostic reasoning for more ...

      2252-2253
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      In January 2006, we published an article by Mangano and colleagues1 that reported the results of an observational study of antifibrinolytic agents to control bleeding in cardiac surgery. The data suggested that patients treated with aprotinin, as compared ...

      Clinical Implications of Basic Research
      2254-2255

      Molecular pathways that modulate neurotoxicity of the β-amyloid peptide have been delineated; these are controlled by another pathway that modulates aging.

      Correspondence
      2256

      To the Editor: We are impressed by the favorable outcome of deep-brain stimulation, as compared with optimal medical management alone, for levodopa-related motor complications of advanced Parkinson's disease in the study reported by Deuschl et al. (Aug. ...

      2257-2260

      To the Editor: We do not believe that Morrison et al. (Aug. 3 issue)1 focused on the right question in the Termination of Resuscitation (TOR) trial. If saving lives is the issue, the question is: What can early, adequate advanced cardiac life support ...

      2260-2261

      To the Editor: In their study of the efficacy of telithromycin in patients with acute asthma exacerbations, Johnston et al. (April 13 issue)1 discount the risk of acute liver failure. They do not mention that in 2001 an advisory committee of the Food and ...

      2261-2262

      To the Editor: I was troubled by the recent, near-unanimous decision of the Food and Drug Administration (FDA) Cardiovascular and Renal Drugs Advisory Committee publicly advocating the safety of aprotinin1 — despite considerable evidence to the contrary,...

      Book Reviews
      2263-2264

      Mental health policy has had a checkered history over the past half-century, particularly in regard to patients with the most serious and persistent mental disorders. In Better but Not Well, Richard Frank and Sherry Glied, two outstanding health ...

      2264-2265

      It is not very often that we find a single voice with the ability to bridge clinical experience and scholarly investigation and, in doing so, find clarity and a vision that speaks to a broad audience. Bradley Lewis is that voice, coming to us as an ...

      2265-2266

      Pediatric Neuropsychiatry is an intriguing title that conveys a sense of opportunity, but it may also cause some confusion. If, indeed, child and adolescent psychiatry is the medical subspecialty dedicated to the understanding and treatment of a broad ...

      2266-2267

      This book recalls the discovery of the way in which impulses are transmitted from one nerve cell to another. By 1900, it had become clear that the nervous system consists of separate nerve cells rather than having a syncytial structure. The next problem ...

      Correction
      2267
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      Management of Sepsis Review Article, N Engl J Med 2006:355;1699-1713.. On page 1706, the second sentence under the heading Activated Protein C should have read “Therapy with activated protein C (24 μg per kilogram per hour for 96 hours) has been reported,”...

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