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October 9, 2008  Vol. 359 No. 15

Audio Summary of this Issue

Perspective
1537-1541

Doctors and other health care providers work in extraordinary times and have unrivaled abilities, but increasingly our health care system gets in the way of their sound medical judgment. Senator Barack Obama writes that reform must emphasize prevention, ...

1537-1541

Americans deserve leadership for real health care reform that provides access to high-quality medical care and ends spiraling costs. Senator John McCain writes that our challenge is to protect and improve the care that doctors, nurses, and hospitals ...

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The future of health care in the United States — access, cost, and quality — is a critical issue in the 2008 presidential election. On September 12, senior health policy advisors — David Cutler of Harvard University for Democrat Barack Obama and Gail ...

Original Articles
1543-1554

In this large, randomized trial, the investigators compared outcomes in patients with chronic obstructive pulmonary disease (COPD) treated with once-daily inhalation of tiotropium or placebo. There was no benefit of treatment on the rate of loss of lung function over time, although benefits were observed in some secondary end points.

1555-1564

Influenza infection causes significant morbidity in pregnant woman and neonates. In this randomized study of 340 pregnant women in Bangladesh, influenza vaccination during pregnancy was found to decrease laboratory-proven influenza infection in neonates by 63% and febrile respiratory illness in the mothers by more than a third.

1565-1576
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A post-trial monitoring study involving follow-up of patients with type 2 diabetes who had been assigned to tight or less-tight blood-pressure control revealed that benefits of previously improved control were not sustained when between-group blood-pressure differences equalized. Early improved blood-pressure control in patients with type 2 diabetes and hypertension was associated with a reduced risk of complications, but it must continue for benefits to be sustained.

1577-1589
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This trial was conducted to determine whether the reduction in microvascular risk and improved glycemic control that had been observed with medical therapy, as compared with conventional dietary treatment, in patients with newly diagnosed type 2 diabetes was sustained during 10 years of follow-up. Despite an early loss of glycemic differences, continued microvascular risk reduction and emergent risk reductions for myocardial infarction and death from any cause were observed.

Clinical Therapeutics
1590-1601

A 45-year-old woman with breast cancer elects to undergo mastectomy and is referred to a plastic surgeon for evaluation for postmastectomy breast reconstruction. For some patients, breast reconstruction restores body image and sexuality and improves the quality of life. Reconstructive surgery does not interfere with detection of breast-cancer recurrence. Special considerations apply to patients who require radiation therapy.

Videos in Clinical Medicine
e18

    Placement of umbilical catheters is an important skill for the treatment of critically ill neonates. Catheters can provide vascular access for resuscitation, monitoring, fluid administration, blood transfusion, and parenteral nutrition. This video demonstrates the placement of both umbilical-artery and umbilical-vein catheters.

    Images in Clinical Medicine
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    A 61-year-old man with small lymphocytic lymphoma–chronic lymphocytic leukemia presented with neck stiffness and bilateral axillary discomfort associated with increasing, diffuse lymphadenopathy. He had received the diagnosis of small lymphocytic lymphoma–...

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    A cough plume may project infectious aerosols into the surrounding air. Sequential images recorded at 3000 frames per second reveal several phases of cough airflow.

    Case Records of the Massachusetts General Hospital
    1603-1614

    A 39-year-old man was admitted to this hospital because of chest pain, arthralgias, and a mediastinal mass. He had had pericarditis 1 year earlier and optic neuritis 5 years earlier. On examination, the first heart sound was absent, the second was loud with a prominent split, and there was a new systolic ejection murmur at the left upper sternal border. Imaging showed an infiltrative mediastinal mass surrounding the aorta and narrowing the lumen of the main and right pulmonary arteries.

    Editorials
    1616-1618

    In 1976, Fletcher et al. published a monograph summarizing the results of an 8-year observational study of the relationship between cigarette smoking, chronic expectoration, and the development of irreversible airflow obstruction.1 At that time, the ...

    1618-1620

      The United Kingdom Prospective Diabetes Study (UKPDS) continues to produce important evidence concerning the evolution of type 2 diabetes and its management. Two studies published in this issue of the Journal provide some answers to two questions of ...

      Clinical Decisions
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      This interactive feature presented the case of a 20-year-old basketball player with acute onset of a red, painful area on his right buttock over the previous 2 days. Readers were invited to vote for one of three possible treatment options.

      Clinical Implications of Basic Research
      1621-1623

      Lethality caused by the H5N1 influenza virus is partly attributed to a “cytokine storm” in the lung, mediated by prostaglandin E2 (PGE2). A recent study shows that mice infected with the virus and treated with an antiviral agent and a PGE2 inhibitor are better able to survive than mice treated with an antiviral agent alone.

      Correspondence
      1624-1625

      To the Editor: Gueugniaud et al. (July 3 issue)1 report that administering the combination of vasopressin and epinephrine, as compared with epinephrine alone, during advanced cardiac life support for out-of-hospital cardiac arrest does not improve ...

      1626

      To the Editor: Evaluating systemwide fall-prevention programs is crucial for translating the now substantial trial-based evidence of the efficacy of certain fall-prevention measures. Tinetti et al. (July 17 issue)1 report a 9% reduction in serious fall-...

      1626-1629

      To the Editor: In the study reported by Groh et al. (June 19 issue),1 during long-term follow-up of patients with myotonic dystrophy type 1, 81 of 406 patients died and one third of the deaths were sudden. How many of these deaths were really due to ...

      1629-1631

      To the Editor: In the Case Record, Busse et al. (June 19 issue)1 discuss a case of Merkel-cell carcinoma in a patient with human immunodeficiency virus (HIV) infection. We disagree with the discussants about similarities between Merkel-cell carcinoma and ...

      1631-1633

      The authors report on an open-label study of an MF59-adjuvanted vaccine against avian influenza. The findings indicate that priming subjects with H5 antigen induces a rapidly mobilized, long-lasting immune memory after the administration of low-dose, ...

      Book Reviews
      1634-1635

      Disorders that cause genitourinary pain and inflammation are common and can be life-altering because of their effects on the quality of life. In the preface of this book, editor Jeannette M. Potts states, “Any physician who sees men or women for signs or ...

      1635

      Renal-cell carcinoma actually comprises a heterogeneous group of diseases with varying clinical presentations, all of which require a multidisciplinary approach to treatment, with contributions from urologists, pathologists, medical oncologists, ...

      1635-1636

      There is a complex emotional, social, and cultural overlay to the experience and treatment of breast disease that makes breast cancer unique. Although physician and historian Robert Aronowitz drew from the writings of key patients, physicians, and cancer ...

      1637

      Anyone who has had even one poor night of sleep will immediately recognize the substantial impact of sleep disturbance on quality of life. Sleep and Quality of Life in Clinical Medicine explores this problem under a magnifying glass.

      The first few ...

      Corrections
      1637

      Human Papillomavirus and Papanicolau Tests to Screen for Cervical Cancer Original Article, N Engl J Med 2007:357;1589-1597.. Bo Johansson, Ph.D., should be listed as the ninth author (page 1589, between Drs. Strander and Forslund). The article has been ...

      1637

      Arthroscopic Surgery for Osteoarthritis of the Knee? Editorial, N Engl J Med 2008:359;1169-1170.. The second sentence of the fifth paragraph (page 1169) should have begun, “In this issue of the Journal, Englund et al. report a high prevalence of meniscal ...

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