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November 12, 2009  Vol. 361 No. 20

Audio Summary of this Issue

Perspective
1917-1919
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Alfred Engelberg and Drs. Aaron Kesselheim and Jerry Avorn discuss proposed bills that would guarantee manufacturers 12 years of market exclusivity for a new biologic agent before any biosimilar product could be approved.

1919-1921

Drs. Margaret Danchin and Julie Bines write that the global recommendation for rotavirus vaccination marks a major step toward reducing the contribution of rotavirus to child mortality. However, 86% of deaths due to rotavirus occur in Africa and Asia, ...

1922-1923

    Dr. Ranjana Srivastava accepted an invitation to speak at a semiannual ecumenical service for deceased oncology patients. In this essay, she describes this deeply humanizing experience.

    e42

    Many German observers are bewildered over the U.S. health care reform debate. Most Europeans see affordable health insurance for everyone as a fundamental element of a stable and prosperous society — an element founded on the principle of communal ...

    e43

    In the current political environment, forging consensus on health care reform has proven challenging. Yet the value of a strengthened primary care infrastructure is one apparent zone of agreement among policymakers. Leading professional societies have ...

    Other Points of View
    e106
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    Underlying the debate over health care reform are two competing visions of medicine. According to one vision, medicine aims to care for people in their communities and to provide affordable health care that counterbalances the effects that inequities of ...

    Original Articles
    1925-1934

    In this study, a consortium of intensive care units (ICUs) in Australia and New Zealand reported their experience with admissions associated with infection with the 2009 H1N1 virus. The overall rate of ICU admission was estimated to be 28.7 per million persons, approximately 15 times that in previous years. During the period of peak transmission in communities, the ICU bed-occupancy rate ranged from 8.9 to 19.0%.

    1935-1944

    Pandemic influenza A (H1N1) virus has spread rapidly around the world during the past 6 months. In this report, investigators from the Centers for Disease Control and Prevention (CDC) describe the clinical characteristics of the earliest patients who were hospitalized with the virus in the United States, during a 2-month period in the spring of 2009.

    1945-1952

    Using stored serum samples from blood donors and subjects in previous influenza vaccine trials, CDC investigators found that vaccination with the routine trivalent seasonal influenza vaccine induced little immunity against the current pandemic H1N1 virus and that 34% of subjects born before 1950 had some immunity to this pandemic virus.

    1953-1962

    In a clinical trial, 806 patients with renovascular disease were randomly assigned either to undergo percutaneous revascularization with medical therapy or to receive medical therapy alone. At a median follow-up of 34 months, the rate of decline in renal function (the primary end point) did not differ significantly between the two groups. Serious complications of revascularization occurred in 23 patients.

    Special Article
    1963-1971
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    This article compares outcomes specified in research protocols with those described in published reports for trials of off-label use of gabapentin that were sponsored by the manufacturer. The authors had access to internal company documents; the article details discrepancies between the published record and the research plans.

    Clinical Practice
    1972-1978
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    A 73-year-old former smoker with a history of hypertension presents with shortness of breath. His blood pressure is 160/75 mm Hg, and his serum creatinine level is 1.4 mg per deciliter. Chest auscultation reveals diffuse rales. His condition improves with diuretics. Imaging shows a diseased aorta and a high-grade ostial lesion of the left renal artery. How should he be further evaluated and treated?

    Images in Clinical Medicine
    1979
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    A 45-year-old man presented to the emergency room with abdominal pain that had been increasing over the previous week and hematemesis and melena that had begun in the preceding 12 hours. He had drunk 36 alcoholic drinks per day for 20 years and had been ...

    e44
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    A 61-year-old man presented with painless white lesions on his tongue. He had been treated with topical and systemic antifungal drugs for presumed oral candidiasis, but the lesions remained unchanged.

    Interactive Medical Case
    e45
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    • CME

    A 31-year-old woman in the 37th week of pregnancy presented to the emergency department with severe bitemporal headache and shortness of breath. Direct the investigation of the case, test your diagnostic and therapeutic skills, and compare your performance with that of others at NEJM.org.

    Case Records of the Massachusetts General Hospital
    1980-1989

    A 60-year-old man with diabetes mellitus and a history of renal transplantation was admitted to this hospital because of mental-status changes, diarrhea, renal insufficiency, diabetic ketoacidosis, and hypotension. On examination, the patient appeared cachectic and confused. Ultrasonographic examination of the pelvis showed the transplanted kidney with a well-circumscribed, rounded, focal hypoechoic lesion within the upper pole. On the fourth hospital day, respiratory distress developed that required mechanical ventilation.

    Editorial
    1991-1993
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    In 1743, when disease was presumed to be astral in origin, European newspapers reported on a contagious influence (influenza in Italian) that was being visited on the citizens of Rome. Two hundred years later, Wilson Smith and colleagues would isolate an ...

    Correspondence
    1994-1996

    To the Editor: In their article, de Boer et al. (Aug. 13 issue)1 suggest that adjuvant systemic therapy may improve disease-free survival in breast cancer. However, the apparent treatment effect may also be due to imbalances in prognostic and predictive ...

    1996-1997

    To the Editor: Cognitive decline is a complex multifactorial process, and so it is important to exclude as many potentially confounding variables as possible when assessing the influence of a single factor. In their longitudinal study, Caselli and ...

    1997-1998

    To the Editor: Wibom et al. (July 30 issue)1 suggest that impaired function of mitochondrial aspartate–glutamate carrier isoform 1 (AGC1) leads to hypomyelination. However, the results of magnetic resonance imaging (MRI) suggest differently. In true ...

    1999-2000

    To the Editor: We are concerned that Young (Aug. 6 issue)1 did not emphasize the considerable help provided by the clinical history in predicting the prognosis for a patient after cardiac arrest. Elements of the clinical history — such as the location of ...

    2000-2001

    Among persons who were at risk for infection with 2009 H1N1 virus, being born before 1957 was associated with a lower infection risk.

    2001-2003

    The authors performed 15 autopsies on deceased patients in whom probable influenza had been diagnosed either clinically or macroscopically.

    Corrections
    2004

    Gossypiboma in the Pouch of Douglas Images in Clinical Medicine, N Engl J Med 2008:359;e9.. The third sentence of the legend should have read, “Magnetic resonance imaging, T2 sagittal view, of the abdomen,” rather than “Computed tomography of the abdomen.”...

    2004

    A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee Original Article, N Engl J Med 2008:359;1097-1107.. In the legend for Figure 2 (page 1102), the third sentence should have read, “Error bars indicate the standard error,” rather ...

    2004

    Five-Year Risk of Colorectal Neoplasia after Negative Screening Colonoscopy Original Article, N Engl J Med 2008:359;1218-1224.. In the References (page 1224), reference 24 should have read: “Brenner H, Hoffmeister M, Stegmaier C, Brenner G, Altenhofen L, ...