Mayo, George L.; Tolentino, Michael J.
doi: 10.1056/NEJMicm040678pmid: 16107617
This 32-year-old woman, who was seven months pregnant, presented with blurring and greenish discoloration of central vision in the left eye.
doi: 10.1056/NEJMp058120pmid: 16107618
In this essay, Dr. Atul Gawande writes that the physical examination is deeply intimate, and the way a doctor deals with the naked body — particularly when the doctor is male and the patient female — inevitably raises questions of propriety and trust.
doi: 10.1056/NEJMp058165pmid: 16107619
In the Supreme Court case Gonzales v. Raich, the justices ruled 6 to 3 that the federal government has the power to arrest and prosecute patients and their suppliers. Dr. Susan Okie explains that it is not yet clear what effect the Court's decision will have on patients.
Windecker, Stephan; Remondino, Andrea; Eberli, Franz R.; Jüni, Peter; Räber, Lorenz; Wenaweser, Peter; Togni, Mario; Billinger, Michael; Tüller, David; Seiler, Christian; Roffi, Marco; Corti, Roberto; Sütsch, Gabor; Maier, Willibald; Lüscher, Thomas;
Jha, Ashish K.; Fisher, Elliott S.; Li, Zhonghe; Orav, E. John; Epstein, Arnold M.
doi: 10.1056/NEJMsa050672pmid: 16107621
BackgroundDifferences in the use of major procedures according to patients' race are well known. Whether national and local initiatives to reduce these differences have been successful is unknown.MethodsWe examined data for men and women enrolled in Medicare from 1992 through 2001 on annual age-standardized rates of receipt of nine surgical procedures previously shown to have disparities in the rates at which they were performed in black patients and in white patients. We also examined data according to hospital-referral region for three of the nine procedures: coronary-artery bypass grafting (CABG), carotid endarterectomy, and total hip replacement.ResultsNationally, in 1992, the rates of receipt for all the procedures examined were higher among white patients than among black patients. The difference between the rates among whites and blacks increased significantly between 1992 and 2001 for five of the nine procedures, remained unchanged for three procedures, and narrowed significantly for one procedure. We examined rates of CABG, carotid endarterectomy, and total hip replacement in 158 hospital-referral regions (79 hospital-referral regions for black men and white men and 79 for black women and white women) with an adequate number of persons for each procedure. We found that in the early 1990s, whites had higher rates for these procedures than blacks in every hospital-referral region. By 2001, the difference between whites and blacks (both men and women) in the rates of these procedures narrowed significantly in 22 hospital-referral regions, widened significantly in 42, and were not significantly changed in the remaining hospital-referral regions. At the end of the study period, we found no hospital-referral region in which the difference in rates between whites and blacks was eliminated for men or women with regard to any of these three procedures.ConclusionsFor the decade of the 1990s, we found no evidence, either nationally or locally, that efforts to eliminate racial disparities in the use of high-cost surgical procedures were successful.
Trivedi, Amal N.; Zaslavsky, Alan M.; Schneider, Eric C.; Ayanian, John Z.
doi: 10.1056/NEJMsa051207pmid: 16107622
BackgroundSince 1997, all managed-care plans administered by Medicare have reported on quality-of-care measures from the Health Plan Employer Data and Information Set (HEDIS). Studies of early data found that blacks received care that was of lower quality than that received by whites. In this study, we assessed changes over time in the overall quality of care and in the magnitude of racial disparities in nine measures of clinical performance.MethodsIn order to compare the quality of care for elderly white and black beneficiaries enrolled in Medicare managed-care plans who were eligible for at least one of nine HEDIS measures, we analyzed 1.8 million individual-level observations from 183 health plans from 1997 to 2003. For each measure, we assessed whether the magnitude of the racial disparity had changed over time with the use of multivariable models that adjusted for the age, sex, health plan, Medicaid eligibility, and socioeconomic position of beneficiaries on the basis of their area of residence.ResultsDuring the seven-year study period, clinical performance improved on all measures for both white enrollees and black enrollees (P<0.001). The gap between white beneficiaries and black beneficiaries narrowed for seven HEDIS measures (P<0.01). However, racial disparities did not decrease for glucose control among patients with diabetes (increasing from 4 percent to 7 percent, P<0.001) or for cholesterol control among patients with cardiovascular disorders (increasing from 14 percent to 17 percent; change not significant, P=0.72).ConclusionsThe measured quality of care for elderly Medicare beneficiaries in managed-care plans improved substantially from 1997 to 2003. Racial disparities declined for most, but not all, HEDIS measures we studied. Future research should examine factors that contributed to the narrowing of racial disparities on some measures and focus on interventions to eliminate persistent disparities in the quality of care.
Clark, Matthew A.; Fisher, Cyril; Judson, Ian; Thomas, J. Meirion
doi: 10.1056/NEJMra041866pmid: 16107623
Soft-tissue sarcomas have traditionally been managed by wide excisional surgery and radiotherapy, with chemotherapy reserved for advanced disease. However, advances in multidisciplinary care have improved the evaluation and treatment of patients with this uncommon tumor. Limb-conserving surgery, superior radiotherapy delivery, and novel adjuvant agents for specific tumors are now available. This article reviews the current understanding and treatment of soft-tissue sarcoma, with an emphasis on recent advances.
Showing 1 to 10 of 27 Articles
doi: 10.1056/NEJMoa051175pmid: 16105989
BackgroundSirolimus-eluting stents and paclitaxel-eluting stents, as compared with bare-metal stents, reduce the risk of restenosis. It is unclear whether there are differences in safety and efficacy between the two types of drug-eluting stents.MethodsWe conducted a randomized, controlled, single-blind trial comparing sirolimus-eluting stents with paclitaxel-eluting stents in 1012 patients undergoing percutaneous coronary intervention. The primary end point was a composite of major adverse cardiac events (death from cardiac causes, myocardial infarction, and ischemia-driven revascularization of the target lesion) by nine months. Follow-up angiography was completed in 540 of 1012 patients (53.4 percent).ResultsThe two groups had similar baseline clinical and angiographic characteristics. The rate of major adverse cardiac events at nine months was 6.2 percent in the sirolimus-stent group and 10.8 percent in the paclitaxel-stent group (hazard ratio, 0.56; 95 percent confidence interval, 0.36 to 0.86; P=0.009). The difference was driven by a lower rate of target-lesion revascularization in the sirolimus-stent group than in the paclitaxel-stent group (4.8 percent vs. 8.3 percent; hazard ratio, 0.56; 95 percent confidence interval, 0.34 to 0.93; P=0.03). Rates of death from cardiac causes were 0.6 percent in the sirolimus-stent group and 1.6 percent in the paclitaxel-stent group (P=0.15); the rates of myocardial infarction were 2.8 percent and 3.5 percent, respectively (P=0.49); and the rates of angiographic restenosis were 6.6 percent and 11.7 percent, respectively (P=0.02).ConclusionsAs compared with paclitaxel-eluting stents, the use of sirolimus-eluting stents results in fewer major adverse cardiac events, primarily by decreasing the rates of clinical and angiographic restenosis.
BackgroundDrug-eluting stents are highly effective in reducing the rate of in-stent restenosis. It is not known whether there are differences in the effectiveness of currently approved drug-eluting stents in the high-risk subgroup of patients with diabetes mellitus.MethodsWe enrolled 250 patients with diabetes and coronary artery disease: 125 were randomly assigned to receive paclitaxel-eluting stents, and 125 to receive sirolimus-eluting stents. The primary end point was in-segment late luminal loss. Secondary end points were angiographic restenosis (defined as in-segment stenosis of at least 50 percent at follow-up angiography) and the need for revascularization of the target lesion during a nine-month follow-up period. The study was designed to show noninferiority of the paclitaxel stent as compared with the sirolimus stent, defined as a difference in the extent of in-segment late luminal loss of no more than 0.16 mm.ResultsThe extent of in-segment late luminal loss was 0.24 mm (95 percent confidence interval, 0.09 to 0.39) greater in the paclitaxel-stent group than in the sirolimus-stent group (P=0.002). In-segment restenosis was identified on follow-up angiography in 16.5 percent of the patients in the paclitaxel-stent group and 6.9 percent of the patients in the sirolimus-stent group (P=0.03). Target-lesion revascularization was performed in 12.0 percent of the patients in the paclitaxel-stent group and 6.4 percent of the patients in the sirolimus-stent group (P=0.13).ConclusionsIn patients with diabetes mellitus and coronary artery disease, use of the sirolimus-eluting stent is associated with a decrease in the extent of late luminal loss, as compared with use of the paclitaxel-eluting stent, suggesting a reduced risk of restenosis.
BackgroundAlthough increased attention has been paid to sex and racial differences in the management of myocardial infarction, it is unknown whether these differences have narrowed over time.MethodsWith the use of data from the National Registry of Myocardial Infarction, we examined sex and racial differences in the treatment of patients who were deemed to be “ideal candidates” for particular treatments and in deaths among 598,911 patients hospitalized with myocardial infarction between 1994 and 2002.ResultsIn the unadjusted analysis, sex and racial differences were observed for rates of reperfusion therapy (for white men, white women, black men, and black women: 86.5, 83.3, 80.4, and 77.8 percent, respectively; P<0.001), use of aspirin (84.4, 78.7, 83.7, and 78.4 percent, respectively; P<0.001), use of beta-blockers (66.6, 62.9, 67.8, and 64.5 percent; P<0.001), and coronary angiography (69.1, 55.9, 64.0, and 55.0 percent; P<0.001). After multivariable adjustment, racial and sex differences persisted for rates of reperfusion therapy (risk ratio for white women, black men, and black women: 0.97, 0.91, and 0.89, respectively, as compared with white men) and coronary angiography (relative risk, 0.91, 0.82, and 0.76) but were attenuated for the use of aspirin (risk ratio, 0.97, 0.98, and 0.94) and beta-blockers (risk ratio, 0.98, 1.00, and 0.96); all risks were unchanged over time. Adjusted in-hospital mortality was similar among white women (risk ratio, 1.05; 95 percent confidence interval, 1.03 to 1.07) and black men (risk ratio, 0.95; 95 percent confidence interval, 0.89 to 1.00), as compared with white men, but was higher among black women (risk ratio, 1.11; 95 percent confidence interval, 1.06 to 1.16) and was unchanged over time.ConclusionsRates of reperfusion therapy, coronary angiography, and in-hospital death after myocardial infarction, but not the use of aspirin and beta-blockers, vary according to race and sex, with no evidence that the differences have narrowed in recent years.