doi: 10.1056/NEJMicm031107pmid: 16611945
This man had obstructive nephropathy necessitating hemodialysis and transplantation. His course was complicated by severe secondary hyperparathyroidism.
Tegtmeyer, Ken; Brady, Glenn; Lai, Susanna; Hodo, Richard; Braner, Dana
doi: 10.1056/NEJMvcm044149pmid: 16611944
This video demonstrates the insertion of an arterial line and considers indications, contraindications, and potential complications.
Berggren, Ruth E.; Curiel, Tyler J.
doi: 10.1056/NEJMp068039pmid: 16611946
Drs. Ruth Berggren and Tyler Curiel write that when patients and staff were evacuated from Charity Hospital in New Orleans, they could not fully comprehend the devastation of the health care infrastructure. Seven months after Katrina, health care in New Orleans remains unacceptably primitive. New Orleans had 7000 HIV-infected citizens before Katrina. Dr. Ruth Berggren writes that the reconstitution of the HIV outpatient clinic was driven by the urgent need to restore antiviral treatment in order to avert virologic resistance and disease progression.
doi: 10.1056/NEJMp068040pmid: 16611947
Two outpatient clinics serving the disenfranchised have adapted in creative ways to deliver community-based care to New Orleans. Charity Hospital's HIV Outpatient (HOP) Clinic, funded under the Ryan White Comprehensive AIDS Resources Emergency Act, responded to Hurricane Katrina by reconstituting itself with a much smaller staff. In the Algiers neighborhood, a new free clinic dubbed the Common Ground Health Clinic has drawn volunteer medical professionals from around the country. In the early days after Katrina, these clinics coalesced around the neediest populations. Today, they are moving from stopgap measures to sustainable models promoting continuity of care. (Figure) The reconstitution . . .
doi: 10.1056/NEJMp068004pmid: 16611948
In The Access Principle, John Willinsky argues that since the knowledge conveyed in scientific publications is a public good, access to it should be broadened as far as possible. Martin Frank writes that Willinsky's argument on behalf of the ultimate goal of open access falls short because it fails to weigh the benefits of such access against the costs in terms of other public goods.
Brubaker, Linda; Cundiff, Geoffrey W.; Fine, Paul; Nygaard, Ingrid; Richter, Holly E.; Visco, Anthony G.; Zyczynski, Halina; Brown, Morton B.; Weber, Anne M.
doi: 10.1056/NEJMoa054208pmid: 16611949
BackgroundWe designed this trial to assess whether the addition of standardized Burch colposuspension to abdominal sacrocolpopexy for the treatment of pelvic-organ prolapse decreases postoperative stress urinary incontinence in women without preoperative symptoms of stress incontinence.MethodsWomen who did not report symptoms of stress incontinence and who chose to undergo sacrocolpopexy to treat prolapse were randomly assigned to concomitant Burch colposuspension or to no Burch colposuspension (control) and were evaluated in a blinded fashion three months after the surgery. The primary outcomes included measures of stress incontinence (symptoms, stress testing, or treatment) and measures of urge symptoms. Enrollment was stopped after the first interim analysis because of a significantly lower frequency of stress incontinence in the group that underwent the Burch colposuspension.ResultsOf 322 women who underwent randomization, 157 were assigned to Burch colposuspension and 165 to the control group. Three months after surgery, 33.6 percent of the women in the Burch group and 57.4 percent of the controls met one or more of the criteria for stress incontinence (P<0.001). There was no significant difference between the Burch group and the control group in the frequency of urge incontinence (32.7 percent vs. 38.4 percent, P=0.48). After surgery, women in the control group were more likely to report bothersome symptoms of stress incontinence than those in the Burch group who had stress incontinence (24.5 percent vs. 6.1 percent, P<0.001).ConclusionsIn women without stress incontinence who are undergoing abdominal sacrocolpopexy for prolapse, Burch colposuspension significantly reduced postoperative symptoms of stress incontinence without increasing other lower urinary tract symptoms.
doi: 10.1056/NEJMoa060900pmid: 16531613
BackgroundIn observational studies, lower homocysteine levels are associated with lower rates of coronary heart disease and stroke. Folic acid and vitamins B6 and B12 lower homocysteine levels. We assessed whether supplementation reduced the risk of major cardiovascular events in patients with vascular disease.MethodsWe randomly assigned 5522 patients 55 years of age or older who had vascular disease or diabetes to daily treatment either with the combination of 2.5 mg of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 or with placebo for an average of five years. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, and stroke.ResultsMean plasma homocysteine levels decreased by 2.4 μmol per liter (0.3 mg per liter) in the active-treatment group and increased by 0.8 μmol per liter (0.1 mg per liter) in the placebo group. Primary outcome events occurred in 519 patients (18.8 percent) assigned to active therapy and 547 (19.8 percent) assigned to placebo (relative risk, 0.95; 95 percent confidence interval, 0.84 to 1.07; P=0.41). As compared with placebo, active treatment did not significantly decrease the risk of death from cardiovascular causes (relative risk, 0.96; 95 percent confidence interval, 0.81 to 1.13), myocardial infarction (relative risk, 0.98; 95 percent confidence interval, 0.85 to 1.14), or any of the secondary outcomes. Fewer patients assigned to active treatment than to placebo had a stroke (relative risk, 0.75; 95 percent confidence interval, 0.59 to 0.97). More patients in the active-treatment group were hospitalized for unstable angina (relative risk, 1.24; 95 percent confidence interval, 1.04 to 1.49).ConclusionsSupplements combining folic acid and vitamins B6 and B12 did not reduce the risk of major cardiovascular events in patients with vascular disease. (ClinicalTrials.gov number, NCT00106886; Current Controlled Trials number, ISRCTN14017017.)
Johnston, Sebastian L.; Blasi, Francesco; Black, Peter N.; Martin, Richard J.; Farrell, David J.; Nieman, Richard B.
doi: 10.1056/NEJMoa044080pmid: 16611950
BackgroundWe conducted a double-blind, randomized, placebo-controlled study to evaluate the efficacy of telithromycin in patients with acute exacerbations of asthma.MethodsA total of 278 adults with diagnosed asthma were enrolled within 24 hours after an acute exacerbation of asthma requiring short-term medical care. The patients were randomly assigned to receive 10 days of oral treatment with telithromycin (at a dose of 800 mg daily) or placebo in addition to usual care. Primary efficacy end points were a change from baseline over the treatment period in symptoms (as recorded by patients in a diary card) and in the peak expiratory flow in the morning at home. The presence of Chlamydophila pneumoniae or Mycoplasma pneumoniae was ascertained by serologic analysis, polymerase chain reaction, and culture.ResultsOf the two prespecified primary outcomes, only asthma symptoms showed a significantly greater reduction among patients receiving telithromycin than among those receiving placebo. Mean (±SD) scores on a test of asthma symptoms (on a 7-point scale, with 0 denoting no symptoms and 6 denoting severe symptoms) were 3.0±1.4 at baseline and 1.7±1.1 at the end of treatment for the telithromycin group and 2.8±1.3 at baseline and 2.0±1.0 at the end of treatment for the placebo group. The mean decrease in symptom scores during the treatment period was 1.3 for telithromycin and 1.0 for placebo (mean difference, −0.3; 95 percent confidence interval, −0.5 to −0.1; P=0.004). There was no significant treatment effect on the other primary outcome measure, a change in morning peak expiratory flow. Nausea was more common among patients in the telithromycin group than in the placebo group (P=0.01). Although 61 percent of patients had evidence of infection with C. pneumoniae, M. pneumoniae, or both, there was no relationship between bacteriologic status and the response to asthma treatment.ConclusionsThis study provides evidence of the benefit of telithromycin in patients with acute exacerbations of asthma; the mechanisms of benefit remain unclear. (ClinicalTrials.gov number, NCT00273520.)
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BackgroundHomocysteine is a risk factor for cardiovascular disease. We evaluated the efficacy of homocysteine-lowering treatment with B vitamins for secondary prevention in patients who had had an acute myocardial infarction.MethodsThe trial included 3749 men and women who had had an acute myocardial infarction within seven days before randomization. Patients were randomly assigned, in a two-by-two factorial design, to receive one of the following four daily treatments: 0.8 mg of folic acid, 0.4 mg of vitamin B12, and 40 mg of vitamin B6; 0.8 mg of folic acid and 0.4 mg of vitamin B12; 40 mg of vitamin B6; or placebo. The primary end point during a median follow-up of 40 months was a composite of recurrent myocardial infarction, stroke, and sudden death attributed to coronary artery disease.ResultsThe mean total homocysteine level was lowered by 27 percent among patients given folic acid plus vitamin B12, but such treatment had no significant effect on the primary end point (risk ratio, 1.08; 95 percent confidence interval, 0.93 to 1.25; P=0.31). Also, treatment with vitamin B6 was not associated with any significant benefit with regard to the primary end point (relative risk of the primary end point, 1.14; 95 percent confidence interval, 0.98 to 1.32; P=0.09). In the group given folic acid, vitamin B12, and vitamin B6, there was a trend toward an increased risk (relative risk, 1.22; 95 percent confidence interval, 1.00 to 1.50; P=0.05).ConclusionsTreatment with B vitamins did not lower the risk of recurrent cardiovascular disease after acute myocardial infarction. A harmful effect from combined B vitamin treatment was suggested. Such treatment should therefore not be recommended. (ClinicalTrials.gov number, NCT00266487.)