Title: NEJM Audio Summary: Supplement to the New England Journal of Medicine, Vol. 358, No. 21.

" This audio summary is sponsored by ortho McNeil Janssen pharmaceutical ink. Visit -- 360 dot com for practice management pod cast. Sample and patient education resources and much more."

" Welcome to the New England Journal of medicine and audio summary for the week of may 22 2008 on doctor Michael -- This week's issue features articles on facilitated PCI in ST elevation my card -- fortune. By -- gruden during PCI for Q my cardinal and far action. Gene therapy for -- congenital -- grosses the collective dynamics of smoking in a large social network. And how HIV guts the immune system a review article on -- lingual immunotherapy. A case report of a woman with bone pain and perspective articles on direct to consumer advertising of medical devices. And on the tragedy of self immolation in Afghanistan. Facilitated PCI in patients with ST elevation my -- went -- action. By Stephen Ellis from the Cleveland clinic Ohio. Immediate per cutaneous coronary intervention PCI he's the treatment of choice for acute ST segment elevation my carnal infraction. In this study the investigators randomly assigned patients -- ST segment elevation my -- on fortune. Who presented six hours or less after the onset of symptoms. To receive treatment with and six cement plus have to -- rent a place combination facilitated PCI. And six MM alone and six MM facilitated PCI or primary -- yeah. Significantly more patients had early ST segment resolution with combination facilitated PCI. 43 point 9%. Then with and six cement facilitated PCI 33 point 1%. Or primary PC -- 31%. The primary and point. Which was the compass that of death from all causes ventricular fibrillation occurring more than 48 hours after random -- nation. Carty eugenics shock and congested heart failure during the first ninety days after -- in the station. Occurred in nine point 8%. Ten point 5%. And ten point 7% of the patients in the combination facilitated PCI group and six MM facilitated PCI group. And primary key Shiite group respectively. Neither facilitation of PCI with rent a place plus set 6 man more facilitation within six -- alone. Significantly improved the clinical outcomes as compared with primary PCI alone. In patients within ST segment elevation my -- went far action. Jane Leopold from Brigham and women's hospital Boston. Rights and an editorial. That this trial confirms that facilitated PCI does not improve the clinical outcome. And increases hemorrhagic events and attendant adverse equally. It is time to abandon the routine use of combination facilitated PCI. Until -- read German for facilitated pharmacological treatment that improve the clinical outcome. And minimizes the risk of bleeding when it is administered before PCI. Is identified."

" By valid prudent during primary PCI in acute my -- deal and fortune. By Greg stone from Columbia University Medical Center New York. By Valerie -- is a direct from been inhibitor. These authors randomly assigned patients with -- ST segment elevation my party on -- action who presented within twelve hours after the onset of symptoms. And who were undergoing primary PCR. To treatment with heparin a cyclical protein to be three a inhibitor. Or to treatment with by -- alone. And tackle regulation with bite -- route no loan as compared with heparin Klesko like approaching two B 38 inhibitors. Resulted in a reduced thirty day rate of net -- clinical events. Nine point 2% versus twelve point 1%. Owing to a lower rate of major bleeding four point 9% for is a point 3%. Treatment with by Valerie and alone as compared with heparin -- like a protein to -- three day inhibitors. Resulted in significantly lower thirty day rates of death from cardiac causes one point 8% versus two point 9%. And death from all causes two point 1% purses three point 1%. In patients with ST segment elevation my -- and fortune who were undergoing primary PCI. And tackle regulation with by valid routing alone as compared with heparin Klesko like approaching two B three inhibitors. Results in significantly reduced thirty day rates of major bleeding and that adverse clinical events. However by -- and was associated with a higher rate of acute stand thrombosis within 24 hours. In an editorial. David morrow from Brigham and women's hospital Boston. Writes that although the study of stone and colleagues is a single open label trial with limitations and observations that call for additional investigation. Their findings indicate that by valid Bruton warrants consideration among the alternatives for ancillary anti from -- therapy. In patients undergoing primary PCR. -- fact of gene therapy on visual function in believers congenital camera grosses. By James Bainbridge from the University College London in the United Kingdom. -- congenital camera so this is a term used to describe a group of -- we inherited. Severe infantile onset Ron -- dystrophy. A form of believers congenital hammer roses is caused by mutant RPE 65. RPE 65 is expressed in the retinal pigment at the killing them. And didn't codes a 65 -- Dalton protein that is a key component of the visual cycle. Early onset severe sentinel dystrophy caused by mutations in RTE 65 is associated with poor vision at birth. And complete loss of vision in early adulthood. These authors administered to three young adult patients so Britain only injections of recombinant -- no associated virus vector Tutu. Expressing our PE 65 complementary DNA. Under the control of human RPE 65 promoter. There were no serious adverse events. There was no clinically significant change in visual acuity. Or in peripheral visual fields on Goldman to -- a tree in any of the three patience. The authors detected no change in written all responses are an electrode written -- graffiti. One patient had significant improvement in visual function on micro -- tree and on dark adapted program tree. This patient also showed improvement in subjective test a visual mobility. These findings provide support for further clinical studies of this experimental approach in other patients with mutant RPE 65. Safety and efficacy of gene transfer for relievers congenital and grosses. By Albert McGwire from the shape our institute Philadelphia Pennsylvania. One form of believers congenital and grosses LC eight to. Is caused by mutations in the retinal pigment at the -- specific 65 kill adult and protein gene RPE 65. These authors investigated the safety of sub -- delivery of a recombinant at no associated virus. Carrying our PE 65 complementary DNA. Each of three patients had a modest improvement in measures of retinal function and so objective tests of visual acuity. In one patient and asymptomatic macular hole developed and although the occurrence was considered to be an adverse event. The patient had some return of retinal function. Although the followup was very short and normal vision was not achieved. This study provides the basis for further gene therapy studies in patients with believers congenital and grosses. Joan Miller from the Massachusetts eye and ear infirmary Boston. Writes in an editorial that the preliminary results from these investigations suggests that in the short term the procedure is safe. Moreover the data are suggestive of efficacy. Both groups recognize that longer follow up and additional subjects are necessary to provide satisfying safety data. Some of the remaining issues include the reproduce ability and persistence of the improved -- function. And whether further retinal degeneration is delayed or averted. Larger studies may show advantages of a particular vector preparation promoter selection or technique. The collective dynamics of smoking in a large social network. By Nicholas Chris stockings from Harvard Medical School Boston. The prevalence of smoking has decreased substantially in the United States over the past thirty years. These investigators examined the extent of the person to person spread of smoking behavior. And the extent to which groups of widely connected people quit together. Despite the decrease in smoking in the overall population. The signs of the clusters of smokers remained the same across time suggesting that whole groups of people were quitting in concert. Smokers were also progressively found in the periphery of the social network. Smoking cessation by a spouse decreased a person's chances of smoking by 67%. Smoking cessation by a sibling decrease the chances by 25%. Smoking cessation by a friend decreased the chances by 36%. Among persons working in small firms smoking cessation by a coworker decrease the chances by 34%. Friends with more education influenced one another more than those with less education. Network phenomena appear to be relevant to smoking cessation. Smoking behavior spreads through close and distant social ties groups of interconnected people stop smoking in concert. And smokers are increasingly marginalized socially. In an editorial Steven Schroeder from the University of California San Francisco. Writes that despite the tremendous recent progress against tobacco use it is premature to declare victory. Tobacco remains our nation's number one health problem. The findings that smokers are increasingly peripheral resonate with how we encounter smokers in the United States today. Many of whom we see furtively puffing outside their places of employment. If these findings apply more broadly. A further reduction in the burden of smoking will require focusing on people who are socially marginalized and who social networks may be limited. And it will require figuring out ways to harnessed the potent social forces that shape behavior. -- immunotherapy. A clinical therapeutics article by Anthony fruit from Brighton general hospital in the United Kingdom. Allergic crime night this is caused by a type one hyper sensitivity response to inhaled allergen particles such as pollen grains. Animal dander. And the feces of house dust mites. Specific immunotherapy also called allergens immunotherapy is a method of reducing sensitivity to a given intelligent. By repeated administration of a dose of that allergens. Although the mechanism by which this benefit occurs is not fully understood. The current consensus is that specific immunotherapy works by inducing -- specific. T regulatory cells that reduce the late phase response to the Arlington. Traditionally specific immunotherapy has been administered as a course of sub cutaneous injections. However limitations of this form of therapy have led to considerable interest in possible alternative approaches. If an allergy and is given in -- doubles by the sub lingual route. A small proportion of the administered dose is absorbed through the buckle me cosa and taken up by local -- excels. These cells then passed to the regional lymph nodes where they can interact with antigen specific lymphocytes. Sub lingual immunotherapy has been adopted in many European countries for patience. Who might otherwise be considered for conventional contraction immunotherapy. The only agent that is currently commercially available for sub lingual immunotherapy -- Is the extract of the grass pollen. The FDA has not approved any agent for sub lingual immunotherapy."

" A 46 year old woman with bone pain. A case record of the Massachusetts General Hospital by -- demand and colleagues. A 46 year old woman was evaluated because of pain in the right hip and leg. Several months earlier -- had developed in her right upper medial -- and had gradually increased in intensity despite treatment with Ibuprofen. Pinto resolved and as he diminished in Cody. A diagnosis of you react disease had been made 25 years earlier. At the time of presentation the patient had high vocals emea hypo farce to Kenya and a dramatic increase in Paris thyroid hormone. Accompanied by vitamin D deficiency. Laboratory test showed low serum calcium and elevated alkaline possible -- levels. The radio graphic images showed -- it but enhancing lesions and to salt and pepper appearance in the -- And there was a nodule in the neck that suggested an enlarged parent thyroid gland."

" Are the skeletal lesions a consequence of metabolic bone disease or of a malignant tumor. Osteoporosis does not cause Riddick lesions but other metabolic bone diseases to be considered include -- disease. Costume -- And us the latest fibrosis cystic. Imaging studies were helpful in this differential diagnosis. How HIV cuts the immune system a clinical implications of basic research article. By -- Paul Johnson from the New England primate research center south Borough Massachusetts. Although in the absence of treatment aged generally develops eight to ten years after infection with HIV type one. The onslaught on the immune system by HIV one begins with the rapid depletion of memory CD four positive T cells. The majority of which resigned in the -- A recent report suggests that HIV one is able to mediate depletion of -- CD four positive T cells in part. By co opting the molecule that helps direct T cells to the -- The integrity and alpha for beta seven. The investigators described a series of detailed experiments supporting the hypothesis that HIV one. Is able to Bahrain and to the -- homing molecule how -- for beta seven. Finding of the HIV one envelope to alpha for beta seven. May be able to and use cellular activation that further enhances the efficiency. Of the spreading of HIV one from one cell to another."

" Peer reviewed in the balance. An editorial by journal editors Gregory -- men Stephen Morrissey and Jeffrey treason. And by George -- from Boston university school of public health."

" In May 2007 lawyers for Pfizer serve the NE JM with a subpoena. Demanding that the journal produce. Peer review and other editorial documents on all manuscripts concerning Pfizer's Cox two inhibitors extra and celebrex. Eleven specific articles that we had published and any others that we had rejected for publication. -- attorney stated that they wanted the critiques. In order to discover quote flaws in methodology and quote in the research that might have been noted by the journal's peer reviewers. We refused to relinquish any peer reviewed documents. In January 2008 Pfizer attorneys filed a motion to compel us to produce those documents we declined again. The motions from Pfizer and the journal were heard in federal court on March 13. Our stand was based on our long held belief that the peer review process works best when it is conducted in confidence. US magistrate judge Leo T Sorkin decided that while the materials Pfizer sought were relevant. Their probative value was limited as -- can concluded. Even though the information sought was relevant quote. The any change -- interest in maintaining the confidentiality of the peer review process. Is a very significant one especially in light of its non party status and tips the scales in favor of the an EJ AM and quote. As we did in this case. We will resist any future attempts to undermine peer review. In the interest of the journal and of those who offer their time and expertise as reviewers."

" CA for PT CA crossing the line in consumer health education. Our perspective article by William -- from the university of buffalo schools of medicine and public health New York. On November 22. Viewers of the nationally televised Thanksgiving Day football game between the Dallas Cowboys and the New York chants. Witness the launch of the first direct to consumer advertising campaign for per cutaneous trans little coronary angioplasty. With a drug commuting coronary stent. -- airing of quote life wide open and quote the 62 commercial for cipher this or on his coated stent produced by Johnson & Johnson. Marked the dawn of a new -- in medical director consumer advertising. Too many consumers the stand to -- may not have seemed surprising or out of place. But in making the leap. From pharmaceuticals to medical devices. The ad campaign raises important questions regarding the net societal benefit of medical advertising directed at the -- public. Has industry crossed the line this time. In the and for cipher. A device is being promoted to millions of people who are ill equipped to make judgments about the many clinically relevant but subtle and complex therapeutic issues. That even specialists continue to debate. These authors write did they believe that the FDA should perform a critical post release review of the life wide open campaign. To assess whether it meets the basic regulatory requirements for non deceptive prescription drug advertise. Until section of valuation is conducted the campaign should be viewed as a device of potentially deceptive advertising. And as a bold preliminary experiment in intervention or psychology. Driven to a fiery death. The tragedy of self immolation in Afghanistan. A perspective article by Anita Ryan from Boston university school of public health Massachusetts. Self immolation is the active burning oneself as a means of suicide. Although reliable data on the scope of this practice are difficult to obtain in Afghanistan and elsewhere. There are indications that self immolation is occurring at a notable and steady rate. Researchers have reported that forced and child marriages. As well as violence perpetrated by husbands in laws and husbands other wives. Were common precursors to act of self immolation. Often self immolation was said to have occurred. After victims spoke out against or sought help in alleviating the violence to which they were subjected. But were ignored. Findings suggest that despite substantial efforts toward improving health and human rights in Afghanistan. Persistent conditions permit violence against women and Afghan women and girls continue to turn to the desperate remedy. -- self immolation. This week's images in clinical medicine features a fourteen year old girl who presented with a traumatic injury to the right. From a water bottle cap. Caused by the increasingly popular adolescent activity of twisting and crushing an empty plastic water bottle. With a cap -- until the cap flies off because of increased pressure. On day four she experienced severe high pain and decreased vision. A blood clot in the interior chamber had decreased in size and at two millimeter layered high FEMA was present. Intra ocular pressure had reason to 42 millimeters Mercury. Urgent surgical intervention in interior chamber washout was required. Also featured in the images in clinical medicine is a 67 year old woman who presented with this -- and peripheral edema. Due to severe tried tested regurgitate -- She had undergone replacement of the might troll and aortic valves with star edwards' heart -- 38 years earlier. As seen in this patient the star edwards' heart valve can function for well over three decades. This concludes the summary of the may 22 issue of the New England Journal of medicine. We -- interested in your feedback about our audio summaries any comments or suggestions may be sent to audio and and you change -- dot org. Thank you for listening"