Title: NEJM This Week: Supplement to the New England Journal of Medicine, Vol. 359, No. 15.

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

" Welcome to the New England Journal of medicine audio summary for the week of October ninth 2008. I'm doctor Michael beer. This week's issue features articles on a four year trial of TO -- opium in CO PD. Effective maternal influenza immunization on mothers and infants. Long term follow up after control of blood pressure in diabetes. Ten year follow up of intensive glucose control in type two diabetes. And inflammation and influenza. A review article on breast reconstruction after mastectomy. A case report of a man with chest pain -- I'll choose an immediate sign romance. And perspective articles on health care reform. Featuring campaign statements from the presidential candidates. This issue also features in new video in clinical medicine showing umbilical vascular categorization. Placement of umbilical catheters is an important skill for the treatment of critically ill Munich's. Catheters can provide vascular access were resuscitation. Monitoring food administration. Blood transfusion and parental nutrition. This video demonstrates the placement of both umbilical artery and umbilical -- catheters. Please visit and EJM dot work to view the video. A four year trial of TO trophy and in chronic obstructive pulmonary disease by Donald passion. From the David Geffen school of medicine at the University of California Los Angeles. In this large randomized trial the investigators compared outcomes in patients with chronic obstructive pulmonary disease CO PD. Treated with once daily inhalation of -- notre opium were placebo. Mean absolutely improvements in FTV one in the TO true opium group. We're maintained throughout the trial ranging from 87 to 103 millimeters before bronco dilation. And from 47 to 65 milliliters after bronco dilation as compared with a placebo group. After -- thirty the differences between the two groups in the rate of decline in the mean FTV one before and after bronco dilation. We're not significant. The mean absolute total score on the St. George's respiratory questionnaire was improve lower in the -- tropea group as compared with a placebo group. And each time point throughout the four year period. Ranging from two point three to three point three units. At four years and thirty days -- pro BM was associated with a reduction in the risk of exacerbation. Related hospitalizations. And respiratory failure. In patients with CO PD. Therapy with TO pro opium was associated with improvement in lung function quality of life. And exacerbate since during a four year period but did not significantly reduce the rate of decline in -- one. In an editorial. John Riley from the University of Pittsburgh school of medicine Pennsylvania. Rights that other than the clinical conclusion that TO pro BM should not be prescribed with the goal of disease modification. But rather for the alleviation of symptoms. What have we learned from this trial. The issue with this trial and other recent large trials might be a signal to noise problem. In our efforts to simplify and clarify our definition of CO PD. We have promulgated an inclusive definition that relies primarily on spiral metric measures to establish the diagnosis. There is increasing recognition that MTV one alone while important does not capture and communicate the hydrogen eighty a CO PD. It is more appropriate to -- CO PD as a syndrome that encompasses a variety of obstructive diseases that share a common exposure. But differ in terms of mechanism of disease and response to therapy. Effectiveness of maternal influenza immunization in mothers and infants. By -- is a month from the international center for -- real disease research Dhaka Bangladesh. Young infants and pregnant women are at increased risk for serious consequences of influenza infection. In activated influenza vaccine is recommended for pregnant women but it's not licensed for infants younger than six months of age. These investigators assessed the clinical effectiveness of -- activated influenza vaccine. Administered during pregnancy. In Bangladesh. Among infants of mothers who received influenza vaccine there were fewer cases of laboratory confirmed influenza than among infants in the control group. Six cases and sixteen cases respectively. With the vaccine effectiveness of 63%. Respiratory illness with fever occurred in 110 infants in the influenza vaccine group. And 153. Infants in the control group with a vaccine effectiveness of 29%. Among the mothers there was a reduction in the rate of respiratory illness with fever of 36%. In activated influenza vaccine reduced proven influenza illness by 63%. In infants up to six months of age. And averted approximately a third of all -- respiratory illnesses in mothers and young infants. Maternal influenza immunization. Is a strategy with substantial benefits for both mothers and infants. Long term follow up after tight control of blood pressure. In type two diabetes. By Marie Holman from the Oxford Centre for diabetes endocrinology and metabolism in the United Kingdom. The United Kingdom prospective diabetes study. Was a multi center trial that indicated that improved glucose control in patients with newly diagnosed type two diabetes -- reduces the risk of clinically evident micro vascular complications. With a relative risk reduction for my party on -- action of 16%. The investigators' report here the results of a ten year post intervention a follow up of the survivor cohort. Differences in blood pressure between the two groups during the trial disappeared within two years after termination of the trial. Significant relative risk reductions found during the trial for any diabetes related and point diabetes related death. Micro vascular disease and stroke in the group receiving tight as compared with less tight blood pressure control. We're not sustained during the post trial followup. No risk reductions were seen jury or after the trial for my party -- fortune or death from any costs. But a risk reduction for peripheral vascular disease associated with tight blood pressure control became significant. Early improvement in blood pressure control in patients with both type two diabetes and hypertension. Was associated with reduced risk of complications. But it appears that -- blood pressure control must be continued if the benefits are to be maintained. Ten year follow up of intensive glucose control in type two diabetes. By every home and from the Oxford Centre for diabetes endocrinology and metabolism in the United Kingdom. During the United Kingdom prospective diabetes study. Patients with type two diabetes malysz who received intensive glucose therapy. With either so funnel urea or insulin or in overweight patients met foreman. Had a lower risk of micro vascular complications. Than did those receiving conventional dietary therapy. The investigators conducted post trial monitoring to determine whether this improved glucose control persisted. And whether such therapy had a long term effect on macro vascular outcomes. Between group differences in quite -- hemoglobin levels were lost after the first year. In this self finally -- insulin group relative reductions in risk persisted at ten years for any diabetes related in point 9%. And micro vascular disease 24%. And risk reductions from my -- in fortune 15%. And death from any cause 13%. Emerged over time as more events occurred. In the Matt foreman group. Significant risk reductions persisted for any diabetes related in point 21%. Mark -- and fortune 33%. And death from any -- 27%. Despite an early loss of question make differences. But continued reduction in micro vascular risk and emergent risk reductions for my -- torture and death from any cause. Were observed during ten years of post trial follow up. A continued benefit after Matt foreman therapy was evident among overweight patients. In an editorial. John Chalmers from the university of Sydney Australia writes that these two United Kingdom prospective diabetes study long term trials. Indicate that in patients with type two diabetes. Intensive glucose control may have a legacy effect whatever its Genesis. Whereas the same benefit does not apply to type blood pressure control. The two studies together highlight the importance of adopting a multi tech corps he'll approach for the prevention of vascular complications in patients with type two diabetes. The results reinforce the importance of maintaining -- go I seem to control. Not only for the prevention of the regional and metabolic complications of diabetes. But also for protection against the development of major cardiovascular disease in the long term. Breast reconstruction after surgery for breast cancer. A clinical therapeutics article by Peter Cordero from the memorial Sloan Kettering cancer center in New York. Approximately 178500. Women in the United States will receive a diagnosis of breast cancer this year. Of whom about 13 will elect to undergo mastectomy. For those women who choose mastectomy. Reconstruction may be offered as an option by the uncle logic and plastic surgeons. Studies suggest that breast reconstruction restores body image improves vitality femininity and sexuality. And positively affects the patient's sense of well being and quality of life. Breast reconstruction generally consists of two stages. Restoration of the breast mound and reconstruction of the nipple a real complex. Current options for implant based reconstruction include immediate reconstruction with a standard or adjustable implant. Two state reconstruction with a tissue expander followed by an implant. Or reconstruction with a combination of an implant and -- hygienist issue. The breast mound can also be reconstructed using the patient's own tissue. A variety of donor sites have been described for reconstruction of the breast including the abdomen back buttocks and -- In all cases it flap of tissue was transferred to the chest to reconstruct the mound. All procedures for breast reconstruction or associated with the increasing morbidity beyond that associated with mastectomy alone. Each procedure has advantages and disadvantages. That must be waived by the patient and her physicians to reach an appropriate decision. A 39 year old man with chest pain are -- edges and a media style maps. A case record of the Massachusetts General Hospital by Peter Merkel and colleagues. A 39 year old man was admitted to the hospital because of chest pain are thrown -- and immediate -- matched. Two months before admission pain in the middle and right chest developed which radiated intermittently to the right arm. Increased in intensity with deep inspiration or changes in position. And was accompanied by fatigue and mild shortness of breath. He had had parent card Titus one year earlier and optic near rightists five years earlier. On examination the first part sound was absent the second was allowed with a prominent split. And there was a new systolic injection murmur at the left upper external border. Imaging showed in infiltrated meeting's final mass surrounding the aorta and narrowing the aluminum the Maine and right pulmonary arteries. The key elements of this case are the sub acute appearance and progressive growth of the middle media -- affecting the pulmonary arteries and cardiac conduction system. The recent onset of arthritis. Other extra thoracic -- system disease. Previous and current -- court record to use and a positive test for anti nuke for -- side of classic auto antibodies. The discussion reviews each of these as a way of arriving at a diagnosis. Insights into inflammation and influenza. Clinical implications of basic research article by Cameron's Simmons from the hospital for tropical diseases ho chi Minh city Vietnam. The emergence of highly path -- Janet Avian influenza H five N one viruses in Asia and they're spread globally. Have delivered a timely reminder of the public health and clinical challenges and influenza pandemic would oppose. There's currently a single oral drug for the treatment of influenza. Then you're a minute ace inhibitor hustle Tamil leader. And no licensed Koran pro drugs. A key therapeutic question addressed in a recent study involving an animal model. Is whether add -- to interventions would improve the outcome of infection. -- felony caused by the H five N one influenza virus is partly attributed to a cited kind storm in the long. The recent study described the specific in addition a cycle oxygen tanks to Cox two expression. In mice infected with the H five N one influenza virus and then treated with Cox two inhibitors. They found a concomitant repression of various cite declines in -- at the -- Cox two expression by empathy illegal -- appears to perpetuate the inflammatory cascade. In a manner that is Independent of direct viral infection. The key finding of the study is that co administration. Of Cox inhibitors and in prepared -- anti viral therapy. Significantly improved survival in mice with establish H five N one infection. As compared with the survival of infected mice treated with anti viral therapy alone. Health care reform and the presidential candidates. The NE JM editors asked Senator John McCain the Republican presidential nominee. And senator Barack Obama the democratic presidential nominee. To describe their plans for reforming the US health care system in order to explore their positions in greater depth. The NE JAM and the Harvard School of Public Health cosponsored the prospective roundtable on September 12. In titled health care in the next administration. And featuring senior health policy advisers David Cutler for Senator Obama. And Gail Wilensky for Senator McCain. A video of this symposium can be seen at any -- M dot pork. Modern healthcare for all Americans. Prospective article by senator Barack Obama. Senator Barack Obama. Writes that doctors and other health care providers worked in extraordinary times and have unrivaled abilities but increasingly. Our health care system gets in the way of their sound medical judgment. Increasing uncompensated care loads administrative rules and insurers coverage decisions inappropriately influence the practice of medicine. Washington sends dictates but no help. Reform must emphasize prevention not just treatment of the sick. Reduce medical errors in malpractice claims and make the practice of medicine rewarding again. Senator Obama's health care plan has 3 central tenets first all American should have access to the benefits of modern medicine. Second we must eliminate the waste that plagues our medical system layers of bureaucracy that serve no purpose. Duplicative tests and procedures that are performed because the right information is not readily available. And doctors providing unnecessary care for fear of being sued. Third we need a public health infrastructure. That works with our medical system to prevent disease and improve health. Access to quality and affordable healthcare for every American -- perspective article by Senator John McCain. Senator John McCain. Rights that Americans deserve leadership for real health care reform that provides access to high quality medical care and and spiraling costs. But the road to reform does not lead through Washington and hugely expensive bureaucratic government controlled system. We have all tangled with the existing bureaucracy enough to know that such an approach would diminish not improve quality. Our challenge is to protect and improve the care that doctors nurses and hospitals deliver while increasing the availability and affordability of health insurance for Americans. Senator McCain believes we can do this in a simple but powerful way restoring doctors and patients to the center of health care decisions. McCain believes the starting point for any health care reform must be restoring the doctor patient relationship. Underlying our health care systems of many troubles are the fundamental problems of cost and access. Senator McCain supports a comprehensive and inclusive approach to lowering costs and reforming our health care system but the focus on four pillars. Access and choice. Quality. Affordability. And portability insecurity. This week's images in clinical medicine features a 61 year old man with small with the city -- chronicling the -- leukemia. Who presented with neck stiffness and bilateral actuary discomfort associated with increasing diffuse slim that not that the physical examination. Revealed massive -- not apathy involving the neck from the level of the man asteroid to the -- clearly -- process. And large nodal masses in both exit way. Coughing and air assaults are also featured in the images in clinical medicine. When healthy volunteer coughs he expels a turbulent chapter of air with density changes that distort -- projected actually -- in the light beam. -- velocity -- early in the cough was obtained from image analysis. Recorded at 3000 frames per second. Several phases of cough air flow are revealed in the figure. There is an increasing interest in visualizing such expelled air close because of concern regarding the transmission of various airborne pathogens such as viruses that cause influenza. And the severe acute respiratory syndrome. TV images and view the video at any EJM dot Award. This concludes the summary of the October ninth issue of the New England Journal of medicine. We are interested in your feedback about our audio summaries. Any comments or suggestions may be sent to audio and can he -- him dot org. Thank you for listening."