Title: NEJM This Week: Supplement to the New England Journal of Medicine, Vol. 360, No. 12.

" Welcome to the New England Journal of medicine audio -- for the week of march 19 2009. I'm doctor Michael beer. This week's issue features articles on racial differences in heart failure in young adults vaccine prevention of maternal CNV infection. Genetic association with ovarian insufficiency. And genetic compensation in human -- disorder. Review articles on carbon monoxide poisoning and on Moya -- a case report of a man with massive rectal bleeding. And perspective articles on the uncertain future for cardiovascular drug development. On eliminating racial and ethnic disparities in cardiac care. And Don denial. Racial differences in incident heart failure among young adults. By Kirsten begins Domingo from the San Francisco general hospital California. These authors pro respectively assessed the incidence of heart failure. Over a twenty year period among more than 5000 blacks and whites of both sexes who were eighteen to thirty years of age baseline. Heart failure developed in 27 participants. All but one of whom were black. The cumulative incidence of heart failure before the age of fifty years. Was one point 1% in black women zero point 9% in black men. Zero point 08%. In white women and 0%. In white man. Heart failure occurred in blacks when they were 39 years of age on average and was predicted by the presence of hypertension. Obesity. Chronic kidney disease and depressed systolic function ten to fifteen years earlier. These findings underscore racial disparity in the development of heart failure. And have implications for strategies aimed at the prevention of this disease."

" Eliminating racial and ethnic disparities in cardiac care. A perspective article by Eric Peterson from Duke University Medical Center Durham, North Carolina. The institute of medicine includes equity as one of six key domains of health care quality. Yet equal treatment for Americans of all races and ethnic groups remains in incompletely realized goal. It has been 25 years insignificant unexplained racial variation in the use of coronary artery bypass grafting was noted in a single institution. Although this finding raised an alert the medical community was skeptical assuming that the data were anomalous or -- founded. Since then however multiple studies have identified similar unexplained racial and ethnic differences in cardiac care. Leaving us today with three pivotal questions. Do racial and ethnic disparities persist in contemporary practice. If so. What are their health consequences. And how can these disparities be overcome. Documenting racial or ethnic disparities is -- start. But it's more important to determine whether such an equal care is associated with adverse patient outcomes. To -- studies linking such differences in care to health outcomes have been limited in size and duration of follow up and have failed to examine the full spectrum of important patient outcomes. Nevertheless. Worrisome data are slowly accumulating. As we enter an era of anticipated socio political transformation. We must make the elimination of disparities in health care one of our highest priorities. Vaccine prevention of maternal side on -- virus infection by Robert pass from the university of Alabama at Birmingham. Congenital infections with -- a virus CNV. Is an important cause of hearing cognitive and motor impairments in newborns. Preventing maternal infection during pregnancy is a potential strategy to minimize neo -- infection and disease. In this phase two trial. More than 400 women without CMV infection who were likely to become pregnant. Were vaccinated with either CMV envelope like -- protein B vaccine. Or placebo. After a minimum of one year of follow up there were 49 confirmed infections. Eighteen in the vaccine group and 31 in the placebo group. Those who received the CMV vaccine had a 50% reduction in the instance of CMV infection over 42 months. And -- from the Stanford university school of medicine Palo Alto, California. Writes that in this study. More adverse events occurred in vaccine recipients than those receiving placebo. But these events were generally mild suggesting that the vaccine safety is acceptable for further studies. Vaccination to prevent congenital CMV infection is likely to require universal infant immunization. Which sets a high bar for vaccine safety particularly for vaccine containing and you adjuvant. The development of an effective CNV vaccine remains a daunting task that will benefit from creative development and trial design strategies. Even so the prevention of the burden of congenital CMV infection. Despite all the challenges must remain a high priority. Mutations in an. By Dioner also from the asked it to -- their Paris. The genetic causes of non syndrome -- ovarian insufficiency. Are largely unknown. A nuclear risk sector. And 581. Also called steroid no gen X-Factor one. Is that key transcription -- regulator of genes involved in the -- Islamic pituitary steroids -- Janet axis. Mutation of an 581. Causes 46 XY disorders have sex development with or without adrenal failure. But growing experimental evidence from studies in mice suggests a key role for this factor in ovarian development and function as well. These authors identified -- series of may sense in frame and freeing shift mutations in the NR five a one gene. In association with anomalies of ovarian development and function. In four of the programs. Whose condition was diagnosed as 46 XY disorders have sex development. The mutation was familial. In each of these families another member of the family with primary ovarian insufficiency. Also harbored the mutation. In all subjects there was no evidence of adrenal dysfunction. These data indicate that mutations in an. Genetic compensation. In human genome make disorder. By mad dash -- and kind men from Strasbourg university hospital France. Deletions and -- applications at 22 Q 11 point two represented economical examples of human genomic disorders. A large deletion at 22 Q 11 point two causes the -- a facial syndrome. Cited genetic studies of the parents of the girl with the 22 Q 11 point two. Revealed an unexpected rearrangement. Of both 22 Q 11 point two regions in the unaffected father. He carried a 22 Q 11 point two deletion on one copy of chromosome 22. And they reciprocal 22 Q 11 point two duplication. On the other copy of chromosome 22. Genetic compensation which is consistent with the normal genotype of the father. Was shown through quantitative expression analyses of genes located within the genetic region associated with the George syndrome. This finding has implications for genetic counseling and represents a case of genetic compensation. In human -- disorder. Carbon monoxide poisoning a clinical practice article by -- Weaver from LDS hospital Salt Lake City, Utah. Carbon monoxide poisoning is -- resulting in more than 50000. Emergency department visits per year in the United States. Sources of carbon monoxide include faulty furnace is inadequate ventilation and heating sources and exposure to engine exhaust. Mild exposures result in headache my Alger dizziness or neuro psychological impairment. Severe exposures to carbon monoxide resulting confusion. Loss of consciousness. Or death. Patients with sub clinical exposures may recognize poisoning only after an acute event or on coincidental discovery of a carbon monoxide leak. In physiological amounts induction is carbon monoxide functions as in Europe transmitter. At low levels. Carbon monoxide may favorably modulate inflammation a popped -- and cell proliferation and it up regulates mitochondria the bio Genesis. As the carbon monoxide exposure increases poisoning results. Patients who have had carbon monoxide poisoning should be treated immediately with normal -- oxygen with a fraction of inspired oxygen as highest possible. Which speeds up the expiration of carbon monoxide. The extent and rate of recovery after poisoning are variable and recoveries often complicated by the development it's clearly. Which can persist after exposure were developed weeks after poisoning in which can be permanent. This article discusses the path of physiological mechanisms of carbon monoxide poisoning and short and long term management. An audio version of this article is available at."

" And -- AM dot org. Moya Moya disease and more and more -- syndrome a review article by our Michael Scott from Children's Hospital Boston. The more and more is syndrome is a cerebral vascular condition that predispose is affected patients to stroke in association with. Progressives to noses of the intra cranial internal carotid arteries and their -- small branches. Reduce blood flow in the major vessels of the interior circulation of the brain. Leads to compensatory development of collateral basket -- by small vessels near the apex of the carotid. On the article surface left two men in trees and branches of the external prodded artery supplying the juror and the base of the skull. In rare cases this process also involves the post here your circulation including the bachelor and posterior cerebral arteries. First described in 1957. As -- of the bilateral internal chronic arteries. The characteristic appearance of the associated network -- that normally dilated collateral vessels on and geography. Was later likened to something easy like a puff of cigarette smoke which in Japanese is more and more. Patients with the characteristic more and more of vascular apathy. Who also have well recognized associated conditions are characterized as having the more and more yeah syndrome. Whereas patients with no known associated risk factors are said to have more and more and it disease. This review describes the demographic characteristics. Path of Genesis evaluation. And treatment of Maureen -- disease and syndrome. Current treatments are designed to prevent strokes by improving blood flow to the affected cerebral hemisphere. And 81 year old man with massive rectal bleeding a case record of the Massachusetts General Hospital by David course -- and politics. And 81 year old man was admitted to the hospital because of massive rectal bleeding. At 4 AM on the David mission he awoke with a feeling of abdominal fullness nausea and rectal urgency. He passed a mixture of bright red blood and soft stool through the rectum. Two episodes of rectal bleeding had occurred in the previous two years and evaluation had disclosed kulana diver to Cuba and do ideal erosion -- Approximately three hours after arrival at the hospital three episodes of diarrhea with red blood occurred within a nineteen minute period. Each episode was preceded by the sensation of abdominal fullness and nausea. Bleeding continued and hypertension persisted despite the administration of food and red cells. The urgent questions are where's the bleeding coming from and what is its -- Several clinical factors are helpful in determining the source and cause of acute rectal bleeding in a case such as this. The nature of the bleeding melanoma or a matter -- and the rate intermittent or cute and massive should be considered. The leading cause of complications and death in patients with massive gastrointestinal bleeding such as this patient. Is a delaying or failure in controlling hemorrhage. Thus the primary surgical goal is to control the hemorrhage rapidly which is difficult when the source of bleeding is unclear. And uncertain future for cardiovascular. Drug development. A perspective article by Alan Garber from the veterans affairs Palo Alto healthcare system California. The past year has been a challenging one for Pfizer the world's largest pharmaceutical company. Its stock price has fallen as it has struggled to boost research productivity going so far as to cut research jobs along with sales positions and spending 68 billion dollars to purchase -- In a bid to strengthen its product portfolio. When he denounced last September -- it was getting out of the business of developing new drugs to prevent or treat cardiovascular disease. The news did not come as a complete surprise. The market for cardiovascular drugs was crowded and Pfizer's recent efforts in the area had faltered. Less than a year earlier late clinical testing suggested that course set tradition. A drug designed to increased levels of high density lipoprotein cholesterol that'd been -- greatest hope for replacing Lipitor is a blockbuster product. Increased mortality. Nevertheless because Pfizer had prospered on the strong performance of its cardiovascular drugs. With nearly thirteen billion in sales in 2007 Lipitor was the world's top selling drug. The announcement repudiated a strategy -- been spectacularly. Successful for years. Did the decision reflects only the strengths and weaknesses of Pfizer's pipeline. Or have the commercial prospects soured so much that we can expect an industrywide decline in innovation in cardiovascular drugs. In these uncertain times. Pfizer's decision is a reminder that pharmaceutical innovation is vulnerable to market forces changes in medical practice and regulatory requirements. Denial. Our perspective article by Iran China treatise -- medical oncologist and introduced in Melbourne Australia. Run John -- this -- describes a patient who came into the clinic. Who'd been diagnosed with breast cancer and had chemotherapy but there was no operation report. The notes reveal that she had presented to the clinic with a locally advanced breast cancer. A multi disciplinary team assessor is requiring pre operative chemotherapy. Followed by a mastectomy radiation therapy and hormone therapy. The file -- chart her progress through chemotherapy. Before stopping abruptly. Treat this cover asks the note saying you were due to see the search and after chemo what'd he say. Picking up country this I was concerned the patient quickly replies no I called up for an appointment and they said they would get back to me. When no one -- I figured I was cured. On examination. In addition to a lump on the net treat -- finds the patient's right breast is hard trans modified by cancer. After Sri this pharmacies the patient out the medical student exclaimed triumphantly that's denial she has to be in denial don't you think. Should the -- is momentarily tempted to embrace this on the spot diagnosis. Which conjures up the image sharpening capable patient. And absolves the position of responsibility. That single word scribbled in her file could change the way every physician views and treat the patient. In an era of increasingly outpatient oriented medical care this patient's story represents an urgent cautionary tale. For many patients dealing with the vagaries of outpatient care is almost as -- challenge as injuring prolonged treatment. The images in clinical medicine features -- 68 year old woman who presented with -- persistent abdominal pain. The sensation of a foreign -- in the pelvis difficulty -- And vaginal discharge. The symptoms had developed over many years after two uncomplicated spontaneous deliveries. On external inspection of the Volvo the pelvic organs were visibly pro lapsed. The pro lapsed structure thirty centimeters in mind consisted of the vagina and the inverted endometrial. The images in clinical medicine also features a 22 year old man who was referred for valuation of an asymptomatic match in the left upper lung. That had been detected on chest X ray performed during a physical screening before the start of military service. Not enhance CT of the chest revealed a well defined mask three centimeters in diameter in the left to provoke containing multiple counts vacations. A magnified image of the mass showed -- vacations have only -- non -- irregular shape. Known as popcorn -- vacations. Popcorn house vacations within a well circumscribed pulmonary nodule. Are highly suggestive of pulmonary Concord have -- This concludes the summary of the march 19 issue of the New England Journal of medicine. We are interested in your feedback about our audio summaries and the comments or suggestions may be sent to audio at -- EJM dot or. Thank you for listening."