Title: NEJM This Week: Supplement to the New England Journal of Medicine, Vol. 360, No. 19.

" Welcome to the New England Journal of medicine audio summary for the week of may seventh 2009. I'm doctor Terry schrader. This week's issue features articles on long term safety and efficacy I've drug eluding verses bare metal stents in Sweden. -- attacks -- stands verses bare metal stents in acute -- Cargill and -- and epilepsy a tax via sensor and Errol deafness to -- at -- and Casey and STI am one mutation. Associated with this syndrome have immunodeficiency. And auto immunity. Vaccine refusal and that risks of vaccine preventable diseases. New York city's war on fat and the origins of brown at a post issue. A review article on scleroderma. A clinical problem solving article describing a red flag. And perspective articles on comparative effectiveness research. Long term safety and efficacy of drug eluding verses bare metal stents in Sweden. By Stephon James from -- a -- university hospital Sweden. This study evaluated the long term outcome with drug eluding stents as compared with bare metal stents. In a very large cohort of patients from Sweden. There was no overall difference between the group that received drug eluding stents and the group that received bare metal stents in the combined in point of death. Or mile -- and parks and relative risk with drug eluding stents zero point 96. Or the individual in points of death relative risk zero point 94. And my -- parks and relative risk zero point 97. And there was no significant difference in outcome among subgroups stratified according to the indication or stent implantation. The average rate every -- notices during the first year was three events per 100 patient years with drug eluding stents. Versus four point seven with bare metal stents. Adjusted relative risk zero point 43. Among high risk patients the adjusted risk of -- was 74%. Lower. With drug eluding stents than with bare metal stents. And only ten lesions would need to be treated to prevent one case agrees to notices. As compared with bare metal stents drug eluding stents are associated with a similar long term incidence of death. Or mile car -- parks and and provide a clinically important decrease in the rate of -- among high risk patients. Hacker attacks -- eluding stents versus bare metal stents in acute mile car -- and parks and by Greg stone from Columbia University Medical Center New York. In this study patients presenting with ST segment elevation -- Len parks and were randomly assigned to receive pack -- eluding stents. Or bare metal stents. Patients who received -- attacks eluding stents as compared with those who received bare metal stents. Had significantly lower twelve month rates of its Kimi had driven target lesion read vascular is nation. Four point 5%. Versus seven point 5%. And target vessel re vascular is nation five point 8% verses eight point 7%. With non inferior rates of the composite safety in point of death -- far action stroke or stent thrombosis. Eight point 1% versus 8%. Patients treated with -- attack -- eluding stents and those treated with bare metal stents had similar twelve month rates of death. Three point 5% and three point 5% respectively. And stent thrombosis. Three point 2% and three point 4% respectively. The thirteen month -- of buying Jerry -- to notices was significantly lower with pack attacked saluting stance then with bare metal stents. 10%. Versus 22 point 9%. The use of a pack attacked -- alluding stent as compared with a bare metal stent reduced the risk of -- to notices. And was equally safe. Epilepsy a taxi sensor on year old deafness to be a lot at the -- CNG 810 mutations. By -- left -- an hour from the great Ormond street hospital University College London. Five children from two can sanguine as family is presented with epilepsy beginning in infancy. And severe a taxi moderate censor a -- deafness. And a real salt losing to be a lot that they. With -- intensive hype okay -- metabolic Alka looses. These authors investigated the genetic basis of this on his -- more recesses of disease. Whole genome linkage analysis in the children. Identified a single relevant -- on chromosome one Q2 three point two containing KC NJ ten. -- codes of potassium channel expressed in the brain inner ear and kidney. In an editorial markets like from the Christiane Albrecht university dot zoom Kiel Germany. Writes that with a delineation of this syndrome. Casey and and as an important player in brain function. ST IM one mutation associated with this syndrome of immunodeficiency. And auto immunity. By topic -- card from the -- tell -- are all fall -- alive Paris. This report describes three siblings with susceptibility to bacterial and viral infections. Auto -- he melodic Anemia immune drama side of Kenya -- that not at the at how to explain on the Italy and other defects. DNA from one of the siblings showed a homicide this mutation in STI am -- A protein involved in store operated calcium entry into cells. Both parents were -- as I guess for the mutation. These cases illustrate that calcium entry is a requirement for lymphocytes activation. Vaccine refusal mandatory immunization. And the risks of vaccine preventable diseases. By -- a homer from Emory University Atlanta Georgia. Vaccines are among the most effective prevention tools available to clinicians. However the success of an immunization program depends on high rates of acceptance and coverage. There is evidence of an increase in vaccine refusal in the United States. And of geographic clustering of refusals that results in outbreaks. Major reasons for vaccine refusal our parental perceptions and concerns about vaccine safety. And a low level of concern about the risk of many vaccine preventable diseases. Children with exemptions from school immunization requirements are at increased risk for measles and pertussis. And can infect others who are too young to be vaccinated. Cannot be vaccinated for medical reasons. Or were vaccinated but did not have a sufficient immunological response. Clinicians can play a crucial role in parental decision making. Although some clinicians have discontinued. Or have consider discontinuing their provider relationship. With patients who refused vaccines. The American academy of pediatrics committee on bioethics. Advises against status. And recommends that clinicians address vaccine refusal by respectfully listening to parental concerns. And discussing their risks of non vaccination. Scleroderma. A review article by Armando -- reality from the university -- Polytechnic. A landmark gay and -- Italy. Scleroderma. Systemic sclerosis is a complex disease. In which extensive fibrosis. Vascular alterations and auto antibodies against various cellular antigens. Are among the principal features. There are two major subgroups in the commonly accepted classification. Of scleroderma. Limited cutaneous scleroderma. And diffuse cutaneous scleroderma. In limited cutaneous scleroderma fibrosis. Is mainly restricted to the hands arms and face. -- it's phenomenon is present for several years before fibrosis appears pulmonary hypertension is frequent. And anti centrum near antibodies occur in fifty to 90% of patients. Diffuse cutaneous scleroderma is a rapidly progressing disorder that affects a large area of the skin. And compromises one or more internal organs. Scleroderma can lead to severe dysfunction and failure of almost any internal organ. Involvement of visceral organs is a major factor in determining the prognosis. They kidneys esophagus heart and lungs are the most frequent targets. Real involvement can be controlled by -- attention converting enzyme inhibitors. Severely debilitating esophageal dysfunction is the most common visceral complication. And lung involvement is the leading cause of death. This account of the mechanisms of scleroderma. Highlight the genetic and molecular changes the cost of vascular changes and fibrosis in the disease. The role of auto antibodies of which there are several in scleroderma. Is unclear. The authors outline a step wise process that begins with inflammation. Reaches its zenith in fibrosis. And instant atrophy. A red flag. A clinical problem solving article by -- phase now from Emory University Atlanta Georgia. A 64 year old man was brought to the emergency department because of sudden onset blurred vision in both size and -- low Pia. As well as a frontal headache that had begun earlier that day. On presentation he was noted to have an altered mental status. His visual symptoms spontaneously resolved shortly after his arrival at the emergency department. On physical examination the patient was lethargic. Was oriented to person in place but not to time. And had difficulty with word finding. -- hemoglobin level was eleven point eight grams for just a leader. The platelet count 234000. Per cubic millimeter and the white cell count. 10300. Per cubic millimeter width 59%. EO senate -- Chest X ray revealed bilateral atypical capacities. This illness is distinguished by its multi system involvement and a marked use in a Philly. Complicated cases with multi system manifestations. Often force clinicians to consider numerous diagnostic possibilities. That spanned a major categories of disease. Including infections. Cancer. Autoimmune disorders and metabolic arrangements. On occasion the initial evaluation and reveals a distinctive finding or clinical red flag. That allows the clinician to transform a broad question. What is causing this multi system illness into a more circumscribed problem. What explains this marked -- Ilia."

" New York city's war on fat health law ethics and human rights article by Michelle -- from Harvard School of Public Health Boston. In February a federal appeals court handed public health officials in New York City. An important victory in their ongoing war on obesity and chronic disease. In the past three years that New York City board of health and mayor Michael Bloomberg have pioneered three uses of the law to combat these health threats and new ways. In order to reduce the prevalence of poorly controlled diabetes the city has required laboratories to report test results indicating elevated levels of like -- hemoglobin. To a citywide registry. To reduce the rate of heart disease the board of health has banned the use of artificial trans fat in food service establishments in the city. Finally the board has required that chain restaurants post calorie information on menu boards. The temporary court ruling affirmed its right to do so. The author of this article reviews -- New York city's efforts to combat obesity. By banning the use of trans fat in restaurants. And requiring chain restaurants to post calorie information on menu boards. She discusses the restaurant industry's ongoing legal challenges to these new policies. New York city's initiatives exemplified the view that traditional justifications. And methods for combating infectious disease should be applied to chronic health conditions. And that the forceful application of law can be a potent tool for combating chronic disease. They showed the potential impact of bold action by local governments. They also illustrated dangers of a decentralized. Approach to public health law making. The origins of brown -- opposed to issue a clinical implications of basic research article by extend and -- from the university of Gothenburg Sweden. What is the source of brown at a post issue. During the formation of the three germ layers the miso -- fills the void between the outer shell active germ. And the inner lining -- term. From this filling developed several specialized cell types including bios sites a different sites and Contra sites. There are two types of a -- sites one that makes up white fat and stores energy in the form of fat. And one that makes -- brown fat and burns energy. The brown fat cell expresses and coupling protein one. So named because it and couples respiration from ATP synthesis. Leading to heat production. Which molecules are critical to the linkages of white and brown fat cells until recently a common origin was as -- However a recent study shows that a dip a sites that make up brown fat have to desperately manages. One seems more closely related to muscle then to white at a post issue. Does comparative effectiveness research threatened personalized medicine. A perspective article by Alan Garber from the veterans affairs Palo Alto health care system in California. The American reinvestment and recovery act gives comparative effectiveness research CER. A large boost in funding over the next two years. Despite a consensus that better information about the relative effectiveness of different medical interventions. Is needed to improve the quality and value of care some -- CER with skepticism. Recently that partnership to improve patient care a coalition of 36 industry patient advocacy and clinician organizations. Raised concerns that CER. Will not take adequate account -- individual patient differences. And may impede the development and adoption of improvements in medical care. And stymie progress in personalized medicine. The controversy stems in part from a perceived contradiction between the concepts of CER and personalized medicine. In CER. Groups of patients are analyzed to compare the effectiveness of alternative medical strategies. With the intent of informing clinical decisions and policies affecting health care. The very name personalized medicine suggests an approach to care that is based on individuals rather than groups. But Alan Garber argues that far from -- personalized medicine. CER offers a way to hasten the discovery of the best approaches to personalization. Providing more and better information with which to craft a management strategy for each individual patient. Debate about funding comparative effectiveness research perspective article by Jerry -- award from Brigham and women's hospital Boston. The proposal to include one point one billion dollars for comparative effectiveness research CEO -- in the federal stimulus package. Encountered a vigorous and well coordinated backlash. The campaign to gut this funding ultimately failed but the debate in engendered and the residents of the opposition's arguments in both lay and policy circles. Reveal much about the issues that will surround such research and its application in the coming years. The contested provisions were designed to support studies comparing the efficacy and safety. And by extension that cost effectiveness. Of alternative ways of addressing common clinical problems. Interventions to be evaluated will include pharmaceuticals. Devices procedures and diagnostic approaches such as imaging studies. This research will -- important information gaps facing clinicians patients and payers concerning what works best. CER represents one of the best investments we can make two -- the health care system away from the fiscal catastrophe at faces. Since such studies will help to reduce spending on poorer clinical decisions. And despair resources for expenditures. That will help patients most. And most importantly. What's the objection after all scientific medicine has always been based on conducting well designed to research to determine what works. The problem is that comparative studies will be threatening to makers and sellers of costly goods and services that offer no benefit over existing alternatives. Then they collected purpose of comparative effectiveness research at perspective article by and and Nyack from the Michael he did they key veterans affairs Medical Center Houston Texas. Surprisingly little attention has been paid to what these authors believe is the most critical question facing ER. -- results significantly improve the quality and safety of the health care received by the average patient. Policy makers and research -- such as the National Institutes of Health. Often assume that the final steps in the translation. Of clinical research the decision to act on new medical evidence. And its implementation in routine care are seamless an automatic. Whereas we know that changing the behavior of physicians and patients is difficult. Though the authors agree that they need foresee ER is clear many of the assumptions regarding the most important aspect of such research. The ultimate implementation of its findings into health care have little empirical support. The authors argue that we need evidence based methods for discovering and describing. How the findings of clinical trials and CER. Can be efficiently implemented and incorporated into routine practice. And implementation of research and development program designed for this purpose could fulfill three important objectives. It could accelerate the translation of evidence into every day care. Enhance the opportunities for doctors and patients to define value balancing expected benefits with costs. On the basis of their understanding of local contacts and constraints. And allow providers and patients to communicate with researchers and policy makers about clinically important issues. Earlier in the research process. The images in clinical medicine features of 76. -- old man who presented with mild back pain at two weeks duration. The physical examination. Revealed a blood pressure of 140 over 85. And a -- the tile non tender abdominal mass. He had received the diagnosis of abdominal aortic and -- and three years earlier but had declined surgical intervention at that time. Oracle or abdominal CT revealed a large infer regal abdominal aortic and -- has -- Measuring fourteen centimeters by seventeen centimeters and it and there -- in the left common Italy -- ardery. Measuring six centimeters by five centimeters. The images in clinical medicine also features -- 74 year old man who presented with a five day history diffuse abdominal pain constipation. Nausea and vomiting. An exploratory lap brought to me was performed and an obstructed segment of intestine was respected. Gross pathological examination. Revealed a constricted segment of -- in their region of the Helio Siegel valve. A sign distract was present at the distill into the constriction. Adjacent to a non absorb -- suture with multiple dark green seek alliance forming a structure resembling a beaded bracelet. The patient had undergone an exploratory lap brought me for intestinal obstruction -- to crohn's disease twenty years previously. The authors suspect that the -- from that surgery became a -- it is for stone formation. This concludes the summary of the may seventh issue of the New England Journal of medicine. We're interested in your feedback about our audience summaries. Any comments or suggestions may be sent to audio at NH AM dot org. Thank you for listening."