Title: NEJM This Week: Supplement to the New England Journal of Medicine, Vol. 361, No. 16.

" Welcome to The New England Journal of Medicine audio summary for the week of October 15 2009. I'm doctor Lisa Johnson. This week's issue features articles on the clinical course of advanced dementia. Functional status of elderly adults before and after initiation of dialysis. Interleukin two in patients with HIV infection and the benefits of taxing sugar sweetened beverages. Review articles on bacterial diarrhea and on cell death. A case report of a man with progressive -- and perspective articles on controlling expenditures by improving care for patients needing costly services. On contaminated dietary supplements and done drug shortages and public health. A new inter active medical case presents the case of the 62 year old woman who visits an urgent care clinic with persistent changeable bleeding. Five hours after periodontal scaling. Direct the investigation of the case test your diagnostic and therapeutic skills. And compare your performance with that of others at any GM dot org. The clinical course of advanced dementia by Susan Mitchell from the Hebrew senior life institute for aging research Austin. The clinical course of nursing home residents with advanced dementia has not been well described. This study examined mortality among patients with advanced dementia who resided in nursing homes. Over a period of eighteen months 54 point 8% of the residents died. The probability of pneumonia was 41 point 1%. A fair trial episode 52 point 6%. And an eating problem 85 point 8%. This six month mortality rate for residents who had pneumonia. Was 46 point 7%. -- episode 44 point 5%. And an eating problem 38 point 6%. Distressing symptoms including Disney and pain were common. In the last three months of life forty point 7% of residents underwent at least one burdensome intervention. Hospitalization. Emergency room visit per renter a therapy or tube feeding. Patients with healthcare proxies who haven't understanding of the prognosis and clinical course. Are likely to receive less aggressive care near the end of life. Greg sacks from the Indiana University School of Medicine Indianapolis. Rates in an editorial that dementia comes with a high burden of symptoms that warrant a palliative care approach. Nursing homes and hold care planning meetings for patients on admission quarterly. And after a significant change in clinical status. Thus there is an existing venue in which providers and families can discuss the sorts of issues raised by this study. And their implications for individual care. Such discussions could modify proxies perceptions about prognosis and expected complications. Altered decisions about the use of burdensome interventions. And increased referrals to palliative care programs and hospice. Functional status of elderly adults before and after initiation of dialysis but man to look Corel to -- From Stanford University School of Medicine Palo Alto, California. Whether functional status before dialysis therapy. Is maintained after its initiation in elderly patients with end stage renal disease is unclear. This study assessed functional status in all nursing home residents in the United States who began to undergo dialysis between June 1998. And October 2000. The median minimum data set activities of daily living score. Increased from twelve during the three months before the initiation of dialysis. To sixteen during the three months after the initiation of dialysis. Three months after the initiation of dialysis functional status had been maintained in 39%. Of nursing home residents. But by twelve months after the initiation of dialysis. 58%. Had died. And pre dialysis functional status had been maintained in only 13%. The initiation of dialysis was associated with a sharp decline in functional status. Indicated by an increase of two point eight points in the minimum data set activities of daily living score. This decline was independent of age sex race and functional status trajectory before the initiation of dialysis. Among nursing home residents with end stage renal disease. The initiation of dialysis is associated with a substantial and sustained decline in functional status. In an editorial Robert Arnold from the University of Pittsburgh School of Medicine Pennsylvania. Writes that prior to the initiation of dialysis. Elderly patients must be informed about its modest benefit in their age group. And the possibility of conservative therapy that does not involve dialysis. Optimal care requires clear informed conversations about the patient's goals. Given his or her disease and the ability of various treatments to achieve these goals. Conservative therapy should be discussed not -- say it last resort when there is nothing left to do. But as a clear option that might be most effective in promoting patient goals. Interleukin two therapy in patients with HIV infection from the inside esprit study group and silk -- scientific committee. In patients infected with human immunodeficiency virus HIV. An increase in the CD four cell count through control of the HIV virus with the use of anti retroviral therapy. Has emerged as an important surrogate marker of improved health. In two prospective randomized studies the addition of interleukin two to anti retroviral therapy. Increase the CD four cell count but was not associated with clinical benefit. Over a median follow up period of 78 years the CD four cell count was higher in the interleukin two group. Then in the group receiving anti retroviral therapy alone. By 53 and 159. Cells per cubic millimeter on average in this silk cut study and esprit respectively. Hazard ratios for opportunistic disease or death from any cause with interleukin two plus anti retroviral therapy. Versus anti retroviral therapy alone. We're zero point 91 in the silk -- study and zero point 94 in -- spree. The hazard ratios for death from any cause and for grade for clinical events. Were one point 06 and one point 10 respectively in the silk -- study. And zero point 90 and one point 23 respectively in history. Despite a substantial and sustained increase in the CD four cell count as compared with anti retroviral therapy alone. Interleukin two plus anti retroviral therapy yielded no clinical benefit in either study. Bacterial diarrhea a clinical practice article by Herbert DuPont from the university of Texas school of public health Houston. Food borne bacterial diarrhea is an emerging health threat. Of the more than five point two million cases of bacterial diarrhea that occur each year in the United States. 80% are a result of food borne transmission. Person to person spread occurs if only a small amount of the pathogens is required for infection. These pathogens include she gala she -- toxin producing -- yet coli and prone to sell and viral agents. The differential diagnosis and evaluation for suspected bacterial diarrhea depends on the setting in which illness occurs and associated clinical features. The stool culture should be attained from all patients with severe diarrhea when diarrhea is prolonged. When fever or dysentery complicate the illness or when an outbreak has occurred. A single examination of the diarrhea stool in a qualified laboratory is sufficient for the diagnosis of most cases of bacterial diarrhea. In patients with bloody diarrhea. -- toxin essay by means of a commercial enzyme in you know SA is warranted in addition to stool culture. If testing for -- attacks and is positive the patient should receive supportive treatment but not antibiotic therapy. Given the potential for some antibiotics to increase toxin production and the risk of the humility curing X syndrome. Antibiotic therapy is indicated for -- dysentery that is not due to -- toxin producing E. Coli. Moderate to severe cases of travelers' diarrhea and in patients with culture proven bacterial diarrhea. And audio version of this article is available at any JM dot org. Cell death a review article by Richard -- from the Washington university school of medicine Saint Louis. All multi cellular organisms require a popped kosice. The control the death of cells without a -- doses to tons of bone marrow and lymph nodes. And -- sixteen kilometer intestine would probably accumulate in human by the age of eighty. Investigations into it popped doses have revealed complex interconnection between various cell death program's. And these networks could affect the treatment of a wide range of diseases. This review with the Trimmer on the three main mechanisms of cell death a cup kosice auto Fiji associated cell death and crisis. Distinctions between eight popped -- new -- it's an auto Fiji. In -- differences in the mode of death and more for logic bio chemical and molecular attributes. Cell death is programmed if it is genetically controlled. Eight popped hostess and auto Fiji associated cell death are the two fundamental types of programmed cell death. The recognition that cell death can occur by genetically controlled processes has enabled advances in unraveling the mechanisms of many diseases. And this new knowledge has facilitated the development of pharmacological agents that initiate or inhibit programmed cell death. Moreover there is now evidence that ms. Crowe says traditionally considered an accidental format cell death. Can in certain instances be initiated or modulated by program to control mechanisms. The authors describe the clinical implication each of these types of cell death. And indicate where advances in our understanding of self -- had inspired new forms of therapy. -- 27 year old man with progressive -- a case record of the Massachusetts General Hospital by an undertaker. The 27 year old man was seen at the hospital because of progressive disk -- and decreased exercise tolerance during the past two years. Imaging studies -- diffuse pulmonary fibrosis. The patient had lighter skin than many in his family although he reported that several family members had light skin and respiratory problems. He had a history of easy bruising. On examination his skin was pale. And there was clubbing of the fingers and -- normal breath sounds he rented irises and horizontal NASDAQ mess. This young man has severe respiratory compromise marked by restrictive physiology and architectural distortion. Traction -- desist and honeycomb like changes suggestive of a five grossing lung disease. However extensive ground glass so past cities are also present as his pulmonary hypertension. The radio graphic appearance of extensive ground glass capacities superimposed on undermined -- brought it changes. -- indicate the development of a new disease process. The onset of a new process in these cases is generally accompanied by an acute or sub acute deterioration in the clinical status of the patients. Which was not described in this case. The discuss and consequently believes that there is one diagnosis in this case leading directly to the pulmonary fibrosis and ground glass of -- cities. And secondarily. To the pulmonary hypertension. The public health and economic benefits of taxing sugar sweetened beverages. And health policy report by Kelly Brownell from Yale university New Haven, Connecticut. The federal government a number of states and cities. And some countries for example Mexico are considering levying taxes on sugar sweetened beverages. The consumption of sugar sweetened beverages has been linked to risks for obesity diabetes and heart disease. Therefore a compelling case can be made for the need for reduced consumption of these beverages. Sugar sweetened beverages are beverages that contain added naturally derived caloric sweeteners such as -- sugar. High fructose corn syrup. Or fruit juice concentrates. All of which have similar metabolic effects. Taxation has been proposed as a means of reducing the intake of these beverages. And thereby lowering health care costs as well as a means of generating revenue that governments can use for health programs. Currently 33 states have sales taxes on soft drinks mean tax rate five point 2%. But the taxes are too small to affect consumption and the revenues are not earmarked for programs related to health. This article examines trends in the consumption of sugar sweetened beverages. Evidence linking these beverages to adverse health outcomes. And approaches to designing a tax system that could promote good nutrition and help the nation recover health care costs associated with the consumption of sugar sweetened beverages. Follow the money. Controlling expenditures by improving care for patients needing costly services. A perspective article by Thomas -- timer from the University of California San Francisco school of medicine. In the United States today 10% of patients account for 70%. Of total healthcare expenditures. Many patients who require high cost care are people with multiple chronic conditions many medications frequent hospitalizations. And limitations on their ability to perform basic daily functions due to physical mental or psychosocial challenges. In 2002. Medicare beneficiaries with five or more chronic conditions. Accounted for 76%. Of Medicare expenditures. Health care spending for people with five or more chronic conditions is seventeen times as high as that for people with no chronic conditions. Because Medicare expenditures will soon become unsustainable. We urgently need to find a way to reduce the cost of care for this rapidly growing group. Care management may be -- health care delivery innovation that can reduce costs while enhancing quality for people with complex health care needs. Care management is a set of activities designed to assist patients and their support systems. In managing medical conditions and related psychosocial problems more effectively. With the aims of improving patients' functional health status enhancing the coordination of care. Eliminating the duplication of services and reducing the need for expensive medical services. It should be targeted to people with complex health care needs who are at high risk for requiring costly care. But not to patients who worked too sick to benefit. American -- Contaminated dietary supplements a perspective article by Peter Cohen from the Cambridge health alliance Somerville Massachusetts. In one of the most dangerous cities in the United States one portly police sergeant has more to worry about the crime. His doctor had been encouraging him for years to lose weight and like millions of other Americans he decided to try a weight loss supplement to help them shed this extra pounds. But instead of losing weight he lost his job. According to the label his diet pills which were imported from Brazil and sold in the United States contained vitamin. And -- Senna and cats Kara. Among other natural ingredients. Not included on the label with the amphetamine detected in his urine drug screen. The now unemployed sergeant is not alone such contaminated supplements represented emerging risk to public health. In July 2009 the US FDA discovered more products most of them labeled as dietary supplements. That contain a wide variety of fund declared active pharmaceutical ingredients. Now more than 140 contaminated products have been identified. But these represent only a fraction of the contaminated supplements on the market. Unfortunately lenient regulatory oversight of dietary supplements combined with the FDA's lack of resources. Has created a marketplace in which manufacturers can introduce hazardous new products with virtual impunity. Although manufacturers have since 2007. Been required to report serious supplement related adverse events to the FDA. The great majority of the estimated 50000 adverse events that occur annually remain on reported. Drug shortages and public health perspective article by Robert Stein -- and national correspondent for the journal. Because the public discussion of drugs is dominated by considerations of their safety effectiveness and cost. It is easy to forget that medications have to be manufactured. From raw materials before they can be prescribed. The continuing shortages of two medications for enzyme deficiency disorders. And ethnic nation 99 -- the radioactive isotope most commonly used in cardiac studies bone scans. And other diagnostic procedures in nuclear medicine. Provide a salient reminder that adequate drug supplies cannot be taken for granted. In late September 2009. The drug shortage page on the FDA website listed fifteen drugs that were in short supply. The reasons included manufacturing delays increases in the demand seen by manufacturers. Sometimes because another manufacturer has left the market. Recalls and shortages of materials. The FDA noted that over the past decade the number of shortages has increased. For reasons ranging from manufacturing problems. Business decisions to stop making certain drugs continued manufacturing of -- product by only one or two companies and limited manufacturing capacity resulting in delays in the production of one drug. While another is made on the same equipment. Recent drug shortages should prompt public health officials industry and governments to anticipate and prepare for the shortages that seem the most likely. And that would have the greatest medical consequences. The images in clinical medicine features a two year old girl who presented with gait disturbance and difficulty using her right hand. MRI of the brain revealed a large left hemisphere torrents if Alex list but extension into the frontal temporal and it's capital Lopes. Despite severe type of plays and -- profusion of the left side of the brain. -- development was relatively preserved and the patient had only mild specificity and a mile disorder a speech. Also featured in the images in clinical medicine is a 21 year old woman with a history of myopia. Who presented with the acute onset of foggy vision in her right -- and associated photo phobia and mild sensation of the presence of a foreign body. She had a bulging cloudy cornea and pro tradition of the lower eyelid and down brigades known as the months and signed. Slit lamp examination showed it Dina and pacification of the central cornea or corneal high drops. Which occurs after rupture of the post -- your cornea leads to an influx of -- humor into the cornea. This concludes the summary of the October 15 issue of The New England Journal of Medicine. We're interested in your feedback about our audio summaries. Any comments or suggestions may be sent to audio at any -- M dot org. Thank you for listening."