NEJM â Collection Updates for Surgery

IMAGES IN CLINICAL MEDICINE: Bleeding Esophageal Varices

Euriko Torrazza-Perez, M.D. and Norberto Carreno, M.D. — Thu, 04Â FebÂ 2010 00:00:00 -05:00

A 52-year-old man with cirrhosis associated with alcohol abuse presented to the emergency department with hematemesis and lightheadedness, which had developed 3 hours earlier, after binge drinking. He had no...

IMAGES IN CLINICAL MEDICINE: Gallstone Ileus

Te-Ming Liu, M.D. and Hsin-Hui Chiu, M.D. — Thu, 28Â JanÂ 2010 00:00:00 -05:00

A 64-year-old woman who had no known medical conditions or surgical history presented with a 2-day history of epigastric fullness and vomiting. The physical examination was unremarkable except for abdominal...

IMAGES IN CLINICAL MEDICINE: Postoperative Tracheal Stenosis

Avijit Datta, M.D. and Alex Cale, F.R.C.S. — Thu, 14Â JanÂ 2010 00:00:00 -05:00

A 45-year-old woman presented for an assessment of breathlessness. She had been receiving inhaled bronchodilators and corticosteroids for years without improvement. Her medical history was notable for prolonged endotracheal intubation...

EDITORIAL: Immune Evasion by Chimeric Trachea

Megan Sykes, M.D. — Thu, 14Â JanÂ 2010 00:00:00 -05:00

The types of allogeneic organs and tissues that can be transplanted have expanded considerably in the past three decades. In addition to organs such as liver, heart, lungs, and pancreas,...

EDITORIAL: Preoperative Biliary Stents in Pancreatic Cancer â Proceed with Caution

Todd H. Baron, M.D., and Richard A. Kozarek, M.D. — Thu, 14Â JanÂ 2010 00:00:00 -05:00

Pancreatic cancer is a common and deadly disease that is diagnosed in more than 40,000 patients annually in the United States, where it is the fourth leading cause of cancer-related...

REVIEW ARTICLE: Nosocomial Bacterial Meningitis

Thu, 14Â JanÂ 2010 00:00:00 -05:00

Nosocomial bacterial meningitis may result from invasive procedures (e.g., craniotomy, placement of internal or external ventricular catheters, lumbar puncture, intrathecal infusions of medications, or spinal anesthesia), complicated head trauma, or...

ORIGINAL ARTICLE: Tracheal Allotransplantation after Withdrawal of Immunosuppressive Therapy

Thu, 14Â JanÂ 2010 00:00:00 -05:00

Reconstruction of long-segment tracheal defects requires a vascularized allograft. We report successful tracheal allotransplantation after indirect revascularization of the graft in a heterotopic position. Immunosuppressive therapy was administered before the...

ORIGINAL ARTICLE: Preoperative Biliary Drainage for Cancer of the Head of the Pancreas

Thu, 14Â JanÂ 2010 00:00:00 -05:00

Background: The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head, are unclear.

Methods:...

ORIGINAL ARTICLE: Preventing Surgical-Site Infections in Nasal Carriers of

Thu, 07Â JanÂ 2010 00:00:00 -05:00

Background: Nasal carriers of Staphylococcus aureus are at increased risk for health careâassociated infections with this organism. Decolonization of nasal and extranasal sites on hospital admission may reduce this risk.

Methods:...

EDITORIAL: Minimizing Surgical-Site Infections

Richard P. Wenzel, M.D. — Thu, 07Â JanÂ 2010 00:00:00 -05:00

Primitive ancestors of Homo sapiens and their colonizing bacteria have coevolved for approximately 500,000 years; some experts estimate that the total number of human cells is 1013 and the total...

IMAGES IN CLINICAL MEDICINE: Giant Abdominal Aortic Aneurysm

James L. Ebaugh, M.D. and Joseph D. Raffetto, M.D. — Thu, 07Â JanÂ 2010 00:00:00 -05:00

A 74-year-old man presented to his outpatient physician after noticing a painless, visible abdominal mass 3 weeks earlier (Panel A). His medical history was significant for 40 pack-years of smoking...

ORIGINAL ARTICLE: ChlorhexidineâAlcohol versus PovidoneâIodine for Surgical-Site Antisepsis

Thu, 07Â JanÂ 2010 00:00:00 -05:00

Background: Since the patient's skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 41-2009 â A 16-Year-Old Boy with Hypothermia and Frostbite

Thu, 31Â DecÂ 2009 00:00:00 -05:00

Dr. Benjamin Sandefur (Emergency Medicine): A 16-year-old boy was admitted to the hospital after being found unconscious in a snow bank at 6 a.m. on New Year's Day. He had...

VIDEOS IN CLINICAL MEDICINE: Endometrial Biopsy

Paul Gordon, M.D., M.P.H. — Thu, 24Â DecÂ 2009 00:00:00 -05:00

...

CLINICAL PRACTICE: Barrett's Esophagus

Prateek Sharma, M.D. — Thu, 24Â DecÂ 2009 00:00:00 -05:00

A 56-year-old obese man with long-standing gastroesophageal reflux who recently received a diagnosis of Barrett's esophagus presents for a follow-up visit. He has been taking omeprazole at a dose of...

IMAGES IN CLINICAL MEDICINE: Hernia through the Foramen Omentale

Adhish Basu, M.D. and Michael Jacobs, M.D. — Thu, 17Â DecÂ 2009 00:00:00 -05:00

An otherwise healthy 48-year-old woman with no medical history presented to the emergency room with colicky abdominal pain, vomiting, and diarrhea of 2 days' duration. The results of a physical...

IMAGES IN CLINICAL MEDICINE: Frostbite

Habib Rehman, M.B., B.S. and Aimee Seguin, M.D. — Thu, 17Â DecÂ 2009 00:00:00 -05:00

A 39-year-old man was found in a snowbank, with the ambient temperature â35Â°C. He had been reported missing the previous evening, after an argument with his girlfriend. The emergency services...

IMAGES IN CLINICAL MEDICINE: Ileocecal Intussusception

John D. Whitfield, M.D. and Gamal Mostafa, M.D. — Thu, 10Â DecÂ 2009 00:00:00 -05:00

A 45-year-old man with no notable medical or surgical history presented with a 24-hour history of intense pain in the right side of the abdomen with associated nausea and vomiting....

EDITORIAL: Cangrelor â A Champion Lost in Translation?

Adnan Kastrati, M.D., and Gjin Ndrepepa, M.D. — Thu, 10Â DecÂ 2009 00:00:00 -05:00

Current guidelines recommend the early use of drugs that block platelet adenosine diphosphate (ADP) receptor P2Y12 in patients with acute coronary syndromes in whom percutaneous coronary intervention (PCI) may be...

EDITORIAL: Hematopoietic Stem-Cell Transplantation for Adults with Sickle Cell Disease

Miguel R. Abboud, M.D. — Thu, 10Â DecÂ 2009 00:00:00 -05:00

Sickle cell disease is an inherited hemoglobinopathy that affects over 70,000 persons in the United States. Sickle hemoglobin (hemoglobin S) polymerizes under conditions of hypoxemia and acidosis, thereby perturbing the...

ORIGINAL ARTICLE: Intravenous Platelet Blockade with Cangrelor during PCI

Thu, 10Â DecÂ 2009 00:00:00 -05:00

Background: Intravenous cangrelor, a rapid-acting, reversible adenosine diphosphate (ADP) receptor antagonist, might reduce ischemic events during percutaneous coronary intervention (PCI).

Methods: In this double-blind, placebo-controlled study, we randomly assigned 5362 patients...

ORIGINAL ARTICLE: Platelet Inhibition with Cangrelor in Patients Undergoing PCI

Thu, 10Â DecÂ 2009 00:00:00 -05:00

Background: Cangrelor, a nonthienopyridine adenosine triphosphate analogue, is an intravenous blocker of the adenosine diphosphate receptor P2Y12. This agent might have a role in the treatment of patients who require...

EDITORIAL: Rise of the Machines â Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure

James C. Fang, M.D. — Thu, 03Â DecÂ 2009 00:00:00 -05:00

Traditionally, the only definitive therapy for patients who have advanced, medically refractory heart failure was replacement of the heart with another human heart. However, transplantation is an inadequate option in...

IMAGES IN CLINICAL MEDICINE: Tuberculous Abscess Manifesting as Unilateral Gynecomastia

Jansen Koh, M.R.C.P. and Augustine Tee, M.R.C.P. — Thu, 03Â DecÂ 2009 00:00:00 -05:00

A 74-year-old man was admitted to our hospital after presenting with fever, nonproductive cough, and a 2-month history of enlargement of the left breast. Examination showed gynecomastia on the left...

CLINICAL THERAPEUTICS: Mitral-Valve Repair for Mitral-Valve Prolapse

Subodh Verma, M.D., Ph.D., and Thierry G. Mesana, M.D., Ph.D. — Thu, 03Â DecÂ 2009 00:00:00 -05:00

A 55-year-old man with a holosystolic murmur of increasing intensity has been seen regularly by his family physician for the past 3 years. He is referred to a cardiologist. The...

ORIGINAL ARTICLE: Advanced Heart Failure Treated with Continuous-Flow Left Ventricular Assist Device

Thu, 03Â DecÂ 2009 00:00:00 -05:00

Background: Patients with advanced heart failure have improved survival rates and quality of life when treated with implanted pulsatile-flow left ventricular assist devices as compared with medical therapy. New continuous-flow...

IMAGES IN CLINICAL MEDICINE: Large Atrial Myxoma

Aman Mundi, M.D. — Thu, 26Â NovÂ 2009 00:00:00 -05:00

A 57-year-old woman with no notable medical history presented with a 4-month history of leg swelling and dyspnea on exertion. Her symptoms had been progressively worsening for 2 weeks before...

IMAGES IN CLINICAL MEDICINE: Air in the Portal and Mesenteric Veins

Diego de Mendoza-Asensi, M.D. and Kenneth Planas, M.D. — Thu, 19Â NovÂ 2009 00:00:00 -05:00

A 73-year-old man with history of smoking, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus presented with respiratory distress. The trachea was intubated, and the patient was admitted...

IMAGES IN CLINICAL MEDICINE: Extensive Bowel Infarction

Janice Cheng, M.B., B.S. and Girish Pande, M.B., B.S. — Thu, 12Â NovÂ 2009 00:00:00 -05:00

A 45-year-old man presented to the emergency room with abdominal pain that had been increasing over the previous week and hematemesis and melena that had begun in the preceding 12...

VIDEOS IN CLINICAL MEDICINE: AnkleâBrachial Index for Assessment of Peripheral Arterial Disease

S. Marlene Grenon, M.D.C.M., Joel Gagnon, M.D., and York Hsiang, M.D. — Thu, 05Â NovÂ 2009 00:00:00 -05:00

...

EDITORIAL: Innovation and Comparative-Effectiveness Research in Cardiac Surgery

Eric David Peterson, M.D., M.P.H. — Thu, 05Â NovÂ 2009 00:00:00 -05:00

Cardiac surgery has always been a unique combination of art and science. The field is advanced by those who push the envelope by suggesting innovations. Yet promising techniques need to...

ORIGINAL ARTICLE: On-Pump versus Off-Pump Coronary-Artery Bypass Surgery

Thu, 05Â NovÂ 2009 00:00:00 -05:00

Background: Coronary-artery bypass grafting (CABG) has traditionally been performed with the use of cardiopulmonary bypass (on-pump CABG). CABG without cardiopulmonary bypass (off-pump CABG) might reduce the number of complications related...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 33-2009 â A 35-Year-Old Woman with Fever, Abdominal Pain, and Hypotension after Cesarean Section

Thu, 22Â OctÂ 2009 00:00:00 -05:00

Dr. Claudius H.O. Conrad (Surgery): A 35-year-old woman was transferred to this hospital because of abdominal pain, fever, and hypotension.

Three days earlier, an elective cesarean section was performed at another...

IMAGES IN CLINICAL MEDICINE: Bronchial Obstruction after Pneumonectomy

Loren J. Harris, M.D. — Thu, 22Â OctÂ 2009 00:00:00 -05:00

A 42-year-old woman underwent right pneumonectomy because of extensive parenchymal destruction due to tuberculosis. Five years after resection, she reported increasing shortness of breath, wheezing, and dyspnea on exertion. A...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 31-2009 â A 26-Year-Old Man with Abdominal Distention and Shock

Thu, 08Â OctÂ 2009 00:00:00 -05:00

Dr. Jeffrey S. Ustin (Trauma, Emergency Surgery, and Surgical Critical Care): A 26-year-old man was admitted to this hospital because of abdominal distention and shock.

The patient had been well until...

IMAGES IN CLINICAL MEDICINE: Staghorn Calculus

Shanmugasundaram Rajaian, M.D. and Nitin Sudhakar Kekre, M.D. — Thu, 08Â OctÂ 2009 00:00:00 -05:00

A 58-year-old man presented with a 1-year history of dysuria. His medical history was notable for recurrent pyelonephritis on the right side. Evaluation at this time revealed staghorn calculus (Panel...

IMAGES IN CLINICAL MEDICINE: Cerebrospinal Fluid Leak

Theo Diekman, M.D., Ph.D. and Bram Mees, M.D. — Thu, 01Â OctÂ 2009 00:00:00 -05:00

A 50-year-old postmenopausal woman with asthma and allergic rhinitis presented with a 6-month history of unilateral rhinorrhea. When she woke in the mornings, she noticed a stain (halo) on her...

EDITORIAL: Variation in Hospital Mortality Associated with Inpatient Surgery â An S.O.S.

Danny O. Jacobs, M.D., M.P.H. — Thu, 01Â OctÂ 2009 00:00:00 -05:00

Health care organizations have appropriately begun to focus increased attention on the quality of medical services they provide to their patients.1 Reports from the Institute of Medicine (IOM) have illustrated...

SPECIAL ARTICLE: Variation in Hospital Mortality Associated with Inpatient Surgery

Thu, 01Â OctÂ 2009 00:00:00 -05:00

Background: Hospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality....

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 30-2009 â A 77-Year-Old Man with Recurrent Transitional-Cell Carcinoma of the Ureter

Thu, 24Â SepÂ 2009 00:00:00 -05:00

Dr. Donald S. Kaufman: A 77-year-old man with a history of transitional-cell carcinoma of the right ureter was seen in the multidisciplinary urologic oncology clinic of this hospital because of...

IMAGES IN CLINICAL MEDICINE: De Garengeot's Hernia

Augustine Chung, B.A. and Amitabh Goel, M.D. — Thu, 10Â SepÂ 2009 00:00:00 -05:00

An 83-year-old woman presented with a 1-week history of an enlarging, painful bulge in the right groin. Examination of the abdomen revealed a diffusely tender and erythematous right-groin mass extending...

CORRESPONDENCE: Ruptured Abdominal Aortic Aneurysm Related to IgG4 Periaortitis

Qi Qian, M.D., Kianoush B. Kashani, M.D., and Dylan V. Miller, M.D. — Thu, 10Â SepÂ 2009 00:00:00 -05:00

To the Editor: Periaortitis that is associated with immunoglobulin G4 (IgG4) plasma-cell infiltration is a rare condition with undefined incidence and clinical features. In a single-center study in Japan, the...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Understanding Abdominal Aortic Aneurysm

Neal L. Weintraub, M.D. — Thu, 10Â SepÂ 2009 00:00:00 -05:00

Abdominal aortic aneurysms occur in up to 9% of adults older than 65 years of age, and the rupture of these aneurysms accounts for about 15,000 deaths in the United...

REVIEW ARTICLE: Intestinal Transplantation

Thomas M. Fishbein, M.D. — Thu, 03Â SepÂ 2009 00:00:00 -05:00

The results of intestinal transplantation have improved over the past decade. During this period, the number of intestinal transplant procedures performed in North America has increased by a factor of...

ORIGINAL ARTICLE: Fluvastatin and Perioperative Events in Patients Undergoing Vascular Surgery

Thu, 03Â SepÂ 2009 00:00:00 -05:00

Background: Adverse cardiac events are common after vascular surgery. We hypothesized that perioperative statin therapy would improve postoperative outcomes.

Methods: In this double-blind, placebo-controlled trial, we randomly assigned patients who had...

ORIGINAL ARTICLE: Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture

Thu, 03Â SepÂ 2009 00:00:00 -05:00

Background: Dupuytren's disease limits hand function, diminishes the quality of life, and may ultimately disable the hand. Surgery followed by hand therapy is standard treatment, but it is associated with...

IMAGES IN CLINICAL MEDICINE: Unilateral Epistaxis

Yueng-Hsiang Chu, M.D. and Jih-Chin Lee, M.D. — Thu, 27Â AugÂ 2009 00:00:00 -05:00

A 44-year-old man presented with a 7-day history of epistaxis on the left side. He reported that he had washed his face in a freshwater stream 7 days before the...

IMAGES IN CLINICAL MEDICINE: Pneumatosis Cystoides Coli

Melina C. Vassiliou, M.D. and Gina L. Adrales, M.D. — Thu, 20Â AugÂ 2009 00:00:00 -05:00

A 25-year-old woman presented with recurrent abdominal pain that had first developed 10 years earlier. Physical examination revealed mild tenderness in the left upper quadrant, without rebound or guarding. Laboratory...

CORRESPONDENCE: Codeine, Ultrarapid-Metabolism Genotype, and Postoperative Death

Thu, 20Â AugÂ 2009 00:00:00 -05:00

To the Editor: Obstructive sleep apnea is not rare in children with hypertrophic tonsils, and the common curative procedure is adenotonsillectomy.1 Codeine is commonly prescribed for pain after adenotonsillectomy.2 The...

IMAGES IN CLINICAL MEDICINE: Rectovesical Fistula

Ethan Rogers, M.D. and Michael Mohseni, M.D. — Thu, 20Â AugÂ 2009 00:00:00 -05:00

An 84-year-old man presented with a foreign body hanging from his rectum. Eleven years earlier, he had undergone a radical prostatectomy for prostate cancer. One week before presentation, he underwent...

CLINICAL PRACTICE: Infection Associated with Prosthetic Joints

Jose L. Del Pozo, M.D., Ph.D., and Robin Patel, M.D. — Thu, 20Â AugÂ 2009 00:00:00 -05:00

The numbers of primary total hip and total knee arthroplasties have been increasing over the past decade, with nearly 800,000 such procedures performed in the United States in 2006 (Figure...

IMAGES IN CLINICAL MEDICINE: Testicular Torsion in a Hydrocele

Eda Okatan, M.D. and Richard Keijzer, M.D., Ph.D. — Thu, 13Â AugÂ 2009 00:00:00 -05:00

A 6-week-old male infant with congenital bilateral hydroceles presented with a reddish, painful, and swollen left scrotum of 2 days' duration. There were no signs of inguinal hernia or fever....

IMAGES IN CLINICAL MEDICINE: Stent-Associated Urinary Calculi

Jovo Bogdanovic, M.D. and Jasenko Djozic, M.D., Ph.D. — Thu, 06Â AugÂ 2009 00:00:00 -05:00

A 54-year-old man was referred because of a 6-month history of lower urinary tract symptoms, microhematuria, and dull pain in the right flank. He had undergone shock-wave lithotripsy for the...

ORIGINAL ARTICLE: Apixaban or Enoxaparin for Thromboprophylaxis after Knee Replacement

Thu, 06Â AugÂ 2009 00:00:00 -05:00

Background: The optimal strategy for thromboprophylaxis after major joint replacement has not been established. Low-molecular-weight heparins such as enoxaparin predominantly target factor Xa but to some extent also inhibit thrombin....

IMAGES IN CLINICAL MEDICINE: Asymmetric Edema of the Upper Lung Due to Mitral Valvular Dysfunction

Siva Raman, M.D. and Sudhakar Pipavath, M.D. — Thu, 30Â JulÂ 2009 00:00:00 -05:00

An 80-year-old woman with chronic obstructive pulmonary disease and mitral-valve prolapse presented with progressive dyspnea, orthopnea, and dry cough, which she reported having had for the previous 3 days. She...

EDITORIAL: Surgical Treatment of Obesity â Weighing the Facts

Malcolm K. Robinson, M.D. — Thu, 30Â JulÂ 2009 00:00:00 -05:00

There has been an explosion in the number of bariatric surgical procedures performed worldwide. It is estimated that in 2005, the number of procedures performed in the United States was...

ORIGINAL ARTICLE: Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery

The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium — Thu, 30Â JulÂ 2009 00:00:00 -05:00

Background: To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization.

Methods: We performed a prospective, multicenter, observational study of 30-day outcomes...

ORIGINAL ARTICLE: Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery

Thu, 16Â JulÂ 2009 00:00:00 -05:00

Background: Vein-graft harvesting with the use of endoscopy (endoscopic harvesting) is a technique that is widely used to reduce postoperative wound complications after coronary-artery bypass grafting (CABG), but the long-term...

IMAGES IN CLINICAL MEDICINE: Telltale Triangle of Pneumoperitoneum

Ming-Yuan Huang, M.D. and Wen-Han Chang, M.D., Ph.D. — Thu, 02Â JulÂ 2009 00:00:00 -05:00

A 56-year-old man presented to the emergency department with a 3-day history of diarrhea and dull epigastric pain. The diarrhea had responded to antidiarrheal agents. However, the epigastric pain had...

ORIGINAL ARTICLE: Preoperative Staging of Lung Cancer with Combined PETâCT

Thu, 02Â JulÂ 2009 00:00:00 -05:00

Background: Fast and accurate staging is essential for choosing treatment for nonâsmall-cell lung cancer (NSCLC). The purpose of this randomized study was to evaluate the clinical effect of combined positron-emission...

IMAGES IN CLINICAL MEDICINE: Ingested Magnets

Luigi Avolio, M.D. and Giuseppe Martucciello, M.D. — Thu, 25Â JunÂ 2009 00:00:00 -05:00

A 9-year-old boy ingested 23 magnets (Panel A). Four days later, he had clinical and surgical evidence of intestinal perforation and peritonitis due to pressure necrosis of the bowel. In...

IMAGES IN CLINICAL MEDICINE: Perforated Umbilical Hernia

Radheshyam Miryala, M.D. and Ryan Neilan, M.D. — Thu, 18Â JunÂ 2009 00:00:00 -05:00

A 68-year-old man with alcoholic cirrhosis, portal hypertension, ascites, and an umbilical hernia presented to the emergency department after an episode of coughing that was followed by a rush of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 19-2009 â A 63-Year-Old Woman with Carcinoma of the Gastroesophageal Junction

Thu, 18Â JunÂ 2009 00:00:00 -05:00

Dr. Stephanie Heon (HematologyâOncology): A 63-year-old woman was seen in the Cancer Center at this hospital for management of adenocarcinoma of the gastroesophageal junction.

The patient had been well until approximately...

IMAGES IN CLINICAL MEDICINE: Plombage Cavities

Ioannis Dimarakis, Ph.D., M.R.C.S. and Jonathan Anderson, F.R.C.S. — Thu, 04Â JunÂ 2009 00:00:00 -05:00

A 73-year-old woman receiving chemotherapy for advanced breast cancer was referred for treatment of a nontuberculous empyema of the thoracic cavity (left side), which had not responded to treatment with...

IMAGES IN CLINICAL MEDICINE: Fecaliths in Crohn's Disease

Agnes K. Liman, M.D. and Blazej Zbytek, M.D., Ph.D. — Thu, 07Â MayÂ 2009 00:00:00 -05:00

A 74-year-old man presented with a 5-day history of diffuse abdominal pain, constipation, nausea, and vomiting. His abdomen was tympanitic without peritoneal signs. Radiography of the abdomen revealed a dilated...

IMAGES IN CLINICAL MEDICINE: Abdominal Aortic Aneurysm

Mohammed Al-Omran, M.D. and Badr Aljabri, M.D. — Thu, 07Â MayÂ 2009 00:00:00 -05:00

A 76-year-old man presented with mild back pain of 2 weeks' duration. The physical examination revealed a blood pressure of 140/85 mm Hg and a pulsatile, nontender abdominal mass (Panel...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2009 â A 36-Year-Old Man with Chest Pain, Dysphagia, and Pleural and Mediastinal Calcifications

Henning A. Gaissert, M.D., Nitra Piyavisetpat, M.D., and Eugene J. Mark, M.D. — Thu, 30Â AprÂ 2009 00:00:00 -05:00

A 36-year-old man was admitted to the hospital because of chest pain, dysphagia, dyspnea, and pleural and mediastinal calcifications.

He had been well until approximately 6 years before admission, when a...

IMAGES IN CLINICAL MEDICINE: Bilateral Subacute Subdural Hematomas

Joshua J. Wind, M.D. and James W. Leiphart, M.D., Ph.D. — Thu, 23Â AprÂ 2009 00:00:00 -05:00

A 43-year-old man presented to the emergency department with a 2-day history of headache; he reported being otherwise healthy. Four weeks earlier, he had been an unrestrained driver involved in...

EDITORIAL: Surgical Ventricular Reconstruction for Heart Failure

Howard J. Eisen, M.D. — Thu, 23Â AprÂ 2009 00:00:00 -05:00

Congestive heart failure is one of the leading causes of death and complications in the developed world, and coronary artery disease is the major cause of heart failure. Efforts to...

CLINICAL THERAPEUTICS: Minimally Invasive Total Knee Arthroplasty for Osteoarthritis

Seth S. Leopold, M.D. — Thu, 23Â AprÂ 2009 00:00:00 -05:00

A 65-year-old woman with osteoarthritis of her right knee is referred by her primary care physician for orthopedic consultation. She is healthy except for some well-controlled hypertension. She is 5...

ORIGINAL ARTICLE: Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

Thu, 23Â AprÂ 2009 00:00:00 -05:00

Background: Surgical ventricular reconstruction is a specific procedure designed to reduce left ventricular volume in patients with heart failure caused by coronary artery disease. We conducted a trial to address...

CLINICAL PROBLEM-SOLVING: A Question Well Put

Thu, 02Â AprÂ 2009 00:00:00 -05:00

A 51-year-old woman with a history of hypertension and depression reported progressively worsening pain in the left thigh over a period of several months, which had made her unable to...

IMAGES IN CLINICAL MEDICINE: Mediastinal Extension of a Goiter

Giuseppe Mercante, M.D. and Verter Barbieri, M.D. — Thu, 26Â MarÂ 2009 00:00:00 -05:00

A 67-year-old woman presented with a 6-month history of dyspnea and dysphagia. Physical examination revealed a small cervical goiter, but the lower poles of the thyroid were not palpable. The...

EDITORIAL: Prevention of Viral Sexually Transmitted Infections â Foreskin at the Forefront

Matthew R. Golden, M.D., M.P.H., and Judith N. Wasserheit, M.D., M.P.H. — Thu, 26Â MarÂ 2009 00:00:00 -05:00

Three landmark randomized, controlled trials conducted in South Africa, Uganda, and Kenya from 2005 through 2007 demonstrated that adult male circumcision reduced the acquisition of human immunodeficiency virus (HIV) by...

ORIGINAL ARTICLE: Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis

Thu, 26Â MarÂ 2009 00:00:00 -05:00

Background: Male circumcision significantly reduced the incidence of human immunodeficiency virus (HIV) infection among men in three clinical trials. We assessed the efficacy of male circumcision for the prevention of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 9-2009 â An 81-Year-Old Man with Massive Rectal Bleeding

Thu, 19Â MarÂ 2009 00:00:00 -05:00

Dr. John C. Lamattina (Surgery): An 81-year-old man was admitted to this hospital because of massive rectal bleeding.

He had been in his usual state of health until 4 a.m. on...

IMAGES IN CLINICAL MEDICINE: Pelvic-Organ Prolapse and Uterine Inversion

Christl Reisenauer, M.D. and Erich Solomayer, M.D. — Thu, 19Â MarÂ 2009 00:00:00 -05:00

A 68-year-old woman presented with dull, persistent abdominal pain, the sensation of a foreign body in the pelvis, difficulty voiding, and vaginal discharge. The symptoms had developed over many years,...

IMAGES IN CLINICAL MEDICINE: Venous Obstruction of the Thigh

Alberto Caggiati, M.D. and Carlo Catalano, M.D. — Thu, 12Â MarÂ 2009 00:00:00 -05:00

A 56-year-old man presented with a post-thrombotic syndrome of the left leg (involving edema, varicose veins, trophic skin changes, and an ulcer, 5 cm in diameter, of the distal medial...

BOOK REVIEW:

Thu, 12Â MarÂ 2009 00:00:00 -05:00

If multiple authorship is a mark of quality, this book is a must-read. With 189 authors covering the oncology of the gastrointestinal tract from the esophagus to the anus, as...

ORIGINAL ARTICLE: Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease

Thu, 05Â MarÂ 2009 00:00:00 -05:00

Background: Percutaneous coronary intervention (PCI) involving drug-eluting stents is increasingly used to treat complex coronary artery disease, although coronary-artery bypass grafting (CABG) has been the treatment of choice historically. Our...

BOOK REVIEW:

Thu, 05Â MarÂ 2009 00:00:00 -05:00

This book for pediatric surgeons, fellows, residents, and pediatric oncologists reflects the extensive experience of its editors and authors in caring for children with cancer. It is well written, well...

BOOK REVIEW:

Thu, 05Â MarÂ 2009 00:00:00 -05:00

Some of us may think that ethics are unimportant in surgery, but the authors of The Ethics of Surgical Practice demonstrate that surgeons operate daily in the theater of moral...

EDITORIAL: Coronary Revascularization in Context

Richard A. Lange, M.D., and L. David Hillis, M.D. — Thu, 05Â MarÂ 2009 00:00:00 -05:00

Coronary-artery bypass grafting (CABG), introduced in 1968, was the only method of coronary revascularization until 1977, when percutaneous balloon angioplasty was first performed. The complications of balloon angioplasty (acute vessel...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 7-2009 â A Pregnant Woman with a Large Mass in the Fetal Oral Cavity

Thu, 26Â FebÂ 2009 00:00:00 -05:00

A 29-year-old pregnant woman was transferred to this hospital at 38 weeks 4 days of gestation because of a large mass that had been detected in the fetal oral cavity...

CLINICAL THERAPEUTICS: Excision and Skin Grafting of Thermal Burns

Dennis P. Orgill, M.D., Ph.D. — Thu, 26Â FebÂ 2009 00:00:00 -05:00

A 45-year-old man was rescued from his burning house. Firefighters removed his smoldering clothes and initiated intravenous access, pulse oximetry, and electrocardiographic monitoring. An endotracheal tube was inserted, and ventilation...

PERSPECTIVE: CABG vs. Stenting â Clinical Implications of the SYNTAX Trial

Thu, 19Â FebÂ 2009 00:00:00 -05:00

In the international SYNTAX trial, 1800 patients with three-vessel or left main coronary artery disease were randomly assigned to either revascularization with coronary-artery bypass grafting (CABG) or percutaneous coronary intervention...

CLINICAL PRACTICE: Epistaxis

Rodney J. Schlosser, M.D. — Thu, 19Â FebÂ 2009 00:00:00 -05:00

A 61-year-old man presents to the emergency room with left-sided epistaxis that has continued for 1 hour. He estimates having lost approximately 1/2 cup of blood and reports no history...

ORIGINAL ARTICLE: Quality of Life after Late Invasive Therapy for Occluded Arteries

Thu, 19Â FebÂ 2009 00:00:00 -05:00

Background: The open-artery hypothesis postulates that late opening of an infarct-related artery after myocardial infarction will improve clinical outcomes. We evaluated the quality-of-life and economic outcomes associated with the use...

BOOK REVIEW:

Thu, 12Â FebÂ 2009 00:00:00 -05:00

The Borden Institute, an agency of the U.S. Army Medical Department Center and School that publishes military textbooks for the Army Medical Department, commonly solicits case reports from the field...

IMAGES IN CLINICAL MEDICINE: A Tuba Player with Air in the Parotid Gland

Deepa Mukundan, M.D. and Oliver Jenkins, M.D. — Thu, 12Â FebÂ 2009 00:00:00 -05:00

A 13-year-old boy who had recently begun playing the tuba presented with a 2-day history of facial swelling on the left side and pain without fever or ear or nasal...

CLINICAL PROBLEM-SOLVING: Needle in a Haystack

Thu, 05Â FebÂ 2009 00:00:00 -05:00

A 50-year-old woman reported multiple loose bowel movements associated with mild, cramping abdominal pain. She had been well until 2 months earlier, when her bowel habits changed from one formed...

IMAGES IN CLINICAL MEDICINE: Traumatic Epidural Hematoma

Gary L. Gallia, M.D., Ph.D. and Michael H. Sobotta, M.B., B.S. — Thu, 05Â FebÂ 2009 00:00:00 -05:00

An 18-year-old intoxicated man was assaulted with a glass bottle on the left parietal region of his head and had a 5-minute loss of consciousness. The patient went home, but...

IMAGES IN CLINICAL MEDICINE: Traumatic Diaphragmatic Rupture with Intrathoracic Liver Herniation

Stephen H. McKellar, M.D. and L. Ray Matthews, M.D. — Thu, 29Â JanÂ 2009 00:00:00 -05:00

A 24-year-old man who had been wearing a seatbelt while driving a car involved in a high-speed motor vehicle crash was taken by ambulance to a local hospital, where his...

IMAGES IN CLINICAL MEDICINE: Metallic Mercury Embolism to the Hand

Antonio Carlos de Souza and Adelino Moreira de Carvalho, M.D., M.Sc., Ph.D. — Thu, 29Â JanÂ 2009 00:00:00 -05:00

Severe pain developed in the left hand of a 46-year-old woman after open heart surgery was performed to repair an atrial septal defect. It was initially thought that this pain...

SPECIAL ARTICLE: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Thu, 29Â JanÂ 2009 00:00:00 -05:00

Background: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a...

BOOK REVIEW:

Thu, 22Â JanÂ 2009 00:00:00 -05:00

Pioneers of Cardiac Surgery has two principal parts, which are complementary and cohesive visions of the history of surgical pioneers. The first part is a short description of the development...

BOOK REVIEW:

Thu, 22Â JanÂ 2009 00:00:00 -05:00

There is a traditional belief that a physician can follow one of two distinct career paths: a medical specialty or a surgical specialty. Anyone working in pancreatic medicine, however, recognizes...

CORRESPONDENCE: Excess Iodine from an Unexpected Source

Seth M. Arum, M.D., Xuemei He, M.D., and Lewis E. Braverman, M.D. — Thu, 22Â JanÂ 2009 00:00:00 -05:00

To the Editor: It is standard practice to induce a decrease in the body's iodine stores before treatment with radioiodine for thyroid cancer. Such patients should avoid an iodine-rich diet,12...

CLINICAL DECISIONS: Management of Prostate Cancer â Polling Results

Robert S. Schwartz, M.D. — Thu, 15Â JanÂ 2009 00:00:00 -05:00

In early December, we presented the case of a 63-year-old man with a rising prostate-specific antigen (PSA) level in Clinical Decisions,1 an interactive feature designed to assess how readers would...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2009 â A 25-Year-Old Man with Pain and Swelling of the Right Hand and Hypotension

Thu, 15Â JanÂ 2009 00:00:00 -05:00

Dr. William D. Binder (Emergency Services): A 25-year-old man was transferred to the emergency department of this hospital because of pain and swelling of the right hand and hypotension.

The patient...

EDITORIAL: Making Small Risks Even Smaller

Michael F. Greene, M.D. — Thu, 08Â JanÂ 2009 00:00:00 -05:00

Cesarean sections performed without antecedent labor are associated with a higher risk of respiratory distress than those performed after the onset of labor, despite the fact that they may have...

IMAGES IN CLINICAL MEDICINE: Diagnosis of Uterine Rupture on CT

Alexandra Grosvenor Eller, M.D. and Barbra Fisher, M.D., Ph.D. — Thu, 08Â JanÂ 2009 00:00:00 -05:00

A 34-year-old woman with seven previous cesarean deliveries and a history of scant prenatal care presented at 32 weeks' gestation with constant, vague lower abdominal pain that had worsened over...

ORIGINAL ARTICLE: Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes

Thu, 08Â JanÂ 2009 00:00:00 -05:00

Background: Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between...

ORIGINAL ARTICLE: Machine Perfusion or Cold Storage in Deceased-Donor Kidney Transplantation

Thu, 01Â JanÂ 2009 00:00:00 -05:00

Background: Static cold storage is generally used to preserve kidney allografts from deceased donors. Hypothermic machine perfusion may improve outcomes after transplantation, but few sufficiently powered prospective studies have addressed...

CLINICAL THERAPEUTICS: Radiation Therapy for Early-Stage Breast Cancer after Breast-Conserving Surgery

Thomas A. Buchholz, M.D. — Thu, 01Â JanÂ 2009 00:00:00 -05:00

A 45-year-old woman with a family history of postmenopausal breast cancer (in a maternal aunt) discovers a mass in the upper outer quadrant of her left breast. A mammogram reveals...

VIDEOS IN CLINICAL MEDICINE: Basic Splinting Techniques

Thu, 25Â DecÂ 2008 00:00:00 -05:00

...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 40-2008 â A 26-Year-Old Man with Blurred Vision

Thu, 25Â DecÂ 2008 00:00:00 -05:00

Dr. Aaron Savar (Neuro-Ophthalmology): A 26-year-old man was seen in the Neuro-Ophthalmology Clinic of the Massachusetts Eye and Ear Infirmary (MEEI) because of blurred vision in the right eye.

Approximately 8...

IMAGES IN CLINICAL MEDICINE: Hypogonadism Due to Pituicytoma in an Identical Twin

Harvey H. Newnham, M.B., B.S. and Livia M. Rivera-Woll, M.B., B.S. — Thu, 25Â DecÂ 2008 00:00:00 -05:00

A 43-year-old man, who is an identical twin, presented with a 2-year history of lethargy, weakness, and headaches and a several-year history of gradual loss of body hair and declining...

IMAGES IN CLINICAL MEDICINE: Subungual Exostosis

Alexandre Campanelli, M.D. and Luca Borradori, M.D. — Thu, 18Â DecÂ 2008 00:00:00 -05:00

A 12-year-old girl with an unremarkable history was evaluated for a nodule of the lateral nail fold on the right hallux that had been present for 3 months (Panel A)....

CLINICAL DECISIONS: Management of Prostate Cancer

Thu, 11Â DecÂ 2008 00:00:00 -05:00

A 63-year-old man who has been under your care for the past 3 years undergoes an annual check-up. He believes he is in excellent health, and he has no medical...

CLINICAL PROBLEM-SOLVING: Taken Out of Context

Michael P. Thomas, M.D., and Andrew Wang, M.D. — Thu, 04Â DecÂ 2008 00:00:00 -05:00

A 25-year-old woman with a history of depression, mitral-valve prolapse, and migraine headaches presented to a hospital emergency department with a 3-day history of subjective fever, diffuse arthralgia, and severe...

PERSPECTIVE: Circumcision â A Surgical Strategy for HIV Prevention in Africa

Thu, 04Â DecÂ 2008 00:00:00 -05:00

In a radical departure from earlier strategies, public health officials are now arguing that circumcision of men should be a key weapon in the fight against infection with the human...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 37-2008 â A 17-Year-Old Boy with a Pituitary Tumor and Skull Abnormalities

Thu, 27Â NovÂ 2008 00:00:00 -05:00

A 17-year-old boy was seen at this hospital because of a pituitary tumor and radiologic evidence of bony abnormalities in the skull. The patient was well until approximately 12 years...

CLINICAL PRACTICE: Primary Retinal Detachment

Donald J. D'Amico, M.D. — Thu, 27Â NovÂ 2008 00:00:00 -05:00

Rhegmatogenous retinal detachment, which refers to detachment due to round holes, tears, or breaks in the retina, is an important cause of visual symptoms and visual loss (Figure 1). The...

VIDEOS IN CLINICAL MEDICINE: Peripheral Intravenous Cannulation

Thu, 20Â NovÂ 2008 00:00:00 -05:00

...

CORRESPONDENCE: Restless Legs Syndrome and Spinal Anesthesia

Thu, 20Â NovÂ 2008 00:00:00 -05:00

To the Editor: The restless legs syndrome (RLS) is a common sensorimotor disorder of unknown cause affecting approximately 10% of the population.1 One uncontrolled study showed that spinal anesthesia caused...

IMAGES IN CLINICAL MEDICINE: Ocular Myiasis

Michael A. Albert, Jr., M.D. and Jill R. Wells, M.D. — Thu, 13Â NovÂ 2008 00:00:00 -05:00

A 49-year-old man presented to the emergency room with a 2-day history of decreased vision in his left eye. He described his vision as âlooking through branches in a tree.â...

IMAGES IN CLINICAL MEDICINE: Reversal of Traumatic Quadriplegia after Closed Reduction

John A. Cowan, Jr., M.D. and John E. McGillicuddy, M.D. — Thu, 13Â NovÂ 2008 00:00:00 -05:00

A 39-year-old woman was struck by a truck traveling at high speed. Cervical computed tomography showed a dislocation between the C5 and C6 vertebrae (Panel A, sagittal reconstruction). Physical examination...

CLINICAL PRACTICE: Anterior Cruciate Ligament Tear

Kurt P. Spindler, M.D., and Rick W. Wright, M.D. — Thu, 13Â NovÂ 2008 00:00:00 -05:00

The passage in 1972 of Title IX legislation, which guarantees equal access to athletic programs for both sexes at any high school or college receiving federal funds, has led to...

CORRESPONDENCE: Problems Associated with the Use of Thyrogen in Patients with a Thyroid Gland

Thu, 16Â OctÂ 2008 00:00:00 -05:00

To the Editor: Juweid et al. (September 18 issue)1 describe the administration of thyrotropin alfa (Thyrogen) to a patient with thyroid cancer who still has a thyroid gland. Genzyme, the...

IMAGES IN CLINICAL MEDICINE: Keratoacanthoma

Rachid Frikh, M.D. and Omar Sedrati, M.D. — Thu, 16Â OctÂ 2008 00:00:00 -05:00

A 45-year-old man presented with a kerotic nodule of the second right toe that had been increasing in size for 4 months. There was no history of trauma and no...

REVIEW ARTICLE: Blunt Aortic Injury

Thu, 16Â OctÂ 2008 00:00:00 -05:00

Blunt aortic injury occurs in less than 1% of motor vehicle crashes but is responsible for 16% of the deaths.1 This injury is second only to head injury as the...

CLINICAL DECISIONS: Management of Skin and Soft-Tissue Infection â Polling Results

Sarah P. Hammond, M.D., and Lindsey R. Baden, M.D. — Thu, 09Â OctÂ 2008 00:00:00 -05:00

In early September, we presented a case of a college athlete with a skin and soft-tissue infection in Clinical Decisions,1 an interactive feature designed to assess how readers would manage...

CLINICAL THERAPEUTICS: Breast Reconstruction after Surgery for Breast Cancer

Peter G. Cordeiro, M.D. — Thu, 09Â OctÂ 2008 00:00:00 -05:00

A 45-year-old woman undergoes core needle biopsy of a breast mass 4 cm in diameter and fine-needle aspiration of a palpable axillary lymph node, the results of both of which...

IMAGES IN CLINICAL MEDICINE: Pneumopericardium

Mehdi Karoui, M.D., Ph.D. and Petru Octav Bucur, M.D. — Thu, 02Â OctÂ 2008 00:00:00 -05:00

A 47-year-old homeless man presented to the emergency department 1 week after the onset of chest pain. He was hemodynamically stable. The physical examination was unremarkable. A routine complete blood...

IMAGES IN CLINICAL MEDICINE: Ludwig's Angina

Jon Heavey, M.D. and Naren Gupta, M.D., Ph.D. — Thu, 02Â OctÂ 2008 00:00:00 -05:00

A 58-year-old healthy man was evaluated for a toothache of 2 days' duration. He was treated with oral penicillin and an opiate analgesic and advised to have the affected teeth...

IMAGES IN CLINICAL MEDICINE: New-Onset Clubbing Associated with Lung Cancer

Bryan A. Faller, M.D. and John P. Atkinson, M.D. — Thu, 25Â SepÂ 2008 00:00:00 -05:00

A 45-year-old woman with a 27-pack-year history of smoking presented for evaluation of progressive distal finger enlargement and polyarthralgias, which had developed over a period of 18 months. During the...

IMAGES IN CLINICAL MEDICINE: Colonic Saccular Diverticula

Elizabeth A. Steensma, M.D. and Fred M. Wu, M.D. — Thu, 18Â SepÂ 2008 00:00:00 -05:00

A 61-year-old woman with severe pulmonary hypertension and an 8-year history of the CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal involvement, sclerodactyly, and telangiectasia) and with a positive anticentromere-antibody test was...

CORRESPONDENCE: Diagnosis of Poorly Differentiated Thyroid Cancer with Radioiodine Scanning after Thyrotropin Alfa Stimulation

Malik Juweid, M.D., Thomas O'Dorisio, M.D., and Mohammed Milhem, M.D. — Thu, 18Â SepÂ 2008 00:00:00 -05:00

To the Editor: Poorly differentiated thyroid cancers are rare and can be difficult for surgeons, endocrinologists, and pathologists to identify.1 These cancers fall into two main histologic categories: insular and...

IMAGES IN CLINICAL MEDICINE: Primary Small-Bowel Enterolithiasis

Robert L. Wroblewski, M.D. and Robert P. Sticca, M.D. — Thu, 18Â SepÂ 2008 00:00:00 -05:00

A 53-year-old woman with a 2-year history of intermittent abdominal pain, diarrhea, and constipation presented for evaluation. Her medical history was significant for congenital imperforate anus requiring a colostomy at...

EDITORIAL: Arthroscopic Surgery for Osteoarthritis of the Knee?

Robert G. Marx, M.D. — Thu, 11Â SepÂ 2008 00:00:00 -05:00

Orthopedic surgeons perform arthroscopic surgery in many joints of the extremities, most commonly the knee. Two or three incisions are routinely made, each measuring approximately 7 mm. The knee is...

IMAGES IN CLINICAL MEDICINE: Extracapsular Hemorrhage from a Parathyroid Adenoma

M. Carola Zillikens, M.D. and Anke Wijbenga, M.D., Ph.D. — Thu, 11Â SepÂ 2008 00:00:00 -05:00

A healthy 34-year-old woman presented with an acute, painful swelling and bluish discoloration of the anterior neck with no associated trauma. She reported having fatigue, anorexia, and depression during the...

ORIGINAL ARTICLE: A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

Thu, 11Â SepÂ 2008 00:00:00 -05:00

Background: The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown.

Methods: We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe...

BOOK REVIEW:

Thu, 04Â SepÂ 2008 00:00:00 -05:00

The statistics alone are daunting. In the United States, traumatic injury is the leading cause of death in the first four decades of life. On average, approximately 2 people are...

BOOK REVIEW:

Thu, 04Â SepÂ 2008 00:00:00 -05:00

Contemporary anesthesia is an important âsafety paradoxâ of excellent outcome despite routine risk. Although it carries perhaps the greatest potential for hazard for millions of patients annually, anesthesia also has...

CLINICAL DECISIONS: Management of Skin and Soft-Tissue Infection

Thu, 04Â SepÂ 2008 00:00:00 -05:00

A 20-year-old college basketball player presents to the emergency department with a 2-day history of a red, painful area on his right buttock. He reports that there was no specific...

REVIEW ARTICLE: Current Management of Acute Cutaneous Wounds

Adam J. Singer, M.D., and Alexander B. Dagum, M.D. — Thu, 04Â SepÂ 2008 00:00:00 -05:00

In 2005, 11.8 million wounds were treated in emergency departments in the United States.1 More than half a million burns and 7.3 million lacerations are treated annually,2 and wounds caused...

IMAGES IN CLINICAL MEDICINE: Squamous-Cell Carcinoma Manifesting as a Cutaneous Horn

Sergio Vano-Galvan, M.D. and Alberto Sanchez-Olaso, Ph.D. — Thu, 28Â AugÂ 2008 00:00:00 -05:00

A healthy 84-year-old woman presented with a 6-month history of a slowly growing asymptomatic lesion on the dorsum of her right hand. Physical examination revealed a keratotic cutaneous horn â...

IMAGES IN CLINICAL MEDICINE: The StewartâTreves Syndrome

Laura B. Pincus, M.D. and Lindy P. Fox, M.D. — Thu, 28Â AugÂ 2008 00:00:00 -05:00

A 67-year-old woman with a history of cancer of the right breast, treated with a modified radical mastectomy, radiation, and chemotherapy in 1990, presented with a 6-month history of an...

REVIEW ARTICLE: Management of Acute Bleeding from a Peptic Ulcer

Thu, 28Â AugÂ 2008 00:00:00 -05:00

Acute upper gastrointestinal hemorrhage, which is defined as bleeding proximal to the ligament of Treitz, is a prevalent and clinically significant condition with important implications for health care costs worldwide....

IMAGES IN CLINICAL MEDICINE: Gossypiboma in the Pouch of Douglas

Marc Possover, M.D., Ph.D. — Thu, 21Â AugÂ 2008 00:00:00 -05:00

A 63-year-old woman presented with a 1-year history of vague pelvic and back pain. She had undergone laparoscopic surgery of the fallopian tubes 27 years earlier owing to infertility. Magnetic...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 26-2008 â A 26-Year-Old Woman with Headache and Behavioral Changes

Thomas D. Sabin, M.D., Jeffrey A. Jednacz, M.D., and Paul N. Staats, M.D. — Thu, 21Â AugÂ 2008 00:00:00 -05:00

Dr. Thomas J. Cummings, Jr. (Psychiatry): A 26-year-old woman was admitted to this hospital because of headache, behavioral changes, abnormal movements, and inability to communicate. The patient had been well,...

IMAGES IN CLINICAL MEDICINE: Benign Mediastinal Teratoma

Lisa M. Jones, M.D. and David A. Bradshaw, M.D. — Thu, 21Â AugÂ 2008 00:00:00 -05:00

A 23-year-old male Marine recruit passed out while bending over after a 2.4-km (1.5-mile) run. Chest radiography showed a mass in the anterior mediastinum (Panel A, arrow). His medical history...

CLINICAL PRACTICE: Idiopathic Sudden Sensorineural Hearing Loss

Steven D. Rauch, M.D. — Thu, 21Â AugÂ 2008 00:00:00 -05:00

A healthy 58-year-old woman answers the telephone and realizes that her hearing is diminished on the left side. She notices aural fullness and loud tinnitus in the affected ear. Later...

BOOK REVIEW:

Thu, 14Â AugÂ 2008 00:00:00 -05:00

The pancreas is one of the least accessible abdominal organs, and even in the 21st century it carries an aura of mystery and challenge. Benign diseases of the pancreas are...

IMAGES IN CLINICAL MEDICINE: Infrarenal Aortic Occlusion

Alan T. Hirsch, M.D. and Michael D. Miedema, M.D. — Thu, 14Â AugÂ 2008 00:00:00 -05:00

A 55-year-old woman awoke with an acute onset of bilateral leg numbness and weakness. Initial evaluation and lumbar magnetic resonance imaging, which was performed to assess the patient for disk...

IMAGES IN CLINICAL MEDICINE: Complex Regional Pain Syndrome Type 1

Oliver Guttmann, M.B., B.S. and Victoria Wykes, M.B., B.S., Ph.D. — Thu, 31Â JulÂ 2008 00:00:00 -05:00

An otherwise healthy and functional 35-year-old man had an undisplaced fracture of the right fifth metacarpal neck after a fall. He presented 21 months later with pain, extensive swelling (Panels...

ORIGINAL ARTICLE: D2 Lymphadenectomy Alone or with Para-aortic Nodal Dissection for Gastric Cancer

Thu, 31Â JulÂ 2008 00:00:00 -05:00

Background: Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia. Whether the addition of para-aortic nodal dissection (PAND) to D2 lymphadenectomy for stage T2,...

PERSPECTIVE: Gastric Cancer in Japan â Honing Treatment, Seeking Causes

Thu, 31Â JulÂ 2008 00:00:00 -05:00

In this issue of the Journal, Sasako and colleagues (pages 453â462) present results from a randomized trial of surgery for gastric cancer conducted in 24 specialized hospitals in Japan. The...

IMAGES IN CLINICAL MEDICINE: Dynamic Tumor Staging

Chang Min Park, M.D. and Jin Mo Goo, M.D. — Thu, 24Â JulÂ 2008 00:00:00 -05:00

A 54-year-old man with a history of smoking presented with acute chest pain at another hospital, where a chest radiograph was obtained as part of diagnostic testing. A mass in...

IMAGES IN CLINICAL MEDICINE: Sclerosing Peritonitis

Katsuya Shiraki, M.D. and Hiroyuki Sakurai, M.D. — Thu, 17Â JulÂ 2008 00:00:00 -05:00

A 59-year-old woman with the BuddâChiari syndrome was admitted for increasing abdominal distention, abdominal pain, and vomiting during a period of 8 weeks. She had normal renal function and had...

IMAGES IN CLINICAL MEDICINE: Bifid Uvula and Aortic Aneurysm

Isidre Vilacosta, M.D. and Victoria CaÃ±adas Godoy, M.D. — Thu, 10Â JulÂ 2008 00:00:00 -05:00

A 24-year-old man was hospitalized for evaluation of an aortic-root aneurysm. He had a family history of aortic disease. Physical examination revealed proptosis, retrognathia, bifid uvula (Panel A), and pectus...

IMAGES IN CLINICAL MEDICINE: Renal Osteodystrophy of the Palate

Yahya Daneshbod, M.D. — Thu, 03Â JulÂ 2008 00:00:00 -05:00

A 20-year-old man who had had idiopathic end-stage renal failure since he was 12 years of age and who was undergoing dialysis once weekly (with stable serum electrolyte, blood urea...

VIDEOS IN CLINICAL MEDICINE: Placement of a Femoral Venous Catheter

Thu, 26Â JunÂ 2008 00:00:00 -05:00

...

EDITORIAL: New Anticoagulants â The Path from Discovery to Clinical Practice

Jens Lohrmann, M.D., and Richard C. Becker, M.D. — Thu, 26Â JunÂ 2008 00:00:00 -05:00

For more than half a century, heparin and vitamin K antagonists have defined anticoagulant therapy for the short-term and long-term management, respectively, of thrombotic disorders of the venous system. The...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 20-2008 â A 57-Year-Old Woman with Abdominal Pain and Weakness after Gastric Bypass Surgery

Thu, 26Â JunÂ 2008 00:00:00 -05:00

Dr. Allyson K. Bloom (Medicine): A 57-year-old woman was admitted to this hospital because of abdominal pain and weakness. One month earlier, a laparoscopic Roux-en-Y gastric bypass and cholecystectomy were...

IMAGES IN CLINICAL MEDICINE: Systemic Sclerosis and Acral Osteolysis

Leonardo Astudillo, M.D. and Elisabeth Arlet-Suau, M.D. — Thu, 26Â JunÂ 2008 00:00:00 -05:00

A 71-year-old woman received a diagnosis of systemic sclerosis more than 30 years ago when she presented with Raynaud's phenomenon and cutaneous sclerosis. At that time she did not require...

CLINICAL PRACTICE: Acute Calculous Cholecystitis

Steven M. Strasberg, M.D. — Thu, 26Â JunÂ 2008 00:00:00 -05:00

Acute calculous cholecystitis is a complication of cholelithiasis, a condition that afflicts more than 20 million Americans annually1 and results in direct costs of more than $6.3 billion.2 Most patients...

ORIGINAL ARTICLE: Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Total Knee Arthroplasty

Thu, 26Â JunÂ 2008 00:00:00 -05:00

Background: We investigated the efficacy of rivaroxaban, an orally active direct factor Xa inhibitor, in preventing venous thrombosis after total knee arthroplasty.

Methods: In this randomized, double-blind trial, 2531 patients who...

ORIGINAL ARTICLE: Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Hip Arthroplasty

Thu, 26Â JunÂ 2008 00:00:00 -05:00

Background: This phase 3 trial compared the efficacy and safety of rivaroxaban, an oral direct inhibitor of factor Xa, with those of enoxaparin for extended thromboprophylaxis in patients undergoing total...

IMAGES IN CLINICAL MEDICINE: Rupture of a Calcified Achilles' Tendon

Marius C. Wick, M.D. and Michael Rieger, M.D. — Thu, 12Â JunÂ 2008 00:00:00 -05:00

A 69-year-old man presented at the emergency room with stabbing pain and swelling of the right lower leg on standing up from a seated position. On clinical examination, rupture of...

IMAGES IN CLINICAL MEDICINE: Bilateral Peritonsillar Abscesses

James F. Fiechtl, M.D. and Lawrence B. Stack, M.D. — Thu, 05Â JunÂ 2008 00:00:00 -05:00

A 19-year-old woman presented to the emergency department with a 10-day history of intermittent odynophagia, voice changes, and fever. Before her visit to the emergency department, she was treated with...

IMAGES IN CLINICAL MEDICINE: Ethmoid Mucocele Causing Visual Impairment

Jae Yong Lee, M.D., Ph.D. — Thu, 05Â JunÂ 2008 00:00:00 -05:00

A 74-year-old man was referred because of left exophthalmos and outward displacement of the orbit (Panel A). His symptoms had progressed slowly over a 4-year period but had worsened rapidly...

VIDEOS IN CLINICAL MEDICINE: Cricothyroidotomy

James Hsiao, M.D., and Victor Pacheco-Fowler, M.D. — Thu, 29Â MayÂ 2008 00:00:00 -05:00

...

EDITORIAL: The Aprotinin Story â Is BART the Final Chapter?

Wayne A. Ray, Ph.D., and C. Michael Stein, M.B., Ch.B. — Thu, 29Â MayÂ 2008 00:00:00 -05:00

The aprotinin story began in 1987, when investigators reported that the use of the drug in patients undergoing repeat open-heart surgery decreased the need for blood transfusion by a factor...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 17-2008 â A 63-Year-Old Man with Metastatic Renal-Cell Carcinoma

Thu, 29Â MayÂ 2008 00:00:00 -05:00

A 63-year-old man was admitted to this hospital because of a mass in the left kidney and pulmonary nodules. The patient had been well until approximately 5 months before admission,...

ORIGINAL ARTICLE: A Comparison of Aprotinin and Lysine Analogues in High-Risk Cardiac Surgery

Thu, 29Â MayÂ 2008 00:00:00 -05:00

Background: Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding and to reduce exposure to blood products. We sought to determine whether aprotinin was superior to either tranexamic...

IMAGES IN CLINICAL MEDICINE: StarrâEdwards Heart Valves

Nicolo Piazza, M.D. and Jean Gregoire, M.D. — Thu, 22Â MayÂ 2008 00:00:00 -05:00

A 67-year-old woman presented with dyspnea and peripheral edema due to severe tricuspid regurgitation. Having had rheumatic heart disease, she had undergone replacement of the mitral and aortic valves with...

IMAGES IN CLINICAL MEDICINE: Ocular Trauma Due to a Water-Bottle Cap

Shiyoung Roh, M.D. and Mark E. Patron, M.D. — Thu, 22Â MayÂ 2008 00:00:00 -05:00

A 14-year-old girl presented with a traumatic injury to the right eye from a water-bottle cap, caused by the increasingly popular adolescent activity of twisting and crushing an empty plastic...

CLINICAL DECISIONS: Management of Carotid Stenosis â Polling Results

Thu, 15Â MayÂ 2008 00:00:00 -05:00

In early April, we presented the case of a 67-year-old man with asymptomatic carotid disease in Clinical Decisions,1 an interactive feature designed to assess how readers would manage a clinical...

IMAGES IN CLINICAL MEDICINE: Giant Ovarian Cyst

Ton-Ho Young, M.D. and Herng-Sheng Lee, M.D., Ph.D. — Thu, 15Â MayÂ 2008 00:00:00 -05:00

A 24-year-old woman (gravida 0, para 0) presented with a history of progressive abdominal distention during the previous year, accompanied by early satiety and constipation. There was no history of...

CLINICAL PRACTICE: Rotator-Cuff Failure

Frederick A. Matsen III, M.D. — Thu, 15Â MayÂ 2008 00:00:00 -05:00

A 63-year-old woman presents with a 2-year history of progressive weakness and discomfort in her right shoulder, especially when she puts dishes on the top shelf in her kitchen. She...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2008 â A 78-Year-Old Man with Anergia and Anhedonia Associated with Cardiovascular Surgery

Thu, 08Â MayÂ 2008 00:00:00 -05:00

Dr. David T. Plante (Psychiatry): A 78-year-old man was admitted to the inpatient psychiatry service of this hospital because of anergia and anhedonia.

Thirty-three months before admission, the patient was told...

EDITORIAL: Percutaneous Intervention vs. Coronary-Artery Bypass Grafting in Left Main Coronary Disease

Robert H. Jones, M.D. — Thu, 24Â AprÂ 2008 00:00:00 -05:00

A recent meta-analysis, report, and editorial all agreed with the need for a randomized trial of percutaneous coronary intervention (PCI) as compared with coronary-artery bypass grafting (CABG) in patients with...

ORIGINAL ARTICLE: Stents versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease

Thu, 24Â AprÂ 2008 00:00:00 -05:00

Background: Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for...

CLINICAL DECISIONS: Management of Carotid Stenosis

Thu, 10Â AprÂ 2008 00:00:00 -05:00

A 67-year-old man with a history of hypertension and hyperlipidemia is seen for a routine examination. His medications include hydrochlorothiazide (25 mg daily), simvastatin (20 mg daily), and aspirin (81...

IMAGES IN CLINICAL MEDICINE: Pseudoaneurysm of the Right Internal Thoracic Artery

Nick P. Jenkins, M.B., B.S. and Huon Gray, M.D. — Thu, 10Â AprÂ 2008 00:00:00 -05:00

A 71-year-old woman underwent successful elective mitral annuloplasty and coronary-artery bypass grafting, with a left internal thoracic artery graft to her left anterior descending coronary artery and saphenous-vein grafts to...

ORIGINAL ARTICLE: Long-Term Results of Carotid Stenting versus Endarterectomy in High-Risk Patients

Thu, 10Â AprÂ 2008 00:00:00 -05:00

Background: We previously reported that, in a randomized trial, carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy for the treatment of carotid artery...

VIDEOS IN CLINICAL MEDICINE: Female Urethral Catheterization

Rafael Ortega, M.D., Linda Ng, M.D., Pavan Sekhar, B.S., and Michael Song, M.A. — Thu, 03Â AprÂ 2008 00:00:00 -05:00

...

CLINICAL PROBLEM-SOLVING: An Unintended Consequence â A 79-year-old man with a 5-month history of fatigue and 20-lb (9-kg) weight loss presented to his local physician

Thu, 03Â AprÂ 2008 00:00:00 -05:00

A 79-year-old man with a 5-month history of fatigue and 20-lb (9-kg) weight loss presented to his local physician. The patient also reported intermittent episodes of high temperature, night sweats,...

EDITORIAL: Effect of Mechanical Ventilation on the Diaphragm

Gary C. Sieck, Ph.D., and Carlos B. Mantilla, M.D., Ph.D. — Thu, 27Â MarÂ 2008 00:00:00 -05:00

It is widely assumed that respiratory-muscle weakness, either intrinsic or due to fatigue, leads to respiratory failure.1 For the past 30 years, attention has been focused on whether the diaphragm...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 10-2008 â A 10-Year-Old Girl with Dyspnea on Exertion

Thu, 27Â MarÂ 2008 00:00:00 -05:00

A 10-year-old girl was seen in the multidisciplinary Airway, Voice, and Swallowing Center for Children at the Massachusetts Eye and Ear Infirmary, associated with this hospital, because of dyspnea and...

IMAGES IN CLINICAL MEDICINE: Small-Bowel Obstruction

Fabrice Dedouit, M.D. and Philippe Otal, M.D. — Thu, 27Â MarÂ 2008 00:00:00 -05:00

A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea and vomiting. Over the previous 10 years, she had had progressive Alzheimer's disease, requiring her to...

ORIGINAL ARTICLE: Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans

Thu, 27Â MarÂ 2008 00:00:00 -05:00

Background: The combination of complete diaphragm inactivity and mechanical ventilation (for more than 18 hours) elicits disuse atrophy of myofibers in animals. We hypothesized that the same may also occur...

IMAGES IN CLINICAL MEDICINE: Spontaneous Otogenic Pneumocephalus

Roberto A. Villa, M.D. and Abelardo Capdevila, M.D. — Thu, 20Â MarÂ 2008 00:00:00 -05:00

A healthy 54-year-old woman presented with progressive abnormal acoustic sensations, aphasia, and visual-field disturbances. She reported no head trauma or recent infection, such as otitis media. An initial cranial radiograph...

EDITORIAL: New Blood, Old Blood, or No Blood?

John W. Adamson, M.D. — Thu, 20Â MarÂ 2008 00:00:00 -05:00

The use of blood transfusions in medicine is so well established that the procedure is an afterthought to many physicians. Scientific advances have rendered blood and blood products extremely safe...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 9-2008 â A 65-Year-Old Woman with a Nonhealing Ulcer of the Jaw

Thu, 20Â MarÂ 2008 00:00:00 -05:00

Dr. Steven E. Smullin (Oral and Maxillofacial Surgery): A 65-year-old woman was seen in the oral surgery clinic of this hospital because of a nonhealing ulcer of the mandible.

Three years...

ORIGINAL ARTICLE: Duration of Red-Cell Storage and Complications after Cardiac Surgery

Thu, 20Â MarÂ 2008 00:00:00 -05:00

Background: Stored red cells undergo progressive structural and functional changes over time. We tested the hypothesis that serious complications and mortality after cardiac surgery are increased when transfused red cells...

IMAGES IN CLINICAL MEDICINE: Green Urine

Piero Stratta, M.D. and Maria Cristina Barbe, M.D. — Thu, 13Â MarÂ 2008 00:00:00 -05:00

A 76-year-old man with renal failure from nephroangiosclerosis received a kidney transplant from a deceased donor. The transplant was functioning well when the patient underwent a radical laryngopharyngoesophagectomy, with colopharyngeal...

EDITORIAL: Depth-of-Anesthesia Monitor and the Frequency of Intraoperative Awareness

Beverley A. Orser, M.D., Ph.D., F.R.C.P.C. — Thu, 13Â MarÂ 2008 00:00:00 -05:00

More than 21 million patients in North America alone receive general anesthesia each year,1 and thanks to increasing knowledge, skill, and sophisticated technology, the vast majority of anesthetic procedures are...

ORIGINAL ARTICLE: DNA Methylation Markers and Early Recurrence in Stage I Lung Cancer

Thu, 13Â MarÂ 2008 00:00:00 -05:00

Background: Despite optimal and early surgical treatment of nonâsmall-cell lung cancer (NSCLC), many patients die of recurrent NSCLC. We investigated the association between gene methylation and recurrence of the tumor.

Methods:...

ORIGINAL ARTICLE: Anesthesia Awareness and the Bispectral Index

Thu, 13Â MarÂ 2008 00:00:00 -05:00

Background: Awareness during anesthesia is a serious complication with potential long-term psychological consequences. Use of the bispectral index (BIS), developed from a processed electroencephalogram, has been reported to decrease the...

CLINICAL PROBLEM-SOLVING: A Key Miscommunication â An 81-year-old woman presented to the emergency department with increasing abdominal distention, nausea, and vomiting

Thu, 06Â MarÂ 2008 00:00:00 -05:00

An 81-year-old woman presented to the emergency department with increasing abdominal distention, nausea, and vomiting. She also reported increasing shortness of breath and fatigue, which had become worse over the...

IMAGES IN CLINICAL MEDICINE: A Medical Mystery: Epigastric Pain

Rangan Murali, M.D. and Bashar M. Attar, M.D., Ph.D. — Thu, 06Â MarÂ 2008 00:00:00 -05:00

An 82-year-old woman presented with respiratory symptoms, and a chest film was obtained. Six years later, she presented with epigastric pain, nausea, and vomiting. What is the diagnosis?...

CLINICAL PRACTICE: Urinary Stress Incontinence in Women

Rebecca G. Rogers, M.D. — Thu, 06Â MarÂ 2008 00:00:00 -05:00

A 45-year-old woman reports losing urine with coughing, laughing, or sneezing since the birth of her last baby. She has been unable to lose the 25 lb (11 kg) that...

IMAGES IN CLINICAL MEDICINE: Chronic Venous Insufficiency and Dystrophic Subcutaneous Calcification

David Miedinger, M.D. and Thomas Daikeler, M.D. — Thu, 28Â FebÂ 2008 00:00:00 -05:00

A 70-year-old woman was referred by her general practitioner for evaluation of an ulcerative lesion on her lower right leg. Subcutaneous white calcifications were seen (Panel A, arrow). She had...

IMAGES IN CLINICAL MEDICINE: Severe Soft-Tissue Infection

Fone-Ching Hsiao, M.D. and Chang-Hsun Hsieh, M.D. — Thu, 28Â FebÂ 2008 00:00:00 -05:00

A 65-year-old woman with a 15-year history of diabetes presented with fever (temperature, 38.5Â°C), chills, malaise, and a rash on the medial surface of the right thigh, vulva, and lower...

EDITORIAL: Learning from Aprotinin â Mandatory Trials of Comparative Efficacy and Safety Needed

Wayne A. Ray, Ph.D. — Thu, 21Â FebÂ 2008 00:00:00 -05:00

Aprotinin, a hemostatic agent that inhibits the fibrinolytic enzyme plasmin,1 was approved by the Food and Drug Administration (FDA) in 1993 for reducing blood loss during coronary-artery bypass grafting (CABG)....

CLINICAL PRACTICE: Lumbar Spinal Stenosis

Jeffrey N. Katz, M.D., M.Sc., and Mitchel B. Harris, M.D. — Thu, 21Â FebÂ 2008 00:00:00 -05:00

A 72-year-old woman with hypertension presents with a 4-month history of lower back discomfort that radiates to both buttocks and lateral thighs. Previously, she had walked 2 miles (3.2 km)...

ORIGINAL ARTICLE: Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis

Thu, 21Â FebÂ 2008 00:00:00 -05:00

Background: Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials.

Methods: Surgical candidates with a history of at...

ORIGINAL ARTICLE: The Effect of Aprotinin on Outcome after Coronary-Artery Bypass Grafting

Thu, 21Â FebÂ 2008 00:00:00 -05:00

Background: Aprotinin has recently been associated with adverse outcomes in patients undergoing cardiac surgery. We reviewed our experience with this agent in patients undergoing cardiac surgery at Duke University Medical...

ORIGINAL ARTICLE: Aprotinin during Coronary-Artery Bypass Grafting and Risk of Death

Thu, 21Â FebÂ 2008 00:00:00 -05:00

Background: Aprotinin (Trasylol) is used to mitigate bleeding during coronary-artery bypass grafting (CABG). Accumulating evidence suggests that this practice increases mortality.

Methods: Using electronic administrative records of the Premier Perspective Comparative...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 5-2008 â An 18-Month-Old Girl with an Advanced Neck Contracture after a Burn

Thu, 14Â FebÂ 2008 00:00:00 -05:00

An 18-month-old girl was transferred from a hospital in China to the Shriners Hospital for Children in Boston for management of a life-threatening neck contracture.

The child had been well until...

ORIGINAL ARTICLE: Local Delivery of Paclitaxel to Inhibit Restenosis during Angioplasty of the Leg

Thu, 14Â FebÂ 2008 00:00:00 -05:00

Background: Drug-eluting stents reduce restenosis in coronary arteries, but clinical trials have failed to prove their efficacy in peripheral arteries. We investigated the use of paclitaxel-coated angioplasty balloons and paclitaxel...

IMAGES IN CLINICAL MEDICINE: Calcified Hematoma of the Skull

Ali-Reza Fathi, M.D. and Dominique Erni, M.D. — Thu, 31Â JanÂ 2008 00:00:00 -05:00

A 46-year-old man presented with a hard subcutaneous mass in the left side of the forehead (Panel A). He reported that the lesion had developed rapidly after a head trauma...

IMAGES IN CLINICAL MEDICINE: Open Mandibular Fracture with Malocclusion

Joseph R. Shiber, M.D. and Kelly Carter, M.D. — Thu, 31Â JanÂ 2008 00:00:00 -05:00

A 21-year-old healthy man presented to the emergency department with mouth pain and bleeding, after being struck with a gun on his right lower jaw. Physical examination revealed upward displacement...

CLINICAL THERAPEUTICS: Endovascular Repair of Abdominal Aortic Aneurysm

Roger M. Greenhalgh, M.D., and Janet T. Powell, M.D., Ph.D. — Thu, 31Â JanÂ 2008 00:00:00 -05:00

A 72-year-old man who was a previous smoker had had transient ischemic attacks that were successfully managed with the use of carotid endarterectomy. Since about 10% of patients with cerebral...

ORIGINAL ARTICLE: Endovascular vs. Open Repair of Abdominal Aortic Aneurysms in the Medicare Population

Thu, 31Â JanÂ 2008 00:00:00 -05:00

Background: Randomized trials have shown reductions in perioperative mortality and morbidity with endovascular repair of abdominal aortic aneurysm, as compared with open surgical repair. Longer-term survival rates, however, were similar...

EDITORIAL: Drug-Eluting Stents â Pushing the Envelope beyond the Labels?

Joseph P. Carrozza, Jr., M.D. — Thu, 24Â JanÂ 2008 00:00:00 -05:00

Unlike jurors, clinicians frequently must make decisions without the luxury of the totality of evidence. When we speak of evidence-based medicine, it is important to remember that available data may...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 3-2008 â An 80-Year-Old Woman with Cutaneous Basal-Cell Carcinomas and Cysts of the Jaws

Ervin H. Epstein, M.D., Jo-Anne O. Shepard, M.D., and Thomas J. Flotte, M.D. — Thu, 24Â JanÂ 2008 00:00:00 -05:00

Dr. Gabriela Rolz-Cruz (Dermatology): An 80-year-old woman was seen in the outpatient clinic of this hospital for management of recurrent ulcerated skin lesions on the scalp.

When the patient was approximately...

ORIGINAL ARTICLE: Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease

Thu, 24Â JanÂ 2008 00:00:00 -05:00

Background: Numerous studies have compared the outcomes of two competing interventions for multivessel coronary artery disease: coronary-artery bypass grafting (CABG) and coronary stenting. However, little information has become available since...

IMAGES IN CLINICAL MEDICINE: Penetrating Orbital Trauma

Harsha S. Reddy, M.D. and Eli Chang, M.D. — Thu, 17Â JanÂ 2008 00:00:00 -05:00

A 15-year-old boy presented with an inability to open his left eye after being assaulted with a pencil. A small laceration was noted on the left eyebrow (Panel A). An...

VIDEOS IN CLINICAL MEDICINE: Examination of the Larynx and Pharynx

Thu, 17Â JanÂ 2008 00:00:00 -05:00

...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 1-2008 â A 45-Year-Old Man with Sudden Onset of Abdominal Pain and Hypotension

Thu, 10Â JanÂ 2008 00:00:00 -05:00

Dr. Megan Fix (Emergency Medicine): A 45-year-old man was transferred on an emergency basis to this hospital from a community health center because of abdominal pain and hypotension.

On the day...

ORIGINAL ARTICLE: Functional Outcome after Language Mapping for Glioma Resection

Nader Sanai, M.D., Zaman Mirzadeh, Ph.D., and Mitchel S. Berger, M.D. — Thu, 03Â JanÂ 2008 00:00:00 -05:00

Background: Language sites in the cortex of the brain vary among patients. Language mapping while the patient is awake is an intraoperative technique designed to minimize language deficits associated with...

IMAGES IN CLINICAL MEDICINE: Small-Bowel Intussusception

Colin H. Wilson, M.R.C.S. and Steve A. White, M.D., F.R.C.S. — Thu, 27Â DecÂ 2007 00:00:00 -05:00

A previously healthy 22-year-old man presented with a 3-month history of intermittent abdominal pain and hypochromic microcytic anemia, with a hemoglobin level of 5.1 g per deciliter and a mean...

SPECIAL REPORT: MilitaryâCivilian Collaboration in Trauma Care and the Senior Visiting Surgeon Program

Thu, 27Â DecÂ 2007 00:00:00 -05:00

On June 14, 2006, the Institute of Medicine released a three-part report on the future of emergency care, underscoring the evolving crisis in access to urgent medical care in the...

CLINICAL PRACTICE: Localized Prostate Cancer

Thu, 27Â DecÂ 2007 00:00:00 -05:00

A 68-year-old man presents with newly diagnosed prostate cancer. Over the past 3 years, his serum prostate-specific antigen (PSA) level has been slowly and steadily increasing (from 4.0 ng per...

IMAGES IN CLINICAL MEDICINE: Calcinosis Associated with Renal Failure

Robert A. Cohen, M.D. and Samir M. Parikh, M.D. — Thu, 20Â DecÂ 2007 00:00:00 -05:00

A 36-year-old woman presented with painless, subcutaneous nodules that had developed during the previous 5 months on her buttocks, shoulders, and left wrist (Panel A). Her medical history was notable...

ORIGINAL ARTICLE: Mutations and Survival in Squamous-Cell Carcinoma of the Head and Neck

Thu, 20Â DecÂ 2007 00:00:00 -05:00

Background: The abrogation of function of the tumor-suppressor protein p53 as a result of mutation of its gene, TP53, is one of the most common genetic alterations in cancer cells....

VIDEOS IN CLINICAL MEDICINE: Central Venous Catheterization â Subclavian Vein

Thu, 13Â DecÂ 2007 00:00:00 -05:00

...

CLINICAL PRACTICE: Erectile Dysfunction

Kevin T. McVary, M.D. — Thu, 13Â DecÂ 2007 00:00:00 -05:00

A 65-year-old man presents to an outpatient clinic, reporting that he can no longer maintain an erection sufficient for intercourse. His medical history includes well-controlled hypertension and stable coronary artery...

ORIGINAL ARTICLE: Outcomes 18 Months after the First Human Partial Face Transplantation

Thu, 13Â DecÂ 2007 00:00:00 -05:00

Background: We performed the first human partial face allograft on November 27, 2005. Here we report outcomes up to 18 months after transplantation.

Methods: The postsurgical induction immunosuppression protocol included thymoglobulins...

CLINICAL PROBLEM-SOLVING: The Leading Diagnosis â A 23-year-old black woman presented to the emergency department with diffuse, colicky abdominal pain of 1 hour's duration

Thomas E. Baudendistel, M.D., Amy K. Haase, M.D., and Faith Fitzgerald, M.D. — Thu, 06Â DecÂ 2007 00:00:00 -05:00

A 23-year-old black woman presented to the emergency department with diffuse, colicky abdominal pain of 1 hour's duration. The pain was followed by nausea and episodes of bilious vomiting and...

CLINICAL THERAPEUTICS: Cochlear Implants for Children with Severe-to-Profound Hearing Loss

Blake C. Papsin, M.D., and Karen A. Gordon, Ph.D. — Thu, 06Â DecÂ 2007 00:00:00 -05:00

A 4-month-old baby girl whose parents and 6-year-old brother have severe-to-profound sensorineural hearing loss is referred for consideration for cochlear implantation. Each of the baby's parents had previously received a...

IMAGES IN CLINICAL MEDICINE: Trichobezoar

Ronald M. Levy, M.D. and Srinadh Komanduri, M.D. — Thu, 22Â NovÂ 2007 00:00:00 -05:00

A previously healthy 18-year-old woman presented with a 5-month history of pain in the left upper quadrant of the abdomen, abdominal distention, postprandial emesis, and weight loss of 18 kg....

IMAGES IN CLINICAL MEDICINE: Cerebral Tuberculoma

Juan Carlos CataÃ±o, M.D. — Thu, 22Â NovÂ 2007 00:00:00 -05:00

A 29-year-old homeless man was admitted to the hospital after being stabbed in the chest. A hemothorax was diagnosed, and a chest tube was placed. One day after admission, he...

IMAGES IN CLINICAL MEDICINE: Harlequin's Darker Side

Martin E. Duddy, M.R.C.P. and Mark R. Baker, M.R.C.P. — Thu, 15Â NovÂ 2007 00:00:00 -05:00

A 39-year-old healthy, female aerobics instructor presented with a 6-week history of flushing on the left side of her face, neck, and upper trunk after 40 minutes of vigorous exercise,...

CLINICAL PRACTICE: Diverticulitis

Danny O. Jacobs, M.D., M.P.H. — Thu, 15Â NovÂ 2007 00:00:00 -05:00

A previously healthy 45-year-old man presents with severe lower abdominal pain on the left side, which started 36 hours earlier. He has noticed mild, periodic discomfort in this region before...

VIDEOS IN CLINICAL MEDICINE: Abscess Incision and Drainage

Thu, 08Â NovÂ 2007 00:00:00 -05:00

...

IMAGES IN CLINICAL MEDICINE: Cocaine-Induced Palatal Perforation

Michael A. Lypka, M.D., D.M.D. and Mark M. Urata, M.D., D.D.S. — Thu, 08Â NovÂ 2007 00:00:00 -05:00

A healthy 25-year-old man presented to the surgical clinic with a hole in the roof of his mouth that allowed nasal regurgitation of food when he ate. The hole had...

IMAGES IN CLINICAL MEDICINE: Peripheral Artery Disease

Ho-Cheol Kang, M.D., Ph.D. and Min-Young Chung, M.D., Ph.D. — Thu, 01Â NovÂ 2007 00:00:00 -05:00

A 69-year-old man presented with a 10-day history of discoloration of the left foot and pain in the left foot while at rest. He reported a 1-year history of intermittent...

EDITORIAL: East Meets West in the Treatment of Gastric Cancer

David Cunningham, M.D., and Yu Jo Chua, M.B., B.S. — Thu, 01Â NovÂ 2007 00:00:00 -05:00

Gastric cancer is a leading cause of illness and death from cancer worldwide, with nearly a million new cases diagnosed each year and a 5-year survival rate of less than...

ORIGINAL ARTICLE: Adjuvant Chemotherapy for Gastric Cancer with S-1, an Oral Fluoropyrimidine

Thu, 01Â NovÂ 2007 00:00:00 -05:00

Background: Advanced gastric cancer can respond to S-1, an oral fluoropyrimidine. We tested S-1 as adjuvant chemotherapy in patients with curatively resected gastric cancer.

Methods: Patients in Japan with stage II...

IMAGES IN CLINICAL MEDICINE: Magnetic Resonance Imaging of Retinal Detachment

Ingo NÃ¶lte, M.D. and Marc A. Brockmann, M.D. — Thu, 25Â OctÂ 2007 00:00:00 -05:00

An 80-year-old woman with a myopia of â19.0 diopters and a history of right-sided retinal detachment underwent a diagnostic workup for a decrease of vision in her right eye. The...

IMAGES IN CLINICAL MEDICINE: Tracheal Bronchus

Baris Bakir, M.D. and Ege Terzibasioglu, M.D. — Thu, 25Â OctÂ 2007 00:00:00 -05:00

A 9-year-old girl with recurrent respiratory infection presented for evaluation for possible active tuberculosis. Multislice computed tomography of the chest showed no evidence of active tuberculosis, but there was an...

ORIGINAL ARTICLE: Cisplatin and Fluorouracil Alone or with Docetaxel in Head and Neck Cancer

Thu, 25Â OctÂ 2007 00:00:00 -05:00

Background: A randomized phase 3 trial of the treatment of squamous-cell carcinoma of the head and neck compared induction chemotherapy with docetaxel plus cisplatin and fluorouracil (TPF) with cisplatin and...

ORIGINAL ARTICLE: Cisplatin, Fluorouracil, and Docetaxel in Unresectable Head and Neck Cancer

Thu, 25Â OctÂ 2007 00:00:00 -05:00

Background: Phase 2 studies suggest that the standard regimen of cisplatin and fluorouracil (PF) plus docetaxel (TPF) improves outcomes in squamous-cell carcinoma of the head and neck. We compared TPF...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 32-2007 â A 62-Year-Old Woman with a Second Breast Cancer

Thu, 18Â OctÂ 2007 00:00:00 -05:00

Dr. David A. Barbie (Medical Oncology): A 62-year-old woman came to this hospital for management of breast cancer.

Six years earlier, a routine mammogram had revealed calcifications in the left breast....

IMAGES IN CLINICAL MEDICINE: Aneurysmal Arteriovenous Fistula

Kim Sinnamon, M.B. and Robert Mullan, M.D. — Thu, 11Â OctÂ 2007 00:00:00 -05:00

A 50-year-old man had a 30-year history of end-stage renal disease associated with idiopathic membranoproliferative glomerulonephritis. His medical history included immune thrombocytopenic purpura, with platelet counts that were persistently less...

VIDEOS IN CLINICAL MEDICINE: Chest-Tube Insertion

Thu, 11Â OctÂ 2007 00:00:00 -05:00

...

IMAGES IN CLINICAL MEDICINE: White Phosphorus Dermal Burns

Johnathan C. Conner, M.D. and Vikhyat S. Bebarta, M.D. — Thu, 11Â OctÂ 2007 00:00:00 -05:00

A 19-year-old man presented with painful burns on his posterior scalp after exposure to an incendiary agent. Smoke emanated from the wounds on removal of the dressing that had been...

PERSPECTIVE: The Development of Prosthetic Heart Valves â Lessons in Form and Function

Thu, 04Â OctÂ 2007 00:00:00 -05:00

The 2007 Lasker Award for Clinical Medical Research, granted in mid-September to Albert Starr and Alain Carpentier, recognizes their extraordinary contributions to the development of the prosthetic heart valve, which...

IMAGES IN CLINICAL MEDICINE: Calciphylaxis with Arterial Calcification

Jonathan Z. Li, M.D. and William Huen, M.D. — Thu, 27Â SepÂ 2007 00:00:00 -05:00

A 53-year-old woman with diabetes mellitus and end-stage renal disease who was undergoing hemodialysis presented with fever, painful finger necrosis, and nonhealing ulceration of the legs. Hand radiographs showed no...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 29-2007 â A 51-Year-Old Man with Gastric Cancer and Lung Nodules

Edward T. Ryan, M.D., Suzanne L. Aquino, M.D., and Richard L. Kradin, M.D. — Thu, 20Â SepÂ 2007 00:00:00 -05:00

Dr. Allison L. McDonough (Internal Medicine): A 51-year-old man with a history of gastric cancer was admitted to the hospital because of a new pulmonary lesion.

The patient had been in...

IMAGES IN CLINICAL MEDICINE: Emphysematous Cholecystitis

Yogesh Shrestha, M.D. and Steven Trottier, M.D. — Thu, 20Â SepÂ 2007 00:00:00 -05:00

A 70-year-old man with a history of heart disease, hyperlipidemia, and diabetes mellitus presented at the hospital with a 4-day history of increasing abdominal pain, nausea, and vomiting. The temperature...

CLINICAL PRACTICE: Gynecomastia

Glenn D. Braunstein, M.D. — Thu, 20Â SepÂ 2007 00:00:00 -05:00

During an evaluation for low back pain, a 67-year-old man is found to have gynecomastia on the right side that is nontender on palpation. Other than a body-mass index (the...

CLINICAL PROBLEM-SOLVING: A Stitch in Time â A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue

Thu, 06Â SepÂ 2007 00:00:00 -05:00

A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue. These symptoms...

EDITORIAL: The Missing Link â Lose Weight, Live Longer

George A. Bray, M.D. — Thu, 23Â AugÂ 2007 00:00:00 -05:00

In this issue of the Journal, two articles â by SjÃ¶strÃ¶m et al.1 and Adams et al.2 â may provide the missing link between intentional weight loss and lives saved...

ORIGINAL ARTICLE: Long-Term Mortality after Gastric Bypass Surgery

Thu, 23Â AugÂ 2007 00:00:00 -05:00

Background: Although gastric bypass surgery accounts for 80% of bariatric surgery in the United States, only limited long-term data are available on mortality among patients who have undergone this procedure...

ORIGINAL ARTICLE: Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects

Thu, 23Â AugÂ 2007 00:00:00 -05:00

Background: Obesity is associated with increased mortality. Weight loss improves cardiovascular risk factors, but no prospective interventional studies have reported whether weight loss decreases overall mortality. In fact, many observational...

IMAGES IN CLINICAL MEDICINE: Endometriosis

Simone Ferrero, M.D. and Valentino Remorgida, M.D. — Thu, 16Â AugÂ 2007 00:00:00 -05:00

A 36-year-old woman presented with a 2-month history of abdominal distention and pain. She reported having dysmenorrhea, dyspareunia, cyclical right shoulder pain (occurring only at the time of menstruation), and...

EDITORIAL: Ultrasound â Now Also for Microbiologists?

Francis A. Waldvogel, M.D. — Thu, 16Â AugÂ 2007 00:00:00 -05:00

The ultrasound system used by bats, dolphins, and whales has developed into a technology that has found numerous applications in diverse fields, including the biomedical domain, where it has been...

ORIGINAL ARTICLE: Sonication of Removed Hip and Knee Prostheses for Diagnosis of Infection

Thu, 16Â AugÂ 2007 00:00:00 -05:00

Background: Culturing of samples of periprosthetic tissue is the standard method used for the microbiologic diagnosis of prosthetic-joint infection, but this method is neither sensitive nor specific. In prosthetic-joint infection,...

IMAGES IN CLINICAL MEDICINE: Asymptomatic Bladder Stones

Yahya Daneshbod, M.D. — Thu, 09Â AugÂ 2007 00:00:00 -05:00

A healthy 26-year-old driver had routine laboratory tests performed to renew his driver's license. Hematuria (3+) was incidentally noted. He reported having had no urinary tract symptoms. Abdominal radiography of...

IMAGES IN CLINICAL MEDICINE: Intravesical Foreign Body

Nicola Mondaini, M.D. and Riccardo Bartoletti, M.D. — Thu, 09Â AugÂ 2007 00:00:00 -05:00

An 82-year-old woman presented with abdominal colic. She had a 20-year history of type 2 diabetes and a 2-year history of recurrent urinary tract infections despite many courses of antimicrobial...

IMAGES IN CLINICAL MEDICINE: An Intraabdominal Cyst

Cornelis H. van der Vlies, M.D. and Olivier R.C. Busch, M.D., Ph.D. — Thu, 02Â AugÂ 2007 00:00:00 -05:00

A 50-year-old woman presented with abdominal tenderness, fever, and vaginal bleeding. Physical examination showed a periumbilical mass and necrosis of the upper wall of the vagina. Laboratory data were notable...

CLINICAL PROBLEM-SOLVING: A Growing Problem â A 36-year-old pregnant woman at 21 weeks of gestation presented with a 4-week history of a dry, nonproductive cough

Wendy W. Yeh, M.D., Sanjay Saint, M.D., M.P.H., and Steven E. Weinberger, M.D. — Thu, 02Â AugÂ 2007 00:00:00 -05:00

A 36-year-old pregnant woman at 21 weeks of gestation presented with a 4-week history of a dry, nonproductive cough. The patient said she had no fever, chills, dyspnea, chest pain,...

IMAGES IN CLINICAL MEDICINE: Ascending Aortic Aneurysm in a Young Adult

Paul D. Harris, M.B., Ch.B. and Chris Cokis, F.A.N.Z.C.A. — Thu, 26Â JulÂ 2007 00:00:00 -05:00

A 37-year-old man presented to the emergency department with chest pain of 2 days' duration. The pain was heavy in character, intermittent, and made worse by deep inspiration and lying...

ORIGINAL ARTICLE: Partial Thrombosis of the False Lumen in Patients with Acute Type B Aortic Dissection

Thu, 26Â JulÂ 2007 00:00:00 -05:00

Background: Patency or thrombosis of the false lumen in type B acute aortic dissection has been found to predict outcomes. The prognostic implications of partial thrombosis of the false lumen...

IMAGES IN CLINICAL MEDICINE: Macular Hemorrhage from Bungee Jumping

Atul K. Jain, M.D. and Michael Gaynon, M.D. — Thu, 19Â JulÂ 2007 00:00:00 -05:00

A 25-year-old woman with no clinically significant medical history and with normal coagulation and hematologic studies went bungee jumping from a vertical height of 150 ft (45.7 m). Immediately afterward,...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 22-2007 â A Woman with a Family History of Gastric and Breast Cancer

Thu, 19Â JulÂ 2007 00:00:00 -05:00

A 38-year-old woman was seen in the Gastrointestinal Cancer Genetics Clinic of this hospital because of a family history of breast and gastric cancer.

Approximately 15 months earlier, mild chronic gastrointestinal...

CLINICAL PRACTICE: Management of an Inherited Predisposition to Breast Cancer

Mark Robson, M.D., and Kenneth Offit, M.D., M.P.H. — Thu, 12Â JulÂ 2007 00:00:00 -05:00

A healthy 33-year-old woman comes to establish care. She reports no breast symptoms, her age at menarche was 14, and she has no children. She notes a family history of...

CLINICAL PROBLEM-SOLVING: A Sinister Development â A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma

Thu, 05Â JulÂ 2007 00:00:00 -05:00

A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma. Her pain worsened acutely during the...

IMAGES IN CLINICAL MEDICINE: Endemic Multinodular Goiter

Daniel Cuevas-Ramos, M.D. and Bernardo PÃ©rez-EnrÃquez, M.D. — Thu, 28Â JunÂ 2007 00:00:00 -05:00

A 72-year-old woman presented for evaluation of dyspnea. thirty-five years earlier, she had noticed a painless, slowly enlarging anterior neck mass. Since she was otherwise asymptomatic and many in her...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 20-2007 â An 11-Year-Old Boy with a Calcified Mass in the Nose

Thu, 28Â JunÂ 2007 00:00:00 -05:00

Dr. Margo McKenna Benoit (Otolaryngology): An 11-year-old boy was referred to a pediatric otolaryngologist at the Massachusetts Eye and Ear Infirmary because of headaches and a right nasal mass. Bifrontal...

CLINICAL PRACTICE: Arteriovenous Malformations of the Brain

Robert M. Friedlander, M.D. — Thu, 28Â JunÂ 2007 00:00:00 -05:00

A 51-year-old woman presents with a generalized tonicâclonic seizure. After a brief postictal period, she recovers fully and does not report headache or other neurologic symptoms. She takes no medications...

ORIGINAL ARTICLE: Needlestick Injuries among Surgeons in Training

Thu, 28Â JunÂ 2007 00:00:00 -05:00

Background: Surgeons in training are at high risk for needlestick injuries. The reporting of such injuries is a critical step in initiating early prophylaxis or treatment.

Methods: We surveyed surgeons in...

CLINICAL PRACTICE: Follow-up of Patients with Early Breast Cancer

Daniel F. Hayes, M.D. — Thu, 14Â JunÂ 2007 00:00:00 -05:00

An otherwise healthy 53-year-old woman is seen for routine care after completing treatment several months earlier for stage II estrogen-receptorâpositive, HER2-positive breast cancer. The treatment consisted of lumpectomy, irradiation, adjuvant...

REVIEW ARTICLE: Prevention and Treatment of Major Blood Loss

Pier Mannuccio Mannucci, M.D., and Marcel Levi, M.D., Ph.D. — Thu, 31Â MayÂ 2007 00:00:00 -05:00

In a medical setting, surgery is the most common cause of major blood loss, defined as a loss of 20% of total blood volume or more. In particular, cardiovascular procedures,...

ORIGINAL ARTICLE: Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis

Thu, 31Â MayÂ 2007 00:00:00 -05:00

Background: Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled...

ORIGINAL ARTICLE: Surgery versus Prolonged Conservative Treatment for Sciatica

Thu, 31Â MayÂ 2007 00:00:00 -05:00

Background: Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.

Methods: We randomly assigned...

PERSPECTIVE: Back Surgery â Who Needs It?

Thu, 31Â MayÂ 2007 00:00:00 -05:00

Back surgery is not the final common pathway for everyone with persistent back pain. It offers specific therapy for specific anatomical derangements associated with specific complexes of symptoms. When surgery...

VIDEOS IN CLINICAL MEDICINE: Central Venous Catheterization

Thu, 24Â MayÂ 2007 00:00:00 -05:00

...

EDITORIAL: Shades of Dry â Curing Urinary Stress Incontinence

Kris Strohbehn, M.D. — Thu, 24Â MayÂ 2007 00:00:00 -05:00

Urinary incontinence is a common condition affecting 20 to 40% of older women.1 The two most common types of urinary incontinence are stress incontinence, the involuntary loss of urine resulting...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 16-2007 â A 61-Year-Old Man with a Mediastinal Mass

Thu, 24Â MayÂ 2007 00:00:00 -05:00

A 61-year-old man was referred to the thoracic oncology service of this hospital for management of a thymoma. He had been well until 6 weeks earlier, when he experienced the...

CLINICAL THERAPEUTICS: Bariatric Surgery for Morbid Obesity

Eric J. DeMaria, M.D. — Thu, 24Â MayÂ 2007 00:00:00 -05:00

A 44-year-old obese woman (height, 1.7 m [65 in.]) has seen her primary care physician for the past 10 years for management of conditions related to her obesity, including diabetes,...

ORIGINAL ARTICLE: Burch Colposuspension versus Fascial Sling to Reduce Urinary Stress Incontinence

Thu, 24Â MayÂ 2007 00:00:00 -05:00

Background: Many surgical procedures are available for women with urinary stress incontinence, yet few randomized clinical trials have been conducted to provide a basis for treatment recommendations.

Methods: We performed a...

IMAGES IN CLINICAL MEDICINE: Duplication of the Inferior Vena Cava

Junaid Masood, F.R.C.S., M.Sc. and Jayanta M. Barua, M.D., F.R.C.S. — Thu, 03Â MayÂ 2007 00:00:00 -05:00

A 68-year-old man with hypertension presented with vague abdominal pain. Ultrasonography of the abdomen showed a renal mass in the left kidney. A computed tomographic scan of the abdomen showed...

CLINICAL PROBLEM-SOLVING: The Drenched Doctor â A 55-year-old male physician was seen in August because of a 1-week history of fever and night sweats

Thu, 03Â MayÂ 2007 00:00:00 -05:00

A 55-year-old male physician was seen in August because of a 1-week history of fever and night sweats. The night sweats required at least one nightly change of his pajamas...

CLINICAL PRACTICE: Superior Vena Cava Syndrome with Malignant Causes

Thu, 03Â MayÂ 2007 00:00:00 -05:00

A 58-year-old man presents with a 2-week history of progressive dyspnea on exertion, neck swelling, decreased appetite, and fatigue. There is no history of syncope or dysphagia. He smoked cigarettes...

ORIGINAL ARTICLE: Age at Surgery for Undescended Testis and Risk of Testicular Cancer

Thu, 03Â MayÂ 2007 00:00:00 -05:00

Background: Undescended testis, which is a risk factor for testicular cancer, is usually treated surgically, but whether the age at treatment has any effect on the risk is unclear. We...

VIDEOS IN CLINICAL MEDICINE: Orotracheal Intubation

Thu, 26Â AprÂ 2007 00:00:00 -05:00

...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 13-2007 â A 46-Year-Old Woman with Gynecologic and Intestinal Cancers

Thu, 26Â AprÂ 2007 00:00:00 -05:00

A 46-year-old woman came to the Center for Cancer Risk Analysis at the Cancer Center of this hospital because of recent diagnoses of endometrial, ovarian, and colonic cancers.

Fifteen weeks earlier,...

CLINICAL PRACTICE: Fecal Incontinence in Adults

Arnold Wald, M.D. — Thu, 19Â AprÂ 2007 00:00:00 -05:00

A 53-year-old otherwise healthy woman presents with a 2-year history of intermittent fecal incontinence. Because of embarrassment, she has curtailed her social and professional activities. Physical activity often precipitates an...

ORIGINAL ARTICLE: Omeprazole before Endoscopy in Patients with Gastrointestinal Bleeding

Thu, 19Â AprÂ 2007 00:00:00 -05:00

Background: A neutral gastric pH is critical for the stability of clots over bleeding arteries. We investigated the effect of preemptive infusion of omeprazole before endoscopy on the need for...

IMAGES IN CLINICAL MEDICINE: Gravid Uterus in an Incisional Hernia

Charu Chanana, M.D. and Neena Malhotra, M.D. — Thu, 12Â AprÂ 2007 00:00:00 -05:00

A 32-year-old healthy woman, gravida 6 with two living children, presented at our clinic for the termination of pregnancy at 18 weeks of gestation. Her only previous abdominal surgeries had...

IMAGES IN CLINICAL MEDICINE: Liver Transplantation for Polycystic Liver Disease

William J. Wall, M.D. — Thu, 12Â AprÂ 2007 00:00:00 -05:00

A 51-year-old woman with polycystic liver and kidney disease had undergone renal transplantation 21 years before presentation. She had no evidence of cerebrovascular malformations. Both her father and aunt also...

REVIEW ARTICLE: Strategies for Safer Liver Surgery and Partial Liver Transplantation

Thu, 12Â AprÂ 2007 00:00:00 -05:00

The liver possesses the unique ability to regenerate within a short period.123 This feature has led to the development of innovative strategies in liver surgery and transplantation. The anatomy of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 10-2007 â A 55-Year-Old Man Impaled in a Rowing Accident

Thu, 29Â MarÂ 2007 00:00:00 -05:00

A 55-year-old man was admitted to this hospital after being impaled by the prow of a racing shell in a rowing accident.

The patient, who was in excellent health, was sculling...

IMAGES IN CLINICAL MEDICINE: Conjunctival Viral Papilloma

Wasee Tulvatana, M.D. and Kittisak Kulvichit, M.D. — Thu, 29Â MarÂ 2007 00:00:00 -05:00

A healthy 9-year-old boy had a 1-year history of an itchy right eye with frequent tearing. Small masses that gradually developed in the right caruncula lacrimalis area were associated with...

IMAGES IN CLINICAL MEDICINE: Dupuytren's Contracture

Edward Calif, M.D. and Shalom Stahl, M.D. — Thu, 22Â MarÂ 2007 00:00:00 -05:00

A 57-year-old man with a history of diabetes mellitus and alcohol consumption was referred to the hand surgery unit owing to contractures of fingers of both hands. He reported that...

IMAGES IN CLINICAL MEDICINE: Evolution of a Thoracic Aortic Aneurysm

Shingo Kawasaki, M.D. and Tatsuya Kawasaki, M.D. — Thu, 22Â MarÂ 2007 00:00:00 -05:00

An 84-year-old man with a history of gastric cancer and hypertension was admitted to the emergency department in shock after loss of consciousness. Ten years earlier he had been given...

CLINICAL PRACTICE: Intermittent Claudication

Christopher White, M.D. — Thu, 22Â MarÂ 2007 00:00:00 -05:00

A 58-year-old, previously healthy mail carrier reports cramping pain in his right calf when he walks. The discomfort has progressively worsened over the past 6 months and now forces him...

IMAGES IN CLINICAL MEDICINE: Small-Bowel Obstruction Due to an Internal Hernia

Kao-Lang Liu, M.D. and Been-Ren Lin, M.D. — Thu, 15Â MarÂ 2007 00:00:00 -05:00

A 48-year-old healthy woman presented with anorexia of 2 days' duration and abdominal pain in the right lower quadrant. Since appendicitis was suspected, she underwent a laparoscopic examination. An inflamed...

IMAGES IN CLINICAL MEDICINE: Calcified Left Atrial Thrombus

Joseph M. Pappachan, M.D. and Benjamin C. Bino, M.D. — Thu, 08Â MarÂ 2007 00:00:00 -05:00

A 21-year-old woman with a history of rheumatic fever at 7 years of age presented with left-sided weakness. A large ischemic infarction involving the territory of the right middle cerebral...

IMAGES IN CLINICAL MEDICINE: Floating Kidneys

Patrick O. Myers, M.D. and Gilles Chassot, M.D. — Thu, 08Â MarÂ 2007 00:00:00 -05:00

A 48-year-old man with multiple myeloma and a history of a repaired umbilical hernia and four thromboembolic events was admitted for cramping abdominal pain associated with back pain and a...

IMAGES IN CLINICAL MEDICINE: Gastric-Outlet Obstruction

Luis M. Franco, M.D. and Natalie J. Dryden, M.D. — Thu, 01Â MarÂ 2007 00:00:00 -05:00

A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration. The pain was continuous, worsened with eating, was associated with nausea,...

IMAGES IN CLINICAL MEDICINE: Bone within Bone â Chronic Osteomyelitis

Avigdor Hevroni, M.D. and Benjamin Z. Koplewitz, M.D. — Thu, 22Â FebÂ 2007 00:00:00 -05:00

An afebrile 8-year-old Ethiopian girl presented with a limp. Two years earlier, she had had mild trauma followed by âbone infectionâ and had received short courses of oral antibiotics. Examination...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 6-2007 â A 28-Year-Old Man with a Mass in the Testis

Thu, 22Â FebÂ 2007 00:00:00 -05:00

A 28-year-old man was referred to this hospital for consultation on the management of an enlarging testicular mass.

One year earlier, he had noticed a small, nontender mass in the posterior...

IMAGES IN CLINICAL MEDICINE: Two Hearts

Reyan A. Ghany, M.D. and Eduardo de Marchena, M.D. — Thu, 15Â FebÂ 2007 00:00:00 -05:00

A 64-year-old man presented with progressive shortness of breath and exercise intolerance due to end-stage ischemic cardiomyopathy. Since he remained severely symptomatic despite maximal medical therapy, he underwent a heterotopic...

EDITORIAL: Is There a Role for the Endoscopic Treatment of Pain from Chronic Pancreatitis?

Grace H. Elta, M.D. — Thu, 15Â FebÂ 2007 00:00:00 -05:00

The treatment of the pain of chronic pancreatitis continues to be problematic. Although severe calcific pancreatitis can be asymptomatic, it can cause disabling pain daily. Medical management with abstinence from...

REVIEW ARTICLE: Perioperative Stroke

Magdy Selim, M.D., Ph.D. — Thu, 15Â FebÂ 2007 00:00:00 -05:00

Stroke is one of the most feared complications of surgery. to provide adequate preventive and therapeutic measures, physicians need to be knowledgeable about the risk factors for stroke during the...

ORIGINAL ARTICLE: Endoscopic versus Surgical Drainage of the Pancreatic Duct in Chronic Pancreatitis

Thu, 15Â FebÂ 2007 00:00:00 -05:00

Background: For patients with chronic pancreatitis and a dilated pancreatic duct, ductal decompression is recommended. We conducted a randomized trial to compare endoscopic and surgical drainage of the pancreatic duct.

Methods:...

CLINICAL PRACTICE: The Incidentally Discovered Adrenal Mass

William F. Young, Jr., M.D. — Thu, 08Â FebÂ 2007 00:00:00 -05:00

A 68-year-old woman is incidentally found to have a left adrenal mass, 2.8 cm in diameter, on abdominal computed tomography that was ordered to evaluate right lower abdominal discomfort (which...

EDITORIAL: Treatment of Uterine Fibroids â Is Surgery Obsolete?

Togas Tulandi, M.D., M.H.C.M. — Thu, 25Â JanÂ 2007 00:00:00 -05:00

In the early 1990s, Jacques H. Ravina first applied the technique of embolization of uterine arteries to treat uterine fibroids in women at high risk for complications during surgery1 in...

IMAGES IN CLINICAL MEDICINE: Contraceptive Failure

Fred C. Cobey, M.D., M.P.H. and Hiroo Takayama, M.D. — Thu, 25Â JanÂ 2007 00:00:00 -05:00

A 60-year-old Somalian woman presented to the emergency department with pain in the upper abdomen. Her medical history was notable for the placement of an intrauterine device (IUD) while she...

ORIGINAL ARTICLE: Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids

The REST Investigators — Thu, 25Â JanÂ 2007 00:00:00 -05:00

Background: The efficacy and safety of uterine-artery embolization, as compared with standard surgical methods, for the treatment of symptomatic uterine fibroids remain uncertain.

Methods: We conducted a randomized trial comparing uterine-artery...

IMAGES IN CLINICAL MEDICINE: Phlegmasia Cerulea Dolens

Kalleen Barham, M.D. and Tina Shah, M.D. — Thu, 18Â JanÂ 2007 00:00:00 -05:00

An 85-year-old woman with newly diagnosed metastatic nonâsmall-cell lung cancer was admitted for pain control. Two days after admission, bluish discoloration of the left great toe was noted. Doppler ultrasonography...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Wound Healing with Electric Potential

Anna Huttenlocher, M.D., and Alan Rick Horwitz, Ph.D. — Thu, 18Â JanÂ 2007 00:00:00 -05:00

The efficient and effective repair of damaged tissue is fundamental to human survival. Wound repair has therefore challenged generations of health care providers, and various strategies have been used to...

EDITORIAL: The End of an Era in Otitis Research

Stephen Berman, M.D. — Thu, 18Â JanÂ 2007 00:00:00 -05:00

Retrospective studies carried out in the 1950s, 1960s, and 1970s suggested an association between otitis media early in life and subsequent developmental impairments in children. Although these studies were not...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2007 â A 49-Year-Old Woman with a Pigmented Lesion on the Arm

John F. Thompson, M.D., F. Stephen Hodi, M.D., and Artur Zembowicz, M.D. — Thu, 18Â JanÂ 2007 00:00:00 -05:00

A 49-year-old woman was seen in the outpatient surgical clinic of this hospital because of a diagnosis of melanoma.

The patient had noted a flat, pigmented lesion on her left upper...

ORIGINAL ARTICLE: Tympanostomy Tubes and Developmental Outcomes at 9 to 11 Years of Age

Thu, 18Â JanÂ 2007 00:00:00 -05:00

Background: Developmental impairments in children have been attributed to persistent middle-ear effusion in their early years of life. Previously, we reported that among children younger than 3 years of age...

IMAGES IN CLINICAL MEDICINE: Complication of Central Venous Catheterization

Hangyuan Guo, M.D. — Thu, 11Â JanÂ 2007 00:00:00 -05:00

A 40-year-old man with Crohn's disease underwent an uncomplicated operation involving lysis of adhesions that were causing intestinal obstruction. After surgery, a cardiologist inserted a central venous catheter through the...

IMAGES IN CLINICAL MEDICINE: Prevertebral Emphysema after a Dental Procedure

Kumar Sujeet, M.D. and Stuti Shankar, M.D. — Thu, 11Â JanÂ 2007 00:00:00 -05:00

A 47-year-old woman with diabetes was seen in the emergency room with difficulty swallowing, bilateral chest pain, and a foreign-body sensation in her throat. Earlier that day, she had undergone...

IMAGES IN CLINICAL MEDICINE: Papillary Fibroelastoma of the Pulmonary Artery

Takeshi Kondo, M.D. and Satoshi Tobe, M.D. — Thu, 04Â JanÂ 2007 00:00:00 -05:00

A 74-year-old man underwent an ultrasonographic examination of the right upper quadrant as part of an evaluation for a hepatoma. Incidentally, a tumor in the pulmonary artery, filling the space...

IMAGES IN CLINICAL MEDICINE: Subconjunctival Swelling â Prolapse of Orbital Fat

Mohammad Tahir Masoud, M.R.C.S.(Edin.) and M. Yusuf Shaikh, F.R.C.S.(Edin.) — Thu, 04Â JanÂ 2007 00:00:00 -05:00

A 59-year-old nonobese man presented with a 7-year history of gradually progressive swelling over the left eye. He had no other clinically significant medical history or history of trauma. There...

EDITORIAL: Technical-Skills Training in the 21st Century

Rajesh Aggarwal, M.R.C.S., and Ara Darzi, M.D. — Thu, 21Â DecÂ 2006 00:00:00 -05:00

Medical education is undergoing a paradigm shift, from the traditional experience-based model to a program that requires documentation of proficiency.1 Technological advances in health care, the development of day-case surgery,...

EDITORIAL: Carbapenems for Surgical Prophylaxis?

Daniel J. Sexton, M.D. — Thu, 21Â DecÂ 2006 00:00:00 -05:00

In this issue of the Journal, Itani and colleagues1 describe a study in which 1002 patients were randomly assigned to receive either ertapenem or cefotetan in a single dose before...

REVIEW ARTICLE: Teaching Surgical Skills â Changes in the Wind

Richard K. Reznick, M.D., M.Ed., and Helen MacRae, M.D. — Thu, 21Â DecÂ 2006 00:00:00 -05:00

Sir William Halsted introduced a German-style residency training system with an emphasis on graded responsibility at Johns Hopkins Hospital in 1889.1 This system remains the cornerstone of surgical training in...

ORIGINAL ARTICLE: Ertapenem versus Cefotetan Prophylaxis in Elective Colorectal Surgery

Thu, 21Â DecÂ 2006 00:00:00 -05:00

Background: Ertapenem, a long-acting carbapenem, may be an alternative to the recommended prophylactic antibiotic cefotetan.

Methods: In this randomized, double-blind trial, we assessed the efficacy and safety of antibiotic prophylaxis with...

PERSPECTIVE: Reconstructing Lives â A Tale of Two Soldiers

Thu, 21Â DecÂ 2006 00:00:00 -05:00

Jason Pepper can't see the deer and wild turkeys that feed in the pasture in front of his new home, an hour's drive from Nashville. But when he sits and...

CLINICAL PRACTICE: Adenomatous Polyps of the Colon

Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. — Thu, 14Â DecÂ 2006 00:00:00 -05:00

A 52-year-old man with no personal or family history of colon cancer, colonic polyps, or inflammatory bowel disease underwent a screening colonoscopy that showed no abnormalities except for a 1.5-cm...

IMAGES IN CLINICAL MEDICINE: Medical Mystery â Abnormal Abdominal Radiograph

Kumiko Tajima, M.D., Ph.D. and Masahiko Kurabayashi, M.D., Ph.D. — Thu, 07Â DecÂ 2006 00:00:00 -05:00

A 50-year-old woman presented to the emergency department with obtundation and hypotension. She had a 1-month history of slight fever, before which she had been well. On abdominal examination, an...

IMAGES IN CLINICAL MEDICINE: Asymptomatic Coronary-Artery Spasm

Michele Hamon, M.D. and Martial Hamon, M.D. — Thu, 23Â NovÂ 2006 00:00:00 -05:00

A 38-year-old man was scheduled to undergo invasive coronary angiography after cardiac scintigraphy revealed silent ischemia of the anterior myocardial wall. He was a smoker and had no other medical...

PERSPECTIVE: Observational Studies of Drug Safety â Aprotinin and the Absence of Transparency

Thu, 23Â NovÂ 2006 00:00:00 -05:00

The full safety profile of a new drug is rarely known at the time of approval by the Food and Drug Administration (FDA). Most drug-development programs designed for treatments of...

IMAGES IN CLINICAL MEDICINE: Fibromuscular Dysplasia of the Renal Artery

Christoph Caliezi, M.D. and Peter Reber, M.D. — Thu, 16Â NovÂ 2006 00:00:00 -05:00

During a routine preoperative checkup before a planned hysterectomy, a healthy 31-year-old woman was noted to have an elevated blood pressure of 230/130 mm Hg, mild headache without chest pain,...

IMAGES IN CLINICAL MEDICINE: Crohn's Disease and an Olive

Susan Shedda, F.R.A.C.S. and Frank Frizelle, F.R.A.C.S. — Thu, 09Â NovÂ 2006 00:00:00 -05:00

An otherwise healthy 45-year-old man presented with a 3-day history of colicky central abdominal pain associated with nausea and vomiting. His bowel habits had not changed, and he had no...

IMAGES IN CLINICAL MEDICINE: Progression of a Pedunculated Polyp

Kuangi Fu, M.D., Ph.D. and Yasushi Sano, M.D., Ph.D. — Thu, 02Â NovÂ 2006 00:00:00 -05:00

A 56-year-old man underwent a colonoscopy after a positive fecal occult-blood test. Colonoscopy revealed two pedunculated polyps, one in the ascending colon and one in the transverse colon. One polyp...

PERSPECTIVE: Public Report Cards â Cardiac Surgery and Beyond

Thu, 02Â NovÂ 2006 00:00:00 -05:00

The debate about public report cards for physicians and hospitals never seems to end.1 Some praise report cards for their role in improving the quality of care, patient safety, and...

VIDEOS IN CLINICAL MEDICINE: Basic Laceration Repair

Todd W. Thomsen, M.D., Derek A. Barclay, M.D., and Gary S. Setnik, M.D. — Thu, 26Â OctÂ 2006 00:00:00 -05:00

...

IMAGES IN CLINICAL MEDICINE: Intrathoracic Splenosis after Remote Trauma

Leah M. Backhus, M.D. and Ross M. Bremner, M.D., Ph.D. — Thu, 26Â OctÂ 2006 00:00:00 -05:00

A healthy 39-year-old man with persistent influenza-like symptoms underwent chest radiography, which showed two pericardial masses (Panels A and B, arrows). Computed tomography (CT) showed that the masses (one 3.3...

EDITORIAL: Carotid-Artery Stenting â Case Open or Closed?

Anthony J. Furlan, M.D. — Thu, 19Â OctÂ 2006 00:00:00 -05:00

As compared with carotid endarterectomy, carotid-artery stenting has uncertain efficacy and safety in patients at risk for stroke from atherosclerotic stenosis of the internal carotid artery. The benefits of carotid...

IMAGES IN CLINICAL MEDICINE: Obturator Hernia

Daniel Kam Yin Chan, M.D., M.B., B.S. — Thu, 19Â OctÂ 2006 00:00:00 -05:00

A previously healthy 102-year-old woman was admitted with abdominal pain and a 3-day history of vomiting. She lived with relatives, but cared for herself, and was able to garden. There...

ORIGINAL ARTICLE: Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis

Thu, 19Â OctÂ 2006 00:00:00 -05:00

Background: Carotid stenting is less invasive than endarterectomy, but it is unclear whether it is as safe in patients with symptomatic carotid-artery stenosis.

Methods: We conducted a multicenter, randomized, noninferiority trial...

PERSPECTIVE: America's New Refugees â Seeking Affordable Surgery Offshore

Thu, 19Â OctÂ 2006 00:00:00 -05:00

The mainstream media have begun to highlight the plight of some new refugees: seriously ill Americans who receive treatment at advanced private hospitals in low-income countries. These patients are not...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 31-2006 â A 15-Year-Old Girl with Severe Obesity

Thu, 12Â OctÂ 2006 00:00:00 -05:00

A 15 1/2-year-old girl was seen in the outpatient Weight Center of this hospital for the evaluation of severe obesity. She had had a normal gestation without complications and had...

IMAGES IN CLINICAL MEDICINE: Plantar Melanoma â A False Vegetant Wart

Vincenzo De Giorgi, M.D. and Daniela Massi, M.D. — Thu, 28Â SepÂ 2006 00:00:00 -05:00

A 53-year-old woman was referred to a dermatologist because of a verrucous nodule on the sole of her right foot (Panels A and B) that had been treated as a...

EDITORIAL: Sentinel-Node Biopsy in Melanoma

Charles M. Balch, M.D., and Natale Cascinelli, M.D. — Thu, 28Â SepÂ 2006 00:00:00 -05:00

In this issue of the Journal, Morton and colleagues report the largest and most important trial of sentinel-lymph-node biopsy for melanoma conducted to date.1 In the trial, 1269 patients with...

IMAGES IN CLINICAL MEDICINE: Intratracheal Melanoma Metastases

Aditya Bardia, M.D., M.P.H. and Ravi D. Rao, M.D. — Thu, 28Â SepÂ 2006 00:00:00 -05:00

A 42-year-old woman with metastatic melanoma presented with a 1-month history of dyspnea and wheezing. The diagnosis of malignant melanoma had been made 6 years earlier on the basis of...

ORIGINAL ARTICLE: Sentinel-Node Biopsy or Nodal Observation in Melanoma

Thu, 28Â SepÂ 2006 00:00:00 -05:00

Background: We evaluated the contribution of sentinel-node biopsy to outcomes in patients with newly diagnosed melanoma.

Methods: Patients with a primary cutaneous melanoma were randomly assigned to wide excision and postoperative...

IMAGES IN CLINICAL MEDICINE: Uni-, Bi-, Tri-, and Quadricuspid Aortic Valves

Matthias R. Schulze, M.D. and Ruth H. Strasser, M.D. — Thu, 21Â SepÂ 2006 00:00:00 -05:00

A 47-year-old woman presented with a 6-month history of left-sided chest pain and minimal dyspnea on exertion. On physical examination, her blood pressure was 120/60 mm Hg and a diastolic...

ORIGINAL ARTICLE: Chemotherapy with Preoperative Radiotherapy in Rectal Cancer

Thu, 14Â SepÂ 2006 00:00:00 -05:00

Background: Preoperative radiotherapy is recommended for selected patients with rectal cancer. We evaluated the addition of chemotherapy to preoperative radiotherapy and the use of postoperative chemotherapy in the treatment of...

IMAGES IN CLINICAL MEDICINE: Anthrax of the Cecum

Antoine Ghossain, M.D. — Thu, 31Â AugÂ 2006 00:00:00 -05:00

A 25-year-old man was admitted for pain and distention of the abdomen. He had a three-day history of dizziness, fatigue, myalgia, and mild fever. On physical examination, he was in...

REVIEW ARTICLE: Cerebral Aneurysms

Jonathan L. Brisman, M.D., Joon K. Song, M.D., and David W. Newell, M.D. — Thu, 31Â AugÂ 2006 00:00:00 -05:00

Saccular intracranial aneurysms, abnormal focal outpouchings of cerebral arteries, cause substantial rates of morbidity and mortality. Recently, major changes have occurred in the way we think about and treat this...

ORIGINAL ARTICLE: A Randomized Trial of Deep-Brain Stimulation for Parkinson's Disease

Thu, 31Â AugÂ 2006 00:00:00 -05:00

Background: Neurostimulation of the subthalamic nucleus reduces levodopa-related motor complications in advanced Parkinson's disease. We compared this treatment plus medication with medical management.

Methods: In this randomized-pairs trial, we enrolled 156...

IMAGES IN CLINICAL MEDICINE: Skin Redundancy after Massive Weight Loss

Arin K. Greene, M.D. and Jonathan M. Winograd, M.D. — Thu, 24Â AugÂ 2006 00:00:00 -05:00

A 30-year-old man presented at our plastic-surgery clinic to request body contouring after massive weight loss (Panels A and B; inset shows patient before weight loss). Two years earlier, the...

IMAGES IN CLINICAL MEDICINE: Inguinal Hernia

David Rosmarin, M.D. and Chen S. Tan, M.D. — Thu, 10Â AugÂ 2006 00:00:00 -05:00

A 68-year-old man with chronic dysuria and increased urinary frequency presented with three weeks of weakness and fever. Physical examination revealed a man with cachexia who had a large, right-sided...

CLINICAL PROBLEM-SOLVING: A Sharp Right Turn

Thu, 03Â AugÂ 2006 00:00:00 -05:00

A 60-year-old man presented to the emergency department for evaluation of rectal bleeding, syncope, and pain in the right leg. Five days earlier, diffuse abdominal pain that worsened with movement...

REVIEW ARTICLE: Chronic Venous Disease

Thu, 03Â AugÂ 2006 00:00:00 -05:00

Chronic venous disease of the lower limbs is manifested by a range of signs, the most obvious of which are varicose veins and venous ulcers. However, the signs also include...

CLINICAL THERAPEUTICS: Biventricular Pacing

John A. Jarcho, M.D. — Thu, 20Â JulÂ 2006 00:00:00 -05:00

A 55-year-old man who had had an anterior-wall myocardial infarction six months previously is admitted with an exacerbation of congestive heart failure. An electrocardiogram shows sinus rhythm with a left...

PERSPECTIVE: Thoughts from the Transition Zone

Thu, 20Â JulÂ 2006 00:00:00 -05:00

I got the call earlier today. A teenager has been on life support at our hospital while awaiting a heart transplant. She was running out of time when we got...

PERSPECTIVE: Taking Heart â Cardiac Transplantation Past, Present, and Future

Thu, 20Â JulÂ 2006 00:00:00 -05:00

Heart transplantation hit the international news with a splash in December 1967, when the first human-to-human transplantation was performed in South Africa by Christiaan Barnard, and the first transplantation in...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 21-2006 â A 61-Year-Old Man with Left-Sided Facial Pain

Emad Eskandar, M.D., Fred G. Barker II, M.D., and James D. Rabinov, M.D. — Thu, 13Â JulÂ 2006 00:00:00 -05:00

A 61-year-old man was seen in a specialty clinic at this hospital because of facial pain. The patient had been in his usual state of health until eight months earlier,...

EDITORIAL: Gastric Cancer â New Therapeutic Options

John S. Macdonald, M.D. — Thu, 06Â JulÂ 2006 00:00:00 -05:00

Gastric and gastroesophageal adenocarcinomas are important health problems. A 2005 analysis1 of the worldwide incidence of and mortality from cancer showed that 934,000 cases of gastric cancer occurred in 2002...

IMAGES IN CLINICAL MEDICINE: Frey's Syndrome

Francesco Prattico, M.D. and Paola Perfetti, M.D. — Thu, 06Â JulÂ 2006 00:00:00 -05:00

A 30-year-old man had a pleomorphic adenoma removed from his left parotid gland. His postoperative course was uncomplicated. Two months later, he noted that his left cheek became wet while...

ORIGINAL ARTICLE: Perioperative Chemotherapy versus Surgery Alone for Resectable Gastroesophageal Cancer

Thu, 06Â JulÂ 2006 00:00:00 -05:00

Background: A regimen of epirubicin, cisplatin, and infused fluorouracil (ECF) improves survival among patients with incurable locally advanced or metastatic gastric adenocarcinoma. We assessed whether the addition of a perioperative...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 19-2006 â A 22-Month-Old Boy with the Rapid Growth of Subcutaneous Nodules

J. Patrick Whelan, M.D., Ph.D., and Artur Zembowicz, M.D., Ph.D. — Thu, 22Â JunÂ 2006 00:00:00 -05:00

Dr. Richard Chou (Rheumatology): A 22-month-old boy was seen in the pediatric rheumatology clinic because of enlarging subcutaneous nodules on the head, legs, and right hand. The patient had been...

IMAGES IN CLINICAL MEDICINE: Zenker's Diverticulum

S. Alam Hannan, M.B., B.S., M.R.C.S. and Ghassan Alusi, M.B., B.S. — Thu, 08Â JunÂ 2006 00:00:00 -05:00

A 68-year-old man was referred because of progressive dysphagia and regurgitation that had reached a stage at which he could no longer eat or drink without coughing and spluttering. He...

IMAGES IN CLINICAL MEDICINE: Pneumoperitoneum Due to Spontaneously Perforated Pyometra

Ming-Shian Tsai, M.D. and Ming-Hsun Wu, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

A 40-year-old woman with long-standing diabetes presented to the emergency room with fever (temperature, 39.5Â°C) and diffuse abdominal pain. On admission, she had a distended abdomen with muscular rigidity, Blumberg's...

VIDEOS IN CLINICAL MEDICINE: Male Urethral Catheterization

Todd W. Thomsen, M.D., and Gary S. Setnik, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

...

EDITORIAL: Necrotizing Enterocolitis in Preterm Infants â Is Laparotomy Necessary?

Alan W. Flake, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

The occurrence of intestinal perforation is a catastrophic event at any age. Its occurrence in a very-low-birth-weight infant with necrotizing enterocolitis, however, is particularly hazardous. Unfortunately, the incidence of necrotizing...

ORIGINAL ARTICLE: Laparotomy versus Peritoneal Drainage for Necrotizing Enterocolitis and Perforation

Thu, 25Â MayÂ 2006 00:00:00 -05:00

Background: Perforated necrotizing enterocolitis is a major cause of morbidity and mortality in premature infants, and the optimal treatment is uncertain. We designed this multicenter randomized trial to compare outcomes...

CLINICAL PRACTICE: Acute Pancreatitis

David C. Whitcomb, M.D., Ph.D. — Thu, 18Â MayÂ 2006 00:00:00 -05:00

A 56-year-old woman presents with severe epigastric pain and vomiting of 14 hours' duration, symptoms that had developed shortly after dinner the previous night. She has no history of alcohol...

PERSPECTIVE: Robotic Surgery â Squeezing into Tight Places

Thu, 18Â MayÂ 2006 00:00:00 -05:00

Back in the 1980s, the rationale for building a surgical robot was the stuff of science fiction. Intent on providing âa doctor in every foxhole,â military strategists envisioned a severely...

IMAGES IN CLINICAL MEDICINE: Rotator-Cuff Tear

Paranee Auethavekiat, M.D. and Clement J. Michet, Jr., M.D. — Thu, 11Â MayÂ 2006 00:00:00 -05:00

A 72-year-old man with advanced glenohumeral and acromioclavicular arthritis presented with a painless mass over his left shoulder that had become progressively larger over a period of about a year...

EDITORIAL: Treatment of Peripheral Arterial Disease â Extending âInterventionâ to âTherapeutic Choiceâ

Alan T. Hirsch, M.D. — Thu, 04Â MayÂ 2006 00:00:00 -05:00

Lower-extremity peripheral arterial disease is an important manifestation of systemic atherosclerosis that is associated with markedly increased rates of cardiovascular ischemic events and death.1 Although most patients with peripheral arterial...

IMAGES IN CLINICAL MEDICINE: Spurious Platelet Count

Michele Siegenthaler, M.D. and Olivier Spertini, M.D. — Thu, 04Â MayÂ 2006 00:00:00 -05:00

A previously healthy 48-year-old man was admitted for severe burns involving his face, thorax, and upper and lower limbs (45 percent of body-surface area) associated with an inhalation injury. The...

ORIGINAL ARTICLE: Balloon Angioplasty versus Implantation of Nitinol Stents in the Superficial Femoral Artery

Thu, 04Â MayÂ 2006 00:00:00 -05:00

Background: Because stent implantation for disease of the superficial femoral artery has been associated with high rates of late clinical failure, percutaneous transluminal angioplasty is preferred for endovascular treatment, and...

IMAGES IN CLINICAL MEDICINE: Sudden Enlargement of the Neck

Stephen McDonnell, M.B., B.S. and Matthew Clark, M.B., B.S. — Thu, 27Â AprÂ 2006 00:00:00 -05:00

A 63-year-old man presented with a sudden enlargement of his neck. During the previous 10 years, his neck had grown progressively larger until he was no longer able to button...

EDITORIAL: The Vexing Problem of Hidden Incontinence

Rebecca G. Rogers, M.D. — Thu, 13Â AprÂ 2006 00:00:00 -05:00

Pelvic-organ prolapse occurs when pelvic organs herniate toward or through the vaginal opening. It is common and costly. Each year, nearly 200,000 women undergo surgery for prolapse; approximately 30 percent...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 11-2006 â A 54-Year-Old Woman with a Mass in the Pelvis

Thu, 13Â AprÂ 2006 00:00:00 -05:00

A 54-year-old woman was referred to the gynecologic oncology clinic of this hospital because of a pelvic mass. Several weeks earlier, urinary frequency, lower abdominal and pelvic pain, and a...

IMAGES IN CLINICAL MEDICINE: Pellagra-like Dermatitis

Neda Ashourian, M.D. and Nico Mousdicas, M.D. — Thu, 13Â AprÂ 2006 00:00:00 -05:00

Three months after undergoing Roux-en-Y bariatric surgery, a 32-year-old woman presented with glossitis, angular cheilitis, and an erythematous, desquamative dermatitis with a distribution indicative of photosensitivity causing a burning sensation...

ORIGINAL ARTICLE: Abdominal Sacrocolpopexy with Burch Colposuspension to Reduce Urinary Stress Incontinence

Thu, 13Â AprÂ 2006 00:00:00 -05:00

Background: We designed this trial to assess whether the addition of standardized Burch colposuspension to abdominal sacrocolpopexy for the treatment of pelvic-organ prolapse decreases postoperative stress urinary incontinence in women...

IMAGES IN CLINICAL MEDICINE: A Medical Mystery â Gangrene and Cutaneous Nodules

Stefan Schanz, M.D. and Anja Ulmer, M.D. — Thu, 06Â AprÂ 2006 00:00:00 -05:00

A 62-year-old man presented with a one-month history of digital gangrene affecting the right hand (Panel A). One digit had been partially amputated 20 years before, after an accident. The...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 10-2006 â A 66-Year-Old Woman with Barrett's Esophagus with High-Grade Dysplasia

Norman S. Nishioka, M.D., and Gregory Y. Lauwers, M.D. — Thu, 30Â MarÂ 2006 00:00:00 -05:00

A 66-year-old woman was referred to the gastroenterology clinic for evaluation and management of Barrett's esophagus with high-grade dysplasia.

Seven months earlier, she had been seen at another hospital because of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 9-2006 â A 35-Year-Old Woman with Recurrent Right-Upper-Quadrant Pain

RocÃo M. Hurtado, M.D., Dushyant V. Sahani, M.D., and Richard L. Kradin, M.D. — Thu, 23Â MarÂ 2006 00:00:00 -05:00

Dr. Amanda F. Peppercorn (Infectious Diseases): A 35-year-old woman was admitted to this hospital because of recurrent abdominal pain in the right upper quadrant. One year earlier, abdominal pain developed...

IMAGES IN CLINICAL MEDICINE: Cholesterol Emboli after Coronary Angioplasty

Omar Rana, M.B., B.S. and William McCrea, F.R.C.P. — Thu, 23Â MarÂ 2006 00:00:00 -05:00

A 72-year-old man presented with unstable angina. An urgent cardiac catheterization showed clinically significant disease in the right coronary artery, which was stented. Twelve hours after the procedure, livedo reticularis...

IMAGES IN CLINICAL MEDICINE: Giant Ganglion Cyst

Neil J. Mortimer, M.R.C.P. and Graham A. Johnston, M.R.C.P. — Thu, 16Â MarÂ 2006 00:00:00 -05:00

A 90-year-old woman presented with a one-month history of a rapidly enlarging cystic lesion on the flexor aspect of her left fifth finger. The lesion was tender and caused impairment...

IMAGES IN CLINICAL MEDICINE: Veiled Right Kidney Sign in a Patient with Valentino's Syndrome

Hsiu-Po Wang, M.D. and Wei-Chih Su, M.D. — Thu, 09Â MarÂ 2006 00:00:00 -05:00

A 72-year-old man presented to the emergency department with severe abdominal pain of two days' duration in the right lower quadrant. He reported recent use of nonsteroidal antiinflammatory drugs for...

REVIEW ARTICLE: Management of Crush-Related Injuries after Disasters

Thu, 09Â MarÂ 2006 00:00:00 -05:00

Disasters can rarely be anticipated, much less prevented. After both natural disasters (e.g., earthquakes, hurricanes, tornadoes, and landslides) and man-made catastrophes (e.g., wars, mining accidents, and terrorist attacks), injuries to...

EDITORIAL: Catheter Ablation of Chronic Atrial Fibrillation â The Gap between Promise and Practice

Mark A. Wood, M.D., and Kenneth A. Ellenbogen, M.D. — Thu, 02Â MarÂ 2006 00:00:00 -05:00

Atrial fibrillation remains the most common heart-rhythm abnormality seen in general clinical practice, and its incidence is increasing. Atrial fibrillation is an enormous health concern because it increases the risk...

CLINICAL PROBLEM-SOLVING: Search for the Complication

Thu, 02Â MarÂ 2006 00:00:00 -05:00

A 58-year-old woman was hospitalized for the evaluation of prolonged fever and hemoptysis. She reported an eight-month history of intermittent fevers, a productive cough, shortness of breath, and hemoptysis, which...

IMAGES IN CLINICAL MEDICINE: The Twiddler Syndrome

W.A.L. Tonino, M.D. and J.B. Winter, M.D., Ph.D. — Thu, 02Â MarÂ 2006 00:00:00 -05:00

A 55-year-old woman received a diagnosis of the sick sinus syndrome. A dual-chamber pacemaker was implanted with one lead in the right atrium and the other lead in the right...

ORIGINAL ARTICLE: Circumferential Pulmonary-Vein Ablation for Chronic Atrial Fibrillation

Thu, 02Â MarÂ 2006 00:00:00 -05:00

Background: We conducted a randomized, controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation.

Methods: A total of 146 patients with a mean (Â±SD) age of 57Â±9...

PERSPECTIVE: Brave New Face

Thu, 02Â MarÂ 2006 00:00:00 -05:00

In her office at the Cleveland Clinic, plastic surgeon Maria Siemionow has been studying the photographs and perusing the medical records of severely disfigured people, looking for the ideal candidate...

IMAGES IN CLINICAL MEDICINE: Malignant Obstruction of the Superior Vena Cava

Ronak S. Kanani, M.D. and Douglas E. Drachman, M.D. — Thu, 23Â FebÂ 2006 00:00:00 -05:00

A 75-year-old man with a substantial smoking history and stage IV nonâsmall-cell carcinoma of the lung presented with progressive symptoms of cough, hoarseness, and swelling of the face and arms....

SOUNDING BOARD: Strategies for Improving Surgical Quality â Should Payers Reward Excellence or Effort?

Nancy J.O. Birkmeyer, Ph.D., and John D. Birkmeyer, M.D. — Thu, 23Â FebÂ 2006 00:00:00 -05:00

Along with many other stakeholders, payers are taking an increasingly active interest in the quality of health care. Simple but effective therapies related to disease prevention, screening, and hospital-based medical...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 6-2006 â A 71-Year-Old Woman with Urinary Incontinence and a Mass in the Bladder

Thu, 23Â FebÂ 2006 00:00:00 -05:00

Dr. Donald S. Kaufman: A 71-year-old woman was referred to this hospital for a second opinion on the management of a malignant tumor of the urinary bladder. Urinary incontinence had...

IMAGES IN CLINICAL MEDICINE: Colonic Ileus

Senator Hazelwood, M.D. and Denise Burton, Ph.D. — Thu, 16Â FebÂ 2006 00:00:00 -05:00

A 77-year-old man with a history of hypertension, diabetes mellitus, and seizure disorder presented to the emergency room with abdominal pain and distention of approximately two to three days' duration....

IMAGES IN CLINICAL MEDICINE: Subacute Urinary Retention

Sameer Kassem, M.D. and Gideon Friedman, M.D. — Thu, 09Â FebÂ 2006 00:00:00 -05:00

An 88-year-old man with benign prostate hypertrophy and ischemic heart disease who had undergone an anterior peritoneal resection due to adenocarcinoma of the rectum presented with a three-month history of...

EDITORIAL: Cetuximab and Radiotherapy for Head and Neck Cancer

Marshall R. Posner, M.D., and Lori J. Wirth, M.D. — Thu, 09Â FebÂ 2006 00:00:00 -05:00

The treatment of head and neck cancer is complex and difficult, both technically and physically. Tumors in each site in the head and neck (oropharynx, hypopharynx, larynx, and oral cavity)...

IMAGES IN CLINICAL MEDICINE: Radiation Recall Reaction after Antimicrobial Therapy

Song K. Kang, M.D. — Thu, 09Â FebÂ 2006 00:00:00 -05:00

A woman with stage T3N0 anal carcinoma was treated with radiotherapy and concurrent chemotherapy with fluorouracil and mitomycin. The total dose of radiotherapy was 5940 cGy, with the high-dose area...

REVIEW ARTICLE: Coronary-Artery Stents

Thu, 02Â FebÂ 2006 00:00:00 -05:00

The use of percutaneously introduced prosthetic devices to maintain the luminal integrity of diseased blood vessels was proposed by Dotter and Judkins in 1964,1 well before the introduction of coronary...

PERSPECTIVE: Volunteering Overseas â Lessons from Surgical Brigades

Thu, 02Â FebÂ 2006 00:00:00 -05:00

Dr. Mark Migliori's approach to international surgical care is minimalist. With another surgeon, two anesthesiologists, and two or three nurses, he travels to a rural hospital in Guatemala. The group...

IMAGES IN CLINICAL MEDICINE: The Importance of Early Cervical-Spine Radiography

Morgan P. McMonagle, M.B. — Thu, 26Â JanÂ 2006 00:00:00 -05:00

A 19-year-old man was brought to the emergency department after a high-speed motorbike collision. The patient had a score of 3 on the Glasgow Coma Scale, (possible scores range from...

EDITORIAL: The Value of Phase 4 Clinical Testing

Gus J. Vlahakes, M.D. — Thu, 26Â JanÂ 2006 00:00:00 -05:00

Since its inception in 1988, the Multicenter Study of Perioperative Ischemia Research Group has examined a number of critical issues concerning the outcomes of cardiac surgery and anesthesia. The group's...

ORIGINAL ARTICLE: The Risk Associated with Aprotinin in Cardiac Surgery

Thu, 26Â JanÂ 2006 00:00:00 -05:00

Background: The majority of patients undergoing surgical treatment for ST-elevation myocardial infarction receive antifibrinolytic therapy to limit blood loss. This approach appears counterintuitive to the accepted medical treatment of the...

EDITORIAL: Reducing the Risk of Gynecologic Cancer in the Lynch Syndrome

Kenneth Offit, M.D., M.P.H., and Noah D. Kauff, M.D. — Thu, 19Â JanÂ 2006 00:00:00 -05:00

The first description of a kindred with hereditary nonpolyposis colorectal cancer (HNPCC) in 1925 was based on the family history of a woman who later died from endometrial cancer. On...

IMAGES IN CLINICAL MEDICINE: Bleeding Angiodysplasia in the Duodenum

Kuang-I Fu, M.D. and Takahiro Fujimori, M.D., Ph.D. — Thu, 19Â JanÂ 2006 00:00:00 -05:00

An 86-year-old woman with cirrhosis and esophageal varices due to chronic hepatitis C infection was referred for evaluation of anemia and fatigue. Esophagogastroduodenoscopy revealed active bleeding in the third part...

ORIGINAL ARTICLE: Prophylactic Surgery to Reduce the Risk of Gynecologic Cancers in the Lynch Syndrome

Thu, 19Â JanÂ 2006 00:00:00 -05:00

Background: Women with the Lynch syndrome (hereditary nonpolyposis colorectal cancer) have a 40 to 60 percent lifetime risk of endometrial cancer and a 10 to 12 percent lifetime risk of...

IMAGES IN CLINICAL MEDICINE: PellegriniâStieda Syndrome

Eric L. Altschuler, M.D., Ph.D. and Thomas N. Bryce, M.D. — Thu, 05Â JanÂ 2006 00:00:00 -05:00

A 38-year-old man with an incomplete spinal cord injury secondary to a diving accident some years before, which caused tetraplegia but preserved some sensation below the neck, reported new pain...

IMAGES IN CLINICAL MEDICINE: Black Hairy Tongue

Andreas Korber, M.D. and Joachim Dissemond, M.D. — Thu, 05Â JanÂ 2006 00:00:00 -05:00

An 85-year-old male cigar smoker with no notable medical history presented with black discoloration and hairy appearance of the tongue, which had lasted for several years. He said he did...

IMAGES IN CLINICAL MEDICINE: Buckshot Ingestion

William M. Cox, M.D. and Gene R. Pesola, M.D., M.P.H. — Thu, 29Â DecÂ 2005 00:00:00 -05:00

A 73-year-old Inuit woman was referred for a barium enema after an incomplete colonoscopy. A preliminary abdominal radiograph showed that the appendix was completely full of lead shot, with the...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 40-2005 â An 18-Year-Old Man with a One-Month History of Nontender Left Mandibular Swelling

Thu, 29Â DecÂ 2005 00:00:00 -05:00

An 18-year-old man was referred by his dentist to the oral and maxillofacial surgery clinic of this hospital because of left mandibular swelling.

One month earlier, the patient first noticed gradual...

ORIGINAL ARTICLE: Rescue Angioplasty after Failed Thrombolytic Therapy for Acute Myocardial Infarction

Thu, 29Â DecÂ 2005 00:00:00 -05:00

Background: The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention...

IMAGES IN CLINICAL MEDICINE: Pseudomembranous Colitis Associated with

Paul L. Wolf, M.D. and Armen Kasyan, M.D. — Thu, 08Â DecÂ 2005 00:00:00 -05:00

A 75-year-old man with peripheral vascular disease, chronic obstructive pulmonary disease, and diabetes mellitus presented with gangrene of the right fourth toe and underwent tarsalâmetatarsal amputation to manage the progression...

CLINICAL PROBLEM-SOLVING: A Hole in the Argument

Thu, 01Â DecÂ 2005 00:00:00 -05:00

An 80-year-old man presented to his physician's office for evaluation of shortness of breath and fatigue four weeks after repair of a hiatal hernia. He reported a mild, nonproductive cough...

CLINICAL PRACTICE: Patent Foramen Ovale in Young Adults with Unexplained Stroke

Jorge R. Kizer, M.D., and Richard B. Devereux, M.D. — Thu, 01Â DecÂ 2005 00:00:00 -05:00

A 38-year-old man notes abrupt loss of vision in his right visual field while reading. He has no significant medical history and reports that he neither smokes nor uses alcohol...

IMAGES IN CLINICAL MEDICINE: Caput Medusae

Pei-Ming Yang, M.D., Ph.D. and Ding-Shinn Chen, M.D. — Thu, 24Â NovÂ 2005 00:00:00 -05:00

A 47-year-old man with a seven-year history of compensated hepatic cirrhosis due to chronic hepatitis B infection presented for routine evaluation. Physical examination revealed a firm liver and mild splenomegaly....

EDITORIAL: Beta-Blockers to Prevent Esophageal Varices â An Unfulfilled Promise

Sandeep Mukherjee, M.D., M.P.H., and Michael F. Sorrell, M.D. — Thu, 24Â NovÂ 2005 00:00:00 -05:00

Variceal bleeding is the most feared complication of portal hypertension in patients with cirrhosis and is a major cause of death. Treatments frequently include endoscopic banding or sclerotherapy of esophageal...

IMAGES IN CLINICAL MEDICINE: Unfortunate Ingestion

M.C. Ruiz, M.D. and J. Soler-Gonzalez, M.D. — Thu, 24Â NovÂ 2005 00:00:00 -05:00

A 37-year-old woman had an eating disorder characterized by frequent episodes of self-induced vomiting. She presented after accidentally swallowing a kitchen fork while attempting to induce emesis. Radiographs of the...

ORIGINAL ARTICLE: Beta-Blockers to Prevent Gastroesophageal Varices in Patients with Cirrhosis

Thu, 24Â NovÂ 2005 00:00:00 -05:00

Background: Nonselective beta-adrenergic blockers decrease portal pressure and prevent variceal hemorrhage. Their effectiveness in preventing varices is unknown.

Methods: We randomly assigned 213 patients with cirrhosis and portal hypertension (minimal hepatic...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 35-2005 â A 56-Year-Old Woman with Breast Cancer and Isolated Tumor Cells in a Sentinel Lymph Node

Thu, 17Â NovÂ 2005 00:00:00 -05:00

Dr. Barbara L. Smith (Surgical Oncology): A 56-year-old woman was referred to the multidisciplinary breast clinic, part of the cancer center of this hospital, for management of invasive breast cancer...

IMAGES IN CLINICAL MEDICINE: Actinomyces Hepatic Abscess with Cutaneous Fistula

Mustafa Saad, M.D. and Jonathan Moorman, M.D., Ph.D. — Thu, 03Â NovÂ 2005 00:00:00 -05:00

A 64-year-old man with a history of colonic resection for adenocarcinoma six years earlier presented with weakness and abdominal discomfort of six months' duration. Computed tomography of the abdomen with...

IMAGES IN CLINICAL MEDICINE: Cerebral Metastases in Breast Cancer

Hannah Rouse, M.B., B.S. and Sarah-Jane Dawson, M.B., B.S. — Thu, 20Â OctÂ 2005 00:00:00 -05:00

A 52-year-old woman received a diagnosis of stage II hormone-receptorânegative, HER2-positive breast carcinoma (2 of 13 nodes positive). She underwent a left segmental mastectomy, axillary dissection, adjuvant chemotherapy (doxorubicin and...

IMAGES IN CLINICAL MEDICINE: Aortic Regurgitation â Bounding Carotids

Carlos Valencia CalderÃ³n,, M.D., Ph.D. and Juana Barthe Carrera, M.D. — Thu, 29Â SepÂ 2005 00:00:00 -05:00

A 66-year-old man with a medical history notable only for locally treated prostate cancer presented with a two-month history of dyspnea on moderate exertion and repeated episodes of angina with...

IMAGES IN CLINICAL MEDICINE: Cullen's and Turner's Signs

Farouk Mookadam, M.D. and Maja Cikes, M.D. — Thu, 29Â SepÂ 2005 00:00:00 -05:00

A 72-year-old man with unstable angina was admitted to the hospital. On the sixth day of heparin therapy, the hemoglobin level decreased from 11.7 to 9.4 g per deciliter. On...

IMAGES IN CLINICAL MEDICINE: Relapsed Colon Cancer

Guido Carillio, M.D. and Raffaele Longo, M.D. — Thu, 22Â SepÂ 2005 00:00:00 -05:00

A 67-year-old man presented with an asymptomatic swelling in the lateral surface of the left thigh three years after resection of a carcinoma of the left colon and synchronous liver...

IMAGES IN CLINICAL MEDICINE: Atherosclerotic Aortic Occlusion

Thanila A. Macedo, M.D. — Thu, 15Â SepÂ 2005 00:00:00 -05:00

A 46-year-old woman presented with lifestyle-limiting claudication of the legs. Symptoms had progressed over the previous seven years. She had hypertension, hyperlipidemia, and a smoking history of one pack per...

EDITORIAL: Prophylactic Thyroidectomy in MEN-2A â A Stitch in Time?

Francis D. Moore, M.D., and Robert G. Dluhy, M.D. — Thu, 15Â SepÂ 2005 00:00:00 -05:00

Multiple endocrine neoplasia (MEN) type 2A (MEN-2A) and type 2B (MEN-2B) illustrate the remarkable pace of knowledge that has been acquired about a group of heritable disorders. In 1961, Sipple...

EDITORIAL: Acute Coronary Syndromes without ST-Segment Elevation â What Is the Role of Early Intervention?

William E. Boden, M.D. — Thu, 15Â SepÂ 2005 00:00:00 -05:00

During the past 15 years, there have been important advances in both percutaneous coronary intervention (PCI) and the pharmacotherapy of acute coronary syndromes without ST-segment elevation. Several carefully designed, randomized...

IMAGES IN CLINICAL MEDICINE: Infarction Due to Myocardial Bridging

Karam Souibri, M.D. and Gilles Grollier, M.D. — Thu, 15Â SepÂ 2005 00:00:00 -05:00

A 45-year-old man with dyslipidemia had a sudden onset of retrosternal chest pain and presented to the emergency department. Findings on the physical examination were unremarkable. His electrocardiogram showed ST-segment...

ORIGINAL ARTICLE: Prophylactic Thyroidectomy in Multiple Endocrine Neoplasia Type 2A

Thu, 15Â SepÂ 2005 00:00:00 -05:00

Background: Medullary thyroid carcinoma is the most common cause of death in patients with multiple endocrine neoplasia (MEN) type 2A (MEN-2A) or type 2B or familial medullary thyroid carcinoma. We...

ORIGINAL ARTICLE: Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes

Thu, 15Â SepÂ 2005 00:00:00 -05:00

Background: Current guidelines recommend an early invasive strategy for patients who have acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level. However, randomized trials have...

EDITORIAL: Pregnancy Failure and Misoprostol â Time for a Change

Beverly Winikoff, M.D., M.P.H. — Thu, 25Â AugÂ 2005 00:00:00 -05:00

Pregnancy failure in the first trimester is one of the commonest reasons for women to seek emergency medical services. Indeed, curettage for this indication was responsible for up to three...

ORIGINAL ARTICLE: Costimulation Blockade with Belatacept in Renal Transplantation

Thu, 25Â AugÂ 2005 00:00:00 -05:00

Background: Renal transplantation is the standard of care for patients with end-stage renal disease. Although maintenance immunosuppression with calcineurin inhibitors yields excellent one-year survival, it is associated over the long...

ORIGINAL ARTICLE: A Comparison of Medical Management with Misoprostol and Surgical Management for Early Pregnancy Failure

Thu, 25Â AugÂ 2005 00:00:00 -05:00

Background: Misoprostol is increasingly used to treat women who have a failed pregnancy in the first trimester. We assessed the efficacy, safety, and acceptability of this treatment in a large,...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Nitric OxideâEluting Polyurethanes â Vascular Grafts of the Future?

Subodh Verma, M.D., Ph.D., and Philip A. Marsden, M.D. — Thu, 18Â AugÂ 2005 00:00:00 -05:00

Aristotle said, âIn all things of nature there is something of the marvelous.â Nitric oxide is one such marvel. Few could have predicted that one atom of nitrogen and one...

EDITORIAL: Health Disparities â Less Talk, More Action

Nicole Lurie, M.D., M.S.P.H. — Thu, 18Â AugÂ 2005 00:00:00 -05:00

During the past decade, hundreds of articles have been published documenting the existence of racial and ethnic disparities in health and health care â a data deluge that has led...

EDITORIAL: Healing Achilles â Sirolimus versus Paclitaxel

David J. Moliterno, M.D. — Thu, 18Â AugÂ 2005 00:00:00 -05:00

Since the inception of percutaneous coronary intervention (PCI), restenosis leading to repeated target-lesion revascularization has been the primary weakness of the procedure and has been repeatedly referred to as its...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 25-2005 â A 40-Year-Old Man with Prolonged Fever and Weight Loss

Dennis L. Kasper, M.D., Dushyant Sahani, M.D., and Joseph Misdraji, M.D. — Thu, 18Â AugÂ 2005 00:00:00 -05:00

A 40-year-old man was admitted to this hospital because of persistent fever, night sweats, anorexia, and weight loss.

The patient had been in excellent health until eight and a half weeks...

IMAGES IN CLINICAL MEDICINE: Four Artificial Heart Valves

Micon Bijl, M.D. and R.B.A. van den Brink, M.D., Ph.D. — Thu, 18Â AugÂ 2005 00:00:00 -05:00

A 67-year-old woman reported having progressive shortness of breath over several months, three years after undergoing aortic-valve replacement for aortic insufficiency. The patient had migraine headaches for which she had...

SPECIAL ARTICLE: Racial Trends in the Use of Major Procedures among the Elderly

Thu, 18Â AugÂ 2005 00:00:00 -05:00

Background: Differences in the use of major procedures according to patients' race are well known. Whether national and local initiatives to reduce these differences have been successful is unknown.

Methods: We...

ORIGINAL ARTICLE: Paclitaxel-Eluting or Sirolimus-Eluting Stents to Prevent Restenosis in Diabetic Patients

Thu, 18Â AugÂ 2005 00:00:00 -05:00

Background: Drug-eluting stents are highly effective in reducing the rate of in-stent restenosis. It is not known whether there are differences in the effectiveness of currently approved drug-eluting stents in...

ORIGINAL ARTICLE: Sirolimus-Eluting and Paclitaxel-Eluting Stents for Coronary Revascularization

Thu, 18Â AugÂ 2005 00:00:00 -05:00

Background: Sirolimus-eluting stents and paclitaxel-eluting stents, as compared with bare-metal stents, reduce the risk of restenosis. It is unclear whether there are differences in safety and efficacy between the two...

IMAGES IN CLINICAL MEDICINE: Patulous Eustachian Tube

Siu Kwan Ng, F.R.C.S.Ed. and Charles Andrew van Hasselt, M.M.E.D. — Thu, 11Â AugÂ 2005 00:00:00 -05:00

A healthy 26-year-old man reported a three-month history of aural fullness and a flapping noise in his right ear. Otoscopy revealed inward-and-outward movements of his right tympanic membrane in time...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 24-2005 â A 58-Year-Old Woman with Early-Stage Estrogen-ReceptorâPositive Breast Cancer

Paula D. Ryan, M.D., Ph.D., Daniel B. Kopans, M.D., and Dennis C. Sgroi, M.D. — Thu, 11Â AugÂ 2005 00:00:00 -05:00

A 58-year-old woman was seen in the multidisciplinary breast-cancer clinic of this hospital for management of early-stage breast cancer.

One month earlier, a routine screening mammogram at another facility revealed an...

IMAGES IN CLINICAL MEDICINE: Chylothorax and Chyloperitoneum

Thai Yen Ly, M.D. and Robert A. Fowler, M.D. — Thu, 11Â AugÂ 2005 00:00:00 -05:00

A 76-year-old man underwent elective repair of an abdominal aortic aneurysm, and in the subsequent eight weeks, exertional dyspnea, orthopnea, and abdominal pain developed. On physical examination, the patient was...

ORIGINAL ARTICLE: Developmental Outcomes after Early or Delayed Insertion of Tympanostomy Tubes

Thu, 11Â AugÂ 2005 00:00:00 -05:00

Background: To prevent later developmental impairments, myringotomy with the insertion of tympanostomy tubes has often been undertaken in young children who have persistent otitis media with effusion. We previously reported...

IMAGES IN CLINICAL MEDICINE: Medical Mystery â Abdominal Pain

Karen M. Kim, M.D. and Richard I. Kopelman, M.D. — Thu, 04Â AugÂ 2005 00:00:00 -05:00

A 40-year-old, previously healthy man presented with a four-day history of pain in the left upper quadrant of the abdomen, accompanied by fatigue, fever, sweating, and sore throat. Physical examination...

IMAGES IN CLINICAL MEDICINE: Transcatheter Treatment of Thromboembolism in the Superior Mesenteric Artery

Akifumi Nishida, M.D. and Kenichiro Fukui, M.D. — Thu, 28Â JulÂ 2005 00:00:00 -05:00

An 88-year-old woman with a history of hypertension and atrial fibrillation presented with an acute onset of severe abdominal pain, vomiting, and diarrhea. She had been taking warfarin for the...

EDITORIAL: Beta-Blocker Therapy in Noncardiac Surgery

Don Poldermans, M.D., and Eric Boersma, Ph.D. — Thu, 28Â JulÂ 2005 00:00:00 -05:00

Perioperative myocardial infarction is a major cause of complications and death among patients undergoing noncardiac surgery.1 Annually in the United States, approximately 27 million patients are given anesthesia for surgical...

CLINICAL PRACTICE: Cervical Radiculopathy

Simon Carette, M.D., M.Phil., and Michael G. Fehlings, M.D., Ph.D. — Thu, 28Â JulÂ 2005 00:00:00 -05:00

A 37-year-old woman presents with a two-week history of severe neck pain radiating to her left shoulder girdle and extending to the arm, forearm, and dorsum of the hand. She...

ORIGINAL ARTICLE: Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery

Thu, 28Â JulÂ 2005 00:00:00 -05:00

Background: Despite limited evidence from randomized trials, perioperative treatment with beta-blockers is now widely advocated. We assessed the use of perioperative beta-blockers and their association with in-hospital mortality in routine...

EDITORIAL: Gastric Bypass and Nesidioblastosis â Too Much of a Good Thing for Islets?

David E. Cummings, M.D. — Thu, 21Â JulÂ 2005 00:00:00 -05:00

As the obesity pandemic continues to worsen and medical interventions remain only moderately effective, bariatric surgery is at present the only method that reliably results in major, long-term weight loss.12...

IMAGES IN CLINICAL MEDICINE: Adenocarcinoma of the Breast in a Man

Andrew Birnie, M.R.C.P. and Sandeep Varma, M.R.C.P. — Thu, 21Â JulÂ 2005 00:00:00 -05:00

An 83-year-old man presented with a one-month history of an enlarging lump on his right nipple. It was asymptomatic. Physical examination revealed an 11-mm erythematous, well-circumscribed nodule attached to the...

ORIGINAL ARTICLE: Hyperinsulinemic Hypoglycemia with Nesidioblastosis after Gastric-Bypass Surgery

Thu, 21Â JulÂ 2005 00:00:00 -05:00

We describe six patients (five women and one man; median age, 47 years; range, 39 to 54) with postprandial symptoms of neuroglycopenia owing to endogenous hyperinsulinemic hypoglycemia after Roux-en-Y gastric...

PERSPECTIVE: Last-Ditch Medical Therapy â Revisiting Lobotomy

Barron H. Lerner, M.D., Ph.D. — Thu, 14Â JulÂ 2005 00:00:00 -05:00

Desperate times call for desperate measures. So thought Walter J. Freeman, a neurologist who became the United States's staunchest advocate of the lobotomy between the 1930s and the 1970s. A...

IMAGES IN CLINICAL MEDICINE: Small-Bowel Prolapse through a Persistent Omphalomesenteric Duct

Daniel F. Saad, M.D. and Kenneth W. Gow, M.D. — Thu, 07Â JulÂ 2005 00:00:00 -05:00

A 23-day-old term male infant presented to the emergency room with acute small-bowel evisceration through the umbilicus (Panel A). His parents had noted periumbilical erythema and mucus-containing umbilical drainage before...

IMAGES IN CLINICAL MEDICINE: Ruptured Ectopic Pregnancy

Sandra D. Lyden, M.D. and Lillian Nojadera, M.D. — Thu, 07Â JulÂ 2005 00:00:00 -05:00

A 33-year-old woman, para 2, presented to the emergency department with a report of vaginal bleeding and abdominal pain of several days' duration. She had no history of pelvic inflammatory...

ORIGINAL ARTICLE: Ovarian Transplantation between Monozygotic Twins Discordant for Premature Ovarian Failure

Thu, 07Â JulÂ 2005 00:00:00 -05:00

Monozygotic 24-year-old twins presented with discordant ovarian function. One had had premature ovarian failure at the age of 14 years, whereas her sister had normal ovaries and three naturally conceived...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 20-2005 â A 58-Year-Old Man with Locally Advanced Pancreatic Cancer

Thu, 30Â JunÂ 2005 00:00:00 -05:00

A 58-year-old man was seen in the gastrointestinal oncology clinic of the cancer center of this hospital for management of pancreatic cancer.

He had been in his usual state of health...

IMAGES IN CLINICAL MEDICINE: Tsunami Sinusitis

Kamonporn Limchawalit, M.D. and Chirotchana Suchato, M.D. — Thu, 23Â JunÂ 2005 00:00:00 -05:00

A 35-year-old man was brought to the hospital after sustaining injuries associated with the tsunami in Southeast Asia on December 26, 2004. The patient had inhaled seawater when he nearly...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 18-2005 â A 45-Year-Old Woman with a Painful Mass in the Abdomen

Michael G. Muto, M.D., Mary Jane O'Neill, M.D., and Esther Oliva, M.D. — Thu, 16Â JunÂ 2005 00:00:00 -05:00

A 45-year-old woman was admitted to this hospital with a painful abdominal mass.

She had first noticed a mass in her lower abdomen on the right side two and a half...

EDITORIAL: Endovascular Repair of Abdominal Aortic Aneurysm â Round Two

Frank A. Lederle, M.D. — Thu, 09Â JunÂ 2005 00:00:00 -05:00

Last year saw the publication of the first randomized comparisons of the endovascular and open techniques for elective repair of abdominal aortic aneurysms. The Dutch Randomized Endovascular Aneurysm Management (DREAM)...

ORIGINAL ARTICLE: Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms

Thu, 09Â JunÂ 2005 00:00:00 -05:00

Background: Two randomized trials have shown better outcomes with elective endovascular repair of abdominal aortic aneurysms than with conventional open repair in the first month after the procedure. We investigated...

EDITORIAL: Methods of Coronary Revascularization â Things May Not Be as They Seem

Bernard J. Gersh, M.B., Ch.B., D.Phil., and Robert L. Frye, M.D. — Thu, 26Â MayÂ 2005 00:00:00 -05:00

During the past three decades, randomized trials and registries have provided extensive evidence regarding the indications for and preferred method of coronary revascularization.1 The initial trials focused on indications for...

IMAGES IN CLINICAL MEDICINE: Crohn's Disease

Philippe de Saussure, M.D. and Claudio Soravia, M.D. — Thu, 26Â MayÂ 2005 00:00:00 -05:00

A 33-year-old woman who had had Crohn's disease for many years reported the development of dull pain in the left lower back, which was associated with sporadic episodes of fever...

ORIGINAL ARTICLE: Long-Term Outcomes of Coronary-Artery Bypass Grafting versus Stent Implantation

Thu, 26Â MayÂ 2005 00:00:00 -05:00

Background: Several studies have compared outcomes for coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), but most were done before the availability of stenting, which has revolutionized the latter...

ORIGINAL ARTICLE: Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer

Thu, 12Â MayÂ 2005 00:00:00 -05:00

Background: In 2002, we reported the initial results of a trial comparing radical prostatectomy with watchful waiting in the management of early prostate cancer. After three more years of follow-up,...

ORIGINAL ARTICLE: Complications of the COX-2 Inhibitors Parecoxib and Valdecoxib after Cardiac Surgery

Thu, 17Â MarÂ 2005 00:00:00 -05:00

Background: Valdecoxib and its intravenous prodrug parecoxib are used to treat postoperative pain but may involve risk after coronary-artery bypass grafting (CABG). We conducted a randomized trial to assess the...

PERSPECTIVE: The Accidental Addict

Howard Markel, M.D., Ph.D. — Thu, 10Â MarÂ 2005 00:00:00 -05:00

All stories of addiction are tragic. Some addictions are so well concealed that, when discovered, they initially appear to be inconceivable. One of the most remarkable tales of a concealed...

IMAGES IN CLINICAL MEDICINE: Mondor's Disease

Jorge Soler-GonzÃ¡lez, M.D. and M.C. Ruiz, M.D. — Thu, 10Â MarÂ 2005 00:00:00 -05:00

A 32-year-old woman presented with a three-day history of tenderness and swelling of the left breast. Physical examination revealed a subcutaneous fibrous lesion that was linear and cordlike. The patient...

EDITORIAL: Timing of Surgery in Asymptomatic Mitral Regurgitation

Catherine M. Otto, M.D., and Christopher T. Salerno, M.D. — Thu, 03Â MarÂ 2005 00:00:00 -05:00

The use of an evidence-based approach to the treatment of valvular heart disease has been hampered by the lack of rigorous data on predictors of the clinical outcome. The timing...

ORIGINAL ARTICLE: Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation

Thu, 03Â MarÂ 2005 00:00:00 -05:00

Background: The clinical outcome of asymptomatic mitral regurgitation is poorly defined, and the treatment is uncertain. We studied the effect on the outcome of quantifying mitral regurgitation according to recent...

PERSPECTIVE: Turf Battles in Coronary Revascularization

Robert S. Huckman, Ph.D., and Gary P. Pisano, Ph.D. — Thu, 03Â MarÂ 2005 00:00:00 -05:00

When percutaneous transluminal coronary angioplasty (PTCA) entered mainstream use in the early 1980s, it represented a suboptimal substitute for coronary-artery bypass grafting (CABG). Over time, however, the outcomes of PTCA...

IMAGES IN CLINICAL MEDICINE: Finger Avulsion with Pulled-Out Flexor Tendon

Georg M. Huemer, M.D. and Karin M. Dunst, M.D. — Thu, 10Â FebÂ 2005 00:00:00 -05:00

A 17-year-old boy jumped over a fence and sustained an avulsion injury to the fifth finger of his right hand when the ring he was wearing caught on the fence....

ORIGINAL ARTICLE: Bilateral Deep-Brain Stimulation of the Globus Pallidus in Primary Generalized Dystonia

Thu, 03Â FebÂ 2005 00:00:00 -05:00

Background: Severe forms of dystonia respond poorly to medical treatment. Deep-brain stimulation is a reversible neurosurgical procedure that has been used for the treatment of dystonia, but assessment of its...

IMAGES IN CLINICAL MEDICINE: Embolization of the Tip of a Central Venous Catheter into the Pulmonary Artery

Andreas J. Morguet, M.D. and Heinz-Peter Schultheiss, M.D. — Thu, 27Â JanÂ 2005 00:00:00 -05:00

A 56-year-old man who had recently undergone coronary-artery bypass grafting and replacement of the mitral and aortic valves underwent aortobifemoral bypass surgery for Fontaine stage IIb arterial occlusive disease. The...

EDITORIAL: Prophylactic Defibrillator Implantation â Toward an Evidence-Based Approach

Alan Kadish, M.D. — Thu, 20Â JanÂ 2005 00:00:00 -05:00

Most patients who have an out-of-hospital cardiac arrest do not survive. Thus, the use of a prophylactic implantable cardioverterâdefibrillator (ICD) for the primary prevention of sudden death is a conceptually...

ORIGINAL ARTICLE: Amiodarone or an Implantable CardioverterâDefibrillator for Congestive Heart Failure

Thu, 20Â JanÂ 2005 00:00:00 -05:00

Background: Sudden death from cardiac causes remains a leading cause of death among patients with congestive heart failure (CHF). Treatment with amiodarone or an implantable cardioverterâdefibrillator (ICD) has been proposed...

PERSPECTIVE: Medicare Coverage of ICDs

Mark B. McClellan, M.D., Ph.D., and Sean R. Tunis, M.D. — Thu, 20Â JanÂ 2005 00:00:00 -05:00

The results of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), reported in this issue of the Journal (pages 225â237), show that there are likely to be expanded clinical...

PERSPECTIVE: Beyond the Purple Heart â Continuity of Care for the Wounded in Iraq

James B. Peake, M.D. — Thu, 20Â JanÂ 2005 00:00:00 -05:00

You can hear the usual hum of the emergency room, and all the familiar beeps of monitors in the operating room provide a backdrop for medical teams boasting the usual...

ORIGINAL ARTICLE: The Risk of Hemorrhage after Radiosurgery for Cerebral Arteriovenous Malformations

Thu, 13Â JanÂ 2005 00:00:00 -05:00

Background: Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage...

ORIGINAL ARTICLE: Mild Intraoperative Hypothermia during Surgery for Intracranial Aneurysm

Thu, 13Â JanÂ 2005 00:00:00 -05:00

Background: Surgery for intracranial aneurysm often results in postoperative neurologic deficits. We conducted a randomized trial at 30 centers to determine whether intraoperative cooling during open craniotomy would improve the...

PERSPECTIVE: Ruptured Cerebral Aneurysms

Dilantha B. Ellegala, M.D., and Arthur L. Day, M.D. — Thu, 13Â JanÂ 2005 00:00:00 -05:00

The brain derives its blood supply from two internal carotid arteries, which supply most of the cerebrum, and two vertebral arteries, which merge to form the basilar artery and supply...

IMAGES IN CLINICAL MEDICINE: Obstructive Lingual Thyroid

Andreas Barthel, M.D. and Stefan R. Bornstein, M.D., Ph.D. — Thu, 06Â JanÂ 2005 00:00:00 -05:00

A 43-year-old woman who was undergoing surgery could not be intubated for the administration of anesthesia because of an unusually narrow oropharynx. Ultrasonography showed a round, solid tumor about 3...

EDITORIAL: Coronary Revascularization before Noncardiac Surgery

Mauro Moscucci, M.D., and Kim A. Eagle, M.D. — Thu, 30Â DecÂ 2004 00:00:00 -05:00

The evaluation of cardiac risk before noncardiac surgical procedures and interventions aimed toward reducing that risk have become an integral part of the contemporary practice of medicine. In the nonoperative...

ORIGINAL ARTICLE: Coronary-Artery Revascularization before Elective Major Vascular Surgery

Thu, 30Â DecÂ 2004 00:00:00 -05:00

Background: The benefit of coronary-artery revascularization before elective major vascular surgery is unclear.

Methods: We randomly assigned patients at increased risk for perioperative cardiac complications and clinically significant coronary artery disease...

EDITORIAL: Bariatric Surgery â Quick Fix or Long-Term Solution?

Caren G. Solomon, M.D., M.P.H., and Robert G. Dluhy, M.D. — Thu, 23Â DecÂ 2004 00:00:00 -05:00

More than 30 percent of the U.S. population is obese (body-mass index [the weight in kilograms divided by the square of the height in meters], 30 or greater), and 4.9...

ORIGINAL ARTICLE: Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery

Thu, 23Â DecÂ 2004 00:00:00 -05:00

Background: Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk, but whether these benefits persist over time is unknown.

Methods: The prospective, controlled Swedish Obese Subjects...

EDITORIAL: The If and When of Surgical Debulking for Ovarian Carcinoma

Tate Thigpen, M.D. — Thu, 09Â DecÂ 2004 00:00:00 -05:00

Celomic epithelial carcinoma of the ovary, in contrast to most other gynecologic cancers, often causes no symptoms in its early stages and is usually diagnosed only after it has spread...

ORIGINAL ARTICLE: Secondary Surgical Cytoreduction for Advanced Ovarian Carcinoma

Thu, 09Â DecÂ 2004 00:00:00 -05:00

Background: We evaluated the effect of adding secondary cytoreductive surgery to postoperative chemotherapy on progression-free survival and overall survival among patients who had advanced ovarian cancer and residual tumor exceeding...

PERSPECTIVE: Caring for the Wounded in Iraq â A Photo Essay

George E. Peoples, M.D., James R. Jezior, M.D., and Craig D. Shriver, M.D. — Thu, 09Â DecÂ 2004 00:00:00 -05:00

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PERSPECTIVE: Casualties of War â Military Care for the Wounded from Iraq and Afghanistan

Atul Gawande, M.D., M.P.H. — Thu, 09Â DecÂ 2004 00:00:00 -05:00

Each Tuesday, the U.S. Department of Defense provides an online update of American military casualties (the number of wounded or dead) from Operation Iraqi Freedom and Operation Enduring Freedom.1 According...

IMAGES IN CLINICAL MEDICINE: Double Aortic Arch Diagnosed by Magnetic Resonance Imaging

Joachim Lotz, M.D. and Paolo Macchiarini, M.D. — Thu, 25Â NovÂ 2004 00:00:00 -05:00

A six-month-old boy who had recurrent respiratory difficulties was admitted to the hospital with acute respiratory failure that required mechanical ventilation. Echocardiography suggested the presence of a double aortic arch....

IMAGES IN CLINICAL MEDICINE: Cholelithiasis

Ensar Yekeler, M.D. and Yakup Akyol, M.D. — Thu, 25Â NovÂ 2004 00:00:00 -05:00

A previously healthy 34-year-old woman who had back pain was referred for radiography of the lumbar spine. The patient's laboratory data were normal. The radiograph showed multiple faceted stones outlining...

ORIGINAL ARTICLE: A Randomized Comparison of Radial-Artery and Saphenous-Vein Coronary Bypass Grafts

Thu, 25Â NovÂ 2004 00:00:00 -05:00

Background: In the past decade, the radial artery has frequently been used for coronary bypass surgery despite concern regarding the possibility of graft spasm. Graft patency is a key predictor...

PERSPECTIVE: Prolonging Patency â Choosing Coronary Bypass Grafts

Bruce W. Lytle, M.D. — Thu, 25Â NovÂ 2004 00:00:00 -05:00

The benefits of coronary bypass surgery last only as long as the grafts continue to function. Aorta-to-coronary saphenous-vein grafts (see diagram), the most widely used type of bypass graft, have...

IMAGES IN CLINICAL MEDICINE: Staghorn Renal-Cell Carcinoma

Lorenzo G. Luciani, M.D. and Lucio Luciani, M.D. — Thu, 11Â NovÂ 2004 00:00:00 -05:00

A 72-year-old woman with a history of hematuria presented with a three-month history of weight loss and anorexia. Computed tomography (Panel A) and ultrasonography showed a solid mass infiltrating the...

IMAGES IN CLINICAL MEDICINE: Getting the Lead Out

Joy Shen, M.D. and Robert Hirschtick, M.D. — Thu, 04Â NovÂ 2004 00:00:00 -05:00

A 32-year-old man reported having had back and abdominal pain, nausea, and constipation for several weeks. The results of laboratory studies were notable for normocytic anemia, a hemoglobin level of...

IMAGES IN CLINICAL MEDICINE: Falciform-Ligament Sign of Pneumoperitoneum

Jiun-Nong Lin, M.D. — Thu, 28Â OctÂ 2004 00:00:00 -05:00

An 87-year-old woman with iatrogenic Cushing's syndrome presented with fever and shock. She had had diarrhea for several days, but after the use of antidiarrheal agents, she had become constipated....

EDITORIAL: Chemoradiotherapy for Rectal Cancer â When, Why, and How?

Robert D. Madoff, M.D. — Thu, 21Â OctÂ 2004 00:00:00 -05:00

Although colon cancer and rectal cancer share many features, clinicians should be aware of important differences in the clinical behavior and treatment of these two distinct diseases. Prominent among these...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 32-2004 â A 68-Year-Old Man with a Large Retroperitoneal Mass

Thu, 21Â OctÂ 2004 00:00:00 -05:00

Dr. David P. Ryan: A 68-year-old man was admitted to the hospital because of a large retroperitoneal tumor.

The patient had been in excellent health. A few days before admission,...

ORIGINAL ARTICLE: Preoperative versus Postoperative Chemoradiotherapy for Rectal Cancer

Thu, 21Â OctÂ 2004 00:00:00 -05:00

Background: Postoperative chemoradiotherapy is the recommended standard therapy for patients with locally advanced rectal cancer. In recent years, encouraging results with preoperative radiotherapy have been reported. We compared preoperative chemoradiotherapy...

EDITORIAL: Abdominal Aortic Aneurysm â Open versus Endovascular Repair

Frank A. Lederle, M.D. — Thu, 14Â OctÂ 2004 00:00:00 -05:00

The publication in this issue of the Journal of the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial1 and the recent publication of a similar study from the United Kingdom2 provide...

REVIEW ARTICLE: Prosthetic-Joint Infections

Werner Zimmerli, M.D., Andrej Trampuz, M.D., and Peter E. Ochsner, M.D. — Thu, 14Â OctÂ 2004 00:00:00 -05:00

Prosthetic-joint replacement is used increasingly to alleviate pain and to improve mobility. Infections associated with prosthetic joints cause significant morbidity and account for a substantial proportion of health care expenditures.12...

ORIGINAL ARTICLE: Fresh Whole Blood versus Reconstituted Blood for Pump Priming in Heart Surgery in Infants

Thu, 14Â OctÂ 2004 00:00:00 -05:00

Background: In an attempt to reduce the coagulopathic and inflammatory responses seen after cardiopulmonary bypass, the use of fresh whole blood during heart operations has become the standard of care...

ORIGINAL ARTICLE: A Randomized Trial Comparing Conventional and Endovascular Repair of Abdominal Aortic Aneurysms

Thu, 14Â OctÂ 2004 00:00:00 -05:00

Background: Although the initial results of endovascular repair of abdominal aortic aneurysms were promising, current evidence from controlled studies does not convincingly show a reduction in 30-day mortality relative to...

PERSPECTIVE: Cardiopulmonary Bypass after 50 Years

L. Henry Edmunds, M.D. — Thu, 14Â OctÂ 2004 00:00:00 -05:00

A little more than 50 years ago, a hole inside a human heart was closed, with a machine maintaining life while the surgery was done. Within the next two years,...

EDITORIAL: Stenting for Carotid-Artery Stenosis

Richard P. Cambria, M.D. — Thu, 07Â OctÂ 2004 00:00:00 -05:00

In the context of his original description of the pathoanatomical relationship of plaque at the carotid bifurcation to ipsilateral hemispheric stroke, C. Miller Fisher predicted that âone day surgeons might...

CLINICAL PRACTICE: Aortic Regurgitation

Maurice Enriquez-Sarano, M.D., and A. Jamil Tajik, M.D. — Thu, 07Â OctÂ 2004 00:00:00 -05:00

A 48-year-old woman who reports mild fatigue but no dyspnea, chest pain, or palpitation is found to have a diastolic cardiac murmur. The blood pressure is 140/50 mm Hg, and...

ORIGINAL ARTICLE: Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients

Thu, 07Â OctÂ 2004 00:00:00 -05:00

Background: 04100728.xml 04100728.xml 04100728.xml Carotid endarterectomy is more effective than medical management in the prevention of stroke in patients with severe symptomatic or asymptomatic atherosclerotic carotid-artery stenosis. Stenting with the...

IMAGES IN CLINICAL MEDICINE: Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm

W. Anthony Lee, M.D. — Thu, 16Â SepÂ 2004 00:00:00 -05:00

A 62-year-old man presented with an acute onset of severe lower back pain, hypotension, and nausea and vomiting. He had a history of hypertension and hypertriglyceridemia. On arrival, the patient...

IMAGES IN CLINICAL MEDICINE: Traumatic Laceration of the Aorta

Frederick B. Rogers, M.D. — Thu, 16Â SepÂ 2004 00:00:00 -05:00

A 37-year-old man was involved in a motor vehicle collision. On examination in the emergency department, the patient was hemodynamically stable but had a steering-wheel imprint on the anterior chest...

REVIEW ARTICLE: Cystic Neoplasms of the Pancreas

Thu, 16Â SepÂ 2004 00:00:00 -05:00

Physicians from a wide range of disciplines are being confronted with questions regarding the management of cystic lesions of the pancreas. Owing to recent improvements in pancreatic imaging, an increasing...

ORIGINAL ARTICLE: Corneal Reconstruction with Tissue-Engineered Cell Sheets Composed of Autologous Oral Mucosal Epithelium

Thu, 16Â SepÂ 2004 00:00:00 -05:00

Background: Ocular trauma or disease may lead to severe corneal opacification and, consequently, severe loss of vision as a result of complete loss of corneal epithelial stem cells. Transplantation of...

PERSPECTIVE: Changing the Cell Source in Cell Therapy?

Graziella Pellegrini, Ph.D. — Thu, 16Â SepÂ 2004 00:00:00 -05:00

One dream of scientists is to be able to rebuild, in vitro, âspare partsâ to replace injured or diseased tissues â a notion that was once relegated to the realm...

IMAGES IN CLINICAL MEDICINE: Gallstone Ileus

John S. Graham, M.D. and Bruce C. Rothwell, M.D. — Thu, 09Â SepÂ 2004 00:00:00 -05:00

An 83-year-old woman was hospitalized with nausea, vomiting, and obstipation. She had been losing weight for six months and had had similar, though less severe, symptoms during that time. She...

ORIGINAL ARTICLE: Cardiac Replacement with a Total Artificial Heart as a Bridge to Transplantation

Thu, 26Â AugÂ 2004 00:00:00 -05:00

Background: The CardioWest Total Artificial Heart orthotopically replaces both native cardiac ventricles and all cardiac valves, thus eliminating problems commonly seen in the bridge to transplantation with left ventricular and...

PERSPECTIVE: Building a Bridge to Heart Transplantation

Dale G. Renlund, M.D. — Thu, 26Â AugÂ 2004 00:00:00 -05:00

End-stage heart failure, characterized by marked symptoms at rest or with minimal activity despite optimal therapy, is designated as stage D heart failure. Frequent, recurring exacerbations may often be treated...

IMAGES IN CLINICAL MEDICINE: Rotationplasty for Ewing's Sarcoma of the Distal Femur

John P. Dormans, M.D. and Sumeet Garg, M.D. — Thu, 19Â AugÂ 2004 00:00:00 -05:00

A five-year-old girl received a diagnosis of Ewing's sarcoma of the distal femur after she noticed a painless mass behind her left knee. The tumor had not metastasized at the...

PERSPECTIVE: The Changing Faces of Children with Cleft Lip and Palate

John B. Mulliken, M.D. — Thu, 19Â AugÂ 2004 00:00:00 -05:00

Many expectant parents worry, consciously or unconsciously, that their baby will be born with a malformation. Cleft lip with or without cleft palate is one of the most common birth...

IMAGES IN CLINICAL MEDICINE: Imperforate Hymen with Hematocolpometra

Sean M. Stone, M.D. and John L. Alexander, M.D. — Thu, 12Â AugÂ 2004 00:00:00 -05:00

An 11-year-old girl presumed to be premenarchal presented to the emergency department with a 24-hour history of constant periumbilical pain that radiated to both flanks. She also noted nausea, urinary...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 25-2004 â A 49-Year-Old Woman with Severe Obesity, Diabetes, and Hypertension

Thu, 12Â AugÂ 2004 00:00:00 -05:00

A 49-year-old woman was evaluated at this hospital for the management of obesity. She had been overweight since childhood; at the age of 10 years she weighed 45.4 kg, at...

IMAGES IN CLINICAL MEDICINE: Lung Herniation after Cardiopulmonary Resuscitation

Laura D. Sprague, D.O. and Filippo J. Ferrigni, M.D. — Thu, 12Â AugÂ 2004 00:00:00 -05:00

A 63-year-old man collapsed, unresponsive and pulseless, at his workplace. Security guards, using an automated external defibrillator, delivered two shocks to his chest and performed cardiopulmonary resuscitation (CPR) until paramedics...

IMAGES IN CLINICAL MEDICINE: Gastrothorax Simulating Acute Tension Pneumothorax

Cornelis P.C. de Jager, M.D. and Ronald J. Trof, M.D. — Thu, 05Â AugÂ 2004 00:00:00 -05:00

A 27-year-old man was admitted to the emergency department because of respiratory failure. Three years earlier, he had undergone surgery to repair a traumatic rupture of the left side of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 24-2004 â A 48-Year-Old Man with Recurrent Gastrointestinal Bleeding

Thu, 29Â JulÂ 2004 00:00:00 -05:00

A 48-year-old man was admitted to the hospital for evaluation of recurrent gastrointestinal bleeding.

He had been well until 33 months earlier, when he had midepigastric pain and passed black stools...

CLINICAL PRACTICE: Use of Lasers for Vision Correction of Nearsightedness and Farsightedness

Steven E. Wilson, M.D. — Thu, 29Â JulÂ 2004 00:00:00 -05:00

A 32-year-old woman with moderate myopia and mild dry eye has worn soft contact lenses for 12 years. She notes decreased tolerance of the lenses and must remove them after...

IMAGES IN CLINICAL MEDICINE: Intussusception of the Small Bowel

Lawrence E. Harrison, M.D. and Steve H. Kim, M.D. — Thu, 22Â JulÂ 2004 00:00:00 -05:00

A 37-year-old man presented to the emergency department with a two-day history of crampy abdominal pain, nausea, and vomiting. On physical examination, his temperature was 37.2Â°C, and his pulse was...

IMAGES IN CLINICAL MEDICINE: Massive Subcutaneous Emphysema after Tracheal Perforation

Kenzo Hirose, M.D. and Brendan C. Visser, M.D. — Thu, 15Â JulÂ 2004 00:00:00 -05:00

A 77-year-old woman underwent laminectomy and posterior spinal fusion from T12 to S1, an operation that was performed while she was in the prone position. At the conclusion of the...

EDITORIAL: TwinâTwin Transfusion â As Good as It Gets?

Nicholas M. Fisk, Ph.D., and Paula Galea, M.D. — Thu, 08Â JulÂ 2004 00:00:00 -05:00

The twin-to-twin transfusion syndrome poses a major challenge for fetal therapy. Untreated, it results in inordinate perinatal mortality and morbidity. It affects two babies, both of whom are structurally normal....

ORIGINAL ARTICLE: Endoscopic Laser Surgery versus Serial Amnioreduction for Severe Twin-to-Twin Transfusion Syndrome

Thu, 08Â JulÂ 2004 00:00:00 -05:00

Background: Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or selective fetoscopic laser...

ORIGINAL ARTICLE: Preoperative PSA Velocity and the Risk of Death from Prostate Cancer after Radical Prostatectomy

Thu, 08Â JulÂ 2004 00:00:00 -05:00

Background: We evaluated whether men at risk for death from prostate cancer after radical prostatectomy can be identified using information available at diagnosis.

Methods: We studied 1095 men with localized prostate...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 20-2004 â A 46-Year-Old Woman with Pelvic-Floor Relaxation after a Second Vaginal Delivery

Lori R. Berkowitz, M.D. — Thu, 24Â JunÂ 2004 00:00:00 -05:00

A 46-year-old woman was admitted to the hospital because of pelvic discomfort and urinary symptoms.

The patient had been well until 10 months earlier, when she had experienced the rapid but...

ORIGINAL ARTICLE: Clostridium Infections Associated with Musculoskeletal-Tissue Allografts

Thu, 17Â JunÂ 2004 00:00:00 -05:00

Background: Allografts are commonly used in orthopedic reconstructive surgery. In 2001, approximately 875,000 musculoskeletal allografts were distributed by U.S. tissue banks. After the death from Clostridium sordellii sepsis of a...

ORIGINAL ARTICLE: Absence of an Effect of Liposuction on Insulin Action and Risk Factors for Coronary Heart Disease

Thu, 17Â JunÂ 2004 00:00:00 -05:00

Background: Liposuction has been proposed as a potential treatment for the metabolic complications of obesity. We evaluated the effect of large-volume abdominal liposuction on metabolic risk factors for coronary heart...

PERSPECTIVE: Infections Transmitted through Musculoskeletal-Tissue Allografts

Robin Patel, M.D, and Andrej Trampuz, M.D. — Thu, 17Â JunÂ 2004 00:00:00 -05:00

The 2003 Institute of Medicine report Microbial Threats to Health: Emergence, Detection, and Response lists âadvances in medical technologies, such as blood transfusions and organ transplants,â as one reason for...

PERSPECTIVE: Thermodynamics, Liposuction, and Metabolism

David E. Kelley, M.D. — Thu, 17Â JunÂ 2004 00:00:00 -05:00

The regulation of body weight adheres to the principles of thermodynamics: a positive energy balance causes weight gain, and weight loss occurs when the energy expenditure exceeds intake. More than...

EDITORIAL: Prevention of Postoperative Nausea and Vomiting â A Multimodal Solution to a Persistent Problem

Paul F. White, Ph.D., M.D. — Thu, 10Â JunÂ 2004 00:00:00 -05:00

Despite the introduction of new antiemetic agents, short-acting anesthetics, and minimally invasive surgical techniques, the incidence of postoperative nausea and vomiting has remained largely unchanged over the past two decades.1...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 18-2004 â A 61-Year-Old Man with Rectal Bleeding and a 2-cm Mass in the Rectum

Thu, 10Â JunÂ 2004 00:00:00 -05:00

A 61-year-old man was referred to this hospital for treatment of a low rectal adenocarcinoma. He had been well until five months previously, when he occasionally began to note blood...

ORIGINAL ARTICLE: A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting

Thu, 10Â JunÂ 2004 00:00:00 -05:00

Background: Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone...

IMAGES IN CLINICAL MEDICINE: Paraesophageal Hernia

Robert J. Canter, M.D. and James P. Greelish, M.D. — Thu, 03Â JunÂ 2004 00:00:00 -05:00

A 34-year-old woman with a nine-month history of postprandial dyspnea and substernal fullness had severe pain in her epigastrium, without emesis, shortly after the ingestion of an evening meal. On...

CLINICAL PRACTICE: Surveillance Strategies after Curative Treatment of Colorectal Cancer

David G. Pfister, M.D., Al B. Benson III, M.D., and Mark R. Somerfield, Ph.D. — Thu, 03Â JunÂ 2004 00:00:00 -05:00

A 63-year-old man underwent complete resection of a T3N0M0, stage II adenocarcinoma of the ascending colon. No adjuvant therapy is planned. There is no family history of colorectal cancer. How...

IMAGES IN CLINICAL MEDICINE: Acquired Arteriovenous Fistula

Oren K. Steinmetz, M.D. and L.P. Palerme, M.D. — Thu, 20Â MayÂ 2004 00:00:00 -05:00

A 35-year-old man presented with high-output congestive heart failure. Fourteen years earlier, he had received a shrapnel wound to the left thigh in a car-bomb attack in Lebanon. As a...

CLINICAL PRACTICE: Plantar Fasciitis

Rachelle Buchbinder, M.B., B.S., F.R.A.C.P. — Thu, 20Â MayÂ 2004 00:00:00 -05:00

A 55-year-old overweight woman presents with a three-month history of pain in her right inferior heel. The pain is worse on taking her first steps in the morning. The physical...

PERSPECTIVE: Evidence-Based Use of Cardiac Procedures and Devices

Mark A. Hlatky, M.D. — Thu, 20Â MayÂ 2004 00:00:00 -05:00

The fundamental principle of evidence-based medicine is that clinical practice should rest on a sound scientific foundation established by clinical studies involving human subjects. The level of evidence needed for...

EDITORIAL: Laparoscopic Resection for Colon Cancer â The End of the Beginning?

Theodore N. Pappas, M.D., and Danny O. Jacobs, M.D., M.P.H. — Thu, 13Â MayÂ 2004 00:00:00 -05:00

Technological advances, which are followed by long periods of catch-up while clinicians learn how to use the new techniques appropriately, often precede true medical progress. Such certainly appears to be...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 15-2004 â A 31-Year-Old Man with Bilateral Testicular Enlargement

Karen K. Ballen, M.D., and Robert P. Hasserjian, M.D. — Thu, 13Â MayÂ 2004 00:00:00 -05:00

A 31-year-old man was admitted to the hospital because of a testicular mass.

The patient had been well until three months before admission, when he noted bilateral testicular swelling that coincided...

IMAGES IN CLINICAL MEDICINE: Stretch Brachial Plexopathy

Judith Lynn Gorelick, M.D. — Thu, 13Â MayÂ 2004 00:00:00 -05:00

A 29-year-old man had a one-month history of weakness of the left hand and painful paresthesias involving the radial half of his palm, as well as the palmar aspect of...

ORIGINAL ARTICLE: A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer

The Clinical Outcomes of Surgical Therapy Study Group — Thu, 13Â MayÂ 2004 00:00:00 -05:00

Background: Minimally invasive, laparoscopically assisted surgery was first considered in 1990 for patients undergoing colectomy for cancer. Concern that this approach would compromise survival by failing to achieve a proper...

IMAGES IN CLINICAL MEDICINE: Cor Triatriatum

Daniel B. Reese, M.D. — Thu, 06Â MayÂ 2004 00:00:00 -05:00

A 29-year-old man presented with severe dyspnea and hemoptysis. He said he had always had a reduced capacity for exercise as compared with his peers. He had an elevated jugular...

ORIGINAL ARTICLE: Postoperative Irradiation with or without Concomitant Chemotherapy for Locally Advanced Head and Neck Cancer

Thu, 06Â MayÂ 2004 00:00:00 -05:00

Background: We compared concomitant cisplatin and irradiation with radiotherapy alone as adjuvant treatment for stage III or IV head and neck cancer.

Methods: After undergoing surgery with curative intent, 167 patients...

ORIGINAL ARTICLE: Postoperative Concurrent Radiotherapy and Chemotherapy for High-Risk Squamous-Cell Carcinoma of the Head and Neck

Thu, 06Â MayÂ 2004 00:00:00 -05:00

Background: 04050628.xml Despite the use of resection and postoperative radiotherapy, high-risk squamous-cell carcinoma of the head and neck frequently recurs in the original tumor bed. We tested the hypothesis that...

EDITORIAL: Mesh Repair of Inguinal Hernias â Redux

Danny O. Jacobs, M.D., M.P.H. — Thu, 29Â AprÂ 2004 00:00:00 -05:00

An abdominal-wall hernia occurs when the abdominal contents protrude through a congenital or acquired defect in the supportive tissues. Although hernias can develop in many locations, including areas weakened by...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2004 â A 66-Year-Old Man with Progressive Neurologic Deficits

Thu, 29Â AprÂ 2004 00:00:00 -05:00

A 66-year-old, right-handed man was admitted to the hospital because of progressive left-sided weakness.

Nineteen years before admission, the patient had received a renal transplant from a living related donor because...

ORIGINAL ARTICLE: Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia

Thu, 29Â AprÂ 2004 00:00:00 -05:00

Background: Repair of inguinal hernias in men is a common surgical procedure, but the most effective surgical technique is unknown.

Methods: We randomly assigned men with inguinal hernias at 14 Veterans...

IMAGES IN CLINICAL MEDICINE: Pseudomyxoma Peritonei

Sanford H. Barsky, M.D. and Kathryn McGonigle, M.D. — Thu, 08Â AprÂ 2004 00:00:00 -05:00

A 55-year-old man presented with a five-month history of increasing abdominal girth, a weight loss of 4.5 kg (10 lb), and occasional episodes of anorexia and nausea. Physical examination revealed...

IMAGES IN CLINICAL MEDICINE: A Complication of Cosmetic Surgery

So Young Moon, M.D. and Gregory Youngnam Chang, M.D. — Thu, 08Â AprÂ 2004 00:00:00 -05:00

A 45-year-old woman who had received local anesthesia underwent injection of abdominal subcutaneous fat into the vertical glabellar frown lines to remove wrinkles. Within a minute after the procedure, she...

REVIEW ARTICLE: Treatment of Infections Associated with Surgical Implants

Rabih O. Darouiche, M.D. — Thu, 01Â AprÂ 2004 00:00:00 -05:00

About half of the 2 million cases of nosocomial infection that occur each year in the United States are associated with indwelling devices. Although less common than infections related to...

ORIGINAL ARTICLE: The Influence of Resection and Aneuploidy on Mortality in Oral Leukoplakia

Thu, 01Â AprÂ 2004 00:00:00 -05:00

Background: Although the standard treatment of oral leukoplakia ranges from watchful waiting to complete resection, the value of these approaches is unknown.

Methods: We studied the relations among resection, ploidy status,...

IMAGES IN CLINICAL MEDICINE: Diffuse Subcutaneous Air Due to a Perforated Colonic Diverticulum

Wen Lai, M.D. and Jonathan Dowell, M.D. — Thu, 25Â MarÂ 2004 00:00:00 -05:00

An 80-year-old man with multiple medical problems underwent a colonoscopy, which was performed to determine the cause of anemia. During the colonoscopy, he reported abdominal discomfort, and profound abdominal distention...

IMAGES IN CLINICAL MEDICINE: Pemberton's Sign

Shehzad Basaria, M.D. and Roberto Salvatori, M.D. — Thu, 25Â MarÂ 2004 00:00:00 -05:00

A 58-year-old woman with a 20-year history of goiter presented with a two-month history of progressive dyspnea on exertion, occasional stridor, and a choking sensation while supine. She had previously...

EDITORIAL: Adjuvant Therapy for Pancreatic Cancer â The Debate Continues

Michael A. Choti, M.D. — Thu, 18Â MarÂ 2004 00:00:00 -05:00

Surgical therapy currently offers the only potential cure for pancreatic adenocarcinoma. Surgical morbidity and mortality have decreased dramatically in recent years; the perioperative mortality associated with pancreaticoduodenectomy in major centers...

ORIGINAL ARTICLE: A Randomized Trial of Chemoradiotherapy and Chemotherapy after Resection of Pancreatic Cancer

Thu, 18Â MarÂ 2004 00:00:00 -05:00

Background: The effect of adjuvant treatment on survival in pancreatic cancer is unclear. We report the final results of the European Study Group for Pancreatic Cancer 1 Trial and update...

PERSPECTIVE: Earthquake Relief â The U.S. Medical Response in Bam, Iran

Jay J. Schnitzer, M.D., Ph.D., and Susan M. Briggs, M.D., M.P.H. — Thu, 18Â MarÂ 2004 00:00:00 -05:00

The magnitude-6.6 earthquake in Bam, Iran, struck at 5:26 a.m. local time on December 26, 2003, while most people were asleep in their homes. It destroyed much of the city....

IMAGES IN CLINICAL MEDICINE: Interdigital Pilonidal Sinus

Peter J. Stern, M.D. and Charles A. Goldfarb, M.D. — Thu, 11Â MarÂ 2004 00:00:00 -05:00

A healthy 39-year-old woman who was employed as an animal groomer presented with a chronic draining cyst in the web between the middle and ring fingers of one hand. The...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 8-2004 â A 28-Year-Old Man with Abdominal Pain, Fever, and a Mass in the Region of the Pancreas

William R. Brugge, M.D., Peter R. Mueller, M.D., and Joseph Misdraji, M.D. — Thu, 11Â MarÂ 2004 00:00:00 -05:00

A 28-year-old man was admitted to the hospital because of abdominal pain and fever.

The patient had been well until 10 days earlier, when mild epigastric pain developed. Two days before...

PERSPECTIVE: Surgery for Severe Obesity

Robert Steinbrook, M.D. — Thu, 11Â MarÂ 2004 00:00:00 -05:00

The epidemic of obesity in the United States has spawned a second epidemic â of bariatric surgery. The number of gastrointestinal surgeries performed annually for severe obesity increased from about...

IMAGES IN CLINICAL MEDICINE: Meckel's Diverticulum in Action

See-Ching Chan, M.D. and Chung-Yau Lo, F.R.C.S., F.A.C.S. — Thu, 19Â FebÂ 2004 00:00:00 -05:00

A 26-year-old man presented with massive gastrointestinal hemorrhage and hypovolemic shock. His hemoglobin level dropped by 4 g per deciliter over a six-hour period. Emergency upper endoscopy to the second...

EDITORIAL: Defining Adequate Surgery for Primary Melanoma

Susan E. Krown, M.D., and Paul B. Chapman, M.D. — Thu, 19Â FebÂ 2004 00:00:00 -05:00

The incidence of malignant melanoma has been rising over the past three decades.1 Much of the increase is accounted for by thin, localized cutaneous melanomas with the potential to be...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 6-2004 â A 35-Year-Old Woman with Extensive, Deep Burns from a Nightclub Fire

Thu, 19Â FebÂ 2004 00:00:00 -05:00

A 35-year-old woman sustained extensive burns and was possibly trampled in a nightclub after a pyrotechnics display set fire to the building. At the scene, she was responsive but confused...

ORIGINAL ARTICLE: Excision Margins in High-Risk Malignant Melanoma

Thu, 19Â FebÂ 2004 00:00:00 -05:00

Background: Controversy exists concerning the necessary margin of excision for cutaneous melanoma 2 mm or greater in thickness.

Methods: We conducted a randomized clinical trial comparing 1-cm and 3-cm margins.

Results Of...

SOUNDING BOARD: Spinal-Fusion Surgery â The Case for Restraint

Thu, 12Â FebÂ 2004 00:00:00 -05:00

The use of spinal-fusion surgery in the United States is rapidly increasing. National survey data indicate that the annual number of spinal-fusion operations rose by 77 percent between 1996 and...

CLINICAL PRACTICE: Acute Renal Colic from Ureteral Calculus

Joel M.H. Teichman, M.D. — Thu, 12Â FebÂ 2004 00:00:00 -05:00

A 39-year-old man reports an eight-hour history of colicky pain in the right lower quadrant radiating to the tip of his penis. He had previously had a kidney stone, which...

PERSPECTIVE: Spinal-Fusion Surgery â Advances and Concerns

Stephen J. Lipson, M.D. — Thu, 12Â FebÂ 2004 00:00:00 -05:00

Spinal arthrodesis (the creation of a fusion) was developed for the treatment of instability and deformity due to tuberculosis, scoliosis, and traumatic injury. Modern spinal surgery was helped by the...

IMAGES IN CLINICAL MEDICINE: Congenital Lymphedema

Jeffrey S. Upperman, M.D. and Edward M. Barksdale, Jr., M.D. — Thu, 05Â FebÂ 2004 00:00:00 -05:00

A full-term infant born to a woman (gravida 1, para 1) with a history of gestational diabetes presented with edema of the right leg (Panel A). When the infant was...

REVIEW ARTICLE: The BuddâChiari Syndrome

K.V. Narayanan Menon, M.D., Vijay Shah, M.D., and Patrick S. Kamath, M.D. — Thu, 05Â FebÂ 2004 00:00:00 -05:00

The BuddâChiari syndrome is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction at the level of the hepatic venules, the large hepatic veins, the inferior vena cava,...

PERSPECTIVE: The Artificial Heart

Sandeep Jauhar, M.D., Ph.D. — Thu, 05Â FebÂ 2004 00:00:00 -05:00

At 10:30 p.m. on December 1, 1982, a retired dentist named Barney Clark was wheeled into an operating room at the University of Utah Medical Center in Salt Lake City....

IMAGES IN CLINICAL MEDICINE: Retroperitoneal Sarcoma

Lena M. Napolitano, M.D. — Thu, 29Â JanÂ 2004 00:00:00 -05:00

A 73-year-old man had sudden, intermittent lower abdominal pain, and he noted that his abdominal girth was increasing. Computed tomographic scans of his abdomen (Panel A) and pelvis (Panel B)...

ORIGINAL ARTICLE: EffusiveâConstrictive Pericarditis

Thu, 29Â JanÂ 2004 00:00:00 -05:00

Background: Effusiveâconstrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction, caused by the visceral pericardium. We conducted a prospective study of...

IMAGES IN CLINICAL MEDICINE: Pneumatosis Intestinalis and Portal Venous Gas

Craig See, M.D. and David Elliott, M.D. — Thu, 22Â JanÂ 2004 00:00:00 -05:00

A 53-year-old woman who had recently been treated for ulcerative colitis with high-dose prednisone and mercaptopurine was admitted with severe abdominal pain and signs of peritoneal irritation. Colonoscopy, radiography of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 3-2004 â A 57-Year-Old Man with Invasive Transitional-Cell Carcinoma of the Bladder

Thu, 22Â JanÂ 2004 00:00:00 -05:00

A 57-year-old man came to this hospital for bladder-sparing treatment of invasive transitional-cell carcinoma of the bladder.

He had had a slight burning sensation on urination for six months, and then...

REVIEW ARTICLE: Multidisciplinary Management of Lung Cancer

Alexander Spira, M.D., Ph.D., and David S. Ettinger, M.D. — Thu, 22Â JanÂ 2004 00:00:00 -05:00

In 2004, an estimated 173,700 Americans will receive a diagnosis of lung cancer, and 164,440 of them will die of the disease. Despite years of research, the prognosis for patients...

IMAGES IN CLINICAL MEDICINE: Intussusception

Duyen Dang, M.D. and David Cromwell, M.D. — Thu, 15Â JanÂ 2004 00:00:00 -05:00

An 80-year-old woman presented with a three-day history of passage of bright red blood from the rectum. She was afebrile and had a blood pressure of 70/52 mm Hg. The...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2004 â A 32-Year-Old Man with Pain and Swelling of the Jaw

Thu, 15Â JanÂ 2004 00:00:00 -05:00

Dr. H. Daniel Clark (Oral and Maxillofacial Surgery): A 32-year-old man was admitted to the hospital because of a mandibular sarcoma. He had been well until two months before...

ORIGINAL ARTICLE: A Polymer-Based, Paclitaxel-Eluting Stent in Patients with Coronary Artery Disease

Thu, 15Â JanÂ 2004 00:00:00 -05:00

Background: Restenosis after coronary stenting necessitates repeated percutaneous or surgical revascularization procedures. The delivery of paclitaxel to the site of vascular injury may reduce the incidence of neointimal hyperplasia and...

SPECIAL ARTICLE: Use of High-Cost Operative Procedures by Medicare Beneficiaries Enrolled in For-Profit and Not-for-Profit Health Plans

Eric C. Schneider, M.D., Alan M. Zaslavsky, Ph.D., and Arnold M. Epstein, M.D. — Thu, 08Â JanÂ 2004 00:00:00 -05:00

Background: It is widely believed that for-profit health plans are more likely than not-for-profit health plans to respond to financial incentives by restricting access to care, especially access to high-cost...

PERSPECTIVE: Patency and the Pump â The Risks and Benefits of Off-Pump CABG

Thomas E. MacGillivray, M.D., and Gus J. Vlahakes, M.D. — Thu, 01Â JanÂ 2004 00:00:00 -05:00

In 1883, the eminent Viennese surgeon Theodor Billroth declared, âLet no man who hopes to retain the respect of his medical brethren dare to operate on the human heart.â Billroth...

ORIGINAL ARTICLE: A Randomized Comparison of Off-Pump and On-Pump Multivessel Coronary-Artery Bypass Surgery

Thu, 01Â JanÂ 2004 00:00:00 -05:00

Background: The effect of the use of coronary-artery bypass surgery without cardiopulmonary bypass and cardiac arrest (âoff pumpâ) on graft patency remains uncertain. We undertook a prospective, randomized, controlled study...

IMAGES IN CLINICAL MEDICINE: Emphysematous Pancreatitis

Hernan A. Bazan, M.D. and Unsup Kim, M.D. — Thu, 25Â DecÂ 2003 00:00:00 -05:00

A 78-year-old man had fever, intermittent nausea and vomiting, and increasing abdominal pain for one week. He said he did not use alcohol. On examination, he had a distended abdomen...

IMAGES IN CLINICAL MEDICINE: Anterior Cervical Osteophytes Causing Airway Compromise

Paul Aronowitz, M.D. and Fabiola Cobarrubias, M.D. — Thu, 25Â DecÂ 2003 00:00:00 -05:00

An 81-year-old man had had mild dysphagia for several years. During the six months before admission, the dysphagia worsened, and he had occasional hemoptysis. For several days before admission he...

ORIGINAL ARTICLE: The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma

Thu, 25Â DecÂ 2003 00:00:00 -05:00

Background: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients...

IMAGES IN CLINICAL MEDICINE: Bleeding Colonic Diverticulum

Sripathi R. Kethu, M.D. and Harlan G. Rich, M.D. — Thu, 18Â DecÂ 2003 00:00:00 -05:00

A 73-year-old man presented with acute lower gastrointestinal bleeding. He was hemodynamically stable, and nasogastric-tube lavage revealed bile with no blood, suggesting a lower gastrointestinal source for the bleeding. Urgent...

PERSPECTIVE: Dispatch from India

Atul Gawande, M.D., M.P.H. — Thu, 18Â DecÂ 2003 00:00:00 -05:00

The puzzle was how the surgeons in India do it. Take a town like Nanded, 400 miles east of Mumbai (as Bombay is now called), in the center of India....

IMAGES IN CLINICAL MEDICINE: Congenital Pulmonary Lymphangiectasia

Cornelia Hagmann, M.D. and Thomas M. Berger, M.D. — Thu, 27Â NovÂ 2003 00:00:00 -05:00

A female infant was born at 40 weeks and 3 days of gestation, weighing 2970 g. The Apgar scores were 8, 10, and 10 at 1, 5, and 10 minutes,...

EDITORIAL: The VolumeâOutcome Conundrum

Kenneth W. Kizer, M.D., M.P.H. — Thu, 27Â NovÂ 2003 00:00:00 -05:00

There is considerable evidence that patients undergoing various types of complex treatments or high-risk surgical procedures have lower mortality rates and otherwise better outcomes if care is provided in hospitals...

SPECIAL ARTICLE: Surgeon Volume and Operative Mortality in the United States

Thu, 27Â NovÂ 2003 00:00:00 -05:00

Background: Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.

Methods: Using information...

ORIGINAL ARTICLE: Concurrent Chemotherapy and Radiotherapy for Organ Preservation in Advanced Laryngeal Cancer

Thu, 27Â NovÂ 2003 00:00:00 -05:00

Background: Induction chemotherapy with cisplatin plus fluorouracil followed by radiotherapy is the standard alternative to total laryngectomy for patients with locally advanced laryngeal cancer. The value of adding chemotherapy to...

PERSPECTIVE: Therapeutic Options for Laryngeal Cancer

Everett E. Vokes, M.D., and Kerstin M. Stenson, M.D. — Thu, 27Â NovÂ 2003 00:00:00 -05:00

Every year in the United States, approximately 9500 new cases of laryngeal cancer are diagnosed, and 3800 patients die of this tumor. Persistent hoarseness is a warning sign that can...

IMAGES IN CLINICAL MEDICINE: Pituitary Apoplexy

Leonard C. Glass, M.D. — Thu, 20Â NovÂ 2003 00:00:00 -05:00

Acute hypotension developed in a 63-year-old man during coronary-artery bypass graft surgery. On awakening from surgery, he reported a severe headache and lightheadedness. Four hours later, he was noted to...

IMAGES IN CLINICAL MEDICINE: Giant Hepatic Hemangioma

Toshimi Kaido, M.D. and Masayuki Imamura, M.D. — Thu, 13Â NovÂ 2003 00:00:00 -05:00

A 46-year-old woman had a one-year history of abdominal distention. Physical examination showed an upper-abdominal mass extending from the right hypochondrium to 10 cm below the umbilicus. Laboratory studies disclosed...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 35-2003 â A 75-Year-Old Man with a Cystic Lesion of the Pancreas

Thu, 13Â NovÂ 2003 00:00:00 -05:00

A 75-year-old man was evaluated in the clinic because of a cystic lesion of the pancreas.

For several years he had had gastroesophageal reflux, which was alleviated by pantoprazole. He continued...

ORIGINAL ARTICLE: A Randomized Trial of Fetal Endoscopic Tracheal Occlusion for Severe Fetal Congenital Diaphragmatic Hernia

Thu, 13Â NovÂ 2003 00:00:00 -05:00

Background: Experimental and clinical data suggest that fetal endoscopic tracheal occlusion to induce lung growth may improve the outcome of severe congenital diaphragmatic hernia. We performed a randomized, controlled trial...

PERSPECTIVE: Fetal Surgery for Congenital Diaphragmatic Hernia

Katharine D. Wenstrom, M.D. — Thu, 13Â NovÂ 2003 00:00:00 -05:00

Diaphragmatic hernia occurs when any of the four separate structures making up the diaphragm (the septum transversum, pleuroperitoneal membranes, dorsal mesentery of the esophagus, and body wall) fail to grow...

REVIEW ARTICLE: Implantable CardioverterâDefibrillators

John P. DiMarco, M.D., Ph.D. — Thu, 06Â NovÂ 2003 00:00:00 -05:00

Despite advances in emergency medical systems and in techniques of resuscitation, sudden death from cardiac arrest remains a major public health problem. Most persons who have an out-of-hospital cardiac arrest...

ORIGINAL ARTICLE: Comparison of Ximelagatran with Warfarin for the Prevention of Venous Thromboembolism after Total Knee Replacement

Thu, 30Â OctÂ 2003 00:00:00 -05:00

Background: In a previous study of the prevention of venous thromboembolism after total knee replacement, the efficacy of ximelagatran, an oral direct thrombin inhibitor that does not require monitoring of...

IMAGES IN CLINICAL MEDICINE: Splenic Sarcoidosis

A 45-year-old woman with a history of mediastinal sarcoidosis, who had been treated with oral corticosteroids six years previously, presented with pain in the left upper quadrant of her abdomen....

IMAGES IN CLINICAL MEDICINE: Intraabdominal Pregnancy after Hysterectomy

Harold C. Wiesenfeld, M.D. and Richard S. Guido, M.D. — Thu, 16Â OctÂ 2003 00:00:00 -05:00

A 31-year-old woman underwent total abdominal hysterectomy for menorrhagia. Her reported last menstrual period had occurred six days before surgery. Twelve weeks after surgery, computed tomography of the abdomen and...

IMAGES IN CLINICAL MEDICINE: Epidural Lipomatosis Causing Spinal Cord Compression

Moahad Saeed Dar, M.D. and Shadi Daoud, M.D. — Thu, 09Â OctÂ 2003 00:00:00 -05:00

A 68-year-old woman with corticosteroid-dependent chronic obstructive pulmonary disease was admitted to the hospital for worsening respiratory symptoms and for new-onset weakness in both legs. Physical examination revealed poor air...

SPECIAL ARTICLE: Racial, Ethnic, and Geographic Disparities in Rates of Knee Arthroplasty among Medicare Patients

Thu, 02Â OctÂ 2003 00:00:00 -05:00

Background: There are large variations in the use of knee arthroplasty among Medicare enrollees according to race or ethnic group and sex. Are racial and ethnic disparities more pronounced in...

IMAGES IN CLINICAL MEDICINE: Chondroid Clival Chordoma

Andreas M. Stark, M.D. and H. Maximilian Mehdorn, M.D., Ph.D. — Thu, 04Â SepÂ 2003 00:00:00 -05:00

A 54-year-old man presented with a history of several weeks of fatigue and weight loss. He also reported atrophy of the testes and loss of secondary hair that had begun...

IMAGES IN CLINICAL MEDICINE: A Bleeding Meckel's Diverticulum

Christian Zellner, M.D. and Andrew K. Roorda, B.A. — Thu, 28Â AugÂ 2003 00:00:00 -05:00

A 29-year-old man presented to the emergency department after two days of hematochezia. He had a hemoglobin level of 7.2 g per deciliter. Esophagogastroduodenoscopy showed no identifiable source of bleeding....

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 27-2003 â A 36-Year-Old Man with Recurrent Epigastric Pain and Elevated Amylase Levels

Thu, 28Â AugÂ 2003 00:00:00 -05:00

A 36-year-old man was referred to the hospital because of recurrent epigastric pain and persistently elevated amylase levels.

The patient had been well until five months earlier, when he began to...

REVIEW ARTICLE: Laryngology and Phonosurgery

Steven M. Zeitels, M.D., and Gerald B. Healy, M.D. — Thu, 28Â AugÂ 2003 00:00:00 -05:00

It has been more than 20 years since Vaughan1 reviewed the state of the art in human laryngology and voice disorders. During that time, an improved understanding of the physiology...

IMAGES IN CLINICAL MEDICINE: Calcified Splenic Cyst

Ton-Ho Young, M.D. and Hung-Shang Tang, M.D. — Thu, 21Â AugÂ 2003 00:00:00 -05:00

A 45-year-old man presented with a two-month history of discomfort in the left upper quadrant. Twenty years earlier, he had been involved in a motor vehicle accident. Physical examination confirmed...

IMAGES IN CLINICAL MEDICINE: Pulsus Paradoxus

Lambert A. Wu, M.D. and Rick A. Nishimura, M.D. — Thu, 14Â AugÂ 2003 00:00:00 -05:00

A 45-year-old woman with a history of Hodgkin's lymphoma that had been treated with mantle-field irradiation 20 years earlier presented with pleuritic chest pain, progressive dyspnea, and presyncope. Notable findings...

EDITORIAL: The Design of Trials Comparing Sentinel-Node Surgery and Axillary Resection

David Krag, M.D., and Takamaru Ashikaga, Ph.D. — Thu, 07Â AugÂ 2003 00:00:00 -05:00

The technique of the sentinel-node biopsy has reoriented our understanding of the dynamics between a solid tumor and its associated lymphatic collection system.1234 Moreover, the sentinel-node biopsy is an excellent...

ORIGINAL ARTICLE: A Randomized Comparison of Sentinel-Node Biopsy with Routine Axillary Dissection in Breast Cancer

Thu, 07Â AugÂ 2003 00:00:00 -05:00

Background: Although numerous studies have shown that the status of the sentinel node is an accurate predictor of the status of the axillary nodes in breast cancer, the efficacy and...

IMAGES IN CLINICAL MEDICINE: Carotid-Artery Thrombosis Secondary to Basal Skull Fracture

Thomas Santarius, M.R.C.S. and David K. Menon, Ph.D. — Thu, 31Â JulÂ 2003 00:00:00 -05:00

A 17-year-old boy dove to catch a cricket ball and struck his head on a teammate's knee. On initial assessment, the score on the Glasgow Coma Scale was 7 and...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 24-2003 â A 10-Year-Old Girl with Recurrent Bouts of Abdominal Pain

Dawn M. McGee, M.D., Susan A. Connolly, M.D., and Robert H. Young, M.D. — Thu, 31Â JulÂ 2003 00:00:00 -05:00

A 10-year-old girl was admitted to the hospital because of abdominal pain, vomiting, and fever.

She had been in excellent health until about 18 months earlier, when she had the first...

ORIGINAL ARTICLE: Risk of Bacterial Meningitis in Children with Cochlear Implants

Thu, 31Â JulÂ 2003 00:00:00 -05:00

Background: In June 2002, the Food and Drug Administration received reports of bacterial meningitis in patients with cochlear implants for treatment of hearing loss. Implants that included a positioner (a...

PERSPECTIVE: Cochlear Implants

George A. Gates, M.D., and Richard T. Miyamoto, M.D. — Thu, 31Â JulÂ 2003 00:00:00 -05:00

Currently, a cochlear implant is the standard treatment for people whose hearing ability is so poor that well-fit hearing aids fail to permit effective oral communication. The implant is a...

IMAGES IN CLINICAL MEDICINE: Chronic Ulcerative Colitis with Megacolon

Andreas M. Kaiser, M.D. and Robert W. Beart, M.D. — Thu, 24Â JulÂ 2003 00:00:00 -05:00

A 53-year-old woman with a history of ulcerative colitis presented with abdominal pain and bloody diarrhea. The abdominal examination revealed a distended and mildly tender abdomen with hypoactive bowel sounds....

ORIGINAL ARTICLE: Acquired von Willebrand Syndrome in Aortic Stenosis

Thu, 24Â JulÂ 2003 00:00:00 -05:00

Background: Aortic-valve stenosis can be complicated by bleeding that is associated with acquired type 2A von Willebrand syndrome. However, the prevalence and cause of the hemostatic abnormality in aortic stenosis...

PERSPECTIVE: Severe Methylenetetrahydrofolate Reductase Deficiency, Methionine Synthase, and Nitrous Oxide â A Cautionary Tale

Richard W. Erbe, M.D., and Robbert J. Salis, M.D. — Thu, 03Â JulÂ 2003 00:00:00 -05:00

In this issue of the Journal, Selzer et al. (pages 45â50) describe the unexpected neurologic deterioration and death of an infant boy who had been anesthetized twice within a short...

ORIGINAL ARTICLE: Adverse Effect of Nitrous Oxide in a Child with 5,10-Methylenetetrahydrofolate Reductase Deficiency

Thu, 03Â JulÂ 2003 00:00:00 -05:00

Nitrous oxide irreversibly oxidizes the cobalt atom of vitamin B12, thereby inhibiting the activity of the cobalamin-dependent enzyme methionine synthase (or 5-methyltetrahydrofolateâhomocysteine S-methyltransferase; Enzyme Commission code EC 2.1.1.13). Methionine synthase...

EDITORIAL: Expression of Concern: Schiffl H, et al. Daily Hemodialysis and the Outcome of Acute Renal Failure. N Engl J Med 2002;346:305-10.

Thu, 22Â MayÂ 2003 00:00:00 -05:00

In the issue of January 31, 2002, we published a study by Helmut Schiffl, M.D., Susanne M. Lang, M.D., and Rainald Fischer, M.D.1 It has come to our attention, through...

REVIEW ARTICLE: Mechanisms of Actions of Inhaled Anesthetics

Thu, 22Â MayÂ 2003 00:00:00 -05:00

âSuffering so great as I underwent cannot be expressed in words . . . but the blank whirlwind of emotion, the horror of great darkness, and the sense of desertion...

SPECIAL ARTICLE: Cost Effectiveness of Lung-VolumeâReduction Surgery for Patients with Severe Emphysema

National Emphysema Treatment Trial Research Group — Thu, 22Â MayÂ 2003 00:00:00 -05:00

Background: The National Emphysema Treatment Trial, a randomized clinical trial comparing lung-volumeâreduction surgery with medical therapy for severe emphysema, included a prospective economic analysis.

Methods: After pulmonary rehabilitation, 1218 patients at...

IMAGES IN CLINICAL MEDICINE: Centrilobular Emphysema with Predominantly Upper-Lobe Involvement

Andetta R. Hunsaker, M.D. and John J. Reilly, M.D. — Thu, 22Â MayÂ 2003 00:00:00 -05:00

A 57-year-old man with severe, disabling end-stage emphysema presented for enrollment in the National Emphysema Treatment Trial. After the completion of pulmonary rehabilitation, he was randomly assigned to the surgery...

ORIGINAL ARTICLE: A Randomized Trial Comparing Lung-VolumeâReduction Surgery with Medical Therapy for Severe Emphysema

National Emphysema Treatment Trial Research Group — Thu, 22Â MayÂ 2003 00:00:00 -05:00

Background: Lung-volumeâreduction surgery has been proposed as a palliative treatment for severe emphysema. Effects on mortality, the magnitude and durability of benefits, and criteria for the selection of patients have...

PERSPECTIVE: The National Emphysema Treatment Trial â How Strong Is the Evidence?

James H. Ware, Ph.D. — Thu, 22Â MayÂ 2003 00:00:00 -05:00

The National Emphysema Treatment Trial (NETT), reported in this issue of the Journal (pages 2059â2073) raises interesting questions about the interpretation of secondary analyses of data collected in clinical trials....

CLINICAL PRACTICE: Small Abdominal Aortic Aneurysms

Janet T. Powell, M.D., Ph.D., and Roger M. Greenhalgh, M.D. — Thu, 08Â MayÂ 2003 00:00:00 -05:00

A 68-year-old man with a 50-year history of smoking presented with amaurosis fugax and was found to have an incidental infrarenal aortic dilatation, with a maximal diameter of 3.2 cm....

IMAGES IN CLINICAL MEDICINE: Abdominal Aortic Aneurysm as an Incidental Finding

Peter H. Lin, M.D. and Alan B. Lumsden, M.D. — Thu, 08Â MayÂ 2003 00:00:00 -05:00

A 56-year-old man was involved in a minor bicycle accident in which the handlebars of the bicycle struck his abdomen. He came to the emergency room with swelling and pain...

IMAGES IN CLINICAL MEDICINE: Cardiac Compression by a Ruptured Aneurysm of the Descending Thoracic Aorta

Jurg Schmidli, M.D. and Thierry Carrel, M.D. — Thu, 01Â MayÂ 2003 00:00:00 -05:00

A 68-year-old man presented with acute thoracic, abdominal, and back pain and progressive shock. In the past, he had undergone repair of an abdominal aortic aneurysm, bilobar wedge resection, and...

CLINICAL PRACTICE: Care after Coronary-Artery Bypass Surgery

Mary E. Charlson, M.D., and O. Wayne Isom, M.D. — Thu, 10Â AprÂ 2003 00:00:00 -05:00

A 71-year-old woman who had a myocardial infarction five years previously and underwent coronary-artery bypass surgery six months ago visits a primary care physician. She had no complications after surgery,...

IMAGES IN CLINICAL MEDICINE: Trichobezoar in a Four-Year-Old Girl

John L. Lanoue, M.D. and Marc S. Arkovitz, M.D. — Thu, 27Â MarÂ 2003 00:00:00 -05:00

A four-year-old girl was brought to her pediatrician by her parents because of intermittent bilious emesis, which had started two weeks earlier. There were no other changes in her bowel...

REVIEW ARTICLE: Preventing Complications of Central Venous Catheterization

David C. McGee, M.D., and Michael K. Gould, M.D. — Thu, 20Â MarÂ 2003 00:00:00 -05:00

In the United States, physicians insert more than 5 million central venous catheters every year.1 Central venous catheters allow measurement of hemodynamic variables that cannot be measured accurately by noninvasive...

IMAGES IN CLINICAL MEDICINE: Appearance of Intraocular Silicone Oil on Computed Tomography

Gavin J. Stringfellow, M.B., B.S. and Ian C. Francis, F.A.S.O.P.R.S. — Thu, 20Â MarÂ 2003 00:00:00 -05:00

A 60-year-old man presented with epiphora, or an abnormal overflow of tears, caused by bilateral primary acquired nasolacrimal-duct obstruction. Computed tomography (CT) of the orbits and sinuses performed as part...

IMAGES IN CLINICAL MEDICINE: Impending Rupture of the Myocardial Wall

Klaus Reynen, M.D. and Ruth H. Strasser, M.D. — Thu, 06Â MarÂ 2003 00:00:00 -05:00

A 45-year-old man with a history of hypertension was admitted to the hospital because of nausea, dizziness, and chest pain. Three weeks previously, the patient had had angina pectoris for...

SPECIAL ARTICLE: A Survey of Liver Transplantation from Living Adult Donors in the United States

Thu, 27Â FebÂ 2003 00:00:00 -05:00

Background: The transplantation of the right lobe of a liver from a living adult donor into an adult recipient has been performed increasingly frequently in the United States. Although the...

IMAGES IN CLINICAL MEDICINE: Cardiac Rupture

Andrew Redfern, F.R.C.S., F.R.C.R. and James Smart, F.R.C.R. — Thu, 13Â FebÂ 2003 00:00:00 -05:00

A 79-year-old man was admitted with atypical chest pain and electrocardiographic changes characteristic of an anterior myocardial infarction. The chest radiograph showed a widened mediastinum, raising the possibility of a...

IMAGES IN CLINICAL MEDICINE: Aneurysm of the Left Anterior Descending Coronary Artery

Dale T. Ashby, M.B., B.S., Ph.D. and Michael B. Collins, M.D. — Thu, 06Â FebÂ 2003 00:00:00 -05:00

A 74-year-old woman with a history of hypertension, hypercholesterolemia, and nonâQ-wave myocardial infarction presented with exertional angina that had worsened over the course of the preceding month. Coronary angiography revealed...

IMAGES IN CLINICAL MEDICINE: Thoracic Echinococcosis

Diana M. Brainard, M.D. and Edward T. Ryan, M.D., D.T.M.&H. — Thu, 06Â FebÂ 2003 00:00:00 -05:00

A 32-year-old Kenyan woman presented in Boston with a three-month history of cough that was initially productive of thick, gray sputum that had gradually become blood-tinged. She had low-grade fevers....

ORIGINAL ARTICLE: A Comparison of On-Pump and Off-Pump Coronary Bypass Surgery in Low-Risk Patients

Thu, 30Â JanÂ 2003 00:00:00 -05:00

Background: The performance of coronary bypass surgery without cardiopulmonary bypass (âoff pumpâ) may reduce perioperative morbidity and costs, but it is uncertain whether the outcome is similar to that involving...

PERSPECTIVE: Off-Pump Coronary-Artery Bypass Surgery

Eric A. Rose, M.D. — Thu, 30Â JanÂ 2003 00:00:00 -05:00

Inspired in 1931 by a bedside vigil for a dying patient with massive pulmonary embolism, John Gibbon had by the early 1950s developed the heartâlung machine, or pump oxygenator. Although...

SPECIAL ARTICLE: Risk Factors for Retained Instruments and Sponges after Surgery

Thu, 16Â JanÂ 2003 00:00:00 -05:00

Background: Risk factors for medical errors remain poorly understood. We performed a caseâcontrol study of retained foreign bodies in surgical patients in order to identify risk factors for this type...

IMAGES IN CLINICAL MEDICINE: Retained Surgical Instrument

Anne Dembitzer, M.D. and Edwin J. Lai, M.D. — Thu, 16Â JanÂ 2003 00:00:00 -05:00

A 59-year-old man with a history of diverticulosis came to the clinic with abdominal pain in the right upper quadrant of two weeks' duration. His surgical history included a subtotal...

IMAGES IN CLINICAL MEDICINE: Page Kidney

Guilherme H.M. Oliveira, M.D. and Alexander Schirger, M.D. — Thu, 09Â JanÂ 2003 00:00:00 -05:00

A 23-year-old man presented with a two-month history of hypertension. At 18 years of age, he had sustained an injury to the left flank while playing college football. His blood...

EDITORIAL: Progress in Research on Pulmonary-Artery Catheters

Polly E. Parsons, M.D. — Thu, 02Â JanÂ 2003 00:00:00 -05:00

Pulmonary-artery catheters are widely used in critically ill patients both for diagnosis and to guide therapy. According to current estimates, there are more than 1.2 million pulmonary-artery catheters placed annually...

ORIGINAL ARTICLE: A Randomized, Controlled Trial of the Use of Pulmonary-Artery Catheters in High-Risk Surgical Patients

Thu, 02Â JanÂ 2003 00:00:00 -05:00

Background: Some observational studies suggest that the use of pulmonary-artery catheters to guide therapy is associated with increased mortality.

Methods: We performed a randomized trial comparing goal-directed therapy guided by a...

IMAGES IN CLINICAL MEDICINE: Mycotic Aneurysms

Joshua Lynfield, M.D. and Peter Kim Nelson, M.D. — Thu, 19Â DecÂ 2002 00:00:00 -05:00

Figure 1. Headache and aphasia suddenly developed in a 49-year-old man. He had a history of aortic valvotomy for severe congenital aortic stenosis 30 years previously, and severe aortic stenosis...

ORIGINAL ARTICLE: An Analysis of Outcomes of Reconstruction or Amputation after Leg-Threatening Injuries

Thu, 12Â DecÂ 2002 00:00:00 -05:00

Background: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated.

Methods:...

PERSPECTIVE: To Reconstruct or Not to Reconstruct?

Thu, 12Â DecÂ 2002 00:00:00 -05:00

In the opening scene of the movie âDances with Wolves,â dazed Union Army soldiers with mangled limbs are laid out, resigned to their turn at the surgeon's cleaver. This scene...

IMAGES IN CLINICAL MEDICINE: Tuberculosis with Atlantoaxial and Craniovertebral Pott's Disease

Ulrich Weber, M.D. and Hans ScherÃ¼bl, M.D. — Thu, 05Â DecÂ 2002 00:00:00 -05:00

Figure 1. A 17-year-old Ethiopian girl presented with a four-month history of fever, malaise, and weight loss, as well as head, neck, and back pain and a two-week history of...

EDITORIAL: Surgical Treatment of Esophageal Cancer â The Advent of the Era of Individualization

Thu, 21Â NovÂ 2002 00:00:00 -05:00

Although esophageal carcinoma is a relatively uncommon cancer in Western countries, there has been a rising incidence of adenocarcinoma of the esophagus and increasing mortality due to that disease in...

ORIGINAL ARTICLE: Extended Transthoracic Resection Compared with Limited Transhiatal Resection for Adenocarcinoma of the Esophagus

Thu, 21Â NovÂ 2002 00:00:00 -05:00

Background: Controversy exists about the best surgical treatment for esophageal carcinoma.

Methods: We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the...

IMAGES IN CLINICAL MEDICINE: Coronary-Artery Calcification

Saib S. Khogali, M.B., Ch.B. and Jonathan N. Townend, M.D. — Thu, 14Â NovÂ 2002 00:00:00 -05:00

Figure 1. A 78-year-old man with long-standing end-stage renal failure and a previous mitral-valve replacement presented with a one-month history of episodes of effort-related syncope. Results of physical examination and...

IMAGES IN CLINICAL MEDICINE: Floating Left Atrial Thrombus

John R. Doty, M.D and Donald B. Doty, M.D. — Thu, 07Â NovÂ 2002 00:00:00 -05:00

Figure 1. A 71-year-old woman with a one-year history of dyspnea on exertion presented to the emergency department with worsening shortness of breath. Physical examination demonstrated rapid atrial fibrillation and...

IMAGES IN CLINICAL MEDICINE: End-Stage Autosomal Dominant Polycystic Kidney Disease

James A. Brown, M.D. — Thu, 07Â NovÂ 2002 00:00:00 -05:00

Figure 1. A 45-year-old man with autosomal dominant polycystic kidney disease presented to the urology clinic for consideration of bilateral nephrectomy as treatment for severe abdominal pain and distention. Magnetic...

IMAGES IN CLINICAL MEDICINE: Atypical Pyoderma Gangrenosum in a Splenectomy Incision

Pareshkumar Patel, M.D. and Arthur Topilow, M.D. — Thu, 31Â OctÂ 2002 00:00:00 -05:00

Figure 1. A 72-year-old woman underwent splenectomy for transfusion-dependent myelofibrosis, and rapidly advancing, nonhealing necrotic skin ulcers developed over the incision site on the eighth postoperative day (Panel A). The...

ORIGINAL ARTICLE: Skin Ulcers Misdiagnosed as Pyoderma Gangrenosum

Thu, 31Â OctÂ 2002 00:00:00 -05:00

Background: Pyoderma gangrenosum is a diagnosis of exclusion, and the misdiagnosis of pyoderma gangrenosum can result in substantial complications in patients who have other causes of severe cutaneous ulceration.

Methods: We...

EDITORIAL: Hysterectomy â Still a Useful Operation

Thu, 24Â OctÂ 2002 00:00:00 -05:00

Hysterectomy is second only to cesarean section as the most frequently performed major operation in the United States. An estimated 633,000 hysterectomies are performed annually.1 Rates of hysterectomy vary significantly...

EDITORIAL: Aspirin with Bypass Surgery â From Taboo to New Standard of Care

Thu, 24Â OctÂ 2002 00:00:00 -05:00

Until a few years ago, we did not understand the pivotal role of platelets in orchestrating the process of inflammation. The discovery in 1998 that CD40 ligand is shed from...

IMAGES IN CLINICAL MEDICINE: Ventricular Septal Rupture after Myocardial Infarction

Duane S. Pinto, M.D. and Thomas M. Tu, M.D. — Thu, 24Â OctÂ 2002 00:00:00 -05:00

Figure 1. Chest pain and diaphoresis developed in an 81-year-old woman with chronic renal insufficiency and hypertension. Although the chest pain resolved, she saw her primary care physician three days...

ORIGINAL ARTICLE: Outcomes after Total versus Subtotal Abdominal Hysterectomy

Thu, 24Â OctÂ 2002 00:00:00 -05:00

Background: It is uncertain whether subtotal abdominal hysterectomy results in better bladder, bowel, or sexual function than total abdominal hysterectomy.

Methods: We conducted a randomized, double-blind trial comparing total and subtotal...

ORIGINAL ARTICLE: Aspirin and Mortality from Coronary Bypass Surgery

Thu, 24Â OctÂ 2002 00:00:00 -05:00

Background: There is no therapy known to reduce the risk of complications or death after coronary bypass surgery. Because platelet activation constitutes a pivotal mechanism for injury in patients with...

EDITORIAL: Rational Local Therapy for Breast Cancer

Thu, 17Â OctÂ 2002 00:00:00 -05:00

In a 1976 lecture to the Society of Surgical Oncology, the late Jerome Urban lamented the loss of a rational approach to the treatment of breast cancer, which he thought...

ORIGINAL ARTICLE: Twenty-Year Follow-up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer

Thu, 17Â OctÂ 2002 00:00:00 -05:00

Background: In 1976, we initiated a randomized trial to determine whether lumpectomy with or without radiation therapy was as effective as total mastectomy for the treatment of invasive breast cancer.

Methods:...

ORIGINAL ARTICLE: Twenty-Year Follow-up of a Randomized Study Comparing Breast-Conserving Surgery with Radical Mastectomy for Early Breast Cancer

Thu, 17Â OctÂ 2002 00:00:00 -05:00

Background: We conducted 20 years of follow-up of women enrolled in a randomized trial to compare the efficacy of radical (Halsted) mastectomy with that of breast-conserving surgery.

Methods: From 1973 to...

IMAGES IN CLINICAL MEDICINE: Ulnar-Nerve Schwannoma

James Chang, M.D. and Matthew B. Klein, M.D. — Thu, 19Â SepÂ 2002 00:00:00 -05:00

Figure 1. A 29-year-old right-handed woman with a five-year history of a slowly enlarging mass on the left palm had a 2-by-2-cm mass over Guyon's canal in the left wrist...

EDITORIAL: Surgery and the Reduction of Mortality from Prostate Cancer

Thu, 12Â SepÂ 2002 00:00:00 -05:00

More than ever, it is important to establish definitively whether aggressive management of localized prostate cancer reduces the rate of death due to prostate cancer, because this tumor is now...

ORIGINAL ARTICLE: Quality of Life after Radical Prostatectomy or Watchful Waiting

Thu, 12Â SepÂ 2002 00:00:00 -05:00

Background: We evaluated symptoms and self-assessments of quality of life in men with localized prostate cancer who participated in a randomized comparison between radical prostatectomy and watchful waiting.

Methods: Between 1989...

ORIGINAL ARTICLE: A Randomized Trial Comparing Radical Prostatectomy with Watchful Waiting in Early Prostate Cancer

Thu, 12Â SepÂ 2002 00:00:00 -05:00

Background: Radical prostatectomy is widely used in the treatment of early prostate cancer. The possible survival benefit of this treatment, however, is unclear. We conducted a randomized trial to address...

ORIGINAL ARTICLE: Use of the Low-Molecular-Weight Heparin Reviparin to Prevent Deep-Vein Thrombosis after Leg Injury Requiring Immobilization

Michael R. Lassen, M.D., Lars C. Borris, M.D., and Roumen L. Nakov, M.D., Ph.D. — Thu, 05Â SepÂ 2002 00:00:00 -05:00

Background: Deep-vein thrombosis is a well-recognized complication after trauma to the legs and subsequent immobilization, but there are no generally accepted approaches to preventing this complication.

Methods: 02090524.xml We performed a...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 26-2002 â An 87-Year-Old Woman with Abdominal Pain, Vomiting, Bloody Diarrhea, and an Abdominal Mass

David L. Berger and Maryam Mohammadkhani — Thu, 22Â AugÂ 2002 00:00:00 -05:00

An 87-year-old woman was admitted to the hospital because of abdominal pain, vomiting, bloody diarrhea, and an abdominal mass.

The patient had been in stable health until two days before admission,...

IMAGES IN CLINICAL MEDICINE: Coronary-Stent Fracture

Pertha S. Chowdhury, M.D. and Renato G. Ramos, M.D. — Thu, 22Â AugÂ 2002 00:00:00 -05:00

Figure 1. A 57-year-old man presented with several hours of chest discomfort accompanied by ischemic changes on his electrocardiogram. He had undergone coronary-artery bypass grafting and subsequent percutaneous coronary intervention...

ORIGINAL ARTICLE: Twenty-Five-Year Follow-up of a Randomized Trial Comparing Radical Mastectomy, Total Mastectomy, and Total Mastectomy Followed by Irradiation

Thu, 22Â AugÂ 2002 00:00:00 -05:00

Background: In women with breast cancer, the role of radical mastectomy, as compared with less extensive surgery, has been a matter of debate. We report 25-year findings of a randomized...

ORIGINAL ARTICLE: Comparison of Stenting with Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery

Thu, 22Â AugÂ 2002 00:00:00 -05:00

Background: Minimally invasive bypass surgery and coronary-artery stenting are both accepted treatments for isolated stenosis of the proximal left anterior descending coronary artery. We compared the clinical outcomes after these...

PERSPECTIVE: Angioplasty versus Minimally Invasive Bypass Surgery

Thu, 22Â AugÂ 2002 00:00:00 -05:00

The modern treatment of coronary artery disease began with the development of coronary bypass surgery more than three decades ago, which was followed by the development of coronary angioplasty more...

IMAGES IN CLINICAL MEDICINE: Fistulizing Crohn's Disease

William Sanchez, M.D. and Edward V. Loftus, M.D. — Thu, 08Â AugÂ 2002 00:00:00 -05:00

Figure 1. A 54-year-old man with a long history of Crohn's disease presented with abdominal pain, low-grade fevers, fatigue, and pneumaturia. Several enterocutaneous fistulas as well as worsening of perianal...

IMAGES IN CLINICAL MEDICINE: Work-Related Vascular Injuries of the Hand â Hypothenar Hammer Syndrome

Manuela Birrer, M.D. and Iris Baumgartner, M.D. — Thu, 01Â AugÂ 2002 00:00:00 -05:00

Figure 1. A 47-year-old construction worker reported a two-month history of blanching of the second to fifth fingers and a recent ulcer on the tip of the third finger of...

PERSPECTIVE: Fetal Surgery for Myelomeningocele

Thu, 25Â JulÂ 2002 00:00:00 -05:00

The most common nonlethal malformation in the spectrum of neural-tube defects is myelomeningocele. This defect, caused by failure of the neural tube to close completely at about four weeks of...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 22-2002 â A 37-Year-Old Man with Unexplained Fever after a Long Trip through South America

James T. Noble and Eugene J. Mark — Thu, 18Â JulÂ 2002 00:00:00 -05:00

A 37-year-old man was admitted to the hospital because of three weeks of intermittent fever and abdominal and back pain.

The patient had been well until about seven months earlier, one...

NEJM â Collection Updates for Surgery

IMAGES IN CLINICAL MEDICINE: Bleeding Esophageal Varices

IMAGES IN CLINICAL MEDICINE: Gallstone Ileus

IMAGES IN CLINICAL MEDICINE: Postoperative Tracheal Stenosis

EDITORIAL: Immune Evasion by Chimeric Trachea

EDITORIAL: Preoperative Biliary Stents in Pancreatic Cancer â Proceed with Caution

REVIEW ARTICLE: Nosocomial Bacterial Meningitis

ORIGINAL ARTICLE: Tracheal Allotransplantation after Withdrawal of Immunosuppressive Therapy

ORIGINAL ARTICLE: Preoperative Biliary Drainage for Cancer of the Head of the Pancreas

ORIGINAL ARTICLE: Preventing Surgical-Site Infections in Nasal Carriers of

EDITORIAL: Minimizing Surgical-Site Infections

IMAGES IN CLINICAL MEDICINE: Giant Abdominal Aortic Aneurysm

ORIGINAL ARTICLE: ChlorhexidineâAlcohol versus PovidoneâIodine for Surgical-Site Antisepsis

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 41-2009 â A 16-Year-Old Boy with Hypothermia and Frostbite

VIDEOS IN CLINICAL MEDICINE: Endometrial Biopsy

CLINICAL PRACTICE: Barrett's Esophagus

IMAGES IN CLINICAL MEDICINE: Hernia through the Foramen Omentale

IMAGES IN CLINICAL MEDICINE: Frostbite

IMAGES IN CLINICAL MEDICINE: Ileocecal Intussusception

EDITORIAL: Cangrelor â A Champion Lost in Translation?

EDITORIAL: Hematopoietic Stem-Cell Transplantation for Adults with Sickle Cell Disease

ORIGINAL ARTICLE: Intravenous Platelet Blockade with Cangrelor during PCI

ORIGINAL ARTICLE: Platelet Inhibition with Cangrelor in Patients Undergoing PCI

EDITORIAL: Rise of the Machines â Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure

IMAGES IN CLINICAL MEDICINE: Tuberculous Abscess Manifesting as Unilateral Gynecomastia

CLINICAL THERAPEUTICS: Mitral-Valve Repair for Mitral-Valve Prolapse

ORIGINAL ARTICLE: Advanced Heart Failure Treated with Continuous-Flow Left Ventricular Assist Device

IMAGES IN CLINICAL MEDICINE: Large Atrial Myxoma

IMAGES IN CLINICAL MEDICINE: Air in the Portal and Mesenteric Veins

IMAGES IN CLINICAL MEDICINE: Extensive Bowel Infarction

VIDEOS IN CLINICAL MEDICINE: AnkleâBrachial Index for Assessment of Peripheral Arterial Disease

EDITORIAL: Innovation and Comparative-Effectiveness Research in Cardiac Surgery

ORIGINAL ARTICLE: On-Pump versus Off-Pump Coronary-Artery Bypass Surgery

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 33-2009 â A 35-Year-Old Woman with Fever, Abdominal Pain, and Hypotension after Cesarean Section

IMAGES IN CLINICAL MEDICINE: Bronchial Obstruction after Pneumonectomy

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 31-2009 â A 26-Year-Old Man with Abdominal Distention and Shock

IMAGES IN CLINICAL MEDICINE: Staghorn Calculus

IMAGES IN CLINICAL MEDICINE: Cerebrospinal Fluid Leak

EDITORIAL: Variation in Hospital Mortality Associated with Inpatient Surgery â An S.O.S.

SPECIAL ARTICLE: Variation in Hospital Mortality Associated with Inpatient Surgery

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 30-2009 â A 77-Year-Old Man with Recurrent Transitional-Cell Carcinoma of the Ureter

IMAGES IN CLINICAL MEDICINE: De Garengeot's Hernia

CORRESPONDENCE: Ruptured Abdominal Aortic Aneurysm Related to IgG4 Periaortitis

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Understanding Abdominal Aortic Aneurysm

REVIEW ARTICLE: Intestinal Transplantation

ORIGINAL ARTICLE: Fluvastatin and Perioperative Events in Patients Undergoing Vascular Surgery

ORIGINAL ARTICLE: Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture

IMAGES IN CLINICAL MEDICINE: Unilateral Epistaxis

IMAGES IN CLINICAL MEDICINE: Pneumatosis Cystoides Coli

CORRESPONDENCE: Codeine, Ultrarapid-Metabolism Genotype, and Postoperative Death

IMAGES IN CLINICAL MEDICINE: Rectovesical Fistula

CLINICAL PRACTICE: Infection Associated with Prosthetic Joints

IMAGES IN CLINICAL MEDICINE: Testicular Torsion in a Hydrocele

IMAGES IN CLINICAL MEDICINE: Stent-Associated Urinary Calculi

ORIGINAL ARTICLE: Apixaban or Enoxaparin for Thromboprophylaxis after Knee Replacement

IMAGES IN CLINICAL MEDICINE: Asymmetric Edema of the Upper Lung Due to Mitral Valvular Dysfunction

EDITORIAL: Surgical Treatment of Obesity â Weighing the Facts

ORIGINAL ARTICLE: Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery

ORIGINAL ARTICLE: Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery

IMAGES IN CLINICAL MEDICINE: Telltale Triangle of Pneumoperitoneum

ORIGINAL ARTICLE: Preoperative Staging of Lung Cancer with Combined PETâCT

IMAGES IN CLINICAL MEDICINE: Ingested Magnets

IMAGES IN CLINICAL MEDICINE: Perforated Umbilical Hernia

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 19-2009 â A 63-Year-Old Woman with Carcinoma of the Gastroesophageal Junction

IMAGES IN CLINICAL MEDICINE: Plombage Cavities

IMAGES IN CLINICAL MEDICINE: Fecaliths in Crohn's Disease

IMAGES IN CLINICAL MEDICINE: Abdominal Aortic Aneurysm

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2009 â A 36-Year-Old Man with Chest Pain, Dysphagia, and Pleural and Mediastinal Calcifications

IMAGES IN CLINICAL MEDICINE: Bilateral Subacute Subdural Hematomas

EDITORIAL: Surgical Ventricular Reconstruction for Heart Failure

CLINICAL THERAPEUTICS: Minimally Invasive Total Knee Arthroplasty for Osteoarthritis

ORIGINAL ARTICLE: Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

CLINICAL PROBLEM-SOLVING: A Question Well Put

IMAGES IN CLINICAL MEDICINE: Mediastinal Extension of a Goiter

EDITORIAL: Prevention of Viral Sexually Transmitted Infections â Foreskin at the Forefront

ORIGINAL ARTICLE: Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 9-2009 â An 81-Year-Old Man with Massive Rectal Bleeding

IMAGES IN CLINICAL MEDICINE: Pelvic-Organ Prolapse and Uterine Inversion

IMAGES IN CLINICAL MEDICINE: Venous Obstruction of the Thigh

BOOK REVIEW:

NEJM â Collection Updates for Surgery

EDITORIAL: Preoperative Biliary Stents in Pancreatic Cancer â Proceed with Caution

ORIGINAL ARTICLE: ChlorhexidineâAlcohol versus PovidoneâIodine for Surgical-Site Antisepsis

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 41-2009 â A 16-Year-Old Boy with Hypothermia and Frostbite

EDITORIAL: Cangrelor â A Champion Lost in Translation?

EDITORIAL: Rise of the Machines â Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure

VIDEOS IN CLINICAL MEDICINE: AnkleâBrachial Index for Assessment of Peripheral Arterial Disease

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 33-2009 â A 35-Year-Old Woman with Fever, Abdominal Pain, and Hypotension after Cesarean Section

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 31-2009 â A 26-Year-Old Man with Abdominal Distention and Shock

EDITORIAL: Variation in Hospital Mortality Associated with Inpatient Surgery â An S.O.S.

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 30-2009 â A 77-Year-Old Man with Recurrent Transitional-Cell Carcinoma of the Ureter

EDITORIAL: Surgical Treatment of Obesity â Weighing the Facts

ORIGINAL ARTICLE: Preoperative Staging of Lung Cancer with Combined PETâCT

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 19-2009 â A 63-Year-Old Woman with Carcinoma of the Gastroesophageal Junction

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2009 â A 36-Year-Old Man with Chest Pain, Dysphagia, and Pleural and Mediastinal Calcifications

EDITORIAL: Prevention of Viral Sexually Transmitted Infections â Foreskin at the Forefront

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 9-2009 â An 81-Year-Old Man with Massive Rectal Bleeding

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 7-2009 â A Pregnant Woman with a Large Mass in the Fetal Oral Cavity

PERSPECTIVE: CABG vs. Stenting â Clinical Implications of the SYNTAX Trial

CLINICAL DECISIONS: Management of Prostate Cancer â Polling Results

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2009 â A 25-Year-Old Man with Pain and Swelling of the Right Hand and Hypotension

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 40-2008 â A 26-Year-Old Man with Blurred Vision

PERSPECTIVE: Circumcision â A Surgical Strategy for HIV Prevention in Africa

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 37-2008 â A 17-Year-Old Boy with a Pituitary Tumor and Skull Abnormalities

CLINICAL DECISIONS: Management of Skin and Soft-Tissue Infection â Polling Results

IMAGES IN CLINICAL MEDICINE: The StewartâTreves Syndrome

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 26-2008 â A 26-Year-Old Woman with Headache and Behavioral Changes

PERSPECTIVE: Gastric Cancer in Japan â Honing Treatment, Seeking Causes