A 49-year-old female passenger was thrown against the doorframe during an automobile accident. After being pulled from the car, she opened her eyes intermittently, moaned, and had flexion withdrawal of her limbs (Glasgow Coma Scale score, 8).
Opioid analgesic overdose is a preventable and potentially lethal condition that results from prescribing practices, inadequate understanding on the patient's part of the risks of medication misuse, errors in drug administration, and pharmaceutical abuse.
June 27, 2012 (10.1056/NEJMoa1204242)
Hydroxyethyl starch (HES) 130/0.4 is widely used for fluid resuscitation in intensive care units (ICUs), but its safety and efficacy have not been established in patients with severe sepsis.
A 57-year-old man presents with an acute onset of left foot pain, numbness, and partial loss of motor function. Four months ago, he underwent endovascular treatment for disabling claudication, which included placement of overlapping polytetrafluoroethylene-coated stents in the left superficial femoral and popliteal arteries. His popliteal and pedal pulses are absent, and the foot is cool and mottled. Angiography reveals complete occlusion of the stent, with thrombosis extending distally into the popliteal and tibial arteries below the knee. How should his case be managed?
According to the World Health Organization (WHO), 0.7% of all deaths worldwide — or more than 500,000 deaths each year — are due to unintentional drowning. Since some cases of fatal drowning are not classified as such according to the codes of the International Classification of Disease, this number underestimates the real figures, even for high-income countries, and does not include drownings that occur as a result of floods, tsunamis, and boating accidents.
Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.
N Engl J Med 2012; 366:1881-1890May 17, 2012
Although several macrolide antibiotics are proarrhythmic and associated with an increased risk of sudden cardiac death, azithromycin is thought to have minimal cardiotoxicity. However, published reports of arrhythmias suggest that azithromycin may increase the risk of cardiovascular death.
May 22, 2012 (10.1056/NEJMoa1202290)
There have been conflicting reports on the efficacy of recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), for the treatment of patients with septic shock.
Anant Subramanian Krishnan, M.D., and Tristan Barrett, M.D. N Engl J Med 2012; 366:e16March 15, 2012
A 47-year-old woman presented to the emergency department with acute shortness of breath and hypoxemia. Her medical history included sex reassignment, for which she was taking estrogen, and a deep-vein thrombosis on the left side, for which she had required treatment with warfarin. She had a family history of fatal pulmonary emboli.
Amantadine hydrochloride is one of the most commonly prescribed medications for patients with prolonged disorders of consciousness after traumatic brain injury. Preliminary studies have suggested that amantadine may promote functional recovery.
A 61-year-old man with spinal cord compression caused by a vertebral hemangioma underwent therapeutic laminectomy of the fifth vertebra and laminectomy and vertebroplasty of the fourth vertebra. During the vertebroplasty, polymethylmethacrylate cement leaked into the paravertebral vascular system. In the recovery room, the patient was mildly hypoxemic but otherwise asymptomatic.
N Engl J Med 2012; 366:250-257January 19, 2012
Patients referred for coronary revascularization procedures are older and are likely to have more extensive extracardiac vascular disease than those referred for such procedures in the past. Despite these trends, mortality rates for coronary-artery bypass grafting (CABG), without concurrent procedures, have continued to decline.1 Nevertheless, adverse neurologic outcomes, including stroke and cognitive decline, remain a major concern for these older patients.
Anna S. Lok, M.D., David F. Gardiner, M.D., Eric Lawitz, M.D., Claudia Martorell, M.D., Gregory T. Everson, M.D., Reem Ghalib, M.D., Robert Reindollar, M.D., Vinod Rustgi, M.D., Fiona McPhee, Ph.D., Megan Wind-Rotolo, Ph.D., Anna Persson, Ph.D., Kurt Zhu, Ph.D., Dessislava I. Dimitrova, M.D., Timothy Eley, Ph.D., Tong Guo, Ph.D., Dennis M. Grasela, Pharm.D., Ph.D., and Claudio Pasquinelli, M.D., Ph.D.
N Engl J Med 2012; 366:216-224January 19, 2012
Patients with chronic hepatitis C virus (HCV) infection who have not had a response to therapy with peginterferon and ribavirin may benefit from the addition of multiple direct-acting antiviral agents to their treatment regimen.
One quarter of strokes are of unknown cause, and subclinical atrial fibrillation may be a common etiologic factor. Pacemakers can detect subclinical episodes of rapid atrial rate, which correlate with electrocardiographically documented atrial fibrillation. We evaluated whether subclinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation.
Approximately 2 million people participate in long-distance running races in the United States annually. Reports of race-related cardiac arrests have generated concern about the safety of this activity.
Pierluigi Tricoci, M.D., Ph.D., Zhen Huang, M.S., Claes Held, M.D., Ph.D., David J. Moliterno, M.D., Paul W. Armstrong, M.D., Frans Van de Werf, M.D., Harvey D. White, D.Sc., Philip E. Aylward, M.D., Lars Wallentin, M.D., Ph.D., Edmond Chen, M.D., Yuliya Lokhnygina, Ph.D., Jinglan Pei, M.S., Sergio Leonardi, M.D., Tyrus L. Rorick, R.N., Ann M. Kilian, B.S., Lisa H.K. Jennings, Ph.D., Giuseppe Ambrosio, M.D., Ph.D., Christoph Bode, M.D., Angel Cequier, M.D., Jan H. Cornel, M.D., Rafael Diaz, M.D., Aycan Erkan, M.D., Ph.D., Kurt Huber, M.D., Michael P. Hudson, M.D., Lixin Jiang, M.D., J. Wouter Jukema, M.D., Ph.D., Basil S. Lewis, M.D., A. Michael Lincoff, M.D., Gilles Montalescot, M.D., José Carlos Nicolau, M.D., Ph.D., Hisao Ogawa, M.D., Matthias Pfisterer, M.D., Juan Carlos Prieto, M.D., Witold Ruzyllo, M.D., Peter R. Sinnaeve, M.D., Ph.D., Robert F. Storey, M.D., D.M., Marco Valgimigli, M.D., Ph.D., David J. Whellan, M.D., Petr Widimsky, M.D., Dr.Sc., John Strony, M.D., Robert A. Harrington, M.D., and Kenneth W. Mahaffey, M.D. for the TRACER Investigators
N Engl J Med 2012; 366:20-33 January 5, 2012
Vorapaxar is a new oral protease-activated–receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation.
Jessica L. Mega, M.D., M.P.H., Eugene Braunwald, M.D., Stephen D. Wiviott, M.D., Jean-Pierre Bassand, M.D., Deepak L. Bhatt, M.D., M.P.H., Christoph Bode, M.D., Paul Burton, M.D., Ph.D., Marc Cohen, M.D., Nancy Cook-Bruns, M.D., Keith A.A. Fox, M.B., Ch.B., Shinya Goto, M.D., Sabina A. Murphy, M.P.H., Alexei N. Plotnikov, M.D., David Schneider, M.D., Xiang Sun, Ph.D., Freek W.A. Verheugt, M.D., and C. Michael Gibson, M.D. for the ATLAS ACS 2–TIMI 51 Investigators. N Engl J Med 2012; 366:9-19 January 5, 2012
Acute coronary syndromes arise from coronary atherosclerosis with superimposed thrombosis. Since factor Xa plays a central role in thrombosis, the inhibition of factor Xa with low-dose rivaroxaban might improve cardiovascular outcomes in patients with a recent acute coronary syndrome.