February 25, 2016 Vol. 374 No. 8:
PERSPECTIVE
701-703
Leaping without Looking — Duty Hours, Autonomy, and the Risks of Research and Practice
L. Rosenbaum
Critics argue, essentially, that there is no ethical way to study residents' duty-hour rules in a randomized fashion. But in assuming that untested practice is safe, we have compromised trainees' freedom to judge for themselves when their patients need them.
703-706
Pharmaceutical Policy Reform — Balancing Affordability with Incentives for Innovation
R.M. Conti and M.B. Rosenthal
In response to concern about high prices of prescription drugs, presidential candidates and lawmakers have proposed a number of policy changes, including enhancing market forces that put pressure on companies to set lower prescription-drug prices out of self-interest.
706-708
History of Medicine: “An Uncommonly Silly Law” — Contraception and Disparities in the United States
H.M. Prescott
Today, conservative social mores are putting U.S. women's access to safe, affordable contraception at risk. But legal threats to women's reproductive health are not new. In 1965, the Supreme Court overturned a Connecticut law that criminalized the use of birth control.
708-711
Dealing with Racist Patients
K. Paul-Emile, A.K. Smith, B. Lo, and A. Fernández
A patient's refusal of care based on the physician's race or ethnic background can raise thorny ethical, legal, and clinical issues — and can be painful and confusing for physicians. Sound decision making in this context turns on five ethical and practical factors.
ORIGINAL ARTICLES
713-727
National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training
K.Y. Bilimoria and Others
In this randomized trial comparing ACGME duty-hour policies with more flexible policies for surgical residents, the flexible policies resulted in noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality.
728-737
Stopping vs. Continuing Aspirin before Coronary Artery Surgery
P.S. Myles and Others
In a randomized trial involving 2100 patients undergoing coronary artery surgery, the risk of bleeding within 30 days after surgery was not higher with aspirin than with placebo, nor was the risk of death or thrombosis within 30 days after surgery lower with aspirin than with placebo.
738-748
Weekly vs. Every-3-Week Paclitaxel and Carboplatin for Ovarian Cancer
J.K. Chan and Others
The dose-dense delivery of chemotherapy (greater frequency of drug delivery) was explored in women with advanced ovarian cancer. All patients received carboplatin; half received paclitaxel weekly and half every 3 weeks. There were no between-group differences in progression-free survival.
749-760
Outcomes of Two Trials of Oxygen-Saturation Targets in Preterm Infants
The BOOST-II Australia and United Kingdom Collaborative Groups
In two trials involving preterm infants, an oxygen-saturation target of 85 to 89% versus 91 to 95% resulted in nonsignificantly higher rates of death or disability at 2 years but in significantly increased risks of the combined outcome and of death alone in post hoc combined analyses.
REVIEW ARTICLE
761-770
Challenges in the Elimination of Pediatric HIV-1 Infection
K. Luzuriaga and L.M. Mofenson
Preventing mother-to-child transmission of HIV-1 requires a series of steps in the care of women and their infants during pregnancy, delivery, and the postpartum period. This review outlines the steps and summarizes progress in resource-limited countries and elsewhere.
IMAGES IN CLINICAL MEDICINE
771
Ocular Rosacea
R. Asoklis and K. Malysko
A 58-year-old man presented with recurrent facial flushing and redness, foreign-body sensation, and blurred vision in both eyes. Examination revealed telangiectasia with hyperemia of the eyelid margins, conjunctival hyperemia, and neovascularization of the cornea in both eyes.
e9
Eggshell Calcifications of the Bladder
P. Nepal and D. Kumar
A 43-year-old man presented with dysuria and intermittent hematuria. Similar episodes had occurred several times in the preceding 6 months, with episodes of rectal bleeding. CT revealed hydroureteronephrosis of the right ureter and kidney, with mural calcifications.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
772-781
Case 6-2016 — A 10-Year-Old Boy with Abdominal Cramping and Fevers
J.A. Biller and Others
A 10-year-old boy was seen in the gastroenterology clinic because of abdominal cramping and fevers. Abdominal imaging studies revealed circumferential thickening of a segment of the colonic wall and mesenteric lymphadenopathy. A diagnostic procedure was performed.
EDITORIAL
783-784
Surgical Resident Duty-Hour Rules — Weighing the New Evidence
J.D. Birkmeyer
Surgical training has always been hard on residents. During my own residency more than 20 years ago, 100-hour workweeks and in-house call every other night were routine. A resident’s life outside the hospital was simply not a priority. Residency may be ...
CORRESPONDENCE
785-788
Point-of-Care Warfarin Monitoring in the ROCKET AF Trial
After an INR-monitoring device used in the ROCKET AF trial was recalled by the FDA because of possible inaccuracies in INR readings under certain conditions, a post hoc reanalysis of the trial data showed no significant effect of this issue on the trial outcomes.
788-789
Excess Mortality among Persons with Type 2 Diabetes
To the Editor: In their analysis of the contribution of type 2 diabetes to mortality in Sweden, Tancredi et al. (Oct. 29 issue)1 appear to interpret differences in risk ratios for diabetes as differences in the risk of death associated with diabetes. The ...
789-790
Nicotinamide for Skin-Cancer Chemoprevention
To the Editor: Chen et al. (Oct. 22 issue)1 report on the Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC) trial, which showed a protective effect of oral nicotinamide in people who are prone to skin cancer. This treatment has an excellent safety ...
791-792
Calcium and Vitamin D for the Prevention of Colorectal Adenomas
To the Editor: Baron et al. (Oct. 15 issue)1 suggest that supplementation with vitamin D or calcium did confer a lower risk of adenoma among participants with longer surveillance and treatment intervals, although the differences in risk during a period of ...
792-793
Lenalidomide plus Rituximab for Mantle-Cell Lymphoma
To the Editor: Ruan et al. (Nov. 5 issue)1 report that combination therapy consisting of lenalidomide plus rituximab was highly effective in patients with previously untreated mantle-cell lymphoma. However, several large clinical studies have shown ...
793-795
Invasive Candidiasis
To the Editor: In their review on invasive candidiasis, Kullberg and Arendrup (Oct. 8 issue)1 raise the question of what is the most appropriate initial antifungal therapy for patients who have previously been exposed to echinocandins for prolonged ...
795-797
SLC25A32 Mutations and Riboflavin-Responsive Exercise Intolerance
A patient with late-onset exercise intolerance had haploinsufficiency of
SLC25A32, which encodes the human mitochondrial flavin adenine dinucleotide transporter. The patient's symptoms were highly responsive to oral supplementation with riboflavin.
797-798
Marijuana Tourism and Emergency Department Visits in Colorado
At a large hospital in Colorado, the rate of ED visits related to cannabis use doubled for out-of-state patients, with little change for in-state patients, from 2013 through 2014, the first year of retail marijuana sales. Statewide data confirmed these differential trends.
