The New England Journal of Medicine

Srinivas, Sunil K.; Manjunath, Cholenahally

doi: 10.1056/NEJMicm1215039pmid: 24047081

A 45-year-old man presented with swelling on the right side of the chest, which he had had for the previous 3 months. Examination revealed pulsatile swelling in the right infraclavicular area.

Abramson, Steven B.; Jacob, Dianna; Rosenfeld, Melvin; Buckvar-Keltz, Lynn; Harnik, Victoria; Francois, Fritz; Rivera, Rafael; Hopkins, Mary Ann; Triola, Marc; Grossman, Robert I.

doi: 10.1056/NEJMp1304681pmid: 24047055

In recent decades, the length of medical training has increased, slowing the entry of new physicians into practice. Experiments with 3-year medical schools, like the one at New York University, attempt to address this delay.

Goldfarb, Stanley; Morrison, Gail

doi: 10.1056/NEJMp1306457pmid: 24047056

Shortening medical school to 3 years, some observers argue, would increase the supply of physicians and reduce the cost of medical training. Data from many years of experiments in shortening medical education, however, suggest that doing so is unwise.

Baker, Jeffrey P.

doi: 10.1056/NEJMp1306380pmid: 24047057

Though the DSM-5 definition of autism refers to it as a spectrum, in important ways it represents an effort to define the syndrome more sharply. It thus reflects one of the central themes in the history of autism: a debate over where to set its boundaries.

Pizzo, Philip A.

doi: 10.1056/NEJMp1306467pmid: 24047058

A year-long journey with chronic pain offers a physician new insights into pain relief in the United States, clarifying the debilitating, depressing, highly individual, and hard-to-measure nature of chronic pain and the health care system's limitations in addressing it.

doi: 10.1056/NEJMtwj130919pmid: N/A

Nishihara, Reiko; Wu, Kana; Lochhead, Paul; Morikawa, Teppei; Liao, Xiaoyun; Qian, Zhi Rong; Inamura, Kentaro; Kim, Sun A.; Kuchiba, Aya; Yamauchi, Mai; Imamura, Yu; Willett, Walter C.; Rosner, Bernard A.; Fuchs, Charles S.; Giovannucci, Edward; Ogino, Shuji;

Shaukat, Aasma; Mongin, Steven J.; Geisser, Mindy S.; Lederle, Frank A.; Bond, John H.; Mandel, Jack S.; Church, Timothy R.

doi: 10.1056/NEJMoa1300720pmid: 24047060

BackgroundIn randomized trials, fecal occult-blood testing reduces mortality from colorectal cancer. However, the duration of the benefit is unknown, as are the effects specific to age and sex.MethodsIn the Minnesota Colon Cancer Control Study, 46,551 participants, 50 to 80 years of age, were randomly assigned to usual care (control) or to annual or biennial screening with fecal occult-blood testing. Screening was performed from 1976 through 1982 and from 1986 through 1992. We used the National Death Index to obtain updated information on the vital status of participants and to determine causes of death through 2008.ResultsThrough 30 years of follow-up, 33,020 participants (70.9%) died. A total of 732 deaths were attributed to colorectal cancer: 200 of the 11,072 deaths (1.8%) in the annual-screening group, 237 of the 11,004 deaths (2.2%) in the biennial-screening group, and 295 of the 10,944 deaths (2.7%) in the control group. Screening reduced colorectal-cancer mortality (relative risk with annual screening, 0.68; 95% confidence interval [CI], 0.56 to 0.82; relative risk with biennial screening, 0.78; 95% CI, 0.65 to 0.93) through 30 years of follow-up. No reduction was observed in all-cause mortality (relative risk with annual screening, 1.00; 95% CI, 0.99 to 1.01; relative risk with biennial screening, 0.99; 95% CI, 0.98 to 1.01). The reduction in colorectal-cancer mortality was larger for men than for women in the biennial-screening group (P=0.04 for interaction).ConclusionsThe effect of screening with fecal occult-blood testing on colorectal-cancer mortality persists after 30 years but does not influence all-cause mortality. The sustained reduction in colorectal-cancer mortality supports the effect of polypectomy. (Funded by the Veterans Affairs Merit Review Award Program and others.)

Wald, David S.; Morris, Joan K.; Wald, Nicholas J.; Chase, Alexander J.; Edwards, Richard J.; Hughes, Liam O.; Berry, Colin; Oldroyd, Keith G.

doi: 10.1056/NEJMoa1305520pmid: 23991625

BackgroundIn acute ST-segment elevation myocardial infarction (STEMI), the use of percutaneous coronary intervention (PCI) to treat the artery responsible for the infarct (infarct, or culprit, artery) improves prognosis. The value of PCI in noninfarct coronary arteries with major stenoses (preventive PCI) is unknown.MethodsFrom 2008 through 2013, at five centers in the United Kingdom, we enrolled 465 patients with acute STEMI (including 3 patients with left bundle-branch block) who were undergoing infarct-artery PCI and randomly assigned them to either preventive PCI (234 patients) or no preventive PCI (231 patients). Subsequent PCI for angina was recommended only for refractory angina with objective evidence of ischemia. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina. An intention-to-treat analysis was used.ResultsBy January 2013, the results were considered conclusive by the data and safety monitoring committee, which recommended that the trial be stopped early. During a mean follow-up of 23 months, the primary outcome occurred in 21 patients assigned to preventive PCI and in 53 patients assigned to no preventive PCI (infarct-artery-only PCI), which translated into rates of 9 events per 100 patients and 23 per 100, respectively (hazard ratio in the preventive-PCI group, 0.35; 95% confidence interval [CI], 0.21 to 0.58; P<0.001). Hazard ratios for the three components of the primary outcome were 0.34 (95% CI, 0.11 to 1.08) for death from cardiac causes, 0.32 (95% CI, 0.13 to 0.75) for nonfatal myocardial infarction, and 0.35 (95% CI, 0.18 to 0.69) for refractory angina.ConclusionsIn patients with STEMI and multivessel coronary artery disease undergoing infarct-artery PCI, preventive PCI in noninfarct coronary arteries with major stenoses significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery. (Funded by Barts and the London Charity; PRAMI Current Controlled Trials number, ISRCTN73028481.)

Labrie, Julien; Berghmans, Bary L.C.M.; Fischer, Kathelijn; Milani, Alfredo L.; van der Wijk, Ileana; Smalbraak, Dina J.C.; Vollebregt, Astrid; Schellart, René P.; Graziosi, Giuseppe C.M.; van der Ploeg, J. Marinus; Brouns, Joseph F.G.M.; Tiersma, E. Stella M.; Groenendijk, Annette G.; Scholten, Piet;