Archive
Preliminary Report: Epidemiology of the Avian Influenza A (H7N9) Outbreak in China
Preliminary Report: Epidemiology of the Avian Influenza A (H7N9) Outbreak in China
Source: New England Journal of Medicine
The first identified cases of human infection with a novel influenza A (H7N9) virus occurred in eastern China during February and March 2013 and were characterized by rapidly progressive pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), and fatal outcomes.1 We analyzed available data from field investigations to characterize the descriptive epidemiology of laboratory-confirmed cases of avian influenza A (H7N9) virus infection in humans reported to the Chinese Center for Disease Control and Prevention (China CDC) as of April 17, 2013. In this report, we summarize the preliminary findings of case investigations and follow-up monitoring of close contacts of persons with confirmed cases of H7N9 virus infection who have been identified to date. This is an ongoing investigation.
A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness
A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness
Source: New England Journal of Medicine
Background
Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.Methods
We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months.Results
Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was −3.2 kg (−7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events.Conclusions
A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE ClinicalTrials.gov number, NCT00902694.)
Monetary Costs of Dementia in the United States
Monetary Costs of Dementia in the United States
Source: New England Journal of Medicine
We used nationally representative data to document comprehensively the incremental increase in costs attributable to dementia that arise from market transactions for goods and services as well as the costs of unpaid caregiving. We found that dementia leads to total annual societal costs of $41,000 to $56,000 per case, with a total cost of $159 billion to $215 billion nationwide in 2010. Our calculations suggest that the aging of the U.S. population will result in an increase of nearly 80% in total societal costs per adult by 2040.
The main component of the costs attributable to dementia is the cost for institutional and home-based long-term care rather than the costs of medical services — the sum of the costs for nursing home care and formal and informal home care represent 75 to 84% of attributable costs. Our estimate places dementia among the diseases that are the most costly to society. The cost for dementia care purchased in the marketplace ($109 billion) was similar to estimates of the direct health care expenditures for heart disease ($96 billion in 2008, or $102 billion in 2010 dollars) and significantly higher than the direct health care expenditures for cancer ($72 billion in 2008, or $77 billion in 2010 dollars). These costs do not include the costs of informal care, which are likely to be larger for dementia than for heart disease or cancer.
Although the costs attributable to dementia reported here are large, they are considerably smaller than those reported by the Alzheimer’s Association, which has estimated that in 2010 the monetary costs alone were $172 billion (2010 dollars) as compared with our estimate of $109 billion. There are several reasons for this higher estimate. It is likely that the cost per case reported by the Alzheimer’s Association is higher because it was estimated on the basis of a sample from a more severely impaired population (persons identified in the Medicare Current Beneficiary Survey as having dementia). The higher cost is also based on a significantly larger estimate of the prevalence of dementia. The national prevalence of dementia used by the Alzheimer’s Association is derived from a study of three Chicago neighborhoods. The diagnostic criteria for dementia used in that study did not require the presence of a limitation in ADLs or IADLs (a criterion that was used in ADAMS), a factor that probably led to the substantially higher estimate of the prevalence of dementia in the Chicago study. Finally, the cost estimate from the Alzheimer’s Association was not adjusted for the costs of coexisting conditions.
Globalization, Climate Change, and Human Health
Globalization, Climate Change, and Human Health
Source: New England Journal of Medicine
he global scale, interconnectedness, and economic intensity of contemporary human activity are historically unprecedented, as are many of the consequent environmental and social changes. These global changes fundamentally influence patterns of human health, international health care, and public health activities. They constitute a syndrome, not a set of separate changes, that reflects the interrelated pressures, stresses, and tensions arising from an overly large world population, the pervasive and increasingly systemic environmental impact of many economic activities, urbanization, the spread of consumerism, and the widening gap between rich and poor both within and between countries.
In recent decades, international connectivity has increased on many fronts, including the flow of information, movements of people, trading patterns, the flow of capital, regulatory systems, and cultural diffusion. These exponential increases in demographic, economic, commercial, and environmental indexes have been labeled the Great Acceleration. Remarkably, the resultant environmental effects are now altering major components of the Earth system. The current geologic epoch is being called the Anthropocene (successor to the Holocene epoch) in recognition of the global force that Homo sapiens has become, pushing or distorting Earth’s great natural global systems beyond boundaries considered to be safe for continued human social and biologic well-being. The loss of biodiversity, the greatly amplified global circulation of bioactive nitrogen compounds, and human-induced climate change have already reached levels that are apparently unsafe.
These changes pose fundamental threats to human well-being and health. For example, a positive relationship has been observed between regional trends in climate (rising temperatures and declining rainfall) and childhood stunting in Kenya since 1975, indicating that as projected warming and drying continue to occur along with population growth, food yields and nutritional health will be impaired. These human-induced climatic changes often act in concert with environmental, demographic, and social stressors that variously influence regional food yields, nutrition, and health. Furthermore, at the current level of global connectedness and interdependence, the environmental impact of human activity has a wider geographic range, although its influence may be offset somewhat by more effective global alerts and more rapid distribution of food aid. The extreme heat and wildfires in western Russia in the summer of 2010 destroyed one third of that country’s wheat yield, and the subsequent ban on exported grain contributed to a rise in the price of wheat worldwide, exacerbating hunger in Russia (where flour prices increased by 20%) and in low-income urban populations in countries such as Pakistan and Egypt. On the economic front, the recent global financial crisis has underscored the domino-like interdependence of national economies.
Primary Prevention of Cardiovascular Disease with a Mediterranean Diet
Primary Prevention of Cardiovascular Disease with a Mediterranean Diet
Source: New England Journal of Medicine
The risk of stroke was reduced significantly in the two Mediterranean-diet groups. This is consistent with epidemiologic studies that showed an inverse association between the Mediterranean diet or olive-oil consumption and incident stroke.
Our results compare favorably with those of the Women’s Health Initiative Dietary Modification Trial, wherein a low-fat dietary approach resulted in no cardiovascular benefit.35 Salient components of the Mediterranean diet reportedly associated with better survival include moderate consumption of ethanol (mostly from wine), low consumption of meat and meat products, and high consumption of vegetables, fruits, nuts, legumes, fish, and olive oil. 36,37 Perhaps there is a synergy among the nutrient-rich foods included in the Mediterranean diet that fosters favorable changes in intermediate pathways of cardiometabolic risk, such as blood lipids, insulin sensitivity, resistance to oxidation, inflammation, and vasoreactivity.
Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis
Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis
Source: New England Journal of Medicine
Symptomatic, radiographically confirmed osteoarthritis of the knee affects more than 9 million people in the United States.1 Meniscal tears are also highly prevalent, with imaging evidence of a meniscal tear observed in 35% of persons older than 50 years of age; two thirds of these tears are asymptomatic.2 Meniscal damage is especially prevalent among persons with osteoarthritis3,4 and is frequently treated surgically with arthroscopic partial meniscectomy. This procedure, in which the surgeon trims the torn meniscus back to a stable rim, is performed for a range of indications in more than 465,000 persons annually in the United States.5
The high prevalence of meniscal tears in patients with osteoarthritis of the knee and the observation that these lesions are often asymptomatic challenge the ability of clinicians to determine whether symptoms are caused by the tear, osteoarthritis, or both. Clinicians who suspect that the tear is symptomatic may refer the patient to a surgeon for arthroscopic partial meniscectomy. The role of arthroscopic surgery in patients with osteoarthritis has been studied in two randomized, controlled trials over the past decade. One trial6 compared arthroscopic débridement and lavage with a sham surgical procedure, and the other7 compared arthroscopic débridement with a nonoperative regimen. Neither trial showed a statistically significant or clinically important difference between the arthroscopic and nonoperative groups with respect to functional improvement or pain relief over a period of 24 months.6,7
These landmark trials established that arthroscopic treatment was not superior to the other interventions in the treatment of knee osteoarthritis, but they did not focus on management of a symptomatic meniscal tear, which is a frequent indication for knee arthroscopy in patients with osteoarthritis of the knee. The efficacy of arthroscopic partial meniscectomy in symptomatic patients with a meniscal tear and osteoarthritis has been evaluated, to our knowledge, in only one randomized, controlled trial, which was a single-center study involving 90 patients.8,9 This study did not show a significant difference in pain relief or functional status between arthroscopic partial meniscectomy plus a physical-therapy regimen and physical therapy alone. Given the frequency and cost of arthroscopic partial meniscectomy and the paucity of data, we designed the Meniscal Tear in Osteoarthritis Research (METEOR) trial to assess the efficacy of arthroscopic partial meniscectomy as compared with a standardized physical-therapy regimen for symptomatic patients with a meniscal tear and concomitant mild-to-moderate osteoarthritis.
Protecting Patient Privacy and Data Security
Protecting Patient Privacy and Data Security
Source: New England Journal of Medicine
On December 4, 2012, two Australian radio DJs called London’s King Edward VII’s Hospital, identified themselves, in fake British accents, as Queen Elizabeth and Prince Charles, and asked about a celebrity patient who had been admitted for pregnancy complications. A nurse, filling in at the reception desk in the early morning hours, answered the phone and, without attempting to verify the callers’ identities, transferred them to the duty nurse caring for the Duchess of Cambridge. The duty nurse then provided them with confidential patient information.1 The Australian DJs broadcast the phone call, considering it a humorous prank, but as the world knows, it had disastrous consequences.
How confident are U.S. hospitals, nursing homes, and physicians’ offices that their staff would appropriately deny patient information to an unknown caller?
50-Year Trends in Smoking-Related Mortality in the United States
50-Year Trends in Smoking-Related Mortality in the United States
Source: New England Journal of Medicine
The disease risks from cigarette smoking increased over most of the 20th century in the United States as successive generations of first male and then female smokers began smoking at progressively earlier ages. American men began smoking manufactured cigarettes early in the 20th century; by the 1930s, the average age at initiation fell below 18 years.1,2 Relatively few women smoked regularly before World War II; their average age at initiation continued to decrease through the 1960s. Women were not included in the earliest prospective epidemiologic studies in the 1950s,3-5 since mortality from lung cancer among women was not yet increasing in the general population.6 The landmark 1964 U.S. Surgeon General’s Report concluded only that “cigarette smoking is causally related to lung cancer in men.”7 Neither sex had yet experienced the full effects of smoking from adolescence throughout adulthood.
The first large, prospective study of smoking and mortality involving both women and men was Cancer Prevention Study I (CPS I), initiated by the American Cancer Society (ACS) in 1959.8,9 The relative risk of death from lung cancer during the first 6 years of follow-up among current smokers, as compared with persons who had never smoked, was 2.69 (95% confidence interval [CI], 2.14 to 3.37) for women and 11.35 (95% CI, 9.10 to 14.15) for men.10 In 1982, the ACS initiated the second Cancer Prevention Study (CPS II), which included nearly 1.2 million men and women nationwide.11 During the intervening 20 to 25 years, the relative risk of death from lung cancer had increased to 11.94 (95% CI, 9.99 to 14.26) for female smokers and to 22.36 (95% CI, 17.77 to 28.13) for male smokers.10,12
Several factors may have altered the health risks incurred by smokers. Smoking patterns have changed. Women who began smoking in the 1950s or thereafter have smoked more like men than they did in previous generations (i.e., starting at an earlier age and smoking more heavily).1 Daily cigarette consumption peaked during the 1970s among male smokers and during the 1980s among female smokers13; smoking prevalence in the two groups has since decreased in parallel. Contemporary smokers have spent much of their lives smoking filtered cigarettes made of blended tobacco.2,14 Women have more difficulty quitting than men; thus, for both current and former female smokers, the number of years of smoking has increased. Male and female smokers today are less educated and less affluent than smokers were 20 to 40 years ago.15 Since the 1950s, there has been a more rapid proportional decrease in the background risk of death from cardiovascular conditions among persons who have never smoked than among smokers.16,17
We calculated death rates and the relative risks associated with active cigarette smoking and smoking cessation during three time periods — 1959–1965, 1982–1988, and 2000–2010 — using data from the two historical ACS cohorts (CPS I and CPS II) and pooled data from five contemporary cohort studies in the United States.18-23 A central question is whether the hazards for women are now approaching those for men as their lifetime smoking behaviors have become increasingly similar.
See: Smokers Who Quit Before Age 40 Have Lifespan Almost as Long as People Who Never Smoked (Science Daily)
Effect of Inhaled Glucocorticoids in Childhood on Adult Height
Effect of Inhaled Glucocorticoids in Childhood on Adult Height
Source: New England Journal of Medicine
The initial decrease in attained height associated with the use of inhaled glucocorticoids in prepubertal children persisted as a reduction in adult height, although the decrease was not progressive or cumulative.
See: Children Taking Steroids for Asthma Are Slightly Shorter Than Peers, Study Finds (Science Daily)
The Growing Role of Emergency Departments in Hospital Admissions
The Growing Role of Emergency Departments in Hospital Admissions
Source: New England Journal of Medicine
Growing use of U.S. emergency departments (EDs), cited as a key contributor to rising health care costs, has become a leading target of health care reform. ED visit rates increased by more than a third between 1997 and 2007, and EDs are increasingly the safety net for underserved patients, particularly adult Medicaid beneficiaries.1 Although much attention has been paid to increasing ED use, the ED’s changing role in our health care system has been less thoroughly examined. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a primary safety net, and a 24/7 portal for rapid inpatient admission. Approximately a quarter of all acute care outpatient visits in the United States occur in EDs, a proportion that has been growing since 2001.2 We examined the proportion of hospital admissions that come through the ED, hypothesizing that use of the ED as the admission portal had increased across conditions.
We analyzed data from the Nationwide Inpatient Sample (NIS), the largest all-payer database of U.S. inpatient care, from 1993 to 2006 (the most recent year for which the ED admission data are available on HCUPnet, an interactive Web-based tool that uses data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality). The NIS contains data from approximately 8 million hospital stays each year and is weighted to produce national estimates. We used HCUPnet to query the NIS regarding trends in the 20 clinical conditions for which patients were most frequently admitted to the hospital in 2006. Clinical Classifications Software was used to group the conditions into clinically meaningful categories. We excluded two conditions for which patients are rarely admitted through the ED (osteoarthritis and back problems), one psychiatric condition that was not consistently coded in claims data (affective disorder), and four obstetrical diagnoses that are generally evaluated in other care settings, such as labor-and-delivery triage areas (liveborn infant, maternal birth trauma, other complications of birth, other complications of pregnancy).
The number of hospital admissions increased by 15.0%, from 34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased by 50.4%, from 11.5 million to 17.3 million. The proportion of all inpatient stays involving admission from the ED increased from 33.5 to 43.8% (P<0.001). In 12 of the 13 conditions for which patients were most frequently admitted and that met our inclusion criteria, an increased proportion of admitted patients came through the ED (P<0.001), regardless of the trend in overall admissions; the exception was coronary atherosclerosis, for which rapid “rule-out” protocols and ED-based chest-pain observation units have reduced the need for inpatient admission.
The Long-Term Effect of Premier Pay for Performance on Patient Outcomes
Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes.…We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
Source: New England Journal of Medicine
In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results.
Full Coverage for Preventive Medications after Myocardial Infarction
Full Coverage for Preventive Medications after Myocardial Infarction
Source: New England Journal of Medicine
In conclusion, in this randomized trial, the elimination of patient copayments for secondary prevention after myocardial infarction did not significantly reduce rates of the composite primary outcome. We did observe beneficial effects on secondary clinical outcomes, including rates of total major vascular events or revascularization procedures, as well as on rates of first major vascular events and patients’ out-of-pocket spending. The intervention did not change overall health spending. This simple strategy may contribute to ongoing efforts to improve the quality of care for patients after myocardial infarction.
Breast-Cancer Adjuvant Therapy with Zoledronic Acid
Breast-Cancer Adjuvant Therapy with Zoledronic Acid
Source: New England Journal of Medicine
Metastasis is a complex process that is dependent on both the biologic features of the primary tumor and cellular interactions within host tissues. In the bone microenvironment, cancer cells stimulate osteoblasts to release receptor activator of nuclear factor κB ligand (RANKL), which binds to its receptor, RANK, on both precursor and mature osteoclasts. The resulting increase in osteoclastic bone resorption leads to the release of bone-derived growth factors that may provide a fertile environment for survival and growth of adjacent cancer cells.1 Thus, targeting bone-cell function provides a potential additional approach to preventing bone metastases as a component of standard adjuvant therapy.2 In many in vivo models, bisphosphonates prevent or delay metastasis.3 In addition, synergistic interactions between aminobisphosphonates and cytotoxic drugs have been shown in preclinical models.4,5
In patients with early-stage breast cancer, several clinical trials have suggested that the adjuvant use of bisphosphonates reduces rates of recurrence and death.6-8 In addition, despite a lack of regulatory approval in most health care systems, the inclusion of a bisphosphonate as part of adjuvant therapy has become increasingly widespread. In this randomized, controlled, open-label phase 3 study, called the Adjuvant Zoledronic Acid to Reduce Recurrence (AZURE) trial, we evaluated the adjuvant use of zoledronic acid in a broad population of patients with stage II or III early-stage breast cancer.
See: Zoledronic Acid Reduces the Recurrence of Breast Cancer in Post-Menopausal Women, Study Finds (Science Daily)
Electronic Health Records and Quality of Diabetes Care
Electronic Health Records and Quality of Diabetes Care
Source: New England Journal of Medicine
We compared EHRs with paper-based records in a long-term regional collaborative that seeks to improve care and outcomes for patients with chronic conditions. EHR sites were associated with higher levels of achievement of and improvement in regionally vetted standards for diabetes care and outcomes. Our findings focus on composite standards, although the results were similar for virtually all component standards. Because the study was observational, it may be subject to selection bias, although our results were similar after adjustment for the more favorable socioeconomic profiles of patients cared for in organizations with EHRs. The association of type of medical record with quality standards was significant across all insurance types. As in other studies, the association was stronger for care — which is largely under the direction of providers — than for outcomes, which also require supportive home and neighborhood environments, active patient engagement, and other resources that foster adherence to prescribed regimens. The association was generally weakest for the uninsured, a vulnerable group that is underrepresented in other studies of EHRs and quality of care.
Apixaban versus Warfarin in Patients with Atrial Fibrillation
Apixaban versus Warfarin in Patients with Atrial Fibrillation
Source: New England Journal of Medicine
In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality. (Funded by Bristol-Myers Squibb and Pfizer; ARISTOTLE ClinicalTrials.gov number, NCT00412984.)
Malpractice Risk According to Physician Specialty
Malpractice Risk According to Physician Specialty
Source: New England Journal of Medicine
Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. The mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics. It was estimated that by the age of 65 years, 75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties.
Genomics and the Eye
Genomics and the Eye
Source: New England Journal of Medicine
The eye has had a pivotal role in the evolution of human genomics. At least 90% of the genes in the human genome are expressed in one or more of the eye’s many tissues and cell types at some point during a person’s life. Consistent with this impressive genomic footprint is the observation that about a third of entries in the Online Mendelian Inheritance in Man database for which a clinical synopsis is provided include a term that refers to the structure or function of the eye. Moreover, the phenotypic effects of even small genetic variations are made readily apparent by the many layers of amplification in the human visual system. For example, a single-nucleotide change in PAX6 can cause an anatomic abnormality of the macula less than a millimeter in diameter that results in noticeably reduced visual acuity and nystagmus.
The heritable inability to correctly perceive the color green, known as Daltonism (after the English chemist John Dalton, who himself was affected), was the first human trait mapped to the X chromosome. The Coppock cataract was the first human trait mapped to an autosome, and Leber’s hereditary optic neuropathy was the first human disease shown to be caused by a mutation in mitochondrial DNA. More recently, age-related macular degeneration (AMD) and glaucoma — two common causes of human blindness — have been shown to be largely genetic, as has Fuchs’ endothelial dystrophy,8 the most common cause of corneal transplantation in developed countries. Here, we review discoveries in mendelian and complex ophthalmic disorders and their implications for genetic testing and therapeutic intervention.
Reforming the Regulations Governing Research with Human Subjects
Reforming the Regulations Governing Research with Human Subjects
Source: New England Journal of Medicine
In the wake of the scandal surrounding the Tuskegee syphilis study, Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The commission investigated and made recommendations regarding basic ethical principles guiding research with human beings and the special principles relating to research with fetuses, prisoners, and children. In 1981, on the basis of the National Commission’s recommendations, the Department of Health and Human Services (DHHS) revised and expanded its regulations regarding the protection of human subjects, which were entered into the Code of Federal Regulations (title 45, part 46). In 1991, subpart A of those regulations, delineating the general rules for informed consent and for the operation of institutional review boards (IRBs), was extended to 14 other federal departments, thus creating what came to be called the Common Rule. (Similar, but not identical regulations, title 21, parts 50 and 56, govern research with human beings regulated by the Food and Drug Administration [FDA].)
Since 1991, there has been almost no change to the Common Rule. Yet research with humans has substantially increased in volume, with more international and multisite studies, more health-services research, and more research with biospecimens. Decades of experience have revealed a great deal about the functioning — and limitations — of existing regulations, and have prompted critical evaluations by the Institute of Medicine, the Government Accountability Office, and many scholars.
Two themes emerge from these critiques. First, there are complaints that the regulations impose a variety of burdensome bureaucratic procedures that seem to do little to protect research participants, yet consume substantial resources. These impediments are claimed to be particularly vexing for researchers conducting studies that pose few physical or psychological risks. More important, critics have noted that current regulations could be doing a significantly better job in protecting research subjects.
Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan
Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan
Source: New England Journal of Medicine
Among the soldiers who were referred for evaluation, a history of inhalational exposure to a 2003 sulfur-mine fire in Iraq was common but not universal. Of the 49 soldiers who underwent lung biopsy, all biopsy samples were abnormal, with 38 soldiers having changes that were diagnostic of constrictive bronchiolitis. In the remaining 11 soldiers, diagnoses other than constrictive bronchiolitis that could explain the presenting dyspnea were established. All soldiers with constrictive bronchiolitis had normal results on chest radiography, but about one quarter were found to have mosaic air trapping or centrilobular nodules on chest CT. The results of pulmonary-function and cardiopulmonary-exercise testing were generally within normal population limits but were inferior to those of the military control subjects.
