NEJM 200TH ANNIVERSARY
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Dialogues in Medicine: Physicians and Patients on 200 Years of Progress
Anthony Fauci, Paul Farmer, Eugene Braunwald and other prominent experts gathered in Boston on June 22 for a day-long symposium with four panel discussions on HIV/AIDS, maternal and fetal health, breast cancer, and cardiology. View the videos on the 200th anniversary site.
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This Week at NEJM.org | September 20, 2012
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Perspective
J.L. Dienstag and A.B. Cosimi | September 19, 2012 | DOI: 10.1056/NEJMp1210159
J.A. Greene, D.S. Jones, and S.H. Podolsky | N Engl J Med 2012;367:1077-1082
K. Outterson | N Engl J Med 2012;367:1082-1085 | Published Online September 12, 2012
J. Kennedy and E. Blodgett | N Engl J Med 2012;367:e16 | Published Online September 5, 2012
Original Articles
R.J. Fox and Others | N Engl J Med 2012;367:1087-1097
R. Gold and Others | N Engl J Med 2012;367:1098-1107
The NICE-SUGAR Study Investigators | N Engl J Med 2012;367:1108-1118
Special Article
A.S. Kesselheim and Others | N Engl J Med 2012;367:1119-1127
Clinical Practice
G.P. DeMuri and E.R. Wald | N Engl J Med 2012;367:1128-1134
Images in Clinical Medicine
K. Watanabe and W. Kida | N Engl J Med 2012;367:1135-1135
A. Arnold and W. Arnold | N Engl J Med 2012;367:e17
Case Records of the Massachusetts General Hospital
L.J. Wirth and Others | N Engl J Med 2012;367:1136-1147
Editorials
A.H. Ropper | N Engl J Med 2012;367:1149-1150
I.B. Hirsch | N Engl J Med 2012;367:1150-1152
J.M. Drazen | N Engl J Med 2012;367:1152-1153
Health Law, Ethics, and Human Rights
W.K. Mariner, L.H. Glantz, and G.J. Annas | N Engl J Med 2012;367:1154-1158 | Published Online July 18, 2012
Clinical Implications of Basic Research
Z. Williams | N Engl J Med 2012;367:1159-1161
Correspondence
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What is the diagnosis?
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Trends: Most Viewed (Last Week)
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September 13, 2012
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Subscribe to NEJM, Now Includes NEJM iPad Edition & Bonus Gifts
NEJM is celebrating its 200th anniversary! Subscribe today and get subscriber-only access to NEJM.org and the NEJM iPad Edition. Your subscription includes 20 FREE online CME exams (earn up to 20 CME Credits) and 50 FREE article views from the NEJM Archive 1812–1989, PLUS your anniversary gift of 200 additional free CME exams and 200 bonus archive views. Subscribe Today!
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CHIEF — MASSACHUSETTS
Baystate Health, western Massachusetts, seeks a strategic-thinking Chief, Pediatric Pulmonology, who will lead a team to build on a tradition of excellence in academics and clinical care. ChooseBaystateHealth.org or contact Melissa Hale at: 413-794-2624 or: Melissa.Hale@BaystateHealth.org
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TEACHING TOPICS from the New England Journal of Medicine
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Teaching Topics | September 20, 2012
Sinusitis in Children: How does sinusitis present in children?
Cranial-Nerve Palsies and Oral Cancer: What is cavernous sinus syndrome?
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NEJM 200th Anniversary
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Dialogues in Medicine: Physicians and Patients on 200 Years of ProgressAnthony Fauci, Paul Farmer, Eugene Braunwald and other prominent experts gathered in Boston on June 22 for a day-long symposium with four panel discussions on HIV/AIDS, maternal and fetal health, breast cancer, and cardiology. View the videos on the 200th anniversary site.
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Teaching Topic
Sinusitis in Children
Clinical Practice
G.P. DeMuri and E.R. Wald
Viral upper respiratory tract infections are common in children of all ages. Acute bacterial sinusitis is purported to complicate about 6 to 8% of cases, although the exact incidence is not known. Children who attend day care are twice as likely to have sinusitis after an upper respiratory tract infection as those who do not attend day care. In the United States, sinusitis affects about 1% of children each year and accounts for more than $1.8 billion in direct health care expenditures and 20 million antibiotic prescriptions per year.
Clinical Pearls
 What are the most common predisposing factors for acute bacterial sinusitis?
The two most common predisposing factors for acute bacterial sinusitis are viral upper respiratory tract infection and allergy. Approximately 80% of episodes of acute bacterial sinusitis are preceded by a viral upper respiratory tract infection.
How does sinusitis present in children?
The presentation of acute bacterial sinusitis conforms to one of three patterns. Most frequently, children present with symptoms of upper respiratory tract infection — nasal congestion (or rhinorrhea), cough, or both — that have persisted for more than 10, but less than 30 days, without subsiding. The rhinorrhea may be of any quality (thick or thin, watery, mucoid, or purulent). The cough, which may be wet or dry, occurs in the daytime but is often worse at night; a cough that occurs only at night is more indicative of postnasal drip or reactive airways disease. Because viral upper respiratory tract infections generally begin to abate within 10 days, it is the persistence of symptoms, without improvement, that is the hallmark of this presentation. The second pattern is characterized by severe symptoms at onset. Children present with a high temperature (≥38.5°C) of at least 3 to 4 days’ duration — a longer period than the 1 to 2 days that is typical of a viral upper respiratory tract infection. Fever is accompanied by rhinorrhea that is purulent (thick, colored, and opaque). The third pattern is characterized by worsening symptoms after an initial improvement.
Table 1. Clinical Criteria for the Diagnosis of Acute Bacterial Sinusitis.
Morning Report Questions
Q. What are the complications of sinusitis and how frequently are they seen?
A. Complications of sinusitis are infrequent, but they may result from the anatomic proximity of the paranasal sinuses to the brain and orbit. These complications may be extracranial, including periorbital inflammatory edema, subperiosteal abscess, orbital cellulitis, orbital abscess, and Pott’s puffy tumor (a subperiosteal abscess of the frontal bone) or intracranial, including subdural empyema, epidural or brain abscess, meningitis, and venous sinus thrombosis.
Q. What are the recommendations for treatment of sinusitis in children?
A. Prompt treatment is recommended for children who meet criteria suggestive of acute bacterial sinusitis. High-dose amoxicillin–clavulanate (90 mg per kilogram per day, divided into two doses per day) is recommended as first-line therapy for children in regions where penicillin-resistant infection is endemic and resistance rates are 10% or higher, those in day care, those older than 2 years of age, and those who have been hospitalized or treated with antibiotics in the past month. If these risk factors are not present, standard-dose amoxicillin–clavulanate (40 mg per kilogram per day, divided into two doses per day) is recommended. Macrolides and trimethoprim–sulfamethoxazole are not recommended because of the high rates of resistance nationally. Levofloxacin is recommended for children with a history of type I hypersensitivity reaction to penicillin. The recommend duration of treatment with amoxicillin–clavulanate or levofloxacin is 10 to 14 days in children.
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Teaching Topic
Cranial-Nerve Palsies and Oral Cancer
Case Records of the Massachusetts General Hospital
L.J. Wirth and Others
Most squamous-cell carcinomas of the head and neck are locally advanced at the time of diagnosis and require multidisciplinary treatment. The location of the cancer is integral to the understanding of its natural history and the development of a multidisciplinary treatment approach.
Clinical Pearls
What is the initial approach to squamous-cell carcinoma of the oral tongue?
Cancer of the oral tongue, one of the most common subsites of squamous-cell carcinoma of the head and neck, is best approached with surgery first, in view of the surgical accessibility of the oral cavity and current techniques for resection and reconstruction that yield good speech and swallowing outcomes.
How does human papillomavirus (HPV) positivity effect the prognosis of squamous cell-carcinomas of the head and neck?
HPV-related squamous-cell carcinomas of the head and neck tend to occur in the oropharynx and typically do not have the extensive lymphovascular and perineural invasion. Expression of p16 is a strong predictor of human papillomavirus positivity. Patients with HPV-positive squamous-cell carcinoma of the head and neck tend to be younger and to have had less exposure to tobacco and alcohol than those with classic (HPV-negative) squamous-cell carcinoma of the head and neck, and have a better prognosis than do patients with HPV-negative tumors, in part because HPV-positive tumors tend to be sensitive to both chemotherapy and radiation.
Morning Report Questions
Q. What is cavernous sinus syndrome?
A. Cavernous sinus syndrome refers to deficits of the third through sixth cranial nerves and has multiple etiologies. The presence of bilateral cavernous sinus syndrome should focus attention to the skull base, and it indicates a process that involves the skull base diffusely. The cavernous sinuses are one of the dural sinuses, and are positioned lateral to the sella turcica. The internal carotid artery and cranial nerves III, IV, V (branches V1 and V2) and VI all pass through the cavernous sinus. Facial infections increase the risk of cavernous sinus thrombosis, which may be manifested with fever, headaches, proptosis, and ocular motor palsies.
Q. How often do patients with metastatic cancer present with leptomeningeal involvement, and how is that manifested?
A. Leptomeningeal involvement occurs in about 5% of patients with metastatic cancer. The hallmark manifestation of this condition is focal neurologic deficits involving the cranial and spinal nerves; symptoms often include headache, difficulty walking, and bowel or bladder dysfunction. Patients with dural spread of cancer often have concurrent leptomeningeal or brain involvement. Results of laboratory tests of the CSF are normal in approximately 15% of patients with leptomeningeal metastases.
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quote of the week
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“The CONFIRM study showed that in patients with relapsing–remitting multiple sclerosis, BG-12 at a dose of 240 mg two or three times daily, as compared with placebo, significantly reduced the rate of relapse, the proportion of patients with a relapse, and disease activity as measured by a range of MRI end points.”
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IMAGE CHALLENGE
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What is the diagnosis?
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images in clinical medicine
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images in clinical medicine
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videos in clinical medicine
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Special Offer
Subscribe to NEJM, Now Includes NEJM iPad Edition & Bonus Gifts
NEJM is celebrating its 200th anniversary! Subscribe today and get subscriber-only access to NEJM.org and the NEJM iPad Edition. Your subscription includes 20 FREE online CME exams (earn up to 20 CME Credits) and 50 FREE article views from the NEJM Archive 1812–1989, PLUS your anniversary gift of 200 additional free CME exams and 200 bonus archive views. Subscribe Today! |
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