T h e n e w e ng l a n d j o u r na l o f m e dic i n e
understanding that the decrease in PSA level is the use of a drug that could be dangerous and
only the result of shrinkage of benign prostatic costs $1,500 per year, if Dr. Klotz wishes to reduce
tissue. For this reason, dutasteride may delay the the overdiagnosis and overtreatment of prostate
diagnosis of prostate cancer until a patient has cancer, why not simply discourage PSA testing?
high-grade disease that may be difficult to cure. Patrick C. Walsh, M.D.
As was concluded in another publication, “in Johns Hopkins Hospital
clinical practice taking dutasteride would prob- Baltimore, MD
ably decrease the number of prostate biopsies
Since publication of his article, the author reports no further
and subsequent radiation treatments and prosta- potential conflict of interest.
tectomies, but it might also increase the number 1. Dutasteride (Avodart) for prevention of prostate cancer. Med
of deaths from the disease.”1 Rather than advising Lett Drugs Ther 2010;52:29. Ultrasound-Guided Internal Jugular Vein Cannulation To the Editor: We wish that Ortega et al. (April nique for additional safety. A micropuncture
22 issue)1 had demonstrated the use of the needle- needle is a very small, 22-gauge needle that can
guide technique in their video of internal jugular enter the jugular vein with little discomfort to
vein cannulation. As noted in the video, it can be the patient. Accidental puncture of the carotid
difficult to determine the location of the tip of artery with this small needle generally does not
the needle, which may be either in front of or lead to major bleeding. The micropuncture tech-
behind the narrow cross-sectional plane of the nique is particularly helpful in children, in pa-
ultrasound image. With the use of a needle guide, tients taking an anticoagulant, and in situations
the operator can direct the needle tip such that it requiring immediate access. Unintentional pene-
intersects the middle of the image on the screen tration of the posterior wall of the internal jugular
at the depth prescribed by the guide. This tech- vein during placement of a central catheter oc-
nique has been shown to be superior to the free- curs frequently, despite the use of ultrasound
hand technique in successfully cannulating the guidance.1 Use of the micropuncture needle can
help to prevent the creation of a large posterior
We believe that the use of ultrasonography hole in the vein, thus reducing the likelihood of
without a needle guide may give the operator a bleeding. In the cardiac catheterization labora-
false sense of security, especially if the person tory at our institution, my colleagues and I re-
doing the procedure lacks experience. Although cently switched to the exclusive use of the micro-
imaging alone may help to identify the target puncture technique to obtain any vascular access.
vein, a needle guide allows for direct, real-time We believe that use of this technique should be-
come the standard of care in clinical practice.
Southern Arizona Veterans Affairs Health Care System
No potential conflict of interest relevant to this letter was re-
No potential conflict of interest relevant to this letter was re- ported. 1. Blaivas M, Adhikari S. An unseen danger: frequency of pos- 1. Ortega R, Song M, Hansen CJ, Barash P. Ultrasound-guided terior vessel wall penetration by needles during attempts to
internal jugular vein cannulation. N Engl J Med 2010;362(16):e57. place internal jugular vein central catheters using ultrasound 2. Augoustides JG, Horak J, Ochroch AE, et al. A randomized guidance. Crit Care Med 2009;37:2345-9.
controlled clinical trial of real-time needle-guided ultrasound for
internal jugular venous cannulation in a large university anes- The Authors Reply: Despite the 18-minute du-
thesia department. J Cardiothorac Vasc Anesth 2005;19:310-5.
ration of our video, the multitude of techniques
and approaches that can be used for internal
To the Editor: In their video, Ortega et al. failed jugular vein cannulation made it necessary for us
to mention the use of the micropuncture tech- to carefully decide which points to include and
n engl j med 363;8 nejm.org august 19, 2010
Downloaded from nejm.org on October 16, 2013. For personal use only. No other uses without permission.
Copyright 2010 Massachusetts Medical Society. All rights reserved.
which to omit. We agree with Maslove and Mihm experience, preferences, and information obtained
that needle guides can be helpful; however, needle from scientific publications. Our video was de-
guides are not universally available. Augoustides signed to be a starting point for this process.
et al., the authors of the article they cite, con- Rafael Ortega, M.D.
clude that needle guides are most helpful in im- Boston University School of Medicine
proving the performance of the the novice opera- Boston, MA
tor and that the difference made when a guide is
used disappears with experience. In addition, the Paul Barash, M.D.
use of a needle guide offers no protection against Yale School of Medicine
arterial puncture.1 Movahed suggests that micro-
puncture should be the standard of care. He bases
Since publication of their article, the authors report no fur-
ther potential conflict of interest.
this recommendation on a report by Blaivas and
Adhikari in which mannequins were used and in 1. Augoustides JG, Horak J, Ochroch AE, et al. A randomized
which the hypothesis concerning the benefit of controlled clinical trial of real-time needle-guided ultrasound for
internal jugular venous cannulation in a large university anes-
micropuncture for ultrasound-guided central ve- thesia department. J Cardiothorac Vasc Anesth 2005;19:310-5. 2. Blaivas M, Adhikari S. An unseen danger: frequency of pos-
Clinicians performing any medical procedure terior vessel wall penetration by needles during attempts to
place internal jugular vein central catheters using ultrasound
modify the technique used on the basis of their guidance. Crit Care Med 2009;37:2345-9. Mortality among Living Kidney Donors and Comparison Populations To the Editor: In an article published in the collected health and nutritional data on 33,994 Journal this past year, Ibrahim et al. (Jan. 29, men, women, and children from 1988 through
2009, issue)1 provide important, much needed 1994. Full details of the survey design may be
data about long-term outcomes of living kidney found in the NHANES III operations manual.2
donors. For a comparison group, the investiga- NHANES III was linked with the National Death
tors used rates of death in the general popula- Index with up to 13 years of follow-up from
tion, which included adults with coexisting med- 1988 through 2000. Data on 16,562 adults who
ical conditions (e.g., heart and kidney disease) were 20 years of age or older with known vital
that would make them ineligible for kidney dona- status were available for analysis. After the ex-
tion. However, it would be preferable to use as a clusion of 1241 participants for whom data on
comparison group persons with a greater simi- estimated GFR or microalbuminuria were miss-
larity to living kidney donors. Therefore, we gen- ing, 15,321 adults remained.
erated death rates for participants in the National
We first determined that the healthy cohort
Health and Nutrition Evaluation Survey (NHANES) of 6053 NHANES participants was demographi-
III who would be eligible for kidney donation cally similar to 16,657 living kidney donors in
(called the “healthy cohort”). These participants the United Network for Organ Sharing (UNOS)
did not have hypertension, diabetes, obesity (de- database for the same period (1988–1994) on the
fined as a body-mass index [BMI; the weight in basis of mean age (36.7 years in NHANES vs.
kilograms divided by the square of the height in 37.3 years in UNOS), male sex (46% vs. 45%),
meters] of >30), a history of stroke or cardiovas- white race (78% vs. 73%), black race (8.3% vs.
cular disease (myocardial infarction or congestive 12.5%), Mexican ancestry (5.3% vs. 10.3%), other
heart failure), reduced kidney function (defined racial or ethnic group (8.4% vs. 3.8%), and mean
as an estimated glomerular filtration rate [GFR] BMI (23.7 vs. 23.5). We then generated death
of <80 ml per minute per 1.73 m2 of body-surface rates according to age and race or ethnic group
in the NHANES III healthy cohort and in the
NHANES III, which was designed as a prob- cohort that was excluded (Table 1).
ability sample of the total U.S. civilian noninsti-
On the basis of our findings, we suggest that
tutionalized population over the age of 2 months, outcome studies for living kidney donors be based
n engl j med 363;8 nejm.org august 19, 2010
Downloaded from nejm.org on October 16, 2013. For personal use only. No other uses without permission.
Copyright 2010 Massachusetts Medical Society. All rights reserved.
‘on-line fraud, behind enemy lines’ by Ian Ross Online and corporate fraud remains a serious concern for global Business. But this paper argues that part of the problem in tackling the ever evolving nature of fraud comes from the very techniques and approaches used to prevent it. The global market research and survey company „Frost & Sullivan‟ estimate that there are 2.28 milli