Aprotinin (Trasylol) is used to control bleeding during coronary-artery bypass grafting (CABG), but in this observational study, there was an increased risk of in-hospital death when this drug was used, as compared with when aminocaproic acid was used. These data concur with those of Shaw et al. in this issue of the Journal and, in conjunction with those from previous studies, call into question the safety of aprotinin use in patients undergoing CABG.

In this single-center study, the use of aprotinin in coronary-artery bypass grafting (CABG) was associated with an increase in mortality and worsening renal function. The results concur with those of Schneeweiss et al. in this issue of the Journal, and together these studies raise concern about the safety of aprotinin in CABG.

Lumbar spinal stenosis is the most common reason for spinal surgery in patients over the age of 65 years. This randomized clinical trial compared surgical decompression with nonsurgical therapy for spinal stenosis without spondylolisthesis. Although the trial was limited by frequent crossover between the two randomized groups and therefore was not definitive, the findings favored surgical decompression over nonsurgical care for this common spine disorder.

Hepatitis E virus (HEV) is considered responsible for acute hepatitis but has not been thought to cause progression to chronic hepatitis. The authors of this paper identified 14 transplant recipients who had acute HEV infection; in 8, the infection evolved to confirmed chronic hepatitis. The numbers of lymphocytes and of CD2, CD3, and CD4 T cells were significantly lower in the patients with chronic hepatitis than in those in whom the infection resolved.

A 72-year-old woman with hypertension presents with a 4-month history of lower back discomfort that radiates to both buttocks and lateral thighs. Previously, she walked 2 miles (3.2 km) a day; now she has difficulty walking two blocks and standing up for more than 15 minutes at a time. Her physical examination is notable only for a slightly stooped posture and a reduction of vibratory sensibility in both great toes. How should she be evaluated and treated?

A 46-year-old woman was seen by a rheumatology consultant because of stiffness of the joints and skin. She had been well until 7 years earlier, when an episode of group A streptococcal pneumonia complicated by septic shock left her with chronic kidney disease and a painful peripheral neuropathy. Three years later, gradually progressive stiffness of the skin of her hands and feet developed, with pain and stiffness of the joints; renal failure worsened, and respiratory distress and congestive heart failure developed. A diagnostic procedure was performed.

Many recombinant-protein drugs such as erythropoietin are now off patent, and the availability of generic versions of these drugs would reduce costs. The federal laws that simplify and expedite approval of generic forms of other drugs do not apply to recombinant-protein drugs. Congress is developing legislation to facilitate the approval of follow-on protein drugs.