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Table of contents for

May 4, 2006  Vol. 354 No. 18

Audio Summary of this Issue

Perspective
1869-1871
Injury to Research Volunteers — The Clinical-Research Nightmare
A.J.J. Wood and J. Darbyshire
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In March, after receiving injections of TGN1412, six volunteers became desperately ill, had multiple-organ failure, and were transferred to an intensive care unit. TGN1412 is a humanized monoclonal antibody agonist of the CD28 receptor. Drs. Alastair Wood ...

1871-1873
Compensation for Injured Research Subjects
R. Steinbrook
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Recent developments have focused renewed attention on the long-standing issue of compensation for injured research subjects. Dr. Robert Steinbrook explains that in the United States, sponsors and institutions are not required to provide either free ...

1874-1877
Focus on Research: Disabled Receptor Signaling and New Primary Immunodeficiency Disorders
C.E. Rudd

    The genetic defects that cause severe combined immunodeficiency have been identified in more than 95 percent of cases. Dr. Christopher Rudd writes that this information permits precise diagnoses and should also permit the development of therapeutic agents ...

    Original Articles
    1879-1888
    Balloon Angioplasty versus Implantation of Nitinol Stents in the Superficial Femoral Artery
    M. Schillinger and Others
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    Implantation of stainless-steel stents for disease of the superficial femoral artery has been associated with high rates of late clinical failure, and balloon angioplasty is therefore the preferred procedure. In this randomized trial, the use of nitinol stents was associated with lower rates of restenosis and better treadmill exercise performance at 6 months and 12 months than was the use of balloon angioplasty.

    1889-1900
    Outcomes among Newborns with Total Serum Bilirubin Levels of 25 mg per Deciliter or More
    T.B. Newman and Others
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    The authors assessed neurodevelopmental outcomes in children who had neonatal total bilirubin levels of at least 25 mg per deciliter but generally below 30 mg per deciliter and who were in most cases treated with phototherapy. As compared with a control group, these children were not more likely to have an abnormal neurodevelopmental outcome at a mean age of five years or a documented neurologic diagnosis. These data provide reassurance that elevated bilirubin levels in the range studied are unlikely to result in adverse neurodevelopmental outcomes.

    1901-1912
    An Antibody-Deficiency Syndrome Due to Mutations in the CD19 Gene
    M.C. van Zelm and Others
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    Four patients from two unrelated families with increased susceptibility to infection, hypogammaglobulinemia, and normal numbers of B cells in the blood were found to have mutations in the CD19 gene. CD19, a protein on the B-cell surface, forms a complex with other proteins that participates in the activation of B cells by antigens.

    1913-1921
    Brief Report: Inherited and Somatic CD3ζ Mutations in a Patient with T-Cell Deficiency
    F. Rieux-Laucat and Others
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    A child with greatly increased susceptibility to viral, bacterial, and fungal infections was found to have inherited an autosomal recessive mutation of the CD3ζ gene. CD3ζ, a component of the T-cell receptor–CD3 complex, is essential for the differentiation and activation of T cells.

    Special Article
    1922-1926
    Shattuck Lecture: The Family Business — To Educate
    R.A. Arky
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    In the 115th annual Shattuck Lecture, Dr. Ronald Arky, the 2005 speaker, considers the history and science of medical education, discusses its current disjointed state, and calls for a restructuring of continuing medical education.

    Clinical Practice
    1927-1935
    Thrombotic Thrombocytopenic Purpura
    J.N. George

      A 40-year-old obese black woman has had weakness and epigastric pain for several weeks and diarrhea and vomiting for four days. She does not appear acutely ill; the physical examination is normal except for abdominal tenderness. Her hematocrit is 25 percent. The platelet count is 10,000 per cubic millimeter. The peripheral-blood smear shows occasional fragmented and polychromatophilic red cells. The serum creatinine level is 1.1 mg per deciliter (97.2 μmol per liter), bilirubin 2.5 mg per deciliter (42.8 μmol per liter), and lactate dehydrogenase 722 U per liter (normal, <250). How should this case be managed?

      Images in Clinical Medicine
      1936
      Spurious Platelet Count
      M. Siegenthaler and O. Spertini
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      A previously healthy 48-year-old man was admitted for severe burns involving his face, thorax, and upper and lower limbs (45 percent of body-surface area) associated with an inhalation injury. The hemoglobin level was 12.3 g per deciliter, the hematocrit ...

      e18
      Scrofula
      S.K. Khalid and O. Jassim
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      This 39-year-old Zambian man presented with a draining neck mass, weight loss, and low-grade fever.

      Clinical Problem-Solving
      1937-1942
      Ring around the Diagnosis
      M.-F. Bonilla, D.R. Kaul, S. Saint, C.M. Isada, and D.J. Brotman

        A 71-year-old retired schoolteacher from rural Ohio presented to his local hospital with a two-week history of malaise, fever, anorexia, chills, and sweats. He had not had a cough or symptoms involving the upper respiratory, gastrointestinal, or urinary tract.

        Editorials
        1944-1947
        Treatment of Peripheral Arterial Disease — Extending “Intervention” to “Therapeutic Choice”
        A.T. Hirsch

          Lower-extremity peripheral arterial disease is an important manifestation of systemic atherosclerosis that is associated with markedly increased rates of cardiovascular ischemic events and death.1 Although most patients with peripheral arterial disease ...

          1947-1949
          Neonatal Hyperbilirubinemia — What Are the Risks?
          J.F. Watchko

            Hyperbilirubinemia is the most common condition requiring evaluation and treatment of newborns, but for the vast majority of neonates, it is a benign, transitional phenomenon of no overt clinical significance. In a few infants, however, serum bilirubin ...

            Correspondence
            1950-1951
            Saw Palmetto for Benign Prostatic Hyperplasia
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            To the Editor: Bent et al. (Feb. 9 issue)1 report that 160 mg of saw palmetto taken twice daily did not improve symptoms of benign prostatic hyperplasia. The authors indicate that the fatty-acid fraction of saw palmetto may be the active ingredient of ...

            1951-1953
            Racial Differences in Lung Cancer
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            To the Editor: The study of ethnic and racial differences in the smoking-related risk of lung cancer by Haiman et al. (Jan. 26 issue)1 omits an analysis of important potential confounders: a family history of cancer and parental exposure to relevant ...

            1953-1957
            Aprotinin in Cardiac Surgery
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            To the Editor: Although potent and effective drugs may have undesirable side effects in some patients, we believe that the study by Mangano et al. (Jan. 26 issue)1 overemphasizes the risk of aprotinin for the prevention of bleeding during cardiac surgery ...

            1958
            Chronic Daily Headache
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            To the Editor: In his article on chronic daily headache (Jan. 12 issue),1 Dodick did not address one condition that, in my experience as a neurologist in the management of chronic pain and headache, is the most common form of headache seen in the clinic. ...

            1958-1960
            Positron-Emission Tomography in Cancer Therapy
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            To the Editor: The excellent review by Juweid and Cheson (Feb. 2 issue)1 on the powerful diagnostic use of 18F-fluorodeoxyglucose (18F-FDG) as a tracer for hypermetabolic neoplasms raises interesting questions about its potential use as a therapeutic ...

            1960-1961
            Medicare Drug Benefit
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            To the Editor: In one of several Perspective articles in the December 29 issue on the Medicare drug benefit, Bach and McClellan paint a decidedly rosy picture of the new prescription-drug benefit.1 Their apparent aim was to reassure nervous physicians ...

            1961-1963
            Resolution of Recurrent Focal Segmental Glomerulosclerosis Proteinuria after Rituximab Treatment
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            To the Editor: Focal segmental glomerulosclerosis recurs in about 30 percent of patients who undergo kidney transplantation for this condition and leads to the nephrotic syndrome and accelerated graft loss.1 Cyclosporine, cyclophosphamide, plasmapheresis,...

            1963-1964
            A Delayed Complication after Injury in World War II
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            To the Editor: In December 2004, an 84-year-old man presented with a painless supraclavicular mass on the right side. The mass had first been noted one year before and had gradually increased in size.

            Sixty-one years earlier, in 1943 during World War II, ...

            Book Reviews
            1965
            Moments of Truth in Genetic Medicine
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            In 1964, Victor McKusick completed the first of a series of field trips to the Amish communities of Pennsylvania. McKusick had two guides for his initial trips: David E. Krusen, a Lancaster physician who had noted a high incidence of achondroplasia among ...

            1965-1966
            Ethical Dilemmas in Pediatrics: Cases and Commentaries
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            The discipline of pediatric ethics is growing up. The conventional approach to bioethical analysis does not work with respect to children as it does for adults. The very foundations of bioethics are different when questions arise in the medical care of ...

            1966-1967
            Patient Autonomy and the Ethics of Responsibility
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            Like many other physicians, Alfred I. Tauber, a professor of medicine and director of the Center for Philosophy and History of Science at Boston University, intensely dislikes the influence that apprehension about the law currently exerts on the practice ...

            1967-1969
            Cystic Fibrosis in the 21st Century
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            More than six decades have passed since the first description of cystic fibrosis as a deadly childhood disease of the pancreas. Since then, it has been recognized as one of the most common fatal recessive diseases among white persons, usually diagnosed ...

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