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December 21, 2006  Vol. 355 No. 25

Audio Summary of this Issue

Perspective
2609-2615
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As thousands of brain-injured veterans come home to recover and rebuild their lives, medical experts have expressed concern about the challenges of providing them with continuing medical care and vocational and emotional support. To see how two ...

2615-2617

Research has shown that a risk factor must have a much stronger association with the disease outcome than we ordinarily see in etiologic research if it is to provide a basis for early diagnosis or prediction in individual patients. James Ware explains the ...

Original Articles
2619-2630
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Ventilator-associated pneumonia is an important cause of nosocomial complications. This large, multicenter study compared the usefulness in guiding therapy of two diagnostic approaches for ventilator-associated pneumonia: bronchoalveolar lavage with quantitative culture and endotracheal aspiration with nonquantitative culture. Clinical outcomes such as the 28-day mortality rate and overall use of antimicrobial agents were similar with the two strategies.

2631-2639

In an analysis from the Framingham Heart Study, 10 biomarkers were evaluated for their ability to predict clinical outcomes. The addition of biomarkers to conventional risk factors resulted in significant increases in the hazard ratios for death and major cardiovascular events but only small increases in the C statistic for each end point. The incremental value of the assessment of biomarkers to the evaluation of established risk factors appears to be modest.

2640-2651

With the availability of cefotetan and cefoxitin possibly ending, effective agents for wound prophylaxis during elective colorectal surgery are needed. In this large randomized, multicenter, double-blind study, ertapenem was found to be superior to cefotetan in the prevention of surgical-site infection but was associated with an increase in Clostridium difficile infection.

2652-2663

A small molecule (FDDNP) that binds amyloid senile plaques and tau neurofibrillary tangles (the neuropathological findings in Alzheimer's disease) was injected into subjects before PET scanning. FDDNP binding was highest in subjects with Alzheimer's disease, intermediate in those with mild cognitive impairment, and lowest in normal controls. Whether there will be clinical applications for this noninvasive method of detecting cerebral plaques and tangles is not known.

Review Articles
2664-2669
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Traditionally, surgeons have been trained and evaluated on the basis of their performance of surgical procedures in live patients. This article in the Medical Education series explores the use of mechanical devices for the teaching and evaluation of surgical skills.

2670-2676

    Autoimmune pancreatitis is a form of chronic pancreatitis characterized by an autoimmune inflammatory process that may involve the biliary ducts, bowel, regional lymph nodes, and sometimes the lung and kidney. Patients with this uncommon form of pancreatitis may present with an obstructing pancreatic mass that mimics pancreatic cancer but responds to corticosteroid treatment. This review summarizes how the diagnosis of autoimmune pancreatitis can be established on the basis of imaging, histologic, and serologic criteria.

    Images in Clinical Medicine
    2677

    A 32-year-old man infected with the human immunodeficiency virus (HIV) who had a CD4 count of 9 cells per cubic millimeter had a 9-month history of weight loss, with progressive weakness and numerous ulcerated lesions of various dimensions on the face (...

    e27
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    This HIV-positive woman presented with fever, chest pain, and hemoptysis. There was a history of intravenous drug use and a 3/6 pansystolic murmur along the left sternal border.

    Case Records of the Massachusetts General Hospital
    2678-2689

    A woman was transferred to this hospital because of seizures and a lesion in the brain. The patient had a history of systemic lupus erythematosus, for which she had received corticosteroids and other immunosuppressive medications. Despite negative biopsy specimens and cultures, broad-spectrum antimicrobial therapy, and escalating doses of corticosteroids, fever persisted, neurologic function worsened, and the patient died on the 54th hospital day. An autopsy was performed.

    Editorials
    2691-2693

    In this issue of the Journal, Heyland et al., writing for the Canadian Critical Care Trials Group, report the results of a multicenter, randomized trial comparing the use of bronchoalveolar lavage and endotracheal aspiration for the diagnosis of ...

    2693-2695

    In this issue of the Journal, Itani and colleagues1 describe a study in which 1002 patients were randomly assigned to receive either ertapenem or cefotetan in a single dose before elective colorectal surgery. Many experienced surgeons and hospital ...

    2695-2696
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    Medical education is undergoing a paradigm shift, from the traditional experience-based model to a program that requires documentation of proficiency.1 Technological advances in health care, the development of day-case surgery, and the setting of quality-...

    Clinical Implications of Basic Research
    2697-2698

      A molecule that regulates protein degradation affects memory loss in a mouse model of Alzheimer's disease.

      Correspondence
      2699-2701

      To the Editor: Adams et al. (Aug. 24 issue)1 state that overweight, defined by a body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) of 25.0 to 29.9 during midlife, is associated with an increased risk of death. ...

      2701-2702

      To the Editor: Jee et al. (Aug. 24 issue)1 report the association between body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) and mortality. We have published articles elsewhere on similar issues with the use of ...

      2702

      To the Editor: The article by Schneier (Sept. 7 issue)1 concerning social anxiety disorder discusses cognitive–behavioral therapy and pharmacotherapy as treatment options. There is no mention of the use of psychoanalytically informed treatment, either by ...

      2703
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      To the Editor: With regard to the article by Jordan et al. (Sept. 21 issue),1 if cancer stem cells are characterized in experimental studies by their ability to regrow a tumor when injected into an immunodeficient animal, then what is evaluated is the ...

      2703-2705
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      To the Editor: Hyponatremia, a common and important complication of subarachnoid hemorrhage, is not mentioned in the review of cerebral aneurysms by Brisman et al. (Aug. 31 issue).1 Hyponatremia is associated with substantially increased morbidity among ...

      2705-2707

      To the Editor: The intravesical administration of bacille Calmette–Guérin (BCG) vaccine for high-risk, non–muscle-invasive bladder cancer and carcinoma in situ is one of the most successful immunotherapies to date.1 Studies in animals have shown that the ...

      Book Reviews
      2708-2709
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      On March 22, 1961, Denis Burkitt, a self-described “bush surgeon” working at Mulago Hospital in Kampala, Uganda, delivered a lecture at Middlesex Hospital Medical School in London entitled “The Commonest Children's Cancer in Tropical Africa — A Hitherto ...

      2709-2710

      Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it.

      — Samuel Johnson, quoted in James Boswell's Life of Samuel Johnson

      Until about 10 years ago, trainees, young faculty, and referring specialists in ...

      2710-2711

      Carcinoma of an unknown primary site (CUP) is a common and often puzzling condition. It is probably underdiagnosed because clinicians may be reluctant to acknowledge the uncertainty of such a diagnosis (a “best guess” diagnosis may be applied). Yet CUP is ...

      2711-2712

      Among the recent offering of new books regarding therapy that targets the apoptotic process, this two-volume work is distinctive because of its wide scope and depth. The contributors are all leading experts in their fields in Europe, North America, ...

      Corrections
      2712

      A Proposal for Radical Changes in the Drug-Approval Process Sounding Board, N Engl J Med 2006:355;618-623.. In Figure 1, the label for the y axis should have read, “Deaths per 100,000 Population,” not “Deaths per 100,00 Population,” as printed. The figure ...

      2712

      Carotid-Artery Stenting — Case Open or Closed? Editorial, N Engl J Med 2006:355;1726-1729.. On page 1727, in the 9th line of the second paragraph of the right column, the sentence should have read, “In the SAPPHIRE trial, a single type of protection ...

      2712

      The Severe Gout of Emperor Charles V Correspondence, N Engl J Med 2006:355;1935-1936.. In the authors' reply, Jaume Ordi, M.D., of the Hospital Clínic d'Investigacions Biomèdiques August Pi i Sunyer, 08036 Barcelona, Spain, should have been included as an ...

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