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January 25, 2007  Vol. 356 No. 4

Audio Summary of this Issue

Perspective
325-328

Last September, a firestorm was ignited over drug-eluting stents when data were released showing an increase in the risk of late stent thrombosis. In response, the FDA held an open meeting of its Circulatory System Devices Panel in December. Dr. Miriam ...

328-330

Drs. Bruce Psaty and Noel Weiss write that the long tradition of leaving to the pharmaceutical industry the task of evaluating the efficacy and safety of its products has permitted manufacturers to make study-design choices that largely determine the ...

331-333

The quality of clinical practice guidelines varies considerably. Dr. Robert Steinbrook discusses various approaches to improving the quality of guidelines and minimizing the potential for inappropriate influences.

Original Articles
335-347

This randomized, double-blind trial of prophylaxis to prevent invasive fungal infections was conducted in 600 patients with severe graft-versus-host disease after hematopoietic stem-cell transplantation. Posaconazole, an extended-spectrum triazole, was as effective as fluconazole in preventing invasive fungal infections (incidence, 5.3% and 9.0%, respectively). With posaconazole, there were fewer cases of invasive aspergillosis infections.

348-359

In this randomized trial of patients undergoing treatment for acute myelogenous leukemia or the myelodysplastic syndrome, prophylaxis with posaconazole resulted in fewer fungal infections and longer survival than did prophylaxis with fluconazole or itraconazole. The difference was primarily due to a lower rate of invasive aspergillosis in the posaconazole group.

360-370

In this multicenter, randomized trial of outcomes of uterine-artery embolization versus surgery for symptomatic fibroids, there were no differences between groups in quality of life at 1 year. Women who underwent embolization had a shorter duration of hospitalization and a shorter interval until the resumption of normal activities but were more likely to require rehospitalization for adverse outcomes or to need reintervention owing to treatment failure.

371-378

A previous study reported in the Journal showed an association between serum antimyelin antibodies (detected by Western blot analysis) and an increased risk of multiple sclerosis in patients with the first evidence of neurologic abnormalities that were suggestive, but not diagnostic, of multiple sclerosis. This prospective study of 462 patients did not reproduce these findings but instead showed that serum antibodies against myelin oligodendrocyte glycoprotein and myelin basic protein were not associated with an increased risk of progression to clinically definite multiple sclerosis.

Clinical Practice
379-386
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A 37-year-old woman who has never been pregnant and her 40-year-old husband have been attempting to conceive a child for the past 3 years. An infertility evaluation has shown no cause for the difficulty. She is ovulating regularly, and a hysterosalpingogram shows that her reproductive tract is anatomically normal. He has a normal sperm count; he has not fathered any children. They are frustrated and want to proceed with in vitro fertilization. What should you advise?

Review Article
387-396

This article in the Medical Education series provides a conceptual framework for and a brief update on commonly used and emerging methods of assessment, discusses the strengths and limitations of each method, and identifies several major challenges in assessing professional competence and performance.

Images in Clinical Medicine
397
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A 60-year-old Somalian woman presented to the emergency department with pain in the upper abdomen. Her medical history was notable for the placement of an intrauterine device (IUD) while she was living in Somalia. After the placement of the IUD, she ...

e4
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This 19-year-old woman underwent chemotherapy for acute myelomonocytic leukemia. Fever persisted despite empirical antibacterial therapy, and the serum alkaline phosphatase level increased to 335 U per liter.

Case Records of the Massachusetts General Hospital
398-407

A 3-year-old boy was admitted to the hospital because of recurrent episodes of respiratory insufficiency. Episodes of wheezing developed at 9 months of age; between 2 and 3 years of age, three episodes of tachypnea and hypoxemia occurred that required admission to the intensive care unit, with intubation and assisted ventilation on two occasions. The episodes were associated with anemia and pulmonary infiltrates. A diagnostic procedure was performed.

Editorials
409-411

Invasive fungal diseases contribute substantially to death and illness associated with the prolonged, profound neutropenia resulting from intensive chemotherapy for hematologic cancers and from myeloablation for allogeneic hematopoietic stem-cell ...

411-413

In the early 1990s, Jacques H. Ravina first applied the technique of embolization of uterine arteries to treat uterine fibroids in women at high risk for complications during surgery1 in an effort to control uterine bleeding. Embolization was then ...

414-415

A fair amount of scrutiny has been given recently to the assessment of medical students' competence before they enter practice. In this issue of the Journal, Epstein provides a timely summary of advances in this arena.1 In contrast, little attention has ...

Correspondence
416-418

To the Editor: Schneider et al. (Oct. 12 issue)1 conclude that the adverse effects of atypical antipsychotic drugs for the treatment of psychosis, aggression, and agitation in patients with Alzheimer's disease offset the advantages. However, they ...

418-421

To the Editor: The results of the trial by Morton et al. (Sept. 28 issue)1 involving sentinel-node biopsy in patients with melanoma do not show a survival benefit with immediate lymphadenectomy for three reasons. First, there were false positive results ...

421-423

To the Editor: In the PROLONG study, Palareti et al. (Oct. 26 issue)1 conclude that patients with an abnormal d-dimer test 1 month after the discontinuation of anticoagulation therapy have a significantly increased incidence of recurrent venous ...

423-424
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To the Editor: In his Clinical Practice article, Schaeffer (Oct. 19 issue)1 recommends the use of the Meares–Stamey 4-glass urine test in the diagnosis of chronic bacterial prostatitis. This investigation seems hard to justify since, as the author states,...

424-425
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To the Editor: According to the instructional Video in Clinical Medicine on lumbar puncture by Ellenby and colleagues (Sept. 28 issue),1 as the spinal needle is incrementally advanced, the stylet should be withdrawn periodically to check for ...

425-426

To the Editor: The ovarian hyperstimulation syndrome is a potentially lethal complication of the administration of gonadotropin for the induction of ovulation. The condition occurs in up to 5% of patients undergoing in vitro fertilization.1 Typical ...

426-428

To the Editor: The presence of antibodies against myelin, myelin oligodendrocyte glycoprotein (MOG), and myelin basic protein (MBP) in serum from patients with a clinically isolated syndrome and multiple lesions detected on magnetic resonance imaging (...

Book Reviews
429

In the mid-1980s, it was discovered that the nonsteroidal antiestrogens tamoxifen and raloxifene (then known as keoxifene) can switch on (estrogenic action) or switch off (antiestrogenic action) responses at estrogen target sites around the body. This ...

429-430

Principles of Molecular Medicine was first published in 1998. When Michael Goossens reviewed the book in the Journal, he emphasized its value in integrating molecular biology and molecular genetics into medical education. Today, one can only concur with ...

430-432

The renaissance in the study of regulatory T cells, which began in the mid-1990s, has much improved our understanding of the developmental mechanisms of autoimmune diseases. T-cell–mediated suppression of the immune response was recognized more than three ...