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September 27, 2007  Vol. 357 No. 13

Audio Summary of this Issue

Perspective
1273-1275
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What happens when the code is unsuccessful? In this essay, Dr. Katharine Treadway writes that we don't talk easily about how hard it is to lose a patient, to confront death.

1275-1277

Do childhood vaccines cause autism? More than 5000 families have filed claims with the federal Vaccine Injury Compensation Program. Stephen Sugarman discusses the autism cases.

1278-1279

On July 9, 1999, the CDC and the American Academy of Pediatrics asked pharmaceutical companies to remove thimerosal from vaccines. Dr. Paul Offit writes that the alarm caused by the removal of thimerosal from vaccines has been quite harmful.

Original Articles
1281-1292

This study examined the association between early exposure to thimerosal, a mercury-containing preservative used in vaccines, and neuropsychological outcomes in children. Among the 42 neuropsychological outcomes assessed, only a few significant associations were identified, and the associations were small and both positive and negative. These findings suggest that exposure to thimerosal-containing vaccines does not reduce neuropsychological functioning in children.

1293-1300
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Some kidney transplants fail despite good HLA matching, so other antigens might be involved. Major-histocompatibility-complex class I–related chain A (MICA) antigens are polymorphic and can elicit antibody production. This study shows that presensitization of kidney-transplant recipients against MICA antigens is associated with an increased frequency of graft loss. Immune response against MICA antigens might contribute to this loss among recipients well matched for HLA.

1301-1310

In a post hoc analysis of the Treating to New Targets study, high-density lipoprotein cholesterol levels in patients receiving statin therapy were shown to be predictive of subsequent major cardiovascular events, even when low-density lipoprotein (LDL) cholesterol levels were taken into account and even among patients with very low levels of LDL cholesterol (<70 mg per deciliter).

1311-1315

This article provides a molecular update of the first published description of pheochromocytoma, attributed to Felix Fränkel, who described an 18-year-old woman with bilateral adrenal “sarcoma and angio-sarcoma.” The authors approached and assessed relatives, ultimately demonstrating the presence of germ-line RET mutations in four living relatives, thus indicating that this patient and members of her family had multiple endocrine neoplasia type 2.

Review Article
1316-1325

    The meaning of uremia, which refers to the illness accompanying kidney failure that is unexplained by derangements in extracellular volume, inorganic ion concentrations, or lack of known renal synthetic products, has changed. We now assume that uremic illness is due largely to the accumulation of organic waste products, not all identified, that are normally cleared by the kidneys. This review considers the pathogenesis and course of uremia.

    Images in Clinical Medicine
    1326
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    A 53-year-old woman with diabetes mellitus and end-stage renal disease who was undergoing hemodialysis presented with fever, painful finger necrosis, and nonhealing ulceration of the legs. Hand radiographs showed no evidence of osteomyelitis but did show ...

    e14
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    This 76-year-old male nursing home resident was undergoing hemodialysis. The patient had no fever, urinary tract symptoms, or leukocytosis. The urinalysis showed a pH of 9.0.

    Case Records of the Massachusetts General Hospital
    1327-1335

      A full-term newborn girl was transferred to this hospital because of multiple cutaneous erosions and papules on the face, trunk, arms, and legs that were present at birth. She was otherwise well, with normal vital signs. A diagnostic procedure was performed.

      Editorial
      1337-1339

      Renal transplantation as the treatment of choice for end-stage renal failure is associated with excellent short-term results. The 1-year patient-survival rate is 96%, and the 1-year allograft-survival rate is more than 90%. Although the 5-year patient-...

      Sounding Board
      1340-1344

      Decision makers sometimes face a default choice — the option that will be implemented if an alternative is not actively chosen. Health care quality can be improved by default options such as administering vaccinations to eligible hospitalized patients who do not decline them. The authors argue that these options should be set strategically and used to improve public health.

      Clinical Implications of Basic Research
      1345-1346

      Mice with latent herpesvirus infections are surprisingly resistant to infection by pathogenic bacteria.

      Correspondence
      1347-1348

      To the Editor: The study of anidulafungin as compared with fluconazole for invasive candidiasis by Reboli et al. (June 14 issue)1 shows the challenges involved in the design and reporting of noninferiority trials.2,3 First, the dose of fluconazole may ...

      1348-1349

      To the Editor: In the study of prophylactic fluconazole in preterm neonates, reported by Manzoni et al. (June 14 issue),1 the incidence of candida sepsis in the control group (14 of 106 infants [13.2%] admitted with a birth weight of <1500 g) was much ...

      1350

      To the Editor: Neven et al. (June 28 issue)1 discuss the use of bone marrow transplantation in the treatment of severe mevalonic aciduria. We provide additional evidence for the effective cure of mevalonic aciduria by hematopoietic stem-cell ...

      1350-1351

      To the Editor: In their article about the relationship between the number of medical conditions and quality of care, Higashi et al. (June 14 issue)1 found that quality of care does not decline among patients with increasing numbers of chronic conditions. ...

      1351-1352

      To the Editor: In their letter to the editor, Gillessen et al. (May 31 issue)1 report that sunitinib therapy induced macrocytosis related to cobalamin deficiency. We have made a similar observation.

      Between October 2005 and March 2007, a total of 40 ...

      1352-1353

      To the Editor: Kaposi's sarcoma associated with HIV infection has been decreasing in incidence and severity since the introduction of antiretroviral therapy.1 These reductions have been attributed to improved immune function directly related to such ...

      Book Reviews
      1354-1355

      The interval between the 4th and the 8th centuries saw the decline of the Roman Empire, the rise of Christianity, the beginning of the Dark Ages in Western Europe, the spread of Islam, and the establishment of the Caliphate. These events echo through time ...

      1355-1357

      When in his medieval masterpiece, The Decameron, Boccaccio pointed his finger at the infidel East as the cause of the “unpleasantness” that sent his storytellers wandering, he expressed the relentlessly popular explanation that epidemic catastrophes were ...

      Corrections
      1357

      Maintenance Therapy with Certolizumab Pegol for Crohn's Disease Original Article, N Engl J Med 2007:357;239-250.. The second sentence of the first paragraph (page 240) should have read “Infliximab and adalimumab are engineered IgG1 monoclonal antibodies ...

      1357

      Skin and Soft-Tissue Infections Caused by Methicillin-Resistant Staphylococcus aureus Clinical Practice, N Engl J Med 2007:357;380-390.. The last sentence of the third paragraph (page 380) should have read “In most areas of the United States, a community-...

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