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September 18, 2008  Vol. 359 No. 12

Audio Summary of this Issue

Perspective
1197-1200

Both the enthusiastic adoption and somewhat lackluster early results of pay for performance have given rise to a broader payment-reform movement, with proposals and pilots emerging from a wide variety of stakeholders and policy leaders. Meredith Rosenthal ...

1200-1202

The federal government is preparing to test the concept of the “medical home” in the Medicare program. The demonstration program will operate for 3 years in rural, urban, and underserved areas in up to 8 states. John Iglehart reports.

1202-1205

Recent efforts to improve primary care in the United States have focused largely on the “medical home.” Dr. Elliott Fisher writes that unrealistic expectations about this approach abound, and insufficient attention is being paid to several important ...

Original Articles
1207-1217

In this comparison of CT colonography and optical colonoscopy in 2600 asymptomatic study participants 50 years of age or older at 15 centers, 90% of large colorectal adenomas and adenocarcinomas detected by optical colonoscopy were also detected on CT colonography, and 10% were missed by CT colonography.

1218-1224

In this study of subjects who had no adenomas or cancers on baseline screening colonoscopy, advanced adenomas were detected in only 1.3% of those who returned for rescreening after 5 years. These findings support a rescreening interval of 5 years or longer for patients at average risk who have normal findings on colonoscopy.

1225-1237

In a multicenter trial, 20,332 patients who had recently had an ischemic stroke were randomly assigned to receive either telmisartan or placebo. All patients also received medications for blood-pressure control at the investigators' discretion. At a mean follow-up of 2.5 years, there was no significant difference between the two study groups in the rates of recurrent stroke or major cardiovascular events.

1238-1251

In this large clinical trial, aspirin plus extended-release dipyridamole was found to have an efficacy similar to that of clopidogrel in the prevention of recurrent stroke. However, aspirin plus extended-release dipyridamole resulted in more bleeding, including intracranial bleeding. The results will help guide therapy for secondary stroke prevention.

Clinical Practice
1252-1260
  • Full Text Audio

A 3-year-old boy is admitted to the hospital with hives and wheezing after eating chocolate mousse. At 18 months of age, contact urticaria developed after he put his hand into a cake mix containing egg. He also has a history of chronic rhinitis, nocturnal cough, severe eczema, and a previous hospitalization for recurrent wheezing. How should this child be evaluated and treated?

Review Article
1261-1270

This review concerns functional contacts between platelets and endothelial cells, with emphasis on the maintenance of vascular integrity by proangiogenic cytokines and growth factors released by platelets. These molecules bind to receptors on the surface of endothelial cells, thereby stabilizing the vascular-endothelium cadherin complex.

Images in Clinical Medicine
1271
  • Free Full Text

A 53-year-old woman with a 2-year history of intermittent abdominal pain, diarrhea, and constipation presented for evaluation. Her medical history was significant for congenital imperforate anus requiring a colostomy at birth with reanastomosis at the age ...

e13
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This 61-year-old woman was admitted to the intensive care unit. She had undergone esophagography with barium 55 days earlier; no abnormalities had been noted.

Case Records of the Massachusetts General Hospital
1272-1283

    A 19-year-old man was admitted to this hospital because of acute abdominal pain, which had begun the previous day. Imaging studies disclosed dilatation of the colon and small bowel, with no obstruction or free air. Administration of fluids and laxatives resulted in resolution of the pain. The patient had had anorexia nervosa since the age of 14 years and had recently lost several kilograms of weight. He was admitted to the psychiatric inpatient unit, and a treatment plan was established.

    Editorials
    1285-1287

    Screening for colorectal cancer has lagged behind other cancer screening, but it is now in a dynamic phase. New screening tests are available, and there is stronger evidence of their effectiveness. Screening rates in the United States have increased and ...

    1287-1289

    If clinical trials were sporting contests, then it would be fair to say that low-dose aspirin plus extended-release dipyridamole (Aggrenox) was the clear favorite against clopidogrel going into the Prevention Regimen for Effectively Avoiding Second ...

    Correspondence
    1290-1291

    To the Editor: Mackenbach et al. (June 5 issue)1 present interesting findings on the magnitude of socioeconomic inequalities in health in Europe, but they provide potentially misleading messages to policy leaders. The authors show that inequalities in ...

    1291-1293
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    To the Editor: Kishimoto et al. (June 5 issue)1 report that contamination of heparin with oversulfated chondroitin sulfate (OSCS) can induce anaphylactoid reactions through activation of the contact system. OSCS can also induce a clinical syndrome that ...

    1294-1295

    To the Editor: In their article and video on the placement of a femoral venous catheter, Tsui et al. (June 26 issue)1 describe several procedural complications. One rare but potentially lethal complication is not mentioned, however. A guide wire and ...

    1295-1297

    To the Editor: Poorly differentiated thyroid cancers are rare and can be difficult for surgeons, endocrinologists, and pathologists to identify.1 These cancers fall into two main histologic categories: insular and other (large cell). Most, but not all, ...

    Book Reviews
    1298

    Pediatric rheumatology has a quality that sets it apart from other pediatric subspecialties. In some respects, this quality is determined by the limited number of board-certified practitioners caring for an ever-growing number of children with autoimmune ...

    1299

    Gastrointestinal disease in children is often the orphan of clinical inquiry and scientific investigation. This book provides a thorough update of the pathophysiology and clinical features of gastrointestinal disease in children and describes therapeutic ...

    1299-1300
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    Obesity is ultimately the result of an imbalance between energy intake and energy expenditure, but this simplistic equation belies the fact that obesity is also a multifactorial disease with complex causes. The prevalence of obesity has increased globally,...

    1300-1301

    The earliest symptoms of autism spectrum disorders often appear before a child's second birthday, but most children with autism are not diagnosed until they are in preschool or elementary school. If they could be diagnosed earlier, they could be treated ...

    Correction
    e14

    Socioeconomic Inequalities in Health in 22 European Countries Special Article, N Engl J Med 2008:358;2468-2481.

    We have discovered an error in the mortality data from England; this error is related to an ambiguity in the labels of educational categories. ...

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