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October 23, 2008  Vol. 359 No. 17

Audio Summary of this Issue

Perspective
1749-1751

Major U.S. health care reform will not be an option much longer: it will be a necessity. Victor Fuchs writes that the debate about health care will be more constructive if all participants take these “inconvenient truths” as a starting point.

1751-1755

The United States spends twice per capita what other major industrialized countries spend on health care. Karen Davis writes that a series of coordinated policy changes has the potential to substantially bend the curve of projected health care spending.

Original Articles
1757-1765

This study examined the mutation status of the K-ras gene in colorectal tumors from patients who were enrolled in a trial of cetuximab, a monoclonal antibody against the epidermal growth factor receptor (EGFR). A survival benefit was found among patients with tumors bearing wild-type K-ras but not among patients with tumors bearing mutated K-ras. Wild-type K-ras is essential in transmitting signals initiated by EGFR.

1766-1777

Toll-like receptors (TLRs) are a central aspect of the innate immune response. Different TLRs are associated with the immune response to different infectious pathogens. In this retrospective analysis, an increased susceptibility to invasive aspergillosis was associated with certain polymorphisms in donor TLR4 in patients who received an allogeneic hematopoietic stem-cell transplant from an unrelated donor.

1778-1785

In patients with symptomatic atrial fibrillation and heart failure, pulmonary-vein isolation was found to be superior to atrioventricular-node ablation with biventricular pacing. Isolation of the pulmonary veins by means of ablation is a viable option for patients with refractory atrial fibrillation and heart failure.

1786-1801
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In this randomized, phase 2 trial involving previously untreated patients with early, relapsing–remitting multiple sclerosis, alemtuzumab, a monoclonal antibody targeting CD52 on lymphocytes and monocytes, was more effective than interferon beta-1a in reducing the progression of disability and relapse. Alemtuzumab caused autoimmune complications, including immune thrombocytopenic purpura (resulting in one death) and thyroid disorders.

Special Article
1802-1810

A program requiring prior authorization for the use of clopidogrel was in place in Canada in 2000. After the prior-authorization requirement was removed in September 2003, the use of clopidogrel in patients receiving coronary stents after myocardial infarction increased substantially and clinical outcomes improved.

Review Article
1811-1821

    This review summarizes relevant studies concerning uric acid and possible links to hypertension, renal disease, and cardiovascular disease. Whether uric acid is an independent risk factor for such diseases is still a point of debate. Current evidence is presented.

    Images in Clinical Medicine
    1822
    • Free Full Text

    A 74-year-old male smoker was hospitalized for a transurethral resection of the prostate. A preoperative chest x-ray raised the suspicion of a finding that had been overlooked 6 months earlier.

    e22

    A 24-year-old man presented with a 2-day history of redness, photophobia, and blurry vision in the right eye. His vision in that eye was 20/50, and corneal sensation was decreased.

    Case Records of the Massachusetts General Hospital
    1823-1832

    A 63-year-old woman was admitted to the hospital because of a 3-week history of dyspnea on exertion, associated left subscapular burning pain, and a mild dry cough. She had a history of ulcerative colitis, which was most recently treated with azathioprine and infliximab. On examination, there were inspiratory wheezes and rales, without expiratory wheezes. Chest imaging showed ground-glass opacities in both lower lobes. A diagnostic procedure was performed.

    Editorials
    1834-1836

      In the United States, cancer is the most common cause of death among people under the age of 85 years, and colorectal cancer is the second most common cause of death from cancer.1 Chemotherapy for colorectal cancer has until recently typically consisted ...

      1836-1838

      Allogeneic hematopoietic stem-cell transplantation is a potentially lifesaving cancer therapy that, at least temporarily, renders patients highly immunocompromised and vulnerable to infection. Aspergillus fumigatus, a common environmental fungus that ...

      1838-1841

      Multiple sclerosis is a cruel disease. It strikes young adults, runs a chronic, unpredictable course, and is eventually disabling for many patients.1 Both inherited and environmental factors influence the risk and course of the disease.2 Multiple ...

      Clinical Implications of Basic Research
      1842-1844

      Mice treated with an agonist of the AMP-activated protein kinase showed an increase in endurance as compared with exercise-trained controls.

      Correspondence
      1845-1848

      To the Editor: As professionals working in a resource-limited country to prevent the transmission of the human immunodeficiency virus (HIV) from mother to child and to promote child survival and the use of highly active antiretroviral therapy (HAART), we ...

      1848-1849

      To the Editor: DesRoches et al. (July 3 issue)1 describe the low level of adoption of electronic health records by primary care physicians in the United States. In contrast, electronic health records have been widely adopted by primary care and hospital ...

      1850

      To the Editor: In their Medical Progress article, Wen and Kesari (July 31 issue)1 review the molecular pathogenesis of gliomas yet do not mention the role that DNA tumor viruses may play in tumor formation. In the same issue, Prins et al.2 provide ...

      1850-1852

      To the Editor: In the discussion of the Case Record by Bonkovsky et al. (June 26 issue)1 about a patient with porphyria who became symptomatic after gastric bypass surgery, there was no mention of the patient's nutritional care, which may have played a ...

      1853

      To the Editor: Chemotherapy-induced nausea and vomiting is an important problem in patients with brain tumors. Because of the high prevalence of seizures, most patients are given antiepileptic drugs. Motivated by a case report,1 we investigated whether ...

      Book Reviews
      1854-1855

      Sterilization is a medical procedure that can immediately evoke concern about violations of medical ethics. Enthusiasm for sterilization may start with beneficence and the desire for social justice, but sterilization has often led to outrageous violations ...

      1855-1856

      In Prescription for Survival, Bernard Lown tells the remarkable story of how he and Eugene Chazov, cardiologists whose countries were on opposite sides of the Cold War, created and nurtured the organization International Physicians for the Prevention of ...

      1856-1857

      This book introduces an evolutionary approach to medicine and offers the reader extensive coverage of medical topics to which evolutionary principles can be applied. The book's 23 chapters were written by an international team of 47 leading researchers ...

      1857-1858

      Recent progress in human and medical genetics has been nothing short of astonishing in its breadth, complexity, and speed. There have been few comprehensive reviews of the ethical and social issues that are posed by achievements in the field, particularly ...

      Corrections
      1859

      Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia Original Article, N Engl J Med 2008:359;130-141.. In the Results section, in the third paragraph under HIV-free Survival at 24 Months (page 138), the second sentence should have ...

      1859

      Toll-like Receptor 3 and Geographic Atrophy in Age-Related Macular Degeneration Original Article, N Engl J Med 2008:359;1456-1463.. The reference list was inadvertently altered during the final processing of the file before publication. We regret the ...

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