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October 30, 2008  Vol. 359 No. 18

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Perspective
1865-1867
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Henry Aaron argues that to cut waste in health care, the first step should be heavy investment in research on what works and what doesn't, and at what cost. The second step would be to extend insurance coverage to the uninsured.

1867-1869

Dr. Eli Adashi and Darrell West discuss how the national debate about “reproductive freedom” has evolved to include the use of human embryos for stem-cell research, the assurance of access to family-planning services and comprehensive sex education, and ...

1869-1871
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Reproductive health policy has been mired in debates over abortion and sexuality, leaving unresolved a cluster of reproductive health problems. Dr. Allan Rosenfield, R. Alta Charo, and Dr. Wendy Chavkin argue that reframing this cluster of issues in terms ...

Original Articles
1873-1884
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This international randomized, controlled trial involving very-low-birth-weight infants aimed to determine whether early insulin replacement reduced hyperglycemia and affected morbidity and mortality. Infants received a continuous infusion of insulin with dextrose support or standard neonatal care for the first week of life. The results show that early insulin in very-low-birth-weight infants had little clinical benefit.

1885-1896

In this randomized trial of infants with a birth weight of 1000 g or less, as compared with conservative phototherapy, aggressive phototherapy did not significantly reduce the rate of death or neurodevelopmental impairment at 18 to 22 months of corrected age but did reduce the rate of neurodevelopmental impairment. Preplanned subgroup analyses suggested a possible increased mortality with aggressive phototherapy in infants weighing 501 to 750 g at birth. These results will help guide decisions about the use of aggressive phototherapy in infants of extremely low birth weight.

1897-1908

In a study of four cohorts of patients from Denmark, the subjects were typed for four single-nucleotide polymorphisms in the gene for C-reactive protein (CRP). The resulting genotypes were correlated with an increase in CRP levels of up to 64%, a result predicting significantly increased risks of ischemic heart disease and ischemic cerebrovascular disease. However, no such increase in risk was observed, a result suggesting that the known association between CRP levels and vascular risk is not causal.

1909-1920

This study aimed to test whether injections of alum-formulated glutamic acid decarboxylase 65 (GAD), a major autoantigen in type 1 diabetes mellitus, would reverse recent-onset disease. C-peptide levels declined in both the treatment group and the control group, without significant between-group differences at month 15 (the primary end point), but they had declined significantly more slowly with treatment by month 30. The authors conclude that alum-formulated GAD may help preserve residual insulin secretion in patients with recent-onset type 1 diabetes.

Special Article
1921-1931
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This study was based on a large survey of patients' experiences in the hospital. Hospitals with the highest nurse-staffing levels received the highest ratings from patients with respect to satisfaction with their care. Furthermore, hospitals that received the highest satisfaction ratings from patients provided a modestly higher quality of clinical care than those that received the lowest ratings.

Review Article
1932-1940

Because of mutations in this opportunistic pathogen, infections with C. difficile have become both more prevalent and more virulent. This article summarizes recent changes in the epidemiology of this infection and explains what is known about the changes in disease severity and the response to therapy. The authors discuss the use of new antibiotics, probiotics, immunotherapy, and even bacteriotherapy.

Images in Clinical Medicine
1941
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A 71-year-old man presented with dizziness, progressive lethargy, and confusion. A complete blood count showed pancytopenia. A peripheral-blood smear and bone marrow aspirate are shown. What is the diagnosis?

Case Records of the Massachusetts General Hospital
1942-1949

    A 58-year-old woman was transferred to this hospital because of severe neck pain, fever, and a spinal epidural mass extending from the level of the fourth to the seventh cervical vertebrae, with evidence of mild cord compression seen on imaging studies. Shortly before transfer to this hospital, a diagnostic test result was received.

    Editorials
    1951-1953

    Advancements in the care of very-low-birth-weight (<1500 g) infants have resulted in increased survival. The provision of adequate nutrition to meet the growth needs of these infants is one of the major challenges encountered by persons responsible for ...

    1953-1955

    One of the most debated topics in cardiovascular medicine is whether C-reactive protein (CRP), a component of the acute-phase response, is a causal factor in the pathogenesis of atherosclerosis.1,2 If it is, the implications could be far-reaching and ...

    1956-1958

    Type 1 diabetes mellitus is an autoimmune disease in which pathologic, autoreactive T cells of the immune system attack the insulin-secreting pancreatic islets of Langerhans. Cytotoxic T cells, which bear the CD8 protein on their membrane, kill islets, ...

    Correspondence
    1959-1962

    To the Editor: After the publication of the results of the Veterans Affairs/National Institutes of Health (VA/NIH) Acute Renal Failure Trial Network (ATN) study by Palevsky et al. (July 3 issue),1 we received more than 80 calls asking whether current ...

    1962-1965

    To the Editor: Heard (July 17 issue)1 reports that acetylcysteine reduces the severity of acetaminophen poisoning–induced liver damage by restoring the hepatic glutathione pool. However, one major concern not mentioned in the article is the possible ...

    1965-1966

    To the Editor: After the publication of our review article about human immunodeficiency virus type 1 (HIV-1) subtype diversity (April 10 issue),1 the data cited in the first row of Table 3 in our article, from an abstract by Nkengafac et al.2 (reference ...

    1966-1968

    The incidence of acute myocardial infarction was significantly increased for the first 3 weekdays after the transition to daylight saving time in the spring. In contrast, in the autumn, only the first weekday was affected significantly.

    Book Reviews
    1969-1970

    The death in July 2008 of Victor A. McKusick marked the end of an era. McKusick, widely considered to be the founding father of medical genetics, gave both a name and an important identity to a new scientific discipline — genomics — when he and Frank ...

    1970-1971

    Did you know that corn originated from weedy teosinte? Or that long before he became the first president of Israel, Chaim Weizmann worked as a biotechnologist in England, where he discovered bacteria that are capable of manufacturing acetone, an ...

    1971-1972

    Molecular epidemiology extends traditional epidemiology studies based on questionnaires by incorporating genetic and molecular measures as biomarkers of exposure, risk, and prognosis. The explosion of genetic information and laboratory methods for high-...

    Correction
    1972

    A Multicenter, Randomized, Controlled Trial of Dexamethasone for Bronchiolitis Original Article, N Engl J Med 2007:357;331-339.. Prashant Mahajan, M.D., M.P.H. was incorrectly identified as “Prashant Majahan, M.D., M.P.H.” in the author list (page 331) ...

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