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July 17, 2008  Vol. 359 No. 3

Audio Summary of this Issue

Perspective
221-224

Despite sweeping changes in scientific knowledge, requirements for admission to medical school have remained virtually unchanged for many decades. Dr. Jules Dienstag writes that he supports greater efficiency and a tighter focus on science that “matters” ...

224-227

Nontraditional students bring maturity, diversity, broader perspectives, and “life experience.” Dr. Sandeep Jauhar asks, are the diverse backgrounds and interests of nontraditional medical students really what the profession needs?

Original Articles
229-241

This 2-year trial, which took place in an isolated workplace that facilitated retention in the study, randomly assigned 322 moderately obese subjects to one of three diets: a low-fat, restricted-calorie diet; a Mediterranean, restricted-calorie diet; or a low-carbohydrate, non–restricted-calorie diet. The results suggest that the Mediterranean and low-carbohydrate diets are effective alternatives to low-fat diets and that personal preferences and metabolic considerations might inform individualized tailoring of dietary interventions.

242-251

This open-label, phase 1–2, single-center study examined the use of intravenous immune globulin and rituximab to reduce anti-HLA antibodies and improve transplantation rates in 20 highly sensitized patients. Sixteen patients (80%) subsequently received a transplant, and the 1-year survival rates for patients and allografts were 100% and 94%, respectively. Larger and longer trials are needed to assess the safety of this approach.

252-261

Effective strategies to prevent falls among elderly persons have been identified but are underutilized. In this comparison of a region of Connecticut in which persons were exposed to interventions to prevent falls and a region without such exposure, the interventions were associated with a 9% reduction in serious injuries from falls. These findings suggest that the dissemination of information about fall prevention may reduce numbers of falls and serious injuries.

262-273
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This study used national registries in Norway to identify children of different gestational-age categories who were born between 1967 and 1983 and to follow them through 2003. The risks of medical and social disabilities increased with decreasing gestational age at birth. Even among those who did not have medical disabilities, the gestational age at birth was associated with the education level attained, income, the receipt of social security benefits, and the likelihood of establishing a family.

Special Article
274-284
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The English pay-for-performance program allows “exception reporting,” in which physicians exclude individual patients from calculations when the quality target should not apply. From April 2005 through March 2006, physicians excluded 5% of patients, and exception reporting accounted for only about 1.5% of the cost of the program.

Clinical Therapeutics
285-292

A 25-year-old man presents to the emergency department with a toothache and is found to have been ingesting large quantities of acetaminophen. Although no acetaminophen is detectable in his blood, his serum alanine aminotransferase concentration is 750 IU per liter, and treatment with acetylcysteine is recommended. Acetylcysteine repletes glutathione stores in the liver. It helps to prevent hepatotoxicity in cases of acetaminophen overdose and also improves survival in patients with acetaminophen-induced hepatic failure.

Images in Clinical Medicine
293
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A 59-year-old woman with the Budd–Chiari syndrome was admitted for increasing abdominal distention, abdominal pain, and vomiting during a period of 8 weeks. She had normal renal function and had never received dialysis. Examination of the ascites revealed ...

e3
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This 58-year-old woman presented with white facial patches that had progressively increased in size (shown under Wood's light). There was also a 2-cm gray lesion on the right leg and inguinal adenopathy.

Case Records of the Massachusetts General Hospital
294-303

    A 52-year-old woman was admitted to this hospital because of fever and confusion. The patient was first taken to the emergency department of another hospital, where she was reported to be lethargic and disoriented. Several hours later, a tonic–clonic seizure occurred, and she was transferred to this hospital. The patient lived in a rural area of Massachusetts and had been bitten by mosquitoes. MRI scans showed multiple bilateral lesions in the brain that were hyperintense. On the fourth hospital day, the result of a diagnostic test was received.

    Editorial
    305-306

    The advent of solid-organ transplantation for the treatment of patients with end-stage organ failure has been one of the most exciting medical advances in the late 20th and early 21st centuries. Thousands of lives have been saved or improved by ...

    Clinical Implications of Basic Research
    307-309

      A post-translationally modified portion of IgG seems to be the critical agent that mediates the antiinflammatory effect of this molecule.

      Correspondence
      310-311

      To the Editor: Sparano et al. (April 17 issue)1 compare the efficacy of two different taxanes, given either weekly or every 3 weeks, in the adjuvant treatment of breast cancer. It is striking that there were no significant differences in disease-free ...

      311-313

      To the Editor: Gurm and colleagues (April 10 issue)1 conclude that carotid stenting is not inferior to carotid endarterectomy in high-risk patients. This conclusion may be misleading. First, patients were at high risk not for stroke but for surgery. ...

      313-315

      To the Editor: Rosenthal (April 24 issue)1 presents a hypothetical case of malaria and states that there is “major concern” about the timeliness of artesunate availability because it is available rapidly only for hospitals that are near the 20 Centers ...

      315-316

      To the Editor: Redline et al. (April 17 issue)1 discuss an interesting case of a newborn with seizures and apnea secondary to perinatal ischemic stroke. Although an accurate diagnosis was made without the use of lumbar puncture and cerebrospinal fluid ...

      316-318

      To the Editor: Our experience has been very similar to that described by Lenart et al. (March 20 issue)1 in their report on atypical fractures of the femoral diaphysis. These fractures have a distinctive pattern and most likely represent completion of a ...

      318-319

      The authors report on a four-generation family carrying a mutation in the gene for ADPKD2 (PKD2) with previously undetected polycystic kidney disease. In the present generation, however, perinatal death due to polycystic kidney disease occurred in the ...

      320-321

      To the Editor: We report the development of locally advanced non–small-cell lung cancer (tumor–node–metastasis [TNM] stage T4N2M0) in a 69-year-old woman with Crohn's colitis. Her condition had been diagnosed in 2000 and had required treatment with ...

      Book Reviews
      322

      According to population studies, the prevalence of the metabolic syndrome in the United States among people over 60 years of age is approximately 45%, and the newest surveys suggest that this figure is now closer to 60%. The more than 3 million hits on ...

      323-324

      Shortly before his election as president, John F. Kennedy wrote, “Let us welcome controversial books and controversial authors.” To this statement we might add “and books on controversial medical topics,” since the book Controversies in Treating Diabetes ...

      324-325

      As one who works in the field of transplantation, I find it hard not to be positively predisposed to a book that begins with the dedication, “To all living donors for their vision and courage.” Living donors have always been crucial to transplantation. In ...

      Correction
      325

      Acute Calculous Cholecystitis Clinical Practice, N Engl J Med 2008:358;2804-2811.. The second sentence in the Strategies and Evidence section, under Diagnosis (page 2805), should have read, “The pain is characteristically episodic, severe, and located in ...