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October 1, 2009  Vol. 361 No. 14

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Perspective
1321-1323

Francis Collins, the physician and geneticist who was sworn in as the 16th director of the NIH in August 2009, anticipates scientific opportunities and budgetary challenges. Dr. Robert Steinbrook interviewed Dr. Collins on September 2.

1324-1325

Dr. Francis Crosson argues that two interacting sets of changes need to occur: movement away from fee-for-service payment of physicians toward prospective payment, and multispecialty integration of physicians combined with hospitals to form new “...

1326-1327
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Dr. Denis Cortese and Jeffrey Korsmo write that we must hold physicians and other providers accountable for providing high-value health care, defined in terms of both quality and cost. They propose that we create a value score for each medical institution ...

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In an address to the American Medical Association on June 15, 2009, President Barack Obama acknowledged that he needed physicians' support on health care reform and offered to work with physicians to achieve the reform he believes is essential. In recent ...

e24

In the past few months, a key point of contention in the health care reform debate has been whether a public health insurance option should be included in the final legislation. Although polls have shown that 52 to 69% of Americans support such an option,...

e25

In a rare address to Congress, designed to consolidate support among Democrats behind one health care reform plan, reassure people with insurance that they would benefit from reform, and offer conciliatory gestures to skeptical Republicans, President ...

Original Articles
1329-1338

Cardiac-resynchronization therapy is recommended for patients with advanced, symptomatic heart failure. This clinical trial found benefit in asymptomatic patients, but since the rate of death was not affected, it remains to be seen whether clinical guidelines will be modified to include asymptomatic patients.

1339-1348

In this randomized trial of treatment versus no treatment for mild gestational diabetes mellitus, rates of the primary outcome (a composite of stillbirth or perinatal death and neonatal hyperbilirubinemia, hypoglycemia, hyperinsulinemia, or birth trauma) did not differ significantly between groups. However, there were significant reductions with treatment in several secondary outcomes, including the frequency of large-for-gestational-age infants, shoulder dystocia, cesarean delivery, and hypertension in pregnancy.

1349-1358

In this randomized trial involving newborn infants with asphyxial encephalopathy, hypothermic therapy did not significantly reduce the rate of the primary outcome (i.e., death or severe neurodevelopmental disability) but did result in improvement in several prespecified secondary neurologic outcomes among survivors.

1359-1367

Three children who received a liver transplant for bile salt export pump (BSEP) deficiency had recurrent disease accompanied by high titers of anti-BSEP antibody, and remission was achieved through the use of an intensified immunosuppressive regimen. This result suggests that disease recurring after transplantation may be caused by an immune reaction against BSEP in the transplanted liver.

Special Article
1368-1375
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In this analysis of more than 84,000 surgical patients enrolled in a prospective quality-improvement study, hospitals with increased postoperative rates of death had similar rates of postoperative complications as other hospitals but higher mortality after complications. These findings suggest that a reduction in mortality will require both prevention of complications and improved care of patients who have complications.

Review Article
1376-1385

Whether it is caused by herpes simplex virus (HSV) type 1 or type 2, neonatal HSV infection is a devastating disease if untreated, and more than 30% of pregnant women in the United States have genital infection with HSV. This review summarizes the current facts on this disease and its early identification and treatment, as well as the prospects for more effective prevention.

Images in Clinical Medicine
1386
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A 76-year-old native Dutch woman was admitted to our intensive care unit for hemodynamic monitoring after undergoing vulvectomy and inguinal lymph-node dissection for vulvar carcinoma. Preoperative evaluation had revealed a history of deep venous ...

e26
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A 50-year-old woman presented with a 6-month history of unilateral rhinorrhea. She reported no headaches, weight change, galactorrhea, or visual disturbance. When she bent forward, drops of clear fluid fell from her right nostril.

Clinical Problem-Solving
1387-1392

    A 52-year-old man presented to the emergency department with a 5-week history of abdominal discomfort. The pain worsened after eating and was associated with nausea and bloating. Two weeks before presentation, the patient's pain localized more to the periumbilical area and was accompanied by early satiety and vomiting. He had no fever, diarrhea, tenesmus, melena, or hematochezia.

    Editorials
    1394-1396

    Cardiac-resynchronization therapy (CRT) received Food and Drug Administration approval for use in selected patients with left ventricular systolic dysfunction in 2001. Since that time, CRT has been embraced as a recommended approach to achieve meaningful ...

    1396-1398

    In 1964, O'Sullivan and Mahan1 proposed glucose-tolerance-test criteria to define gestational diabetes mellitus — that is, any degree of glucose intolerance that first occurs or is first identified during pregnancy. Women whose glucose levels exceeded ...

    1398-1400

    Health care organizations have appropriately begun to focus increased attention on the quality of medical services they provide to their patients.1 Reports from the Institute of Medicine (IOM) have illustrated how frequently errors occur in our hospitals ...

    Sounding Board
    1401-1406

    The authors argue that in the context of appropriate efforts to reduce medical errors by correcting problems in care-delivery systems, health care organizations have underemphasized individual responsibility. They propose punishing providers who repeatedly do not adhere to procedures for improving patient safety, such as hand washing.

    Correspondence
    1407-1410

    To the Editor: In the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial (ClinicalTrials.gov number, NCT00006305) reported on by Frye and colleagues (June 11 issue),1 patient inclusion was based on a coronary anatomy that was ...

    1410-1411

    To the Editor: Mauer et al. (July 2 issue)1 used structural hallmarks of diabetic renal disease to show that early blockade of the renin–angiotensin system did not slow progression of type 1 diabetic nephropathy. The study excluded patients whose blood ...

    1411-1413

    To the Editor: Bosch and colleagues (July 2 issue)1 observe that although conventional hemodialysis filters do not remove myoglobin (molecular weight, 17.8 kD), hemodiafiltration with super-high-flux dialyzers may be effective.2 We used a hemodialysis ...

    1413-1415

    To the Editor: In their Perspective article (June 25 issue),1 Bodenheimer et al. accurately depict our nation's intensifying primary care crisis. Although studies have found that increasing the number of primary care physicians leads to better and ...

    1415-1416

    To the Editor: The Sézary syndrome is a leukemic, cutaneous, epidermotropic T-cell lymphoma. Pruritus, insomnia, and depression impair the quality of life and can lead to suicide.1 Substance P is a key mediator of pruritus.2 An increase in the expression ...

    Corrections
    1416

    Intestinal Transplantation Review Article, N Engl J Med 2009:361;998-1008.. In Table 2 (page 1000), the heading above the first column of data should have read “Children (N=1031),” and the heading above the second column should have read “Adults (N=733).” ...

    1416

    Case 22-2009: A 59-Year-Old Man with Skin and Pulmonary Lesions after Bone Marrow Transplantation Case Records of the Massachusetts General Hospital, N Engl J Med 2009:361;287-296.. The article title should have read, “Case 22-2009: A 59-Year-Old Man with ...

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