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October 29, 2009  Vol. 361 No. 18

Audio Summary of this Issue

Perspective
1717-1720

Drs. Lisa Schwartz and Steven Woloshin write that much critical information that the FDA has at the time of approval may fail to make its way into the drug label and relevant journal articles.

1720-1722
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Health economist Victor Fuchs discusses four specific health care reforms that should be enacted this year.

1722-1725
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Drs. Gary Franklin and Brian Budenholzer discuss the use of evidence-based principles in improving the quality of care, reducing overuse and underuse of health care services, and determining what benefits should be covered by Washington State's public ...

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After months of wrangling with Republicans over the appropriate role of government in health care, the Senate Finance Committee's 13 Democrats were joined by a lone Republican, Senator Olympia Snowe of Maine, on October 13 in approving a reform bill that ...

Original Articles
1727-1735

Homozygous mutations in the CARD9 gene, with a premature termination codon, are associated with chronic mucocutaneous candidiasis in an Iranian family. Dysfunction of CARD9 impairs the innate signaling of dectin-1, an antifungal pattern-recognition receptor.

1736-1747

In this 3-year multicenter trial, patients with suboptimal glycated hemoglobin levels while receiving metformin and sulfonylurea therapy were randomly assigned to add biphasic, prandial, or basal insulin. During the first year, sulfonylurea therapy was replaced by additional insulin for unacceptable hyperglycemia or subsequently for a glycated hemoglobin level of more than 6.5%. Basal- or prandial-based insulin regimens more often achieved glycated hemoglobin targets. Fewer hypoglycemic episodes and less weight gain occurred with regimens initiated with basal insulin.

1748-1759

This study from four Australian centers examined whether low-dose, continuous oral antibiotic therapy would prevent urinary tract infection in children (under the age of 18 years) who had already had one or more microbiologically proven urinary tract infections. Long-term, low-dose trimethoprim–sulfamethoxazole was associated with a modest decrease in the number of urinary tract infections in predisposed children.

1760-1767

A family with recurrent mucocutaneous candidiasis was evaluated for a potential genetic cause. An early-stop-codon mutation in the β-glucan receptor dectin-1 was found in the affected family members. These data suggest an important role of dectin-1 in mucosal antifungal defense.

Clinical Practice
1768-1775
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A 24-year-old man presents to an outpatient clinic, reporting that 36 hours previously he had receptive anal intercourse without the use of a condom with an anonymous male partner. The patient is known to the clinical practice and has had several negative tests for human immunodeficiency virus infection, most recently 6 months previously. How should he be evaluated and treated?

Review Article
1776-1785

    Noroviruses are now recognized as the leading cause of epidemics of gastroenteritis and an important cause of sporadic gastroenteritis among both children and adults. In the United States, more than 90% of the outbreaks of gastroenteritis for which the cause could not previously be identified can now be attributed to this virus. Understanding the nature of immunity to the norovirus is a key determinant for future improvements in the control and prevention of this viral infection.

    Images in Clinical Medicine
    1786
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    A 68-year-old man who had hypertension, diabetes, and atrial fibrillation and was being treated with warfarin was discovered snoring and unarousable at home. He had been in his usual state of good mental and physical health earlier in the day. There was ...

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    A 39-year-old woman presented with progressive shortness of breath, fatigue, and edema. The physical examination revealed hypotension, tachycardia, jugular venous distention, pulsus paradoxus, and distant heart sounds.

    Case Records of the Massachusetts General Hospital
    1787-1796

      A 20-year-old man was admitted to this hospital because of sore throat, fever, and a diffuse rash for 1 week. Testing for streptococcal pharyngitis and mononucleosis was negative. Amoxicillin and clavulanate were prescribed, and the next day, a red, itchy rash developed on the medial surface of his right arm; the lesions became raised, enlarged, and painful and spread from his arms to his legs, back, hands, feet, and perioral area, without mucosal involvement. Examination disclosed a diffuse eruption of tender violaceous-pink papulovesicles, which progressed to hemorrhagic crusting. A diagnostic procedure was performed.

      Editorials
      1798-1801

      We lead inextricably mycotic lives: yeasts leaven our bread, ferment our wine and beer, and inhabit our skins, mouths, and gastrointestinal tracts; however, not all is harmony. Hippocrates reported aphthous ulcers consistent with thrush in patients with ...

      1801-1803

      Patients with type 2 diabetes have peripheral insulin resistance and inadequate insulin secretion by pancreatic beta cells. During meals, reduced first-phase insulin secretion results in postprandial hyperglycemia and in a 35% decrease in hepatic glycogen ...

      1804-1806

      Approximately one third of children who have a urinary tract infection — the most frequent serious bacterial infection in young febrile children — have vesicoureteral reflux, a congenital condition in which the urine flow is retrograde from the bladder ...

      Correspondence
      1807-1808

      To the Editor: Dondorp et al. (July 30 issue)1 describe artemisinin-resistant Plasmodium falciparum, based on a prolonged parasite clearance time, in Pailin, western Cambodia, as compared with Wang Pha, on the Thai–Burmese border. Paradoxically, post-...

      1808-1809

      To the Editor: McHutchison et al. (Aug. 6 issue)1 report a similar rate of sustained virologic response among patients who received low-dose peginterferon alfa-2b plus ribavirin and patients who received other regimens. Although the groups of patients ...

      1809-1811

      To the Editor: Plotkin et al. (July 23 issue)1 report a sustained tumor-volume reduction in 4 of 10 patients and a hearing response in 4 of 10 patients with neurofibromatosis type 2 after bevacizumab treatment. The authors' conclusion that tumor ...

      1811-1812

      To the Editor: Frank et al. (July 9 issue)1 do not discuss the issue of therapeutic misconception2 — namely, the belief by a research subject that the investigational agent is actually therapeutic. Admittedly, there was no concrete evidence for this ...

      1812-1813

      The cumulative live-birth rates were 43.9% in the single-embryo-transfer group and 51.1% in the double-embryo-transfer group. The multiple-birth rate was significantly lower in the single-embryo-transfer group.

      Corrections
      1814

      Mutations in SYNGAP1 in Autosomal Nonsyndromic Mental Retardation Original Article, N Engl J Med 2009:360;599-605.. In the author list (page 599), “Elizabeth Perreault-Linck, M.Sc.” should have been “Elizabeth Perreau-Linck, M.Sc.” The article has been ...

      1814

      Apixaban or Enoxaparin for Thromboprophylaxis after Knee Replacement Original Article, N Engl J Med 2009:361;594-604.. In the disclosure statement (page 604), Astellas should have been included in the list of companies from which Dr. Lassen reports ...

      1814

      Atypical Antipsychotic Drugs and the Risk of Sudden Cardiac Death Original Article, N Engl J Med 2009:360;225-235.. In Table 3 (page 233), the values listed in the columns “No. of Person-Years” and “No. of Sudden Deaths” for haloperidol and thioridazine ...