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July 23, 2009  Vol. 361 No. 4

Audio Summary of this Issue

Perspective
325-328

Directed by Congress to rapidly develop a list of broad-based priorities for the Department of Health and Human Services (DHHS) to consider as it implements a new agenda for comparative-effectiveness research (CER), the Institute of Medicine (IOM) ...

328-330

Despite a plethora of diagnostic and treatment options, practical information that can guide health care choices for an individual patient are often elusive, and the resultant clinical uncertainty is an important factor driving regional variations in ...

331-333

The American Recovery and Reinvestment Act of 2009 (ARRA), the stimulus package signed into law by President Barack Obama on February 17, 2009, directs $1.1 billion to support “the development and dissemination of research assessing the comparative ...

Original Articles
335-344

Typhoid remains an important cause of illness and death in the developing world. In this phase 4 trial in Kolkata, India, 37,673 subjects were vaccinated with either Vi typhoid vaccine or hepatitis A vaccine. The Vi vaccine was approximately 61% effective in preventing typhoid infection in vaccine recipients and was 44% effective in unvaccinated members of the same clusters as the Vi-vaccine recipients, suggesting that Vi vaccination has indirect benefits for those in close contact with vaccine recipients.

345-357

Atypical hemolytic–uremic syndrome, a complex of microangiopathic hemolytic anemia, thrombocytopenia, and renal failure, is not associated with shigella toxin — unlike typical hemolytic–uremic syndrome — but is often associated with abnormal activation of complement by mutant components of the system. This study shows that in some patients with the atypical syndrome, there are disabling mutations of the THBD gene, which encodes thrombomodulin. As a result of these mutations, regulation of complement activation on cell surfaces is impaired, and cells are not protected from activated complement.

358-367

After determining that vascular endothelial growth factor (VEGF) was expressed in vestibular schwannomas, the investigators administered bevacizumab, an anti-VEGF monoclonal antibody, to 10 consecutive patients who had neurofibromatosis 2 and vestibular schwannomas. Some patients had a reduction in tumor volume and improvement in hearing.

Special Article
368-378
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In 2004, England introduced a pay-for-performance system to reward family physicians for achieving clinical-quality targets. This analysis of the quality of care for coronary heart disease, asthma, and diabetes from 1998 through 2007 shows that although there was an initial gain in quality after the system was introduced, quality improvement subsequently slowed.

Clinical Practice
379-387
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A healthy 29-year-old woman who has been trying to conceive presents with vaginal spotting for the past 5 days and intermittent crampy abdominal pain in her left lower quadrant for the past 3 days. Her last menstrual period was 6 weeks and 2 days before presentation. She has had a spontaneous vaginal delivery and an anembryonic gestation treated by dilation and curettage. How should this patient be evaluated and treated?

Images in Clinical Medicine
388
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A 53-year-old woman was admitted to the hospital for evaluation of a 1-week history of lower abdominal pain and dysuria. She was afebrile. Plain abdominal radiography showed air throughout the urinary tract in the kidneys, ureters, and bladder (arrows). ...

e4
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A 36-year-old woman was seen after congenital myotonic dystrophy was diagnosed in her newborn son. She had swum competitively and could run 5 to 8 km without difficulty. However, careful examination revealed percussion myotonia and grip-release myotonia.

Case Records of the Massachusetts General Hospital
389-400

    A 13-year-old boy was admitted to the hospital because of headache, nausea, seizures, renal failure, and hypertension. Three weeks earlier, headaches, fatigue, and anorexia developed, with constipation and occasional nausea and vomiting. On the day of admission, nausea and vomiting became severe; episodes of numbness of the right leg and dizziness occurred, and he came to the emergency department, where he was found to be hypertensive with renal failure. A diagnostic procedure was performed.

    Editorials
    402-403
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    More than a decade ago, David Kessler, then Commissioner of the Food and Drug Administration (FDA), launched a bold initiative to regulate tobacco. He believed that since nicotine is an addictive substance, it fell under the statutory authority of the FDA ...

    403-405

    Enteric fevers encompass typhoid fever caused by Salmonella enterica serotype Typhi (S. Typhi) and paratyphoid fever caused by serotype Paratyphi A or B (S. Paratyphi). These human-restricted pathogens are acquired by ingesting contaminated water or food, ...

    Health Policy Report
    406-414

    In this report, the authors review the experience to date with the Medicare Part D prescription-drug plan and discuss the challenges facing policymakers.

    Correspondence
    415-421

    To the Editor: In the April 9 issue, van Marken Lichtenbelt et al.,1 Cypess et al.,2 and Virtanen et al.3 report on functioning supraclavicular brown adipose tissue in adult humans. Van Marken Lichtenbelt et al. conclude that brown-adipose-tissue ...

    421-422

    To the Editor: In their study of the use of electronic health records, Jha et al. (April 16 issue)1 report that only 1.5% of U.S. hospitals have comprehensive electronic-records systems, and 7.6% have a basic system that includes a capacity to store ...

    422-424
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    To the Editor: Supportive care is the mainstay of therapy for acute myocarditis. In his review article on this topic, Cooper (April 9 issue)1 notes that studies of immunosuppressive therapy have not shown a clear beneficial role, as compared with usual ...

    424-425

    To the Editor: The number of patients who would need to be treated to prevent a given adverse outcome in one patient, called the number needed to treat, is often used in randomized trials and observational studies to provide a simple measure of the ...

    425-427

    To the Editor: Muscle glycogen storage diseases are rare inborn diseases caused by errors of metabolism associated with either dynamic, exercise-related symptoms or permanent muscle weakness. The most common glycogen storage disease, McArdle's disease (...

    Book Reviews
    428

    The fascinating field of infectious diseases is evolving rapidly. The discovery of new pathogens, the reappearance of old ones, and the emergence of new information have made infectious diseases books like this one a welcome addition for physicians who ...

    428-429

    A decade ago, a textbook linking the human genome and diseases of the kidney would have contained more questions than answers. This is probably the first textbook dedicated to the genetics of kidney disease. Its 47 chapters, written by 87 contributing ...

    429-430

    Much has changed in the field of reproduction since 1978, when Louise Brown, the first “test-tube baby,” was born. In the United States, approximately 1 in 80 births is now the result of in vitro fertilization. Originally developed to treat infertility ...

    Corrections
    431

    Overseas Screening for Tuberculosis in U.S.-Bound Immigrants and Refugees Original Article, N Engl J Med 2009:360;2406-2415.. The term “incidence” should be replaced with “prevalence” in four places in the article. In Table 1 (page 2409) and Table 2 (page ...

    431

    Toll-like Receptor 3 and Geographic Atrophy in Age-Related Macular Degeneration Original Article, N Engl J Med 2008:359;1456-1463.. In the Statistical Analysis subsection of Methods (page 1458), the P value given at the end of the first sentence should ...

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