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January 7, 2010  Vol. 362 No. 1

Audio Summary of this Issue

Perspective
1-3
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Michael Chernew and colleagues write that the historical flow of valuable but costly medical advances raises a profound question: can that flow be maintained in future years without rates of spending increase that wreak economic havoc?

3-5

Peter Lee and colleagues argue that the harmonization of payment models would require a few simple steps that build on the revision of fee-for-service payments to reflect services' value for patients.

6-7

After reading physician-rating sites, Dr. Shaili Jain is reassured that what patients want from their physicians is not all that different from what good physicians want to offer their patients.

Original Articles
9-17

Staphylococcus aureus is an important cause of surgical-site infections. In this randomized trial, eradication of colonization by rapid screening at admission and subsequent decolonization (with intranasal mupirocin and chlorhexidine skin washes) were associated with a decrease in postoperative surgical-site infections.

18-26

The skin is a source of infection associated with surgery. In this multicenter, randomized trial, the preoperative application of chlorhexidine–alcohol was found to be a more effective skin preparation than povidone–iodine for preventing incisional infections.

27-35
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Pregnant women are at increased risk for clinically significant complications associated with influenza infection. This study analyzed data reported for 239 women of reproductive age who were hospitalized with 2009 H1N1 influenza in California between April 23 and August 11, 2009; 94 were pregnant and 8 were postpartum. Intensive care was required in 18 pregnant women and 4 postpartum women, and 8 died. Infection with the 2009 H1N1 virus can cause significant morbidity and mortality in pregnant and postpartum women.

36-44
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A genomewide association study involving children of Northern European ancestry who had asthma yielded an association with a locus on chromosome 1q31 that was replicated in two additional case–control series, one involving subjects of Northern European ancestry and the other, children of African ancestry. The implicated locus houses DENND1B, which is expressed by natural killer cells and dendritic cells of the immune system.

45-55

In the global 2009 H1N1 influenza pandemic, children are particularly vulnerable to severe disease. During the winter (May through July 2009) in Buenos Aires, the death rate associated with 2009 H1N1 influenza in children was 10 times that associated with seasonal influenza in 2007 (1.1 vs. 0.1 per 100,000 children).

Clinical Practice
56-65
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A 54-year-old woman with type 2 diabetes presents for care. Her creatinine level has increased from 1.1 mg per deciliter (97 μmol per liter) 4 years ago to 3.1 mg per deciliter (274 μmol per liter) at the most recent measurement (estimated glomerular filtration rate, 26 ml per minute per 1.73 m2 of body-surface area). Her urinary protein excretion is 2.8 g per 24 hours. Her blood pressure is 155/90 mm Hg, and the glycated hemoglobin level is 7.6 mg per deciliter. Her current medications include an oral hypoglycemic agent, an angiotensin-converting–enzyme inhibitor, a statin, and a thiazide diuretic. How should her case be managed?

Images in Clinical Medicine
66
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A 74-year-old man presented to his outpatient physician after noticing a painless, visible abdominal mass 3 weeks earlier (Panel A). His medical history was significant for 40 pack-years of smoking and a left mandibulectomy, parotidectomy, neck dissection,...

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This 63-year-old woman with diabetes mellitus presented with an ulcerating rash on the shins, groin, and face. It had been worsening for 4 years despite specialized wound care. Given her history, abdominal CT was performed and glucagon levels were ...

Clinical Problem-Solving
67-73

    A 57-year-old man presented to the emergency department with painful purple discoloration of three toes on his left foot. He had also had intermittent blurry vision, intermittent chest pain, fatigue, anorexia, drenching night sweats, and a weight loss of 7 kg (15 lb) over the previous 3 weeks. His roommate commented that the patient had been slightly confused.

    Editorial
    75-77

    Primitive ancestors of Homo sapiens and their colonizing bacteria have coevolved for approximately 500,000 years; some experts estimate that the total number of human cells is 1013 and the total number of colonizing microbes is 1014. Despite this 10-to-1 ...

    Correspondence
    78-79

    To the Editor: The analysis of variation in hospital mortality by Ghaferi et al. (Oct. 1 issue)1 requires further scrutiny. The primary exposure variable used by these authors was risk-adjusted mortality. However, there are difficulties in applying risk-...

    79-81

    To the Editor: Ginès and Schrier (Sept. 24 issue)1 offer a succinct and thoughtful review of various causes of renal failure in cirrhosis, including the hepatorenal syndrome, hypovolemia due to hemorrhage or fluid losses, parenchymal disease, and drug-...

    81-84

    To the Editor: In his review article on parenteral nutrition in the critically ill patient, Ziegler (Sept. 10 issue)1 does not include a detailed discussion of glycemic control. The original Leuven study combined intensive insulin therapy with early ...

    84-85

    To the Editor: In his Clinical Practice article, Lieberman (Sept. 17 issue)1 recommends colonoscopy for colorectal-cancer screening, but he gives little attention to immunochemical fecal occult-blood tests. The overall performance of screening programs ...

    86

    To the Editor: In his Perspective article, Crosson (Oct. 1 issue)1 discusses a concept for health care delivery called integrated delivery systems, which is similar to the vertical-integration system proposed by Hillary Clinton. Each system was designed ...

    86-87

    To the Editor: Oseltamivir-resistant infection with the 2009 pandemic influenza A (H1N1) virus has so far been described only rarely and is conferred by the H275Y substitution in the neuraminidase enzyme.1 Only 3 of the 32 patients with oseltamivir-...

    88-89

    To the Editor: A 10-year-old girl with acute lymphoblastic leukemia was transferred to our hospital on August 31. The patient required mechanical ventilation for worsening lobar pneumonia, despite the administration of broad-spectrum antibiotics (for ...