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March 18, 2010  Vol. 362 No. 11

Audio Summary of this Issue

Perspective
965-967

Congress makes explicit projections of federal government spending on health care over the next decade, and the media dutifully report these numbers. Victor Fuchs warns us that lost in the din are two critical problems related to future spending — one ...

967-970

    Over the past decade, limited attention has been paid to the HIV epidemic in the United States. However, Dr. Wafaa El-Sadr and colleagues write that the prevalence of HIV infection in some U.S. populations now rivals that in some sub-Saharan African ...

    970-973

    The complex agenda for comparative-effectiveness research outlined by the Institute of Medicine and the Federal Coordinating Council will require sustained, mission-focused leadership. Jordan VanLare and colleagues propose a five-step process.

    e36

    The President can legitimately claim to have already passed the first round of health care reform in 2009, with the renewal of CHIP and the stimulus bill. Gail Wilensky describes further possible steps in incremental reform.

    e37

    Dr. Annekathryn Goodman traveled with a U.S. national disaster team to Haiti, where they set up a mobile tent hospital on the sites of a devastated school and a nearby adolescent clinic. On the second day, she began what she came to call “touch rounds.”

    e38
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    Dr. Ofer Merin and colleagues write that every mass-casualty event raises ethical issues concerning the priorities of treatment, but the Haiti disaster was exceptional in several ways.

    e39

    The Obama administration and its congressional allies are poised to go it alone on a tortuous path toward enactment of ambitious health care reforms. John Iglehart reports.

    Original Articles
    975-985

    Many children have uncontrolled asthma symptoms when treated with low-dose inhaled corticosteroids (ICS). In this three-way crossover trial, the investigators asked whether doubling the dose of ICS, adding a leukotriene-receptor antagonist to the ICS, or adding a long-acting beta-agonist to the ICS would result in better asthma control. Most children had a best response to the long-acting beta-agonist, but some children had a best response to an increased dose of ICS or a leukotriene-receptor antagonist.

    986-993

    The principal tool used to estimate a woman's risk of breast cancer is the Breast Cancer Risk Assessment Tool, or the Gail model, which includes the number of first-degree relatives with breast cancer, age at menarche, age at first live birth, and number of previous breast biopsies. In this study, the addition of data on genetic variants associated with breast cancer yielded only a minor improvement in the performance of the model.

    994-1004
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    Increasingly widespread public access to automatic external defibrillators in Japan was associated with earlier administration of shocks by laypersons and an increase in the frequency of survival with minimal neurologic impairment after an out-of-hospital cardiac arrest.

    1005-1013
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    The mechanism of benefit of corticosteroid therapy in infantile hemangioma is unknown. In this study, hemangioma-derived stem cells showed vasculogenic activity in vivo when implanted into nude mice. Systemic treatment with dexamethasone or pretreatment of the stem cells with dexamethasone inhibited vasculogenesis. Dexamethasone suppressed the production of vascular endothelial growth factor A (VEGF-A). Silencing of VEGF-A with short hairpin RNA also inhibited vasculogenesis.

    Special Article
    1014-1021
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    Some insurance companies are offering patients incentives to choose lower-cost physicians. This study shows that the current methods used to generate physicians' cost profiles do not have high reliability and that the systems using these cost profiles to identify lower-cost physicians will incorrectly classify many physicians.

    Clinical Practice
    1022-1029
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    A 57-year-old man presents 2 weeks after prostate biopsy with fever, chills, and new lumbar back pain. His temperature is 39.7°C; he has an enlarged, tender prostate and lumbar spine tenderness. His white-cell count is 9100 per cubic millimeter, and the C-reactive protein level is 343 mg per liter. Urine and blood cultures reveal multidrug-resistant extended-spectrum β-lactamase–producing Escherichia coli susceptible to imipenem. How should he be evaluated and treated?

    Images in Clinical Medicine
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    A 25-year-old Sudanese man with a 1-month history of coughing up bloodstained sputum was referred to our facility. Six years earlier, he had had a similar episode lasting 5 weeks, during which he had also had night sweats, weight loss, and fatigue. At ...

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    A 46-year-old woman reported intermittent colicky abdominal pain and loose stool. Laboratory evaluation was unremarkable, with no evidence of anemia. Colonoscopy was performed.

    Case Records of the Massachusetts General Hospital
    1031-1040

    A 22-year-old woman was admitted to this hospital because of hypercalcemia and a pelvic mass. One month before admission, abdominal pain developed, followed by abdominal fullness, anorexia, nausea, vomiting, polydipsia, and nocturia. A computed tomographic scan of the pelvis showed a complex right adnexal mass. The serum calcium level was 17.2 mg per deciliter. A diagnostic procedure was performed.

    Editorials
    1042-1043

      Asthma is both easy and hard to treat. It is easy to treat because the vast majority of patients with asthma require little medication for a lot of benefit. In a patient with asthma previously untreated with a controller (i.e., a medication whose primary ...

      1043-1045

      The completion of the first draft sequence of the Human Genome Project in 2001 heralded the arrival of personalized medicine, in which the risk and course of a disease can be predicted on the basis of a person's genotype. During the past 5 years, several ...

      Correspondence
      1046-1048

      To the Editor: Taylor and colleagues (Nov. 26 issue)1 find that the use of extended-release niacin causes a significant regression of carotid intima–media thickness when combined with a statin. We agree with Kastelein and Bots in the accompanying ...

      1048-1049

      To the Editor: Harrington et al.1 and Bhatt et al.2 (Dec. 10 issue) describe the results of studies of platelet inhibition with intravenous cangrelor in patients undergoing percutaneous coronary intervention (PCI). In the study by Harrington et al., 996 ...

      1050-1051

      To the Editor: The article by Schulman et al. (Dec. 10 issue)1 shows that a fixed dose of the thrombin antagonist dabigatran is noninferior to warfarin in the treatment of acute venous thromboembolism. The authors specifically point out in the Abstract ...

      1051-1052

      To the Editor: In the recently published Total Body Hypothermia for Neonatal Encephalopathy Trial (TOBY) regarding the use of hypothermia to treat perinatal asphyxial encephalopathy by Azzopardi and colleagues (Oct. 1 issue),1 the primary outcome was a ...

      1052-1054

      To the Editor: The Sounding Board article on continuing medical education (CME) by Morris and Taitsman (Dec. 17 issue)1 did little to advance informed discussion about the role of commercial support in CME, as it relied on outdated sources, inappropriate ...

      1054-1055

      The authors found that exclusion of lesbians and gay men from clinical trials in the United States is not uncommon, particularly in studies with sexual function as an end point. It is likely that most gay and lesbian patients are unaware that their sexual ...

      Points of View
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      One of the first children I cared for after my arrival on the USNS Comfort, the U.S. Navy's floating medical treatment facility docked at Port-au-Prince, Haiti, was a 10-month-old boy who had been brought to the ship nearly dead from malnutrition. Prior ...

      e42

      More than a month after the recent earthquake, the Haitian government reported that 6000 to 8000 people had lost limbs or digits, but they did not address the bigger question: What's the plan for these amputees?1

      Nearly a decade ago, Sierra Leone emerged ...

      Corrections
      1056

      Contaminated Heparin Associated with Adverse Clinical Events and Activation of the Contact System Original Article, N Engl J Med 2008:358;2457-2467. and Outbreak of Adverse Reactions Associated with Contaminated Heparin Original Article, N Engl J Med 2008:...

      1056

      Transfusion of RhD-Positive Blood in “Asia Type” DEL Recipients Correspondence, N Engl J Med 2010:362;472-473.. In the second paragraph, the fifth sentence should begin, “We distinguished Asia type DEL through Rh C, c, E, and e phenotypes” (rather than “...