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August 12, 2010  Vol. 363 No. 7

Audio Summary of this Issue

Perspective
601-603
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After nearly a century of failed attempts, comprehensive health care reform was enacted on March 23, 2010, when President Barack Obama signed the Affordable Care Act (ACA). In attempting to modernize and improve a large part of the health care system, it ...

604-606

Some types of academic–industry relationships are an essential component of the research enterprise in the life sciences. Empirical data show that more than half of academic scientists have such relationships, which most often involve consulting, ...

606-607

The quarterly “report card” sits on my desk. Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my ...

Original Articles
609-619

In this study, adults with progressive chronic kidney disease and an estimated glomerular filtration rate between 10 and 15 ml per minute per 1.73 m2 (stage V chronic kidney disease) were randomly assigned to early or late initiation of dialysis. Early initiation of dialysis was not associated with an improvement in survival or clinical outcomes.

620-628
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In patients with advanced idiopathic pulmonary fibrosis, treatment with sildenafil was compared with placebo. In the sildenafil group, there was a nonsignificant trend toward improvement and some benefit in other physiological measures and symptom scores.

629-639

The use of marrow stem cells to treat seven children with severe epidermolysis bullosa caused by loss-of-function mutations in COL7A, the gene encoding type VII collagen (C7), was examined. The investigators observed increases in C7 deposition, the presence of donor cells in the skin, and an amelioration of symptoms.

640-652

Investigators examined whether the intensity of treatment can be reduced in patients with early-stage Hodgkin's lymphoma without compromising antitumor efficacy. In a comparison of two with four cycles of ABVD chemotherapy plus either 20 or 30 Gy of involved-field radiation therapy, no significant differences were noted in disease-free or overall survival between the most and the least intensive regimens.

Review Article
653-662

This article summarizes the issues involved in the treatment of patients with early-stage Hodgkin's lymphoma. Long-term follow-up reveals an increasing burden of complications in patients who received combined methods of treatment.

Images in Clinical Medicine
663
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An 18-year-old woman presented with a 2-month history of visual loss in the right eye. Visual acuity was 20/100 in the affected eye and 20/20 in the left eye. Ophthalmoscopy revealed an orange–yellow tumor (Panel A, arrow) with tortuous feeding vessels ...

e10
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A 31-year-old woman with a history of prolactinoma was admitted at the 39th week of her first pregnancy for headache and nausea. She had been receiving bromocriptine until she became pregnant. The neurologic examination, which included a dilated fundus ...

Interactive Medical Case
e11
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A 31-year-old woman originally from Nepal presented to her physician after unsuccessful attempts at pregnancy for the past 18 months. She had no history of sexually transmitted diseases, pelvic inflammatory diseases, use of an intrauterine device, exposure to diethylstilbestrol, abnormal Papanicolaou smears, or previous pregnancies. What diagnostic and management steps do you choose? Direct the investigation of the case, test your diagnostic and therapeutic skills, and compare your performance with that of others at NEJM.org.

Case Records of the Massachusetts General Hospital
664-675

A 56-year-old woman was admitted because of the sudden onset of dyspnea and hypotension. At 16 years of age, she had received combination chemotherapy and extended-field radiation therapy for Hodgkin's lymphoma. On admission, an electrocardiogram showed an acute myocardial infarction. A stent was placed, but hypotension and acidosis persisted, and the patient died.

Editorials
677-678
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Each week, half a million readers access the Journal electronically, and our content is now seen online by about four times as many people as those who see the print edition. This mode of information delivery has expanded tremendously since the Journal ...

678-680

Renal-replacement therapy for patients with end-stage renal disease was introduced approximately 50 years ago, yet the optimal timing for the initiation of dialysis is still debated. In recent years there has been a trend toward initiating dialysis at a ...

680-682

With an area of almost 2 m2, the human skin forms a large physical barrier between the organism and the environment. Diseases of the skin can have a severely negative effect on the quality and length of life of the persons affected.

Although effective ...

Sounding Board
683-688
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The authors argue that quality measures in health care should be based on strong evidence that a care process directly improves outcomes, should capture the actual performance of a process, should address a process proximate to the desired outcome, and should not have unintended adverse consequences.

Clinical Implications of Basic Research
689-691

    Molecular dissection in three models of sepsis implicates a signaling pathway in maintaining adhesion of endothelial cells to protect against vascular leak.

    Correspondence
    692-695

    To the Editor: In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial (ClinicalTrials.gov number, NCT00000620) reported on by Ginsberg et al. (April 29 issue),1 the use of fenofibrate in patients with type 2 diabetes mellitus who were ...

    695-697

    To the Editor: The members of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study group (April 29 issue)1 report that targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the ...

    698

    To the Editor: Poon et al. (May 6 issue)1 describe the successful use of bar codes to reduce the error rate in order transcription and medication administration. We observed similar results at our 653-bed facility, Baystate Medical Center, during a 6-...

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