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Articles 
William F. Clark, A. Keith Stewart, Gail A. Rock, Marion Sternbach, David M. Sutton, Brendan J. Barrett, A. Paul Heidenheim, Amit X. Garg, David N. Churchill the Canadian Apheresis Group In patients with acute renal failure at the onset of multiple myeloma, the standard treatment has been 5 to 7 plasma exchanges to reduce the serum concentration of nephrotoxic immunoglobulin light chains. In this multicenter randomized trial, plasma exchange did not reduce the composite outcome of death, dialysis dependence, or glomerular filtration rate less than 30 mL/min per 1.73 m2 at 6 months.
Brandi J. Witt, Robert D. Brown, Jr., Steven J. Jacobsen, Susan A. Weston, Barbara P. Yawn, and Véronique L. Roger This study examined the relationship between myocardial infarction (MI) and subsequent stroke in persons living in Olmsted County, Minnesota. Myocardial infarction was associated with a marked increase in the risk for stroke, particularly early after MI, compared with the risk in a population without MI. The risk for death after MI was much higher in patients who had had a stroke.
Shiu Man Wong, Andrew C.F. Hui, Po-Yee Tong, Dawn W.F. Poon, Evelyn Yu, and Lawrence K.S. Wong In this clinical trial, 60 adults with lateral epicondylitis were randomly assigned to receive an injection of botulinum toxin in the painful area or an injection of placebo. Botulinum toxin injection reduced pain substantially for up to 3 months. Some patients had transient digit paresis or weak finger extension.
Improving Patient Care
Bruce Leff, Lynda Burton, Scott L. Mader, Bruce Naughton, Jeffrey Burl, Sharon K. Inouye, William B. Greenough, III, Susan Guido, Christopher Langston, Kevin D. Frick, Donald Steinwachs, and John R. Burton This 3-site quasi-experiment enrolled patients who required hospital-level care for pneumonia, cellulitis, chronic obstructive pulmonary disease, and heart failure. In the 3 sites, 69%, 69%, and 29% of patients who were offered hospital-at-home care chose it over acute hospital care. Patients received fewer invasive procedures in hospital-at-home care and had a shorter stay (3.2 days vs. 4.9 days) and less delirium. Hospital-at-home care was less expensive.
Academia and Clinic
Donald A. Barr Some of the population groups identified through genetic analyses have resembled what have been historically categorized as "races." Some argue that a patient's race predicts underlying genetic traits well enough to predict outcomes of treatment. Others argue that racially defined groups are too heterogeneous to make useful predictions for individuals. Physicians must translate this scientific debate into individualized clinical decisions. Is it appropriate to use a patient's self-identified "race" to help decide treatment?
Updates
Carolyn Crandall and Janet P. Pregler This Update reviews the past year's publications in women's health that have the most relevance to the practice of internal medicine. The authors have included a summary of new guideline recommendations for the prevention of heart disease in women. The Update also covers breast cancer, ovarian cancer, cervical cancer, menopause, osteoporosis, and recurrent vulvovaginal candidiasis.
Reviews
Timothy D. Starner and Paul B. McCray, Jr. Infants and children with cystic fibrosis experience transient, often asymptomatic Pseudomonas aeruginosa infections within the first years of life. These infections eventually become chronic, as infections with initially nonmucoid P. aeruginosa become mucoid–biofilm infections, which are associated with morbidity and mortality. The question now facing clinicians is how to best manage lower-airway bacterial infection or inflammation in these mostly asymptomatic younger patients with cystic fibrosis.
History of Medicine
J. V. Hirschmann Although Benjamin Franklin was not formally trained as a physician, he had many medical interests, including experimentation, shrewd observations about health and disease in himself and others, civic activities, and inventions of medical devices. These achievements show his capacity for detailed, perceptive insights; his fastidiousness in recording his observations; and his thoughtful analyses of scientific phenomena and human conduct. In medicine, perhaps uniquely in his life, his major interests intersected: scientific pursuits, civic activities, amused scrutiny of human behavior, and improving the lot of his fellow man.
Editorials
Morie A. Gertz Renal insufficiency is a challenging clinical problem in patients with multiple myeloma. The standard therapy has been plasma exchange, which reduces serum light chain levels while chemotherapy reduces the number of light chain–secreting malignant plasma cells. In this issue, Clark and colleagues' study challenges this widely held standard of patient management.
Seth L. Pullman In this issue, Wong and colleagues report that botulinum toxin (BTx) was significantly more effective than placebo for reducing pain in lateral epicondylitis. Their findings also implied that pain reduction might have been attributable to a direct analgesic effect from BTx. These findings are promising because BTx injections are less harmful than other therapies for lateral epicondylitis, such as corticosteroids or surgery, and BTx can provide long-lasting results.
Sasha Shepperd In their quasi-experimental study, which is reported in this issue, Leff and colleagues attempted to obtain robust data about the effectiveness of hospital at home in several U.S. settings. However, their results have not shifted the weight of evidence toward (or away from) the conclusion that hospital-at-home care offers worthy net benefits. Despite increasing interest in the potential of such services, the objective evidence is insufficient to gauge the health or economic benefits of this type of care.
On Being a Doctor
James L. Glazer Elderly, hard of hearing, and sporting a chart full of comorbidities, Doc had driven his ATV into the back of a road grader. The piece of heavy machinery rolled backward, crushing him beneath its wheels. Here in northwestern Alaska there is no pavement, and ATVs are the only way to get around. Doc's family had been trying to get him off his Honda for a year. They feared that his declining health would lead to an accident such as this.
Letters Correction: Work Disability Related to Musculoskeletal Disorders
Health Care Costs
Generic Drug Savings
Management of Menopause-Related Symptoms
International Committee of Medical Journal Editors' Definition of a Clinical Trial
Entopic Phenomenon as Initial Presentation of Acute Myelogenous Leukemia
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