Coronary artery disease and peripheral vascular disease often coexist. Patients with unstable coronary disease benefit from coronary revascularization before vascular surgery, but in patients with stable coronary disease the situation is not so clear. In this randomized trial, there was no benefit from preoperative coronary revascularization among patients with stable coronary disease who underwent elective surgery for abdominal aortic aneurysm or vascular disease of the legs. Therefore, prophylactic revascularization should be reserved for patients at higher risk.

Age-related macular degeneration is a common cause of blindness. In this study, intraocular injection of an agent (pegaptanib) that blocks the receptor for vascular endothelial growth factor (VEGF) retarded the rate of vision loss caused by age-related macular degeneration. Endophthalmitis occurred in a few of the patients who received injections. Although the long-term safety and efficacy of pegaptanib therapy are unknown, these results suggest that long-term studies of pegaptanib in the treatment of age-related macular degeneration are needed.

A polymerase-chain-reaction assay of 21 genes performed on paraffin-embedded samples from women with node-negative, estrogen-receptor–positive breast cancer was the basis for calculating a score for the risk of distant recurrence. The difference in risk between women with low and high recurrence scores was significant. The recurrence score also predicted overall survival.

The recurrence score can estimate the risk of distant recurrence in individual patients with breast cancer.

The authors describe a patient with life-threatening opioid intoxication despite having received only moderate doses of codeine. Blood levels of morphine and morphine-6-glucuronide were elevated. CYP2D6 genotyping showed three or more functional alleles, a finding consistent with ultrarapid metabolism. Toxicity was attributed to this genotype, in combination with inhibition of CYP3A4 activity by other medications and a transient reduction in renal function.

A 25-year-old registered nurse comes for a visit to initiate prenatal care after receiving a positive result on a pregnancy test. On review of her vaccination status, she reports that she declined hepatitis B vaccination when it was offered by her current employer because she does not draw blood and thus does not consider herself at risk. Should she receive the vaccine? What are the current recommendations for hepatitis B vaccination?

A 42-year-old woman was referred to a specialty clinic for evaluation of microscopic hematuria of 14 years' duration. It had been first detected during an episode of cystitis, but persisted thereafter with 1+ proteinuria. She had borderline hypertension. Two sisters also had hematuria and her brother had died of renal failure. Urinalysis showed dysmorphic red cells. A diagnostic procedure was performed.

This review of the mechanism of osteopetrosis incriminates molecular defects in osteoclasts as the cause of the imbalance between bone formation by osteoblasts and bone resorption by osteoclasts. Numerous kinds of defects of osteoclast function can cause osteopetrosis in experimental animals, but only one class of defect — the inability to acidify — has been identified in osteopetrosis in humans.

Quality-measurement and payment-for-performance programs encourage physicians to deliver care that is consistent with practice guidelines. In the treatment of patients with multiple medical problems, adherence to disease-specific guidelines often requires the use of 10 or more medications, yet the marginal benefits and adverse effects of the 8th, 9th, or 10th medication in such patients are not known. The authors emphasize the importance of considering patients' quality of life, preferences, and values when prescribing medications for those with multiple chronic illnesses.