The N Engl J Med image of the week shows a tongue at different stages of the condition. Notably, no complaints are mentioned by the patient (perhaps there were none). Geographic tonuge, oral candidiasis, lichen planus, hairy leukoplakia and pemphigus vulgaris are in the differential diagnosis. We review these tongue conditions. Caplacizumab, an anti–von Willebrand-factor humanized single-variable-domain immunoglobulin (nanobody), inhibits the interaction between ultralarge von Willebrand factor multimers and platelets. In a phase 2, controlled study, investigators randomly assigned patients with acquired thrombotic thrombocytopenic purpura to subcutaneous caplacizumab (10 mg daily) or placebo during plasma exchange and for 30 days afterward. The primary endpoint was the time to a response, defined as confirmed normalization of the platelet count. Major secondary endpoints included exacerbations and relapses. The findings serve to elucidate thrombotic microangiopathy and could help those patients with deficiency of ADAMTS13. All say that the burden of dementia in old people is getting worse. Epidemiologists have addresed the issue. Participants in the Framingham Heart Study have been under surveillance for incident dementia since 1975. In this analysis, which included 5205 persons 60 years of age or older, epidemiologists used Cox proportional-hazards models adjusted for age and sex to determine the 5-year incidence of dementia during each of four epochs. They also explored the interactions between epoch and age, sex, apolipoprotein E ε4 status, and educational level. They examined the effects of these interactions, as well as the effects of vascular risk factors and cardiovascular disease, on temporal trends. The investigators found that oldsters are not becoming demented at the expected rate. Instead, the incidence of dementia seems to be decreasing. A new pacemaker technology is on the horizon. The Micra transcatheter pacing system, a leadless right ventricular pacemaker, was successfully implanted in 99.2% of 725 patients in whom implantation was attempted. The device met prespecified criteria for pacing capture threshold in 98.3% of the patients who were followed for 6 months. This follow-up study confirms the utility of the device. HIV-associated Cryptococal meningitis is generally treated with antimycotic drugs and corticosteroids so that the consequences of brain-stem inflammatory damage can be minimized. Data from TB patients support this strategy. We inspect a doubleblind trial testing corticosteroids against plebo in patients with Cryptococcal meningitis. Steroids did not help; as a matter of fact, the trial was stopped because the treatment made the disease worse. Antigen-driven selection has been implicated in the pathogenesis of monoclonal gammopathies. Gaucher’s disease is assoictated with the development of multiple myleomoa. An interesting paper suggests that long-term immune activation by lysolipids may underlie both Gaucher’s disease–associated gammopathies and some sporadic monoclonal gammopathies. The N Engl J Med review deals with urinary tract infection in elderly men. The case of the week is a woman with a cutaneous ulcer, lympadenopathy, and fever. She had spent much time out of doors in the woods of New England. Lancet investigators tested the effectiveness of the probiotic, Bifidobacterium breve BBG-001, to reduce necrotising enterocolitis, late-onset sepsis, and death in preterm infants. However, the strategy was a failure. The efficacy of hydroxycarbamide (hydroxyurea) in preventing stroke in sickle-cell anemia patients is unknown. Hydroxyurea as effective as transfusions. Treatment strategies in children with dermatomyositis have not been rigorously tested. A study suggests that combined treatment with prednisone and either ciclosporin or methotrexate at disease onset is more effective than prednisone alone. Finally, investigators assessed the safety and efficacy of the long-acting GLP-1 analogue, liraglutide, in patients with non-alcoholic steatohepatitis. Liraglutide was safe, well tolerated, and led to histological resolution. We conclude with histiocytes in urine and subsequent systemic disease.