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In patients treated with natalizumab, PML incidence was about 11 cases per 1000 patients with 25 to 48 months of treatment, prior immunosuppressant use, and anti–JC virus antibody–positive status. The incidence was estimated to be 0.09 cases or fewer per 1000 antibody-negative patients.
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A 48-year-old woman was admitted to the hospital because of diplopia, headaches, and papilledema. Imaging revealed cysts in the fourth ventricle and spinal canal. A diagnostic procedure was performed.

and G.A. Donnan
Patients with stroke are at high risk for subsequent vascular events, including recurrent stroke (highest risk), myocardial infarction, and death from vascular causes. This article reviews recommended strategies to reduce the risk of a subsequent stroke in patients with a history of transient ischemic attack (TIA) or stroke.
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and Y.D. Teng
The effective treatment of spinal cord injury and the establishment of a robust source of cells that do not trigger a host immune response have been two major goals of stem-cell research. A recent study reaches toward these goals, but substantial challenges remain.
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An 89-year-old man was brought to the emergency department for evaluation of changes in his cognition and personality. He exhibited poor memory for recent events and difficulty expressing himself.
Direct the investigation of the case, test your diagnostic and therapeutic skills, and compare your performance with that of others.
Slowly increasing oral doses of L-dopa induced at least partial improvement of some manifestations in a series of 28 patients with Parkinsonism.
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Reviewing: Lancet Neurol 2012 Apr
A post hoc analysis of the focal epilepsy arm in the SANAD trial reveals outcome predictors for patients receiving specific AED treatments.
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Reviewing: Lancet Neurol 2012 May
Oral lasmiditan, a novel 5-HT1F receptor agonist, appears to be a safe and effective acute migraine therapy without the vasoactive adverse effects of triptans.
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Case Records of the Massachusetts General Hospital
Case 15-2012 — A 48-Year-Old Woman with Diplopia, Headaches, and Papilledema
Presentation of Case. Dr. Rocío Hurtado (Infectious Diseases): A 48-year-old woman was admitted to the hospital because of diplopia, headaches, and papilledema. The patient had been well until 2 weeks before admission, when diplopia developed, which improved when she covered either eye. One week…
Clinical Implications of Basic Research
Stem Cells and Spinal Cord Repair
For the past couple of decades, clinicians have watched the stem-cell field with a mixture of anticipation and skepticism. No group of patients has been more expectant than those with spinal cord injuries. Therapies for spinal cord injury have been promised almost since the dawning of the stem-cell…
Clinical Practice
Secondary Prevention after Ischemic Stroke or Transient Ischemic Attack
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations. Stage. A 62-year-old…
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Editorial
Predicting Risk of Progressive Multifocal Leukoencephalopathy from Natalizumab
After a century of futility in the treatment of multiple sclerosis, there is now a deluge of drugs that alter the course of the disease. The half-dozen new oral drugs have excited the most interest, but the monoclonal antibodies, and specifically natalizumab, have a more focused biologic activity…
Original Article
Risk of Natalizumab-Associated Progressive Multifocal Leukoencephalopathy
Natalizumab (Tysabri, Biogen Idec and Elan Pharmaceuticals) is approved for the treatment of relapsing–remitting multiple sclerosis in more than 50 countries and also for the treatment of moderate-to-severe Crohn's disease in the United States. As of February 2012, approximately 100,000 patients…
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Correspondence
Chronic Cyclic Nonnephrogenic Magnesium Depletion without Losses
To the Editor: Magnesium wasting with hypomagnesemia is well known, but cyclic disorders of magnesium without losses are not usually reported. Similarly, diastolic heart failure and obstructive sleep apnea are rarely described in connection with magnesium depletion. A 56-year-old woman was admitted…
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Correspondence
Spurious Elevations of Vitamin B12 with Pernicious Anemia
To the Editor: Within a 3-week period, two women, 46 and 48 years of age, presented with peripheral neuropathy and associated pancytopenia with macrocytic anemia. Clinical suspicion for pernicious anemia was high, but vitamin B12 levels were 1644 pg per milliliter (1228 pmol per liter) and 1321 pg…
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Case Records of the Massachusetts General Hospital
Case 13-2012 — A 62-Year-Old Man with Paresthesias, Weight Loss, Jaundice, and Anemia
Presentation of Case. Dr. Norifumi Kamo (Medicine): A 62-year-old man was admitted to this hospital because of paresthesias, weight loss, jaundice, and anemia. The patient had been well until approximately 2 months before admission, when numbness, tingling ("pins and needles"), and burning in his…
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Case Records of the Massachusetts General Hospital
Case 12-2012 — A 10-Month-Old Girl with Vomiting and Episodes of Unresponsiveness
Presentation of Case. Dr. Helen H. Yeung (Pediatrics): A 10-month-old girl was seen in the emergency department at this hospital because of vomiting and episodes of unresponsiveness. The patient had been well until 2 a.m. on the day of admission, when she awoke with vomiting that was associated…
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Original Article
Vorapaxar in the Secondary Prevention of Atherothrombotic Events
Platelets play a central role in atherothrombosis and are an important target for pharmacotherapy. In patients with acute coronary syndromes, the use of potent platelet inhibitors has been shown to reduce the rate of thrombotic events at the cost of increased bleeding.– In contrast, among…
Original Article
A Randomized Trial of Tenecteplase versus Alteplase for Acute Ischemic Stroke
Thrombolytic treatment with alteplase, a recombinant tissue plasminogen activator, for acute ischemic stroke is of proven benefit. However, alteplase is far from ideal, with incomplete and often delayed reperfusion in many patients. Tenecteplase, a genetically engineered mutant tissue plasminogen…
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Review Article
Mechanisms of Disease: Monogenic Mitochondrial Disorders
To function normally, human cells require energy in the form of ATP. In many cell types, ATP is primarily generated by mitochondria, which are also key players in other important cellular processes, such as adaptive thermogenesis, ion homeostasis, innate immune responses, production of reactive…
Editorial
Patent Foramen Ovale Closure — Closing the Door Except for Trials
Patent foramen ovale is a well established cause of stroke. A thrombus from venous structures can embolize through a patent foramen ovale and ultimately reach the brain. However, a patent foramen ovale can also be present in 25% of healthy people. Although detected in nearly twice as many patients…
Original Article
Closure or Medical Therapy for Cryptogenic Stroke with Patent Foramen Ovale
As many as 40% of acute ischemic strokes have no identifiable cause and are classified as cryptogenic.– Some cryptogenic strokes or transient ischemic attacks (TIAs) may be the result of an embolus from the venous system traversing from the right to left atrium and into the systemic circulation…
Original Article
Placebo-Controlled Trial of Oral Laquinimod for Multiple Sclerosis
Laquinimod is an oral quinoline-3-carboxamide small molecule selected for its efficacy and safety from a pool of 60 quinoline-3-carboxamide derivatives of the parent compound, roquinimex, a drug previously evaluated in phase 2 trials of treatment for multiple sclerosis but withdrawn because of…
Original Article
Donepezil and Memantine for Moderate-to-Severe Alzheimer's Disease
Most studies evaluating cholinesterase inhibitors for the treatment of Alzheimer's disease have focused on patients with mild-to-moderate disease. Despite questions about the methods used in the trials and about the clinical significance of reported benefits,, guidelines advocate treatment with a…
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Editorial
Discontinuing Donepezil or Starting Memantine for Alzheimer's Disease
Donepezil, the most frequently prescribed cholinesterase inhibitor for the treatment of Alzheimer's disease, was marketed in 1997 on the basis of the results of 3-month and 6-month clinical trials showing that patients had improvements in cognitive test scores and in the ability to perform daily…
Review Article
Current Concepts: Dysfunction of the Diaphragm
The diaphragm is the dome-shaped structure that separates the thoracic and abdominal cavities. It is the principal muscle of respiration, is innervated by the phrenic nerves that arise from the nerve roots at C3 through C5, and is primarily composed of fatigue-resistant slow-twitch type I and fast…
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Case Records of the Massachusetts General Hospital
Case 7-2012 — A 79-Year-Old Man with Pain and Weakness in the Legs
Presentation of Case. Dr. Aida E. Kuri (Medicine): A 79-year-old man was admitted to this hospital because of pain and weakness in the legs. The patient had multiple medical problems but had been in his usual state of health until 6 days before admission, when progressive, generalized pain and…
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