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December 30, 2004  Vol. 351 No. 27

Perspective
2787-2791

Many believe that the practice of somatic-cell nuclear transfer with the goal of generating an embryonic stem-cell line is justified. Dr. Rudolf Jaenisch discusses the science and ethics of nuclear transplantation.

2791-2792

The study of human embryonic stem cells is a matter of intense public debate, primarily because derivation of such cells requires the destruction of human blastocysts, a procedure that some find morally objectionable. William Hurlbut, M.D., of Stanford ...

2792-2794

Dr. Howard Markel writes that as a profession, doctors are not only determined, but also somewhat obsessed with primacy and quite comfortable with intense competition.

Original Articles
2795-2804

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.

2805-2816
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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.

2817-2826

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.

2827-2831

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.

Clinical Practice
2832-2838

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?

Review Article
2839-2849

    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.

    Images in Clinical Medicine
    2850
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    A previously healthy 54-year-old woman presented with a two-week history of pelvic pain. On physical examination, she had limited movement, without tenderness in the bones. An initial radiographic survey of skeletal bone showed multiple lytic lesions in ...

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    This 68-year-old woman was resuscitated after cardiac arrest. Echocardiography showed a dilated left atrium and severe mitral-valve stenosis. A free-floating thrombus caused intermittent occlusion of the mitral valve.

    Case Records of the Massachusetts General Hospital
    2851-2859

    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.

    Editorials
    2861-2863

    The evaluation of cardiac risk before noncardiac surgical procedures and interventions aimed toward reducing that risk have become an integral part of the contemporary practice of medicine. In the nonoperative setting, it is generally accepted that the ...

    2863-2865

    Neovascularization leads to blindness in a large number of ocular disorders, most notably age-related macular degeneration, diabetic retinopathy, retinopathy of prematurity, and other vascular occlusive diseases. Various versions of scatter-...

    2865-2867

    During the past two decades, molecular biologists have been dissecting the heterogeneity of human cancer — a diversity that oncologists have long appreciated, especially because patients who have similar stages and grades of cancer and whose tumors have ...

    2867-2869

    The response to many drugs in common use varies greatly among patients. After the intake of identical doses of a given agent, some patients may have clinically significant adverse effects, whereas others may have no therapeutic response. Some of this ...

    Sounding Board
    2870-2874

    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.

    Correspondence
    2875-2878

    To the Editor: Merck has been proactive and conscientious in evaluating the cardiovascular profile of rofecoxib (Vioxx); Dr. Topol's remarks to the contrary in his Perspective article (Oct. 21 issue)1 are false. First, his description of the time line ...

    2879

    To the Editor: Marcellin and colleagues (Sept. 16 issue)1 report that patients with hepatitis B e antigen (HBeAg)–negative chronic hepatitis B had higher rates of a sustained response to treatment with peginterferon alfa-2a than with lamivudine.1 HBeAg-...

    2879-2880

    To the Editor: The Journal's support (Sept. 23 issue)1 for the proposal of the National Institutes of Health (NIH) to make the results of NIH-sponsored research more readily available to the public2 is commendable, as is its policy of making articles ...

    2881

    To the Editor: Wang and Bashore's statement that physical examination provided “little guidance” in the case described in their Clinical Problem-Solving article (Sept. 2 issue)1 is challenging in its omissions. Admittedly, the patient's extreme obesity ...

    2881-2883

    To the Editor: In reviewing the differential diagnosis in the case of a woman with disturbances in gait, cognition, and autonomic function, Schlossmacher provides a scholarly discussion of multiple-system atrophy (Aug. 26 issue),1 but he errs by ...

    2883

    To the Editor: Recent reports suggest that mutations in the epidermal growth factor receptor (EGFR) gene predict sensitivity to EGFR kinase inhibitors. In particular, patients with lung cancers containing mutations in the EGFR kinase domain have had ...

    Book Reviews
    2884

    Although one might expect a book about generosity in medicine to involve a discussion of charity in health care, Arthur W. Frank engages the reader as a person who might alternatively be a patient or a physician. The Renewal of Generosity is about a ...

    2885

    Death with dementia challenges a society not only to rethink but also to revalue its health care system. Moreover, as Ethical Foundations of Palliative Care for Alzheimer Disease reveals, care for persons dying with dementia exposes bioethics as a ...

    2886-2887

    In the past two decades, public and professional debates over the procurement and allocation of solid organs for transplantation have led to specific changes in policy and to organizational reforms. However, transplantation procedures for nonorgan tissues ...

    2887-2888

    In 1971, I was 10 years old and growing up in Brooklyn, New York. I was never a good eater, and the summer of that year was no different. Every dinner at the small dinette was an interminable ordeal punctuated by my mother's insistent plaint, “Eat, Jerry. ...

    Corrections
    2888

    Premature Birth and Later Insulin Resistance Original Article, N Engl J Med 2004:351;2179-2186.. On page 2179, line 11 under Results, and on page 2184, in Table 3, under the column heading Premature Appropriate-for-Gestational-Age Group, the 95 percent ...

    2888

    Hypocalciuric Hypercalcemia and Autoantibodies against the Calcium-Sensing Receptor Correspondence, N Engl J Med 2004:351;2237-2238.. Lines 11 and 12 of the letter by Rickels and Mandel should have read, “We recently diagnosed familial hypocalciuric ...

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