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April 7, 2005  Vol. 352 No. 14

Perspective
1403-1405
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The motivation for making statins available over the counter is understandable: to increase access to an effective and underused therapy. Dr. Brian Strom writes that it is unclear that such a switch would help to achieve that goal.

1405-1407

Very soon, Congress must decide whether to extend the moratorium on the development of new specialty hospitals that are partly owned by physicians who refer their patients to them. John Iglehart explains the issues surrounding the emergence of physician-...

1408-1410

April 12, 1955, was supposed to be Tommy Francis's day, writes Dr. Howard Markel. The distinguished epidemiologist was scheduled to conduct an international press conference on the field trial he had just completed, evaluating the efficacy of the ...

1411-1412

It was one of the worst pharmaceutical disasters in U.S. history, states Dr. Paul Offit. Scientists found that two production pools of the polio vaccine contained live poliovirus.

Original Articles
1413-1424

The finding of shortened telomeres in leukocytes from patients with aplastic anemia prompted a search for mutations in genes that maintain the structure of the telomerase complex. Mutations in TERT, the gene encoding telomerase reverse transcriptase, were found in seven unrelated patients.

1425-1435

Patients with stable coronary artery disease may benefit from therapy to lower low-density lipoprotein (LDL) cholesterol levels, but optimal target levels are unknown. This study showed that intensive lowering of LDL cholesterol levels to a mean of 77 mg per deciliter (2.0 mmol per liter) with 80 mg of atorvastatin per day produced greater clinical benefit than lowering levels to a mean of 101 mg per deciliter (2.6 mmol per liter) with 10 mg of atorvastatin per day. These results could affect practice patterns by redefining target levels of LDL cholesterol in patients with stable coronary disease.

1436-1444

Data on community-acquired methicillin-resistant Staphylococcus aureus infections were obtained by population-based surveillance in Baltimore and Atlanta and by laboratory-based surveillance in Minnesota. From 2001 through 2002, between 8 and 20 percent of all staphylococcal infections were with methicillin-resistant organisms. Most infections involved the skin. A quarter of the patients were hospitalized because of their infections.

1445-1453

Over a 15-month period at one center, 14 patients were identified who presented with community-acquired necrotizing fasciitis due to Staphylococcus aureus infection. Their median age was 46 years, and risk factors included current or past injection-drug use (six patients) and previous methicillin-resistant infections. Four patients had no serious coexisting conditions or risk factors.

Special Article
1454-1462
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This study showed that Medicare patients who underwent cardiac revascularization in specialty cardiac hospitals were less severely ill than similar patients who were treated in general hospitals. Cardiac hospitals had lower unadjusted mortality rates, but the rates were similar after adjustment for the severity of illness and procedural volume.

Clinical Practice
1463-1472

    A 17-year-old boy with a six-month history of acne presents for initial evaluation and treatment. Physical examination reveals closed and open comedones and a large number of erythematous papules and pustules (50 or more) on the face and upper trunk. How should he be treated?

    Images in Clinical Medicine
    1473
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    Between 1949 and 2002, this patient underwent four lifesaving procedures. This plain chest radiograph highlights all four of the procedures. What are they?

    Clinical Problem-Solving
    1474-1479

      A previously healthy, 22-year-old man presented to an emergency department reporting three days of intermittent abdominal pain. Although the pain was initially mild and crampy and was relieved with bismuth subsalicylate, on the day he went to the hospital the patient awoke with severe, midepigastric pain and had two episodes of diarrhea. During the preceding week, he had had a productive cough and had noticed a slight decrease in exercise tolerance.

      Editorials
      1481-1483

      Telomeres are DNA–protein complexes at the ends of linear eukaryotic chromosomes. They consist of double-stranded, short, repeated sequences of nucleotides, a 3' single-strand overhang of nucleotides, and telomere-binding proteins. Telomeric DNA typically ...

      1483-1484

      The evidence of the effectiveness of statins in the treatment of stable coronary heart disease (CHD) continues to grow. Large-scale, randomized, secondary-prevention trials involving patients with CHD have shown that statins reduce the clinical ...

      1485-1487

      Laypeople and health care professionals alike recognize Staphylococcus aureus as an important cause of disease and understand that antibiotic-resistant strains pose a threat to the community. Before the availability of antibiotics, invasive staphylococcal ...

      Correspondence
      1488-1489

      To the Editor: Pyomyositis is common in tropical regions but is rarely reported in temperate climates. In the United States, most cases are associated with human immunodeficiency virus infection or other immunosuppressive conditions, including diabetes ...

      1489-1490

      To the Editor: Strains of methicillin-resistant Staphylococcus aureus that produce Panton–Valentine leukocidin and that are associated with soft-tissue infections and necrotizing pneumonia are emerging worldwide,1 most often as a source of community-...

      1491-1492
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      To the Editor: I participated in the study reported by Barger and colleagues (Jan. 13 issue),1 and my comments might inform interpretations of the results by nonparticipants. The 2737 interns who responded represented only 15 percent of the 18,447 ...

      1492-1495

      To the Editor: McFalls et al. (Dec. 30 issue)1 report on a randomized trial demonstrating that prophylactic coronary revascularization before vascular surgery is not beneficial. However, methodologic concerns limit its generalization to high-risk ...

      1495-1496

      To the Editor: The primary outcome of the Swedish Obese Subjects (SOS) Study, reported by Sjöström et al. (Dec. 23 issue),1 was mortality, but only secondary outcomes are presented. There is a statement in the report that “the safety monitoring committee ...

      1496-1497

      To the Editor: The recent article by Dave et al. (Nov. 18 issue)1 is an important study correlating gene expression with survival in follicular lymphoma. My colleagues and I have reexamined their findings.

      Analysis with the use of standard tools such as ...

      1497-1499

      To the Editor: Like Bloche and Marks in their Perspective article on doctors in combat (Jan. 6 issue),1 the American Medical Association (AMA) applauds the outstanding work of military physicians in treating wounded soldiers under extremely challenging ...

      Book Reviews
      1500-1501

      After decades of study, our collective fascination with the care of dying patients shows no sign of receding. The dying patient remains the nexus of a complex interaction of medical and nursing care, ethics, law, and economics, and important questions ...

      1501-1502

      Jocelyn Downie, director of the Health Law Institute at Dalhousie University in Halifax, Nova Scotia, Canada, has written an advocate's brief favoring the legalization of euthanasia and physician-assisted suicide. Her primary target is the 1993 ruling of ...

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