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December 1, 2005  Vol. 353 No. 22

Audio Summary of this Issue

Perspective
2317-2318

In July, the FDA reported that it was aware of four U.S. deaths due to sepsis in women who had used mifepristone and announced its second revision to the black-box warning in eight months. Dr. Michael Greene writes that these deaths have important ...

2319-2321

When randomized, controlled trials, for a variety of reasons, fail to provide data on overall mortality, should epidemiologic studies step into the breach? Wayne Ray cautions that there are formidable challenges involved in conducting studies of mortality ...

2321-2323

Dr. Davor Solter writes that there is hope among scientists and many legislators that federal funding could be extended to cover embryonic stem-cell lines if such lines could be derived without destroying a viable human embryo. He comments on two recent ...

Original Articles
2325-2334

This report presents the outcomes for the first 1004 patients with AIDS who received combination antiretroviral therapy at a clinic in Port-au-Prince, Haiti. Despite high rates of poverty, malnutrition, and tuberculosis, the outcomes were similar to those in developed countries, providing evidence in support of international efforts to make antiretroviral treatment available to people with AIDS in developing countries.

2335-2341

Recently, the FDA issued an advisory stating that atypical antipsychotic medications (such as olanzapine and risperidone) increase mortality among elderly patients. This study compared mortality rates among elderly patients who began using either atypical antipsychotic agents or conventional drugs (such as perphenazine and thioridazine). Conventional agents were associated with a higher rate of death. Thus, elderly patients should not be switched from atypical to conventional agents to reduce the risk of death.

2342-2351

The authors measured mRNA for the T-cell marker FOXP3, as well as for CD25, CD3ε, perforin, and 18S ribosomal RNA in the urine of patients who had undergone renal transplantation, correlating results with biopsy findings and renal function. Only FOXP3 mRNA correlated inversely with serum creatinine levels in patients with acute rejection, thus providing a potentially noninvasive means of predicting outcome in acute rejection.

2352-2360

The authors report four deaths due to endometritis and toxic shock syndrome associated with C. sordellii that occurred within one week after abortions that were medically induced by administration of oral mifepristone and intravaginal misoprostol. Clinical findings included tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever.

Clinical Practice
2361-2372

A 38-year-old man notes abrupt loss of vision in his right visual field while reading. He has no significant medical history and reports that he does not smoke or use alcohol or illicit drugs. Physical examination reveals right homonymous hemianopia but no other abnormalities. MRI reveals acute left occipital infarction and normal head and neck vessels. Transesophageal echocardiography shows a patent foramen ovale without atrial septal aneurysm. What are the implications of this finding, and what therapy should be recommended?

Review Article
2373-2383

    This review considers the role of low-dose aspirin for the prevention of atherothrombosis, discussing the molecular mechanism of action of aspirin as well as clinical and epidemiologic studies of aspirin as an antiplatelet agent, with special emphasis on the benefits and risks in different patient populations.

    Images in Clinical Medicine
    2384
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    This 71-year-old man was evaluated for severe anemia, ecchymosis of the lower limbs, and hemorrhages of the oral cavity. What is the diagnosis?

    Clinical Problem-Solving
    2385-2390
    • Video

    An 80-year-old man presented for evaluation of shortness of breath and fatigue four weeks after repair of a hiatal hernia. He reported a mild, nonproductive cough and abdominal bloating. Before the surgery, he had been very active and had had no dyspnea.

    Editorials
    2392-2394
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    Many arguments have been raised over the years to justify not moving rapidly forward with antiretroviral treatment programs for people living with the human immunodeficiency virus (HIV) and AIDS in settings with limited resources. The standard litany ...

    2394-2396

    In comparing current clinical outcomes in renal transplantation with those of 30 years ago,1 graft failure from immunologic factors and death from opportunistic infection in the first year after transplantation are no longer common clinical outcomes. The ...

    Sounding Board
    2397-2402
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    Most HIV infections are spread by persons who do not know that they are infected. This article argues that it is time to adopt the proven strategies that have contained other epidemics: widespread voluntary screening, improved notification of the partners of infected persons, and case management with close monitoring. In the United States, this approach might have the potential to prevent at least half of all cases of HIV infection each year.

    Correspondence
    2403-2404

    To the Editor: The article by Zhang et al. (Aug. 25 issue)1 demonstrated the usefulness of treatment of early pregnancy failure with intravaginal misoprostol but did not describe the serious complications that can arise from such administration of this ...

    2404-2408

    To the Editor: The article by Dibra et al. (Aug. 18 issue)1 advances our understanding of the differences between paclitaxel-eluting stents and sirolimus-eluting stents when used to prevent restenosis in patients with diabetes. However, in this study, ...

    2408-2409
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    To the Editor: In the article by Pinto et al. (Sept. 1 issue),1 the examination of the sailor presenting with dyspnea and weight gain revealed that his “jugular venous pressure was not elevated,” leading the discussant to dismiss a cardiac cause. In fact,...

    2409-2410

    To the Editor: The Medical Mystery in the October 6 issue1 shows a 10-year-old boy with one brown and one blue eye, with mild ptosis and miosis of the lighter, left eye (Fig. 1). Both eyes respond equally to light and have normal vision; both are normal ...

    2410-2411

    To the Editor: Orthotopic liver transplantation has been performed in at least 10 patients who have maple syrup urine disease (MSUD).14 In the first patients, transplantation was for nonmetabolic reasons (hepatic failure with hepatitis A1 and ...

    Book Reviews
    2412-2413

    John Hunter is rightly regarded as the founder of scientific surgery, but he has long been a lightning rod for controversy, within his own lifetime and even today. In this new biography, Wendy Moore brings Hunter to life in all his flawed, combustible ...

    2413-2414

    In 1957, the discovery of an antiviral agent that could rival the bactericidal power of penicillin generated excitement in government, industry, the media, and the general public. Nearly 50 years later, this class of biologic agents collectively called ...

    2414-2415
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    In the current era of e-mailed electronic snapshots, frequent intercontinental travel, and advanced pharmaceutical marketing, picture postcards from abroad bearing promotional messages for drugs might appear quaint or hokey or downright bizarre. Yet in ...