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December 29, 2005  Vol. 353 No. 26

Audio Summary of this Issue

Perspective
2733-2735

This year, Medicare introduced the prescription-drug benefit. Drs. Peter Bach and Mark McClellan write that taking advantage of the new prescription-drug benefit will require some effort, but the effort will pay off for Medicare beneficiaries and their ...

2735-2739

Drs. Richard Kravitz and Sophia Chang describe how the task of sorting through the myriad of Medicare Part D alternatives will fall squarely on patients and their physicians. Whether physicians are ready to meet the challenge is uncertain.

2739-2741
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The new Medicare Part D will improve access to medications for millions of Americans. Rachel Elliott and coauthors explain that one subgroup of beneficiaries, however, may inadvertently be made worse off: the 7.2 million people enrolled in both Medicaid ...

2742-2743

Dr. Richard Platt and Alexander Ommaya write that an unintended effect of the Medicare Part D benefit could be the creation of the world's most valuable resource for understanding how drugs are used, especially by the elderly and the chronically ill, and ...

2743-2745

Stroke in sickle cell anemia occurs in about 11 percent of patients under 20 years of age. Dr. Orah Platt writes that it appears that transfusion does not simply prevent stroke but actually reverses the stenotic lesion.

Original Articles
2747-2757
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In a randomized comparison of letrozole with tamoxifen for the adjuvant treatment of early-stage, hormone-receptor–positive breast cancer in more than 8000 postmenopausal women, disease-free survival was significantly longer in the letrozole group. The five-year survival rates were 84.0 percent in the letrozole group and 81.4 percent in the tamoxifen group.

2758-2768

In this multicenter trial, patients in whom thrombolytic therapy for acute myocardial infarction failed were randomly assigned to repeated thrombolysis, conservative therapy, or emergency percutaneous coronary intervention (rescue PCI). Event-free survival was better among patients assigned to rescue PCI.

2769-2778
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Prophylactic transfusions have been shown to prevent stroke in children with sickle cell disease, but at the risk of iron overload. This trial of transfusion cessation in children with sickle cell disease who were not considered to be at high risk for stroke showed that cessation was associated with either Doppler blood-flow recordings suggesting a high risk of stroke or stroke itself.

Special Article
2779-2787
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As of September 13, 2005, the International Committee of Medical Journal Editors has required that all trials submitted for publication be registered in a public database. This study examines the records registered in ClinicalTrials.gov from May 11 to October 11, 2005. The number of trials in the database approximately doubled, and the information about the trials became more specific.

Clinical Practice
2788-2796

    A 62-year-old man presents with a three-day history of progressive dyspnea, nonproductive cough, and low-grade fever. His blood pressure is 100/60 mm Hg, his heart rate 110 beats per minute, his temperature 37.9°C, and his oxygen saturation while breathing room air 86 percent. Chest auscultation reveals rales and rhonchi bilaterally. A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette. How should this patient be evaluated to establish the cause of the acute pulmonary edema and to determine appropriate therapy?

    Images in Clinical Medicine
    2797
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    A 37-year-old man was evaluated because of a two-year history of asymptomatic thickening and darkening of the skin on his axillae (Panel A), neck, face, and arms. The patient had no history of diabetes mellitus or other endocrine disorders, alcohol abuse, ...

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    This 73-year-old Inuit woman was referred after an incomplete colonoscopy. A preliminary abdominal radiograph showed something in the appendix.

    Case Records of the Massachusetts General Hospital
    2798-2805

    An 18-year-old man reported gradual painless swelling of the left mandible that had occurred over one month. An examination showed enlargement of the left mandible, with normal dentition. Imaging studies revealed a large, cystic lesion in the ramus and body of the left mandible. A diagnostic and therapeutic procedure were performed.

    Editorials
    2807-2809

    Great strides have been made in the diagnosis and treatment of early-stage breast cancer, thanks to advances in molecular medicine, interdisciplinary treatment, and rapid electronic communication. Hormonal therapy, the first and most successful targeted ...

    2809-2811
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    One measure of medical progress is new treatments. The discovery of a novel therapy takes time and money, but more important, it requires the mutual effort of groups that, while they share the common goal of improved treatment, often have fundamentally ...

    2811-2812
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    The arguments in favor of the registration of clinical trials are now familiar.14 Chief among these addresses the practice of selective reporting, whereby negative or detrimental studies are not brought into the public domain, which experts on the ...

    2813-2814

    Drs. Gregory Curfman, Stephen Morrissey, and Jeffrey Drazen report on recently obtained information regarding inaccuracies in data in the report of the Vioxx Gastrointestinal Outcomes Research study that raises concern about certain conclusions in the ...

    Correspondence
    2815-2817

    To the Editor: Wang et al. (Sept. 22 issue)1 constructed a 22-phage-peptide detector for prostate cancer, with 81.6 percent sensitivity and 88.2 percent specificity. Previously, we constructed a decision tree for classifying prostate cancer, using five ...

    2817-2818

    To the Editor: In their report on the effects of early prophylactic thyroidectomy in patients with multiple endocrine neoplasia type 2A (MEN-2A) (Sept. 15 issue),1 Skinner et al. identified a group of patients with postoperative calcitonin levels that ...

    2818-2820

    To the Editor: Nigro et al. (Sept. 29 issue)1 report on the administration of cytomegalovirus (CMV) hyperimmune globulin to 68 pregnant women with primary CMV infection and conclude that this treatment “may be effective in the treatment and prevention of ...

    2820

    To the Editor: The article by Adem and colleagues (Sept. 22 issue)1 described three patients with severe sepsis caused by Staphylococcus aureus who had, at autopsy, bilateral adrenal hemorrhage. Two of the patients had elevated serum cortisol levels. Is ...

    2821-2822

    To the Editor: In Table 3 of their excellent review, Macario and Conway de Macario (Oct. 6 issue)1 state that an elevated level of circulating heat-shock protein (HSP) 70 has not been associated with any disease. However, we recently described elevated ...

    2822-2823

    To the Editor: Service et al. (July 21 issue)1 recently reported on six patients with hyperinsulinemic hypoglycemia and nesidioblastosis after Roux-en-Y gastric bypass surgery. The authors postulated that the rapid presentation of nutrients in the ...

    Book Reviews
    2824

    As we approach the 25th anniversary of the first reports of the disease that would become known as AIDS, one might wonder what more there is to be written about the responses to the epidemic by Western nations. Much of the territory covered in Peter ...

    2825-2826

    It is a welcome breath of fresh air to read William H. Foege's preface to Global Health Leadership and Management. He zeroes in on the looming crisis in global public health with a tiger's instinct for the jugular vein.

    Bridging the huge gap between the ...

    2826

    During the past decade, a growing body of interdisciplinary academic literature has explored the relationship between health and human rights. Not surprisingly, much of that scholarship has focused on either the health implications of human rights ...

    Corrections
    2827

    Peritoneal Dialysis and Epithelial-to-Mesenchymal Transition of Mesothelial Cells Original Article, N Engl J Med 2003:348;403-413.. On page 408, Panel H of Figure 3 contains several errors. The corrected version of this figure appears with the full text ...

    2827

    Case 25-2005: A 40-Year-Old Man with Prolonged Fever and Weight Loss Case Records of the Massachusetts General Hospital, N Engl J Med 2005:353;713-722.. On page 714, lines 4 through 6 of the right-hand column should have read, “Pathological examination of ...

    2827
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    Chronic Insomnia Clinical Practice, N Engl J Med 2005:353;803-810.. On page 806, in Table 3, under the column heading Contraindications or Drug Interactions, all five listings should have read, “Drugs that inhibit CYP3A4” or “CYP1A2,” rather than “Drugs ...

    2827
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    Psoriasis Correspondence, N Engl J Med 2005:353;848-850.. On page 848, lines 8 and 9 of the letter by Khan should have read “. . . and in humans, these cells express the forkhead transcription factor FOXP3,” rather than “FOX33,” as printed. We regret the ...

    2827

    Direct Thrombin Inhibitors Review Article, N Engl J Med 2005:353;1028-1040.. On page 1029, in Figure 1, the arrow pointing from activated protein C and protein S to factors IXa and VIIIa should have been dashed (indicating an inhibitory pathway), rather ...