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February 2, 2006  Vol. 354 No. 5

Audio Summary of this Issue

Perspective
437-440
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The FDA has been struggling for nearly two decades over the possible approval of a do-it-yourself home test for HIV. Drs. Alexi Wright and Ingrid Katz write that it finally looks possible.

440-442
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Knowledge of serologic status is required for the appropriate targeting of services and interventions. Drs. Kevin De Cock, Rebecca Bunnell, and Jonathan Mermin discuss how the increased resources available for combating HIV and AIDS, the strong emphasis ...

443-445

Every year, thousands of physicians travel to developing countries to volunteer their skills and knowledge. Dr. Adam Wolfberg describes the core set of challenges that distinguishes overseas medical work from the usual clinic routine.

445-447

Dr. Marlene Haffner writes that when the Orphan Drug Act was passed in 1982, few suspected the extent to which this law would alleviate the plight of patients with rare diseases.

Original Articles
449-461
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This randomized study of patients in a medical ICU compared insulin infusion to normalize the blood glucose level with conventional therapy. Overall, insulin infusion was associated with decreased morbidity but not decreased mortality. However, a lower relative risk of both was observed among patients receiving insulin who remained in the ICU for more than three days, although predicting length of stay on admission to the ICU is not possible. Further studies are needed to confirm these data.

462-471
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In a randomized trial and subsequent open-label study, the orphan drug intravenous human botulism immune globulin (BIG-IV) was safe and effective in treating infant botulism. Its use reduced the mean length of the hospital stay, duration of intensive care, duration of mechanical ventilation, and per patient hospital charges. Efficacy was greater when the drug was given within three days after hospital admission. These data support the prompt use of BIG-IV in infants in whom botulism is suspected.

472-482

Patients with schizophrenia are often treated with multiple antipsychotic drugs, but the benefits are not known. In this eight-week randomized, controlled trial in patients with severe schizophrenia and a poor response to clozapine, the combination of clozapine and risperidone did not achieve better control of symptoms than clozapine alone. The findings of this small, short-term study do not support the addition of risperidone to clozapine for patients with severe schizophrenia.

Review Articles
483-495

    At present, 90 to 95 percent of percutaneous coronary interventions involve the implantation of a stent, often a drug-eluting stent, though most published data originated in the era of bare-metal stents. This article reviews the indications for and biology of coronary-artery stents, focusing on recent advances in drug-eluting stents.

    496-507

    Positron-emission tomography has become an important tool for evaluating tumors, detecting occult cancer, and staging and restaging tumors. This review includes a slideshow with scans from 10 patients with common cancers.

    Images in Clinical Medicine
    508
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    This elderly man had recurrent hematuria and a serum creatinine level of 4.4 mg per deciliter.

    Clinical Problem-Solving
    509-514

      A 46-year-old Mexican immigrant presented with epigastric pain and vomiting of coffee-grounds material. He reported fatigue, malaise, jaundice, and a weight loss of 20 lb (9.1 kg) during the previous two months. He had also had dark stools, light-headedness, and mild shortness of breath, but no fever, chills, or night sweats.

      Editorials
      516-518

      Among the critically ill, elevations in blood glucose, a marker previously ignored or described as adaptive, became a major therapeutic target after a 2001 study indicated a mortality benefit of intensive insulin therapy among patients in a surgical ...

      518-520

      Schizophrenia is a serious chronic illness that requires lifelong medication. In some patients, the illness is refractory to even highly effective medications such as clozapine, and these patients desperately need more effective treatment regimens. Less ...

      Clinical Implications of Basic Research
      521-523

      Definitive endodermal cells have been generated from human embryonic stem cells — a process that is key to their potential use in the treatment of type 1 diabetes mellitus.

      Correspondence
      524-525

      To the Editor: Calin et al. (Oct. 27 issue)1 report on genomic mutations within microRNA loci in patients with chronic lymphocytic leukemia (CLL). We believe that the frequency with which such mutations can be found was not accurately estimated and that ...

      525-526

      To the Editor: Mellinghoff et al. (Nov. 10 issue)1 identified coexpression of epidermal growth factor receptor (EGFR) deletion mutant variant III (EGFRvIII) and the tumor-suppressor protein PTEN as a molecular signature in pretreatment glioblastoma ...

      526-528

      To the Editor: Recent reports have noted the presence of novel mutations of the epidermal growth factor receptor (EGFR) gene in small samples of DNA extracted from paraffin-embedded sections or laser-microdissected specimens.1,2 Nagahara et al.1 reported ...

      528-530

      To the Editor: As African physicians who have experience in both the developing and the developed worlds, we believe that Mullan (Oct. 27 issue),1 like others who have written about the metrics of the physician brain drain,2 overlooks three important ...

      530-531

      To the Editor: Project planners who are seeking to cultivate a network of patients willing to provide their health information to genomic-cohort investigators, as described by Kohane and Altman (Nov. 10 issue),1 cannot afford to ignore how increasing ...

      531-532

      To the Editor: We are concerned that Dr. Akbar and his colleagues, as reported in their letter to the editor (Sept. 29 issue),1 used explanted cerebrospinal fluid shunt valves in their study of the susceptibility of these valves to malfunctions when ...

      532-533

      To the Editor: The recent three-month nationwide shortage of intravenous formulations of vitamin B1 (thiamine) highlights the fact that only one company, American Pharmaceutical Partners, is manufacturing this lifesaving drug.1 This shortage was the ...

      Book Reviews
      534-535

      The first four lines of this fine biography summarize the man: “Harvey Cushing (1869–1939) was one of the first American medical men to be the world leader in his field. He was one of the first great surgeons produced by the United States, and in the ...

      535-536

      The first Nobel Prize in Physiology or Medicine, awarded in 1901, bypassed the premier microbiologist of the period, Robert Koch, who identified the causes of tuberculosis and anthrax, as well as the key architects of the new field of immunology, Elie ...

      536-537

      James Atlas's My Life in the Middle Ages: A Survivor's Tale is a successful melding of heartfelt, profound emotion and narrative finesse. This should come as no surprise to those who know his work: Atlas, a regular contributor to the New York Times, the ...

      Corrections
      537

      Breast Cancer of an Accessory Nipple Images in Clinical Medicine, N Engl J Med 2005:353;1835.. Line 13 should have read, “The patient is receiving chemotherapy,” rather than “receiving neoadjuvant chemotherapy,” as printed.

      537

      γ-Hydroxybutyric Acid Review Article, N Engl J Med 2005:352;2721-2732.. On page 2724, lines 8 through 11 under the subhead GHB Toxicity should have read, “In some series, GHB was the second most common drug detected in the urine of young people presenting ...