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October 5, 2006  Vol. 355 No. 14

Audio Summary of this Issue

Perspective
1409-1412

Dr. Robert Steinbrook writes that since ranibizumab and bevacizumab have never been directly compared, physicians can only speculate about which drug is superior with regard to safety, efficacy, and frequency of administration. The price difference is ...

1412-1414

Today, there is talk about an epidemic of atrial fibrillation. Dr. Bruce Fye recounts the clues that led clinical investigators to propose that atrial fibrillation was a common arrhythmia in patients with cardiac disease.

1415-1417

Medical language struggles to differentiate aging from disease, healthy aging from unhealthy aging, and optional aging from obligatory aging. Dr. Kate Scannell writes that accepting the reality of aging may be uniquely problematic in the United States, ...

Original Articles
1419-1431

Previous studies have suggested that targeting intravitreal vascular endothelial growth factor A (VEGF-A) counters choroidal neovascularization and hence age-related macular degeneration. A double-blind, placebo-controlled trial of ranibizumab, which neutralizes all isoforms of VEGF-A, for treatment of minimally classic and occult age-related macular degeneration retarded the progression of the disease and improved visual acuity in some patients.

1432-1444

Previous studies have implicated intravitreal vascular endothelial growth factor A (VEGF-A) as a target for countering neovascularization and, therefore, age-related macular degeneration. This double-blind, controlled trial comparing ranibizumab, which neutralizes all isoforms of VEGF-A, with photodynamic therapy with verteporfin showed that ranibizumab was better able to retard the progression of predominantly classic neovascular age-related macular degeneration.

1445-1455

In standard immunotherapy, small amounts of allergen are injected to induce a state of clinical tolerance of allergen reexposure. In this trial, the investigators studied immunotherapy in which a ragweed allergen was conjugated to an oligonucleotide. The vaccine did not reduce the albumin level in nasal-lavage fluid (the primary end point) but did have a positive effect on an array of secondary end points, suggesting that this approach merits further study in larger, structured trials.

1456-1465

Anemia is a principal feature of the myelodysplastic syndrome with deletion of chromosome 5q; most patients require transfusions, and iron overload develops as a consequence. In this phase 2 trial, lenalidomide reduced dependence on transfusions in most patients, and two thirds of them could stop transfusions altogether. The drug, an analogue of thalidomide, also reversed chromosomal and cytologic abnormalities in many patients.

Clinical Practice
1466-1473
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A previously healthy 18-year-old college freshman presented at an emergency department with acute onset of fever and headache. He was listless, febrile, and hypotensive. Petechiae were noted over his thorax. Meningococcemia was suspected (and subsequently confirmed by blood cultures positive for Neisseria meningitidis serogroup C). Despite prompt administration of antibiotics and other support, the patient's illness was fulminant and he died 12 hours after the onset of symptoms. Should he have previously received meningococcal vaccine, and what measures should be taken to protect his close contacts and his community?

Review Article
1474-1485

This review describes the mechanisms entailed in the leading cause of blindness in the United States.

Images in Clinical Medicine
1486

A 55-year-old man presented with a 1-month history of yellow discoloration of his palms and soles (arrow, right palm, as compared with a normal palm to the left). Diabetes mellitus had been diagnosed 1 month before admission. His conjunctiva were not ...

e15

This 62-year-old man with diabetes and end-stage renal disease with an arteriovenous fistula presented with a possible stenosis of the fistula. Multislice CT was used to detect the lesions.

Clinical Problem-Solving
1487-1491

    Urinary urgency and fever developed in a 55-year-old, bedridden woman with multiple sclerosis, a long-term indwelling Foley catheter, and multiple prior urinary tract infections. The patient had recently been transferred from an assisted-living facility to a skilled-nursing facility because of progressive disability. The laboratory evaluation revealed pancytopenia.

    Editorial
    1493-1495

    Age-related macular degeneration, a potentially blinding disease, is now epidemic in the developed world. Roughly one in three people will be affected to some degree by the age of 75 years.1 Medicine's tremendous successes in the battles against cancer, ...

    Correspondence
    1496-1497

    To the Editor: Kulkarni and colleagues (July 6 issue)1 found that the level of carbon in airway macrophages in children was strongly associated with expiratory flow rates, although in the 64 healthy children with sufficient numbers of airway macrophages ...

    1497-1500

    To the Editor: The primary end point of the study by Marenzi et al. (June 29 issue)1 was the occurrence of contrast-medium–induced nephropathy, defined as an increase in the serum creatinine concentration of 25% or more from the baseline value within the ...

    1500-1501

    To the Editor: The editorial by Utiger (June 29 issue)1 summarizes the effects of iodine deficiency. However, his recommendation of an iodine intake of 300 to 400 μg per day far exceeds the following recommendations of the Institute of Medicine: 150 μg ...

    1502

    To the Editor: In his Health Policy Report (June 29 issue),1 Iglehart seems to suggest that patients, payers, and physicians alike would be well served if a great effort was made by the imaging community to work together and identify new measures of ...

    1502-1503
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    To the Editor: Schmitt et al., in their letter to the editor (June 22 issue),1 suggest that Takayesu et al. were incorrect in their assessment that a serum creatinine level of 3.8 mg per deciliter was caused by ingestion of ethylene glycol because it ...

    1503-1505

    To the Editor: Tropheryma whipplei (formerly T. whippelii) causes Whipple's disease, an infectious disorder involving the digestive tract.1 The organism can be seen within macrophages in the duodenum, but T. whipplei was first isolated from specimens of ...

    Book Reviews
    1506-1507

    The history of our explorations of the nature, meaning, and treatment of pain opens a window on multiple aspects of human culture: physiology and pharmacology, obstetrics and bacteriology, psychology and philosophy, art and literature, and politics and ...

    1507-1508

    In the spectrum of eye diseases, few rival age-related macular degeneration. Moderately advanced dry macular degeneration alone is estimated to affect more than 8 million Americans over 55 years of age. Age-related macular degeneration is the leading ...

    1508-1509
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    During the past two decades, diabetes has become one of the most important public health problems — a consequence of increasing awareness and a dramatic increase in the number of people who receive a diagnosis of type 2 diabetes. It is not simply ...

    Correction
    1509

    Regression of Aortic Aneurysms through Pharmacologic Therapy? Clinical Implications of Basic Research, N Engl J Med 2006:354;2067-2068.. On page 2068, in Figure 1, “Collagen layer” should have been labeled “Fenestrated elastic lamella,” and the collagen ...