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August 3, 2006  Vol. 355 No. 5

Audio Summary of this Issue

Perspective
437-440

A surprising court decision this past May has advanced an effort to allow terminally ill people to purchase experimental drugs after initial safety testing but before they have been shown to work. Dr. Susan Okie reports.

440-443
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The control and virtual elimination of measles in the United States is a public health success. However, Dr. E. Kim Mulholland writes that as long as measles continues to circulate in other parts of the world, cases will continue to be imported.

443-445

In this essay, Dr. Ranjana Srivastava, a volunteer at a refugee clinic, describes caring for a patient who was denied refugee status, and thus, access to health care. Dr. Srivastava asks where, really, does our duty as physicians lie?

Original Articles
447-455

In 2005, an outbreak of measles occurred that was traced to a student who had returned home to Indiana from a trip to Romania. At a gathering attended by the student, there were an estimated 50 people who lacked evidence of measles immunity, of whom 16 (32 percent) acquired measles. One health care worker also became infected, and severe respiratory distress developed, requiring ventilator support.

456-466

In this study, mutations in the gene encoding the sulfonylurea receptor, a component of the beta-cell ATP-sensitive potassium channel, are described in infants with neonatal diabetes. Some of these infants were successfully weaned from insulin by treatment with sulfonylureas.

467-477

The beta-cell ATP-sensitive potassium channel is made up of two subunits — SUR1 and Kir6.2 — and its normal function is critical to insulin secretion. This study shows that in 44 of 49 patients with diabetes caused by Kir6.2 mutations, treatment was successfully switched from subcutaneous injection of insulin to oral sulfonylureas.

478-487

A clinical prediction rule for the termination of resuscitation during out-of-hospital cardiac arrest was validated in a study of 1240 patients treated by emergency medical technicians (EMTs) trained to use defibrillation. In arrests not witnessed by EMTs, there was no return of spontaneous circulation, no countershocks were administered, and the survival rate was 0.5 percent.

Review Article
488-498

This account of chronic venous disease summarizes the clinical aspects of the disorder and reviews the recent advances in studies of the hydrodynamic and biochemical changes that underlie the disorder.

Images in Clinical Medicine
499
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A 39-year-old woman presented at a clinic for a second opinion regarding a diagnosis of age-related macular degeneration, which had been noted on routine ophthalmologic examination. She reported having no visual problems. Her medical history was notable ...

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This 54-year-old smoker presented with weight loss and a burning sensation in her hands and feet. Her pupils were asymmetric and unresponsive to light.

Clinical Problem-Solving
500-505

    A 60-year-old man presented to the emergency department for evaluation of rectal bleeding, syncope, and pain in the right leg. Five days earlier, diffuse abdominal pain that worsened with movement had developed in association with nausea, anorexia, and malaise. Shortly before admission, the patient had a single episode of gross hematochezia and hematuria followed by syncope, as well as intense pain in the right leg.

    Editorials
    507-510

    The revolution in molecular biology has led to widespread appreciation of a principle first described by the British physician A.E. Garrod approximately 100 years ago — that “inborn errors of metabolism” teach us much about human biology in health and ...

    510-512

    Cardiac arrest is a leading cause of death in the United States.1 In spite of periodic updates of the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of the American Heart Association (AHA) (hereafter referred to as the AHA ...

    Clinical Implications of Basic Research
    513-515

    A recent study in a rat model of coronary-artery occlusion shows that pretreatment with 1,6-bis(phosphocholine)-hexane inhibits increased myocardial damage that results from human C-reactive protein.

    Occasional Notes
    516-520

    Holy Roman Emperor Charles V was known to have had attacks of gout from early adulthood. This study provides objective confirmation of the clinical diagnosis on the basis of an examination of the mummified terminal phalanx of one of his fingers. The analysis demonstrated typical gouty tophi, eroding bone and extending into the soft tissues.

    Correspondence
    521-524

    To the Editor: Schillinger et al. (May 4 issue)1 demonstrated the superiority of primary stenting with nitinol stents, as compared with balloon angioplasty, in patients with peripheral-artery disease. However, the findings raise an issue with regard to ...

    525

    To the Editor: In his Shattuck Lecture, Dr. Arky (May 4 issue)1 stated that “continuing medical education [CME] is in trouble.” CME, still dominated by classroom lectures, does not produce measurable changes in physicians' performances.

    Osler's teaching ...

    526-527

    To the Editor: Kaushansky (May 11 issue)1 reports that “more recent studies indicate that patients treated for breast cancer with cyclophosphamide and doxorubicin may have an increased risk of myelodysplasia or acute myelogenous leukemia if they have ...

    527-528

    To the Editor: A 2700-g male infant, born at 35 weeks of gestation by cesarean section, was found to have fetal ascites without apparent cause at 33 weeks of gestation. The mother had IgG antibodies but not IgM antibodies against cytomegalovirus (CMV). ...

    528-529

    To the Editor: We wish to report our clinical experience with the use of cyclooxygenase-2 (COX-2) inhibitors to control pain in patients treated with free vascular flaps after undergoing ablative surgery to resect an oral cancer. From January 1997 to ...

    Book Reviews
    530-531

    There's nobody better than the Brits at breaking scientific bad news in plain, blunt language. Consider this dispiriting assessment of medical and public health professionals' track record to date on helping overweight children: “Regrettably, most dietary ...

    531-532

    Infectious Diseases of the Fetus and Newborn Infant is an excellent source of information on infections in newborns, especially those transmitted from mother to baby. The stated goal of the editors is “to provide a complete, critical, and contemporary ...

    532-533

    Neural Tube Defects: From Origin to Treatment offers a comprehensive, timely, and sobering review of many aspects of neural tube defects and provides a wealth of information that is communicated (for the most part) in a clear and readable fashion. The ...

    Corrections
    533

    A MicroRNA Signature Associated with Prognosis and Progression in Chronic Lymphocytic Leukemia Original Article, N Engl J Med 2005:353;1793-1801.. On page 1796, in Table 2, the column head “Level of Expression in Group 4” and the corresponding footnote ...

    533

    Aromatase Inhibitors — A Triumph of Translational Oncology Editorial, N Engl J Med 2005:353;2807-2809.. On page 2807, the sentence that begins five lines from the bottom of the right-hand column should have read, “The Italian Anastrozole Trial (ITA), with ...

    533

    The Challenge of Subgroup Analyses — Reporting without Distorting Perspective, N Engl J Med 2006:354;1667-1669.. On page 1668, the formula on line 3 of the middle column should have read “1−0.951/K” rather than “(1−0.95)1/K,” as printed. We regret the ...