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March 27, 2008  Vol. 358 No. 13

Audio Summary of this Issue

Perspective
1321-1323

Federal grants to community health centers will have increased to $2.2 billion in fiscal 2009, if Congress accepts President Bush's proposed budget for this program. John Iglehart writes that the chaotic mix of private and public activities that make up ...

1324-1325

How can we capture transformative innovation in order to address problems in global health? Dr. Tadataka Yamada discusses a new initiative by the Bill and Melinda Gates Foundation.

Original Articles
1327-1335

Weaning patients from mechanical ventilation after modest periods of diaphragmatic inactivity can be difficult. In this study, changes in the cross-sectional area and biochemical composition of biopsy specimens from brain-dead patients with inactive diaphragms at the time of organ donation were compared with similar measurements from patients undergoing thoracic surgery. The data were consistent with atrophy of the diaphragm after periods of inactivity on the order of a day.

1336-1345

In an analysis from the Multi-Ethnic Study of Atherosclerosis, 6722 men and women without cardiovascular disease from four ethnic groups underwent coronary calcium scanning and were followed for a median of 3.8 years. For each ethnic group, there was an increase in the risk of subsequent coronary events with an increase in the baseline coronary calcium score.

1346-1353
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In this large observational study of primiparous women, the cervical length at mid-pregnancy was an independent predictor of the risk of cesarean section during labor at term and specifically of cesarean section performed for poor progress during labor. These findings suggest that the failure of labor to progress at term may be related to dysfunctional development of the uterus much earlier in pregnancy.

Special Article
1354-1361
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The Prescription Drug User Fee Act (PDUFA) imposes deadlines for the completion of drug reviews by the Food and Drug Administration. This study showed that PDUFA regulations resulted in a concentration of approval decisions in the weeks immediately preceding deadlines. Drugs that were approved just before the deadlines, as compared with drugs approved at other times, had higher rates of subsequent safety problems.

Clinical Therapeutics
1362-1369

An 18-year-old woman with sickle cell anemia presents with recurrent painful crises, and treatment with hydroxyurea is recommended. Hydroxyurea causes a shift toward the production of red cells containing fetal hemoglobin. A possible increase in the risk of acute leukemia due to hydroxyurea therapy remains the subject of debate.

Review Article
1370-1380

This review explains how the heart responds to physiologic or pathologic conditions. Exercise, pregnancy, and postnatal growth cause physiologic growth; neurohumoral activation, hypertension, and myocardial injury cause hypertrophic growth, which increases the risk of heart failure and malignant arrhythmia. Atrophy of the heart can arise from protracted bed rest, prolonged weightlessness, or mechanical unloading with a ventricular assist device.

Images in Clinical Medicine
1381
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A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea and vomiting. Over the previous 10 years, she had had progressive Alzheimer's disease, requiring her to live in a long-term care facility. On physical examination, ...

e14
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A 60-year-old man with advanced HIV was admitted because of altered mental status, fever, and seizure-like activity. Two hours after the administration of acyclovir, his urine became cloudy and white.

Case Records of the Massachusetts General Hospital
1382-1390

    A 10-year-old girl was seen because of dyspnea and noisy respirations. Three weeks earlier, sharp pain in the chest and shortness of breath had developed abruptly, followed by dyspnea and noisy respirations with exertion. Symptoms did not improve with the use of bronchodilators. A diagnostic procedure was performed.

    Editorials
    1392-1394

    It is widely assumed that respiratory-muscle weakness, either intrinsic or due to fatigue, leads to respiratory failure.1 For the past 30 years, attention has been focused on whether the diaphragm muscle is especially susceptible to fatigue in patients ...

    1394-1396

    The thoughtful clinician takes it to be self-evident that intensity of therapy should be proportional to risk of disease.1,2 Ever since Bigger coined the term “risk stratification” to characterize this intuitive process,3 more than 3000 articles (...

    Clinical Implications of Basic Research
    1397-1398

    Inducing skeletal myoblasts to express a gap-junction protein prevents arrhythmias when these myoblasts are used to treat myocardial infarction.

    Correspondence
    1399-1401

    To the Editor: Mai et al. (Dec. 13 issue) report that dexamethasone improved survival among patients with definite bacterial meningitis.1 However, dexamethasone was associated with decreased survival in the group of patients with probable meningitis, ...

    1402-1405
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    To the Editor: We respectfully challenge the notion of Iannuzzi and colleagues (Nov. 22 issue)1 that in all cases (other than cases of Löfgren's syndrome) “a biopsy specimen should be obtained from the involved organ that is most easily accessed.” We ...

    1405-1407

    To the Editor: In their discussion of a woman with rash, fever, and hypotension, Sabatine et al. (Nov. 22 issue)1 state that the patient was being treated with doxycycline for possible cellulitis of the face 2 days before admission. One day before ...

    1407

    To the Editor: In my review of African American Bioethics: Culture, Race, and Identity, edited by Lawrence Prograis, Jr., and Edmund D. Pellegrino (Jan. 10 issue),1 I failed to cite passages from Lynn Smitherman's review of the same book, published in ...

    1408-1409

    To the Editor: Type 2 citrullinemia is an adult-onset, autosomal recessive disorder characterized by episodes of hyperammonemic encephalopathy. It is caused by mutations in the SLC25A13 gene, which encodes the liver-specific isoform of the mitochondrial ...

    1409-1411

    To the Editor: Trastuzumab, an antibody against the protein product of the human epidermal growth factor receptor type 2 (HER2) gene, improves progression-free survival and overall survival when added to chemotherapy in patients with metastatic breast ...

    Book Reviews
    1412-1413

    The publication of Comprehensive Textbook of AIDS Psychiatry marks the coming of age of this newly recognized specialty section of the Academy of Psychosomatic Medicine and documents the evolution over the past three decades of psychiatric care for people ...

    1413-1414

    More than 100 years ago in London, William Farr plotted the geographic distribution of cholera deaths and John Snow surveyed his neighbors. Surveillance of infectious diseases has been, and continues to be, the most widely applied element of public health ...

    1414-1415

    Countless books on how to be a psychotherapist include sections on coping with stress and burnout, and there exists a growing literature that is completely devoted to this modern affliction. One might reasonably wonder whether there is a need for yet ...