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May 15, 2008  Vol. 358 No. 20

Audio Summary of this Issue

Perspective
2089-2091

Hannah Poling was diagnosed with encephalopathy caused by a mitochondrial enzyme deficit. Her parents believed that vaccines had triggered her encephalopathy, and they sued the Department of Health and Human Services for compensation under the Vaccine ...

2091-2093

Dr. David Shulkin has begun making late-night administrative rounds at the hospital where he is president and chief executive officer. These visits are part of an initiative intended to address the stark discrepancy in quality between daytime and ...

Original Articles
2095-2106

Several regimens are used as initial antiretroviral therapy for HIV-1 infection, but few direct comparisons are available. In this randomized, open-label study, efavirenz plus two nucleoside reverse-transcriptase inhibitors (NRTIs), lopinavir–ritonavir plus two NRTIs, and lopinavir–ritonavir plus efavirenz were compared. Initial therapy with efavirenz plus two NRTIs was associated with less virologic failure than was lopinavir–ritonavir plus two NRTIs. The NRTI-sparing regimen of lopinavir–ritonavir plus efavirenz had virologic efficacy similar to that of efavirenz plus two NRTIs but was more likely to select for drug resistance.

2107-2116

To predict the risk of death from cardiovascular causes in a community-based cohort of elderly men, the authors used a combination of biomarkers (troponin I, N-terminal pro−brain natriuretic peptide, cystatin C, and C-reactive protein). The addition of these markers to a model with traditional cardiovascular risk factors significantly improved risk stratification as compared with a model that used only the traditional risk factors.

2117-2126
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In this large, retrospective registry study, patients hospitalized with acute decompensated heart failure who had elevated cardiac troponin levels had higher mortality rates than those who were negative for troponin, even after correction for other predictive variables. Measurement of cardiac troponin, which may reflect myocyte injury, is useful for risk stratification of such patients.

2127-2137

In a previous phase 2 placebo-controlled trial, recombinant activated factor VII (rFVIIa) reduced growth of the hematoma and improved survival and functional outcome in patients with intracerebral hemorrhage. Those findings were not reproduced in this phase 3 trial, in which rFVIIa reduced hematoma growth but did not improve clinical outcomes.

Clinical Practice
2138-2147
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A 63-year-old woman presents with a 2-year history of progressive weakness and discomfort in her right shoulder, especially when she puts dishes on the top shelf in her kitchen. She is otherwise healthy and has had no injuries. Physical examination shows some atrophy of the muscles in the right shoulder and weakness when the right arm is elevated. Magnetic resonance imaging shows a large defect in the rotator cuff. How should her case be managed?

Review Article
2148-2159

Heart failure results not only from cardiac overload or injury but also from a complex interplay among genetic, neurohormonal, inflammatory, and biochemical changes acting on cardiac myocytes, the cardiac interstitium, or both. This review focuses on biomarkers for heart failure other than routinely determined laboratory values and discusses how these might be used in assessing and managing heart failure.

Images in Clinical Medicine
2160
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A 55-year-old bisexual man presented with a few weeks' history of lethargy followed by the onset of a widespread nonpruritic rash that covered much of his body, including the palms (Panel A). Vesiculopustular waxy lesions consistent with keratoderma ...

e22
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This 24-year-old woman presented with a history of progressive abdominal distention accompanied by early satiety and constipation.

Case Records of the Massachusetts General Hospital
2161-2168

A 55-year-old man was referred to this hospital for management of prostate cancer. An elevated serum prostate specific antigen (PSA) level was found during evaluation of urinary symptoms; core needle biopsies of the prostate disclosed adenocarcinoma, with a Gleason score of 6 out of 10. Examination and computed tomography showed a smoothly enlarged prostate and no lymphadenopathy. Options for management were discussed.

Editorials
2170-2172

Drugs that are used to treat patients with human immunodeficiency virus (HIV) infection are classified according to their target. The first ones to be developed were nucleoside reverse-transcriptase inhibitors (NRTIs), which lead to premature termination ...

2172-2174

Guidelines for the assessment of cardiovascular risk remain focused squarely on established risk factors.1 Although it is known that tools based on these risk factors, such as the Framingham Risk Score, have a number of limitations when applied in ...

2174-2176

Intracerebral hemorrhage accounts for 10 to 15% of all strokes. It is the type of stroke with the highest mortality, with a 1-year survival rate of less than 50%.1 Most intracerebral hemorrhages occur in patients who have hypertension, which is the major ...

Clinical Decisions
e23
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  • Interactive/Multimedia

This interactive feature presented the case of a patient with carotid stenosis. Readers were invited to vote for one of three possible treatment options.

Correspondence
2177-2179

To the Editor: We wish to express a number of concerns about the methods used in the study of mild traumatic brain injury by Hoge et al. (Jan. 31 issue).1 We learned through firsthand experience in the combat zone that immediately after a concussion, the ...

2179-2180

To the Editor: The acceptance of a partial face allograft as a promising procedure for patients with facial disfigurement will depend on long-term functional results. An impressive recovery of sensory function was reported by Dubernard et al. (Dec. 13 ...

2180-2182

To the Editor: The importance of the study reported by Turner et al. (Jan. 17 issue),1 on selective publication of antidepressant trials, can hardly be overstated because it shows how researchers and clinicians are deprived of accurate data, resulting in ...

2182-2183

To the Editor: In their editorial about physicians and executions, Curfman et al. (Jan. 24 issue)1 are correct that our profession has no place in the process of legal execution in this country. I would point out that growing public sentiment against ...

2183

To the Editor: I was deeply disturbed by the discussion, led by Gawande, on physicians and executions (Jan. 31 issue).1 Except for Truog's principled objection to capital punishment on moral grounds, it seems as if the participants were missing the point ...

2184-2185

To the Editor: The Perspective article by Hunter et al. (Jan. 10 issue)1 concludes that commercialization of personal genomics is premature in light of the lack of data to support the analytic and clinical validity and clinical utility of these tests. ...

2185-2186

To the Editor: Triptans are serotonin-receptor agonists used in the treatment of migraine headaches. When administered in combination with certain drugs, such as selective serotonin-reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake ...

Book Reviews
2187-2188

This book about the ongoing revolution in human longevity and its implications for society was written by Robert Butler, a professor of geriatrics who is still working at the age of 80. The book is unique in that Butler not only describes the medical and ...

2188-2189

Human embryonic stem cells were isolated 10 years ago with the use of knowledge that had been gained from more than 20 years of research in rodents and nonhuman primates. The scientific goalposts have changed constantly since then, and each change has ...

2189

Like it or not, we are defined by being male or female. One of the first things children can tell you about themselves is their sex, and they are remarkably accurate in making the same distinction about their peers. This skill marks the beginning of a ...

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