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June 12, 2008  Vol. 358 No. 24

Audio Summary of this Issue

Perspective
2537-2539

The conventional wisdom for guidelines and performance measures has been that the clinician's key focus ought to be on reducing risk factors below specific levels. Drs. Harlan Krumholz and Thomas Lee argue that this approach neglects the importance of ...

2540-2543

The quest for a fully immunogenic vaccine against influenza H5N1 viruses has gone on for more than 10 years. Dr. Peter Wright writes that with tissue-culture–grown vaccine, the production schedule could be altered to permit incorporation of late-emerging ...

Original Articles
2545-2559
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Intensive glucose lowering targeting glycated hemoglobin levels of less than 6.0% was unexpectedly associated with an increase in overall mortality in high-risk patients with type 2 diabetes in the ACCORD trial. The findings identify a previously unrecognized risk of intensive glucose lowering in such patients.

2560-2572

As compared with standard glucose control in patients with type 2 diabetes, intensive glucose control in the ADVANCE trial reduced the risk of nephropathy but not the risk of macrovascular events. There was no significant difference between the two groups in overall mortality. These findings, along with those of the ACCORD trial, raise complex questions about the role of intensive glucose control in type 2 diabetes.

2573-2584

There is a need for a vaccine against avian influenza (H5N1). In this initial study, the administration of two doses of a whole-virus H5N1 vaccine derived from Vero cell culture was shown to induce neutralizing-antibody responses to clades 1, 2, and 3 of H5N1 virus strains.

2585-2593

Somatic characteristics of neuroblastoma tumors — such as MYCN amplification — are associated with more aggressive disease. This report shows that persons who inherit variants on chromosome 6p22 are more susceptible to the development of the disease than those who do not inherit these variants.

Clinical Practice
2594-2605
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A 23-year-old woman has palpitations. Over the past 6 months, she has had a 10-lb (4.5-kg) weight loss. Her pulse is 119 beats per minute, and blood pressure is 137/80 mm Hg. Her thyroid gland is diffusely enlarged. She has eyelid lag but no proptosis. The level of thyrotropin is 0.02 μU per ml (normal range, 0.35 to 4.50), and free thyroxine is 4.10 ng per deciliter (normal range, 0.89 to 1.76). How should she be further evaluated and treated?

Review Article
2606-2617

    Age-related macular degeneration is the leading cause of irreversible blindness in people 50 years of age or older in the developed world. This article reviews the clinical and histopathological features of age-related macular degeneration and its genetics and epidemiology and discusses current management options and research advances.

    Images in Clinical Medicine
    2618
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    A 69-year-old man presented at the emergency room with stabbing pain and swelling of the right lower leg on standing up from a seated position. On clinical examination, rupture of the Achilles' tendon was suspected. Plain radiographs showed a complete ...

    e28
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    This 89-year-old woman was admitted with hypercapnic respiratory failure. She had a long history of osteoporosis and multiple vertebral compression fractures.

    Case Records of the Massachusetts General Hospital
    2619-2628

      A 68-year-old man was admitted to the hospital because of headache and loss of vision in the right eye, 3 1/2 months after orthotopic liver transplantation. Four weeks after transplantation, headaches and jaw claudication developed, followed by blurred vision in the right eye. Two weeks before admission, an ophthalmologist began therapy with prednisone; symptoms improved and then worsened 2 days before admission. On admission, additional diagnostic studies were performed.

      Editorials
      2630-2633
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      Diabetes is associated with a reduced lifespan, largely as a consequence of cardiovascular disease.13 Although diabetes significantly increases the risk of cardiovascular events,1 the relative increase in events for each percent increase in glycated ...

      2633-2635

      Cardiovascular disease in patients with diabetes is clearly associated with the degree of hyperglycemia, as measured clinically with the use of glycated hemoglobin.13 However, there remains an unanswered question in diabetes management: Does the ...

      2635-2637

      Neuroblastoma has a notorious reputation among solid tumors of childhood because of its frequently massive and widespread tumor burden. Yet stage for stage, this embryonal neoplasm of the sympathetic nervous system has become the most curable of the ...

      Correspondence
      2638-2639

      To the Editor: We find the description of a “new arenavirus” by Palacios and colleagues (March 6 issue)1 interesting, but we consider several of their conclusions to be unjustified or misleading. First, the characterized virus is simply lymphocytic ...

      2639-2641

      To the Editor: I do not agree with Svilaas and colleagues (Feb. 7 issue)1 that thrombus aspiration during percutaneous coronary intervention (PCI) in patients who have myocardial infarction with ST-segment elevation improves clinical outcomes. In their ...

      2641-2644

      To the Editor: Hannan et al. (Jan. 24 issue)1 are to be commended for appropriately selecting patients with multivessel coronary disease for stenting or bypass surgery. Their clinical judgment ensured that unadjusted survival rates were equal in the two ...

      2644-2645

      To the Editor: Schermerhorn and colleagues (Jan. 31 issue)1 examined the relative effectiveness of endovascular versus open repair of abdominal aortic aneurysms. They used a propensity-score approach to match the open-repair and endovascular-repair ...

      2645-2647

      To the Editor: Hauser et al. (Feb. 14 issue)1 report positive results of a phase 2 trial of rituximab in relapsing–remitting multiple sclerosis. I wish to draw attention to the Food and Drug Administration (FDA) public health advisory concerning ...

      2647-2648

      To the Editor: As Katz and Harris (Feb. 21 issue)1 note, electromyography is not routinely necessary in the diagnostic workup of spinal stenosis. However, a complete electrodiagnostic examination (i.e., nerve-conduction studies and electromyography) can ...

      2648-2649

      To the Editor: Christopoulos et al. (March 6 issue)1 report a case of primary ovarian insufficiency associated with imatinib. Although the data provided are suggestive of primary ovarian insufficiency, the cause-and-effect relationship is speculative, ...

      2649-2651

      Despite their self-limited course, infantile capillary hemangiomas can impair vital or sensory functions or cause disfigurement. These authors have observed in 11 children that propranolol can inhibit the growth of these hemangiomas.

      Book Reviews
      2652-2653

      Biographies that are most apt to appeal to physicians offer a coherent and accurate account of the subject's contributions to medicine, along with insights into his or her character and personality. Georgina Ferry amply fulfills these criteria in her ...

      2653-2654
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      The venerable neurologist Charles Miller Fisher once said, “Coma is a continuum rather than a single state.” Eelco Wijdicks's book justifies and expands on that idea. Although the term “coma” is derived from the Greek word koma, meaning a deep (presumably ...

      2654-2655
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      Nidoviruses summarizes current information about a somewhat obscure but increasingly relevant group of viruses that contain the coronaviruses that infect humans, including the virus that causes the severe acute respiratory syndrome (SARS). The SARS ...