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February 7, 2008  Vol. 358 No. 6

Audio Summary of this Issue

Perspective
549-551

U.S. health care expenditures rose 6.7% in 2006. Robert Kuttner argues that the extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization.

552-555

Dr. Bruce Korf describes the effects of the LMNA mutation in the Hutchinson–Gilford progeria syndrome. He writes that this syndrome may teach us about mechanisms of one of the most common conditions — old age.

Original Articles
557-567

Acute myocardial infarction with ST-segment elevation is treated with the use of percutaneous coronary intervention (PCI), but distal embolization of thrombotic material may limit the clinical efficacy of this procedure. In this study, aspiration of the thrombus during PCI improved reperfusion and clinical outcome. Thrombus aspiration appears to be a substantial advance in the treatment of acute myocardial infarction.

568-579

Hypersensitivity reactions to abacavir are tightly associated with HLA-B*5701. In this global, multicenter, prospective, randomized study, 1956 patients with HIV-1 infection who had not previously received abacavir were randomly assigned to undergo HLA-B*5701 screening or to receive the standard of care. Screening eliminated immunologically confirmed hypersensitivity reaction to abacavir in this predominantly white population. In this case, a pharmacogenetic test can prevent the toxic effects of this drug.

580-591
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In this study, 160 patients with type 2 diabetes and persistent microalbuminuria received either intensive therapy or conventional therapy for a mean of 7.8 years, followed by observation for a mean of 5.5 years. Intensive intervention with multiple drug combinations and behavior modification appeared to have a sustained benefit in reducing vascular complications and death from any cause and from cardiovascular causes.

592-604

This article describes the detailed phenotype of 15 children, 1 to 17 years of age, with Hutchinson–Gilford progeria syndrome, a rare, sporadic autosomal dominant premature aging syndrome causing death at approximately 13 years of age. Most cases are caused by an LMNA gene mutation that produces an abnormal lamin A, “progerin.” Since progerin accumulates in normal cells with age, understanding this syndrome may offer insight into normal aging.

605-614
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Menkes disease is a fatal neurodegenerative disorder caused by mutations in a copper-transport gene. In this study of 81 newborns at risk for Menkes disease, a screening test indicating low dopamine-β-hydroxylase activity demonstrated high sensitivity and specificity. Twelve newborns who screened positive for Menkes disease and received early copper treatment had better neurologic outcomes than did patients in a historical control group who received diagnosis and treatment later.

Clinical Practice
615-624
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A 65-year-old man reports a 6-month history of dizziness, light-headedness, weakness, and fatigue while upright. He takes no medication and has no personal or family history of neurologic disease. On physical examination, his supine blood pressure is 160/100 mm Hg, with a heart rate of 72 beats per minute; on standing, his blood pressure falls to 70/40 mm Hg, with no change in heart rate. The results of the remainder of the examination, including neurologic examination, are normal. How should he be evaluated and treated?

Images in Clinical Medicine
625
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A 55-year-old man presented with a 2-year history of painful jaw enlargement and progressively ill-fitting dentures. He had no headaches or visual-field defects and did not have hyperhidrosis, oily skin, glucose intolerance, heart failure, or an increase ...

e6
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This 77-year-old woman underwent resection of a papillary carcinoma of the right breast. Isosulfan blue dye was used to define lymphatic drainage. Blue hives developed on upper arms and chest as a result of an allergic reaction to the dye.

Clinical Problem-Solving
626-632

    A 26-year-old man presented with a 1-month history of persistent cough productive of white sputum, which was occasionally tinged with blood. He reported mild pleuritic chest pain but had no dyspnea, fever, chills, night sweats, or weight loss. The patient had had no epistaxis or episodes of sinusitis. One week before presentation, he received an empirical course of azithromycin, with no resolution of his symptoms.

    Editorials
    634-637
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    A little over 50 years ago, my father had a heart attack. He was driven to the hospital by friends after having “indigestion” for 2 days. He spent 2 weeks as an inpatient on an unmonitored rehabilitation ward and was treated principally with warfarin and ...

    637-639

    The accumulating knowledge of human genomic variation is being used for the development of personalized medicine, with the aims of decreasing the number of adverse drug reactions and increasing the efficacy of drug treatment. Considerable pharmacogenomic ...

    640

    Each year thousands of reviewers contribute their expertise to peer review, a process that contributes critically to the quality of the Journal. The editors and the authors of the papers submitted to the Journal are grateful for the help of all our ...

    Correspondence
    641-644

    To the Editor: The outcome measures appear to have been chosen post hoc by Mayrand et al. (Oct. 18 issue)1 in their screening trial comparing human papillomavirus (HPV) testing with Papanicolaou (Pap) testing.1,2 The “conservative” outcome definition ...

    644

    To the Editor: In his Clinical Practice article on the assessment of patients' competence to consent to treatment (Nov. 1 issue),1 Appelbaum invokes the ability to reason as a central criterion for capacity. I consider this ethically troublesome. The ...

    645-646

    To the Editor: Lisanby (Nov. 8 issue)1 reports, in her Clinical Therapeutics article, on the use of electroconvulsive therapy (ECT) in patients with depression. ECT is rarely recommended in patients with schizophrenia (except for those with acute ...

    647

    To the Editor: Rice and colleagues (Oct. 25 issue)1 report a severe neonatal presentation of medium-chain acyl–coenzyme A dehydrogenase (MCAD) deficiency and suggest that newborn screening results should be communicated by 72 hours of age. In practice, ...

    647-648

    To the Editor: We report on two cases of melanoma in women with multiple sclerosis who were treated with natalizumab (Tysabri, Biogen Idec and Elan Pharmaceuticals), a humanized monoclonal antibody against α4 integrins. Patient 1 was a 46-year-old woman ...

    649-650

    The authors report on the case of a 41-year-old man with primary malignant melanoma of the skin. The primary lesion had intratumorous rhabdoidlike features and subsequent complete metastatic rhabdomyosarcomatoid transdifferentiation.

    Book Reviews
    651-652

    Surrogate Motherhood and the Politics of Reproduction presents a fascinating history of the influences that have shaped surrogacy laws and practice in the United States. Markens, a self-described feminist sociologist, presents her view that the ...

    652-653

    The ambitious goal of this guide, published by the World Bank, is to provide thumbnail introductions to 65 topics related to the immensely complex terrain of policies and laws relating to the human immunodeficiency virus (HIV) and AIDS. With a few pages ...

    653-654

    Surgery is constantly evolving, with refinements to technique being made to optimize outcomes while minimizing morbidity. Correspondingly, minimally invasive procedures have assumed a more prominent role in many surgical disciplines. For example, ...

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