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September 25, 2008  Vol. 359 No. 13

Audio Summary of this Issue

Perspective
1309-1312

In July, the American Academy of Pediatrics released revised recommendations for the management of hypercholesterolemia in children, and within days, it had elicited a firestorm of controversy. Drs. Sarah de Ferranti and David Ludwig discuss the inclusion ...

1313-1315

The 2008 U.S. presidential election is already the most expensive ever, with overall fund-raising surpassing that for the 2004 contest and the Democrats holding a large lead in the money race. Dr. Robert Steinbrook writes that it is remarkable that the ...

Original Articles
1317-1329

Intravenous thrombolysis with alteplase improves the outcomes after acute stroke when alteplase is given within 3 hours after the onset of symptoms. In this randomized trial involving patients who presented between 3 and 4.5 hours after the onset of stroke, clinical outcomes were modestly better in patients treated with alteplase than in patients given placebo (favorable outcome in 52% vs. 45% of patients).

1330-1342

In an analysis of patients undergoing coronary-artery stenting for acute myocardial infarction in Massachusetts, recipients of drug-eluting stents were compared with recipients of bare-metal stents in propensity-matched cohorts. Mortality rates and repeat target-vessel revascularization rates at 2 years were significantly lower with drug-eluting stents. The rates of reinfarction were reduced in patients with myocardial infarction without ST-segment elevation who were treated with drug-eluting stents.

1343-1356

In this randomized, placebo-controlled trial, the combination of simvastatin and ezetimibe had no effect on the progression of aortic stenosis, despite substantial lowering of low-density lipoprotein cholesterol. There was a reduction in the need for coronary bypass surgery in the simvastatin–ezetimibe group, but unexpectedly, active treatment was also associated with an increased incidence of cancer.

Special Article
1357-1366

The Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial involving the combination of ezetimibe and simvastatin in patients with aortic stenosis suggested an increased incidence of cancer associated with the use of active therapy. The current analysis of two other ongoing trials of ezetimibe and simvastatin does not support the suggestion of an increased incidence of cancer but does show increased cancer mortality.

Review Article
1367-1380

    The Molecular Origins of Cancer series continues with this review of molecular and genetic mechanisms of lung cancer. The authors review genetic susceptibility to lung cancer and four genes of importance in the evolution of the disease: EGFR, KRAS, the PI3K–Akt–mTOR complex, and TITF1. They also discuss gene profiling and protein profiling, with emphasis on the clinical value of these methods.

    Images in Clinical Medicine
    1381
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    A 36-year-old woman with mild mental retardation and facial angiofibromas presented for evaluation of recurrent seizures, which she reported having had since childhood. Periungual fibromas were seen in the feet. These lesions, usually seen in adults, are ...

    e15
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    This 45-year-old woman presented with progressive distal finger enlargement and polyarthralgias.

    Case Records of the Massachusetts General Hospital
    1382-1391

      A 47-year-old premenopausal woman came to this hospital for treatment of breast cancer. A mass that measured 5 cm in diameter was present in the left breast; needle biopsies showed infiltrating ductal carcinoma that was grade 2 of 3, hormone receptor–positive, HER2/neu-negative. An evaluation of the staging disclosed a solitary lesion in the T6 vertebral body, which was asymptomatic. A management decision was made.

      Editorials
      1393-1395

      Stroke, the most common cause of disability in the world among adults, remains the only neurologic disorder for which physicians are potentially able to completely reverse disabling deficits.1 Thrombolytic therapy, which can restore neurologic functions ...

      1395-1398

      Calcific aortic stenosis is a progressive disease that results in stiff valve leaflets with eventual obstruction to left ventricular outflow. Once symptoms occur, valve replacement is the only effective treatment, and there are no known therapies to ...

      1398-1399
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      The randomized clinical trial is considered to be the most reliable tool to assess the efficacy and safety of new drugs. At times, however, randomized trials detect adverse events that are unanticipated and not easily explained on the basis of current ...

      1400-1402

      Interventions for the prevention or treatment of disease that are based on our understanding of the pathobiologic features of the illness can provide benefit in how a patient feels or functions or in whether the patient survives. Such benefits are ...

      Clinical Implications of Basic Research
      1403-1405

      A specific type of satellite cell can engraft dystrophic tissue in a mouse model of Duchenne's muscular dystrophy and can improve the strength and duration of muscle contractility.

      Correspondence
      1406-1407

      To the Editor: In their discussion of polygenics and breast cancer, Pharoah et al. (June 26 issue)1 do not mention cost-effectiveness. If we take 3% for the reduction in total disease burden estimated by Pharoah et al. and apply it to the calculated 0.6-...

      1407-1409
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      To the Editor: In his Clinical Practice article on Graves' disease, Brent (June 12 issue)1 comments on the combined use of antithyroid drugs and radioiodine and refers to the results of our trial,2 showing no effects of antithyroid drugs on radioiodine ...

      1410

      To the Editor: We wish to retract our letter to the editor, “Duration of Survival in Patients with Myeloma Treated with Thalidomide,” which was published in the Journal on July 10, 2008.1 The content of this letter, submitted in February 2008 and ...

      1410-1411

      A 57-year-old man presented with a 4-day history of increasing orbital pain and swelling in the right eye. A diagnosis of orbital inflammatory disease due to bisphosphonate infusion was made.

      Book Reviews
      1412-1413

      In an interesting coincidence, these two books on insomnia were written not by experts in the field but by two professors in the humanities. You might then expect the books to share some common elements, but that is not the case. Insomnia is a whimsical ...

      1413-1414

      Joseph A. Califano, Jr., has had a distinguished career as a civil servant and was the secretary of Health, Education, and Welfare under President Jimmy Carter. In his latest book, High Society, he discusses the extent of substance and alcohol abuse in ...

      Corrections
      1414

      Genetics of Warfarin Response Correspondence, N Engl J Med 2008:358;2741-2744.. The final sentence in the letter from Mannucci et al. (p. 2743) should have read, “Unfortunately, the primary outcomes of this trial are not bleeding and thrombosis, but ...

      1414

      Brain-Derived Neurotrophic Factor and Obesity in the WAGR Syndrome Original Article, N Engl J Med 2008:359;918-927.. The abstract (p. 918) included a trial-registration number, but since the article reported a further analysis of trial data, not the trial ...