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October 2, 2008  Vol. 359 No. 14

Audio Summary of this Issue

Perspective
1421-1423

The pressures employers face have worsened as health care costs have grown faster than wages. Dr. Robert Galvin writes that although the business community has been a reluctant actor in this arena, it remains skeptical that its interests will be served by ...

1424-1425

Many executives take part in one of modern medicine's most expensive and least proven approaches to care: the executive physical. Dr. Brian Rank argues that executive physicals are not good for the patients who undergo them, for the companies that pay for ...

1426-1427

By inhibiting the biosynthesis of endogenous cholesterol, the statin drugs lower elevated blood cholesterol levels much more effectively than any dietary or other drug regimen. Dr. Daniel Steinberg describes how statins have revolutionized preventive ...

Original Articles
1429-1441

The CCR5 coreceptor may be a therapeutic target to block HIV infection. HIV-1–infected patients who had received previous antiretroviral treatment were enrolled in one of two phase 3, placebo-controlled, double-blind international studies of treatment with maraviroc (a CCR5 antagonist). Maraviroc significantly lowered the HIV-1 viral load and increased the CD4 cell count at 48 weeks.

1442-1455

In key subgroups of the HIV-infected patients in the MOTIVATE 1 and MOTIVATE 2 studies, a consistent treatment benefit of maraviroc over placebo was seen at 48 weeks. These subgroups include patients with a low baseline CD4 cell count and a high HIV viral load at screening and those receiving no active background antiretroviral agents. In patients in whom maraviroc failed, the CXCR4-using virus was often present at failure.

1456-1463

A variant of the toll-like receptor 3 (TLR3) provides protection against geographic atrophy, or “dry” age-related macular degeneration, and reduces apoptosis of cultured retinal pigment epithelial cells on exposure to TLR3 ligand. Because double-stranded RNA is a ligand of TLR3, this finding gives rise to the hypothesis that viral infection causes this disease and to concerns about therapeutic intraocular injection of short interfering RNA.

1464-1476
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In this randomized study, patients undergoing intensive therapy for type 1 diabetes mellitus who had glycated hemoglobin levels of 7.0 to 10.0% were stratified into three prespecified age groups and were assigned to receive continuous glucose monitoring or usual monitoring. The primary outcome was the change in glycated hemoglobin levels after 26 weeks. Continuous glucose monitoring was associated with improved glycemic control in adults but not in children and adolescents with type 1 diabetes.

Clinical Practice
1477-1485

Shortly after being elbowed in the flank during a basketball game, a 35-year-old healthy man has severe, colicky abdominal pain followed by gross hematuria. A renal ultrasound scan reveals bilateral polycystic kidneys and liver cysts. The blood pressure is 160/100 mm Hg. The serum creatinine concentration is 0.9 mg per deciliter (80 μmol per liter). The pain subsides in 2 days with analgesics, rest, and fluids; the gross hematuria resolves in 4 days, although microscopic hematuria persists.

Review Article
1486-1500

More effective and less resistance-prone antiviral agents are now available to treat hepatitis B virus (HBV) infection. Profound, durable, therapeutic HBV DNA suppression to slow and reverse the progression of chronic HBV infection is important, given the evidence linking high-level HBV replication and the late consequences of chronic HBV infection. This article reviews strategies for treating HBV infection.

Images in Clinical Medicine
1501
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A 58-year-old healthy man was evaluated for a toothache of 2 days' duration. He was treated with oral penicillin and an opiate analgesic and advised to have the affected teeth pulled. He returned less than 24 hours later reporting severe swelling in the ...

e16
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This 47-year-old homeless man presented to the emergency department with 1 week of chest pain and a blood count with 27,000 leukocytes per cubic millimeter.

Clinical Problem-Solving
1502-1507

    A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea on exertion, edema of the legs, a nonproductive cough, and scant hemoptysis. He also reported occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.

    Editorial
    1509-1511

    The development of new drugs against human immunodeficiency virus type 1 (HIV-1) has resulted in combination therapy that can inhibit various steps of viral replication. Maraviroc is an example of a new class of such drugs that have a novel mechanism of ...

    Health Law, Ethics, and Human Rights
    1512-1518

    In the 2008 U.S. Supreme Court case, Baze v. Rees, the Court ruled that Kentucky's three-drug protocol (sodium thiopental, pancuronium bromide, and potassium chloride) for lethal injection does not constitute cruel and unusual punishment and does not violate the U.S. Constitution. The author summarizes the seven separate opinions written by the justices and discusses the implications of the decision.

    Correspondence
    1519-1521

    To the Editor: In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study (June 12 issue),1 the intensive-therapy group differed from the standard-therapy group not only in the glycated hemoglobin level achieved but also in the number of ...

    1522

    To the Editor: In their article on rhythm control as compared with rate control for atrial fibrillation, Roy et al. (June 19 issue)1 conclude that “rate control should be considered a primary approach for patients with atrial fibrillation and congestive ...

    1523-1524

    To the Editor: In their article on the developmental origin of disease, Gluckman et al. (July 3 issue)1 state that “an altered long-term risk of disease is initially induced through adaptive responses that the fetus or infant makes to cues from the ...

    1524-1526

    A man in his early 30s presented with an intermittent eczematous eruption over the shaft of his penis and scrotum. A careful history-taking revealed that the rash coincided with his wife's intermittent courses of azathioprine for Crohn's disease.

    1526-1527

    To the Editor: Dengue, the most common vectorborne viral infection worldwide,1 is predominantly transmitted by the Aedes aegypti mosquito. We describe a well-documented cluster of blood transfusion–associated dengue infections in Singapore, a country in ...

    Book Reviews
    1528-1529

    Do we need more doctors in the United States? The current debate surrounding this question has all the elements of a great policy drama. It is a topic that affects each of us as patients and professionals. Interpretation of the workforce data, as well as ...

    1529-1530

    Intern is an excellent, well-written book in which Sandeep Jauhar describes his first 2 years of internship and residency in internal medicine at New York Hospital (now New York–Presbyterian Hospital), a prestigious academic medical center in New York ...

    1530-1531

    The world's poorest people face formidable health challenges. According to the Population Reference Bureau, the average life expectancy in sub-Saharan Africa is 49 years, which lags far behind the North American average of 78 years. About one third of all ...

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