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November 27, 2008  Vol. 359 No. 22

Audio Summary of this Issue

Perspective
2305-2309

Creativity is needed as physicians and managers struggle to make professional life sustainable for the country's shrinking pool of primary care doctors. Dr. Susan Okie reports on strategies to help office-based physicians “work smarter, not harder.”

2309-2311

Drs. Rita Redberg and Judith Walsh argue that the continued unrestrained use of new technology, in the absence of evidence-based criteria, portends a bleak future for Medicare and our health care system. They discuss cardiac CT angiography as a recent ...

Original Articles
2313-2323

In this study, microarrays of stromal-cell RNA showed one signature that correlated with extracellular-matrix deposition and monocytic infiltration and another that reflected tumor blood-vessel density. Immune cells, fibrosis, and angiogenesis in the microenvironment strongly influence the behavior of these lymphomas.

2324-2336

In an international study, the authors evaluated the diagnostic performance of coronary angiography by means of 64-row multidetector computed tomography (CT). The technique accurately identified obstructive coronary lesions, but the positive and negative predictive values were inadequate for this technology to replace conventional coronary angiography with the use of contrast medium.

2337-2345

This study shows an association between variants of CNTNAP2 and a diminished ability to repeat nonsense words, a behavioral marker of specific language impairment. It suggests a common susceptibility factor for this disorder and autism, which has also been associated with some of the same variants in CNTNAP2.

Clinical Practice
2346-2354
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A 57-year-old man noted flashing lights in his right eye, followed 2 days later by a cluster of dark floaters that mildly interfered with his vision. Over the course of the next week, he noted a progressive loss of the nasal visual field in that eye, with an eventual striking loss of central acuity that prompted him to seek ophthalmologic evaluation. Examination of the fundus with the pupil dilated showed a retinal detachment involving the temporal retina, including the macula. How should his case be managed?

Review Article
2355-2365

New molecular, cellular, and immunologic techniques used to study host–pathogen interactions have led to a reexamination of the role of infection in chronic obstructive pulmonary disease (COPD). There is now considerable evidence that infection plays a major role in the pathogenesis and clinical course of COPD. A vicious circle of infection and inflammation is thought to lead to exacerbations of the disease.

Images in Clinical Medicine
2366
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A 69-year-old patient presented with chronic bilateral knee pain. No recent trauma or underlying medical condition was reported. A radiograph revealed multiple bilateral calcifications ventral to the tibial plateau, projecting from the infrapatellar ...

e28
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Recent advances in ultrasound imaging allow visualization of the cervical part of the thoracic duct. The movements of chyle and blood are identified with the use of a method of digital subtraction that separates static tissue from the flow in the vessels ...

Case Records of the Massachusetts General Hospital
2367-2377

Headaches developed when the boy was 12 years old and became progressively worse; they were associated with progressive vision loss, mood changes, worsening school performance, fatigue, cold intolerance, and weight gain. Examination disclosed bitemporal hemianopia, decreased visual acuity, positive Hoffman's sign on the right, no chest or facial hair, and mild obesity. Magnetic resonance imaging revealed a cystic lesion in the sellar and suprasellar region and a heterogeneous, destructive bone lesion at the base of the skull. A diagnostic procedure was performed.

Editorials
2379-2381

The recent coming of age of genomic techniques and bioinformatics tools has led to an unprecedented proliferation of publications on genomewide association studies and expression profiling for use in genetic analysis, molecular classification, and ...

2381-2383

Without instruction, most children master the complexities of spoken language by the age of 6 or 7 years. About 5% of apparently healthy children, however, struggle to acquire basic competence in one or more aspects of spoken language and are classified ...

Health Policy Report
2384-2389
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After reviewing recently released Oval Office tapes, Blumenthal and Morone conclude that President Lyndon Johnson played a larger role in the passage of Medicare and Medicaid in 1965 than historians have reported. They believe the revised version of events suggests that successful enactment of major health care reform would require strong commitment and speedy action on the part of our next president.

Correspondence
2390-2391

To the Editor: Mitnick and colleagues (Aug. 7 issue)1 have raised awareness about the clinical management and outcomes of extensively drug-resistant tuberculosis in Peru. Although a cure rate of 60% is encouraging, we caution against generalizing these ...

2392-2393

To the Editor: The article by Sasako et al. (July 31 issue)1 addresses the efficacy of D2 lymphadenectomy alone versus D2 lymphadenectomy plus para-aortic nodal dissection (PAND) for gastric cancer. The finding of nearly equivalent rates of survival ...

2393-2395

To the Editor: In their Perspective article (July 31 issue),1 Forman and Pisani ask, “Why does gastric cancer occur so frequently in Japan?” One answer was proposed more than 30 years ago by Matsudo et al.,2 who detected talc in the normal gastric mucosa ...

2395-2396

To the Editor: In their article on the management of acute cutaneous wounds, Singer and Dagum (Sept. 4 issue)1 recommend topical nonsteroidal antiinflammatory drugs for the treatment of first-degree burns. They refer to a study that investigated the ...

2396-2398

To the Editor: A 41-year-old man was admitted to our hospital with ventricular tachycardia in 2003. Biopsy specimens obtained from the right ventricle showed neutral lipid deposition in cardiomyocytes. In 2004, the patient had catecholamine-dependent ...

2398-2400

This report from Uzbekistan describes the development of fluoroquinolone-resistant and extensively drug-resistant tuberculosis during second-line treatment for multidrug-resistant (MDR) tuberculosis. Exogenous reinfection with extensively drug-resistant ...

Book Reviews
2401-2402

Hardly a week goes by without a person who is alleged to be mentally ill committing some act of violence — and it is always covered by the media. What is the cause of the epidemic? E. Fuller Torrey, an indefatigable advocate for the adequate treatment of ...

2402-2403

Paul Lombardo's book is an authoritative history of the U.S. Supreme Court's infamous decision, Buck v. Bell (1927), which held that Virginia's mandatory sterilization law did not violate Carrie Buck's constitutionally protected rights. Lombardo, an ...

2403

Once, physician Thomas Graboys had it all — devoted patients, the best and brightest colleagues, a loving family, and a terrific physique. For the past decade, however, he has faced a succession of profound personal losses. His first wife died of cancer, ...