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July 24, 2008  Vol. 359 No. 4

Audio Summary of this Issue

Perspective
333-335

The growing number of biologic drugs for cancers and other serious conditions is a harbinger of things to come. Drs. Thomas Lee and Ezekiel Emanuel write that recent headlines about their high costs serve as warnings about the financial and ethical ...

335-337

Russell Korobkin and Dr. Rahul Rajkumar write that GINA is emblematic of this country's piecemeal and inconsistent approach to health care policy, which makes little sense and leaves many Americans without access to care or in danger of financial ruin if ...

Original Articles
339-354
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For patients infected with multidrug-resistant human immunodeficiency virus type 1 (HIV-1), therapeutic options are limited. Raltegravir is a new molecule that inhibits HIV integrase. In two phase 3 studies, raltegravir was found to be superior to placebo, in the context of optimized background antiviral therapy, in suppressing HIV viral load at 48 weeks (62.1% vs. 32.9%).

355-365
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In subgroups of two phase 3 studies, patients with high-risk features for failure of antiretroviral therapy, such as a low CD4 count, high base-line level of human immunodeficiency virus (HIV) type 1 RNA, or unfavorable genotypic or phenotypic sensitivity score, raltegravir was superior to placebo in terms of a virologic response at 48 weeks. However, among these patients, in whom antiretroviral therapy had been used previously, 23% of raltegravir recipients had virologic failure by 48 weeks.

366-377

This study describes a method for capturing circulating tumor cells in patients with non–small-cell lung cancer with the use of antibody tethered to microposts. The isolated cells were of sufficient quantity and purity to genotype and thus could feasibly be used to guide genotype-specific treatment.

378-390
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No effective therapy is available for advanced hepatocellular carcinoma. In this randomized trial involving 602 patients with advanced hepatocellular carcinoma, sorafenib, a multikinase inhibitor of Raf, vascular endothelial growth factor receptor, and platelet-derived growth factor receptor, improved median survival by 3 months, as compared with placebo (10.7 vs. 7.9 months, P<0.001). Adverse events, including diarrhea and weight loss, were more frequent in patients receiving sorafenib.

Clinical Practice
391-403
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A 58-year-old man is found on laboratory testing to have a serum calcium level of 6.0 mg per deciliter (normal range, 8.5 to 10.5), an albumin level of 3.9 g per deciliter, and a phosphorus level of 6.0 mg per deciliter (normal range, 2.5 to 4.5). His medical history is notable only for long-standing hearing difficulties. He reports no history of neck surgery and is asymptomatic. His ionized calcium level is 0.75 mmol per liter (normal range, 1.10 to 1.32). How should his case be further evaluated and treated?

Images in Clinical Medicine
404
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A 66-year-old man had progressive reduction of global spine movement for more than two decades that eventually resulted in complete spinal immobility. Extensive calcification of the intervertebral ligaments, bilateral ossification of the outer layer of ...

e4
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In this 54-year-old man with a mass in the right lower lobe, there was concern about chest-wall invasion. A real-time echo changed the diagnosis from stage IIb to stage Ib.

Case Records of the Massachusetts General Hospital
405-414

    A 26-year-old man experienced the sudden onset of back pain. Magnetic resonance imaging disclosed a pathologic fracture of the T9 vertebral body. A chest radiograph and computed tomography of the chest showed a mass in the upper lobe of the left lung, with involvement of the hilar and mediastinal structures. Diagnostic testing was performed, and a management decision was made.

    Editorials
    416-418

    Human immunodeficiency virus (HIV) infection has been transformed over the past two decades from a fatal to a chronic disease, because of combination antiretroviral therapy — a medical triumph.1 However, HIV has proven to be a masterful escape artist with ...

    418-420

    The treatment of non–small-cell lung cancer has made limited but clinically significant progress during the past two decades of clinical research. Through carefully designed clinical trials, investigators have identified several chemotherapeutic drugs to ...

    420-422

    Primary liver cancer is the fifth most common cancer worldwide and the third most common cause of death from cancer, resulting in more than 600,000 deaths per year. The major risk factors for hepatocellular carcinoma are chronic hepatitis B or hepatitis C ...

    Correspondence
    423-425

    To the Editor: Seung et al. (April 24 issue)1 report that there was no significant difference in rates of death and major cardiovascular events between matched cohorts of patients undergoing coronary-artery bypass grafting (CABG) or percutaneous coronary ...

    426-427

    To the Editor: The investigators of the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) (April 10 issue)1 report that telmisartan is equivalent to ramipril in patients with vascular disease or high-risk ...

    427-431

    To the Editor: Avidan et al. (March 13 issue)1 confirm that bispectral index (BIS)–guided care achieves a 0.2% incidence of awareness during anesthesia in high-risk patients, as previously reported,2 but further conclusions and recommendations are not ...

    431-434

    To the Editor: Since 2004, when my colleagues and I published a report estimating the number of excess deaths resulting from the invasion of Iraq,1 we have made further assessments, published in 2006.2 The report on the Iraq Family Health Survey (IFHS) (...

    434-435

    To the Editor: The limitation of the article by Mongan et al. (April 3 issue)1 on options for slowing the growth of health care costs is the acceptance only of reforms that will not irritate powerful, entrenched corporate and labor interests. Our system ...

    435-437

    These authors determined the effect of the shortage of chemotherapeutic agents on the outcome of acute lymphoblastic leukemia in Iraqi children during the period of UN sanctions (1990–2002). Many of the children received less than 50% of the prescribed ...

    Book Reviews
    438

    In the past half-century, life expectancy has increased considerably. As a result, we need to develop a more comprehensive understanding of aging than we have now. Whether in health or in disease, age affects many parts of the body — including the kidneys ...

    438-439

    In Gaetano Donizetti's opera L'Elisir d'Amore (The Elixir of Love), the itinerant Dr. Dulcamara peddles a “marvelous elixir that awakens love,” and in a vocally demanding patter song proclaims that his “superhuman elixir can, in a moment, not only cure ...

    440

    Thirty years of practice have finally convinced me that the mind and body are indeed connected. As this fascinating book explains, the idea of these connections goes back a long way. The author, Anne Harrington, a historian of science, attempts to answer ...

    Correction
    440

    Lead Poisoning Due to Adulterated MarijuanaCorrespondence, N Engl J Med 2008:358;1641-1642.. One of the authors' names was inadvertently omitted in the published letter: Katharina Timper, M.D. (University Hospital Leipzig, Leipzig, Germany), should have ...

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