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March 26, 2009  Vol. 360 No. 13

Audio Summary of this Issue

Perspective
1273-1276

For every increase of 1 percentage point in the national unemployment rate, it is estimated that an additional 1 million Americans turn to Medicaid for coverage and another 1.1 million go uninsured. Diane Rowland writes that the number of uninsured is ...

1276-1278

Two related but distinct options are emerging for electronic health records: the stand-alone personal health record (PHR) and the “integrated PHR.” Drs. Paul Tang and Thomas Lee believe that integrated PHRs will play a major role in influencing health-...

1278-1281
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President Obama's economic stimulus package includes a $19 billion investment in health information technology. Drs. Kenneth Mandl and Isaac Kohane discuss how we can best take advantage of this unprecedented opportunity to computerize health care while ...

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In two large randomized trials, researchers examined the effect of annual prostate-specific–antigen (PSA) screening on the rate of death from prostate cancer and found that it was small and was offset by false positive diagnoses. Since screening may have ...

Original Articles
1283-1297
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In this study, adults who were expected to require treatment in the intensive care unit on 3 or more consecutive days were randomly assigned to undergo intensive blood glucose control (target range, 81 to 108 mg per deciliter [4.5 to 6.0 mmol per liter]) or conventional blood glucose control (180 mg per deciliter [10.0 mmol per liter]). The primary end point was death from any cause within 90 days after randomization. Intensive glucose control increased mortality among the patients.

1298-1309

Male circumcision has been shown to reduce the acquisition of the human immunodeficiency virus (HIV) in circumcised men. In two studies in Uganda involving 3393 adolescent boys and men who were seronegative for HIV and for herpes simplex virus type 2 (HSV-2), circumcision reduced the acquisition of HSV-2 and the prevalence of high-risk human papillomavirus (HPV) infection but not the acquisition of syphilis.

1310-1319

In this study involving nearly 77,000 men, investigators analyzed the effect of screening with prostate-specific–antigen testing and digital rectal examination on the rate of death from prostate cancer, as compared with usual care. After a follow-up of 7 years, the death rates from prostate cancer did not differ significantly between the two study groups. Data from the 10-year follow-up (which were 67% complete) also showed no significant difference in prostate-cancer mortality.

1320-1328

In this trial, investigators tested the effect of prostate-specific–antigen testing on the death rate from prostate cancer in more than 162,000 men between the ages of 55 and 69 years in seven European countries. A significant reduction in prostate-cancer mortality was found after a median follow-up of 9 years. Overdiagnosis and overtreatment were important limitations of the screening program.

Clinical Therapeutics
1329-1335

A 61-year-old black woman with chronic obstructive pulmonary disease is referred for enrollment in a pulmonary rehabilitation program. Pulmonary rehabilitation includes high-intensity exercise to improve muscle function and reduce dynamic hyperinflation of the lungs, as well as education to promote collaborative self-management strategies. Patients with unstable angina or recent myocardial infarction may not be good candidates for pulmonary rehabilitation.

Images in Clinical Medicine
1336
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A 59-year-old man was referred to our hospital for the management of genital warts. Multiple, asymptomatic, smooth, round, skin-colored papules were observed at the corona of the glans penis. Physical examination of the genitalia was otherwise ...

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A 67-year-old woman presented with a 6-month history of dyspnea and dysphagia. Physical examination revealed a small cervical goiter, but the lower poles of the thyroid were not palpable.

Case Records of the Massachusetts General Hospital
1337-1344

    A 23-year-old woman came to the adolescent and young adult medicine clinic at this hospital to establish care and to receive counseling regarding oral contraception, screening for sexually transmitted infections, and vaccination against human papillomavirus. Pathological examination of a Papanicolaou smear disclosed a high-grade squamous intraepithelial lesion. Additional diagnostic testing was performed, and management decisions were made.

    Editorials
    1346-1349

    For the past decade, hospitals have focused on the inpatient management of hyperglycemia, particularly in the intensive care unit (ICU). Extensive observational data have shown a consistent, almost linear relationship between blood glucose levels in ...

    1349-1351

    Three landmark randomized, controlled trials conducted in South Africa, Uganda, and Kenya from 2005 through 2007 demonstrated that adult male circumcision reduced the acquisition of human immunodeficiency virus (HIV) by 50 to 60%.13 Complications ...

    1351-1354

    In the United States, most men over the age of 50 years have had a prostate-specific–antigen (PSA) test,1 despite the absence of evidence from large, randomized trials of a net benefit. Moreover, about 95% of male urologists and 78% of primary care ...

    Clinical Implications of Basic Research
    1355-1357

    Maternal microchimerism in fetal blood and tissue, which is probably a consequence of the induction of the regulatory T cells in fetal lymph nodes, has implications for immunosuppression and our understanding of autoimmunity.

    Correspondence
    1358-1359

    To the Editor: In their prospective, open-label trial, Pagnoux et al. (Dec. 25 issue)1 compared azathioprine (at a dose of 2 mg per kilogram of body weight per day) with methotrexate (at a dose of 0.3 μg per kilogram per week, progressively increased to ...

    1360-1361

    To the Editor: With the availability of strong evidence that prevention of type 2 diabetes among people at high risk for the disease might be feasible,1 the interest in identifying people at high risk who might benefit from interventions is topical. ...

    1361-1362

    To the Editor: Ladroue et al. (Dec. 18 issue)1 describe a patient with a newly discovered mutation of the gene encoding prolyl hydroxylase domain 2 (PHD2). In addition to erythrocytosis, this patient had recurrent abdominal tumors. The authors state that ...

    1362-1363

    To the Editor: In his Clinical Therapeutics article on radiation therapy for early-stage breast cancer after breast-conserving surgery, Buchholz (Jan. 1 issue)1 states that “the breast remains tender to palpation and the skin remains hyperpigmented for 6 ...

    1363-1364

    To the Editor: Because of the growing number of patients worldwide who are receiving implantable cardioverter–defibrillators (ICDs)1 and the increasing number of indications for their use, physicians and patients need thorough safety guidelines about ...

    Book Reviews
    1365-1366

    The idea for this engaging autobiography originated in English novelist and scientist C.P. Snow's concept of two separate cultures — the culture of the arts and the culture of the sciences. In several of his novels, Snow explores the differences between ...

    1366-1367

    The core assumption of Managing Relationships with Industry is that “with very few exceptions, physicians are ethical, patient-centered professionals.” Hence, the authors — three lawyers and one physician — aim to guide physicians who wish to avoid being ...

    1367-1368

    The Wisdom of Whores is an engaging account of the author's journey through a wide range of positions on the epidemic of human immunodeficiency virus (HIV) infection and AIDS — and a critique of the many things that have gone wrong in the global battle ...

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