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May 28, 2009  Vol. 360 No. 22

Audio Summary of this Issue

Perspective
2269-2271

The debate over health care reform has increasingly centered on the issue of “public-plan choice.” Jacob Hacker writes that public-plan choice can be made to work in a way that is effective, enduring, and acceptable to key stakeholders.

2271-2273

Mark Pauly argues that reform should envision the expansion of offerings for all groups: many more private options for the heavily subsidized and moderately more private- and public-plan options for others.

2273-2275

The idea of a government health insurance company to compete with for-profit and not-for-profit private companies is gaining political momentum. Victor Fuchs writes that a close look at how the present health care system functions suggests that this new ...

Original Articles
2277-2288
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In this sham-controlled, randomized trial involving patients with dysplastic Barrett's esophagus, patients who were treated with radiofrequency ablation were more likely to have complete eradication of dysplasia and intestinal metaplasia and less likely to progress to more severe dysplasia or cancer. Adverse events included chest pain and esophageal stricture.

2289-2301
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This article describes mutations or deletions in TET2 in patients with a spectrum of myelodysplastic syndromes and myeloproliferative disorders. The defect was independent of the JAK2 V617F mutation in such patients. It occurs in primitive hematopoietic stem cells and is an early event in the course of the disease. Since TET2 has features of a tumor-suppressor gene, it may have an initiating role in some cases of myelodysplastic syndromes and myeloproliferative disorders.

2302-2309
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In this longitudinal study of cognitive function and aging, which included 456 participants who agreed to post-mortem brain examination and died between 69 and 103 years of age, the relationship between the pathological features of Alzheimer's disease and clinical dementia at the time of death was attenuated in the oldest old persons. For example, the odds ratio for the association between dementia and neocortical neuritic plaques was 8.6 at 75 years of age but only 2.5 at 95 years of age.

2310-2318

Dehydroepiandrosterone (DHEA) sulfotransferase (SULT2A1) transforms the androgen precursor DHEA to its inactive sulfate ester DHEAS, which prevents DHEA conversion to active androgens. SULT2A1 requires 3′-phosphoadenosine-5′-phosphosulfate (PAPS) for catalytic activity. This article reports compound heterozygous mutations in PAPSS2, the gene encoding human PAPS synthase 2, in a girl with premature pubarche. Thus, PAPSS2 deficiency appears to be a monogenic adrenocortical cause of androgen excess.

Clinical Practice
2319-2327
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A 52-year-old receptionist presents with an ulcer on her ankle of 1 year's duration. Narcotic analgesics once or twice a day and leg elevation reduce the pain. She has not had diabetes and does not smoke. Physical examination reveals an ulcer above the medial malleolus, with a clean bed of granulation and surrounded by hyperpigmented skin. Pedal pulses are easily palpable. How should she be evaluated and treated?

Review Article
2328-2339

Clinicians must be aware of the growing list of causes and predisposing factors that may lead to the life-threatening disorder of acute adrenal insufficiency. This review provides a guide to the recognition and treatment of adrenal insufficiency, whether it is primary or secondary to disease, hereditary disorders, medication use, or critical illness.

Images in Clinical Medicine
2340
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An 84-year-old man presented with an isolated sensation of a lump in the back of his throat and difficulty swallowing that had developed over several months. A year earlier, the patient had received a diagnosis of lymphoma involving the inguinal lymph ...

e28
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A 69-year-old woman had been taking acenocoumarol for 10 years for the treatment of deep vein thrombosis. The drug was withdrawn before implantation of a pacemaker. Twenty-four hours later, intense lingual pain developed.

Case Records of the Massachusetts General Hospital
2341-2351

    A 30-year-old man was admitted to this hospital because of progressive neurologic deficits, which had begun 1 year earlier with headaches and word-finding difficulties, followed by seizures and cognitive and motor deficits. Imaging studies revealed progressive lesions involving predominantly the white matter, basal ganglia, and brain stem. He had a history of painful genital and oral ulcers, associated with arthralgias, for which immunosuppressive medications had been given. A diagnostic procedure was performed.

    Editorials
    2353-2355

    In the past four decades, the incidence of esophageal adenocarcinoma has increased by 500%, paralleled by a similar increase in the rate of death associated with this often fatal disease.1,2 This type of esophageal cancer develops from a precursor lesion ...

    2355-2357

    The myelodysplastic syndromes, myeloproliferative disorders, and acute myeloid leukemia (AML) are seemingly unrelated diseases except for their origin in hematopoietic precursor cells in bone marrow. A principal feature of the myeloproliferative disorders,...

    2357-2359

      Survivors to the age of 95 years are a select and hardy few. At current mortality rates, only about 8% of persons will live to the age of 95, and only about half of those will escape dementia. To some extent, they may just be the lucky few. However, there ...

      Health Law, Ethics, and Human Rights
      2360-2365

      In 2008, the U.S. Supreme Court ruled that a District of Columbia law banning citizens from keeping loaded handguns in their homes for self-defense violated the Second Amendment to the Constitution. The authors discuss the Court's decision and its implications.

      Correspondence
      2366-2367

      To the Editor: In their article on the Women's Health Initiative (WHI) study of combined hormone therapy, Chlebowski et al. (Feb. 5 issue)1 describe a marked decrease in the risk of breast cancer after the discontinuation of menopausal treatment. Using a ...

      2367-2370

      To the Editor: Gnant et al. (Feb. 12 issue)1 report on the Austrian Breast and Colorectal Cancer Study Group trial 12 (ABCSG-12) (ClinicalTrials.gov number, NCT00295646), which looked at the use of goserelin plus either tamoxifen or anastrozole with or ...

      2370-2372

      To the Editor: The outcomes for living kidney donors, shown in the study by Ibrahim et al. (Jan. 29 issue),1 are reassuring. Key strengths of the study are the large sample and the long follow-up. However, limitations include a highly selected and ...

      2372-2375

      To the Editor: Haynes et al. (Jan. 29 issue)1 report on a surgical safety checklist to reduce morbidity and mortality in a global population. Transferring the concept of checklists from aviation to surgery sounds intuitively sensible. However, to claim ...

      2375-2376

      To the Editor: Point-of-sale terminals are devices used worldwide for credit-card or debit-card transactions or to print a variety of coupons. These machines print receipts on thermal paper covered with N-propyl-acrylamide and acrylate tints.

      We report ...

      Book Reviews
      2377-2378

      Few conditions are more devastating to the physical, emotional, and social health of an infant or child than epidermolysis bullosa. The disease is actually a group of congenital abnormalities of the skin, and it encompasses a variety of genetic ...

      2378-2379

      The study of chronic lymphocytic leukemia (CLL) is a rapidly changing field. A new understanding of the nature of the disease, better delineation of its limits, and more effective treatments that have supplanted chlorambucil — the 50-year-old standby — ...

      2379

      A search in PubMed for publications that address pediatric nephrology, pediatric critical care, acute kidney injury, and acute dialysis yields more than 1000 publications in the past 15 years, with the greatest number published in the past 7 years. The ...

      Correction
      2379

      Valsartan for Prevention of Recurrent Atrial Fibrillation Original Article, N Engl J Med 2009:360;1606-1617.. In Table 1 (page 1608), “Echocardiographic findings at randomization” should read, “Electrocardiographic findings at randomization.” We regret ...