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February 19, 2009  Vol. 360 No. 8

Audio Summary of this Issue

Perspective
745-747

In November 2008, the U.S. Court of Appeals for the First Circuit upheld against constitutional attack a New Hampshire statute that prohibits data miners from selling information about physicians' prescribing histories to pharmaceutical companies for use ...

747-749

When physicians care for patients, they leave behind electronic tracks that allow others to observe their clinical decisions, and these observations can be deployed in the service of both commercial and social goals. Drs. David Grande and David Asch write ...

749-751

Ralph Catalano asks, does a contracting economy affect the health of a population? And if so, how?

e10

In the international SYNTAX trial, 1800 patients with three-vessel or left main coronary artery disease were randomly assigned to either revascularization with coronary-artery bypass grafting (CABG) or percutaneous coronary intervention involving drug-...

Original Articles
753-764
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There is substantial variation in the dose of warfarin required to achieve therapeutic anticoagulation. In this study, mathematical models for warfarin dosage were constructed that used either clinical factors alone or clinical and genetic factors. The model incorporating genetic factors, when tested retrospectively with data from an international cohort, provided better estimates than a model that included only clinical factors.

765-773
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Isocitrate dehydrogenases, encoded by the IDH1 and IDH2 genes, catalyze the reduction of NADP+ to NADPH in the brain. One or the other of these two genes was found to be mutated in 70% of 445 gliomas of World Health Organization grade II or III. The mutations abolished the enzymatic activity of the IDH1 and IDH2 proteins. The evidence suggests that mutation of an IDH gene is an early event in the development of gliomas.

774-783

This substudy of the Occluded Artery Trial, in which high-risk patients with an occluded infarct-related artery who were in stable condition were randomly assigned to percutaneous coronary intervention (PCI) or medical therapy alone, showed a marginal advantage in cardiac physical functioning in the medical-therapy group at 4 months but not thereafter; costs were higher and quality-adjusted survival was marginally lower in the PCI group.

Clinical Practice
784-789
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A 61-year-old man presents to the emergency room with left-sided epistaxis that has continued for 1 hour. He estimates having lost approximately 1/2 cup of blood and reports no history of nasal obstruction, epistaxis, trauma, bleeding diathesis, or easy bruising. He has a history of hypertension. Medications include atenolol and baby aspirin. How should this patient be evaluated and treated?

Review Article
790-800

This review discusses the results of DNA microarray signatures in breast cancer. These signatures have been useful in the classification of breast cancers, and they have an association with clinical outcomes. Surprisingly, there is little overlap in the types of genes among several useful microarray signatures. The true value of these signatures will become apparent only when prospective trials, now in progress, have been completed.

Images in Clinical Medicine
801
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A 68-year-old woman presented with fever and dull pleuritic pain in the left chest wall. Chest radiography revealed a large mass with an air-fluid level in the right hemithorax (Panel A) and a suggestion of pneumonia in the left lower lobe. Computed ...

e11
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A 22-year-old man presented with a 1-month history of severe pubic itch that was worst at night. There were no systemic illnesses, genital lesions, or pruritus outside the groin area.

Case Records of the Massachusetts General Hospital
802-809

A 37-year-old woman had a 4-month history of episodes of vertigo, followed by tinnitus, decreased hearing in her right ear, and right facial weakness; on the day of admission, she had a generalized seizure. On admission, she was confused and combative and had garbled speech, a right facial droop, and generalized hyperreflexia. Magnetic resonance imaging of the brain and spinal cord revealed multifocal linear and nodular enhancement of the leptomeninges. A diagnostic procedure was performed.

Editorials
811-813

If it were not for the great variability among individuals, medicine might as well be a science and not an art.

— Sir William Osler (1892)

Over the past half century, biomedical science has developed randomized, controlled clinical-trial methods that can ...

813-815

Whether mutations in metabolic pathways contribute to the pathogenesis of cancer is controversial.1,2 Cancer cells have long been noted to preferentially metabolize glucose through glycolysis, a discovery that has been translated to the clinic through ...

Sounding Board
816-823

In recent years, the number of clinical trials conducted in the United States has declined, and the majority of study sites are now outside the United States, with marked growth of research in developing countries. The authors discuss the implications of the globalization of clinical research and make recommendations about how to address the challenges that have emerged.

Special Report
824-830

In September 2007, President George W. Bush signed into law a bill requiring the registration of clinical trials in phase 2 or beyond and the public reporting of the results of those trials. This article reviews the initial implementation of the law and considers its strengths and weaknesses.

Correspondence
831-833

To the Editor: Although Talmor et al. (Nov. 13 issue)1 observed an improvement in oxygenation in patients with acute lung injury that was managed by estimating transpulmonary pressure, there was an extrapulmonary (i.e., abdominal) cause of the acute ...

833-836

To the Editor: Karapetis et al. (Oct. 23 issue)1 investigated K-ras mutations by means of direct sequencing of polymerase-chain-reaction (PCR) products. The detection of low-prevalence mutations by means of direct sequencing is problematic.2 Very ...

836

To the Editor: The article on screening mammography by Gilbert et al. (Oct. 16 issue)1 favorably compares single reading plus computer-aided detection with double reading in the United Kingdom. This finding will have no direct effect in the United States,...

837-838
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To the Editor: In his Perspective article, Kesselheim (Nov. 6 issue)1 expresses concern about priority-review vouchers for drugs for the treatment of neglected tropical diseases. We proposed the voucher program in 2006,2 it became law in 2007, and the ...

838-840

To the Editor: Carnitine palmitoyltransferase II (CPT2) deficiency is a rare autosomal recessive disorder of mitochondrial fatty acid oxidation. The most common form of this disorder is characterized by muscle stiffness, myalgia, and exercise intolerance,...

Book Review
841-844

Psychotropic drugs are sometimes used to treat particular diseases such as obsessive–compulsive disorder, schizophrenia, and panic attacks. More often, however, they are used to alleviate the stresses of everyday life and to enhance well-being. This more ...