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September 24, 2009  Vol. 361 No. 13

Audio Summary of this Issue

Perspective
1225-1227

Doctors make most of the decisions to use medical resources, thereby determining what the United States spends on medical care. Dr. Arnold Relman proposes a reformed health care system based on tax-supported, universal insurance, with medical care ...

1227-1230
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Some physicians, hospital administrators, and legislators have succumbed to a behavioral bias: they believe that their hospital or region spends more because their patients are sicker and poorer than those in other regions. Jason Sutherland, Dr. Elliott ...

1230-1233

The FDA does not currently require label statements regarding a product's comparative effectiveness. Dr. Randall Stafford, Todd Wagner, and Philip Lavori propose an expanded labeling requirement that would provide explicit information about proven ...

e21
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Amid widespread recognition that the U.S. health care system cannot continue its current upward cost spiral, forever widening the life-expectancy gap between rich and poor, Britain's National Health Service (NHS) has made a cameo appearance as bogeyman in ...

Original Articles
1235-1248

Patients with acute myeloid leukemia (AML) who were more than 60 years of age received treatment to induce a complete remission that consisted of cytarabine and daunorubicin; the latter was given at a dose of either 45 mg per square meter of body-surface area (the conventional dose of the drug) or 90 mg per square meter. As compared with patients who received the conventional dose of daunorubicin, those who received the high dose had a significantly higher rate of complete remission without an increase in toxic effects.

1249-1259

Patients with AML who were between 17 and 60 years of age were randomly assigned to receive induction therapy with the standard dose of daunorubicin or twice the standard dose; the two groups also received a standard dose of cytarabine. Rates of complete remission and overall survival were best in the high-dose group, especially among patients with a favorable or an intermediate cytogenetic risk profile.

1260-1267

Data are scarce regarding the comparative efficacies of the inactivated (intramuscular administration) and live attenuated (intranasal administration) seasonal influenza vaccines. During the 2007–2008 influenza season, 1952 healthy young adults were enrolled in a randomized, double-blind, placebo-controlled study of these two vaccines. The inactivated vaccine was found to have an absolute efficacy of 68%, whereas the live attenuated vaccine had an absolute efficacy of 36%.

1268-1278

This double-blind trial was designed to determine whether rasagiline slows the progression of Parkinson's disease. As compared with delayed treatment, early treatment with rasagiline at a dose of 1 mg per day achieved benefits consistent with a disease-modifying effect, but 2 mg per day did not result in similar benefits.

Review Article
1279-1290

Renal failure, a challenging complication of cirrhosis, is one of the most important risk factors for liver transplantation. In recent years, substantial progress has been made toward understanding the pathogenesis and natural history of renal failure in cirrhosis. This review discusses recently identified information about renal failure in cirrhosis and clinical interventions that may assist in the prevention and management of this complication.

Images in Clinical Medicine
1291
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A healthy, 23-year-old, nulliparous woman presented with lower abdominal pain, which she reported having had intermittently for the previous year. She had no other symptoms of gastrointestinal distress. A peripheral-blood smear showed no Howell–Jolly ...

e22
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A 51-year-old woman was found to have a small, pinkish tumor of the left iris. The visual acuity was not affected, and the intraocular pressure was normal.

Case Records of the Massachusetts General Hospital
1292-1299

A 77-year-old man was seen at this hospital because of a mass in the left ureter and cytologic examination of a urine specimen that was positive for transitional-cell carcinoma. Eight years earlier, right nephroureterectomy was performed because of transitional-cell carcinoma of the right renal pelvis. Several years later, cytologic examination of urine specimens was positive for transitional-cell carcinoma, but no tumor was evident on examination until 10 months before evaluation, when circumferential thickening of the left ureter was seen on imaging studies. A management decision was made.

Editorial
1301-1303

    Acute myeloid leukemia (AML) is a heterogeneous hematologic cancer whose wide range of outcomes probably reflects the accumulation of various acquired mutations that block the differentiation of blood-cell progenitors or confer a proliferative advantage ...

    Statistics in Medicine
    1304-1306

      Delayed-start study designs are a new way to distinguish a treatment's effects on long-term disease progression from its potential short-term effects on disease symptoms. In this article, the strengths, weaknesses, and key design assumptions of this type of trial are examined.

      Clinical Implications of Basic Research
      1307-1309

      In mice, short-term treatment with interferon-α pushes dormant hematopoietic stem cells into a state of proliferation. This finding may be relevant to the treatment of patients with chronic myelogenous leukemia, and treatment may be more effective if patients are first “primed” with interferon-α.

      Correspondence
      1310-1312

      To the Editor: Pui and colleagues (June 25 issue)1 report a high likelihood of event-free and overall survival among children with acute lymphoblastic leukemia (ALL) treated with an intensive regimen of intrathecal chemotherapy and systemic drugs that ...

      1312-1315

      To the Editor: The investigators of ACTIVE (Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events) (May 14 issue)1 address the pivotal clinical question, “Will the addition of clopidogrel to aspirin reduce the risk of ...

      1315-1316

      To the Editor: In the Case Record of a 63-year-old woman with carcinoma of the gastroesophageal junction, Kwak et al. (June 18 issue)1 provide an excellent overview of the available evidence-based perioperative treatment options, including adjuvant ...

      1316-1317

      To the Editor: Although evidence-based, cost-effective medicine is an important concept and a goal to strive for, these concepts must be applied in a way that is cognizant of the needs of real-world patients. The decision by the Centers for Medicare and ...

      1317-1318

      The authors report on two women who presented with anaphylaxis a few minutes after ingesting a generic omeprazole capsule. The generic drug that each of the women took contained approved soybean oil as an excipient.