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April 1, 2010  Vol. 362 No. 13

Audio Summary of this Issue

Perspective
1161-1163
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At what point does a modification of a device warrant an entirely new approval process? And who should make that decision? Dr. Alan Garber describes how the FDA might best approach its role as a device regulator.

1164-1166

Dr. William Maisel and Tadayoshi Kohno write that the complex and sophisticated features of medical devices have created a susceptibility to security breaches that could compromise the performance of such devices and the safety and privacy of patients.

1166-1168

Projections of growing federal debt largely reflect anticipated increases in health care spending. Michael Chernew and colleagues explain the basics of deficits and debt and their implications for health care reform.

1169-1171

The FDA has conducted a comprehensive review of the benefits and risks of using LABAs to treat asthma. Drs. Badrul Chowdhury and Gerald Dal Pan discuss the agency's conclusions.

e44
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Health care reform legislation has languished in political purgatory for the past 2 months, teetering between historic enactment and epic collapse. The House of Representatives and the Senate both passed health care legislation at the end of 2009. After a ...

e45

Among the most nettlesome obstacles in the yearlong debate over increasing the accessibility and affordability of health insurance has been the question of what effect health care reform legislation would have on the incidence of abortion. The recent ...

Original Articles
1173-1180
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This longitudinal study involving older adults identified five trajectories during the last year of life: no disability, catastrophic disability, accelerated disability, progressive disability, and persistently severe disability. Most of the subjects who died suddenly had no disability, and most of those who died from advanced dementia had persistently severe disability; however, the course of disability was not predictable for the majority of the subjects, who died from other causes.

1181-1191

Genetic diagnosis of diseases that are genetically heterogeneous — such as Charcot–Marie–Tooth disease — can be a challenge. This study involves the sequencing of an affected person's whole genome; the authors conclude that his disease was caused by mutations affecting SH3TC2 (the SH3 domain and tetratricopeptide repeats 2 gene).

1192-1202
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Dutasteride, an inhibitor of 5α-reductase in the prostate, was tested in a large, randomized trial to determine its ability to prevent prostate cancer. Over the 4 years of the trial, dutasteride, as compared with placebo, reduced the relative risk of biopsy-detected prostate cancer by 23%. The reduction was limited mainly to tumors with Gleason scores of 5 or 6; by year 4, there were 12 tumors with Gleason scores of 8 to 10 in the dutasteride group but only 1 in the placebo group.

1203-1210

In a patient with muscle weakness and cardiac arrhythmia, marked depletion of glycogen was shown in skeletal muscle and an accumulation of abnormal storage material was shown in the heart. Sequencing of the glycogenin-1 gene revealed a nonsense mutation in one allele and a missense mutation, Thr83Met, in the other. These mutations resulted in inactivation of the priming of glycogen synthesis.

Special Article
1211-1218
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Data from a national study showed that more than one quarter of older adults who died between 2000 and 2006 required decision making at the end of life but lacked decision-making capacity. Most of these subjects had advance directives (living wills, health care proxies, or both) and received care consistent with their preferences. These findings suggest that advance directives are valuable.

Clinical Practice
1219-1226
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A 42-year-old man presents with decreased libido, erectile dysfunction, and headaches. He reports no weight change, gynecomastia, fatigue, or other symptoms. He takes no medications. Testicular size is decreased. His prolactin level is 648 μg per liter (normal value, <15). Magnetic resonance imaging reveals a sellar mass (2.5 by 1.5 by 2.0 cm) that is 5 mm below the optic chiasm and that extends bilaterally into the cavernous sinuses. What are the diagnostic and therapeutic considerations?

Images in Clinical Medicine
1227
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A 26-year-old man presented with a 5-day history of cough, fever, and mild dyspnea. He had an exanthematous vesicular rash that had started 3 days before the respiratory symptoms began. He smoked cigarettes (30 per day for the previous 14 years). His ...

e46
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A 58-year-old man with Parkinson's disease presented with an incapacitating freezing of gait. Despite this, the patient's ability to ride a bicycle was remarkably preserved.

Clinical Problem-Solving
1228-1233

    A 62-year-old, generally healthy man presented with a “clogged” sensation and a 6-week history of diminished hearing in his right ear. He had no tinnitus, ear pain, or dizziness.

    Editorials
    1235-1236

    Physicians have long recognized that pinpointing specific causes of disease in individual patients enables therapies that are the most likely to confer benefit with the fewest adverse effects. We also recognize the potential for disease prevention through ...

    1237-1238

    Are we making progress in the chemoprevention of prostate cancer? The disease is an ideal target: not only is it the most common cancer among men in the United States, it has the highest age-specific incidence of any cancer. If we could prevent the ...

    1239-1240

    Twenty years ago, Congress passed the Patient Self-Determination Act, hoping to improve end-of-life care through the use of advance directives. The statute stimulated the development of a cornucopia of planning documents. Patients can sign a living will ...

    Correspondence
    1241-1242

    To the Editor: Hunninghake et al. (Dec. 31 issue)1 report an association between single-nucleotide polymorphisms (SNPs) in MMP12 and lung function in children with asthma and in adults who smoke, as well as an association with a reduced risk of chronic ...

    1242-1243

    To the Editor: Omland et al. (Dec. 24 issue)1 report that an increased level of cardiac troponin T, as measured by a new, high-sensitivity assay, was associated with the incidence of death from cardiovascular causes and heart failure but not with ...

    1244-1245

    To the Editor: Jha and colleagues (Dec. 31 issue)1 report no association between hospital performance on one of two measures of discharge planning and rates of hospital readmissions within 30 days for patients with heart failure. However, there is little ...

    1245-1247

    To the Editor: Markowitz and Bertagnolli (Dec. 17 issue)1 summarize recent developments in the molecular basis of colorectal cancer, but they neglect to mention several aspects regarding prognostic and predictive markers for colorectal cancer. Despite ...

    1247-1248

    To the Editor: In his letter to the Editor, Guttler (Jan. 7 issue)1 purports to defend the case for integrated health care delivery systems, while cautioning that physicians who attempt to “place themselves ahead of the curve” with innovative and ...

    1248-1249

    To the Editor: Viral and postviral myocarditis are the major causes of acute and chronic dilated cardiomyopathy.1 To gain insight into the pathogenesis of parvovirus B19–associated myocarditis as an endothelial-cell–mediated disease (Figure 1A), we ...

    Points of View
    e47
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    On February 24, 2010, the U.S. House of Representatives passed the Health Insurance Industry Fair Competition Act, which would eliminate the antitrust exemptions granted to health insurers under the McCarran–Ferguson Act of 1945.1 The goal of the bill is ...

    Corrections
    1250

    The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages Health Policy Report, N Engl J Med 2009:361;1599-1605.. In the fourth paragraph under “An Effective Tax Policy and Projected Effects” (page 1602), the “1.0” in both the third and ...

    1250

    A New Mechanism of Leukemia Drug Resistance? Clinical Implications of Basic Research, N Engl J Med 2007:357;77-78.. In the second sentence of the third paragraph (page 77), “generate and secrete large amounts” should have read “generate large amounts.” In ...

    1250

    Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children Original Article, N Engl J Med 2009:361;1748-1759.. In Table 2 (page 1756), under “Renal scan at 1 yr,” the words “at baseline” should not have followed “Normal results” and “...