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April 15, 2010  Vol. 362 No. 15

Audio Summary of this Issue

Perspective
1353-1356

Innovative malpractice reforms can be implemented by health care institutions and liability insurers without requiring changes in the law. Michelle Mello and Dr. Thomas Gallagher focus on emerging models of disclosure of medical injuries and early ...

1356-1358
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Recently, the U.S. Supreme Court reached one of its most controversial decisions in years, in Citizens United v. Federal Election Commission. Lainie Rutkow and colleagues write that, with this decision, the Court has effectively opened the financial ...

1358-1361

    Dr. Perri Klass describes an oh-no moment: she had sent a baby and his mother out after a clinical encounter and then needed to get hold of them but couldn't. Dr. Klass writes about the feeling you get sometimes in primary care of tossing your patients ...

    e51

    Now that President Barack Obama has signed into law the Patient Protection and Affordable Care Act, pundits and politicians are debating whether the landmark legislation will be a political asset or an albatross. The truth is that the legacy of this new ...

    Original Articles
    1363-1373

    This clinical trial of outcomes in patients with atrial fibrillation showed that lenient rate control (resting heart rate, <110 beats per minute) was not inferior to strict rate control (resting heart rate, <80 beats per minute). On the basis of the results, strict rate control may be abandoned as a therapeutic strategy in many patients with permanent atrial fibrillation.

    1374-1382

    Two trials enrolled a total of 2701 patients who had undergone implantation of a drug-eluting coronary stent and had been receiving dual antiplatelet therapy for at least 12 months. They were randomly assigned to either continuation or discontinuation of clopidogrel therapy. At 19.2 months after randomization, the rate of myocardial infarction or death from cardiac causes did not differ significantly between the two groups.

    1383-1395

    In this randomized trial comparing infliximab, azathioprine, and combination therapy in adults with moderate-to-severe Crohn's disease, infliximab and combination therapy were superior to azathioprine. Adverse events were similar in the three groups.

    1396-1406

    Pompe's disease is caused by a deficiency of acid alpha glucosidase, which degrades lysosomal glycogen. Late-onset Pompe's disease is characterized by progressive muscle weakness and loss of respiratory function, leading to early death. In this randomized, placebo-controlled trial of a recombinant human acid alpha glucosidase, walking distance improved and pulmonary function stabilized over an 18-month period in patients treated with the active drug.

    Clinical Practice
    1407-1416
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    A 67-year-old man presents with progressive dyspnea. He has smoked cigarettes since he was 15 years of age. Worsening breathlessness forced him to retire as a laborer. His physical examination is notable for distant breath sounds on auscultation, with a prolonged expiratory phase. Spirometry reveals severe airflow obstruction (ratio of forced expiratory volume in first second [FEV1] to forced vital capacity, 0.43; FEV1, 34% of the predicted value). How should this case be managed?

    Review Article
    1417-1429

    This review summarizes recent evidence concerning molecular changes in the commonest type of lymphoma, diffuse large-B-cell lymphoma. Detailed studies have revealed three subtypes, each with distinctive clinical and molecular features. The molecular dissection of these tumors is uncovering new possibilities for treatment, some of which are already in clinical trials.

    Images in Clinical Medicine
    1430
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    A 32-year-old man with a 20-year history of smoking presented with a 1-month history of nonproductive cough at night, dyspnea, left thoracic pain, and an involuntary weight loss of 7 kg (15 lb). Physical examination was notable for shallow breathing and ...

    e52
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    This 25-year-old man with HIV who was receiving antiretroviral therapy had a 1-week history of diplopia and headache. The neurologic examination revealed an inability to abduct the right eye with horizontal gaze.

    Interactive Medical Case
    e53
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    A 45-year-old white man was brought to the emergency room by emergency-medical-services personnel after a syncopal event. He did not report any chest pain. He was found to have a monomorphic, wide-complex tachycardia at a rate of 240 beats per minute, ...

    Case Records of the Massachusetts General Hospital
    1431-1437

    A 69-year-old woman presented to this hospital because of a 2-month period of increasing apathy, confusion, and depression. She had a history of connective-tissue disease and idiopathic thrombocytopenic purpura. Ten days before admission, a magnetic resonance image of the brain was obtained, which was abnormal.

    Editorials
    1439-1441

    Untreated atrial fibrillation is usually associated with a rapid, irregular ventricular response and is often accompanied by symptoms including palpitations, fatigue, dyspnea, and dizziness. It is widely accepted that slowing the ventricular response, ...

    1441-1443

    As compared with bare-metal stents, drug-eluting stents reduce restenosis in every clinical situation and every type of lesion studied. Why, then, do some cardiologists use drug-eluting stents in 90% of patients and other cardiologists in 10%? The ...

    Clinical Decisions
    e54
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    Readers' recommendations and comments, along with detailed results of polling, are now available.

    Correspondence
    1444-1446

    To the Editor: The findings by Lowy and colleagues (Jan. 21 issue)1 demonstrate the value of fully human monoclonal antibodies in preventing the recurrence of Clostridium difficile infection. The prevalence of C. difficile infection in hospitalized ...

    1446-1448

    To the Editor: Zhang and colleagues (Dec. 31 issue)1 report that genes in the nucleotide-binding oligomerization domain containing 2 (NOD2)–mediated signaling pathway are associated with susceptibility to infection with Mycobacterium leprae in China. ...

    1448-1449
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    To the Editor: Sharma (Dec. 24 issue)1 says that ablation is not recommended for nondysplastic Barrett's esophagus because of an unacceptably high number of patients who would need to be treated (the number needed to treat) to prevent one case of ...

    1449-1450

    To the Editor: Pober (Jan. 21 issue)1 provides a comprehensive account of the current knowledge about Williams–Beuren syndrome, and she reviews associated genitourinary abnormalities such as urinary frequency, urgency, nocturia, bladder diverticula, ...

    Corrections
    1450
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    Barrett's Esophagus Clinical Practice, N Engl J Med 2009:361;2548-2556. In the fourth paragraph of the Endoscopic Surveillance subsection (page 2550), the last sentence should have ended with “endoscopic surveillance twice during the initial year and ...

    1450

    Rosuvastatin and Cardiovascular Events in Patients Undergoing Hemodialysis Original Article, N Engl J Med 2009:360;1395-1407. In the penultimate paragraph of the Discussion section (page 1405), the P value in the fifth sentence should have been 0.03 ...

    1450

    Effect of Herpes Simplex Suppression on Incidence of HIV among Women in Tanzania Original Article, N Engl J Med 2008:358;1560-1571. In the Results section, the third paragraph under Reported Sexual Behavior, Episodes of Genital Ulceration, and HSV ...