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Table of contents for

November 11, 2010  Vol. 363 No. 20

Audio Summary of this Issue

Perspective
1881-1883
A “Broader Regulatory Scheme” — The Constitutionality of Health Care Reform
S. Rosenbaum
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Although a federal court in Florida has allowed a state challenge to the constitutionality of health care reform to proceed to the next stage of litigation,1 a second federal court in Michigan has already swiftly dispatched identical claims on the merits. ...

1883-1885
Writing New Rules for Insurers — Progress on the Medical Loss Ratio
T.S. Jost
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Few undertakings in the short history of the implementation of health care reform have been as difficult or contentious as the drafting of regulations to define the statute's “medical loss ratio” requirement. Beginning in 2011, health insurers must report ...

1885-1887
Four-Dollar Generics — Increased Accessibility, Impaired Quality Assurance
N.K. Choudhry and W.H. Shrank
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The affordability of prescription medications is one of the most pressing public health issues in the United States. Many patients take less than their prescribed doses to make medications last longer or do not fill prescriptions at all because of cost.1 ...

e30
Health Care in the 2010 Congressional Election
R.J. Blendon and J.M. Benson
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Eight months after the enactment of historic health care reform legislation (the Patient Protection and Affordable Care Act), the country faces a midterm congressional election with all seats inthe House of Representatives and one third of Senate seats up ...

Original Articles
1889-1899
Romiplostim or Standard of Care in Patients with Immune Thrombocytopenia
D.J. Kuter and Others
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  • CME

The platelet-stimulating agent romiplostim was compared with standard interventions for chronic immune thrombocytopenic purpura. Patients given romiplostim had higher platelet counts, less treatment failure, fewer bleeding episodes, and better quality of life.

1900-1908
Dietary Intervention in Infancy and Later Signs of Beta-Cell Autoimmunity
M. Knip and Others
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This study investigated whether feeding with a highly hydrolyzed milk formula would decrease the incidence of diabetes-associated autoantibodies in genetically susceptible children. The intervention appeared to have a long-lasting effect on markers of beta-cell autoimmunity.

1909-1917
Clopidogrel with or without Omeprazole in Coronary Artery Disease
D.L. Bhatt and Others
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In patients receiving dual antiplatelet therapy, omeprazole reduced the risk of upper-GI toxic effects but did not increase the risk of cardiovascular events; statistical power to assess cardiovascular events was low, however, so the findings are not definitive.

1918-1927
Brief Report: Stem-Cell Gene Therapy for the Wiskott–Aldrich Syndrome
K. Boztug and Others
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The authors report the long-term (up to 3 years) correction of the Wiskott–Aldrich syndrome in two patients through retroviral infection of CD34+ hematopoietic cells after busulfan-induced transient myelosuppression.

Special Article
1928-1937
Effect of a Comprehensive Surgical Safety System on Patient Outcomes
E.N. de Vries and Others
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This study compared surgical outcomes before and after implementation of a comprehensive checklist, including marking of the operative side and use of postoperative instructions. Complications decreased from 27 to 17 per 100 patients, and mortality decreased from 1.5 to 0.7%.

Review Article
1938-1948
Current Concepts: Triple-Negative Breast Cancer
W.D. Foulkes, I.E. Smith, and J.S. Reis-Filho
  • CME

Triple-negative breast cancer, so called because it lacks expression of the estrogen receptor, progesterone receptor, and HER2, is often, but not always, a basal-like breast cancer. This review focuses on its origin, molecular and clinical characteristics, and treatment.

Images in Clinical Medicine
1949
A Smooth Patch on the Tongue
P. Basak and S. Jesmajian
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A smooth, well-demarcated patch without papillae on the posterior portion of the tongue was discovered incidentally while the oropharynx of a 65-year-old woman was being examined. On inquiry, she said that she had been aware of the unusual appearance of ...

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Acoustic Findings in a Patient with Radiation Pneumonitis
R. Murphy and A. Vyshedskiy
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  • Interactive/Multimedia

A 77-year-old woman presented to the hospital with shortness of breath and fever, 2 months after receiving radiation therapy to the right chest for breast cancer. A diagnosis of radiation pneumonitis was made, and the patient was treated with ...

Case Records of the Massachusetts General Hospital
1950-1957
Case 34-2010 — A 65-Year-Old Woman with an Incorrect Operation on the Left Hand
D.C. Ring, J.H. Herndon, and G.S. Meyer
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  • CME
  • Comments
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A 65-year-old woman was admitted to the day-surgery unit of this hospital for release of a trigger finger of the left ring finger. A carpal-tunnel release was performed. After the procedure, the surgeon realized he had performed the wrong operation.

Editorials
1959-1961
Management of Immune Thrombocytopenia — Something Old, Something New
J.N. George

    For most of my career, the management of immune thrombocytopenia has evolved from clinical experience rather than clinical evidence. When I was a medical student at Ohio State University in 1960, my mentors were shifting their initial treatment for immune ...

    1961-1963
    Infant Formula, Autoimmune Triggers, and Type 1 Diabetes
    D.M. Harlan and M.M. Lee

      Families are devastated when a child receives a diagnosis of type 1 diabetes. Although tremendous strides in insulin-based treatments — made feasible by technical advances such as continuous glucose monitors, modern “designer” insulin formulations, and ...

      1963-1965
      Strategies for Improving Surgical Quality — Checklists and Beyond
      J.D. Birkmeyer

        Long standard in the safety-conscious aviation industry, checklists are now being promoted aggressively in the medical literature and popular press.1–3 Almost all U.S. hospitals mandate simple preoperative “time-outs” to minimize the risk of egregious ...

        Correspondence
        1966-1968
        Sipuleucel-T Immunotherapy for Castration-Resistant Prostate Cancer
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        To the Editor: Kantoff et al. (July 29 issue)1 report that the use of sipuleucel-T immunotherapy prolonged overall survival among patients with metastatic castration-resistant prostate cancer, regardless of the previous or subsequent use of chemotherapy. ...

        1968-1970
        Maternal or Infant Antiretroviral Drugs to Reduce HIV-1 Transmission
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        To the Editor: The article by Chasela et al. (June 17 issue)1 is an important contribution to the field of prevention of mother-to-child transmission of the human immunodeficiency virus type 1 (HIV-1), since it shows that the use of either a maternal ...

        1971
        Myocardial Fibrosis in Hypertrophic Cardiomyopathy
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        To the Editor: Ho and colleagues (Aug. 5 issue)1 report that an elevated level of serum C-terminal propeptide of type I collagen (PICP) may be interpreted as a biomarker of myocardial fibrosis in patients who are genotype-positive for one of the ...

        1972-1975
        Acute Pulmonary Embolism
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        To the Editor: In their review article, Agnelli and Becattini (July 15 issue)1 discuss many important topics in acute pulmonary embolism. We would like to highlight the importance of the use of pulmonary magnetic resonance imaging (MRI) in the diagnosis ...

        1975-1976
        Accountability Measures to Promote Quality Improvement
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        To the Editor: Chassin et al. (Aug. 12 issue)1 describe the recent history of accountability measures in hospitals, which, they argue, promote quality improvement. But measurement for the purpose of accountability or judgment and measurement for the ...

        1976
        Incomplete Testosterone Suppression in Prostate Cancer
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        To the Editor: We have witnessed a new renaissance in the treatment of castration-resistant prostate cancer,1 but the progression of this disease beyond a form treatable by means of hormone deprivation still begs scientific and clinical inquiry. The ...

        1977
        Interaction of Clopidogrel and Omeprazole
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        To the Editor: The label for clopidogrel warns physicians to “avoid concomitant use of . . . strong or moderate CYP2C19 inhibitors.” Such inhibitors (e.g., omeprazole) decrease the formation of the active metabolite of clopidogrel, the source of its ...

        Corrections
        1977
        Everolimus in Patients with Autosomal Dominant Polycystic Kidney Disease
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        Everolimus in Patients with Autosomal Dominant Polycystic Kidney Disease Original Article, N Engl J Med 2010;363:830-840. The appendix (page 840) should have included the following members of the study team: “Leipzig: C. Mayer, T. Lindner.” The article ...

        1977
        Medical Student Debt — Is There a Limit?
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        Medical Student Debt — Is There a Limit? Perspective, N Engl J Med 2008;359:2629-2632. In the seventh paragraph, beginning “Although it usually . . .” (page 2630), “Baylor University” should have been “Baylor College of Medicine.” We regret the error. The ...

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