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November 29, 2001  Vol. 345 No. 22

Original Articles
1583-1592

Patients with coronary disease and low high-density lipoprotein (HDL) cholesterol levels are at risk for coronary events. This study found that a combination of niacin and simvastatin was very effective over a period of three years in reducing the frequency of coronary events and causing a slight regression of coronary lesions, as measured by angiography. By contrast, antioxidant vitamins had no benefit, and the addition of antioxidant vitamins to niacin and simvastatin attenuated their beneficial effect.

1593-1600

In this double-blind study, a combination of folate, vitamin B12, and pyridoxine was found to reduce the rate of restenosis in patients who had undergone coronary angioplasty. There was less benefit in patients who had received stents than in those who had not. Vitamin therapy also resulted in lower plasma homocysteine levels, a potential mechanism of the clinical effect.

1601-1606

In the summer of 2000, there was an outbreak of tularemia on the island of Martha's Vineyard in Massachusetts. This case–control study identified 15 patients with Francisella tularensis infection, including 11 with primary pneumonic tularemia. One patient died. The patients were more likely than controls to have used a lawn mower or brush cutter in the two weeks before the illness.

1607-1610
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This case report provides a description of the first case of fatal inhalational anthrax in the United States in 25 years. This 63-year-old newspaper photo editor had a rapidly progressive febrile illness, and lumbar puncture showed cloudy cerebrospinal fluid with numerous polymorphonuclear leukocytes and many large gram-positive bacilli, singly and in chains. A diagnosis of inhalational anthrax was made, and despite aggressive treatment the patient died soon thereafter. The infection appeared to have been transmitted through mail contaminated with anthrax spores as a result of biologic terrorism.

Images in Clinical Medicine
1611
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Figure 1. A seven-month-old male infant was hospitalized with a two-day history of swelling of the left arm and a weeping lesion at the left elbow (Panel A). The patient was afebrile but had a 2-cm open sore, with surrounding erythema and induration, that ...

Special Article
1612-1620

The Shattuck Lecture is delivered at the Annual Meeting of the Massachusetts Medical Society. In the 111th lecture, Dr. Barbara McNeil discusses a core problem in health policy, the barriers to improvement in the quality of medical care. She focuses on two key impediments: uncertainty about which therapeutic and diagnostic interventions are actually effective, and cost pressures, which may result in the underuse of potentially valuable medical treatments and techniques.

Review Article
1621-1626

Infection with Bacillus anthracis, commonly known as anthrax, has reemerged as a weapon of bioterrorism. This review article revisits and updates our 1999 review of anthrax and contains practical information for the physician faced with a possible case of this dangerous infection.

Case Records of the Massachusetts General Hospital
1627-1634

Presentation of Case

A 76-year-old man was admitted to the hospital because of atrial fibrillation and increasing dyspnea.

The patient had been well until three weeks earlier, during an unseasonably warm period in late autumn, when a nonproductive cough ...

Editorials
1636-1637

Recently, great strides have been made in the use of various pharmacologic interventions for the treatment of patients with cardiovascular disease. One strategy, the use of lipid-altering therapy for both primary and secondary prevention, has reduced ...

1637-1639
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Tularemia, which is caused by the gram-negative bacillus Francisella tularensis, is now a rare infection in the United States. The peak incidence was in 1939, when about 2300 cases were reported. The decline may be related to the fact that wild rabbits ...

Correspondence
1641-1643

To the Editor: In a trial comparing coronary-artery bypass surgery with stenting for the treatment of multivessel coronary disease, Serruys et al. (April 12 issue)1 conclude that both treatments offer protection against death, stroke, and myocardial ...

1643-1644

To the Editor: We are surprised by the certainty with which Fiorillo et al. (Aug. 2 issue)1 conclude that the so-called pseudomonas hot-foot syndrome accounts for the unprecedented cluster of cases they describe. All 40 cases occurred 10 to 40 hours ...

1644

To the Editor: The case report by Srinivasan et al. (July 26 issue)1 makes one wonder when glanders was first suspected as this patient's illness. The patient's work history included potential exposure to Burkholderia mallei without personal protective ...

1644-1645

To the Editor: Vochem et al. (Aug. 2 issue)1 describe a neonate with disseminated Pseudomonas aeruginosa infection that was associated with a contaminated tub bath. Of concern is the description of ampicillin, cefotaxime, and gentamicin as “...

1645-1646

To the Editor: Only nine cases of acromegaly caused by pituitary carcinoma have been reported.1 We describe a 47-year-old woman who presented in July 1996 with the features of acromegaly and an elevated mean serum growth hormone level of 58.4 mU per ...

1646-1647

To the Editor: We report the case of an otherwise healthy 34-year-old man, employed in the mailroom of a New York City daily newspaper, who presented with a rapidly growing nodule over the flexor surface of his left forearm (Figure 1). He stated that the ...

Book Reviews
1648

Reductionism is, in the words of Peter Medawar, “the most successful research stratagem ever devised.” Thanks to reductive analysis, biomedical research has produced countless pieces of information. What we need from time to time is a fresh selection of ...

1648-1649
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Medical toxicology, which encompasses the pathophysiology, diagnosis, and treatment of clinical problems related to poisoning and drug intoxication, has in the past decade become an established subspecialty with demonstrated breadth and depth of ...

Corrections
1652

Valvular Heart Disease Review Article, N Engl J Med 1997:337;32-41.. On page 38, in Table 1, the heading of the second column should have read, “End-Systolic Dimension,” not “End-Diastolic Dimension,” as printed. We regret the error.

1652

A Comparison of Budesonide and Mesalamine for Active Crohn's Disease Original Article, N Engl J Med 1998:339;370-374.. On page 372, the sentence that begins on line 8 of the right-hand column should have read, “The median time to remission was also ...