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September 26, 2002  Vol. 347 No. 13

Perspective
966-967

    Sepsis, a leading cause of death in the United States, is now viewed physiologically as a proinflammatory and procoagulant response to invading pathogens. There are three recognized stages in the hierarchy of the inflammatory response, with progressively ...

    Original Articles
    969-974
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    Antithrombotic therapy is routinely prescribed after myocardial infarction. This study compared the effect of warfarin, aspirin, or the combination of both medications on a composite end point of death, nonfatal reinfarction, or thromboembolic stroke. Both warfarin regimens were superior to the aspirin regimen. The combined-therapy regimen was somewhat more favorable than the warfarin-alone regimen but not significantly so.

    975-982

    Interferon-based therapies combined with ribavirin are effective for chronic hepatitis C, but many patients do not have a response and side effects are common. Pegylated interferons are more efficacious than standard interferons. In this large trial, peginterferon alfa-2a plus ribavirin resulted in a higher rate of sustained virologic response (56 percent) than interferon alfa-2b plus ribavirin (44 percent) and peginterferon alfa-2a alone (29 percent). Side effects occurred less often with peginterferon alfa-2a plus ribavirin than with interferon alfa-2b plus ribavirin.

    983-991

    Familial aggregation occurs among persons with renal calcium stones or bone demineralization, suggesting a genetic propensity toward these disorders. In this study of 14 patients with stones and 6 with bone demineralization, all of whom also had hypophosphatemia and decreased renal phosphate reabsorption, 2 patients were found to have unique mutations in the type 2a sodium–phosphate cotransporter.

    Images in Clinical Medicine
    992
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    Figure 1. A 54-year-old man had an acute primary episode of Raynaud's disease after surfing for 80 minutes in water that was 21°C. The distinctive asymmetric pallor of the terminal phalanges of the fourth digit on the right hand persisted for 40 minutes. ...

    Special Article
    993-1000
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    Recombinant human activated protein C has been shown to reduce mortality among patients with severe sepsis. Given the high cost of activated protein C ($6,800 per therapeutic course) and the high incidence of severe sepsis, the economic implications of widespread use of activated protein C are important. In this cost-effectiveness analysis, the authors report that activated protein C is associated with a cost of about $28,000 per year of life gained and $47,000 per quality-adjusted year of life gained. However, treatment of patients with an APACHE II score of 24 or less is associated with a cost of $575,000 per year of life gained.

    Clinical Practice
    1001-1008

    A 37-year-old woman reports that her fingers turn blue when they are exposed to the cold and that she has fatigue, arthralgias, and a history of small, painful digital ulcers. How should she be evaluated and treated?

    Case Records of the Massachusetts General Hospital
    1009-1017

    Presentation of Case

    An eight-year-old girl was admitted to the hospital because of fever, cough, hemoptysis, and pulmonary consolidations.

    She had been well until six days before admission, when she was visiting El Salvador. A sore throat developed, with ...

    Editorials
    1019-1022

    Despite encouraging trends over the past three decades, coronary heart disease remains the leading cause of death in the United States and other industrialized countries. Recent data from the National Center for Health Statistics and the National Heart, ...

    1022-1024

    Phosphate leads two lives — an ancient intracellular one and a more recent extracellular one. Inside cells, phosphate has a structural role in nucleic acids and phospholipids, forms high-energy ester bonds (e.g., in adenosine triphosphate and guanosine ...

    Clinical Implications of Basic Research
    1025-1026

      Prostacyclin inhibits platelets and dilates blood vessels, whereas thromboxane A2 activates platelets and constricts vessels. In mice lacking receptors for prostacyclin, intimal injury provokes a severe reaction within the artery, whereas in mice lacking thromboxane A2 receptors the response is subdued. These findings are relevant to clinical concerns that cyclooxygenase-2 inhibitors, which specifically impair the formation of prostacyclin, may increase susceptibility to cardiovascular events. Aspirin, which inhibits both prostacyclin and thromboxane A2, protects against arterial thrombosis.

      Sounding Board
      1027-1030

        A new hypothesis with implications for the treatment of sepsis has recently been tested — the hypothesis that part of the pathophysiology of sepsis is caused by unrestricted or inappropriate coagulation in the microcirculation. Three agents that block ...

        1030-1034

        In 2001, the Food and Drug Administration (FDA) evaluated an application for the use of drotrecogin alfa (activated), or recombinant human activated protein C (Xigris, Eli Lilly), in patients with severe sepsis. The use of activated protein C, as compared ...

        Correspondence
        1035-1036

        To the Editor: In this issue of the Journal, Warren et al.1 and Siegel2 offer their views on the approval of drotrecogin alfa (activated), or recombinant human activated protein C, for the treatment of severe sepsis. We concur with Dr. Siegel's comments ...

        1036-1037

        To the Editor: In their report on the efficacy of activated protein C in reducing mortality from sepsis at 28 days (March 8, 2001, issue),1 Bernard et al. presented the results of a retrospective subgroup analysis, which showed that the administration of ...

        1037-1040

        To the Editor: Kauff et al. (May 23 issue)1 present data suggesting that salpingo-oophorectomy provides protection against breast or gynecologic cancer in women with a BRCA1 or BRCA2 mutation. Although the follow-up period was relatively short and ...

        1040-1041

        To the Editor: Brightling et al. (May 30 issue)1 report that, in patients with asthma, there is mast-cell infiltration of airway smooth muscle associated with hyperresponsiveness. As pointed out by the authors and by Black in an accompanying editorial,2 ...

        1041-1043

        To the Editor: According to Ganzini and Block (May 23 issue),1 “experts assert that with excellent palliative care, most requests for hastened death would not be made.” They consider rates of physician-assisted death of 10 to 20 percent, as reported for ...

        1043-1044

        To the Editor: In 1990, I proposed the Journal's stringent policy for authors of review articles and editorials1 because I thought it was the best way to preserve our readers' confidence in the objectivity of those articles. The recent extraordinary ...

        1044-1045

        To the Editor: The report by Ostrowsky et al. (May 16 issue)1 and the Perspective by Verghese2 highlight the importance of impairment due to alcohol and drug dependence among physicians and other health care workers. Addiction spares no race or class in ...

        Book Reviews
        1046

        Like motorists who slow down to stare at the aftermath of car crashes, most people are fascinated by meteorologic disasters. The perils of weathering a hurricane, a tsunami's destruction of property, and the human drama of a flood all make for riveting ...

        1046-1047

        Sexual assault has become a complicated issue over the past decade and poses many difficulties in prevention and diagnosis. With the availability of disabling drugs such as “ecstasy,” the phrase “slipped a Mickey Finn” has taken on new meaning, not only ...

        1047-1048

        How does a modern journalist tell a story subtitled The Rise and Fall of America's Premier Mental Hospital? A book about McLean Hospital, an institution that for nearly 200 years treated mentally ill members of Boston's social and intellectual elite, ...

        1048-1049

        An extensive body of empirical research, which has grown dramatically over the past 10 years, has documented the profoundly important influence of body image on the quality of life. The editors of this book have made an important and timely contribution ...

        Corrections
        1050
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        Photo filler (August 8, 2002;347:400). The photograph printed on page 400 should have been credited to Robert B. Cubberley, M.D., rather than Glenn Zachow, M.D. We regret the error.

        1050

        Seizure Associated with the Use of Visicol for Colonoscopy Correspondence, N Engl J Med 2002:346;2095.. On page 2095, the last name of the third author of the letter should have been "Prizont" rather than "Prizant." We regret the error.