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October 31, 2002  Vol. 347 No. 18

Perspective
1394-1395

    After all, in spite of opinion, prejudice or error, Time will fix the real value upon this discovery, and determine whether I have imposed upon myself and others, or contributed to the benefit of science and mankind.

    — William Withering, 1785

    Since 1785, ...

    Original Articles
    1397-1402

    Congestive heart failure has an extremely poor prognosis. This investigation from the Framingham Heart Study tracked trends over a 50-year period in the incidence of heart failure and in survival after its onset. During this period, the incidence of heart failure declined among women but not among men, whereas survival improved among both men and women.

    1403-1411
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    The Digitalis Investigation Group previously reported no difference in mortality between patients with heart failure who received digoxin and those who received placebo. In this post hoc analysis, men and women in the trial were analyzed separately. Digoxin therapy had no effect on mortality in men but was associated with an increase in overall mortality among women (33.1 percent in the digoxin group vs. 28.9 percent in the placebo group).

    1412-1418
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    It can be difficult to distinguish pyoderma gangrenosum from other causes of cutaneous ulceration. In this study, the authors identified 95 patients with skin ulcers that resembled pyoderma gangrenosum. The ulcers were actually caused by vascular occlusive or venous disease, vasculitis, cancer, infection, drug-induced or exogenous tissue injury, or other inflammatory disorders. Most patients who received a diagnosis of pyoderma gangrenosum were treated, and 36 percent of those who were treated had exacerbation of their underlying condition or a delay in its diagnosis.

    Images in Clinical Medicine
    1419
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    Figure 1. A 72-year-old woman underwent splenectomy for transfusion-dependent myelofibrosis, and rapidly advancing, nonhealing necrotic skin ulcers developed over the incision site on the eighth postoperative day (Panel A). The abdominal-wall ulcers were ...

    Special Article
    1420-1425
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    In India nearly 500,000 people die each year from tuberculosis. Recent improvements in the national tuberculosis-control program are standardizing treatment, follow-up, and mandated reporting. More than 200,000 new health workers have been trained, and about 3.4 million patients have been evaluated. Nearly 800,000 patients have been treated, with a success rate of approximately 83 percent. The cost is about $50 per patient treated.

    Review Article
    1426-1432
    • Video

    When ventricular septal rupture complicates acute myocardial infarction, the mortality rate is high and immediate operative intervention is indicated. This review explains that septal rupture has become less common with reperfusion therapy but that rapid diagnosis remains crucial. Doppler echocardiography is usually diagnostic and can be used to estimate the size of the left-to-right shunt.

    Case Records of the Massachusetts General Hospital
    1433-1440

    Presentation of Case

    A 55-year-old right-handed man was admitted to the hospital because of difficulty with his handwriting and motor problems in his right leg.

    The patient, who was a teacher, had been well until five months earlier, when he began to ...

    Editorials
    1442-1444

    We are in the midst of a proclaimed epidemic of heart failure, as evidenced by increases in the number of hospitalizations for heart failure, the number of deaths attributed to heart failure, and the costs associated with care.1 In this issue of the ...

    1444

    This issue of the Journal contains a description of a remarkable tuberculosis-control program that was launched in India just over nine years ago.1 In the years since its inception, over 20,000 medical officers and over 100,000 related personnel have been ...

    Clinical Implications of Basic Research
    1445-1447

    Multiple sclerosis is the most common nontraumatic disorder of the central nervous system in young adults. Twenty years after the onset of disease, 90 percent of cases will have entered a progressive phase.

    Strong circumstantial evidence implicates an ...

    Correspondence
    1448-1449

    To the Editor: In the Women's Contraceptive and Reproductive Experiences (Women's CARE) Study, Marchbanks et al. (June 27 issue)1 carefully verified previous investigations showing that there is no association between combination oral contraceptives and ...

    1449-1451

    To the Editor: We agree with Hansen et al. (March 7 issue)1 that many studies of birth defects after in vitro fertilization suffer from methodologic problems, but we believe that their study has similar limitations. The authors compared the outcomes of ...

    1451-1452

    To the Editor: Schieve et al. (March 7 issue)1 suggest that the observed increase in the risk of low birth weight among singleton infants conceived with assisted reproductive technology is more likely to be due to the treatment than to an underlying ...

    1452-1453

    To the Editor: Castellsagué et al. (April 11 issue)1 did not correct for several of the major known risk factors for cervical cancer: race or ethnic group, smoking, human immunodeficiency virus (HIV) infection, poor diet, long-term use of oral ...

    1453-1455

    To the Editor: According to the article by Geng et al. (May 9 issue),1 the majority of cases of active tuberculosis in the New York City area are now reactivation cases in recently arrived immigrants. However, current guidelines advise chemoprophylaxis ...

    1455-1456
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    To the Editor: Dr. Foster (June 13 issue)1 highlights the epic tragedy of AIDS orphans in Africa and the absolute necessity of providing highly active antiretroviral therapy to adults in Africa. Current initiatives of the United Nations Program on HIV/...

    1456

    To the Editor: Hepatitis E virus (HEV) is the leading cause of water-borne epidemics of hepatitis in many developing countries in Asia and Africa, where high mortality has been reported among infected pregnant women.1 Recently, it has become clear that ...

    Book Reviews
    1457-1458

    James S. Olson has taken on the task of recounting the entire history of breast cancer — from Queen Atossa, who lived in Babylon in 490 b.c., to Dr. Jerri Nielsen, who was trapped in Antarctica in 1999 — and has done it in a concise, attractive, enjoyable ...

    1458

    Less than a decade ago, as the editor-in-chief of American Psychiatric Press, I asked a senior colleague for an opinion about publishing a book on women's mental health. I was told that there were insufficient data to generate a full-length book and that ...

    1459

    This is the third edition of a book that was previously titled Stress and Women Physicians. A new author, Erica Frank, has been added, as have data from the Women Physicians' Health Study, of which Frank is the principal investigator. With these additions,...

    Health Policy Report
    1462-1470

    To stimulate more evaluation of the safety and efficacy of medications in children, two federal regulations were established. The pediatric exclusivity provision gives an additional six months of patent protection to companies that voluntarily test a medication in children, whereas the pediatric rule requires pediatric studies if a drug is important for children.

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