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November 14, 2002  Vol. 347 No. 20

Perspective
1546-1547

An early and essential event in the evolution of cancer is loss of the normal control mechanisms responsible for the orderly progression of cells through the cell cycle, with consequent reduced fidelity of DNA replication and inappropriate cell division. ...

Original Articles
1549-1556
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Can adjuvant treatment with dexamethasone reduce morbidity and mortality in adults with acute bacterial meningitis? In this randomized, double-blind trial, which involved 301 patients, the outcomes were clearly better in the group that received dexamethasone for four days, in addition to antibiotics, than in the group that received placebo and antibiotics. With dexamethasone treatment, the risk of an unfavorable outcome was greatly reduced (relative risk, 0.59), and mortality was reduced from 15 percent to 7 percent.

1557-1565

Studies have suggested that C-reactive protein, a marker of inflammation, may predict the risk of cardiovascular events, including coronary events. In this study of nearly 28,000 women, C-reactive protein levels were found to predict the risk of subsequent cardiovascular events independently of other known coronary risk factors. C-reactive protein and low-density lipoprotein cholesterol levels were found to be complementary in the prediction of risk.

1566-1575
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The level of cyclin E, part of a molecular network that controls the cell cycle, is increased in breast-cancer cell lines. In breast-cancer tissue, high levels of cyclin E correlated with a poor outcome, whereas low levels correlated with a good outcome.

1576-1583
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In women with diabetes, treatment of asymptomatic bacteriuria has been recommended to prevent complications. In this trial, 55 women with diabetes and asymptomatic bacteriuria were randomly assigned to receive antimicrobial therapy and 50 to receive placebo. After a mean follow-up of 27 months, the rates of symptomatic urinary tract infection were similar: 42 percent in the treated group and 40 percent in the placebo group. There were also no significant differences between the two groups in the rates of pyelonephritis or hospitalization for urinary tract infection, although the 95 percent confidence intervals for these differences were wide.

Images in Clinical Medicine
1584
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Figure 1. A 78-year-old man with long-standing end-stage renal failure and a previous mitral-valve replacement presented with a one-month history of episodes of effort-related syncope. Results of physical examination and echocardiography were consistent ...

Special Article
1585-1592
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Mortality from all causes is higher for persons with less education and for black persons. This study examined cause-specific mortality to estimate the relative contribution of major health problems to these educational and racial disparities in life expectancy. The diseases that contributed most to the educational disparity were smoking-related diseases. Ischemic heart disease accounted for 12 percent of the disparity, lung cancer 8 percent, stroke 6 percent, congestive heart failure 5 percent, and lung disease 5 percent. The racial disparity was not driven by mortality from smoking-related illness but by hypertension, human immunodeficiency virus infection, diabetes, and trauma.

Review Article
1593-1603

The apparent complexity of the genetic, biochemical, and physiological changes in cancer cells threatens to stall the elucidation of the origins of cancer and the development of new treatments for malignant diseases. The authors propose a considerably simplified scheme in which only five alterations are required to transform cells from a normal to a malignant phenotype.

Case Records of the Massachusetts General Hospital
1604-1611

Presentation of Case

A nine-year-old right-handed girl was admitted to the hospital because of a suprasellar mass.

The girl had been well, with normal development, until about six months earlier, when her mother observed that she reported “feeling cold” ...

Editorials
1613-1615

In 1988, a landmark study was reported on the use of adjunctive treatment with dexamethasone in infants and children who had bacterial meningitis.1 The rationale for this study was based on studies involving animal models of bacterial meningitis, which ...

1615-1617

Prediction is very difficult, especially about the future.

— Niels Bohr

More than 20 years ago, 246 risk factors for coronary heart disease (CHD) had already been identified, and the number continues to grow.1 Advances in genomics and proteomics will ...

1617-1618

The application of quantitative bacteriology to urine cultures almost five decades ago led to prospective scientific investigations of the epidemiology, pathogenesis, diagnosis, treatment, and prevention of urinary tract infections.1 Numerous studies have ...

Correspondence
1619-1622
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To the Editor: In the May 16 issue, three articles deal with public policy on stem-cell research.13 The authors of all three articles agree that reproductive cloning should be banned but that research on therapeutic cloning (i.e., nuclear ...

1622-1623

To the Editor: Whyte et al. (July 18 issue)1 report that homozygous deletion of the gene encoding osteoprotegerin is a potential cause of juvenile Paget's disease in some Navajo patients. A deficiency of osteoprotegerin leads to unopposed effects of its ...

1623-1624

To the Editor: Lai et al. (June 27 issue)1 report that lansoprazole after the eradication of Helicobacter pylori was significantly better than eradication alone in decreasing the risk of recurrence of ulcer complications in patients with long-term low-...

1624-1625

To the Editor: Hata et al. (July 4 issue)1 report that inactivated varicella vaccine given before and after hematopoietic-cell transplantation reduces the risk of zoster. The primary end point of their study was the development of zoster within 12 months ...

1625-1626

To the Editor: In his Clinical Practice article (July 4 issue),1 Antin does not discuss an important cause of late death after hematopoietic stem-cell transplantation: invasive fungal infection. Several centers have reported that such infections (such as ...

1626

To the Editor: Freedman's conclusions about the stability of timidity in genetically engineered mice (July 18 issue)1 are not supported by longitudinal studies in children. It is unjustifiable to suggest that temperamentally inhibited children are ...

1626-1627

To the Editor: A healthy 20-year-old woman presented with breast pain and bilateral purulent nipple discharge three weeks after having her nipples pierced. She received a course of antibiotics (cephalexin), and her infection resolved. Two weeks later, ...

Book Reviews
1628-1629

”This book argues that by allowing patients to move them [emotionally], physicians gain access to a source of understanding illness and suffering that can make them more effective healers.” By the beginning of the 21st century, this statement, which opens ...

1629-1630

You will search medical textbooks in vain for the differential diagnosis distinguishing modern illness from postmodern illness. But if this dichotomy and the evolution of the former condition into the latter were established, the project of narrative ...

1630

All medical students are required to write “history and physicals” (“H&Ps”) about their patients. In our urban clinic, I ask students to write one H&P in a narrative format — that is, to have the patient describe for the student what it is like to have a ...

Health Policy Report
1633-1638

Systems for reporting adverse events can reduce medical errors by uncovering remediable problems in processes of care; however, current reporting systems are neither widely used nor highly effective. Reporting systems work best when they are confidential and easy to use, provide expert analysis of reports, and give timely feedback.