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August 15, 2002  Vol. 347 No. 7

Perspective
462-463

Eons ago, a retrovirus hijacked a gene from a chicken cell and enclosed it within its own genome. The captured gene was not idle, however: it gave the renegade virus the ability to cause tumors in chickens with amazing rapidity. The virus is the Rous ...

Original Articles
465-471
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This prospective study examined the changes in bacterial isolates from sputum samples obtained monthly from 81 outpatients with chronic obstructive pulmonary disease. There were 374 acute exacerbations of lung disease, which were significantly associated with the acquisition of a new strain of Haemophilus influenzae, Moraxella catarrhalis, or Streptococcus pneumoniae (relative risk for any new strain, 2.15). An exacerbation was diagnosed at 33 percent of the clinic visits that coincided with the appearance of a new bacterial strain in the sputum.

472-480

Unresectable or metastatic gastrointestinal stromal tumors fail to respond to conventional chemotherapy and are usually fatal within 12 to 18 months. Most gastrointestinal stromal tumors have a defect in KIT, a transmembrane tyrosine kinase receptor. The abnormality prevents the death of the cell and forces it to proliferate. The effects of imatinib mesylate, which blocks the abnormal signaling by KIT, was studied in 147 patients with advanced gastrointestinal stromal tumors. There were no complete responses, but about half the patients had a stable partial response.

481-487

Imatinib mesylate blocks the activity of three protein tyrosine kinases: ABL, KIT, and platelet-derived growth factor receptor β (PDGFRB). These kinases have crucial roles in chronic myelogenous leukemia (ABL), gastrointestinal stromal tumors (KIT), and certain myeloproliferative diseases (PDGFRB). The first two types of neoplasms have been shown to respond to imatinib mesylate. This article reports that in four patients, a myeloproliferative disorder involving a rearranged PDGFRB gene also responded to the drug.

488-496

Polyomavirus BK (BKV) nephropathy, an emerging cause of renal-allograft failure, may be linked to immunosuppressive regimens containing tacrolimus or mycophenolate mofetil. This prospective, single-center study examined urine for cells with viral inclusions, measured BKV DNA in plasma, and evaluated renal-biopsy specimens for evidence of nephropathy in 78 renal-transplant recipients who were being treated with such regimens. Four of five patients in whom BKV nephropathy developed were among the 77 percent of patients who had BKV antibodies before transplantation. The probability of BKV nephropathy was 8 percent (95 percent confidence interval, 1 to 15 percent).

Images in Clinical Medicine
497
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Figure 1. A 48-year-old man with diabetes mellitus underwent pancreas–kidney transplantation for end-stage renal disease. One month later, he was treated for rejection, and computed tomography of the chest showed no pulmonary infiltrates. Nine months ...

Clinical Practice
498-504

A 43-year-old man presents with heavy snoring; his bed partner reports that he sometimes stops breathing while he sleeps. He has hypertension controlled by medication but is otherwise healthy. He admits to feeling sleepy at times when he drives, although he has not had any motor vehicle accidents. His body-mass index is 33, and he has a large neck circumference (46 cm). How should he be evaluated and treated?

Review Article
505-516

    After international travel, up to 5 percent of travelers become ill enough to seek medical attention. This review focuses on the most common and most serious illnesses seen in persons from the industrialized world who have traveled to developing countries. The authors provide practical guidance for the diagnosis and management of fever, persistent diarrhea, and skin lesions in patients who present with these conditions after international travel.

    Case Records of the Massachusetts General Hospital
    517-524

    Presentation of Case

    A 46-year-old woman was admitted to the hospital because of extensive pulmonary infiltrates.

    The patient had felt well until several weeks before admission, when she began to have abdominal swelling and increasingly severe jaundice. ...

    Editorials
    526-527

    Patients with chronic obstructive pulmonary disease have exacerbations characterized by increased dyspnea, accompanied by increases in coughing, sputum production and purulence, and wheezing. Although most of these episodes are self-limited, they are ...

    527-530

    Viruses are particularly troublesome pathogens in transplant recipients. Viral infections enhance susceptibility to opportunistic infection both by causing tissue injury and by contributing to systemic immunosuppression.1 Such infections increase the rate ...

    Correspondence
    531-533

    To the Editor: The observations of Albert et al. (April 11 issue)1 on the protective effects of long-chain n–3 fatty acids (largely available in fish) with regard to sudden death may have profound clinical implications. These findings confirm previous ...

    533

    To the Editor: The April 4 Image in Clinical Medicine by Bhatti and Seville1 is of a man with hematogenous anaerobic osteomyelitis. We would like to add that the combination of a dental infection with fusobacterium and subsequent systemic spread is ...

    533-535

    To the Editor: The study by Fried et al. (April 4 issue)1 demonstrates that many people with severe illnesses are even more concerned about becoming disabled than about dying. Some opponents of the right to assisted dying argue that these persons are ...

    535-537

    To the Editor: In their review article on medical events during commercial airline flights (April 4 issue),1 Gendreau and DeJohn underplay the threat of lawsuits and report that “no litigation has been brought to date against a physician who has rendered ...

    537-538

    To the Editor: Congressman Henry A. Waxman (March 21 issue)1 is to be applauded for his tireless efforts in tobacco control. The actions of the U.S. delegation at the Framework Convention on Tobacco Control (FCTC) in May 2001 were disappointing, and it ...

    538-539
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    To the Editor: We learned from an online publication of the Network for Advancement of Transfusion Alternatives1 that Goodnough and colleagues cited data from the work of our group2 in a 1999 review article in the Journal to support the hypothesis that ...

    539-540

    To the Editor: The tyrosine kinase inhibitor imatinib mesylate specifically inhibits the BCR-ABL kinase, and has shown promising results in phase 1 and 2 trials in patients with chronic myelogenous leukemia at various stages of the disease.1,2 We ...

    Book Reviews
    541

    Few medical issues arouse such strongly passionate opinions among health care professionals and laypersons alike as the debate about physician-assisted suicide. This valuable and intentionally provocative book will add much light — and undoubtedly some ...

    542

    Not the least of the achievements of Ian McEwan's recent novel Atonement (New York: Doubleday, 2002) is its vivid portrait of the work of nurses in London during the Second World War. These nurses worked in the hospital rather than at home, and at heart, ...

    542-543
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    A consequence of the growth of sleep medicine is the number of textbooks that attempt to capture the richness, complexity, and diversity of this specialty. With increased recognition and board certification, the field has engendered a number of books on ...

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