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November 6, 2003  Vol. 349 No. 19

Perspective
1787-1789

Since they were first described, preexcitation syndromes have intrigued physicians. The interest derives in part from the myriad bizarre electrocardiographic abnormalities associated with these syndromes and from the variety of complex arrhythmias that ...

1789-1792

Over the past 15 years, deciphering of the molecular defects in primary immunodeficiencies has spawned a stream of information on how the immune system works. These advances have been facilitated by the development of powerful new tools that make possible ...

Original Articles
1793-1802

Postmenopausal women with early breast cancer who have undergone successful initial therapy receive five years of treatment with tamoxifen, an antagonist of the estrogen receptor. This placebo-controlled trial investigated whether the administration of letrozole, an aromatase inhibitor, after five years of tamoxifen therapy is beneficial. The trial was stopped because of a statistically significant reduction in the rate of breast-cancer–related events in the letrozole group as compared with the placebo group.

1803-1811

Many asymptomatic patients with a Wolff–Parkinson–White pattern on the electrocardiogram are at low risk for arrhythmias. However, younger asymptomatic patients with inducible arrhythmias may be at higher risk. This study found that prophylactic catheter ablation of accessory pathways in such patients greatly reduced the risk of arrhythmias.

1812-1820
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Using highly sensitive techniques, researchers identified pathologic prion protein in about one third of muscle and spleen specimens obtained at autopsy from patients with sporadic Creutzfeldt–Jakob disease. Pathologic prion protein has previously been found only in central nervous system and olfactory-nerve tissue from such patients.

1821-1828

Three closely related infants with a form of severe combined immunodeficiency characterized by the absence of T cells but normal numbers of B cells were found to have an identical germ-line mutation in the CD3δ gene. The mutation prevented synthesis of the CD3δ protein and was associated with a block early in the development of thymocytes into mature T cells.

Images in Clinical Medicine
1829
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A 66-year-old man was admitted to the hospital with a two-day history of left-sided pleuritic chest pain and progressive shortness of breath. A right pneumonectomy had been performed 17 years earlier for non–small-cell bronchogenic carcinoma. A computed ...

e18
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A four-week-old with a mass at the base of his neck.

Clinical Practice
1830-1835

A healthy 19-year-old woman comes in for a routine appointment. She is sexually active in a monogamous relationship; her partner uses condoms most of the time. Pregnancy is not currently desired. She has had sexual intercourse several times since her last menses, including an episode of unprotected intercourse four days earlier. A urine pregnancy test is negative. Should emergency contraception be prescribed?

Review Article
1836-1847

Most people do not survive out-of-hospital cardiac arrest, and those who do may have substantial long-term cognitive and motor impairment. ICDs may avert such events. This review discusses the mechanisms of ICDs, clinical studies of their effectiveness, and management issues.

Clinical Problem-Solving
1848-1853

    Foreword

    In this Journal feature, information about a real patient is presented in stages (boldface type) to expert clinicians from several specialties, who respond to the information, sharing their reasoning with the reader (regular type). The authors' ...

    Editorials
    1855-1857

    In this issue of the Journal, Goss et al.1 report results from a trial that will have a considerable effect on the treatment of early-stage breast cancer. The study was led by the National Cancer Institute of Canada Clinical Trials Group and was a joint ...

    1857-1859

    Five years of tamoxifen therapy is the standard adjuvant endocrine therapy for early-stage, hormone-receptor–positive breast cancer.13 Randomized trials have demonstrated the superiority of five years of treatment over shorter durations for the ...

    Sounding Board
    1860-1865

    Eight years ago, Harold E. Varmus, then the director of the National Institutes of Health (NIH), convened a panel to evaluate the status of clinical research in the NIH portfolio and to make recommendations for strengthening this component of the U.S. biomedical research effort. This Sounding Board article examines the outcome of the panel's recommendations.

    Correspondence
    1866-1868

    To the Editor: In the study by McGlynn et al. (June 26 issue),1 participants received only about half of recommended care. It may be possible to double efficiency by working harder and smarter, as Steinberg suggests in his accompanying editorial,2 but ...

    1868-1869

    To the Editor: Ross et al. (Aug. 14 issue)1 suggest that a history of brain tumor in childhood predisposes patients to subsequent psychosis but not to major depression. This result is at odds with our experience that depressive disorders are common in ...

    1869-1870

    To the Editor: We read with interest the work of Bozzette et al. (Feb. 20 issue),1 who describe reduced rates of cardiovascular events among patients with human immunodeficiency virus (HIV) infection in the era of highly active antiretroviral therapy (...

    1870-1872
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    To the Editor: Clayton's description of the case of Sierra Creason misrepresents the facts (Aug. 7 issue).1 The thyroid values were not “abnormally low.” Thousands of unaffected newborns had the same negative results. The case was not one of congenital ...

    1872-1873

    To the Editor: In the review article by Merlini and Bellotti (Aug. 7 issue),1 familial Mediterranean fever was listed as one of the common periodic-fever syndromes that may lead to reactive (amyloid protein A, or AA) amyloidosis. However, there is no ...

    1873-1874
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    To the Editor: The Perspective article by Morse (May 29 issue)1 addresses the transmission of West Nile virus through organ transplantation and blood transfusion. Less than 1 percent of the more than 4000 cases diagnosed in 2002 were attributed to ...

    1874-1875

    To the Editor: Bailey and Chaitman (Aug. 7 issue)1 present an electrocardiogram from a patient with a traumatic intracerebral hemorrhage. The electrocardiogram shows rather marked ST-segment and T-wave abnormalities, and the authors state that the ...

    1875-1876

    To the Editor: The outbreak of severe acute respiratory syndrome (SARS) in Taiwan described by Hsieh (Aug. 14 issue)1 grew rapidly from mid-April 2003. We note the chronologic relation between this rapid wave of infections and the visit of a resident of ...

    Book Reviews
    1877-1878

    Paul Farmer is a 44-year-old specialist in infectious diseases and an attending physician at the Brigham and Women's Hospital in Boston. His biographer, Tracy Kidder, read his book on the connections between poverty and disease — Infections and ...

    1878

    There are many reasons why physicians need to provide culturally competent health care. Increasing numbers of patients belong to minority groups, have limited proficiency in English, or were born in foreign lands. Culturally competent physicians may be ...

    1878-1879

    I recently listened to a presentation by Dr. Mervyn Hardinge, founding dean and professor emeritus at Loma Linda University's School of Public Health. With candor and humor, he eloquently reviewed the history of modern vegetarianism by recounting his ...

    1879-1880
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    Books with nearly 100 pages of references, not to mention notes, are treasures as resources, even if their content and the discussion they contain require much work of the reader. Remembering Trauma is such a book. It is not, however, about remembering ...

    Corrections
    1880

    Neoadjuvant Chemotherapy plus Cystectomy Compared with Cystectomy Alone for Locally Advanced Bladder Cancer Original Article, N Engl J Med 2003:349;859-866.. On page 864, lines 3 to 5 of the last partial paragraph should have read, “The estimated risk of ...

    1880
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    Mind the Gap Clinical Problem-Solving, N Engl J Med 2003:349;1465-1469.. On page 1466, in the formula that begins on line 4 of the third paragraph in the left-hand column, the first amount should have read “2× the serum sodium level,” rather than “2× the ...