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July 24, 2003  Vol. 349 No. 4

Perspective
319-320

Each winter, a number of surveillance networks are put in place to detect unusual outbreaks of severe respiratory disease. Last winter, although there had been some minor activity, nothing serious came up until late February 2003, when Dr. Carlo Urbani ...

320-323

Life forms that have low body mass can hunt for food on the undersurface of branches or along shear cliff faces quite unperturbed by gravity. For larger animals, the hunt for dinner and the struggle to avoid becoming someone else's meal require rapid ...

323-325

Some patients with aortic stenosis have recurrent bleeding into their skin or gastrointestinal tract. Several studies suggest that this bleeding is caused by an acquired defect in von Willebrand factor and that replacement of the aortic valve restores the ...

325-326

Researcher Linda Ganzini, M.D., says she was “stunned” after tallying the questionnaire results reported in this issue of the Journal (pages 359–365): Among the hospice nurses in Oregon who were surveyed, nearly twice as many had cared for patients who ...

Original Articles
327-334
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Bone loss increases after menopause, yet bone strength depends on structural characteristics such as bone size. In this study, the bone mass and skeletal structure of the distal radius were evaluated by single-photon absorptiometry in 108 women, all of whom were followed from menopause for a mean of 15 years. During follow-up, the mean bone mineral density decreased and the medullary bone diameter and periosteal diameter increased annually. The bone-strength index decreased.

335-342
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The failure to perform prostate biopsy in all members of a screened population affects the sensitivity and specificity of the measurement of prostate-specific antigen (PSA). Correction for verification bias with the use of a mathematical method revealed that the usual threshold value of 4.1 ng of PSA per milliliter for a recommendation of biopsy misses 82 percent of prostate cancers in men younger than 60 years and 65 percent in older men.

343-349
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Some patients with aortic stenosis have a bleeding tendency that may result, as this study shows, from an acquired form of von Willebrand syndrome. High shear forces at the stenotic valve change the shape of the von Willebrand protein, resulting in proteolysis, loss of the largest multimers, and reduction in platelet adhesion to the vascular endothelium.

350-357
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This small, placebo-controlled, randomized trial evaluated the direct application of epidermal growth factor (EGF) and oral 5-aminosalicylic acid (a conventional therapy). After 2 weeks, most patients given EGF enemas were in remission, and they continued to do well at 4 and 12 weeks.

Images in Clinical Medicine
358
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A 53-year-old woman with a history of ulcerative colitis presented with abdominal pain and bloody diarrhea. The abdominal examination revealed a distended and mildly tender abdomen with hypoactive bowel sounds. Plain films of the abdomen showed two ...

e4
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A nine-month-old was seen for failure to thrive and bruising around the eyes.

Special Article
359-365

In Oregon, 102 hospice nurses reported having cared for a patient who decided to stop eating and drinking, usually because the patient was ready to die. Most of these patients died within 15 days, and most died without excess suffering.

Review Article
366-381

    This review article discusses the ways in which the environment, diet, and genes contribute to the development of prostate cancer. Some dietary components increase the risk of prostate cancer, whereas other seem to be protective. Studies of familial prostate cancer are beginning to reveal genes that may have a role in the disease, but population studies have not yet pinpointed a major genetic factor. Prostatitis may have an important role in initiating the pathway to prostate cancer.

    Case Records of the Massachusetts General Hospital
    382-391

    Presentation of Case

    A 79-year-old woman with a gastric B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type was admitted to the hospital because of erosive mucosal and cutaneous lesions.

    The patient had been well until 14 months before ...

    Editorials
    393-395

    Verification bias can influence the interpretation of the most important screening test for prostate cancer, measurement of prostate-specific antigen (PSA). Such bias arises when the presence or absence of prostate cancer has not been verified by prostate ...

    395-397

    The treatment of active ulcerative colitis largely relies on the nonspecific antiinflammatory effects of aminosalicylates (mesalamine and sulfasalazine) and the broad immunosuppressive actions of corticosteroids and other potent immunomodulators.1 Data ...

    Correspondence
    398-400

    To the Editor: We have two major concerns regarding the report by Ridker et al. on low-intensity warfarin therapy (April 10 issue).1 First, in this study, low-dose, long-term warfarin therapy resulted in a relative reduction in the risk of recurrent ...

    401-402

    To the Editor: Prandoni et al. (April 10 issue)1 report the results of a case–control study suggesting an association between atherosclerosis and deep venous thrombosis. In fact, the 95 percent confidence interval for the prevalence of plaque in the ...

    402-405

    To the Editor: The article by Schechter and Gladwin (April 10 issue)1 is flawed by a fundamental error. The conclusions that the authors draw from reports of measured S-nitrosohemoglobin levels and decomposition rates are not disciplined by quantitative ...

    405-407

    To the Editor: In their informative and practical review of the management of drug and alcohol withdrawal, Kosten and O'Connor (May 1 issue)1 advocate the use of diazepam at a dose of 5 to 10 mg every two to four hours for the management of delirium ...

    407-408

    To the Editor: Paraneoplastic pemphigus has been reported in patients with Castleman's disease, and bronchiolitis obliterans in association with paraneoplastic pemphigus can eventuate in respiratory failure and death.14 Anatomically, there is a diffuse ...

    Book Reviews
    409-410

    Though it might seem like the ultimate reductionist approach, the sequencing of the human genome is in fact a major advance toward achieving an integrated understanding of physiology. Contrary to the commonly used metaphor, a genome is not a ladder with ...

    410

    The aim of this new edition of The Genetic Basis of Common Diseases is to present the state of the art in the understanding of the genetics of specific illnesses. A disease is regarded as common if its prevalence is higher than 1 in 1000. The etiology of ...

    411

    This collection of essays focuses on all aspects of the emerging field of pharmacogenomics except the science that underpins it. This omission is understandable because the science of pharmacogenomics is currently clouded by uncertainty. Pharmacogenomics ...

    411-412

    The quantitative analysis of the heritability of mental disorders, together with the demonstration of specific neuronal actions of psychotropic drugs, changed the conception of mental illness from a personal and family disgrace to a disorder of brain ...

    Corrections
    412

    Hodgkin's Disease — Clinical Trials and Travails Perspective, N Engl J Med 2003:348;2375-2376.. On page 2375, the epigraph should have been attributed to Louis Pasteur, rather than to René J. Dubos, as printed.

    412

    A 20-Hour Treatment for Acute Acetaminophen Overdose Correspondence, N Engl J Med 2003:348;2471-2472.. On page 2472, lines 11 and 12 of the left-hand column should have read “48 hours after the administration of the N-acetylcysteine loading dose,” rather ...