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May 27, 2004  Vol. 350 No. 22

Perspective
2231-2233

Dr. Gerry McElvaney describes how in March 2004 the Irish government implemented a law banning smoking in the workplace. This was the first law of its kind in Europe.

2233-2236

    Dr. Danielle Ofri shares her experiences in caring for a difficult patient.

    2236-2238

    Chronic thromboembolic pulmonary hypertension (CTPH) is believed to result from single or recurrent pulmonary thromboemboli arising from sites of venous thrombosis. The occurrence of CTPH after a diagnosis of acute pulmonary embolism has been considered ...

    Original Articles
    2239-2246

    Almost 3000 men who received a placebo in the Prostate Cancer Prevention Trial and who never had a prostate-specific antigen (PSA) level of more than 4.0 ng per milliliter during the seven years of the trial underwent a prostate biopsy at the end of the study. Biopsy revealed prostate cancer in 449 men (15 percent), 67 of whom had high-grade tumors.

    2247-2256

    In critically ill patients, both albumin and saline are commonly used for fluid resuscitation, but it is unknown whether one intravenous fluid is superior to the other. In this clinical trial in critically ill patients in the intensive care unit, the use of albumin and saline resulted in similar outcomes at 28 days.

    2257-2264

    Chronic thromboembolic pulmonary hypertension is believed to be rare after an episode of acute pulmonary embolism. This study showed that the incidence of this serious complication was nearly 4 percent — substantially higher than previously reported — and was associated with previous pulmonary embolism, large perfusion defects, and an idiopathic presentation. Possible approaches to prevention are discussed.

    2265-2271

    Black patients with chronic hepatitis C have a higher prevalence of genotype 1 infection and a lower rate of response to treatment. In this prospective study of 100 black and 100 non-Hispanic white patients with chronic hepatitis C (98 percent genotype 1), black patients had a lower rate of response to treatment with peginterferon alfa-2b and ribavirin (19 percent vs. 52 percent, P<0.001).

    Review Article
    2272-2279

    This review explains our current understanding of the syndromes of defective glucose counterregulation and hypoglycemia unawareness in persons with diabetes. The physiologic defenses against hypoglycemia — the glucagon and epinephrine responses — are compromised in most people with type 1 diabetes and in many with advanced type 2 diabetes. In addition to hypoglycemia, exercise and sleep are causes of autonomic failure that must be recognized and require changes in the management of diabetes.

    Images in Clinical Medicine
    2280
    • Free Full Text

    A 68-year-old woman with diabetes mellitus that was treated with insulin was hospitalized because of abdominal pain and vomiting. She had been treated empirically for a urinary tract infection with trimethoprim–sulfamethoxazole for five days before ...

    e20
    • Free Full Text

    A man and his fiancée had pruritus of two months' duration. They had similar skin lesions.

    Case Records of the Massachusetts General Hospital
    2281-2290

    A woman who had recently fractured her ankle said she had chest pain and then collapsed at home. She had no palpable pulse but was resuscitated and taken to the hospital; additional episodes of pulseless electrical activity occurred. An electrocardiogram showed a rate of 56, atrioventricular dissociation, and a right bundle-branch block. A bedside echocardiogram showed no pericardial tamponade. Despite aggressive resuscitation, her blood pressure and oxygen saturation remained low. A therapeutic procedure was performed.

    Editorials
    2292-2294

    Prostate cancer is the second leading cause of death from cancer among men in the United States. In the era before prostate-specific antigen (PSA) screening, most prostate cancers were identified at a stage (T2 or T3) that could not be cured. Today, with ...

    2294-2296

    The Saline versus Albumin Fluid Evaluation (SAFE) Study, reported in this issue of the Journal, 1 heralds a new era in critical care marked by the large, simple, randomized trial popularized by cardiologists. In a study of fluid resuscitation involving ...

    Legal Issues in Medicine
    2297-2301

    The author discusses the legal and ethical issues raised by the 2003 Supreme Court decision in the case of former dentist Charles Sell. The case focused on the legality of the forcible administration of psychiatric medication for the purpose of making a defendant competent to stand trial. The Court ruled that when certain criteria were met, a judge could order involuntary medication to restore competence. The Court, however, did not permit the forcible treatment of Sell, because these criteria had not been met.

    Clinical Implications of Basic Research
    2302-2304

    Targeting the collagen gene in bone mesenchymal stem cells can prevent the synthesis of mutant collagen and therefore represents a potential strategy for the treatment of diseases such as osteogenesis imperfecta.

    Correspondence
    2305-2306

    To the Editor: In their article about excision margins for melanoma, Thomas et al. (Feb. 19 issue)1 conclude that a 3-cm margin of excision, as compared with a 1-cm margin, is associated with reduced locoregional recurrences. But is a reduction in ...

    2306-2308

    To the Editor: Shane et al. (Feb. 19 issue)1 found minimal differences between the benefits conferred by alendronate and those conferred by calcitriol, and the authors speculated (as did Lindsay, in an accompanying Perspective article2) that combination ...

    2308-2310

    To the Editor: Celli and colleagues (March 4 issue)1 propose the use of a new index (the BODE index) that has excellent predictive power with regard to outcome in chronic obstructive pulmonary disease (COPD). The BODE index combines four variables: the ...

    2310-2312

    To the Editor: In their article on pericardial constriction, Sagristà-Sauleda et al. (Jan. 29 issue)1 note the critical contribution of the visceral layer of the pericardium to the pathogenesis of constrictive pericarditis. We fully agree with this point ...

    2313-2314

    To the Editor: The medical mystery in the April 1 issue1 involved a 23-year-old Peace Corps volunteer in Gambia. Painless ulcers developed on his lower legs (Figure 1A) and did not respond to local or systemic antimicrobial therapy.

    A slit-skin smear ...

    2314

    To the Editor: Sheridan et al. (Feb. 19 issue)1 fail to consider that carbonaceous sputum, confusion, agitation, dyspnea, and lactic acidosis in their burned patient are all signs of potential cyanide poisoning from smoke inhalation. This oversight is ...

    2315-2316

    To the Editor: Twenty-four-hour ambulatory blood-pressure monitoring is used to differentiate so-called white-coat hypertension from more prolonged and frequent hypertension.1,2 We describe a patient in whom the monitoring device itself was instrumental ...

    Book Reviews
    2317

    Wheezing, an extremely common symptom in young children, is a major diagnostic and therapeutic challenge for the pediatrician. The underlying causes are diverse, and knowledge about asthma in older children and adults cannot be extrapolated to young ...

    2317-2318

    As a consequence of the steep worldwide rise in obesity in children and adolescents, type 2 diabetes, once rarely seen in this age group, has emerged and is changing the face of pediatric diabetology. One dire prediction from the Centers for Disease ...

    2318

    This necessary and long-overdue textbook on allergic disorders in infants and children covers a wide range of topics, thus ensuring a good overview of the entire field. It covers food allergy extensively in nine well-written chapters, whose topics range ...

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