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June 10, 2004  Vol. 350 No. 24

Perspective
2435-2437

In the U.S. physician workforce there is an ever-increasing dependence on international medical graduates. Dr. Graham McMahon discusses the implications.

2438-2440

In non-Western countries, deaths due to cardiovascular disease tend to occur a decade or two earlier than in Western countries. Dr. K. Srinath Reddy explains the trends.

Original Articles
2441-2451

In this factorial trial, the prophylactic use of dexamethasone, droperidol, ondansetron, and total intravenous anesthesia each resulted in similar reductions in the risk of postoperative nausea and vomiting. In this population of patients at high risk for nausea and vomiting, the rates of nausea and vomiting were 52 percent in those given no antiemetic intervention and 37 percent, 28 percent, and 22 percent in those given one, two, and three interventions, respectively.

2452-2460

About one in six patients who are extubated after intubation for respiratory failure require reintubation. In this multicenter study, patients (about 10 percent of whom had chronic obstructive pulmonary disease) who met predefined criteria for recurrent respiratory failure within 48 hours after extubation were randomly assigned to receive medical therapy (followed by reintubation, if needed) or noninvasive ventilation by face mask (also followed by reintubation, if needed). There was no difference in the rate of reintubation between the groups. The rate of death in the intensive care unit was higher in the noninvasive-ventilation group than in the standard-therapy group.

2461-2470

Nasopharyngeal carcinoma is intimately associated with Epstein–Barr virus (EBV) infection. This study shows that measurements of EBV DNA in plasma can be useful in monitoring patients with nasopharyngeal carcinoma.

2471-2480

In this phase 1–2 trial, 52 infants infected with human immunodeficiency virus type 1 (HIV-1) were assigned to treatment with one of three combination antiviral regimens. Effective suppression of HIV-1 was associated with the initiation of treatment at or before three months of age and with treatment with the regimen of stavudine, lamivudine, nevirapine, and nelfinavir as opposed to reverse-transcriptase inhibitors alone.

2481-2486

This Brief Report describes three patients with von Hippel–Lindau disease who had hearing loss due to a microscopic tumor of the endolymphatic sac. In two patients, the tumor cells contained a mutation in the von Hippel–Lindau gene. These cases show that radiologically undetectable endolymphatic-sac tumors can cause deafness in patients with von Hippel–Lindau disease.

Review Article
2487-2498
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Pneumocystis pneumonia remains the most prevalent opportunistic infection in patients infected with the human immunodeficiency virus. Molecular techniques have provided new insights into the complex cell biology of this fungus. The authors summarize advances that have resulted from studies of the cell biology, biochemistry, and genetics of pneumocystis in the past several years and provide recommendations for the diagnosis of pneumocystis pneumonia and for prophylaxis and treatment.

Images in Clinical Medicine
2499
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A 26-year-old man presented with blisters and erosions that had developed on his tongue over a 48-hour period (Panel A). The blisters had appeared primarily in his mouth, but several had also appeared on his face and trunk. There was no involvement of his ...

e22
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A 60-year-old man presented after a fall and minor trauma to the head.

Case Records of the Massachusetts General Hospital
2500-2509

A 61-year-old man with a five-month history of rectal bleeding was referred for the treatment of a low rectal adenocarcinoma. The diagnosis, staging, and management of low rectal adenocarcinoma are discussed.

Editorials
2511-2512

Despite the introduction of new antiemetic agents, short-acting anesthetics, and minimally invasive surgical techniques, the incidence of postoperative nausea and vomiting has remained largely unchanged over the past two decades.1 The high incidence of ...

2512-2515

Noninvasive mechanical ventilation has been used increasingly over the past decade in an effort to avoid endotracheal intubation and to accelerate the discontinuation of mechanical ventilation. Noninvasive ventilation as adjunctive therapy can be applied ...

Clinical Implications of Basic Research
2516-2517

Administering erythropoietin to rats with diabetic neuropathy prevents and partly reverses biochemical and physical deficits in nerve and muscle. Certain drawbacks limit the immediate applicability of this approach in patients.

Correspondence
2518-2520

To the Editor: The article by Contreras et al. (March 4 issue)1 on the treatment of proliferative lupus nephritis omitted some important issues. Only the median duration of treatment was provided, but the interquartile ranges would have been helpful, ...

2520-2521

To the Editor: Choi et al. (March 11 issue)1 studied diet in relation to gout but did not control for the use of aspirin or diuretics. These agents are used by a very large number of people. They raise uric acid levels, and they cause gout.

To the ...

2521-2522

To the Editor: We commend Gladwin et al. (Feb. 26 issue)1 on their large prospective study of pulmonary hypertension in the population of patients with sickle cell disease. The pathogenesis of pulmonary hypertension in sickle cell disease remains unclear ...

2522-2524
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To the Editor: In his review of cellulitis (Feb. 26 issue),1 Swartz does not stress the effect that the emergence of community-acquired methicillin-resistant Staphylococcus aureus has had on treatment strategies for a “usual case of cellulitis” at many ...

2524-2525
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To the Editor: We appreciate Schafer's concise approach to thrombocytosis (March 18 issue)1 but are less enthusiastic about promoting anagrelide as first-line therapy for patients with essential thrombocythemia. There have been no controlled trials of ...

2525-2526
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To the Editor: In a review article on diabetic retinopathy (Jan. 1 issue),1 Frank stated that the mechanism for the effect of panretinal, or scatter, laser treatment on diabetic retinopathy is unclear. Two references, from 1978 and 1982, were cited to ...

2526-2527

To the Editor: McCormack and Rabbitts (Feb. 26 issue)1 discuss the role of activation of the T-cell oncogene LMO2 in inducing clonal T-cell proliferation in two patients after gene therapy for X-linked severe combined immunodeficiency (SCID), a condition ...

2527-2528

To the Editor: As illustrated in Case 40-2003 (Dec. 25 issue),1 it is often difficult to find the source of infection in a child who has tuberculosis. In 2001, we cared for a five-month-old girl who presented with miliary tuberculosis and multiple ...

Book Reviews
2529-2530

Both Mark Twain and his alter ego, Samuel Langhorne Clemens (1835–1910), had opinions about everything; they certainly had a lot to say about American medicine as it was practiced from the mid-19th century into the early 20th century.

(Figure)

In this ...

2530-2531

Theobald Smith is best remembered today for the discovery in the 1880s, with Daniel E. Salmon, of the organisms that cause Texas cattle fever and hog cholera. As this lucidly written biography argues, there was a good deal more to Smith than that: he was ...

Correction
2531

Soluble TREM-1 and the Diagnosis of Pneumonia Correspondence, N Engl J Med 2004:350;1904-1905.. On page 1904, in the right-hand column, the names of the authors should have been listed as Hugues Georges, M.D., Olivier Leroy, M.D., and Benoit Guery, M.D., ...