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January 22, 2004  Vol. 350 No. 4

Perspective
323-324

Sexual reproduction requires three types of differentiation: gonadal for the production of gametes, genital for the conveyance of gametes to a point of fertilization, and behavioral for the urge to behave sexually. Two articles in this issue of the ...

324-327

Naturally occurring poxvirus infections affect humans and many species of animals and insects. Smallpox, the dreaded disease caused by the only human-specific orthopoxvirus pathogen, variola, was successfully eradicated in the last century by the ...

327-330

The National Institutes of Health (NIH) is widely regarded as the world's premier biomedical research institution. The doubling of the NIH budget over the past decade reflects the trust that the American people place in this federal government agency and ...

330-332

For at least 25 years, states have served as laboratories for health care reform initiatives, advancing strategies that have later been enacted by the federal government. In the 1970s, Hawaii led the way when it required most employers to provide health ...

Original Articles
333-341

Sparse outcome data exist for genetic males who are assigned female sex at birth to overcome severe phallic inadequacy occurring in cloacal exstrophy, a rare, complex pelvic defect. This article reports the subsequent sexual identity of 16 genetic males, 14 of whom were assigned to female sex soon after birth. Eight of 14 subjects assigned to female sex declared themselves male over time; the 2 raised as males remained so.

342-350

In June 2003, monkeypox was diagnosed in several patients in the midwestern United States who presented with fever, sweats, skin lesions, and lymphadenopathy. This investigation describes the initial 11 patients in the outbreak, all of whom had contact with ill pet prairie dogs from the same distributor.

351-360
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This large international trial, conducted in 33 countries, showed that postoperative cisplatin-based chemotherapy improved overall survival among patients with completely resected non–small-cell lung cancer. The benefit was small but statistically significant.

361-366

A 21-year-old student from New Hampshire presented with two tender, 2-cm nodules that developed after she became febrile during a stay in the Republic of Congo, where she had cared for chimpanzees. The diagnosis of tanapox was established with the use of electron microscopy and polymerase-chain-reaction analysis of tissue samples. The poxvirus infection is endemic to equatorial Africa and has been diagnosed in North America only rarely. It must be distinguished from smallpox, monkeypox, and several other infections that represent major public health problems.

Review Articles
367-378

This review elucidates the molecular mechanisms of sex determination and sex differentiation with examples from embryology, animal models, and clinical syndromes. Sex reversal, defective masculinization, pseudohermaphroditism, and syndromes involving the gonads and other organs are some of the clinical problems discussed.

379-392

Despite years of research, the five-year survival rate among patients with lung cancer is a mere 14 percent. Lung cancer is divided into two major types — non–small-cell lung cancer and the more aggressive small-cell lung cancer. This review considers the treatment of each type in the framework of multidisciplinary management and recent clinical trials.

Images in Clinical Medicine
393
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A 17-day-old black neonate presented with ambiguous genitalia. A sharp line separated hypopigmented skin on the left side of the abdomen from normally pigmented skin on the right side. A pendulous, wrinkled labioscrotal fold contained a gonad on the right ...

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The clinical condition deteriorated rapidly in this 53-year-old woman treated for ulcerative colitis.

Case Records of the Massachusetts General Hospital
394-402

Presentation of Case

A 57-year-old man came to this hospital for bladder-sparing treatment of invasive transitional-cell carcinoma of the bladder.

He had had a slight burning sensation on urination for six months, and then he observed gross hematuria. ...

Editorial
404-405

In patients with cancer who undergo surgery with curative intent but who are known to be at risk for a recurrence, postoperative chemotherapy increases the chance of a cure. The basis of this adjuvant therapy rests on demonstrations in animal models that ...

Sounding Board
406-410

    Payment incentives as a part of physicians' compensation are commonplace but have been aimed predominantly at restricting expensive services. A novel concept is the payment of physicians for providing high-quality care, on the basis of explicit measures of quality. Such a system has recently been adopted in the United Kingdom. The authors believe that the idea is worth pursuing, but they point out important impediments and challenges to its successful implementation.

    Clinical Implications of Basic Research
    411-412

      A recent study shows that crystalline uric acid acts as an immunologic adjuvant by triggering the maturation of dendritic cells, which can then prime the T-cell response.

      Correspondence
      413-414

      To the Editor: Although the randomized trial by Moses et al. (Oct. 2 issue)1 shows a benefit of sirolimus-eluting stents as compared with the same bare-metal stent without drug elution (Bx Velocity), the effect on clinical restenosis is overstated. With ...

      414-415

      To the Editor: Although the conclusion of the article by Sawaya et al. on the interval between cervical-cancer screenings (Oct. 16 issue)1 may be correct, they failed to note one of the large biases. They presumed the same sensitivity and specificity for ...

      415-416

      To the Editor: In his article on schizophrenia, Freedman (Oct. 30 issue)1 may have understated the relative benefits of clozapine, which has proven advantages over other antipsychotic drugs in mitigating refractory positive and negative symptoms,2 ...

      416-417

      To the Editor: In discussing the case of a girl with hepatosplenomegaly and pain in the thigh (June 26 issue),1 Larsen arrived at the diagnosis of Gaucher's disease, and he correctly points out that Gaucher's disease can be diagnosed by assaying ...

      417

      To the Editor: Wiesenfeld and Guido describe an unusual case of intraabdominal pregnancy occurring within a few weeks of hysterectomy (Oct. 16 issue).1 In postulating a possible mechanism to account for the timing of conception and implantation, they ...

      418-419

      To the Editor: In February 1965, a 19-year-old man presented with an extranodal natural-killer-cell–T-cell lymphoma, nasal type, affecting the nasal cavity. One of us made the diagnosis of “granuloma gangraenescens,” which was considered to be an ...

      419-420

      To the Editor: Sickness and health figure prominently in the fiction of Thomas Mann (1875–1955). Whereas his preoccupation with disease may at first seem distasteful to the lay reader,1 it enhances his appeal for the reader who is a physician.2 Mann's ...

      Book Reviews
      421-422

      This unique and superbly accomplished contribution to the understanding of race, ethnic background, class, and opportunity in medicine was written before the Supreme Court's landmark decision in June 2003 preserving affirmative action at the University of ...

      422

      A revolution is sweeping the field of biology that holds that the influences of nature and nurture are so inextricably linked that it is difficult to speak of them as distinct forces that shape who we are. We now know that our environment can change us ...

      423
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      Most books that come my way these days end up on a shelf gathering dust and are seldom if ever consulted after an initial inspection. For many clinicians and basic scientists, the preferred method of retrieving information and reference data is with the ...

      Correction
      423

      Subcutaneous Fondaparinux versus Intravenous Unfractionated Heparin in the Initial Treatment of Pulmonary Embolism Original Article, N Engl J Med 2003:349;1695-1702.. On page 1702, in the Appendix, the list of participating investigators should have ...