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December 2, 2004  Vol. 351 No. 23

Perspective
2363-2365

Drs. Tran Tinh Hien, Menno de Jong, and Jeremy Farrar address the concern that currently circulating H5N1 viruses will evolve into a pandemic strain by adapting to humans through genetic mutation or reassortment with human influenza strains.

2365-2366

Dr. Thomas H. Lee describes how at his hospital, they were so far short of an adequate supply that they needed to be far more restrictive than the CDC guidelines permitted.

2367-2368

Hepatitis E virus is now commanding attention in regions of Sudan and Iraq. Once again, contaminated water is implicated. Suzanne U. Emerson and Dr. Robert H. Purcell discuss the omnipresence of Hepatitis E.

2369-2370

At the Fernald State School for the Feebleminded in Waltham, Massachusetts, Fred Boyce and hundreds of other children were subjected to systematic physical, sexual, and emotional abuse. Dr. Norman Fost writes about Boyce and The State Boys Rebellion by ...

2370-2372

In acute myeloid leukemia (AML), the most common type of acute leukemia in adults, there is clonal expansion and arrested maturation of myeloid precursor cells in the bone marrow, frequently resulting in granulocytopenia, thrombocytopenia, and anemia. The ...

Original Articles
2373-2383

In patients with heart failure, atrial fibrillation may exacerbate ventricular dysfunction and symptoms. In this study, catheter ablation was performed to restore sinus rhythm in patients with heart failure and refractory atrial fibrillation. The results show improvement in the left ventricular ejection fraction, symptoms, exercise capacity, and quality of life.

2384-2391

Patients with infrequent episodes of atrial fibrillation and only mild heart disease may not be good candidates for prophylactic antiarrhythmic therapy or radiofrequency ablation. This study shows that as-needed therapy with oral flecainide or propafenone is very effective in terminating acute episodes of atrial fibrillation outside the hospital, thus reducing the need for hospitalization and emergency room care. Although this approach is effective, it is applicable to only about 10 percent of patients with episodic atrial fibrillation.

2392-2402

In a multicenter trial comparing two approaches to in vitro fertilization among women under 36 years of age, the transfer of a single fresh embryo followed by the transfer of a single previously frozen embryo (if the first cycle was unsuccessful) resulted in a marked reduction in the rate of multiple gestations without a substantial decrease in the rate of live births.

2403-2407
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A father and two of his children were found to have acute myeloid leukemia (AML) and an identical germ-line mutation in the CEBPA gene. The product of this gene, C/EBPα, participates in the differentiation of early myeloid cells.

Clinical Practice
2408-2416

A 77-year-old woman with a history of hypertension treated with metoprolol presents for her annual examination. She reports no new symptoms. The examination is remarkable only for an irregular heart rate. Electrocardiographic testing reveals atrial fibrillation at an average rate of 75 beats per minute. She has no history of arrhythmia, coronary disease, valvular disease, diabetes, alcohol abuse, or transient ischemic attack or stroke. What should her physician advise?

Review Article
2417-2427

The epidemiology of acute gastrointestinal illness is complex. The relevant infectious agents may spread from person to person or they may be acquired from a common food or environmental source, often water, but also from animal exposure. This article examines direct human-to-human spread of acute gastrointestinal illness, defined as a syndrome of vomiting, diarrhea, or both that begins abruptly in otherwise healthy persons and is most often self-limited.

Images in Clinical Medicine
2428
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An 88-year-old man was admitted to the hospital with a sudden onset of shortness of breath. Deep venous thrombosis and pulmonary embolism were diagnosed. During an echocardiogram, a large cystic mass was incidentally detected in the liver. Computed ...

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In 1848, Phineas Gage, a construction foreman, triggered an explosion that propelled an iron shaft through his head. He regained consciousness within minutes.

Clinical Problem-Solving
2429-2434

    A 38-year-old woman presented to the emergency room for evaluation of shortness of breath and jaundice. The previous day, several hours after she had attended a wedding, a headache developed, she had mild dizziness, and she noticed that her urine was dark brown. The day after the wedding, she awoke with mild shortness of breath and yellow discoloration of her eyes and skin.

    Editorials
    2436-2437

    Not so long ago, medical research reports were published in medical journals, to be read and evaluated primarily by physicians. If patients ever learned anything about research studies, it was from their physicians. But patterns of communication have ...

    2437-2440

    Heart failure is often complicated by atrial fibrillation, and atrial fibrillation can exacerbate and in some cases cause heart failure. Adverse effects of atrial fibrillation include a loss of atrial contribution to ventricular filling, a nonphysiologic ...

    2440-2442

    Since its introduction in 1978,1 human in vitro fertilization has rapidly become one of the most successful and widely used techniques in the treatment of infertility. Worldwide, an estimated 1.2 million children have been born as a result of in vitro ...

    Sounding Board
    2443-2447

      The authors discuss the vaccine industry in the United States and explain why the nation is vulnerable to vaccine shortages. They describe the Institute of Medicine's proposal for a federal subsidy program to provide stronger incentives for companies to develop new vaccines and to manufacture existing ones.

      Correspondence
      2448-2450

      To the Editor: The data presented by Juurlink et al. (Aug. 5 issue)1 regarding hyperkalemia that was attributed to spironolactone do not justify the conclusion that the rate of admission for hyperkalemia increased. The authors identified “all hospital ...

      2450-2451

      To the Editor: In his excellent review, Palmer (Aug. 5 issue)1 discusses strategies for minimizing the incidence and degree of hyperkalemia in patients taking inhibitors of the renin–angiotensin–aldosterone system.2 One strategy he does not suggest is ...

      2451-2452

      To the Editor: Goldenberg et al. (Sept. 9 issue)1 report interesting data about the usefulness of the D-dimer test to predict outcomes in children after a first thromboembolic event. In children, 95 percent of venous thromboembolic events are secondary ...

      2452-2454

      To the Editor: Cristofanilli et al. (Aug. 19 issue)1 assume that the circulating epithelial cells detected by the CellSearch System are tumor cells. This may be the case in most of the blood samples examined, but a formal proof was not attempted. A ...

      2454-2455
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      To the Editor: Belmaker (July 29 issue)1 reviews the syndrome of bipolar disorder. The lifetime prevalence of bipolar disorders among patients in primary care and general medical settings is considerably higher2 than the approximately 1 percent ...

      2455-2456

      To the Editor: Although its purpose was to extol the use of video-capsule endoscopy, Case 24-2004 in the July 29 issue1 illustrates the greed for certainty that feeds the increasing costs of medical care. The pictures are educational, but an enteroclysis ...

      2456-2457

      To the Editor: In 1979, we reported the results of treating 19 patients who had acute myelogenous leukemia in first remission with intensive chemotherapy, radiation therapy, and transplantation of allogeneic marrow from HLA-identical siblings between ...

      Book Reviews
      2458-2459

      Public recognition of Alain Enthoven transcends his field. The emeritus Marriner S. Eccles Professor of Public and Private Management at Stanford University, Enthoven rose to fame as the architect of a health care strategy known as “managed competition.” ...

      2459

      The profession of medicine encompasses a wide variety of ways in which a physician can dedicate his or her life within the traditional areas of clinical practice, research, education, and administration. In this book, Jerome Kassirer, a former editor-in-...

      2460-2461

      Despite the past century's fascination with measuring every facet of life, little is known about the “middle years.” After all, living into middle age is a relatively recent phenomenon in human history. A white man born in 1900 in the United States had an ...

      Corrections
      2461

      A Randomized Trial of Exemestane after Two to Three Years of Tamoxifen Therapy in Postmenopausal Women with Primary Breast Cancer Original Article, N Engl J Med 2004:350;1081-1092.. On page 1083, in Figure 1, the number of patients who were assigned to ...

      2461

      Management of Cutaneous Melanoma Review Article, N Engl J Med 2004:351;998-1012.. On page 1009, in the left-hand column, second full paragraph, line 5 should have cited reference number 91, rather than number 90, as printed. We regret the error.

      2461

      Laboratory Reference Values Case Records of the Massachusetts General Hospital, N Engl J Med 2004:351;1548-1563.. On page 1560, in the continuation of the table entitled Metabolic and Endocrine Tests, under the column heading SI Units, the range of values ...

      2461

      Review of Myelin Biology and Disorders Book Review, N Engl J Med 2004:351;1806-1807.. On page 1807, line 4 of the left-hand column should have read “Steve Goldman,” rather than “Jim Goldman,” as printed. We regret the error.