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June 16, 2005  Vol. 352 No. 24

Perspective
2471-2473

R. Alta Charo describes how physicians, nurses, and pharmacists are increasingly claiming a right to the autonomy not only to refuse to provide services they find objectionable, but even to refuse to refer patients to another provider and, more recently, ...

2473-2476

It has been known for some time that suicide rates among doctors are higher than those in the general population, writes Dr. Eva Schernhammer. The gap in suicide rates evidently begins as early as medical school, where overall suicide rates are higher ...

Original Articles
2477-2486

Consensus is lacking as to whether routine screening and treatment for gestational diabetes mellitus is warranted. This large randomized trial of the treatment of gestational diabetes demonstrated that serious perinatal complications were significantly less common among the offspring of women who received dietary advice, blood glucose monitoring, and insulin therapy as needed to maintain glycemic control than among the offspring of women who received routine care.

2487-2498

Bortezomib, an inhibitor of proteasomes (sites of protein degradation in cells), has activity against advanced multiple myeloma. This study compared bortezomib with high-dose dexamethasone relatively soon after a relapse of multiple myeloma had occurred with other treatments. Bortezomib was superior to dexamethasone in all end points and prolonged overall survival.

2499-2507

In this six-week randomized trial of MLN02 — a humanized antibody to the α4β7 integrin — in patients with ulcerative colitis, MLN02 was associated with higher rates of remission than was placebo (33 percent in the group receiving 0.5 mg per kilogram, 32 percent in the group receiving 2.0 mg per kilogram, and 14 percent in the placebo group; overall P=0.03). These preliminary data suggest that blockade of the α4β7 integrin with a humanized antibody may be an effective therapy for ulcerative colitis.

2508-2514
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A 15-year-old girl presented with clinical rabies one month after being bitten by a bat. She was treated with ribavirin and amantadine plus agents to induce coma and suppress bursts of activity on electroencephalography. She survived and after five months was alert and communicative, although with generalized choreoathetosis, dysarthria, and an unsteady gait.

Special Article
2515-2523

This study compared results of household surveys conducted in the United States from 1990 to 1992 and from 2001 to 2003 and found no change in the prevalence of mental disorders during that period. The prevalence of treatment increased, but most respondents with mental disorders still did not receive treatment between 2001 and 2003.

Clinical Practice
2524-2533

A 47-year-old man reports a six-month history of intermittent chest discomfort while playing squash. He describes lower substernal tightness with numbness of the left upper arm only during exertion. He does not smoke. His father died suddenly at the age of 49 years. His blood pressure is 138/84 mm Hg. The level of total cholesterol is 261 mg per deciliter, low-density lipoprotein cholesterol 172 mg per deciliter, and high-density lipoprotein cholesterol 50 mg per deciliter, and the triglyceride level is 113 mg per deciliter. An exercise test is positive, with pain and 1.5 mm of horizontal ST-segment depression at stage 4 of the Bruce protocol. How should the patient's case be managed?

Images in Clinical Medicine
2534
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A 62-year-old woman had progression of multiple myeloma despite many therapies, including an autologous hematopoietic stem-cell transplantation. Infusions of bortezomib (1.3 mg per square meter of body-surface area) were administered as an intravenous ...

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This five-year-old girl had an episode of respiratory distress with collapse of the right lung. During bronchoscopy, multiple tracheal papillomas were seen.

Case Records of the Massachusetts General Hospital
2535-2542

A 45-year-old woman noted a mass in her lower abdomen that was intermittently painful. An examination disclosed a slightly tender mass, 4 cm in diameter, on the right side of the lower abdomen. Imaging studies showed a solid mass in the right lower abdominal wall. A diagnostic procedure was performed.

Editorials
2544-2546

Gestational diabetes mellitus, broadly defined as carbohydrate intolerance beginning or first recognized during pregnancy,1,2 was originally described decades ago and has since been the subject of extensive research. Yet the most recent guidelines of the ...

2546-2548

Multiple myeloma is a neoplastic plasma-cell dyscrasia that will cause more than 11,000 deaths in 2005 in the United States alone.1 The usefulness of the many therapies for multiple myeloma is limited, and virtually all patients eventually die from the ...

2549-2550

Worldwide, some 55,000 people die every year from rabies, mostly in Asian and African countries where canine rabies is endemic. Children are frequently the victims of rabies. In the United States, indigenous cases of rabies in humans usually occur through ...

Correspondence
2551-2552

To the Editor: Srinivasan and colleagues (March 17 issue)1 report the transmission of rabies virus from an organ donor to four recipients. Three recipients had neurologic deterioration and encephalitis and died about five weeks after transplantation; one ...

2553

To the Editor: Arad et al. (Jan. 27 issue)1 report that LAMP2 mutations (Danon's disease) are an important cause of hypertrophic cardiomyopathy. That one of their patients had an “adolescent response to cardiac disease,” however, strangely misses the ...

2553-2555
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To the Editor: Okie's Perspective article (March 17 issue)1 on the Food and Drug Administration (FDA) covers important ground but misses a key issue. No drug is absolutely safe; drug safety is always assessed in relation to the disease being treated. We ...

2555-2557
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To the Editor: Preston's editorial (March 17 issue)1 on obesity and its influence on longevity, which accompanies the report by Olshansky et al.,2 focused my thinking on morbidity versus mortality. Preston wrote that “the current life expectancy at birth ...

2557-2559

To the Editor: Dual infection with different strains of HIV type 1 (HIV-1) is reported with increasing frequency, attributed mostly to coinfection at the time of the primary infection. However, some patients were superinfected with a second virus after ...

Book Reviews
2560

In the relatively brief time since September 11, 2001, legions of articles have been published, grants submitted, journals launched, and textbooks edited on the subject of terrorism involving biologic agents. Much of the work has focused on the agents ...

2561

Hardly a week passes without a new report describing an association between vascular risk factors and dementia. With our rapidly growing elderly population, dementia is becoming an increasing public health burden. This book is an update on the link ...

2562

The recognition that modest changes in temperature may modulate the outcome after global or focal cerebral ischemia, or both, has led to the use of mild-to-moderate hypothermia to reduce reperfusion injury in diverse clinical settings — for example, after ...

2562-2563

This book is an excellent guide for any physician who transfuses blood, because it applies clinically relevant information to the decision to transfuse blood components. The book provides guidance for the clinical practice of blood-component therapy, and ...

Corrections
2563
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What Ails the FDA? Perspective, N Engl J Med 2005:352;1063-1066.. On page 1064, in the last paragraph in the left-hand column, line 3 should have read, “For new molecular entities (drugs whose active ingredient has never before been approved in the United ...

2563

Therapy for Colorectal Cancer Correspondence, N Engl J Med 2005:352;1820-1822.. In the letter by Kountouras et al., lines 3 through 7 should have read, “Regional infusion of interleukin-2 or interferon gamma through the hepatic artery, combined with ...