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December 8, 2005  Vol. 353 No. 23

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Perspective
2421-2423

Dr. Julie Parsonnet writes that the clinical and scientific importance of H. pylori has exceeded everyone's wildest expectations. Yet the most important legacy of Marshall and Warren's Nobel Prize may have less to do with science than with the inspiration ...

2423-2426

Robert Koch was honored, 100 years ago, with the Nobel Prize in Physiology or Medicine. Stefan Kaufmann describes Koch's achievements in bacteriology.

2426-2428

When Robert Koch announced that he had discovered a “remedy for tuberculosis,” it made news around the world. Dr. Howard Markel writes that within a day after analyzing the mass of clinical data, Arthur Conan Doyle came to a startling conclusion: “The ...

2428-2431

What all of Roueché's stories had in common were mysterious illnesses or deaths, the causes of which were elucidated by clever detective work. Dr. Barron Lerner writes that as Roueché began to write more about clinical medicine, he broke new ground.

Original Articles
2433-2441

There have been increases in both the rate and the severity of C. difficile–associated disease. This report details the emergence of an epidemic strain, BI/NAP1, in eight health care facilities over the past five years. This strain is associated with increased resistance to fluoroquinolone as well as the presence of a novel toxin known as binary toxin CDT.

2442-2449

In the first half of 2003, the number of C. difficile infections (22.5 per 1000 admissions) increased in Quebec, Canada. This outbreak was associated with fluoroquinolone and cephalosporin use as well as an increase in C. difficile–associated mortality (to 6.9 percent) and colectomy (to 1.9 percent). The outbreak strain was found to have enhanced virulence, as suggested by the presence of binary toxin genes and the partial deletion of a toxin-repressor gene.

2450-2461

In this randomized trial of patients with elevated uric acid levels and gout, febuxostat, a new nonpurine selective inhibitor of xanthine oxidase, was compared with allopurinol. The incidence of gout flares was similar in patients treated with allopurinol and febuxostat. Both doses of febuxostat (80 and 120 mg) were more effective than 300 mg of allopurinol in lowering uric acid levels.

2462-2476

Infliximab is a monoclonal antibody against tumor necrosis factor α and is effective in the treatment of Crohn's disease. This article reports the results of two randomized, placebo-controlled trials of infliximab in patients who had active ulcerative colitis despite conventional therapy. Infliximab was more effective than placebo in achieving and maintaining clinical response and remission.

Review Article
2477-2490

    In the United States, renal cancer is the 7th leading malignant condition in men and the 12th in women, accounting for 2.6 percent of all cancers. This article discusses the evolving presentation, understanding, and treatment of this disease.

    Images in Clinical Medicine
    2491

    A 75-year-old man with peripheral vascular disease, chronic obstructive pulmonary disease, and diabetes mellitus presented with gangrene of the right fourth toe and underwent tarsal–metatarsal amputation to manage the progression of gangrene, followed by ...

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    This 80-year-old man was referred to the rheumatology clinic. He had received colchicine and urate-lowering drugs intermittently over several years.

    Case Records of the Massachusetts General Hospital
    2492-2501

    A 35-year-old man screamed during sleep and became unresponsive. Personnel from emergency medical services found him in ventricular fibrillation; normal rhythm was restored, but he did not regain consciousness. An electrocardiographic examination in the emergency department showed ST-segment elevation, and there was evidence of pseudoephedrine in the serum. The results of cardiac catheterization were normal. A diagnostic procedure was performed.

    Editorials
    2503-2505

    Recent experience with influenza, the severe acute respiratory syndrome (also known as SARS), avian influenza, and community-acquired methicillin-resistant Staphylococcus aureus has demonstrated how old pathogens can emerge with increased virulence and ...

    2505-2507

    Gout is a relatively common cause of legendary, severe pain as well as tophi, joint deformities, and nephropathy. Unlike most noninfectious diseases, frequently a pharmacologic “cure” for gout is attained. Shortcomings in the management of gout — due to ...

    Clinical Implications of Basic Research
    2508-2509

    A newly identified protein — heme carrier protein 1 — apparently mediates the uptake of cellular heme. Mutations impairing the activity of this protein might account, in part, for the broad spectrum of clinical severity observed in patients with genetic hemochromatosis.

    Correspondence
    2510-2511

    To the Editor: Wills et al. (Sept. 1 issue)1 recently described a study of three fluid solutions, including 6 percent dextran 70, for resuscitation of children with the dengue shock syndrome. The authors observed a high rate of allergic-type reactions (...

    2511-2513
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    To the Editor: Wilder-Smith and Schwartz (Sept. 1 issue)1 mention that serotypes of dengue virus are distinguishable by the plaque-reduction neutralization test.2 But they neglect to include this test in Table 2 of the article, which lists laboratory ...

    2513-2515

    To the Editor: The large observational study by Lindenauer et al. (July 28 issue)1 seems to confirm that the administration of beta-blockers improves the postoperative outcome of very high-risk patients undergoing major surgery. Owing to the ...

    2515

    To the Editor: We question the electrocardiographic findings in the case of dextrocardia presented by Yin and Mohamed in Images in Clinical Medicine (Sept. 1 issue).1 We agree that the reverse R-wave progression across the precordial leads, with the ...

    2516

    To the Editor: In Case 28-2005 (Sept. 15 issue),1 the authors describe a 42-year-old man who had a systemic necrotizing vasculitis secondary to the Churg–Strauss syndrome with rapidly progressive glomerulonephritis (with a serum creatinine level of 5.7 ...

    2516-2517

    To the Editor: Despite improvements in the management of type 1 diabetes mellitus, severe hypoglycemia is not rare among young patients. The incidence of severe hypoglycemia ranges from 0.02 to 0.07 case per patient–month, including episodic recurrence ...

    2517-2518

    To the Editor: An increasing number of patients with HIV infection and viral cirrhosis are receiving liver transplants; among such patients, short-term survival is similar to that among patients undergoing transplantation who do not have HIV infection.1 ...

    Book Reviews
    2519-2520

    The cornea is the major refractive element of the eye. Its perfect transparency depends on the order of its collagen fibrils and an avascularity determined by intrinsic vasogenic inhibitors. Hydration is regulated by a posterior endothelial layer; ...

    2520-2521

    Acid–Base Disorders and Their Treatment is the second work on this subject by Madias and Gennari after a nearly 20-year hiatus since their first book, Acid–Base (Boston: Little, Brown, 1982). These two collaborators were joined by Adrogué and Galla in ...

    2521-2522

    This book is one of the best, most thorough overviews published on dwarfism and related topics. What makes it unique is the combination of the personal experience of the author with dwarfism (her daughter was born with achondroplasia) and her professional ...

    2522

    Weighing in at close to 20 lb, this two-volume textbook is an excellent source of information concerning diagnostic and scientific aspects of dermatopathology. It should be no surprise that nearly 2000 pages would be required to cover the numerous ...

    Correction
    2523

    Sleep — A New Cardiovascular Frontier Editorial, N Engl J Med 2005:353;2070-2073.. On page 2071, in the left-hand column, lines 16 through 19 should have read, “. . . sudden death, death from heart failure, and cardiac transplantation occurred in 19 ...