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July 28, 2005  Vol. 353 No. 4

Perspective
329-331

    Drs. Alexi Wright and Ingrid Katz describe a small revolution in patient safety that is taking place in the basement of their hospital. Bar coding is the latest technology designed to improve patient safety at a time when hospitals are under increased ...

    331-333

    The Food and Drug Administration has approved an implantable device that can store the medical identifier of a patient. Last December, one of these chips was placed in the right upper arm of the author, Dr. John Halamka.

    333-335
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    The father of an infant in rural Africa with fever buys malaria medicine, but a day later, the baby is dead. Kenneth Arrow, Helen Gelband, and Dean Jamison write that the outcome has little to do with the curability of the disease and everything to do ...

    335-337
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    Drs. Alan Magill and Claire Panosian describe a scenario in which a blood smear from a traveler or a U.S. soldier recently returned from Africa shows intraerythrocytic rings of P. falciparum. Neither intravenous quinine nor oral, rectal, or intravenous ...

    337-339

    How plausible, Dr. Wallace Sampson asks, are claims that echinacea, or purple coneflower, a perennial that is native to North America, is an effective treatment for viral respiratory disease?

    Original Articles
    341-348
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    Either placebo or a preparation of chemically defined extracts from Echinacea angustifolia root was administered to 399 volunteers before or after inoculation with rhinovirus. These rigorously controlled studies found no evidence that echinacea is effective in treating or preventing the common cold.

    349-361

    In this large, retrospective cohort study of patients who underwent major noncardiac surgery, perioperative beta-blockade was associated with a significantly reduced risk of death in the hospital among those who were at high risk but not among those at low risk. These data support recommendations for wider use of perioperative beta-blockade in high-risk patients and need to be confirmed in a large randomized trial.

    362-368

    In a man with Crohn's disease who was treated with natalizumab and subsequently died, reexamination showed that the fatal lesion was progressive multifocal leukoencephalopathy and not an astrocytoma. Analysis of serial serum specimens showed that JC virus first appeared about three months after the initiation of natalizumab therapy.

    369-374

    A 46-year-old woman with multiple sclerosis died from progressive multifocal leukoencephalopathy after receiving 37 doses of natalizumab plus interferon beta-1a as part of a clinical trial. At autopsy, there were diffuse macroscopic and microscopic PML lesions. JC virus was identified in cerebrospinal fluid before death and in brain tissue at autopsy. There was extensive necrosis and cavitation, with no inflammatory response.

    375-381
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    Progressive multifocal leukoencephalopathy developed in a man with multiple sclerosis while he was receiving interferon beta-1a and natalizumab. Quadriparesis, global aphasia, and minimal responsiveness ensued. Three months after natalizumab was stopped and after receiving cytarabine, he became alert and communicative, though he had continued neurologic disabilities.

    Special Article
    382-391
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    With data from the 2000 and 2001 National Health Interview Surveys, the authors estimate that 6.6 percent of children in the United States had been uninsured for the previous 12 months and an additional 7.7 percent had had insurance for only part of the year. Children who had been uninsured for all or part of the year were much more likely to go without needed medical care than were children who had continuous coverage.

    Clinical Practice
    392-399

      A 37-year-old woman presents with a two-week history of severe neck pain radiating to her left shoulder girdle and extending to the arm, forearm, and dorsum of the hand. Physical examination reveals weakness of her left triceps, finger extensors, and wrist flexors, as well as hypoesthesia of the third digit and a diminished triceps reflex. How should her case be managed?

      Images in Clinical Medicine
      400

      A 28-year-old Asian woman presented with pyrexia of unknown origin, oral and genital ulcers, and hemoptysis. A chest radiograph showed bilateral central hilar opacities (Panel A, arrows). A computed tomographic scan of the chest showed bilateral pulmonary-...

      e4

      This woman with a history of atrial fibrillation presented with an acute onset of severe abdominal pain. A scan of the abdominal area was performed after the administration of contrast material.

      Case Records of the Massachusetts General Hospital
      401-410

        A 57-year-old man with chronic active HBV infection was found to have a mass in the liver on routine screening. The results of a fine-needle aspiration biopsy suggested hepatocellular carcinoma. A multidisciplinary group discusses pathophysiology and management.

        Editorials
        412-414

          Perioperative myocardial infarction is a major cause of complications and death among patients undergoing noncardiac surgery.1 Annually in the United States, approximately 27 million patients are given anesthesia for surgical procedures; of these, ...

          414-416

          In this issue of the Journal, there are reports describing in detail three patients in whom progressive multifocal leukoencephalopathy (PML) developed during treatment with natalizumab, a humanized monoclonal antibody against α4 integrins.13 These ...

          417

            In clinical trials, the term “patients at risk” refers to the altruistic people who volunteer to participate in studies of novel treatments. In this issue of the Journal, three reports13 provide details about patients who were participating in trials ...

            418-419

            Nearly 15 percent of children in the United States are inadequately insured because they lack health insurance for all or part of the year. In this issue of the Journal, Olson and colleagues1 describe the potent effect of inadequate insurance coverage on ...

            Correspondence
            420-422

            To the Editor: In his review article (April 14 issue), Baird1 states that prescribing “chloroquine . . . in any setting, except one in which its effectiveness has recently been demonstrated, should be considered irresponsible.” As physicians who have ...

            422-423

            To the Editor: Falsey et al. (April 28 issue), in their report on respiratory syncytial virus (RSV) infection in elderly and high-risk adults,1 claim that “the symptoms and signs of RSV infection and those of influenza were not substantially different” ...

            424-427

            To the Editor: Boushey et al. (April 14 issue)1 report that regularly scheduled treatment with budesonide for mild persistent asthma has no significant advantage over intermittent short-course treatment. We compared data from a large pediatric survey of ...

            427-428

            To the Editor: Almond et al. (April 14 issue)1 excluded an important variable in their assessment of hyponatremia in marathon runners. Excess fluid intake is clearly a contributor to low serum sodium concentrations,2 but numerous long-distance runners in ...

            429-430

            To the Editor: In his review of inflammation, atherosclerosis, and coronary artery disease, Hansson (April 21 issue)1 focuses on T cells, macrophages, and mast cells as the cellular components of the immune system that play a key role in ischemic heart ...

            430

            To the Editor: I am extremely disturbed by the implications of Esmail's comments in his Perspective article on the case of Harold Shipman (May 5 issue)1: Esmail calls for a more questioning attitude toward doctors and better systems for monitoring their ...

            430-432

            To the Editor: The medical mystery in the June 2 issue1 involved a 49-year-old man who reported fatigue, arthralgia, and headache, along with a two-day history of chest pain; an electrocardiogram (Figure 1) had been obtained. The patient was ...

            432-433

            The Brief Reports on natalizumab were referred to Biogen Idec, the manufacturer, which offers the following response: After learning of one confirmed and one suspected case of progressive multifocal leukoencephalopathy (PML) in patients treated with ...

            Book Reviews
            434-435

            American medicine increasingly reflects the face of elder care. The proportion of the population over the age of 65 increased throughout the 20th century, and it will increase markedly over the next two decades. Geriatric patients are the largest group of ...

            435-436

            In her first book, Singular Intimacies: Becoming a Doctor at Bellevue (Boston: Beacon Press, 2003), Danielle Ofri describes how it was to be a medical student at Bellevue Hospital in New York. Now, in Incidental Findings, Ofri tells how it is to be an ...

            436
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            This well-organized and clearly written book provides a fascinating inside look at the development of Deaf culture. As noted in the introduction to the book, the authors use the convention of capitalizing Deaf when referring to members of a distinct ...