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June 7, 2007  Vol. 356 No. 23

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Perspective
2341-2343

Patient rights governing research on almost all available human embryonic stem-cell lines have now been reexamined by the U.S. Patent and Trademark Office. Fiona Murray discusses the important lessons that this case provides about universities' use of ...

2343-2346

On May 2, the FDA ordered that all antidepressant medications carry an expanded black-box warning incorporating information about an increased risk of suicidal symptoms in young adults 18 to 24 years of age. Dr. Richard Friedman and Andrew Leon write that ...

2346-2347

The spectrum of clinical illness varies with the bartonella species causing the infection, but even among patients infected with the same species, the clinical features can be surprisingly variable. Dr. Gary Wormser writes that meticulous bedside-to-bench ...

Original Articles
2349-2360

Amyloid A (AA) amyloidosis, a complication of chronic inflammatory conditions, develops when proteolytic fragments of serum amyloid A protein are deposited in tissues as amyloid fibrils. This placebo-controlled trial investigated the effect of eprodisate, a small molecule that inhibits amyloid fibril polymerization and tissue deposition in patients with renal AA amyloidosis. As compared with placebo, the drug slowed a decline in renal function. Eprodisate is a member of a new class of compounds that interfere with interactions between amyloidogenic proteins and glycosaminoglycans.

2361-2371
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This study evaluated clinical features, organ function, and survival in a group of 374 patients with amyloid A amyloidosis. Median survival after diagnosis was 133 months; renal dysfunction was the predominant disease manifestation. Mortality, amyloid burden, and renal prognosis all significantly correlated with the serum amyloid A concentration during follow-up.

2372-2380

This retrospective analysis assessed the efficacy of adjuvant mitotane treatment in prolonging recurrence-free survival in adrenocortical cancer, which carries a high risk of recurrence. Survival was significantly prolonged in patients receiving mitotane, as compared with those who did not. Adjuvant mitotane may prolong recurrence-free survival in patients with radically resected adrenocortical carcinoma.

2381-2387

A 43-year-old woman returned from a trip to Peru and had fever, rash, and splenomegaly. A new bartonella species has been identified as the causative agent.

Special Article
2388-2398

Mortality due to coronary heart disease has declined substantially in the United States in recent decades. A previously validated model was used to estimate the roles of specific cardiac treatments and changes in risk factors in this decline. Approximately 47% of the decrease in mortality was attributed to therapeutic interventions and 44% to changes in risk factors.

Review Article
2399-2405

    Some investigators have viewed breast cancer as a local disease that then spreads; others have seen it as a systemic disease from the start. This review argues for another view, since the failure to achieve initial local control allows some tumors to disseminate later, reducing a patient's chance of long-term survival. Recent evidence supports a larger role for aggressive, local therapy for breast cancer.

    Images in Clinical Medicine
    2406
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    A 73-year-old woman presented with new-onset periorbital purpuric, nonblanching, nonpruritic lesions. The lesions appeared spontaneously and were not associated with any recent trauma. She did not take aspirin, nonsteroidal antiinflammatory drugs, or any ...

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    This 40-year-old alcoholic had a 4-year history of diabetes mellitus. He reported passing bulky, foul-smelling stools.

    Clinical Problem-Solving
    2407-2411

      A 34-year-old black woman presented to a walk-in clinic with a 3-day history of malaise. Her colleagues had noticed yellowing of her eyes over the past few days.

      Editorials
      2413-2415

        All forms of amyloidosis are characterized by the deposition of extracellular fibrils in various tissues. These fibrils are the result of the misfolding of a protein from its normal α-helical configuration into a β-pleated sheet. Amyloid fibrils are rigid,...

        2415-2418

        Adrenocortical carcinoma is a rare, highly malignant neoplasm with an incidence of 2 cases per 1 million population per year worldwide, representing 0.2% of all cases of cancer. Several treatment strategies in patients with advanced disease have resulted ...

        Clinical Implications of Basic Research
        2419-2420

        The integrity of the synovium depends on the adhesion molecule cadherin-11. Mice that are deficient in this molecule are resistant to induced inflammatory arthritis.

        Correspondence
        2421-2422
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        To the Editor: The study by Shrestha et al. (March 1 issue),1 which evaluated a vaccine for hepatitis E virus (HEV), represents a major advance but continues to raise ethical concerns. The trial of the HEV recombinant protein (rHEV) vaccine, conducted by ...

        2422-2424

        To the Editor: The Special Article by Landon and colleagues (March 1 issue)1 on improving the management of chronic disease at community health centers illustrates the importance of identifying appropriate outcomes when measuring the effectiveness of ...

        2424-2426

        To the Editor: In his review article on amiodarone for atrial fibrillation, Zimetbaum (March 1 issue)1 did not mention that there are two forms of amiodarone-induced thyrotoxicosis (AIT) — an important distinction that has a major influence on subsequent ...

        2427-2429

        To the Editor: The Sounding Board article by Hanto on the ethical challenges posed by solicitation of organ donation (March 8 issue)1 does not clearly distinguish between directed donation and solicitation. Although effective solicitation requires ...

        2429-2430
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        To the Editor: The Clinical Problem-Solving article by Safdar et al. (March 1 issue)1 concerns an immunocompromised woman who received the diagnosis of pulmonary nocardiosis. The authors recommended that if the patient still required immunosuppression ...

        2430-2431

        To the Editor: The mobile aortic thrombus described by Adam et al. (Feb. 22 issue)1 as suggestive of intraaortic endocarditis does not even warrant a diagnosis of possible endocarditis, according to the Duke criteria.2 At admission, the patient had ...

        2431-2432
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        To the Editor: A healthy 29-year-old medical resident awoke one Sunday morning with intense pain in the right shoulder. He did not recall any recent injuries or trauma and had not participated in any sports or physical exercise recently. He consulted a ...

        Book Reviews
        2433-2434

        The numbers speak for themselves. In India in 2001, there were 921 girls born for every 1000 boys. In some Indian states, the ratio was lower still — 793 girls for every 1000 boys in Punjab, for example — and census data from 1901 to the present show that ...

        2434-2435
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        This book is a bold attempt to address the vexed question of ethics and intersex. Sharon Sytsma has brought together 20 contributions from a range of professionals. Many of the chapters are written in essay form. Overall, it is difficult to justify rating ...

        2435-2436

        Homosexuals have never been popular. For millennia, there have been religious objections to same-sex attraction and behavior — people who had sexual contact with members of their own sex were regarded as sinful or depraved. In the late 19th century, ...

        2436-2437

        Once upon a time there was a great body of law with vast dormant powers. That law, the police power in public health, has been quietly used by administrators and policymakers alike as a tool for protecting the public health with little fanfare and great ...

        Corrections
        2437

        The Rise of In-Store Clinics — Threat or Opportunity? Perspective, N Engl J Med 2007:356;765-768.. The third sentence of the seventh paragraph (page 767) should have read “Both the American Medical Association and the American Academy of Family Physicians ...

        2437

        Current Concepts: The Serotonin Syndrome Review Article, N Engl J Med 2005:352;1112-1120.. The legend for Figure 4 (page 1117) should have included the sentence “Criteria adapted from Dunkley.2” The text has been corrected on the Journal's Web site at ...

        2437

        Left Ventricular Assist Devices and Drug Therapy in Heart Failure Correspondence, N Engl J Med 2007:356;869-872.. The fourth sentence of the letter (page 869) should have read “The survival rate after explantation in the study cohort (81.8% at 4 years) is ...