This randomized trial investigated the influence of the width of the margin of the surgical excision (1 cm or 3 cm) on the risk of recurrence and death in patients with high-risk cutaneous melanoma (as defined by a tumor thickness of 2 mm or more). A 1-cm margin was associated with a higher risk of locoregional recurrence than was a 3-cm margin, but three years after surgical treatment, overall survival was similar in the two groups.

It is clear that the depth of the lesion is a major prognostic factor in cutaneous melanoma, but the ideal width of excision is unclear. The authors of this large trial recommend against the use of a 1-cm margin of excision for high-risk lesions.

This randomized trial compared alendronate with calcitriol for the prevention of bone loss during the first year after cardiac transplantation. A reference group concurrently underwent transplantation but did not receive either drug. Bone loss and the rate of fractures did not differ significantly between the intervention groups. Both intervention groups sustained less bone loss at the hip than the reference group did. Calcitriol was associated with a greater risk of hypercalciuria.

Since it is necessary to monitor the serum and urinary calcium levels in calcitriol-treated patients, alendronate may be the preferred drug in this setting.

This prospective study, involving over 400,000 women with consecutive singleton births in Sweden, demonstrated that women whose first infant was small for gestational age had an increased risk of stillbirth during their second pregnancy, especially if their first child was also delivered preterm. However, the absolute risk of stillbirth was low, even among women with a prior adverse outcome of pregnancy.

A history of stillbirth is known to increase the subsequent risk of stillbirth. This study indicates that other adverse reproductive outcomes may also be markers for an increased risk of stillbirth.

Symptoms of overactive bladder are common, are often distressing, and may have serious adverse consequences. Myriad factors — disorders of the lower urinary tract, neurologic conditions, behavioral factors, and a variety of commonly prescribed drugs — may cause this syndrome. This review considers the pathophysiology, diagnostic evaluation, and current treatment of overactive bladder syndrome.

Promising future directions in drug therapy include antimuscarinic agents with increased selectivity for the bladder, new drug-delivery systems, and drugs that affect the sensory innervation of the lower urinary tract.

Acute chemical emergencies can occur as a result of an industrial accident, occupational exposure, a natural disaster, or an act of terrorism. This article reviews empirical principles for rapid recognition and treatment of the clinical syndromes, or toxidromes, caused by asphyxiants, cholinesterase inhibitors, respiratory irritants, and blistering agents. Treatment should be provided as soon as possible after an acute chemical exposure, usually before laboratory tests can confirm the specific chemicals involved.

Many of the survivors of the Rhode Island nightclub fire in February 2003 sustained severe burns. In this Case Record, the multidisciplinary care of one of these patients is discussed.

A recent study shows that atherosclerotic plaques can generate ozone and that ozone may oxidize low-density lipoprotein — thus raising the possibility of new biomarkers for atherosclerosis.

On December 8, President Bush signed the Medicare Prescription Drug Improvement and Modernization Act of 2003. In this Health Policy Report, Iglehart discusses the new drug benefit and the contentious political process that led to this major reform of Medicare. Beginning in 2006, Medicare will cover 75 percent of a beneficiary's first $2,250 in annual drug expenses. Medicare will also pay 95 percent of expenses above $5,100. The program is voluntary and requires payment of a monthly premium and a $250 deductible. Coverage will be more generous for low-income elderly persons.