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There is no definitive answer, in part because the initial symptoms of influenza, anthrax and other infections can resemble one another. And yet it may not be safe to wait for a confirmed diagnosis of inhalation anthrax before a course of antibiotics is begun, because early antibiotics treatment appears to be essential to saving anthrax patients' lives. In addition, at least one inhalation anthrax patient has reported a sore throat as among his early symptoms, and a sore throat is not a common symptom of influenza, Dr. [David Gilbert] said. Some inhalation anthrax patients have also experienced a feeling of heaviness in the chest. For the broad population to pay careful attention to early symptoms may have taken on even greater importance with Kathy T. Nguyen's death of inhalation anthrax in New York City today, less than a week after she experienced her first, mild symptoms. Ms. Nguyen, 61, became ill at a time when federal health officials had begun urging doctors to pay special attention to postal workers who complained of mild, vague symptoms, because those symptoms might develop into a flulike illness that has often preceded the more severe symptoms of anthrax

Anthrax was not suspected when Mr. [Ernesto Blanco], who suffered from chronic lung disease, was admitted to Cedars for pneumonia on Oct. 1. The underlying lung disease might have made him more susceptible to inhalation anthrax. Because he worked at American Media, a swab of his nose was taken, and it showed anthrax spores. He did not show classic symptoms of inhalation anthrax, which suggests that doctors may need to modify their description of the condition, and his case was re-classified as ''atypical inhalation anthrax.'' The change was based on laboratory tests that showed evidence of Bacillus anthracis in bloody fluid in the sac covering his lungs. Anthrax spores can cause different types of infection, depending on where they enter the body. If they invade via a break in the skin, the result is cutaneous anthrax, which often resolves without treatment and is easily cured by antibiotics. But if the spores are breathed into the lungs, inhalation anthrax can occur. Doctors believe that the inhalation form is often fatal because by the time the symptoms of infection appear, a bacterial toxin is already doing its deadly work, and it may be too late for antibiotics to help. Second, an epidemiologic study in 1957 found that four of five workers died after contracting inhalation anthrax at a goat-hair processing plant in Manchester, N.H., over 10 weeks. The workers were all too familiar with anthrax; in the previous 16 years, 136 had developed cutaneous anthrax, the most curable form. Although air sampling showed that workers often breathed Bacillus anthracis spores at the plant, none developed inhalation anthrax until 1957

The first recipient of a self-contained artificial heart had minor surgery this week to create an opening in his neck so a breathing tube could be passed into his windpipe and connected..

A second artificial heart implant seems weeks away because four surgical teams in other cities that expect to implant the device need time to gear up and meet federal requirements, the principal researchers and Abiomed, AbioCor's manufacturer, said in interviews. Dr. Laman A. Gray Jr., Dr. [Robert D. Dowling]'s partner, said he had treated patients as sick as the AbioCor recipient who still recovered with a ventricular assist device and subsequently a heart transplant. To boost the AbioCor recipient's morale a few days after the implant, Dr. Gray said, he brought him a visitor who had been just as sick when he received a ventricular assist device. The man also had a transplant and is now back working as a school principal. At its weekly meetings, a Hahnemann committee has been referring patients who are ineligible for heart transplants for consideration as AbioCor recipients, Dr. [Louis E. Samuels] said. The evaluation involves a number of tests, including CT scans of the chest to determine whether the AbioCor will fit. The chest must be large enough to hold a grapefruit-size artificial heart, an energy coil, battery and controller, totaling a little more than four pounds

Dr. [Robert D. Dowling] said his team would face many unknowns. One is the possible formation of blood clots in the device, which can lead to a stroke. The doctors have prescribed anti-coagulants to prevent such clots. But they have had to stop the drugs or keep the doses small because the man has had bleeding from inflammation of his stomach. The man needs to regain 30 pounds of muscle that wasted when he was suffering from end-stage heart failure. He is receiving 2,900 calories a day through a feeding tube and additional calories in his diet that is gradually including solid foods, Dr. Dowling said, and ''has regained a small amount of muscle mass.'' The AbioCor has worked flawlessly as it has beat more than 5 million times in the man, pumping about 7 liters of blood a minute compared with the 2 liters his diseased heart could deliver, Dr. Dowling said. Earlier, the doctors and technicians manually set the number of heart beats, but now the device regulates itself automatically as it adjusts to the man's activity

Dr. Marcelle Layton, an assistant commissioner in the health department's communicable disease bureau, confirmed the gist of the account by Dr. [Richard P. Fried], a specialist in infectious diseases. The C.D.C. was not notified, Dr. Layton said, because the initial culture tests performed on Ms. [Erin O'Connor] and on the letter showed no evidence of anthrax. Dr. Fried said he re-examined Ms. O'Connor on Oct. 3 and on Oct. 8, when the lesion had developed into a black crust, which is characteristic of cutaneous anthrax. But Dr. Fried and the health department were perplexed because anthrax did not grow on the culture taken from the skin lesion. Ms. O'Connor then went to Dr. Marc Grossman, a dermatologist at Columbia-Presbyterian Center, who had never seen a case of anthrax. But on Oct. 4, when the first case of anthrax was reported in Florida, Dr. Grossman had readied and given a lecture on cutaneous anthrax to young doctors at the school

The CBS News building, on West 57th Street in Manhattan, was not evacuated. Workers -- including the woman who tested positive for anthrax spores -- remained at their jobs. And health officials did not recommend antibiotic treatment for large numbers of workers. All this was in sharp contrast to the response at NBC when a case of cutaneous anthrax was diagnosed in an assistant to Tom Brokaw on Oct. 9, said Dr. Stephen M. Ostroff, an epidemiologist from the Centers for Disease Control and Prevention. It is not clear when she was exposed to anthrax spores, but the normal incubation period for cutaneous anthrax is one to seven days. Anthrax is not contagious, so the risk of her co-workers' developing it is almost negligible, said Dr. Ostroff, who is in New York City supervising the agency's investigation of cases associated with NBC, ABC and CBS. Only one person has developed cutaneous anthrax at each network, Dr. Ostroff said. Also, anthrax spores have not been identified in any of the nasal swabs taken among more than 300 co-workers of Erin O'Connor, the NBC employee who developed cutaneous anthrax, Dr. Ostroff said

An envelope that might (or might not) be filled with ominous powder, the possibility that someone might slip across a border with a jar of viruses, the impossibility of guarding every subway entrance and roof ventilator against a terrorist with a spray can: ''In these times,'' said Dr. Frank Bia, an expert on infectious diseases and microbiology at Yale, ''the unthinkable has become thinkable.'' The response to confirmed anthrax cases in Florida, New Jersey, New York and Washington, is being viewed as a painful drill that has exposed gaping deficiencies in the country's ability to cope with bioterrorism. Experts on infectious diseases cited a number of areas that needed to be improved, including these: ''Our imaginations have not been broad enough,'' said Dr. Frank Bia, an expert in infectious diseases and microbiology at Yale. ''When someone comes to the emergency room with something unusual, doctors must trust their instincts and sixth sense to make the pieces fit together.''

Officials are recommending a 10-day course of the powerful antibiotic Cipro for thousands of postal workers around Washington while epidemiologists figure out who among them were most likely to have been infected. Those at risk would receive a 60-day course of Cipro or other equally effective antibiotics.Dr. Anne Schuchat, an epidemiologist at the Centers for Disease Control and Prevention in Atlanta, said in an interview that the four Washington postal workers who came down with inhaled anthrax -- two of whom died on Monday -- experienced initial symptoms of fever, headache, chills, sweating and malaise for a couple of days -- in short, the symptoms of flu. The recommendations apply only to areas where inhaled anthrax has been diagnosed or is strongly suspected. Elsewhere, flulike symptoms ''would not make us think of anthrax,'' said Dr. Schuchat, who is an expert in the epidemiology of respiratory illness. Because chest X-rays of postal workers in the early stage of inhalation anthrax have shown the swollen lymph nodes, Dr. Schuchat said, her agency is urging doctors to consider taking X-rays and carefully examining them for the abnormality. ''The mediastinal X-ray findings were immediate clues that something unusual was going on,'' she said, and led to more extensive testing that detected anthrax in the patients

Inhalation anthrax should be treated with two or more antibiotics, not just one, as previously recommended, the Centers for Disease Control and Prevention said in its weekly report. It made that change in part because patients who have survived inhalation anthrax have been treated with combinations of antibiotics. Previously, penicillin was recommended as a first-line drug for anthrax. But now, the agency says laboratory studies of anthrax bacteria from victims of the attacks show that the germs have some resistance to penicillin, which could make it less effective than other antibiotics. Using drugs in combination can sometimes overcome resistance, and so penicillin can still be used along with other antibiotics. One step was exposing the anthrax bacteria to a number of antibiotics to determine how susceptible the bacilli were to the drugs. The initial tests showed that the anthrax bacilli were mostly sensitive to penicillin, [Julie L. Gerberding] said. But there was some resistance. And the scientists knew from experience in patients that bacteria exposed to penicillin could switch on an enzyme that destroyed the drug