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June 29, 2006  Vol. 354 No. 26

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Perspective
2745-2747
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Health care information companies compile and sell individual physicians' prescribing data to pharmaceutical manufacturers. Dr. Robert Steinbrook writes that more and more physicians have rebelled after becoming aware that drug companies have access to ...

2748-2749

How many times each day does an incidental finding lead to other tests, additional inconclusive results, and still further testing? Dr. John Stone writes that with a growing number of “incidentalomas,” what to tell the patient remains unclear.

Original Articles
2751-2763

A group of 870 consecutive patients with colorectal cancer were tested for germ-line mutations in DNA repair genes. A two-stage model was devised to predict the presence of mutations in DNA repair genes. A combination of clinical measures and immunohistochemical staining of the tumor for DNA repair proteins gave a positive predictive value of 80 percent and a sensitivity of 62 percent for mutation carriers.

2764-2772

Prior observational studies have found elevated homocysteine levels among patients with Alzheimer's disease and inverse associations between homocysteine levels and performance on cognitive tests among community-dwelling older adults. In this two-year randomized trial involving healthy elderly persons with elevated homocysteine levels, treatment with folate and vitamins B12 and B6 lowered plasma homocysteine levels but did not improve cognitive performance.

2773-2782

In this study, consecutive patients with acute myocardial infarction who were undergoing primary angioplasty were randomly assigned to N-acetylcysteine at standard or double doses or to placebo. Creatinine concentrations increased after primary angioplasty in 33 percent of the patients in the control group, 15 percent of those in the standard-dose group, and 8 percent of those in the high-dose group (P<0.001). Intravenous N-acetylcysteine followed by oral N-acetylcysteine may prevent contrast-medium–induced nephropathy in patients undergoing angioplasty.

2783-2793

Low or high iodine intake may lead to thyroid dysfunction. In this study, the prevalences of overt and subclinical hypothyroidism and autoimmune thyroiditis were increased with increasing iodine intake in regions of China with iodine intake that was mildly deficient (median urinary iodine excretion, 84 μg per liter), more than adequate (median, 243 μg per liter), and excessive (median, 651 μg per liter).

Clinical Practice
2794-2801

    A 26-year-old woman with a summer home on Long Island, New York, had a low-grade fever, malaise, arthralgias, headache, and neck pain one week after removing a tick from her thigh. Examination reveals a nontender oval (8 by 12 cm), homogeneously erythematous lesion at the site of the tick bite, consistent with erythema migrans. How should this case be managed? What if she had presented earlier, just after removing the tick?

    Images in Clinical Medicine
    2802
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    A 55-year-old man presented with a two-day history of headache, fever, and generalized weakness. He had received a cadaveric kidney transplant five years earlier. His medications included 5 mg of tacrolimus twice a day and 10 mg of prednisone daily. On ...

    e27
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    This woman with a surgical scar on the neck and hypothermia became obtunded. The video shows delayed relaxation phase of the biceps reflex.

    Case Records of the Massachusetts General Hospital
    2803-2813
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    An 84-year-old man with a pacemaker was hospitalized for staphylococcal bacteremia and renal failure. Fever and respiratory symptoms had developed two weeks earlier; blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Fever and bacteremia persisted despite antibiotic therapy, and slowly progressive renal failure developed. A diagnostic procedure was performed.

    Editorials
    2815-2817

    This year, colorectal cancer will strike about 150,000 people in the United States and 500,000 worldwide. Much of the morbidity and mortality of the disease could be prevented if we knew more about the risk of colorectal cancer developing and were able to ...

    2817-2819

    Finding treatments for the prevention of dementia is an important challenge for medical research.1 Dementia currently affects about 4.5 million persons in the United States, and many more have cognitive impairment. The disorder is characterized by an ...

    2819-2821

    In normal adults, the daily production rate of the two biologically active thyroid hormones, tetraiodothyronine (which is better known as thyroxine and has four iodine atoms) and triiodothyronine (which has three), is approximately 100 μg and 30 μg, ...

    Health Policy Report
    2822-2828

    Spending on imaging services has grown rapidly in recent years, and annual costs are now estimated to be $350 per person in the United States. Iglehart discusses the dramatic rise in physicians' use of imaging and the controversy surrounding recent changes in Medicare payment policies designed to curb the growth.

    Correspondence
    2829-2830

    To the Editor: The authors of the Fifth Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS-5) study (April 6 issue)1 point out that despite the presence or absence of administration of unfractionated heparin, bleeding rates were ...

    2830-2832

    To the Editor: On behalf of the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment (ExTRACT)–Thrombolysis in Myocardial Infarction (TIMI) 25 Study investigators, Antman et al. (April 6 issue)1 compared the use of seven days ...

    2832

    To the Editor: Kyle et al. (March 30 issue)1 cite a study that my colleagues and I conducted2 that was, contrary to their statement, population based. We found a population prevalence of monoclonal gammopathy of undetermined significance (MGUS) of 3.6 ...

    2832-2833

    To the Editor: Although the Perspective article by Shuchman and Redelmeier (March 30 issue)1 regarding problems at the Canadian Medical Associatio n Journal (CMAJ) was intended to provide a “perspective” on recent events at the journal, I would remind ...

    2833-2834

    To the Editor: Podolsky et al. (March 16 issue)1 describe a woman admitted to the hospital with a brain mass and hyponatremia (serum sodium, 131 mmol per liter). The day after admission, she had a generalized tonic–clonic seizure and required tracheal ...

    2834-2835

    To the Editor: The fungal component 1,3-β-D-glucan is increasingly used to diagnose opportunistic invasive mycoses in immunocompromised patients.13 The 1,3-β-D-glucan assay (Fungitell, Associates of Cape Cod) was recently approved by the Food and Drug ...

    2835-2837

    To the Editor: It is considered potentially harmful to administer imipenem–cilastatin to patients with IgE-mediated hypersensitivity to penicillins1 because of a 47.4 percent rate of cross-reactivity (9 of 19 subjects) found in a single study2 on the ...

    Book Reviews
    2838-2839

    The detection of breast cancer early in its natural history is one of the major objectives of cancer control. However, mere detection is not sufficient. A successful outcome demands the application of skills at every level of the process — organizing ...

    2839-2840

    After Ernest A. McCulloch and James E. Till received the Albert Lasker Medical Research Award in Basic Research in 2005, they wrote a commentary in Nature Medicine. In it, they asked themselves, “Why now?” After all, their papers on the colony-assay model ...

    2840-2841

    Psychogenic movement disorders are difficult to understand and treat, so writing a book about them is challenging. The topic straddles two distinct professions and traditions — neurology and psychology — which, in my experience, often clash in their ...