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August 24, 2006  Vol. 355 No. 8

Audio Summary of this Issue

Perspective
753-756

The concept of personal responsibility is that if we follow healthy lifestyles and are good patients, we will be rewarded by feeling better and spending less money. Dr. Robert Steinbrook writes that the details of programs that emphasize personal ...

756-758

West Virginia is planning to ask residents who are eligible for Medicaid because of low income to sign documents outlining “member responsibilities and rights.” Drs. Gene Bishop and Amy Brodkey explain that the plan has implications far beyond its effects ...

758-760

Dr. Tim Byers asks, what are we to do about the epidemic of adiposity, both collectively and personally? This baby boomer epidemiologist (BMI, 27.3) discusses the health risks associated with being a little overweight.

760-761

The lethality of Chagas' heart disease is undisputed. Dr. James Maguire writes that difficult challenges lie ahead for the elimination of transmission and millions of people remain chronically infected.

Original Articles
763-778

This study prospectively examined body-mass index in relation to the risk of death from any cause in more than 500,000 members of the AARP who were 50 to 71 years of age. The risk of death was increased for the highest and lowest categories of body-mass index in both men and women and among both overweight and obese men and women who were healthy and had never smoked. Excess body weight during midlife, including overweight, is associated with an increased risk of death.

779-787

This 12-year prospective Korean cohort study from the National Health Insurance Corporation indicates that the relationship between the risk of death from any cause and body-mass index is J-shaped — higher in underweight, overweight, and obese men and women than in those of normal weight. The association between body-mass index and mortality varies according to the cause of death and is modified by age, sex, and smoking history.

788-798

Aggressive arterial aneurysms, such as thoracic aortic aneurysms and aortic dissection, were found to be caused by mutations in the genes encoding the transforming growth factor β (TGF-β) receptor I or II, which are characteristic of the Loeys–Dietz syndrome. Screening for these mutations in persons at risk may allow preventive measures to be taken.

799-808

In a cohort of patients with Chagas' heart disease, multivariate analysis was used to identify six risk factors for death: New York Heart Association class III or IV, cardiomegaly, left ventricular systolic dysfunction, nonsustained ventricular tachycardia, low QRS voltage, and male sex. These variables were incorporated into a risk score that was validated in a second cohort of patients.

Clinical Practice
809-817

    A 63-year-old man with coronary artery disease who has recently undergone bypass surgery presents with dyspnea. Laboratory testing reveals a platelet count of 86,000 per cubic millimeter, as compared with 225,000 per cubic millimeter at the time of discharge nine days earlier. Findings on chest radiography are unremarkable; spiral computed tomography of the chest shows a pulmonary embolism. Heparin-induced thrombocytopenia is suspected. What diagnostic studies are warranted, and how should this patient be treated?

    Review Article
    818-829
    • Video

    Dystonia is a movement disorder characterized by sustained muscle contractions, repetitive twisting movements, and abnormal postures of the trunk, neck, face, or arms and legs. Dystonia is often confused with spasticity or rigidity and is even mistakenly attributed to psychogenic causes. This review covers recent advances in the causes and treatment of both primary and secondary dystonias, including those that are drug-induced, related to acquired brain lesions, or part of heredodegenerative syndromes.

    Images in Clinical Medicine
    830
    • Free Full Text

    A 30-year-old man presented at our plastic-surgery clinic to request body contouring after massive weight loss (Panels A and B; inset shows patient before weight loss). Two years earlier, the patient had undergone an open gastric bypass for morbid obesity,...

    e7
    • Free Full Text

    This 83-year-old woman with glaucoma and atrial fibrillation was receiving warfarin. She woke up with pain in the right eye and what she thought was a big bruise.

    Case Records of the Massachusetts General Hospital
    831-839
    • Video

    A 19-year-old woman had difficulty walking and painful spasms in her legs and arms, worse at night than in the morning, which had slowly worsened since the age of 8 years. Tremors occurred in her arms, and she had insomnia, anxiety, and irritability. There was no weakness or cognitive impairment. A diagnostic test was performed.

    Editorial
    841-844

    Reviewing the entry on Marfan's syndrome in my medical school–era edition of Harrison's Principles of Internal Medicine, circa 1980, reminded me anew of the transformative potential of molecular medicine. In describing this striking genetic disorder, the ...

    Correspondence
    845-846

    To the Editor: The observation that adjuvant chemotherapy with cyclophosphamide, epirubicin, and fluorouracil (CEF) yielded survival results superior to those obtained with cyclophosphamide, methotrexate, and fluorouracil (CMF) in premenopausal women ...

    846-847

    To the Editor: The study by Moss et al. (May 25 issue)1 is impressive because it represents a successful multicenter, prospective, randomized trial investigating therapies for necrotizing enterocolitis. However, 60 percent of the study cohort did not ...

    848-850

    To the Editor: Jacobson et al. (June 1 issue)1 report a positive association between body-mass index (BMI) and gastroesophageal reflux disease (GERD). In this study, women with frequent GERD symptoms were more likely to use asthma medications than were ...

    850-851

    To the Editor: Variability of blood pressure is increasingly being recognized as having a predictive value in clinical outcomes independently of the 24-hour average measurement, as in the review article by Pickering and colleagues (June 1 issue).1 ...

    851-852

    To the Editor: Farzaneh-Far et al. (June 1 issue)1 describe a case of massive pulmonary embolism, stating that in more than 80 percent of patients with acute pulmonary embolism, echocardiography reveals abnormalities. However, others report that most ...

    852-853

    To the Editor: Although the addition of a long-acting β2-agonist such as salmeterol to an inhaled corticosteroid has been demonstrated to provide greater control of asthma than does a substantially increased dose of the inhaled corticosteroid,1 this ...

    Book Reviews
    854-855

    As a child, Francis Crick was afraid that there would be nothing left for him to discover when he was an adult. In his book, Francis Crick, Matt Ridley shows us how wrong Crick was. We read of Crick's years at the Admiralty Research Laboratory during ...

    855

    Rolf Luft described the first case of mitochondrial disease in 1962, and for more than 25 years, disorders affecting the “batteries” of the cell were confined to research papers and neurology grand rounds. The sequencing of the mitochondrial genome and ...

    855-856

    In Allergy, Mark Jackson examines an array of scientific, socioeconomic, environmental, and political factors that have shaped allergy — both as an ailment and as a field of scientific research — from 1906 to the present. The result is not a tale of ...

    Corrections
    856

    Immune Cells in Colorectal Cancer Correspondence, N Engl J Med 2006:354;1531-1532.. In the letter by Wolf et al., the third reference on page 1531 should have been “Wolf D, Wolf AM, Rumpold H, et al. The expression of the regulatory T cell-specific ...

    856

    Laparotomy versus Peritoneal Drainage for Necrotizing Enterocolitis and Perforation Original Article, N Engl J Med 2006:354;2225-2234.. On page 2233, on line 10 of the Appendix, the name J.S. Upperman should have appeared along with those of other ...

    856

    Alemtuzumab for Refractory Celiac Disease in a Patient at Risk for Enteropathy-Associated T-Cell Lymphoma Correspondence, N Engl J Med 2006:354;2514-2515.. On page 2514 of the letter, the sentence that begins three lines from the bottom of the right-hand ...