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June 26, 2008  Vol. 358 No. 26

Audio Summary of this Issue

Perspective
2757-2760

After 2 years, health care reforms in Massachusetts have ramped up rapidly, the number of people without health insurance has been substantially reduced, and overall public and political support remains broad. Dr. Robert Steinbrook writes that not all the ...

2760-2763

Now, more than 150 years after Darwin's theory of the origins of interspecies differences, genomewide association studies have identified more than 100 new chromosomal regions at which DNA variation influences risk of common human diseases and clinical ...

Original Articles
2765-2775

Rivaroxaban is an orally administered direct inhibitor of factor Xa. As compared with enoxaparin, rivaroxaban was more effective in preventing venous thromboembolism after hip replacement, without a significant increase in major bleeding.

2776-2786

This trial compared rivaroxaban with enoxaparin for thromboprophylaxis after total knee replacement. Rivaroxaban was superior to enoxaparin in the prevention of venous thrombosis, and the two drugs had similar safety profiles.

2787-2795

Murine studies suggest that aortic-root dilation in Marfan's syndrome is due to excessive signaling by transforming growth factor β (TGF-β) and can be mitigated by TGF-β antagonists, such as angiotensin II–receptor blockers (ARBs). This study reviewed data on 18 pediatric patients with Marfan's syndrome who had begun ARB therapy and had been followed for at least 12 months. The rate of increase in aortic-root diameter was significantly slowed after the initiation of ARB therapy.

Special Article
2796-2803
  • Free Full Text

This article reviews the genetic susceptibility to breast cancer, with emphasis on genomewide association studies that have uncovered six single-nucleotide polymorphisms with a strong statistical association with breast cancer. Individually, these alleles are associated with a small relative risk, but when combined, they could facilitate population-based screening for breast cancer.

Clinical Practice
2804-2811
  • Full Text Audio

A 42-year-old woman presents with severe pain in the right upper quadrant, which started 15 hours earlier. She has had episodic pain in that location previously that lasted up to 2 hours. She has had one episode of vomiting with the current attack. Her temperature is 38.5°C, and the heart rate is 95 beats per minute. How should her condition be evaluated and treated?

Videos in Clinical Medicine
e30

    A femoral venous catheter may be necessary when peripheral access to the circulatory system is compromised and no other sites for placing a central catheter are available. This video demonstrates the insertion of a femoral venous catheter and explains the indications and potential complications.

    Images in Clinical Medicine
    2812
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    A 71-year-old woman received a diagnosis of systemic sclerosis more than 30 years ago when she presented with Raynaud's phenomenon and cutaneous sclerosis. At that time she did not require long-term therapy. She now presents with fever and venous ...

    e31

    In this 28-year-old man with heart failure and marked jugular venous distention, fluoroscopy confirmed immobilization of one aortic prosthetic valve leaflet. Repeat fluoroscopy 6 months later revealed normal bileaflet motion of the aortic-valve ...

    Case Records of the Massachusetts General Hospital
    2813-2825

      A 57-year-old woman was admitted to the hospital because of abdominal pain and weakness, 1 month after gastric bypass surgery. In the month after the operation, episodes of tachycardia, bradycardia, diarrhea, dark urine, and abdominal pain occurred, with urine cultures that were positive for bacteria. After admission, weakness and numbness in the legs and arms developed and progressed to flaccid quadriparesis. A diagnostic test was performed.

      Editorials
      2827-2829

      For more than half a century, heparin and vitamin K antagonists have defined anticoagulant therapy for the short-term and long-term management, respectively, of thrombotic disorders of the venous system. The history of their development is instructive. In ...

      2829-2831

      Almost three decades ago, Victor McKusick and I reviewed Marfan's syndrome in the Journal and advised traditional medical and surgical approaches to management.1 The holy grail at that time was the cause of this autosomal dominant condition, based on the ...

      Sounding Board
      2832-2837

      A debate exists about informing potential organ-transplant recipients about the general risks associated with transplantation and the specific risks associated with a particular organ. In this article, the authors discuss whether and how the behavioral risks of donors should be considered and how that might affect choices and outcomes.

      Correspondence
      2838-2840

      To the Editor: Rothenberg and colleagues (March 20 issue)1 provide data on the use of mepolizumab, an anti–interleukin-5 monoclonal antibody, for corticosteroid sparing in patients with non–life-threatening hypereosinophilic syndrome who were negative ...

      2840-2842

      To the Editor: Koch et al. (March 20 issue)1 report increased risks of postoperative complications and death among patients undergoing cardiac surgery who were given blood that had been stored for more than 2 weeks, as compared with those given newer ...

      2842-2845

      To the Editor: The article by Jha et al. (March 13 issue)1 on the large and growing number of deaths in India due to smoking draws attention to the need for effective implementation of the national tobacco control act of 2003 in India.2 Recent data show ...

      2845-2847

      To the Editor: In their review article, Munoz-Price and Weinstein (March 20 issue)1 state that “Acinetobacter is a gram-negative coccobacillus” and that it is “nonreactive in many biochemical tests commonly used to differentiate among gram-negative ...

      2847-2848

      To the Editor: In the Perspective article by Cohen et al. (Feb. 14 issue),1 a narrow construction of what constitutes prevention leads to erroneous conclusions about its potential impact and cost-effectiveness. The authors do not address preventive ...

      2848-2849

      To the Editor: As reported by Shulman et al. (Jan. 31 issue),1 the first signs of a malignant condition in a young pregnant woman with lymphoma involving the mediastinum and left breast were noted at 26.1 weeks' gestation, and a live-born infant was ...

      2849-2850

      To the Editor: Primary coenzyme Q10 deficiency is considered to be the only treatable mitochondrial disorder, since patients have a response to oral coenzyme Q10 supplementation. The disease usually manifests with nephropathy and encephalomyopathy.1 It ...

      Book Reviews
      2851

      Are increases in the incomes of countries necessary or sufficient for the good health of their people? In this book, James Riley argues that they are not. Woven into the case studies of 12 low-income countries that achieved high life expectancies are two ...

      2852

      In July 2003, Rose Firestein, a tenacious lawyer working with the New York State attorney general's office on a consumer fraud lawsuit against GlaxoSmithKline, noticed something curious on the Web site of the Food and Drug Administration (FDA) — a press ...

      2853
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      Controversy over the modern medical malpractice system has raged ever since the first malpractice crisis took place in 1975, but it is only during the past few years that empirical studies have generated the data that are necessary to produce an accurate ...

      2854

      Madelon Finkel's compendium of essays on the influence of politics, ideologies, and greed on science and public health spans a wide range of topics, from breast implants to dietary supplements. The essays are rich in historical perspectives but ...

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