Sudden emotional distress, such as that caused by an unexpected death, can sometimes produce severe transient left ventricular dysfunction. This stress-induced cardiomyopathy appears to be a form of myocardial stunning associated with marked sympathetic stimulation.

In a study of 43 patients with low-risk myelodysplastic syndromes, lenalidomide, a thalidomide derivative, ameliorated anemia and allowed the discontinuation of transfusions in over half the patients.

These results indicate that lenalidomide is a promising new treatment for low-grade myelodysplastic syndromes. Neurologic toxicity, the main adverse effect of thalidomide was not seen, but neutropenia and thrombocytopenia were problems.

Although some kidney-transplant recipients with severe vascular rejection have antibodies against HLA antigens, others do not. Severe vascular rejection accompanied by accelerated hypertension, and even convulsions, resembles preeclampsia. Activating antibodies targeting the angiotensin II type 1 receptor have been found in preeclampsia, and the authors sought and detected such antibodies in patients with severe vascular rejection. These results suggest that a pathway mediated by a non-HLA, angiotensin II type 1 receptor may be involved in vascular rejection.

The authors estimate that routine HIV screening in health care settings with a 1 percent prevalence of HIV infection costs about $15,000 per quality-adjusted life-year gained. The cost remains below $50,000 when the prevalence of HIV is above 0.05 percent. When the potential benefits of reduced HIV transmission are excluded, screening populations with a 1 percent prevalence of HIV infection costs about $42,000 per quality-adjusted life-year gained.

Routine screening for HIV is cost-effective, except in settings with an extremely low prevalence of HIV infection.

This cost-effectiveness analysis compared routine screening for HIV with current detection of HIV through selective screening and patients who present with opportunistic infections. One-time screening cost $38,000 per quality-adjusted life-year gained when HIV prevalence is 1 percent, and $113,000 for the general population of the United States (0.1 percent prevalence). Screening for HIV has the potential to reduce the transmission of HIV and may be associated with lower cost-effectiveness ratios.

These findings support the CDC's recommendation of routine HIV screening in populations with at least a 1 percent prevalence of HIV and suggest that screening also may be cost-effective in populations with lower prevalence.

A 32-year-old man has a three-month history of difficulty sleeping. On questioning, he mentions that he drinks four to six glasses of wine three to four times per week. How should his case be assessed and managed?

A 35-year-old man who had recently emigrated from Brazil had swelling and pain in his right nostril that had worsened over six months. A physical examination disclosed swelling and erythema of the right nasal vestibule, with tenderness and crusting. The lesion did not respond to antibiotic therapy. A biopsy disclosed necrotizing granulomatous inflammation without evidence of microorganisms. A diagnostic procedure was performed.