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Table of contents for

July 8, 2010  Vol. 363 No. 2

Audio Summary of this Issue

Perspective
101-103

More than half the cost of health care reform is meant to be paid for through reductions in Medicare spending. Dr. Robert Berenson examines current sources of savings and strategies for identifying future savings in Medicare and its provider-payment ...

103-105

The Patient Protection and Affordable Care Act creates an Independent Payment Advisory Board (IPAB) to ensure that Medicare spending doesn't grow too quickly and to make recommendations about controlling national health care costs. Timothy Jost explores ...

105-107
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Dr. Daniel Martin and colleagues describe their experience with a comparative-effectiveness study that highlights important roadblocks and dramatic changes needed in federal infrastructure for such research to be conducted efficiently.

Original Articles
109-122

In a randomized trial, men 65 years of age or older who had low serum testosterone levels and limitations in mobility were assigned to either placebo or testosterone gel to be applied daily for 6 months. The primary end point was improvement in leg-press strength, which was greater with testosterone therapy than with placebo. However, the trial was stopped early because of a greater number of cardiac adverse events in the testosterone group.

123-135

The investigators sought evidence-based criteria for identifying late-onset hypogonadism in men between the ages of 40 and 79 years on the basis of the association between symptoms and a low testosterone level. The data suggest that late-onset hypogonadism can be defined by the presence of at least three sexual symptoms with a total testosterone level of less than 11 nmol per liter and a free testosterone level of less than 220 pmol per liter.

136-146

This study compared two new-generation drug-eluting coronary stents that release zotarolimus or everolimus. Clinical and angiographic outcomes were similar with the two stents, although there was a somewhat higher rate of stent thrombosis with the zotarolimus stent.

147-155

Corneal damage may become permanent if the supply of limbal stem cells is compromised. In this long-term follow-up study of 113 eyes treated with autologous transplantation of limbal stem-cell cultures, a transparent, renewing corneal epithelium was restored in 77% of eyes and remained stable over time.

Clinical Practice
156-165

A 44-year-old man presents with dyspnea and new atrial fibrillation. He received a diagnosis of mild mitral regurgitation at 28 years of age but has not seen a physician in many years. Physical examination reveals a holosystolic murmur and a soft S3. Repeat echocardiography shows a flail posterior leaflet and moderately severe mitral regurgitation. How should this case be managed?

Review Article
166-176

Over the past 5 years, genomewide association studies have yielded a wealth of insight into genes and chromosomal loci that contribute to susceptibility to disease. This article, the second in the Genomic Medicine series, describes the design of these studies and considers the extent to which the data they provide are useful in predicting the risk of disease.

Images in Clinical Medicine
177
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A 32-year-old man presented with a 6-month history of severe headaches, hemiparesis on the left side, and impaired hearing in the left ear. His medical history was otherwise unremarkable. Magnetic resonance imaging with gadolinium revealed a large mass (...

e2

This 15-year-old girl reported progressively worsening pain and redness in her left eye. The diagnosis of scleritis with peripheral ulcerative keratitis was made. Testing for antineutrophilic cytoplasmic antibody was positive.

Case Records of the Massachusetts General Hospital
178-186

A 32-year-old woman was evaluated because of oligomenorrhea and difficulty becoming pregnant. At 25 years of age, after 5 years of oral contraceptive use, irregular menstrual cycles developed, and she was unable to become pregnant. She reported acne and increased facial hair; results of laboratory tests were consistent with anovulation. She became pregnant after two cycles of clomiphene, gestational diabetes developed, she delivered a healthy infant, and she breast-fed normally. Glucose intolerance and amenorrhea persisted after delivery. A diagnostic test was performed.

Editorials
188-189

The great variability in the processes that different journals use to ask about and report authors' potential conflicts of interest creates confusion for authors, readers, and the public. To help lessen this confusion, the International Committee of ...

189-191

It is now clear that men have gradual declines in average serum testosterone levels as they age. These decreases begin by middle age and continue into old age.1,2 Although the decreases are substantial in many men, they are quite variable. Some men, even ...

Sounding Board
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A task force of the Accreditation Council for Graduate Medical Education (ACGME) has proposed modifications in the current requirements for medical residency training programs, including in the limits on resident hours. This article explains the proposed changes and the rationale for them and invites input on the new requirements, which are scheduled for implementation in 2011.

Correspondence
192-193

To the Editor: Biliary tract cancers are associated with a poor prognosis and are frequently diagnosed in advanced stages. Valle et al. (April 8 issue)1 report on the treatment of advanced biliary tract cancer and on the good results of the Advanced ...

193-195

To the Editor: Petersen et al. (March 25 issue)1 report on a relationship between storage of triglycerides in the liver and two variant alleles of the gene encoding apolipoprotein C3 (APOC3) that increased apolipoprotein C expression. Using proton ...

195-196

To the Editor: In his editorial on individualized genomics, Lifton (April 1 issue)1 predicts that whole-genome sequencing could eventually be scaled to routine clinical practice, in part because “innovation and intense competition” will drive down ...

196-197

To the Editor: The Perspective article by Garber (April 1 issue)1 overstates the impact of the Supreme Court's 2008 decision upholding federal preemption for medical-device companies. The 8-to-1 decision did not bestow immunity on medical devices ...

Corrections
198

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis Original Article, N Engl J Med 2010:363;11-23 (10.1056/NEJMoa0912321; published on May 26, 2010, at NEJM.org). In Figure 2, (page 9), the y axis in Panel C should have been labeled “...

198

Regional Variations in Diagnostic Practices Special Article, N Engl J Med 2010:363;45-53 (10.1056/NEJMsa0910881; published on May 12, 2010, at NEJM.org). The title of Table 1 (page 5) should have read, “Baseline Characteristics of the Study Population,” ...

198

Cisplatin plus Gemcitabine versus Gemcitabine for Biliary Tract Cancer Original Article, N Engl J Med 2010:362;1273-1281. In the Methods section of the Abstract (page 1273), the first sentence should have begun, “We randomly assigned 410 patients with ...

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