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December 29, 2011  Vol. 365 No. 26

Audio Summary of this Issue

Perspective
2445-2447
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Implementation of accountable care organizations (ACOs) is still at an early stage, but the growing experience with these organizations and the public comments regarding the Medicare ACO program point to five key challenges — and possible approaches to overcoming them.

2447-2449
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Moves to protect the copyright of the Mini–Mental State Examination, the standard of care for cognitive screening, have left clinicians at risk of legal action for infringement and distribution and made a new tool, apparently seen as derivative, unavailable.

2449-2451

Primary care medicine was once considered the noblest profession, but medical students today believe the work is too hard, the hours too long, the pay too low. But if you think being a primary care doctor is hard, meet Mary. Not many people have it harder than she does.

e48
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Many people believe that improving clinical quality — reducing readmissions, shortening lengths of stay, and building efficiency into clinical processes — will reduce health care costs. So why haven't years of work in quality improvement had a measurable effect on costs?

Original Articles
2453-2462

This trial compared a restrictive hemoglobin threshold with a liberal threshold for blood transfusion among hip-surgery patients with risk factors for CVD. The liberal strategy resulted in more transfusions and did not reduce death or inability to walk independently.

2463-2472

Thromboprophylaxis with low-molecular-weight heparin is known to prevent deep-vein thrombosis in acutely ill medical patients. This large trial showed no effect of enoxaparin on 30-day mortality, which was virtually identical in the active-treatment and placebo groups.

2473-2483

Incorporating bevacizumab in a chemotherapy regimen (7.5 mg/kg every 3 weeks for five or six cycles) and then continuing bevacizumab alone for a total of 12 months of treatment extended progression-free survival in advanced and high-risk early-stage ovarian cancer.

2484-2496

The addition of bevacizumab to chemotherapy (15 mg/kg for six cycles) followed by extended therapy with bevacizumab every 3 weeks for a total of 15 months of treatment improved progression-free survival by 4 months in incompletely resected stage III or IV ovarian cancer.

2497-2506

CLL is a heterogeneous disease with a variable clinical course and response to therapy. New genetic lesions have been noted in subgroups of patients through whole-exome and whole-genome sequencing. An abnormality in RNA splicing has been found in 15% of patients.

Review Article
2507-2518

Proteases that process larger precursor proteins into smaller functional proteins are involved in a wide range of physiologic processes. Derangements in the function of these enzymes play a role in many diseases.

Images in Clinical Medicine
2519
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Cranial CT imaging revealed a metal foreign body at the edge of the foramen magnum in an 85-year-old man who had been hit by a bullet 82 years earlier. There was no evidence of neural damage.

e49
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A 19-year-old woman was brought to the ER after a nearby lightning strike in which her Great Dane dog had been instantly killed. She briefly lost consciousness and found herself on the wet ground, calling for help.

Case Records of the Massachusetts General Hospital
2520-2530

A 52-year-old man was admitted to this hospital because of weakness, leg swelling, and hypokalemia. During the hospital course, multiple infections were diagnosed and imaging studies revealed enlarged adrenal glands. A diagnostic procedure was performed.

Editorials
2532-2533

    Even though red-cell transfusion is an accepted and widely used intervention, questions regarding which patients should receive transfusions and under what circumstances continue to spark debate. There has been limited evidence from clinical trials to ...

    2534-2535

    Massively parallel sequencing of cancer genomes is revealing a panoramic view of the genetic drivers of human neoplasms. In this issue of the Journal, Wang et al.1 describe an analysis of the coding sequences of samples from 91 patients with chronic ...

    Clinical Implications of Basic Research
    2536-2538

    Obtaining hematopoietic stem cells (HSCs) for transplantation depends on effective egress of HSCs from bone marrow into the peripheral circulation on induction. This process is impaired in a mouse model of diabetes and in patients undergoing autologous transplantation.

    Correspondence
    2539-2540

    To the Editor: In their population-based cohort study, Hvid-Jensen et al. (Oct. 13 issue)1 report an annual risk of esophageal adenocarcinoma of 0.12% among patients with Barrett's esophagus. This annual risk increased to 0.26% when high-grade dysplasia ...

    2540-2541

    To the Editor: Vestbo and colleagues (Sept. 29 issue)1 reported on the variability in the rate of the decline in forced expiratory volume in 1 second (FEV1) in patients with chronic obstructive pulmonary disease (COPD) from the cohort in the Evaluation ...

    2541-2542

    Community circulation of an oseltamivir-resistant strain of the novel pandemic influenza A (H1N1) virus has been identified in Australia.