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May 24, 2012  Vol. 366 No. 21

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Perspective
1949-1951

Waste in U.S. health care — spending on interventions that don't benefit patients — amounts to at least 30% of health care spending and is a major driver of cost increases. So the ethical debate about cost containment is shifting focus from rationing to waste avoidance.

1951-1953
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The belief that cost should be no object in health care has limited efforts to control medical spending; elected officials generally insist that cutting services that yield no value will be sufficient. But eliminating such waste would merely postpone the reckoning.

1953-1955

The Commonwealth Fund Commission on a High Performance Health System believes the government should facilitate communities' efforts to improve care for patients with multiple chronic conditions, through improved primary care, payment reform, and better information.

1955-1957
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Gaining prompt access to primary care is a growing concern for all American adults. In Massachusetts, average wait times for new patients to obtain an internal-medicine appointment rose by 82% in the 2 years after health insurance coverage was expanded; ...

Original Articles
1959-1967
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The risk of recurrence of venous thromboembolism persists for many years after anticoagulant treatment is withdrawn.1,2 This risk is particularly high among patients with unprovoked venous thromboembolism,2 about 20% of whom have a recurrence within 2 ...

1968-1977
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Idiopathic pulmonary fibrosis is a chronic, progressive lung disease of unknown cause characterized by the histopathological pattern of usual interstitial pneumonia.1 The median survival of patients with idiopathic pulmonary fibrosis after diagnosis is 2 ...

1978-1986

Pseudomonas aeruginosa is an important pathogen in patients with cystic fibrosis. In this report, data suggest that estrogen may play a role in the modulation of virulence factors in P. aeruginosa and thus affect clinical exacerbations in women with cystic fibrosis.

1987-1997

This trial assessed the utility of preoperative urodynamic testing in women with uncomplicated stress–predominant urinary incontinence. Women having office evaluation alone had 1-year treatment-success rates noninferior to those of women also having urodynamic testing.

1998-2007
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This study involved women at high risk for unintended pregnancy who received free contraception. Long-acting reversible contraception was associated with a significantly lower risk of pregnancy than contraceptive pills, patch, or ring and was highly effective regardless of age.

Clinical Therapeutics
2008-2016

Foreword

This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this ...

Images in Clinical Medicine
2017
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A 19-year-old woman with type 1 diabetes mellitus and suspected cystic fibrosis presented with a 1-day history of acute abdominal pain. Plain radiography revealed a typical mechanical obstruction.

e32
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A 17-year-old girl presented with a 10-year history of transient excessive wrinkling of her palms after brief exposure to water and sweating. She reported some uncomfortable tightness of the skin during these epi¬sodes.

Case Records of the Massachusetts General Hospital
2018-2026
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A 32-year-old woman noted a crease in her right breast. Imaging studies showed a suspicious mass, and a biopsy specimen revealed infiltrating ductal carcinoma, positive for HER2. Staging showed liver lesions consistent with metastases. Management decisions were made.

Editorial
2028-2030

Venous thromboembolism, including deep-vein thrombosis and pulmonary embolism, is a common condition, with an annual incidence of 2 to 3 cases per 1000 in the general population.1 Although the risk of recurrence is only about 1% per year in patients with ...

Correspondence
2031-2035

To the Editor: Harrison et al. (March 1 issue)1 report findings of the Controlled Myelofibrosis Study with Oral JAK Inhibitor Treatment II (COMFORT-II) that may herald a new era in treating myelofibrosis. At week 48, 30% of patients in the ruxolitinib ...

2035-2036

To the Editor: Postow et al. (March 8 issue)1 report an abscopal effect in a patient with melanoma treated with ipilimumab and radiotherapy, with a response in nonirradiated lesions.

We have hypothesized that the radiation-induced death of tumor cells ...

2036-2037

To the Editor: Systematic and thorough fluoroscopic examination provides essential diagnostic information in patients with unilateral or bilateral diaphragmatic dysfunction. The physician can substantially improve patient comfort and cooperation by ...

2038-2040

The authors report a dramatic response to vemurafenib in a patient with hairy-cell leukemia refractory to nucleosides and rituximab.

Corrections
2040

Case 13-2012: A 62-Year-Old Man with Paresthesias, Weight Loss, Jaundice, and Anemia Case Records of the Massachusetts General Hospital, N Engl J Med 2012;366:1626-1633. In the Vitamin B12 Deficiency subsection of Differential Diagnosis (page 1630), the ...

2040

The Road to an Effective HIV Vaccine Editorial, N Engl J Med 2012;366:1343-1344. In the final paragraph of the article (page 1344), the penultimate sentence, “But if properly designed and conducted, they may play an indispensable, iterative role on the ...

2040

Case 8-2012: A 53-Year-Old Man with Crohn's Disease, Diarrhea, Fever, and Bacteremia Case Records of the Massachusetts General Hospital, N Engl J Med 2012;366:1039-1045. In the third paragraph of the Presentation of Case section, in the sentence beginning,...

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