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May 24, 2012  Vol. 366 No. 21

Audio Summary of this Issue

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

About 20% of patients with venous thrombosis or embolism but no defined risk factors have a recurrence within the first 2 years after stopping anticoagulation therapy. These authors report that 100 mg of aspirin a day nearly halved the risk of recurrence, with no increase in bleeding.

1968-1977

    Many treatments used for idiopathic pulmonary fibrosis (IPF) have not been rigorously tested. This article reports discontinuation of treatment with prednisone, azathioprine, and N-acetylcysteine (NAC) because of increased mortality, as compared with N-acetylcysteine alone or placebo.

    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

    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

    A 62-year-old man receives a diagnosis of diffuse large B-cell lymphoma; treatment with a regimen including the anti-CD20 antibody rituximab is recommended. Rituximab has been shown to improve progression-free survival when added to standard chemotherapy regimens for lymphoma.

    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
    • CME

    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,...