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  • Sexual Harassment in Medicine — #MeToo
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-12-13
    Reshma Jagsi

    The problem of sexual harassment seems as severe in medicine as elsewhere, and standing up to harassers is hard for victims and institutions alike. As we work to become more proactive, it’s valuable to participate in the now open conversation about workplace harassment.

    更新日期:2018-01-18
  • Hepatitis A Outbreak in California — Addressing the Root Cause
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-12-06
    Margot Kushel

    Most people affected by California’s hepatitis A outbreak are homeless, and infectious diseases are one of many health threats they face. To address the root cause of their health problems, we will need sustained efforts to fix the housing-affordability crisis.

    更新日期:2018-01-18
  • Nudge Units to Improve the Delivery of Health Care
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Mitesh S. Patel, Kevin G. Volpp, David A. Asch
    更新日期:2018-01-18
  • E-Cigarettes and the Harm-Reduction Continuum
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Amy L. Fairchild, Ju Sung Lee, Ronald Bayer, James Curran
    更新日期:2018-01-18
  • Household-Contact Investigation for Detection of Tuberculosis in Vietnam
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Greg J. Fox, Nguyen V. Nhung, Dinh N. Sy, Nghiem L.P. Hoa, Le T.N. Anh, Nguyen T. Anh, Nguyen B. Hoa, Nguyen H. Dung, Tran N. Buu, Nguyen T. Loi, Le T. Nhung, Nguyen V. Hung, Phan T. Lieu, Nguyen K. Cuong, Pham D. Cuong, Jessica Bestrashniy, Warwick J. Britton, Guy B. Marks
    更新日期:2018-01-18
  • Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Willemien J. van Driel, Simone N. Koole, Karolina Sikorska, Jules H. Schagen van Leeuwen, Henk W.R. Schreuder, Ralph H.M. Hermans, Ignace H.J.T. de Hingh, Jacobus van der Velden, Henriëtte J. Arts, Leon F.A.G. Massuger, Arend G.J. Aalbers, Victor J. Verwaal, Jacobien M. Kieffer, Koen K. Van de Vijver, Harm van Tinteren, Neil K. Aaronson, Gabe S. Sonke
    更新日期:2018-01-18
  • Long-Term Follow-up of Monoclonal Gammopathy of Undetermined Significance
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Robert A. Kyle, Dirk R. Larson, Terry M. Therneau, Angela Dispenzieri, Shaji Kumar, James R. Cerhan, S. Vincent Rajkumar

    Background Monoclonal gammopathy of undetermined significance (MGUS) occurs in approximately 3% of persons 50 years of age or older. Methods We studied 1384 patients who were residing in southeastern Minnesota and in whom MGUS was diagnosed at the Mayo Clinic in the period from 1960 through 1994; the median follow-up was 34.1 years (range, 0.0 to 43.6). The primary end point was progression to multiple myeloma or another plasma-cell or lymphoid disorder. Results During 14,130 person-years of follow-up, MGUS progressed in 147 patients (11%), a rate that was 6.5 times (95% confidence interval [CI], 5.5 to 7.7) as high as the rate in the control population. The risk of progression without accounting for death due to competing causes was 10% at 10 years, 18% at 20 years, 28% at 30 years, 36% at 35 years, and 36% at 40 years. Among patients with IgM MGUS, the presence of two adverse risk factors — namely, an abnormal serum free light-chain ratio (ratio of kappa to lambda free light chains) and a high serum monoclonal protein (M protein) level (≥1.5 g per deciliter) — was associated with a risk of progression at 20 years of 55%, as compared with 41% among patients who had one adverse risk factor and 19% among patients who had neither risk factor. Among patients with non-IgM MGUS, the risk of progression at 20 years was 30% among those who had the two risk factors, 20% among those who had one risk factor, and 7% among those who had neither risk factor. Patients with MGUS had shorter survival than was expected in the control population of Minnesota residents of matched age and sex (median, 8.1 vs. 12.4 years; P<0.001). Conclusions Significant differences were noted in the risk of progression between patients with IgM MGUS and those with non-IgM MGUS. Overall survival was shorter among patients with MGUS than was expected in a matched control population. (Funded by the National Cancer Institute.) Supported in part by research grants (CA107476, CA168762, and CA186781) from the National Cancer Institute. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. Source Information From the Divisions of Hematology (R.A.K., A.D., S.K., S.V.R.), Biostatistics (D.R.L., T.M.T.), and Epidemiology (J.R.C.), Mayo Clinic, Rochester, MN. Address reprint requests to Dr. Kyle at the Division of Hematology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, or at kyle.robert@mayo.edu.

    更新日期:2018-01-18
  • Somatic Activating KRAS Mutations in Arteriovenous Malformations of the Brain
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Sergey I. Nikolaev, Sandra Vetiska, Ximena Bonilla, Emilie Boudreau, Suvi Jauhiainen, Behnam Rezai Jahromi, Nadiya Khyzha, Peter V. DiStefano, Santeri Suutarinen, Tim-Rasmus Kiehl, Vitor Mendes Pereira, Alexander M. Herman, Timo Krings, Hugo Andrade-Barazarte, Takyee Tung, Taufik Valiante, Gelareh Zadeh, Mike Tymianski, Tuomas Rauramaa, Seppo Ylä-Herttuala, Joshua D. Wythe, Stylianos E. Antonarakis, Juhana Frösen, Jason E. Fish, Ivan Radovanovic

    Background Sporadic arteriovenous malformations of the brain, which are morphologically abnormal connections between arteries and veins in the brain vasculature, are a leading cause of hemorrhagic stroke in young adults and children. The genetic cause of this rare focal disorder is unknown. Methods We analyzed tissue and blood samples from patients with arteriovenous malformations of the brain to detect somatic mutations. We performed exome DNA sequencing of tissue samples of arteriovenous malformations of the brain from 26 patients in the main study group and of paired blood samples from 17 of those patients. To confirm our findings, we performed droplet digital polymerase-chain-reaction (PCR) analysis of tissue samples from 39 patients in the main study group (21 with matching blood samples) and from 33 patients in an independent validation group. We interrogated the downstream signaling pathways, changes in gene expression, and cellular phenotype that were induced by activating KRAS mutations, which we had discovered in tissue samples. Results We detected somatic activating KRAS mutations in tissue samples from 45 of the 72 patients and in none of the 21 paired blood samples. In endothelial cell–enriched cultures derived from arteriovenous malformations of the brain, we detected KRAS mutations and observed that expression of mutant KRAS (KRASG12V) in endothelial cells in vitro induced increased ERK (extracellular signal-regulated kinase) activity, increased expression of genes related to angiogenesis and Notch signaling, and enhanced migratory behavior. These processes were reversed by inhibition of MAPK (mitogen-activated protein kinase)–ERK signaling. Conclusions We identified activating KRAS mutations in the majority of tissue samples of arteriovenous malformations of the brain that we analyzed. We propose that these malformations develop as a result of KRAS-induced activation of the MAPK–ERK signaling pathway in brain endothelial cells. (Funded by the Swiss Cancer League and others.) Supported by research grants to Dr. Nikolaev from the Swiss Cancer League (LSCC 2939-02-2012 and KSF-3985-08-2016), Dinu Lipatti (2014), and Novartis (14B065). Ms. Khyzha was supported by a Canada Graduate Scholarship from the Natural Sciences and Research Council of Canada. Dr. DiStefano was supported by a Postdoctoral Fellowship from the Toronto General Hospital Research Institute. Dr. Suutarinen was supported by a research grant from the Petri Honkanen Foundation. Dr. Herman was supported by a grant from the National Institutes of Health (2T32HL007676). Dr. Wythe was supported by an American Heart Association Grant-in-Aid (16GRNT31330023). Dr. Antonarakis was supported by a grant from the European Research Council. Dr. Frösen was supported by research grants from the Finnish Medical Foundation and Kuopio University Hospital. Dr. Fish was supported by an operating grant from the Canadian Institutes of Health Research (CIHR) (MOP-119506) and a Team Project Award from the University of Toronto Medicine by Design initiative, which receives funding from the Canada First Research Excellence Fund and a Canada Foundation for Innovation equipment grant; he also received an Early Researcher Award from the Ontario Ministry of Research and Innovation and funding from the Canada Research Chair Program from the CIHR. Dr. Radovanovic was supported by the Timothy P. Susco Chair of Research Award from the Brain Aneurysm Foundation, the Toronto General and Western Hospital Foundation, and received seed support from the Department of Surgery and Division of Neurosurgery at the University Health Network. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. Drs. Nikolaev, Vetiska, Frösen, Fish, and Radovanovic contributed equally to this article. This article was published on January 3, 2018, at NEJM.org. We thank the staff of the Princess Margaret Genomics Centre and Bioinformatics Services (C. Virtanen and Z. Lu) for generating the RNA and DNA sequencing data used in this study; the staff of the Centre for Applied Genomics at the Toronto Hospital for Sick Children (T. Paton) for performing droplet digital polymerase-chain-reaction analyses; Zhiqi Chen from University Health Network for help with cell biology assays; and Melanie Peralta from the Pathology Research Program, University Health Network, Toronto, for technical help with immunohistochemical analyses. Source Information From the Department of Genetic Medicine and Development, University of Geneva Medical School (S.I.N., X.B., S.E.A.), Service of Genetic Medicine, University Hospitals of Geneva (S.I.N., S.E.A.), and iGE3, Institute of Genetics and Genomics of Geneva (S.E.A.) — all in Geneva; the Department of Fundamental Neurobiology, Krembil Research Institute (S.V., M.T., I.R.), Toronto General Hospital Research Institute (E.B., N.K., P.V.D., J.E.F.), the Department of Pathology (T.-R.K.), the Division of Neurosurgery, Department of Surgery (V.M.P., T.K., H.A.-B., T.T., T.V., G.Z., M.T., I.R.), and the Joint Division of Medical Imaging, Department of Medical Imaging (V.M.P., T.K.), Toronto Western Hospital, University Health Network, the Department of Laboratory Medicine and Pathobiology, University of Toronto (E.B., N.K., P.V.D., T.-R.K., J.E.F.), and the Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research (E.B., N.K., P.V.D., J.E.F.) — all in Toronto; the Department of Molecular Medicine, AIV Institute, University of Eastern Finland (S.J., B.R.J., S.S., S.Y.-H., J.F.), and the Hemorrhagic Brain Pathology Research Group, Department of Neurosurgery and NeuroCenter (S.J., B.R.J., S.S., T.R., J.F.), and the Department of Pathology (T.R.), Kuopio University Hospital — all in Kuopio, Finland; and the Cardiovascular Research Institute and the Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston (A.M.H., J.D.W.). Address reprint requests to Dr. Nikolaev at sergey.nikolaev@unige.ch, to Dr. Frösen at juhana.frosen@kuh.fi, to Dr. Fish at jason.fish@utoronto.ca, or to Dr. Radovanovic at ivan.radovanovic@uhn.ca.

    更新日期:2018-01-18
  • Elimination of Cost Sharing for Screening Mammography in Medicare Advantage Plans
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Amal N. Trivedi, Bryan Leyva, Yoojin Lee, Orestis A. Panagiotou, Issa J. Dahabreh
    更新日期:2018-01-18
  • Toxic Alcohols
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Edward W. Campion
    更新日期:2018-01-18
  • Butterfly Glioma
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Juveria Siddiqui, Anant S. Krishnan
    更新日期:2018-01-18
  • Rib Fracture Associated with Bordetella pertussis Infection
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    John A. Zambrano, Talia N. Herman
    更新日期:2018-01-18
  • In the Balance
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Caren G. Solomon, Amy Miller, Bruce D. Levy, Joseph Loscalzo

    This interactive case features a 71-year-old man who presented with a 3-day history of changes in mental status. Test your diagnostic and therapeutic skills at NEJM.org.

    更新日期:2018-01-18
  • Case 2-2018 — A 41-Year-Old Woman with Vision Disturbances and Headache
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Richard C. Cabot, Eric S. Rosenberg, Virginia M. Pierce, David M. Dudzinski, Meridale V. Baggett, Dennis C. Sgroi, Jo-Anne O. Shepard, Allison R. Bond, Emily K. McDonald, Sally H. Ebeling
    更新日期:2018-01-18
  • A Neglected Epidemic
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Barry R. Bloom
    更新日期:2018-01-18
  • Ovarian Cancer Treatment — Are We Getting Warmer?
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    David R. Spriggs, Oliver Zivanovic

    Disclosure forms provided by the authors are available with the full text of this editorial at NEJM.org. Source Information From Memorial Sloan Kettering Cancer Center, New York.

    更新日期:2018-01-18
  • Countering HIV — Three’s the Charm?
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17
    Elizabeth G. Phimister
    更新日期:2018-01-18
  • Bivalirudin versus Heparin Monotherapy in Myocardial Infarction
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17

    To the Editor: In the VALIDATE-SWEDEHEART trial, Erlinge et al. (Sept. 21 issue)1 compared bivalirudin with heparin monotherapy in patients with acute myocardial infarction who were undergoing percutaneous coronary intervention (PCI). Treatment included the use of one of the new P2Y12 inhibitors (ticagrelor, cangrelor, or prasugrel), which was given at least 60 minutes before PCI. Patients who received or were planned to receive glycoprotein IIb/IIIa inhibitors were excluded from enrollment, and the low rates of ischemic events and stent thrombosis are probably attributable to the early administration of the new P2Y12 inhibitors. In the current era, in which immediate reperfusion . . .

    更新日期:2018-01-18
  • Evaluation and Management of Lower-Extremity Ulcers
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17

    To the Editor: In their review article, Singer et al. (Oct. 19 issue)1 mention the use of linezolid alone for the coverage of gram-positive and gram-negative and anaerobe bacteria in patients with diabetes who have lower-extremity infected ulcers. Linezolid is a synthetic oxazolidinone that inhibits the formation of the initiation complex for protein synthesis.2 It has excellent skin and soft-tissue penetration,3 and in vitro studies suggest that linezolid may inhibit the bacterial toxin synthesis and modulate the host immune response.4 However, its antibacterial spectrum is mostly restricted . . .

    更新日期:2018-01-18
  • Noninferiority Trials
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17

    To the Editor: Mauri and D’Agostino (Oct. 5 issue)1 address the challenges in noninferiority trials. Yet an ethical issue was not discussed — how to convince candidate participants2 that it is worth giving up part of the benefit provided by the current standard of care in exchange for advantages (e.g., convenience or fewer side effects) that are often of different clinical value than enhanced efficacy and are in any case not known at the outset of the trial.3 The authors illustrate their discussion using the case of noninferiority trials of new oral anticoagulants for the prevention of stroke and thromboembolism . . .

    更新日期:2018-01-18
  • Crisis in the Sustainability of the U.S. Blood System
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-17

    To the Editor: Unbundling blood products from diagnosis-related group–based comprehensive reimbursement for medical procedures, along with establishing Medicare reimbursement schedules for blood products on the basis of current costs rather than historical charges, would provide some relief from the financial crisis in the blood industry that Klein et al. (Oct. 12 issue)1 describe. However, inefficiencies of the blood market that the authors also describe would remain. These include the monopsonistic structure of the market, which limits blood suppliers’ pricing power and, consequently, their reserve capacity to respond to future biologic threats to products that are inherently vulnerable to them. The . . .

    更新日期:2018-01-18
  • 更新日期:2018-01-11
  • In-Person Health Care as Option B
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Sean Duffy, Thomas H. Lee

    Face-to-face interactions will certainly always have a central role in health care. But a system focused on high-quality nonvisit care would work better for many patients — and quite possibly for physicians as well.

    更新日期:2018-01-11
  • 更新日期:2018-01-11
  • Massachusetts’ Proposed Medicaid Reforms — Cheaper Drugs and Better Coverage?
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-12-13
    Benjamin D. Sommers, Aaron S. Kesselheim
    更新日期:2018-01-11
  • Osimertinib in Untreated EGFR-Mutated Advanced Non–Small-Cell Lung Cancer
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-11-18
    Jean-Charles Soria, Yuichiro Ohe, Johan Vansteenkiste, Thanyanan Reungwetwattana, Busyamas Chewaskulyong, Ki Hyeong Lee, Arunee Dechaphunkul, Fumio Imamura, Naoyuki Nogami, Takayasu Kurata, Isamu Okamoto, Caicun Zhou, Byoung Chul Cho, Ying Cheng, Eun Kyung Cho, Pei Jye Voon, David Planchard, Wu-Chou Su, Jhanelle E. Gray, Siow-Ming Lee, Rachel Hodge, Marcelo Marotti, Yuri Rukazenkov, Suresh S. Ramalingam
    更新日期:2018-01-11
  • Transfer of Fresh versus Frozen Embryos in Ovulatory Women
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Yuhua Shi, Yun Sun, Cuifang Hao, Heping Zhang, Daimin Wei, Yunshan Zhang, Yimin Zhu, Xiaohui Deng, Xiujuan Qi, Hong Li, Xiang Ma, Haiqin Ren, Yaqin Wang, Dan Zhang, Bo Wang, Fenghua Liu, Qiongfang Wu, Ze Wang, Haiyan Bai, Yuan Li, Yi Zhou, Mei Sun, Hong Liu, Jing Li, Lin Zhang, Xiaoli Chen, Songying Zhang, Xiaoxi Sun, Richard S. Legro, Zi-Jiang Chen
    更新日期:2018-01-11
  • IVF Transfer of Fresh or Frozen Embryos in Women without Polycystic Ovaries
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Lan N. Vuong, Vinh Q. Dang, Tuong M. Ho, Bao G. Huynh, Duc T. Ha, Toan D. Pham, Linh K. Nguyen, Robert J. Norman, Ben W. Mol
    更新日期:2018-01-11
  • Long-Term Effects of Inhaled Budesonide for Bronchopulmonary Dysplasia
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Dirk Bassler, Eric S. Shinwell, Mikko Hallman, Pierre-Henri Jarreau, Richard Plavka, Virgilio Carnielli, Christoph Meisner, Corinna Engel, Alexander Koch, Karen Kreutzer, Johannes N. van den Anker, Matthias Schwab, Henry L. Halliday, Christian F. Poets
    更新日期:2018-01-11
  • 更新日期:2018-01-11
  • Multiple Sclerosis
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Dan L. Longo
    更新日期:2018-01-11
  • Cowpox Virus Infection
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Ewa Talarek, Magdalena Marczynska
    更新日期:2018-01-11
  • Iris Abscess
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Xuejing Chen, Caroline R. Baumal
    更新日期:2018-01-11
  • Case 1-2018 — A 39-Year-Old Woman with Rapidly Progressive Respiratory Failure
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Richard C. Cabot, Eric S. Rosenberg, Virginia M. Pierce, David M. Dudzinski, Meridale V. Baggett, Dennis C. Sgroi, Jo-Anne O. Shepard, Allison R. Bond, Emily K. McDonald, Sally H. Ebeling
    更新日期:2018-01-11
  • Osimertinib as First-Line Treatment in EGFR-Mutated Non–Small-Cell Lung Cancer
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    Sanjay Popat

    Genetic analysis is now routine in metastatic non–small-cell lung cancer (NSCLC) to identify somatic sensitizing mutations in EGFR, typically L858R and exon 19 deletion (Ex19del). Patients with these genotypes are treated with first- or second-generation epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) (e.g., erlotinib, gefitinib, and afatinib) preferentially over chemotherapy owing to their marked superiority in tumor response, progression-free survival, and quality of life. Such molecular selection has seen median overall survival increase among patients with such genetic variants, from a median of 7.9 months in 20021 to 27.3 months in 2015.2 However, despite rapid and durable responses, acquired . . .

    更新日期:2018-01-11
  • Romosozumab versus Alendronate and Fracture Risk in Women with Osteoporosis
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10

    To the Editor: In their report on ARCH (the Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk), Saag and colleagues (Oct. 12 issue)1 report that postmenopausal women with osteoporosis who received 12 months of treatment with romosozumab, an antisclerostin antibody, followed by alendronate had a significantly lower risk of fracture than did those who received alendronate alone.1 However, there was a higher rate of serious cardiovascular adverse events in the romosozumab group than in the alendronate group (2.5% vs. 1.9%), including a higher rate of cardiac ischemic and cerebrovascular events (0.8% vs. 0.3%). Those findings were not . . .

    更新日期:2018-01-11
  • Canakinumab for Atherosclerotic Disease
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10
    更新日期:2018-01-11
  • Oxygen Therapy in Suspected Acute Myocardial Infarction
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10

    To the Editor: Hofmann et al. (Sept. 28 issue)1 found that oxygen supplementation in patients with suspected myocardial infarction who did not have hypoxemia at baseline did not affect 1-year mortality or the incidence of rehospitalization after 30 days. The trial outcome measures did not include any related to neurologic function or quality of life, despite the fact that cognitive deficits and functional disability often occur after myocardial infarction.2 It is unknown whether myocardial infarction, particularly in patients who have chronic hypertension or who are elderly, compromises cerebral perfusion at values that would be considered normotensive in most . . .

    更新日期:2018-01-11
  • Electrolyte Disturbances in Chronic Alcohol-Use Disorder
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-10

    To the Editor: We agree with Palmer and Clegg (Oct. 5 issue)1 that improper treatment of hyponatremia in patients with liver disease can produce cerebral demyelination, as reported by us2 and others. Moreover, another factor promoting demyelination is a hypoxic or anoxic episode before treatment of hyponatremia.2 In animals with normonatremia, hypoxia produces demyelination.3 However, a safe approach for the therapy of hyponatremic encephalopathy in patients with liver disease should be revisited. In our practice, we have used a 100-ml bolus of 3% saline rather than a continuous infusion.4 This can be repeated one or two times in sequential fashion . . .

    更新日期:2018-01-11
  • Toward a Culture of Scientific Inquiry — The Role of Medical Teaching Services
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Katrina Armstrong, Rajesh Ranganathan, Mark Fishman

    With trainees increasingly exposed to a culture that values efficiency, clinical protocols, and specialized expertise over scientific debate and critical thinking, new programs are creating linkages between unexplained patient presentations and scientific inquiry.

    更新日期:2018-01-04
  • Toward Competency-Based Medical Education
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Deborah E. Powell, Carol Carraccio

    Competency-based medical education holds the promise of producing a better-trained workforce — and for many physicians, this training could be accomplished within a shorter time frame.

    更新日期:2018-01-04
  • Removing ERISA’s Impediment to State Health Reform
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Erin C. Fuse Brown, Ameet Sarpatwari

    Many state-led health care reforms, including those addressing prescription-drug costs and surprise medical bills, have been thwarted by the Employee Retirement Income Security Act, a federal law that sets minimum standards for private employer-sponsored benefit plans.

    更新日期:2018-01-04
  • Chasing Seasonal Influenza — The Need for a Universal Influenza Vaccine
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-11-29
    Catharine I. Paules, Sheena G. Sullivan, Kanta Subbarao, Anthony S. Fauci

    As we prepare for a potentially severe influenza season, we must consider whether our current vaccines can be improved and whether longer-term, transformative vaccine approaches are needed to minimize influenza-related morbidity and mortality.

    更新日期:2018-01-04
  • Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-11-11
    Raul G. Nogueira, Ashutosh P. Jadhav, Diogo C. Haussen, Alain Bonafe, Ronald F. Budzik, Parita Bhuva, Dileep R. Yavagal, Marc Ribo, Christophe Cognard, Ricardo A. Hanel, Cathy A. Sila, Ameer E. Hassan, Monica Millan, Elad I. Levy, Peter Mitchell, Michael Chen, Joey D. English, Qaisar A. Shah, Frank L. Silver, Vitor M. Pereira, Brijesh P. Mehta, Blaise W. Baxter, Michael G. Abraham, Pedro Cardona, Erol Veznedaroglu, Frank R. Hellinger, Lei Feng, Jawad F. Kirmani, Demetrius K. Lopes, Brian T. Jankowitz, Michael R. Frankel, Vincent Costalat, Nirav A. Vora, Albert J. Yoo, Amer M. Malik, Anthony J. Furlan, Marta Rubiera, Amin Aghaebrahim, Jean-Marc Olivot, Wondwossen G. Tekle, Ryan Shields, Todd Graves, Roger J. Lewis, Wade S. Smith, David S. Liebeskind, Jeffrey L. Saver, Tudor G. Jovin
    更新日期:2018-01-04
  • Trial of Contralateral Seventh Cervical Nerve Transfer for Spastic Arm Paralysis
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-12-20
    Mou-Xiong Zheng, Xu-Yun Hua, Jun-Tao Feng, Tie Li, Ye-Chen Lu, Yun-Dong Shen, Xiao-Hua Cao, Nai-Qing Zhao, Jia-Ying Lyu, Jian-Guang Xu, Yu-Dong Gu, Wen-Dong Xu
    更新日期:2018-01-04
  • Myeloablative Autologous Stem-Cell Transplantation for Severe Scleroderma
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Keith M. Sullivan, Ellen A. Goldmuntz, Lynette Keyes-Elstein, Peter A. McSweeney, Ashley Pinckney, Beverly Welch, Maureen D. Mayes, Richard A. Nash, Leslie J. Crofford, Barry Eggleston, Sharon Castina, Linda M. Griffith, Julia S. Goldstein, Dennis Wallace, Oana Craciunescu, Dinesh Khanna, Rodney J. Folz, Jonathan Goldin, E. William St. Clair, James R. Seibold, Kristine Phillips, Shin Mineishi, Robert W. Simms, Karen Ballen, Mark H. Wener, George E. Georges, Shelly Heimfeld, Chitra Hosing, Stephen Forman, Suzanne Kafaja, Richard M. Silver, Leroy Griffing, Jan Storek, Sharon LeClercq, Richard Brasington, Mary E. Csuka, Christopher Bredeson, Carolyn Keever-Taylor, Robyn T. Domsic, M. Bashar Kahaleh, Thomas Medsger, Daniel E. Furst

    Myeloablative autologous hematopoietic stem-cell transplantation achieved long-term benefits in patients with scleroderma, including improved event-free and overall survival, at a cost of increased expected toxicity. Rates of treatment-related death and post-transplantation use of DMARDs were lower than those in previous reports of nonmyeloablative transplantation. (Funded by the National Institute of Allergy and Infectious Diseases and the National Institutes of Health; ClinicalTrials.gov number, NCT00114530.)

    更新日期:2018-01-04
  • Acute Pyelonephritis in Adults
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Caren G. Solomon

    Decisions regarding disposition and treatment in patients with pyelonephritis should be guided by assessment of the likelihood of pathogen resistance to antimicrobial agents and by patient factors (e.g., illness severity, coexisting conditions, and psychosocial situation).

    更新日期:2018-01-04
  • Favism and Glucose-6-Phosphate Dehydrogenase Deficiency
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Dan L. Longo

    When persons with G6PD deficiency eat fava beans, acute hemolytic anemia may develop. It is caused by the generation of free radicals from the metabolism of glucosides in the beans. The free radicals damage red cells, resulting in intravascular and extravascular lysis.

    更新日期:2018-01-04
  • Poland Syndrome
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Kelsey R. Kennedy, Apphia L. Wang

    An 86-year-old man presented to the dermatology clinic for a routine examination and was noted to have an absent right pectoralis major muscle and brachydactyly of the right hand — findings consistent with the Poland syndrome.

    更新日期:2018-01-04
  • Pneumomediastinum Associated with Influenza A Infection
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Christopher T. Mansbridge, Matthew Inada-Kim

    A 33-year-old man with fever, lethargy, and hypoxemia received a diagnosis of influenza A infection. Pneumomediastinum and opacities in both lungs were seen on chest imaging.

    更新日期:2018-01-04
  • Going from A to Z
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Caren G. Solomon

    A 70-year-old man presented to the emergency department with a 3-month history of diarrhea, without blood or mucus. He also noted nausea, nonbloody emesis, and weight loss.

    更新日期:2018-01-04
  • A New DAWN for Imaging-Based Selection in the Treatment of Acute Stroke
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-11-11
    Werner Hacke

    Two years ago, the publication of the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands),1 which investigated endovascular mechanical thrombectomy for the treatment of acute ischemic stroke, was called “a first step in the right direction.” Since then, there have been five trials of thrombectomy for stroke that have shown positive outcomes. A pooled analysis of these trials2 confirmed the efficacy of thrombectomy that is performed within 6 hours after the onset of stroke in patients with occlusion of a cerebral large vessel (intracranial internal carotid artery or proximal middle cerebral . . .

    更新日期:2018-01-04
  • Rewiring to Regain Function in Patients with Spastic Hemiplegia
    N. Engl. J. Med. (IF 72.406) Pub Date : 2017-12-20
    Robert J. Spinner, Alexander Y. Shin, Allen T. Bishop

    Spastic hemiplegia results from several relatively common disorders, including stroke, traumatic brain injury, and cerebral palsy. Frequently, upper-limb function is impaired. In this issue of the Journal, Zheng et al.1 report a new approach to the treatment of this condition: the use of a contralateral C7 nerve transfer from the nonparalyzed side to the paralyzed side in order to engage the unimpaired cerebral hemisphere. Nerve transfers have long been performed as treatment for lesions affecting the lower motor neurons, mostly involving the brachial plexus. Gu and colleagues at Huashan Hospital, Fudan University, in Shanghai have pioneered nerve transfers, particularly those . . .

    更新日期:2018-01-04
  • Management of Sentinel-Node Metastasis in Melanoma
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Lisa Caulley, Charles M. Balch, Merrick I. Ross, Caroline Robert

    This interactive feature about melanoma with sentinel lymph-node metastasis offers a case vignette accompanied by essays that support either recommending or not recommending completion lymph-node dissection to improve disease control and provide precise staging.

    更新日期:2018-01-04
  • Making a Better Hematopoietic Stem Cell — Timing Is Everything
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Elizabeth G. Phimister

    Ex vivo manipulation of hematopoietic stem cells renders them susceptible to apoptosis. A study using a mouse model demonstrates a strategy to guard against their apoptotic demise.

    更新日期:2018-01-04
  • Ofatumumab for TTP in a Patient with Anaphylaxis Associated with Rituximab
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03
    Maeve P. Crowley, Vickie McDonald, Marie Scully

    A patient with refractory thrombotic thrombocytopenic purpura had anaphylaxis associated with rituximab that was mediated by human antichimeric antibodies. The patient was successfully treated with ofatumumab, with restoration of ADAMTS13 levels.

    更新日期:2018-01-04
  • Weight and Metabolic Outcomes 12 Years after Gastric Bypass
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03

    To the Editor: The study by Adams et al. (Sept. 21 issue)1 provides further evidence regarding the durable effects of bariatric surgery on both weight loss and type 2 diabetes. It also supports data from randomized, controlled trials indicating that bariatric surgery is the most effective current therapy for the management of both conditions. However, we note that the authors chose to define diabetes outcomes using criteria that differ from those used in other recent similar studies. Indeed, a number of differing diabetes outcome definitions have been used in the published literature, which raises concern regarding the comparability of these . . .

    更新日期:2018-01-04
  • Delirium in Hospitalized Older Adults
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03

    To the Editor: Marcantonio (Oct. 12 issue)1 lists urinary tract infection as a contributing factor to delirium in older patients and recommends evaluating and treating such patients for urinary tract infection. However, underlying cognitive and functional deficits predispose elderly patients to both delirium and asymptomatic bacteriuria, creating an association even without causation.2 The attribution of delirium to coincidentally discovered (and probably causally unrelated) bacteriuria leads to considerable use of antibiotic agents, with uncertain benefit and possible harms. This clinical scenario represents a contentious evidence-free zone. Infectious disease specialists regard this entity as asymptomatic bacteriuria, for which high-quality evidence supports nontreatment.2,3 . . .

    更新日期:2018-01-04
  • Adverse Effects of Red-Cell Transfusion
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03

    To the Editor: In their review article about red-cell transfusion, Carson et al. (Sept. 28 issue)1 note the costs and damage to cells that are associated with pathogen reduction. They also refer to platelets and plasma in their discussion of the Intercept (Cerus) technology, which involves a lengthy procedure that exposes patients to amotosalen (a synthetic psoralen), glutathione, and ultraviolet light. Increased costs are associated with this process for platelets,2 and a recently reported randomized, controlled trial comparing transfusions of Intercept-treated platelets with standard platelet transfusions3 showed that the increments in platelet counts after transfusion were significantly lower in the . . .

    更新日期:2018-01-04
  • Global Burden of Rheumatic Heart Disease
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-01-03

    To the Editor: Watkins et al. (Aug. 24 issue)1 report that the health-related burden of rheumatic heart disease has declined worldwide. However, the authors emphasize mainly heart failure as the burden of rheumatic heart disease, whereas other complications were neglected. Patients with mild rheumatic heart disease that may not be clinically detectable are at increased risk for death and complications from other heart-related causes. For example, transient or sustained atrial fibrillation is sometimes observed in clinically asymptomatic patients with mild or moderate rheumatic mitral stenosis, which is often diagnosed on echocardiography after complications, such as stroke, have occurred.2-4 Stroke, peripheral-artery . . .

    更新日期:2018-01-04
Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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