Refine Search

New Search

Results in The New England Journal of Medicine: 199,114

(searched for: container_group_id:(2035))
Page of 3,983
Articles per Page
by
Show export options
  Select all
Comment
, Paul Manhas, Katie Gates, , Frank L Van De Veerdonk, , , Guy Thwaites, Marcel Wolbers
The New England Journal of Medicine, Volume 377, pp 1402-1403; https://doi.org/10.1056/nejmc1709123

Abstract:
Le et al. (June 15 issue)1 report that amphotericin B was superior to itraconazole in the treatment of talaromycosis and that the rates of adverse events were higher with amphotericin B use. However, some issues need to be discussed. The investigators did not report severity of illness or preexisting medical conditions. The treatment of talaromycosis depends on the severity of the infection, because itraconazole is recommended for milder forms of talaromycosis and amphotericin B or voriconazole for more severe forms.2 The efficacy of treatment in both study groups can be misleading if, for instance, patients were not adequately treated or were overtreated on the basis of the severity of their infection. The presence of preexisting medical conditions could influence treatment outcomes, because patients with these conditions may be more susceptible to negative outcomes.
Comment
Phillips Rupert, Chaudry Sabah,
The New England Journal of Medicine, Volume 377, pp 1400-1402; https://doi.org/10.1056/nejmc1710381

Abstract:
Jaiswal and colleagues (July 13 issue)1 report that the presence of clonal hematopoiesis of indeterminate potential (CHIP) was associated with coronary heart disease. However, the use of the JAK2 V617F mutation as a marker of CHIP may be misleading, particularly when the mutant allele burden is high (up to 52% in this study). Unlike all the other mutations that were evaluated by the authors, JAK2 V617F is an initiating mutation that causes deregulated production of red cells and platelets.2 It is a major criterion in the classification of the World Health Organization (WHO) for a diagnosis of myeloproliferative neoplasms, diseases that are often diagnosed after major thrombosis, including myocardial infarctions.3-5 Jaiswal and colleagues considered that leukocyte counts can be used to rule out myeloproliferative neoplasms, whereas hematocrit and platelet counts are much more relevant for this purpose, especially in polycythemia vera and essential thrombocythemia. In the absence of full blood counts, one could speculate that many of the patients with a high JAK2 V617F allele burden are more likely to have undiagnosed myeloproliferative neoplasms than to be healthy CHIP carriers. Therefore, we suggest that the JAK2 V617F mutation should not be included in the definition of CHIP because of its specific involvement in the pathogenesis of myeloproliferative neoplasms.
Debra F. Weinstein, Fidencio Saldana
The New England Journal of Medicine, Volume 377, pp 1913-1915; https://doi.org/10.1056/nejmp1713102

Abstract:
While we wait for Congress to act to protect the “Dreamers” — the young immigrants who were covered by the Deferred Action for Childhood Arrivals program — graduate medical education programs and their potential applicants have tough decisions to make.
Henry J. Aaron
The New England Journal of Medicine, Volume 377, pp 2207-2209; https://doi.org/10.1056/NEJMp1713346

Abstract:
According to a June 2017 poll, Americans agree by a 60-to-39 margin that the federal government bears a responsibility to ensure health care for all Americans; 33% said that they favored a “single-payer” health system, 12% more than in 2014.1 The prevailing belief that the government should actively promote broader health insurance coverage contrasts strikingly with the nearly successful effort this year to repeal the Affordable Care Act (ACA), executive orders that threaten to destabilize ACA marketplaces, and repeated calls by the majority party in Congress to slash Medicaid spending.
Roy C. Ziegelstein, Charles G. Prober, Lloyd B. Minor, George Q. Daley, Paul B. Rothman, Edward M. Hundert
The New England Journal of Medicine, Volume 377, pp 2415-2417; https://doi.org/10.1056/nejmp1713146

Abstract:
In 2016, the average cost of attending medical school (including tuition and fees) in the United States was $253,720 for in-state graduates and $313,897 for out-of-state graduates.1 Nearly three in four graduates had educational debt, and the median educational debt was $190,000.2 Average debt related to medical education alone was $167,172.1 These figures suggest that, without scholarship support, only students with access to substantial personal resources or students willing to incur large amounts of educational debt can hope to attend medical school.
James A. Morone
The New England Journal of Medicine, Volume 377, pp 2209-2211; https://doi.org/10.1056/NEJMp1713510

Abstract:
In April 1946, President Harry Truman introduced a single-payer health plan and met the same reaction that would greet Senator Bernie Sanders (I-VT) and his colleagues when they proposed “Medicare for All” in September 2017. “It is believed by competent Congressional observers to have little chance of approval,” reported the New York Times back in 1949. Newsweek was blunter: “No chance at all.” Neither Truman nor Sanders even bothered to include financing for their plans. Truman had no more success with a scaled-back proposal to cover only people over 65 years of age, but 13 years later President Lyndon Johnson signed the Truman revision into law as Medicare, declaring that the United States was finally harvesting “the seeds of compassion and duty” that his predecessor had sown.1 A proposal with no chance in one era had become law in another. Medicare proved so popular that it came to be a third rail of American politics — dangerous to touch. What lessons does Truman’s success hold for today’s “no chance” Medicare for All?
, , Gerrit Haaker, , , , Margarete Pfäfflin, Christian Elger, , , et al.
The New England Journal of Medicine, Volume 377, pp 1648-1656; https://doi.org/10.1056/nejmoa1703784

Abstract:
Detailed neuropathological information on the structural brain lesions underlying seizures is valuable for understanding drug-resistant focal epilepsy. We report the diagnoses made on the basis of resected brain specimens from 9523 patients who underwent epilepsy surgery for drug-resistant seizures in 36 centers from 12 European countries over 25 years. Histopathological diagnoses were determined through examination of the specimens in local hospitals (41%) or at the German Neuropathology Reference Center for Epilepsy Surgery (59%). The onset of seizures occurred before 18 years of age in 75.9% of patients overall, and 72.5% of the patients underwent surgery as adults. The mean duration of epilepsy before surgical resection was 20.1 years among adults and 5.3 years among children. The temporal lobe was involved in 71.9% of operations. There were 36 histopathological diagnoses in seven major disease categories. The most common categories were hippocampal sclerosis, found in 36.4% of the patients (88.7% of cases were in adults), tumors (mainly ganglioglioma) in 23.6%, and malformations of cortical development in 19.8% (focal cortical dysplasia was the most common type, 52.7% of cases of which were in children). No histopathological diagnosis could be established for 7.7% of the patients. In patients with drug-resistant focal epilepsy requiring surgery, hippocampal sclerosis was the most common histopathological diagnosis among adults, and focal cortical dysplasia was the most common diagnosis among children. Tumors were the second most common lesion in both groups. (Funded by the European Union and others.)
Comment
The New England Journal of Medicine, Volume 377, pp 1692-1694; https://doi.org/10.1056/nejmc1711335

Abstract:
The study conducted by Jordan et al. (Aug. 3 issue)1 included a low-risk population (2 patients did not have donor-specific antibodies) and pretreatment class I donor-specific antibody levels (the major risk factor for antibody-mediated rejection) were modest (mean [±SD] fluorescence intensity, 5660±2364), yet a high rate of rejection occurred (10 of 22 patients [45%] with donor-specific antibodies). These data raise serious concerns for higher-risk patients.
The New England Journal of Medicine, Volume 377, pp 1657-1665; https://doi.org/10.1056/nejmra1614676

Abstract:
There has been a sharp increase in the demand for fertility preservation. This review summarizes the indications and current options and describes new techniques and strategies, including those for women with newly diagnosed malignant disease.
The New England Journal of Medicine, Volume 377, pp 1688-1690; https://doi.org/10.1056/nejmc1711659

Abstract:
Left-handed people possess less hemispheric lateralization than right-handers,1 meaning that there is generally less differentiation between the functions of the right and left hemispheres of the brain. In a letter published in the Journal in 1982, McLean and Ciurczak2 claimed that in baseball this lack of lateralization provides a relative advantage to batters who both throw and bat left-handed. They found an overrepresentation of left-handed batters in professional baseball, relative to lesser-skilled controls, and higher batting averages among professionals who throw left-handed and bat left-handed than among those who throw right-handed and bat left-handed or those who throw right-handed and bat right-handed ( Table 1 ). However, our reanalysis, 35 years later, shows an oversight that could have supported a very different conclusion.
, Michael S. Gee, Oscar J. Benavidez, Erik S. Shank, Kevin A. Raskin, Allan M. Goldstein, Branko Bojovic
The New England Journal of Medicine, Volume 377, pp 1667-1677; https://doi.org/10.1056/NEJMcpc1706105

Abstract:
Dicephalic, dithoracic, omphalo-ischiopagus 22-month-old conjoined twins were evaluated in the pediatric surgery clinic. Twin A was smaller and less active than Twin B; imaging studies revealed complex congenital heart disease. Management decisions were made.
Eden R. Cardozo, Warren J. Huber, Ashley R. Stuckey,
The New England Journal of Medicine, Volume 377, pp 1607-1609; https://doi.org/10.1056/nejmp1709585

Abstract:
Connecticut and Rhode Island recently became the first U.S. states to mandate insurance coverage of fertility-preservation services for patients about to undergo a medical treatment — surgery, radiation, or chemotherapy — that may have deleterious effects on the gonads.
Comment
, Paul A Reilly, Jeffrey I Weitz, , Jou-Fang Deng, , ,
The New England Journal of Medicine, Volume 377, pp 1690-1692; https://doi.org/10.1056/nejmc1711337

Abstract:
Data provided by Pollack and colleagues (Aug. 3 issue)1 suggest a dissociation between the normalization of the coagulation profile and the establishment of effective hemostasis after the administration of idarucizumab in patients with uncontrolled bleeding. The median time to the cessation of bleeding was 2.5 hours among patients with nonintracranial hemorrhage. In analyses reported separately, the median time to the cessation of bleeding was 3.5 hours among patients with gastrointestinal bleeding and 4.5 hours among those with nonintracranial and nongastrointestinal bleeding.2 The median time to the cessation of bleeding was 11.4 hours when intracranial hemorrhage was included in the analysis involving patients with serious bleeding.3 Should clinicians rely solely on idarucizumab and hope that their patients do not die from uncontrolled hemorrhage while waiting for hemostasis to be established? A reasonable approach would be to administer blood-component therapy (e.g., prothrombin complex concentrate and activated prothrombin complex concentrate) — a bridge between the normalization of the coagulation profile and the establishment of hemostasis, according to in vitro and preclinical data4,5 — in addition to idarucizumab. It can be reasonably argued that the establishment of effective hemostasis with blood-component and idarucizumab therapy outweighs the risk of thrombotic adverse events among patients with serious hemorrhaging. The effectiveness and need for further blood-component and idarucizumab therapy may be assessed by serial clinical assessments and a serial profile of clotting times.
Angela M. Caliendo, Richard L. Hodinka
The New England Journal of Medicine, Volume 377, pp 1685-1687; https://doi.org/10.1056/nejmcibr1704902

Abstract:
A new method for detecting infectious disease involves the use of a genetic probe and an enzyme that is activated once the probe specifically binds the DNA of the pathogen.
Comment
The New England Journal of Medicine, Volume 377, pp 1698-1699; https://doi.org/10.1056/nejmc1711803

Abstract:
In the discussion of preventive therapy for migraines, Charles (Aug. 10 issue)1 did not include aspirin as an effective option. Several large, randomized, double-blind, placebo-controlled trials, including the Physicians’ Health Study,2 have reported that the regular use of low-dose aspirin is effective in migraine prevention. A recent systematic review of studies on migraine prophylaxis with aspirin confirmed that regular use of low-dose aspirin can reduce the frequency of migraine.3 A comparison study of aspirin and metoprolol for migraine prevention reported reductions in migraine frequency in both groups, with the metoprolol group having a greater response (42.5%, vs. 29.6% in the aspirin group) but also having more medication-related side effects than the aspirin group.4 Another recent review of drugs for migraine also neglected to discuss the effectiveness of aspirin in prophylaxis.5 Given its documented effectiveness, low side-effect profile (especially in the young), and low cost, aspirin should not be overlooked as a useful means of migraine prevention.
The New England Journal of Medicine, Volume 377, pp 1605-1607; https://doi.org/10.1056/nejmp1710608

Abstract:
There are now an estimated 19.5 million people worldwide living with HIV and receiving antiretroviral therapy (ART). That’s approximately half of all people thought to be living with the virus in 2017 — an extraordinary achievement in global health and human solidarity. The United Nations agencies, led by the Joint United Nations Program on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), have committed to the goals of ending the AIDS pandemic as a public health threat by 2030 and ensuring that by 2020, 90% of people with HIV infection know they have it, 90% of those infected are receiving ART, and sustained viral suppression is achieved in 90% of those receiving treatment.1 This last goal is critically important both to individual health and survival and to epidemic control of HIV, since data continue to mount showing that viral suppression greatly reduces the risk of continued transmission — whether sexual or perinatal — of the virus.
Raphael Rush
The New England Journal of Medicine, Volume 377, pp 1610-1611; https://doi.org/10.1056/NEJMp1709679

Abstract:
“I blacked out driving the other day,” my patient said. “Just for a few seconds, in a parking lot, and I’ve been fine ever since.”
Rekha Dwivedi, , , , , Mani Kalaivani, , Chandra S. Bal, , Sada N. Dwivedi, et al.
The New England Journal of Medicine, Volume 377, pp 1639-1647; https://doi.org/10.1056/nejmoa1615335

Abstract:
Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but additional data are needed from randomized trials. In this single-center trial, we randomly assigned 116 patients who were 18 years of age or younger with drug-resistant epilepsy to undergo brain surgery appropriate to the underlying cause of epilepsy along with appropriate medical therapy (surgery group, 57 patients) or to receive medical therapy alone (medical-therapy group, 59 patients). The patients in the medical-therapy group were assigned to a waiting list for surgery. The primary outcome was freedom from seizures at 12 months. Secondary outcomes were the score on the Hague Seizure Severity scale, the Binet–Kamat intelligence quotient, the social quotient on the Vineland Social Maturity Scale, and scores on the Child Behavior Checklist and the Pediatric Quality of Life Inventory. At 12 months, freedom from seizures occurred in 44 patients (77%) in the surgery group and in 4 (7%) in the medical-therapy group (P<0.001). Between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the score on the Hague Seizure Severity scale (difference, 19.4; 95% confidence interval [CI], 15.8 to 23.1; P<0.001), on the Child Behavior Checklist (difference, 13.1; 95% CI, 10.7 to 15.6; P<0.001), on the Pediatric Quality of Life Inventory (difference, 21.9; 95% CI, 16.4 to 27.6; P<0.001), and on the Vineland Social Maturity Scale (difference, 4.7; 95% CI, 0.4 to 9.1; P=0.03), but not on the Binet–Kamat intelligence quotient (difference, 2.5; 95% CI, −0.1 to 5.1; P=0.06). Serious adverse events occurred in 19 patients (33%) in the surgery group, including hemiparesis in 15 (26%). In this single-center trial, children and adolescents with drug-resistant epilepsy who had undergone epilepsy surgery had a significantly higher rate of freedom from seizures and better scores with respect to behavior and quality of life than did those who continued medical therapy alone at 12 months. Surgery resulted in anticipated neurologic deficits related to the region of brain resection. (Funded by the Indian Council of Medical Research and others; Clinical Trial Registry–India number, CTRI/2010/091/000525.)
Comment
, Xavier Jouven, Jean P Empana, Katherine Esposito, , Maria I Maiorino, Song J Lee, , , Shilpa N Bhupathiraju, et al.
Published: 28 September 2017
The New England Journal of Medicine, Volume 377, pp 1303-1305; https://doi.org/10.1056/nejmc1710523

Abstract:
Sotos-Prieto et al. (July 13 issue)1 report that improvement in diet quality during the 12-year study period was consistently associated with a reduced risk of death. Their report may be easily interpreted as suggesting that beneficial effects of specific foods or a type of diet (e.g., the Alternate Mediterranean Diet and Dietary Approaches to Stop Hypertension [DASH] diet, as evaluated in the study) contributed to the reduction in the risk of death.
Comment
, R Jeffrey Karnes, , Gerald L Andriole, Michael K Brawer, , Laurence Klotz
Published: 28 September 2017
The New England Journal of Medicine, Volume 377, pp 1301-1303; https://doi.org/10.1056/nejmc1710384

Abstract:
In reporting the results of the Prostate Cancer Intervention versus Observation Trial (PIVOT), Wilt et al. (July 13 issue)1 indicate no significant decrease in all-cause or prostate-cancer mortality among men assigned to surgery, as compared with those assigned to observation (hazard ratio, 0.84; 95% confidence interval, 0.70 to 1.01; P=0.06). These results almost certainly reflect a type II error from a lack of power. The authors enrolled 731 men from a targeted accrual of 2000 men. Doubling the trial cohort to 1462 patients (still well short of the targeted accrual) would have resulted in a 76% probability of a significant effect.2
Comment
Chao Cao, Xue Kong,
Published: 21 September 2017
The New England Journal of Medicine, Volume 377, pp 1204-1205; https://doi.org/10.1056/nejmc1709523

Abstract:
Nair et al. (June 22 issue)1 found in the ZONDA trial that the median blood eosinophil counts fell dramatically after treatment with benralizumab. In a previous trial, Bleecker et al.2 found that blood eosinophil counts were reduced by benralizumab treatment. To avoid bias, what was done to prevent unmasking of the trial-group assignment to the investigators by means of the patients’ eosinophil counts?
Comment
Published: 21 September 2017
The New England Journal of Medicine, Volume 377, pp 1202-1204; https://doi.org/10.1056/nejmc1709128

Abstract:
Denic et al. (June 15 issue)1 found a fairly constant single-nephron glomerular filtration rate (GFR) among kidney donors, even with declining numbers of nephrons in persons younger than 70 years of age. It is unclear whether there was a correlation between the number of nephrons and the single-nephron GFR in an analysis adjusted for demographic characteristics and other variables. It would be informative if the authors examined their data using such adjustments.
Keith Romano, James H. Maguire, Valeria Pazo, Xiaohua Qian, Anand Vaidya
Published: 21 September 2017
The New England Journal of Medicine, Volume 377; https://doi.org/10.1056/nejmimc1616026

Abstract:
Interactive Medical Case from The New England Journal of Medicine — The Road Less Traveled
The New England Journal of Medicine, Volume 377, pp 2105-2107; https://doi.org/10.1056/nejmp1713247

Abstract:
Most complaints about the Affordable Care Act (ACA) (e.g., high and rising insurance premiums, large deductibles, and insurer exits) relate to nongroup insurance markets. These markets, the ones that were the most dysfunctional before the ACA, provide coverage to just 7% of the nonelderly population (under 65 years of age) and 6% of the full U.S. population. The ACA’s changes to employer-sponsored insurance plans, Medicare, and Medicaid were more limited, and enrollees are generally satisfied with those coverage options. The problems with the nongroup market, though significant, are fixable, and correcting them does not necessitate disruption of coverage for the remaining 94% of the population.
Jeanne M. Lambrew
The New England Journal of Medicine, Volume 377, pp 2107-2109; https://doi.org/10.1056/nejmp1712948

Abstract:
At the end of the 2017 Obamacare repeal-and-replace legislative battle (and before the next one begins), it is worth taking stock of why — defying the odds — the Affordable Care Act (ACA) still stands. From my perspective as an Obama administration veteran of every near-death experience of the law to date, this one is notable for its unlikely heroes.
Comment
Jonathan P. Piccini, W. Schuyler Jones
The New England Journal of Medicine, Volume 377, pp 1580-1582; https://doi.org/10.1056/nejme1710753

Abstract:
The management of atrial fibrillation in patients who have undergone percutaneous coronary intervention (PCI) for the treatment of coronary-artery disease is a common and difficult challenge. In patients with atrial fibrillation, oral anticoagulation is administered to reduce the risk of stroke. In patients who have undergone PCI, dual antiplatelet therapy is administered to prevent major adverse cardiovascular events and stent thrombosis. The use of triple therapy is common in clinical practice; one in four older patients with atrial fibrillation who have had an acute myocardial infarction receives triple therapy.1 Although triple therapy may minimize the risk of stent thrombosis and . . .
Comment
Ming-Ju Tsai, ,
The New England Journal of Medicine, Volume 377, pp 1602-1602; https://doi.org/10.1056/nejmc1710379

Abstract:
The article by Brown et al. (July 13 issue)1 provides a comprehensive review of the mechanisms, pathophysiological processes, and clinical features of amyotrophic lateral sclerosis (ALS). However, although the options for disease-modifying treatment for ALS are limited, the importance of multidisciplinary symptom-based management, which may increase survival and improve quality of life, should be emphasized.2
, Marjolein Dremmen, Aaike Van Den Berg, , Laura M.E. Blanken, Ryan L. Muetzel, Koen Bolhuis, Rosa M. Mulder, , Toyah A. Jansen, et al.
The New England Journal of Medicine, Volume 377, pp 1593-1595; https://doi.org/10.1056/nejmc1710724

Abstract:
Incidentally discovered findings on brain magnetic resonance imaging (MRI) in healthy persons pose medical and ethical considerations regarding management.1 The prevalence of incidental findings on brain MRI has been described in adult populations,2 but less is known about incidental findings in children. We report the prevalence of incidental findings on brain MRI in a large, single-center neuroimaging study involving a general pediatric population. From April 2013 through November 2015, a total of 3966 children (mean age, 10.1 years; range, 8.6 to 11.9) in the population-based Generation R Study3 — designed to prospectively identify early environmental and genetic influences on normal and abnormal growth, development, and health during fetal life, childhood, and young adulthood — underwent MRI scanning of the brain on a single 3-Tesla scanner. Scans were systematically reviewed by trained researchers and neuroradiologists for the presence of incidental findings ( Table 1 ).
Reed V. Tuckson, , Michael L. Hodgkins
The New England Journal of Medicine, Volume 377, pp 1585-1592; https://doi.org/10.1056/nejmsr1503323

Abstract:
Telehealth, a term used interchangeably with telemedicine, has been defined as the use of medical information that is exchanged from one site to another through electronic communication to improve a patient’s health.1 The purpose of this article is to present policy-relevant trends in telehealth adoption, to describe the state of the telehealth evidence base, and to assist physicians, other health care professionals, and researchers in identifying key priorities for telehealth research. Such research is necessary to fully realize the promise of telehealth to address socially desirable goals such as the quadruple aim in health care: improving the patient experience of care, improving the health of populations, reducing the per capita cost of health care, and improving the experience of providing care.
The New England Journal of Medicine, Volume 377, pp 1551-1558; https://doi.org/10.1056/nejmsa1701791

Abstract:
The Hospital Readmissions Reduction Program penalizes hospitals that have high 30-day readmission rates across specific conditions. There is support for changing to a hospital-wide readmission measure to broaden hospital eligibility and provide incentives for improvement across more conditions.
, Susan H. Wootton, Catherine Eppes
The New England Journal of Medicine, Volume 377, pp 1505-1507; https://doi.org/10.1056/nejmp1707273

Abstract:
Perspective from The New England Journal of Medicine — A Devastating Delay — Zika and the Implementation Gap
Dafna Gladman, William Rigby, Valderilio F. Azevedo, Frank Behrens, , Andrzej Kaszuba, Elizabeth Kudlacz, Cunshan Wang, Sujatha Menon, Thijs Hendrikx, et al.
The New England Journal of Medicine, Volume 377, pp 1525-1536; https://doi.org/10.1056/nejmoa1615977

Abstract:
Tofacitinib is an oral Janus kinase inhibitor that is under investigation for the treatment of psoriatic arthritis. We evaluated tofacitinib in patients with active psoriatic arthritis who had previously had an inadequate response to tumor necrosis factor (TNF) inhibitors. In this 6-month randomized, placebo-controlled, double-blind, phase 3 trial, we randomly assigned 395 patients, in a 2:2:1:1 ratio, to four regimens: 5 mg of tofacitinib administered orally twice daily (132 patients); 10 mg of tofacitinib twice daily (132 patients); placebo, with a switch to 5 mg of tofacitinib twice daily at 3 months (66 patients); or placebo, with a switch to 10 mg of tofacitinib twice daily at 3 months (65 patients). Data from the patients who received placebo during the first 3 months of the trial were pooled. The primary end points were the percentage of patients who had at least 20% improvement according to the criteria of the American College of Rheumatology (ACR20 response) and the change from baseline score on the Health Assessment Questionnaire–Disability Index (HAQ-DI; scores range from 0 to 3, with higher scores indicating greater disability) at the month 3 analysis. At 3 months, the rates of ACR20 response were 50% with the 5-mg dose of tofacitinib and 47% with the 10-mg dose, as compared with 24% with placebo (P<0.001 for both comparisons); the corresponding mean changes from baseline in HAQ-DI score were −0.39 and −0.35, as compared with −0.14 (P<0.001 for both comparisons). Serious adverse events occurred in 4% of the patients who received the 5-mg dose of tofacitinib continuously and in 6% who received the 10-mg dose continuously. Over the course of 6 months, there were four serious infections, three herpes zoster infections, one myocardial infarction, and one ischemic stroke among the patients who received tofacitinib continuously. Elevations of aspartate and alanine aminotransferase concentrations of three or more times the upper limit of the normal range occurred in more patients who received tofacitinib continuously than in patients who received placebo followed by tofacitinib. In this trial involving patients with active psoriatic arthritis who had had an inadequate response to TNF inhibitors, tofacitinib was more effective than placebo over 3 months in reducing disease activity. Adverse events were more frequent with tofacitinib than with placebo. (Funded by Pfizer; OPAL Beyond ClinicalTrials.gov number, NCT01882439.)
Ameet Sarpatwari, Niteesh K. Choudhry
The New England Journal of Medicine, Volume 377, pp 1509-1511; https://doi.org/10.1056/nejmp1708911

Abstract:
HIPAA regulations designed to protect patient privacy may be preventing patient-engagement tools from reaching their full potential. It may be time to reassess what levels of privacy and security are reasonable and appropriate for providing effective care.
, Abhijeet Dhoble
The New England Journal of Medicine, Volume 377; https://doi.org/10.1056/nejmicm1615835

Abstract:
Images in Clinical Medicine from The New England Journal of Medicine — Takotsubo Cardiomyopathy
, Florian J. Fintelmann, , Amulya Nagarur, Frank B. Cortazar
The New England Journal of Medicine, Volume 377, pp 1569-1578; https://doi.org/10.1056/NEJMcpc1703513

Abstract:
A 64-year-old man presented with headache, dyspnea, wheezing, cough, and night sweats. He had eosinophilia, sinusitis on CT, and abnormal results on pulmonary-function tests, including an elevated fraction of exhaled nitric oxide. Diagnostic tests were performed.
Philip Mease, Stephen Hall, , Désirée van der Heijde, Joseph F. Merola, Francisco Avila-Zapata, Dorota Cieślak, Daniela Graham, Cunshan Wang, Sujatha Menon, et al.
The New England Journal of Medicine, Volume 377, pp 1537-1550; https://doi.org/10.1056/nejmoa1615975

Abstract:
Tofacitinib is an oral Janus kinase inhibitor that is under investigation for the treatment of psoriatic arthritis. We evaluated tofacitinib in patients with active psoriatic arthritis who previously had an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (DMARDs). In this 12-month, double-blind, active-controlled and placebo-controlled, phase 3 trial, we randomly assigned patients in a 2:2:2:1:1 ratio to receive one of the following regimens: tofacitinib at a 5-mg dose taken orally twice daily (107 patients), tofacitinib at a 10-mg dose taken orally twice daily (104), adalimumab at a 40-mg dose administered subcutaneously once every 2 weeks (106), placebo with a blinded switch to the 5-mg tofacitinib dose at 3 months (52), or placebo with a blinded switch to the 10-mg tofacitinib dose at 3 months (53). Placebo groups were pooled for analyses up to month 3. Primary end points were the proportion of patients who had an American College of Rheumatology 20 (ACR20) response (≥20% improvement from baseline in the number of tender and swollen joints and at least three of five other important domains) at month 3 and the change from baseline in the Health Assessment Questionnaire–Disability Index (HAQ-DI) score (scores range from 0 to 3, with higher scores indicating greater disability) at month 3. ACR20 response rates at month 3 were 50% in the 5-mg tofacitinib group and 61% in the 10-mg tofacitinib group, as compared with 33% in the placebo group (P=0.01 for the comparison of the 5-mg dose with placebo; P<0.001 for the comparison of the 10-mg dose with placebo); the rate was 52% in the adalimumab group. The mean change in the HAQ-DI score was −0.35 in the 5-mg tofacitinib group and −0.40 in the 10-mg tofacitinib group, as compared with −0.18 in the placebo group (P=0.006 for the comparison of the 5-mg dose with placebo; P<0.001 for the comparison of the 10-mg dose with placebo); the score change was −0.38 in the adalimumab group. The rate of adverse events through month 12 was 66% in the 5-mg tofacitinib group, 71% in the 10-mg tofacitinib group, 72% in the adalimumab group, 69% in the placebo group that switched to the 5-mg tofacitinib dose, and 64% in the placebo group that switched to the 10-mg tofacitinib dose. There were four cases of cancer, three serious infections, and four cases of herpes zoster in patients who received tofacitinib during the trial. The efficacy of tofacitinib was superior to that of placebo at month 3 in patients with psoriatic arthritis who had previously had an inadequate response to conventional synthetic DMARDs. Adverse events were more frequent with tofacitinib than with placebo. (Funded by Pfizer; OPAL Broaden ClinicalTrials.gov number, NCT01877668.)
, Apostolos Tassiopoulos, Robert S. Kirsner
The New England Journal of Medicine, Volume 377, pp 1559-1567; https://doi.org/10.1056/nejmra1615243

Abstract:
Even with the best available care, at least 25% of leg ulcers and foot ulcers are not fully healed after 6 months of treatment. This review summarizes the pathophysiological features and explains current management of venous, arterial, neuropathic diabetic, and pressure ulcers.
Comment
Robert A. Colbert,
The New England Journal of Medicine, Volume 377, pp 1582-1584; https://doi.org/10.1056/nejme1709907

Abstract:
Psoriasis is a chronic inflammatory skin disease that affects 2 to 4% of the population.1 Inflammatory arthritis develops in approximately 30% of patients with psoriasis and can have a major effect on activities of daily living and quality of life.2 Peripheral joint involvement in patients with psoriatic arthritis can be oligoarticular or polyarticular and can cause joint destruction. Several medications are used to treat psoriatic arthritis, and the choice of agent and the timing of administration in the course of the disease depend on disease manifestations, their severity, and prognostic factors.2 Therapy typically involves the sequential use of nonsteroidal antiinflammatory . . .
Jerome Groopman, Pamela Hartzband
The New England Journal of Medicine, Volume 377, pp 1507-1509; https://doi.org/10.1056/nejmp1709917

Abstract:
When we consider regret in medicine, we typically think of the feeling that follows a poor clinical outcome. For example, a friend in his late 60s had prostatitis. He did not like taking pills and after reading up on treatment options, he insisted on a once-a-day regimen with a fluoroquinolone antibiotic. It led to prompt relief of symptoms. But several weeks later, he had a spontaneous rupture of his Achilles tendon — a recognized though rare side effect of the drug. “Why did I insist on that antibiotic?” he asked bitterly, as he trawled over his care. His story contains two essential elements that lead to regret: imagining that the present situation would have been better if one had acted differently, and self-recrimination for having made a choice that led to a bad outcome.
Zirui Song
The New England Journal of Medicine, Volume 377, pp 2309-2311; https://doi.org/10.1056/NEJMp1710020

Abstract:
Legislation requiring that providers be paid traditional Medicare prices for out-of-network services provided to marketplace enrollees would have both direct and indirect salutary effects on the insurance market and expenditures.
Carmen D. Zorrilla
The New England Journal of Medicine, Volume 377, pp 1801-1803; https://doi.org/10.1056/nejmp1713196

Abstract:
Hurricane Maria hit Puerto Rico on September 20 and caused unprecedented damage affecting the island’s 3.4 million inhabitants (see Figure 1 ). Though no one in Puerto Rico was spared at least some impact, the poor and vulnerable were disproportionately affected. Loss of communication and electricity, scarcity of water, isolation of some residents, slow coordination of the aid that has been sent, and the magnitude and scope of the necessary repairs all merit a call for help from and the engagement of the global community. Indeed, Puerto Ricans and U.S. Virgin Islanders are U.S. citizens and expect the same federal aid and support during natural disasters as the rest of the United States.
The New England Journal of Medicine, Volume 377, pp 1804-1806; https://doi.org/10.1056/nejmp1712854

Abstract:
Extreme events often cast in bold relief what we do and don’t know about medicine and public health. In recent weeks, three hurricanes, each characterized by “unprecedented” features, have illuminated our knowledge gaps regarding the consequences of disasters and their mitigation.
Reed V. Tuckson, Victor J. Dzau, Nicole Lurie
The New England Journal of Medicine, Volume 377, pp 1806-1808; https://doi.org/10.1056/nejmp1711834

Abstract:
Recently, our country’s heart was broken by the devastation wrought by three hurricanes affecting several U.S. states and territories. These tragedies remind us that natural disasters happen frequently and that no community is immune to them. Each year, the United States experiences approximately 60 presidentially declared major disasters, and billions of dollars are spent on recovery.1 We believe these disasters should serve as a vivid call to action for health and social service professionals to work collaboratively with other key stakeholders to ensure that their communities have engaged in the disaster planning necessary to mitigate health challenges, respond to the immediate effects, and — too often overlooked — prepare for the longer-term recovery and rebuilding efforts required for infrastructure to support the health and welfare of all community members.
Edward R. Marcantonio
The New England Journal of Medicine, Volume 377, pp 1456-1466; https://doi.org/10.1056/nejmcp1605501

Abstract:
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.
Mohamad Hanouneh, Teresa K. Chen
The New England Journal of Medicine, Volume 377, pp 1467-1467; https://doi.org/10.1056/NEJMicm1704369

Edward Gane, Eric Lawitz, David Pugatch, Georgios Papatheodoridis, Norbert Bräu, Ashley Brown, , Vincent Leroy, , , et al.
The New England Journal of Medicine, Volume 377, pp 1448-1455; https://doi.org/10.1056/nejmoa1704053

Abstract:
Chronic hepatitis C virus (HCV) infection is more prevalent among patients who have chronic kidney disease than among those who do not have the disease. Patients with chronic kidney disease who also have HCV infection are at higher risk for progression to end-stage renal disease than those who have chronic kidney disease without HCV infection. Patients with both HCV infection and advanced chronic kidney disease have limited treatment options. We conducted a multicenter, open-label, phase 3 trial to evaluate the efficacy and safety of treatment with the combination of the NS3/4A protease inhibitor glecaprevir and the NS5A inhibitor pibrentasvir for 12 weeks in adults who had HCV genotype 1, 2, 3, 4, 5, or 6 infection and also had compensated liver disease (with or without cirrhosis) with severe renal impairment, dependence on dialysis, or both. Patients had stage 4 or 5 chronic kidney disease and either had received no previous treatment for HCV infection or had received previous treatment with interferon or pegylated interferon, ribavirin, sofosbuvir, or a combination of these medications. The primary end point was a sustained virologic response 12 weeks after the end of treatment. Among the 104 patients enrolled in the trial, 52% had genotype 1 infection, 16% had genotype 2 infection, 11% had genotype 3 infection, 19% had genotype 4 infection, and 2% had genotype 5 or 6 infection. The sustained virologic response rate was 98% (102 of 104 patients; 95% confidence interval, 95 to 100). No patients had virologic failure during treatment, and no patients had a virologic relapse after the end of treatment. Adverse events that were reported in at least 10% of the patients were pruritus, fatigue, and nausea. Serious adverse events were reported in 24% of the patients. Four patients discontinued the trial treatment prematurely because of adverse events; three of these patients had a sustained virologic response. Treatment with glecaprevir and pibrentasvir for 12 weeks resulted in a high rate of sustained virologic response in patients with stage 4 or 5 chronic kidney disease and HCV infection. (Funded by AbbVie; ClinicalTrials.gov number, NCT02651194.)
, Tracy A. Ziolek,
The New England Journal of Medicine, Volume 377, pp 1412-1414; https://doi.org/10.1056/nejmp1707991

Abstract:
To increase colorectal cancer screening rates, ABC Health System decides to send birthday cards to patients when they turn 50. The cards read, “It’s your 50th birthday — treat yourself to a colonoscopy!” and contain coupons for free Gatorade and MiraLAX and a book of crossword puzzles to keep the recipient occupied while on the toilet. ABC’s idea is that some whimsy might help overcome colonoscopy’s “ickiness” barrier. XYZ Health System has the same goal. The birthday cards they send include notification of a prescheduled colonoscopy appointment, with options for selecting a more convenient time. Their idea is to frame screening as the default. Both ABC and XYZ health systems plan evaluations with pre–post designs to assess whether screening rates change. No one objects, since the approaches are well-meaning, plausible, safe, and consistent with clinical guidelines.
Page of 3,983
Articles per Page
by
Show export options
  Select all
Back to Top Top