New Interactive Medical Case: “The Road Less Traveled”

Posted by • September 25th, 2017

A 26-year-old woman presented to the emergency department with a 1-week history of worsening pleuritic chest pain. She recalled the development of a dull, substernal ache several days after a 5-hour flight home from Puerto Rico, where she had spent 3 weeks hiking in national parks and exploring several caves.

The ache progressed over the ensuing days to a constant, stabbing pain that worsened with deep inspiration and coughing. She had not taken any medication for the pain. The patient reported no fevers, chills, shortness of breath, wheezing, sputum production, hemoptysis, weight loss, night sweats, leg swelling, or diarrhea and no changes in appetite or urinary habits. She had no history of venous thromboembolism, cancer, or environmental or drug allergies and did not use oral contraceptives.

Test your diagnostic and therapeutic skills with this Interactive Medical Case! Video, animation, and interactive content allow you to receive feedback on your choices made based on a series of questions and exercises, review the condition and optimal treatment steps involved in a complex evolving patient history, and earn CME credit or MOC points.

You can also browse through a list of 47 previous Interactive Medical Cases and polish your skills in a wide range of medical scenarios.

New Interactive Medical Case: “All That Wheezes”

Posted by • August 3rd, 2017

A 20-year-old woman with a history of allergic rhinitis presented to her physician in the autumn with persistent cough and shortness of breath. She had been seen 6 weeks earlier for nasal congestion, rhinorrhea, postnasal drip, and cough that had bothered her on and off throughout the summer. Her symptoms occurred at home and at work. Just recently she had begun to have shortness of breath while walking to the bus stop.

During coughing episodes, she could hear herself wheezing. Her grandmother’s albuterol inhaler had given her some relief from wheezing at night. The nasal congestion abated when she used fluticasone nasal spray and loratadine, but the cough persisted. The patient reported no fevers, chills, sputum production, headache, joint or muscle aches, heartburn, nausea, vomiting, or frequent throat clearing.

Test your diagnostic and therapeutic skills with this free Interactive Medical Case! Video, animation, and interactive content allow you to receive feedback on your choices made based on a series of questions and exercises, review the condition and optimal treatment steps involved in a complex evolving patient history, and earn CME credit or MOC points.

You can also browse through a list of 47 previous Interactive Medical Cases and polish your skills in a wide range of medical scenarios.

New Clinical Decisions Article: Management of Septic Shock

Posted by • June 19th, 2017

The newest addition to our Clinical Decisions series gives you a chance to decide how you would treat Ms. Jones, a 65-year-old woman with a history of hypertension who has come to the emergency room after experiencing 3 days of chills and dysuria. After checking vital signs, conducting a physical examination and urinalysis, you make a preliminary diagnosis of sepsis, specifically coming from a urinary source. Once the patient has been stabilized, you must decide which of the two given treatments for septic shock leave her with the best chance of survival. In one method, treatment would continue under the early, goal-directed therapy (EGDT) protocol, and, in the other, by continuous intravenous administration of antibiotics and vasopressors, guided by measurement of clinical signs. Read more about this case, form your opinion as to which option will be more effective and share your thoughts here.

Clinical Decisions are a great way to help you evaluate treatment options and gain insight from colleagues. The articles include a case vignette, plus clinically acceptable management options, each supported in a short commentary by a respected clinician. You are invited to vote for, and comment on, the options at NEJM.org, where a diverse range of thinking is presented. Browse previous Clinical Decisions articles here!

 

Diversity in Residency

Posted by • June 5th, 2017

African-American physicians-in-training may be isolated within the walls of their institutions, alienated by their patients, and disconnected from their training programs. Listen to the challenges and aspirations of these inspiring African-American residents.

This podcast is the third in a series that reflects medicine’s most pressing issues through the eyes of residents. “The House” provides residents with a forum to share their stories from the bedside, where they are learning far more than the lessons of clinical medicine.

Visit the Dr. Darryl Powell Memorial Page, and donate to help patients with Sickle Cell Disease.

The UCSF Office of Diversity and Outreach offers a list of Unconscious Bias Resources.

For additional reading on this topic: 

The Perils and Rewards of Critical Consciousness Raising in Medical Education

Dealing with Racist Patients

Structural Racism and Supporting Black Lives — The Role of Health Professionals

#BlackLivesMatter — A Challenge to the Medical and Public Health Communities

Graduate Medical Education in the Freddie Gray Era

Bias, Black Lives, and Academic Medicine

 

Dan Weisberg is a resident in Internal Medicine and Primary Care at Brigham and Women’s Hospital and Harvard Medical School.

Ramya Ramaswami is a 2016-2017 NEJM editorial fellow. She is a medical oncologist within the National Health Services of the United Kingdom.

NEJM Perspective Podcast on the Future of Transgender Insurance Coverage

Posted by • May 19th, 2017

In this episode of the NEJM Perspective Audio Interview series, Kellan Baker, a senior fellow at the Center for American Progress, speaks with NEJM Managing Editor Stephen Morrissey on the past and future of insurance coverage for transgender people. As a small, poorly understood population, transgender people frequently encounter discrimination that includes mistreatment by health care providers, rejection by employers, and harassment in restrooms and other places of public accommodation. These experiences exacerbate health disparities such as high rates of depression, anxiety, exposure to violence, and HIV infection.

However, as Baker explains, it was not always this way. As early as the 1960s, American universities and hospitals began making strides towards providing equal care to all people, regardless of gender identity. This progress continued into the 1980s, but was halted when an exclusion on gender transition related coverage was introduced to the Medicare and Medicaid programs. These exclusions often left gender dysphoria patients without coverage, but were approved in part because they allowed employers to lower the cost of employee insurance coverage.

In recent years, pressure has been placed on health care providers, insurance companies, and government agencies to recognize gender dysphoria as a medical condition, and progress has been made toward standardized services related to gender transition. Baker acknowledges the progress, but says the highly bipartisan landscape of today has left transgender people without a solid way of getting the coverage they need.

Baker gives us a glimpse into how he believes recent events surrounding the topic — including court cases, independent research studies and examples of government intervention in insurance coverage provided by large employers — will shape the future of how transgender people are able to safely and cost-effectively go through gender transition. To listen to the full podcast, click here.

To listen and to more interviews in our archive and subscribe to our Perspective Audio Interview series, click here.

New Review Article Looks at Collaborations among Researchers, Patient Groups, and Industry

Posted by • May 10th, 2017

A growing approach to developing new treatments is a partnership among researchers, patient groups, and industry. A new article in the Clinical Trials review series gives three examples of such collaborations.

“In an era of reduced federal funding for basic and preclinical research and drug development (coupled with a higher bar for regulatory compliance),” the authors write, “the challenges that many medical professionals are routinely faced with continue to remain daunting and require new and collaborative approaches for ongoing success.” This article explains how such collaborations have helped to bridge the preclinical phase to early human research trials.

In the article, the authors describe three examples — in cystic fibrosis, multiple myeloma, and type 1 diabetes — when academic institutions, industry partners, federal agencies, and disease-focused foundations shared relevant information. “In each of the cited cases,” write the authors, “none of the major advances could have occurred in a timely manner if the partners had worked independently.”

The Changing Face of Clinical Trials series is a collection of review articles that examine the current challenges in the design, performance, and interpretation of clinical trials. Read more articles in the series here.

Three New Perspective Articles on Data Sharing

Posted by • April 28th, 2017

From “Learning What We Didn’t Know — The SPRINT Data Analysis Challenge”

This week, the New England Journal of Medicine released three new Perspective articles highlighting different discussions surrounding the sharing of clinical trial data in medicine.

The first, Bridging the Data-Sharing Divide — Seeing the Devil in the Details, Not the Other Camp, explains how the movement toward sharing data from clinical trials has divided the scientific community, and that the battle lines were evident the recent summit sponsored by NEJM. On one side stood many clinical trialists, whose lifeblood — randomized, controlled trials (RCTs) — may be threatened by data sharing. On the other side stood data scientists — many of them hailing from the genetics community, whose sharing of data markedly accelerated progress in that field.

Whose Data Are They Anyway? Can a Patient Perspective Advance the Data-Sharing Debate? explores the patient perspective on data sharing. Most patients haven’t thought much about data sharing, according to Sara Riggare, an engineer and doctoral student at the Health Informatics Center at Karolinska Institutet in Stockholm, but those who have “find the current system unreasonable. Patients expect that health care professionals and researchers use patient data in the best possible way.” Perhaps, seeing clinical trial data as the property of each patient might simplify the data-sharing discussion.

To better understand the complexities and potential benefits of data sharing, the Journal, with the assistance of the Harvard Medical School Department of Biomedical Informatics, sought to create a practical example of sharing data in the context of clinical trials, which became the SPRINT Data Analysis Challenge. The final article released this week, Learning What We Didn’t Know — The SPRINT Data Analysis Challenge, helps us decide how this contest helped to solve the question of  whether a clinical trial data set could be used by other investigators to produce new findings.

There’s Still Time to Participate in Clinical Decisions: Management of Sciatica

Posted by • April 3rd, 2017

Time hasn’t run out to participate in our last Clinical Decisions article discussion, Management of Sciatica. You have through April 5th to vote and discuss on whether you would recommend Mr. Winston, a 50-year-old bus driver who has come to your office with a 4-week history of pain in his left leg and lower back, undergo lumbar disk surgery or receive nonsurgical therapy. Read the entire case to make sure you have enough information to make an informed decision, then vote for the option that you would recommend for Mr. Winston. Participate here!

Clinical Decisions are a great way to help you evaluate treatment options and gain insight from colleagues. The articles include a case vignette, plus clinically acceptable management options, each supported in a short commentary by a respected clinician. You are invited to vote for, and comment on, the options at NEJM.org, where a diverse range of thinking is presented. Browse previous Clinical Decisions articles here!

 

New NEJM Articles on Data Sharing, and Still Time to Register for #NEJMDataSummit

Posted by • March 31st, 2017

Two new articles that explore data sharing were published by NEJM this week. The first, a Sounding Board article titled Data Authorship as an Incentive to Data Sharing, explains how designating a “data author” in clinical trials could help solve the major issue of providing academic credit to investigators who gather data in these trials. The other, a Special Article titled Use of the National Heart, Lung, and Blood Institute Data Repository, offers insight into the Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC) of the National Heart Lung and Blood Institute’s (NHLBI). The BioLINCC handles the preparation, presentation and use of clinical data. Depending on the complexity of the study, data preparation can take anywhere from 85 to 350 hours, showing that it is a very intense and significant step in data sharing.

Speaking of data sharing… there’s still time! If you want to be able to participate in this unique opportunity to make meaningful contributions to our free web event on Sharing Clinical Trial Data, don’t forget to sign up now. Where else will you be given the opportunity to engage with leading experts in moderated Q&A sessions, share your perspective in online working groups, and help explore possible solutions for the responsible sharing of data? Sound interesting? Sign up here.

New Clinical Decision Article: Management of Sciatica

Posted by • March 27th, 2017

In this week’s Clinical Decision, a 50-year-old bus driver comes to you with a 4-week history of pain in his left leg and lower back. He describes a combination of severe sharp and dull pain that originated in his left buttock and radiated to the dorsolateral aspect of his left thigh, as well as vague aching over the lower lumbar spine. After the first visit, you prescribe 150 mg of pregabalin per day, which is gradually increased to 600 mg daily because the symptoms had not abated.

Ten weeks after the initial onset of his symptoms, he returns for an evaluation. The medication has provided minimal alleviation of his sciatic pain. You discuss options for the next steps in managing his sciatica, but he is uncertain about invasive procedures such as lumbar disk surgery even though he feels limited by his pain.

What steps should you take next? Read the opinions, share your comments, and vote now!

Clinical Decisions are a great way to help you evaluate treatment options and gain insight from colleagues. The articles include a case vignette, plus clinically acceptable management options, each supported in a short commentary by a respected clinician. You are invited to vote for, and comment on, the options at NEJM.org, where a diverse range of thinking is presented. Browse more Clinical Decisions articles here!