NEJM 200th Anniversary Documentary
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Getting Better is a 45-minute documentary video that tells three remarkable stories of medical progress — in surgery, leukemia, and HIV/AIDS. Atul Gawande, Vincent DeVita, Tony Fauci, Paul Farmer, and other prominent experts explore research, clinical practice, and patient care, and how health care has continued to get better over the past 200 years. View the film in its entirety, or in segments, now on the 200th anniversary website.
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This Week at NEJM.org | August 23, 2012
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Perspective
P.M. LeBlanc, K.A. Hollinger, and K.C. Klontz | August 22, 2012 | DOI: 10.1056/NEJMp1206063
D. Havlir and C. Beyrer | N Engl J Med 2012;367:685-687 | Published Online July 18, 2012
G.H. Sun, J.D. Steinberg, and R. Jagsi | N Engl J Med 2012;367:687-690
E. van Ginneken and K. Swartz | N Engl J Med 2012;367:691-693
Original Articles
L.M.S. Carlsson and Others | N Engl J Med 2012;367:695-704
E.K. Alexander and Others | N Engl J Med 2012;367:705-715 | Published Online June 25, 2012
N.H. Afdhal and Others | N Engl J Med 2012;367:716-724
S.K. Browne and Others | N Engl J Med 2012;367:725-734
B.S. Kennedy and Others | August 22, 2012 | DOI: 10.1056/NEJMoa1205114
Special Article
M.A. Schuster and Others | N Engl J Med 2012;367:735-745
Clinical Therapeutics
A.H. Ropper | N Engl J Med 2012;367:746-752
Images in Clinical Medicine
M. Esfandbod and M. Kabootari | N Engl J Med 2012;367:753-753
A.M. Moughty and G. O'Connor | N Engl J Med 2012;367:e12
Case Records of the Massachusetts General Hospital
M.S. Drapkin, R.S. Kamath, and J.Y. Kim | N Engl J Med 2012;367:754-762
Editorials
D.O. Jacobs | N Engl J Med 2012;367:764-765
J.L. Jameson | N Engl J Med 2012;367:765-767 | Published Online June 25, 2012
Health Law, Ethics, and Human Rights
M.M. Mello, S.N. Goodman, and Ruth R. Faden | August 22, 2012 | DOI: 10.1056/NEJMhle1207160
Clinical Implications of Basic Research
J.T. Rosenbaum | N Engl J Med 2012;367:768-770
Correspondence
Corrections
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Trends: Most Viewed (Last Week)
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Watch the NEJM Dialogues in Medicine Webcast
View the all-star cast of expert physicians, health professionals, and patients as they discuss the progress of medicine. Watch now
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The University of Mississippi School of Medicine is seeking a Chair of the Department of Medicine. The successful candidate should have a superb record of proven leadership, mentoring, administrative abilities and scholarly activity. S/he will balance commitment to the education, patient care, and research missions of the department and bring a commitment to expand the national visibility and prestige of the department, which is poised for significant growth in all areas. The University of Mississippi School of Medicine and its clinical partner, the University of Mississippi Health Care, educate and train the majority of Mississippi's medical professionals. University of Mississippi Health Care encompasses specialty hospitals and clinical practice sites across the state....
Looking for a new practice opportunity? View this job and other listings at NEJM CareerCenter. Search now for both permanent and locum tenens jobs in many specialties.
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TEACHING TOPICS from the New England Journal of Medicine
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Teaching Topics | August 23, 2012
Fever and Back Pain: How is brucellosis diagnosed?
Eltrombopag in Cirrhosis: What were the results of this study, which looked at eltrombopag versus placebo in patients with chronic liver disease and thrombocytopenia?
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NEJM 200th Anniversary Documentary
 |
|
Getting Better is a 45-minute documentary video that tells three remarkable stories of medical progress — in surgery, leukemia, and HIV/AIDS. Atul Gawande, Vincent DeVita, Tony Fauci, Paul Farmer, and other prominent experts explore research, clinical practice, and patient care, and how health care has continued to get better over the past 200 years. View the film in its entirety, or in segments, now on the 200th anniversary website.
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Teaching Topic
Fever and Back Pain
Case Records of the Massachusetts General Hospital
M.S. Drapkin, R.S. Kamath, and J.Y. Kim
Brucellosis is widespread in the Middle East. Serologic surveys have shown that 2 to 15% of camels in this geographic area have antibodies against brucella. A recent report describes brucellosis in two persons returning home to Singapore after drinking unpasteurized camel’s milk during the Hajj pilgrimage. In animals in the Middle East, Brucella melitensis (serovar 2 or 3) predominates; in humans, serovar 3 is the cause of most cases.
Clinical Pearls
 What is the typical presentation of brucellosis?
Fever is the primary symptom of brucellosis, often with chills; osteoarticular disease is the most common complication when focal infection is diagnosed. One third of patients with brucellosis have hepatic or splenic enlargement, and 10% have genitourinary involvement. Brucellosis often involves the spine; in children, the sacroiliac joint is most frequently involved; in older patients spinal infection is most frequent, and 60% of cases are lumbar, most often at the L4 or L5 level.
How do you distinguish a spinal infection secondary to tuberculosis from one involving brucella?
According to the authors, it has been suggested that the constellation of back pain, elevations in the erythrocyte sedimentation rate and the level of serum C-reactive protein, a history of previous tuberculosis, and involvement of posterior spinal elements on imaging is pathognomonic of tuberculosis. Marked destruction of vertebral bodies, usually in the thoracic or thoracolumbar area, is more common in tuberculosis, whereas disk destruction is seen more often in brucellosis. Paravertebral abscesses are less common in brucellosis than in tuberculosis, but they can occur. On MRI, a well-defined abnormal paraspinal signal and a thin, smooth abscess wall suggest tuberculous infection.
Morning Report Questions
Q. How is brucellosis diagnosed?
A. The incubation period for brucellosis ranges from 1 to 2 weeks for acute disease to months for late disease. Diagnosis of brucellosis can prove difficult. In automated blood-culture systems, growth often can be detected after 3 to 5 days of incubation. Laboratory personnel should be alerted to the need to hold the cultures longer than the customary 5 days and also to take precautions to avoid infection themselves. If cultures are negative, a presumptive diagnosis can be made serologically, although seropositivity can derive from previous infection and not necessarily indicate active infection, especially in people who have resided in endemic regions.
Q. What is the appropriate treatment for brucella infection?
A. Initial treatment typically includes doxycycline for six weeks and IM streptomycin for the first 14 to 21 days, or six weeks of doxycycline and rifampin.
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Teaching Topic
Eltrombopag in Cirrhosis
Original Article
N.H. Afdhal and Others
Thrombocytopenia is frequently observed in patients with chronic liver disease, with studies suggesting that it occurs in up to 76% of patients with cirrhosis. The degree of thrombocytopenia is proportional to the severity of the liver disease, and a high degree of thrombocytopenia is an indicator of advanced disease.
Clinical Pearls
What are the limitations of platelet transfusions in patients with severe liver disease?
Platelet transfusions are commonly used to reduce the risk of bleeding during a procedure, but their short duration of efficacy and the risk of transfusion reactions limit their use. Furthermore, the development of antiplatelet antibodies (alloimmunization) can cause refractory thrombocytopenia in up to half of patients who receive multiple transfusions.
What is the mechanism of action of eltrombopag?
Eltrombopag is an oral thrombopoietin-receptor agonist approved for use in patients with chronic immune thrombocytopenia
Morning Report Questions
Q. What were the results of this study, which looked at eltrombopag versus placebo in patients with chronic liver disease and thrombocytopenia?
A. Treatment with eltrombopag at a dose of 75 mg once daily for 14 days reduced the need for platelet transfusions in patients with chronic liver disease and thrombocytopenia who were undergoing elective invasive procedures. Platelet counts were increased during treatment with eltrombopag and for up to 2 weeks after treatment. The key secondary end point of noninferiority with regard to the rate of bleeding episodes (with a noninferiority margin of 10 percentage points) was met (23% in the placebo group and 17% in the eltrombopag group; absolute difference, –6 percentage points; 95% CI, –15 to 3).
Q. How did serious adverse events differ in the two study groups?
A. An increased risk of portal-vein thrombosis was observed among patients receiving eltrombopag. Thrombotic events occurred in 6 patients (7 events) in the eltrombopag group and 2 patients (3 events) in the placebo group (odds ratio with eltrombopag, 3.04; 95% CI, 0.62 to 14.82). With the exception of thrombotic events, rates of serious adverse events were similar in the study groups. Nine of the 10 events involved the portal venous system, including all the events in patients who received eltrombopag; these patients presented with symptomatic portal-vein or splanchnic-vein thromboses. Of the 6 patients in the eltrombopag group who had a portal-vein thrombosis, 5 had the event when the platelet count was higher than 200,000 per cubic millimeter.
Table 2. Adverse Events Occurring in at Least 3% of Patients in Either Study Group.
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quote of the week
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“The results of this analysis show that bariatric surgery, as compared with usual care, reduces the long-term incidence of type 2 diabetes by 78% in obese patients. This risk reduction was achieved despite a less favorable risk profile in the surgery group at baseline. Among patients with impaired fasting glucose, bariatric surgery reduced the risk by 87%, and type 2 diabetes did not develop in approximately 10 of 13 obese patients who underwent bariatric surgery. This risk reduction is at least twice as large as that observed with lifestyle interventions in moderately obese, prediabetic persons.”
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IMAGE CHALLENGE
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What is the diagnosis?
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images in clinical medicine
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images in clinical medicine
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videos in clinical medicine
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Special Offer
Watch the NEJM Dialogues in Medicine Webcast
View the all-star cast of expert physicians, health professionals, and patients as they discuss the progress of medicine. Watch now |
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