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Literature

Resources that summarize, explain, and put research into context

From Pages to Practice

Sickle cell disease (SCD) is the most common monogenic disorder caused by a point mutation in the <em>HBB</em> gene, which encodes β-hemoglobin. The resulting substitution of valine for glutamic acid modifies the erythrocyte morphology such that it is predisposed...

Progress in Sickle Cell Disease Gene Therapies

If you have ever looked at a pediatric chest radiograph, you may recall seeing a large thymic shadow overlying the mediastinum. That shadow disappears with age as the thymus atrophies and involutes. Children born with an absent or hypoplastic thymus, such...

Don’t Underestimate the Health Consequences of Thymus Removal in Adults

Patients with major depressive disorder (MDD) often require multiple medications trials to achieve remission. Treatment-resistant depression (TRD) — defined as lack of response to two or more medication trials — affects up to 30% of patients with MDD. Patients with...

Escaping Treatment-Resistant Depression with Esketamine

Glucagon-like peptide 1 (GLP-1) receptor agonists are gaining attention for the management of type 2 diabetes and obesity. These drugs have multifactorial effects that include stimulating glucose-dependent insulin secretion, delaying gastric emptying, and inhibiting postprandial glucagon secretion. Consequently, GLP-1 receptor agonists...

Promising Results for GLP-1 Receptor Agonists in Obesity-Related HFpEF

A 40-year-old man with bipolar I disorder who is currently on a mood stabilizer is feeling better after a recent depressive episode. During the episode, he was treated with an adjunctive antidepressant. Now that his depression is in remission, you are...

Duration of Adjunctive Antidepressants After Remission of Depression in Bipolar I Disorder

Ms. Apple is a 74-year-old woman with a history of overweight but otherwise very active and still working as a part-time schoolteacher. At a primary care visit, she explains that she is concerned about memory loss because her mother developed dementia...

Diet for Prevention of Cognitive Decline in Older Adults

Mr. Wang is a 73-year-old male with a history of atrial fibrillation (AF) and diabetes who presented with left-sided weakness. Head imaging showed an ischemic stroke affecting the superficial cortical branch of the right middle cerebral artery. When should he restart...

Early Anticoagulation After Stroke Due to Atrial Fibrillation Prevents Recurrent Ischemic Events

Men who receive a diagnosis of low- or intermediate-risk clinically localized prostate cancer can live for decades. Each treatment option is associated with different effects on quality of life and sexual, urinary, and bowel function. To compare the effectiveness of these...

Similarly Low 15-Year Mortality After Monitoring, Surgery, or Radiotherapy for Prostate Cancer

Pulmonary arterial hypertension (PAH) involves the obliteration of the small arterioles of the pulmonary vasculature. PAH is categorized as World Health Organization (WHO) group 1 pulmonary hypertension, based on the presence of elevated pulmonary arterial pressures, normal pulmonary capillary wedge/left heart...

Lung Story Short: A New Therapy for Pulmonary Arterial Hypertension

The perennial question of whether to use glucocorticoids to treat patients with community acquired pneumonia (CAP) continues to consume hours of discussion in intensive care units (ICUs). Pneumonia elicits an inflammatory response in the lung, which left unchecked, can lead to a deleterious decline in pulmonary function and oxygenation. Glucocorticoids...

Should Glucocorticoids Be All the Rage in the Treatment of CAP?

Some anticoagulation decisions in patients with thrombosis are straightforward, thanks to a preponderance of data. First provoked deep-vein thrombosis (DVT)? There’s a guideline for that (no less than 3 months of anticoagulation). Recurrent DVT, pulmonary embolism, or decisions between a direct...

Hydrochlorothiazide or Chlorthalidone for Hypertension?

Venous thromboembolism (VTE) is the most common cause of preventable death in hospitalized medical patients, yet pharmacologic prophylaxis remains underutilized. The Virchow’s triad of venous stasis, vascular injury, and hypercoagulability is key in the assessment of VTE risk. Based on the Padua Score — a validated risk assessment model that...

Broken Bones and Thromboprophylaxis: Is Aspirin Enough?

Opioid use disorder (OUD) continues to be a national crisis in the United States. President Biden has identified battling the opioid crisis as a top priority and the U.S. Department of Health and Human Services (HHS) has awarded $1.6 billion to...

Methadone or Buprenorphine in Mothers and Neonates: A Tale of Two Drugs for OUD

Going with the Flow — Rivaroxaban Prophylaxis in Noncirrhotic Portal Venous Thrombosis

Tuberculosis (TB) is the leading cause of death worldwide from a single infectious agent. TB is caused by the bacillus Mycobacterium tuberculosis , infecting about a quarter of the world’s population. Drug-resistant TB continues to be a threat to public health; in 2019, approximately 465,000 patients worldwide had rifampicin-resistant disease,...

Assessing What’s PRACTECAL in Rifampicin-Resistant Tuberculosis

Eosinophils are granulocytes theorized to have developed in humans to guard against parasitic infections, including nematodes that reside in human intestines. As a result, eosinophils appear to be normal constituents of gastrointestinal tissue, with an increasing gradient... ...

Dupilumab for Eosinophilic Esophagitis: Therapy for a Tough Diagnosis to Swallow?

Mr. Pool is a 64-year-old man with high blood pressure while taking lisinopril, diabetes (HbA1c level, 7.3), obesity (BMI, 32 kg/m<sup>2</sup> ), and dysplipidemia while taking statin therapy (elevated triglyceride of 270 mg/dL and low HDL of 33 mg/dL...

Fibrate Therapy Does Not Reduce Cardiovascular Events in Patients with Mild-to-Moderate Hypertriglyceridemia

The pancreas is a notoriously complex endocrine organ and when inflamed can cause a wide range of clinical symptoms, ranging from simple epigastric pain, nausea, and vomiting, all the way to circulatory collapse and acute respiratory distress syndrome (ARDS). As...

Fluid Resuscitation in Pancreatitis

Cigarette smoking is the leading cause of chronic obstructive pulmonary disease (COPD). More than 3 million people worldwide die of COPD each year, accounting for approximately 6% of all deaths. COPD is a heterogenous condition with various phenotypes including emphysema...

Inhalers for Smokers' Cough? Time for a RETHINC

When an area of the myocardium is not moving normally, it is important to realize that all may not be lost. Although ischemia can lead to infarction —or death of the cardiomyocytes— the cells may survive by “hibernating” or suspending the...

To PCI or Not to PCI — a Revascularization Question

Skills

Educational and interactive tools to sharpen your diagnostic abilities

Screening for osteoporosis is recommended in postmenopausal women on the basis of age and risk factors. Treatment approaches are determined by T score and the presence or risk of fracture.

Postmenopausal Osteoporosis

A 19-year-old man was evaluated because of kidney cysts. Three years earlier, he had received a diagnosis of diabetes when abdominal pain and increased urinary frequency had developed. A diagnosis was made. ...

A Man with Diabetes and Kidney Cysts

Liver transplantation, first performed in humans 60 years ago, is now the standard of care for patients with life-threatening liver disease. This article focuses on current developments in liver transplantation.

Liver Transplantation

In two randomized trials, the use of gantenerumab (an anti-Aβ monoclonal antibody) did not lead to slower clinical decline than placebo over 116 weeks among persons with early Alzheimer’s disease.

Gantenerumab in Early Alzheimer’s Disease

Injection of botulinum toxin into each splenius capitis muscle at baseline and week 12 was more effective than placebo in reducing the severity of essential head tremor over 18 weeks. Effects waned at 24 weeks. ...

Catatonia

A 49-year-old woman was found unconscious at work. Evaluation was notable for aphasia, apraxia, and marked thrombocytopenia and anemia. A diagnosis was made.

A Woman with Loss of Consciousness and Thrombocytopenia

A 75-year-old man with a history of atrial tachyarrhythmias, tricuspid regurgitation, and pericarditis presented with worsening dyspnea, leg swelling, and abdominal bloating after recent catheter ablation.

Encased in Peril

This article reviews the pathophysiology, evaluation, and treatment of cystic fibrosis, including recent advances with the use of highly effective modulator therapy.

Cystic Fibrosis

This phase 3 trial of patisiran, a small interfering RNA that targets hepatic production of the transthyretin protein, showed efficacy in treating transthyretin-mediated (ATTR) cardiac amyloidosis.

Patisiran for Transthyretin Cardiac Amyloidosis

An 86-year-old man was admitted to the hospital because of shortness of breath and hypoxemia. Echocardiography revealed severe tricuspid regurgitation and a patent foramen ovale. A diagnosis was made.

A Man with Shortness of Breath

SIAD varies in severity and is most common in older persons. Severe SIAD warrants emergency treatment; management of less severe illness includes fluid restriction, sodium chloride supplementation, and medication. ...

Syndrome of Inappropriate Antidiuresis

A 62-year-old woman was evaluated for recurrent hemorrhagic pericardial effusion. Fourteen years earlier, she had undergone transcatheter closure of an atrial septal defect. A diagnosis was made.

A Woman with Recurrent Hemorrhagic Pericardial Effusion

Shiga toxin–producing <em>E. coli</em> causes clinically important morbidity, particularly in children. Use of optimized diagnostics for identifying STEC and reporting toxin genotypes is essential.

STEC and the Hemolytic–Uremic Syndrome

In a randomized trial involving patients with advanced heart failure and atrial fibrillation, catheter ablation decreased the risk of cardiovascular events at a median of 18 months.

Catheter Ablation for Advanced Heart Failure and AFib

A 33-year-old man with ulcerative colitis presented with bloody diarrhea, an 8-month history of worsening fatigue and diarrhea, and a 4-month history of fevers, drenching night sweats, and unintentional weight loss. ...

Digging into the Histology

In patients with polymyalgia rheumatica with relapse during prednisone tapering, interleukin-6 receptor antagonist sarilumab increased disease remission and reduced glucocorticoid exposure at 1 year.

Sarilumab for Relapsing Polymyalgia Rheumatica

In patients with atrial high-rate episodes, edoxaban did not significantly reduce the incidence of stroke and cardiovascular outcomes as compared with placebo, but it led to a higher incidence of bleeding. ...

Anticoagulation and Atrial High-Rate Episodes

A 50-year-old woman with a history of Roux-en-Y gastric bypass presented with confusion. She had anasarca and an albumin level of 1.9 g per deciliter (reference range, 3.3 to 5.0). A diagnosis was made. ...

A Woman with Confusion

A 34-year-old woman was admitted to the hospital because of abdominal distention, fatigue, and acute kidney injury that occurred 10 months after orthotopic liver transplantation. A diagnosis was made.

A Woman with Abdominal Distention and Acute Kidney Injury

The author reviews the patient, provider, and device factors that contribute to central line–associated bloodstream infections and discusses preventive strategies.

Central Line–Associated Bloodstream Infections

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Resources that summarize, explain, and put research into context.

Beyond Journal Club Podcast from Core IM

What is the difference between semaglutide (Ozempic, Wegovy, Rybelsus) and tirzepatide (Mounjaro) in metabolic outcomes and mechanism? How did we find out diabetes medications can help with weight loss? SURMOUNT-1 asked the question, "Does tirzepatide, a once weekly injectable drug used...

The SURMOUNT-1 Trial: How Did Diabetes Medications Become Weight Loss Meds?

Does adding revascularization by percutaneous coronary intervention (PCI) to optimal medical therapy improve survival and heart failure hospitalizations in patients with severe ischemic left ventricular systolic dysfunction? Some evidence suggests that patients with low ejection fraction benefit from revascularization by PCI....

The REVIVED Trial: Does PCI Save Lives in Heart Failure and CAD?

Clinical Pearls & Morning Report

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Rotation Prep

Curated and distilled information to get you up to speed fast

Featured Rotation

Rebecca Saff, MD, PhD, is the Allergy/Immunology Fellowship Director and an Assistant Physician at Massachusetts General Hospital and an Instructor in Medicine at Harvard Medical School. She is involved in drug allergy research, particularly looking at the epidemiology of drug allergy, and has an interest in physician wellness, serving on the advisory board for the Center for Physician Well-Being.

Allergy and Immunology encompasses an array of conditions ranging from rare diseases such as primary immunodeficiency to more common disorders like asthma and allergic rhinitis. In this rotation guide, we cover key areas in allergy and immunology that will help in the care of patients with these disorders.

Allergy/Immunology

Work & Life

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Guidance for navigating your career and life

The New England Journal of Medicine invites applications from physicians at any career stage for a one-year, full-time, paid editorial fellowship beginning in July 2024. Several fellows will be selected for the 2024–25 year; applications are due by August 15, 2023. Learn more about the NEJM editorial fellowship and how...

The NEJM Editorial Fellowship

Most physicians remember the day they discovered where they would spend the next several years in residency training. Many also remember the moment elation gave way to reality as they began to calculate the cost of living and loans (averaging nearly $200,000) and realize it was more than their future...

Valuing the Resident Physician: Advocating for Change

In the first part of this series, Improving Feedback Exchanges with Residents: Can You Hear Me Now? , we reviewed basic knowledge and skills related to feedback exchanges in medical training. We defined the difference between feedback and assessment, highlighted the key components of high-quality feedback, identified barriers to feedback...

How to Receive and Deliver High-Quality Feedback

Feedback is defined as information describing an individual’s performance in a given activity that is intended to guide their future performance. Medical trainees are becoming increasingly aware that feedback is a critical component of clinical training. In a two-part series on improving formal feedback exchanges, we will focus on the...

Improving Feedback Exchanges with Residents: Can You Hear Me Now?

Whether you are a student, resident, or faculty member, no doubt you have attended obligatory talks on well-being and burnout. The attention to high rates of burnout in the U.S. health care workforce, and its unsurprising increase during the pandemic , has been beneficial, but concerns have been raised that...

It’s OK to Not Be OK

When you dedicate years to studying and practicing medicine, you learn that certain steps are required to maintain good health and prevent illness and disease. However, the concept of systematically and proactively cultivating good habits applies to many aspects of life,...

Five Steps to Improve Your Financial Health in Residency

Conflict is a natural part of everyday life; disagreements are bound to happen when we interact with others. As physicians, we often work in time-pressured, high-stakes circumstances and engage with teams comprised of people with different backgrounds and perspectives.

Conflict Management and Resolution as a Resident

Welcome new doctors! Yesterday you were medical students and today you are physicians! What a scary feeling. Remember that everyone shares similar concerns and fears as they start their residency and wants to succeed. Getting into residency is the beginning of an incredible journey. Savor it, relax, enjoy the ride,...

Surviving the First Month as a Doctor: Advice from the Community

Physician burnout and well-being are hot topics among medical professionals throughout the health care delivery and educational continuum — for good reason. Current estimates of the impact of physician burnout approach or exceed 50%, and most experts suggest that the percentage is growing.

Connection and Meaning: Resident Leadership to Combat Burnout

The fields of precision medicine and digital health have the potential to transform medicine by increasing access to health-related data at the touch of a finger, seamlessly sharing electronic medical records among institutions, improving the efficiency of healthcare delivery, and providing access to unprecedented granularity of patient data...

Precision Medicine: Help Pave the Way

The global effort to share data and resources about the ongoing Covid-19 pandemic has led to a flood of information as infections peak at different times around the world. 

Using Artificial Intelligence to Help Manage the Covid-19 Data Burden

Quality improvement (QI) is a disciplined effort to make healthcare delivery safer, more effective, patient-centered, timely, equitable, and efficient (less wasteful). These six domains were established by the National Academy of Medicine in 1999 as the tenets of... ...

What Is Quality Improvement?

Although every resident develops his or her own style for each of these roles, the following practical strategies were discussed in a NEJM Resident 360 discussion (How to Lead a Team on the Wards: The Art to Being an Effective Resident).

The Art of Leading with the Right Balance as a Senior Resident

The last time you stepped inside an operating room may have been the third year of medical school, but during residency you will care for many patients who require surgery, either electively or emergently. Calling a surgical consult can be daunting or intimidating, especially if the problem or situation is...

Advice for Calling a Surgical Consult

Notes are often the last thing standing between you and (finally) going home.  In one large-scale survey of internal medicine residents, two-thirds reported spending more than 4 hours per day on medical record documentation and clerical duties; only one-third...

Note to Self: Principles for Better Documentation

Internship and residency are incredibly demanding intellectually, emotionally, physically, and socially. This post addresses ways to establish habits that will lead to a successful and healthy transition to the practice of medicine during residency.    ...

Addressing Wellness in Residency: Ready, Set, Go!

Dr. Richard Brian Gunderman offers guidance for preventing burnout in residency.

Recognizing and Surviving Burnout

After many long nights huddled over textbooks, agonizing over the brachial plexus, committing childhood exanthems to memory, and making surgical knots of any loose fiber within arm’s reach, you have finally received the news of a lifetime: You’re accepted to a...

Prepping for PGY-1

Dr. Carol McLaughlin, director of the Global Health Equities Track in the internal medicine residency program at the University of Pennsylvania, writes about what it takes to pursue a career in global health and how can you plan for it during residency.

Opportunities in Global Health for Residents 

When most people think of librarians, they picture the stereotypical older woman with glasses and a bun who shushes them for talking too loudly. In the past, librarians were the keepers of information but have now evolved to become navigators of...