Learning/CME
CME activities, cases, challenges, videos, and more teaching and learning tools from the New England Journal of Medicine.
CME
- In this randomized trial involving patients with noncystic fibrosis bronchiectasis, the rate of pulmonary exacerbations over a 52-week period was lower with brensocatib (10 mg or 25 mg per day) than with placebo.
- A 56-year-old woman experiencing homelessness was evaluated at this hospital because of sore throat and a pruritic rash on her face, chest, abdomen, and legs. A diagnosis was made.
- In this randomized trial conducted over the 2019–2024 influenza seasons, baloxavir resulted in a significantly lower incidence of transmission of influenza virus from patients to household contacts than placebo.
- This review considers enteral nutrition in the context of disease-related malnutrition, provides evidence for the use of enteral nutrition in hospitalized patients, and discusses practice considerations.
- A 79-year-old woman was evaluated for cough and weight loss. Chest imaging and thoracentesis findings confirmed the presence of an exudative right pleural effusion. A diagnosis was made.
- In this trial, obinutuzumab, a humanized type II anti-CD20 monoclonal antibody, plus standard therapy provided significantly better renal responses than standard therapy alone in patients with lupus nephritis.
Clinical Cases
A 56-year-old woman experiencing homelessness was evaluated at this hospital because of sore throat and a pruritic rash on her face, chest, abdomen, and legs. What is the diagnosis? Cast your vote.
This interactive feature describes a 46-year-old patient requesting initiation of estrogen therapy. Test your diagnostic and therapeutic skills.
This feature about a woman with diabetic ketoacidosis offers a case vignette accompanied by two essays, one supporting the use of balanced crystalloid fluids for fluid resuscitation and the other recommending the use of isotonic saline. Cast your vote.
A 72-year-old woman with type 2 diabetes had somnolence after a urologic procedure for bladder cancer. She had respiratory acidosis and anion-gap metabolic acidosis. What is the diagnosis? Cast your vote.
This feature about a child unvaccinated against measles, mumps, and rubella offers a case vignette accompanied by two essays, one supporting accepting the child as a patient without mandating the MMR vaccine and the other declining the patient unless she receives the vaccine. Cast your vote.
This interactive feature describes a woman who received a diagnosis of hypertension and preeclampsia at 27 years of age. After giving birth, her blood pressure remained elevated. Test your diagnostic and therapeutic skills.
Clinical Pearls
Bronchiectasis is a progressive disease, and frequent exacerbations are critical events associated with decline in lung function, worse quality of life, and premature death from any cause. No available interventions have been shown to slow the decline in lung function, and the burden of exacerbations remains high, with most patients having two or more exacerbations per year.
A consistent and established standard of care for bronchiectasis is lacking. International guidelines recommend airway clearance techniques, mucoactive agents, and antibiotics for the treatment of infection, but current approaches do not adequately address inflammation or slow disease progression. Brensocatib is an oral, selective, competitive, and reversible inhibitor of dipeptidyl peptidase 1 (DPP-1). Chronic airway inflammation in bronchiectasis is characterized by excessive release of neutrophil serine proteases, such as neutrophil elastase, which overwhelm endogenous protease inhibitors. Neutrophil serine protease precursors are converted to functional enzymes during neutrophil maturation in the bone marrow by DPP-1 and are released during neutrophil activation.
The rash associated with varicella is polymorphic, including erythematous macules, papules, vesicles, and crusts at various stages at the same time. Lesions typically spread in a cephalocaudal manner, starting on the scalp and face and progressing to the trunk, arms, and legs. Additional symptoms include fever and malaise. The rash is accompanied by pruritus, as opposed to pain.
Varicella-zoster virus is transmitted primarily through direct contact with skin lesions of affected patients or inhalation of aerosols from respiratory secretions. Aerosolization of the virus from skin lesions can also occur. Therefore, in addition to assiduous observation of standard precautions, implementation of contact and airborne isolation precautions is done as soon as possible. The patient is placed in a negative-pressure isolation room; if such a room is not immediately available, a private room is used, with the door kept closed, and the patient is asked to wear a surgical mask. Health care personnel, even those regarded as immune to varicella, use a fit-tested respirator and wear a gown and gloves. Transmission can occur until all the skin lesions are dry and crusted, and these isolation precautions are observed until then.
