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About 20% of patients with venous thrombosis or embolism but no defined risk factors have a recurrence within the first 2 years after stopping anticoagulation therapy. These authors report that 100 mg of aspirin a day nearly halved the risk of recurrence, with no increase in bleeding.
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A 32-year-old woman noted a crease in her right breast. Imaging studies showed a suspicious mass, and a biopsy specimen revealed infiltrating ductal carcinoma, positive for HER2. Staging showed liver lesions consistent with metastases. Management decisions were made.
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Gaining prompt access to primary care is a growing concern in the United States, where there’s an imbalance between demand and capacity. One solution is to change the culture of primary care so that physicians share the care with an empowered health care team.
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Hone Your Skills: Videos, Images, Cases
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images in clinical medicineMay 24, 2012 | L.-Y. Lin
and J.-U. WongA 19-year-old woman with type 1 diabetes mellitus and suspected cystic fibrosis presented with a 1-day history of acute abdominal pain. Plain radiography revealed a typical mechanical obstruction.
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Interactive Medical CaseApril 12, 2012 | A. Vaidya,
D.A. Solomon, and C.H. FantaA 38-year-old woman had shortness of breath, fever, and cough with yellow sputum soon after childbirth. Her symptoms initially resolved with antibiotics, but she soon had nonproductive cough, wheeze, and shortness of breath.
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videos in clinical medicineOctober 8, 2009 | S. Malempati
and OthersBone marrow aspiration is performed to assess cellular morphology and to conduct tests on the bone marrow. Bone marrow biopsy is often performed in tandem to provide information about the marrow and the extent of the disease. This video demonstrates both procedures.
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images in clinical medicineMay 24, 2012 | L. Weibel
and R. SpinasA 17-year-old girl presented with a 10-year history of transient excessive wrinkling of her palms after brief exposure to water and sweating. She reported some uncomfortable tightness of the skin during these episodes.
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Interactive Medical CaseOctober 15, 2009 | J.M. Conners
and K.A. BrittonA 62-year-old woman presented to the urgent care clinic with gingival bleeding after periodontal scaling of her lower right second molar. She had undergone the procedure 5 hours before presentation, and the bleeding had persisted despite the application of pressure and ice.
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images in clinical medicineMay 17, 2012 | L. Cifuentes
and M. ZiaiA 6-year-old girl who was born with a plaque on her forehead presented to the clinic. The plaque was smooth, elevated, and arranged in a linear pattern on the forehead. It then gradually grew down along the facial midline, conforming to Blaschko’s lines.
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Interactive Medical CaseDecember 22, 2011 | J.J. Ross
and OthersThis interactive feature presents the case of a 50-year old woman with a history of breast cancer who presented with fatigue and shortness of breath.
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videos in clinical medicineJune 28, 2007 | A. Edelman
and OthersThis video demonstrates how to perform a comprehensive pelvic examination, including an examination of the external genitalia, a Papanicolaou test to screen for cervical dysplasia, a bimanual examination, and a rectovaginal examination.
Clinical Pearls
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What percentage of unintended pregnancies results from contraceptive failure?
Effectiveness of Long-Acting Reversible Contraception
May 24, 2012 | B. Winner and OthersApproximately half of unintended pregnancies result from contraceptive failure, usually owing to incorrect or inconsistent use of contraception, and the remainder are due to nonuse. The most commonly used contraceptive method in the United States is the oral contraceptive pill. Annual failure rates with typical use of oral contraceptive pills are estimated at 9% for the general population, 13% for teenagers, and 30% or higher for some high-risk subgroups.
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What is the current recommendation for treatment in a patient with HER2-positive metastatic breast cancer?
Case 16-2012: A 32-Year-Old Woman with HER2-Positive Breast Cancer
May 24, 2012 | J. Baselga and OthersThe outcome of patients with HER2-positive breast cancer has markedly improved with the advent of molecular targeting of the HER2 receptor with the humanized monoclonal antibody trastuzumab (Herceptin, Genentech). In patients with metastatic HER2-positive breast cancer, although single-agent trastuzumab is clinically active, the highest clinical benefit is observed when trastuzumab is given in combination with chemotherapy. Multiple agents in combination with trastuzumab have shown clinical activity. However, the only randomized trials that have shown improved survival are those involving the use of taxanes.
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Summary and Comment
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May 10, 2012 | A. S. Brett
Reviewing: Ann Surg 2012 AprA new model uses three predictors and a 9-point scoring system.
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Summary and Comment
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May 15, 2012 | T. L. Schwenk
Reviewing: Am J Psychiatry 2012 May 1Elevated incidence of suicide attempts, depression, mania, and delirium
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Original Article
Colorectal-Cancer Incidence and Mortality with Screening Flexible Sigmoidoscopy
Colorectal cancer is the second leading cause of cancer-related deaths in the United States. Colorectal-cancer mortality– and incidence, are reduced with screening by means of fecal occult-blood testing. Endoscopic screening with flexible sigmoidoscopy or colonoscopy is more sensitive than fecal…
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Editorial
Why You Should Care about Screening Flexible Sigmoidoscopy
The clinical outcomes of colorectal-cancer screening in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, now presented by Schoen et al. in the Journal, show that the programmatic use of flexible sigmoidoscopy reduced colorectal-cancer incidence by 21%, with a benefit…
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Clinical Practice
Secondary Prevention after Ischemic Stroke or Transient Ischemic Attack
Foreword. 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 authors' clinical recommendations. Stage. A 62-year-old…
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Original Article
Association of Coffee Drinking with Total and Cause-Specific Mortality
Coffee is one of the most widely consumed beverages, both in the United States and worldwide. Since coffee contains caffeine, a stimulant, coffee drinking is not generally considered to be part of a healthy lifestyle. However, coffee is a rich source of antioxidants and other bioactive compounds,…
Perspective
200th Anniversary Article: The Evolving Primary Care Physician
The primary care doctor is a rapidly evolving species — and in the future could become an endangered one. As the United States grapples with the dual challenges of making health care more widely available and reducing the national price tag, it's hard to say how primary care physicians will fit…
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Case Records of the Massachusetts General Hospital
Case 14-2012 — A 43-Year-Old Woman with Fever and a Generalized Rash
Presentation of Case. Dr. Sarah Gee (Dermatology): A 43-year-old woman was admitted to the hospital because of fever and a generalized rash. The patient had a history of atopic dermatitis and had been in her usual health until approximately 1 week before admission, when a painful, pruritic rash…
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Clinical Problem-Solving
Whistling in the Dark
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 38-year-old woman living in…
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Perspective
Becoming a Physician: Freedom from the Tyranny of Choice — Teaching the End-of-Life Conversation
Thirty years ago, an intern had a conversation with a patient that he regrets to this day. The patient, a young man with widely metastatic lymphoma, unresponsive to chemotherapy, now had progressive dyspnea. The intern knew that even with intubation, his patient would soon die. Although the norm at…
Perspective
Evidence, Preferences, Recommendations — Finding the Right Balance in Patient Care
A 75-year-old man was admitted to the hospital for the third time in 3 months for congestive heart failure. His ejection fraction was 15%, and he was receiving state-of-the-science treatment, including intravenous inotropic agents. He was not a candidate for a heart transplant, but the possibility…
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Case Records of the Massachusetts General Hospital
Case 13-2012 — A 62-Year-Old Man with Paresthesias, Weight Loss, Jaundice, and Anemia
Presentation of Case. Dr. Norifumi Kamo (Medicine): A 62-year-old man was admitted to this hospital because of paresthesias, weight loss, jaundice, and anemia. The patient had been well until approximately 2 months before admission, when numbness, tingling ("pins and needles"), and burning in his…
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Editorial
Surgery or Medical Therapy for Obese Patients with Type 2 Diabetes?
Type 2 diabetes is one of the fastest growing epidemics in human history and is closely associated with obesity. Furthermore, the disease has multiple manifestations and is associated with progressive beta-cell failure. Although lifestyle measures, including weight loss and physical activity,…
Clinical Therapeutics
Insulin-Pump Therapy for Type 1 Diabetes Mellitus
Foreword. This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are…
Original Article
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
The growing incidence of obesity and type 2 diabetes mellitus globally is widely recognized as one of the most challenging contemporary threats to public health. Uncontrolled diabetes leads to macrovascular and microvascular complications, including myocardial infarction, stroke, blindness,…
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