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Case Records of the Massachusetts General Hospital
Case 4-2012 — A 37-Year-Old Man with Muscle Pain, Weakness, and Weight Loss
Presentation of Case. Dr. Ian J. Barbash (Medicine): A 37-year-old man was admitted to this hospital because of muscle pain and weakness. The patient had been well until the evening before admission, when mild diffuse myalgias developed. He awoke in the morning with diffuse muscle cramps and…
- February 9, 2012
- Rhee E.P., Scott J.A., Dighe A.S.
- N Engl J Med 2012; 366:553-560
- CME
A 37-year-old man was admitted to this hospital because of 12 hours of muscle pain and weakness, resulting in the inability to rise from bed. Brief episodes of similar symptoms had occurred during the past month. He reported blurred vision, gynecomastia, and weight loss.
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Perspective
Painful Inequities — Palliative Care in Developing Countries
When Artur, a former KGB agent in Ukraine, developed prostate cancer that metastasized to his bones, his pain grew so intense that he moved hours away from his family so they would not witness his suffering. "I don't want them to see me cry," he said. Lacking access to the opioid regimens that we…
- January 19, 2012
- Lamas D. and Rosenbaum L.
- N Engl J Med 2012; 366:199-201
- Free Full Text
Whereas effective treatment for noncommunicable diseases may be too costly to disseminate globally, opioids for pain control are cheap to produce. Yet 80% of the population, including millions of patients with terminal cancer, lacks adequate access to pain treatment.
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Perspective
Alleviating Suffering 101 — Pain Relief in the United States
The magnitude of pain in the United States is astounding. More than 116 million Americans have pain that persists for weeks to years. The total financial costs of this epidemic are $560 billion to $635 billion per year, according to Relieving Pain in America, the recent report of an Institute of…
- January 19, 2012
- Pizzo P.A. and Clark N.M.
- N Engl J Med 2012; 366:197-199
An Institute of Medicine committee has found that the magnitude of pain in the United States is vast — and costly. It concluded that relieving acute and chronic pain is a significant overlooked problem and that education is key to the cultural transformation required.
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Correspondence
In Vivo Biomechanical Measurements of a Football Player's C6 Spine Fracture
To the Editor: During an investigation of concussion in American football players, we captured in vivo biomechanical data on a cervical spine fracture as it occurred in a male athlete (age, 18 years; height, 189.0 cm; weight, 79.4 kg) who was performing a head-down tackling maneuver. The…
- July 21, 2011
- N Engl J Med 2011; 365:279-281
- Free Full Text
- Video
Sports are a common cause of spine injuries. Video footage documented an 18-year-old football player who sustained a cervical spine fracture during a head-down tackling maneuver. A telemetry system in the player's helmet measured the location and magnitude of the impact that caused the injury.
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Clinical Practice
Vertebral Fractures
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 72-year-old…
- April 28, 2011
- Ensrud K.E. and Schousboe J.T.
- N Engl J Med 2011; 364:1634-1642
- CME
- Full Text Audio
This article reviews the implications of documentation of vertebral fracture for subsequent fracture risk and its role as an adjunct to bone-density assessment. Strategies for the management of vertebral fractures are also discussed.
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Case Records of the Massachusetts General Hospital
Case 4-2011 — A 4-Year-Old Boy with Back Pain and Hypercalcemia
Presentation of Case. Dr. Lisa Charo Bain (Pediatrics): A 4-year-old boy was admitted to this hospital because of back pain and refusal to walk. One week before admission, the patient fell from a single step, after which he reported pain in his lower back and buttocks, which worsened during the…
- February 10, 2011
- El Saleeby C.M., Grottkau B.E., Friedmann A.M., Westra S.J., Sohani A.R.
- N Engl J Med 2011; 364:552-562
- CME
A 4-year-old boy was admitted to this hospital because of a 1-week history of back pain, with sleepiness, constipation, and refusal to walk. The serum calcium level was elevated. Initial radiographs and MRI studies were interpreted as normal. Diagnostic tests were performed.
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Perspective
A Flood of Opioids, a Rising Tide of Deaths
Faced with an epidemic of drug abuse and overdose deaths involving prescription opioid pain relievers, the Food and Drug Administration (FDA) plans to require opioid makers to provide training for physicians and patient-education materials on the appropriate prescribing and use of extended-release…
- November 18, 2010
- Okie S.
- N Engl J Med 2010; 363:1981-1985
- Free Full Text
Faced with an epidemic of drug abuse and overdose deaths, the FDA has proposed a Risk Evaluation and Mitigation Strategy for prescription opioid pain relievers, involving improved education for physicians and patients about risks associated with long-acting opioids.
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Editorial
Nerve Growth Factor and Pain
Osteoarthritis, a common, painful condition, occurs at a rate of 1% per year and affects the majority of people who are over 55 years of age. In a proof-of-concept, phase 2 study in this issue of the Journal, Lane and colleagues report that blocking the activity of nerve growth factor with a…
- October 14, 2010
- Wood J.N.
- N Engl J Med 2010; 363:1572-1573
Osteoarthritis, a common, painful condition, occurs at a rate of 1% per year and affects the majority of people who are over 55 years of age. In a proof-of-concept, phase 2 study in this issue of the Journal, Lane and colleagues¹ report that blocking the ...
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Original Article
Tanezumab for the Treatment of Pain from Osteoarthritis of the Knee
Nerve growth factor is a neurotrophin that regulates the structure and function of responsive sensory neurons, including small-diameter nociceptive afferents. There has been increasing recognition of the potential role of nerve growth factor in pain modulation through nociceptor sensitization.–…
- October 14, 2010
- Lane N.E., Schnitzer T.J., Birbara C.A., et al.
- N Engl J Med 2010; 363:1521-1531
- Free Full Text
Modeling studies show that increased expression of nerve growth factor is associated with increased pain. This study tested the safety and efficacy of the monoclonal antibody tanezumab — which targets nerve growth factor — for the treatment of knee pain in patients with osteoarthritis.
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Images in Clinical Medicine
A White Hand and a Red Hand — Erythromelalgia
Figure 1.
- October 7, 2010
- Lipsker D.
- N Engl J Med 2010; 363:1463
- Free Full Text
A 14-year-old girl presented for evaluation of 3 years of intermittent episodes of acute pain in the hands and feet. She had no other medical history. These episodes of pain were frequently triggered by physical exercise and bathing. During physical ...
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Editorial
Prescribing Tai Chi for Fibromyalgia — Are We There Yet?
Fibromyalgia is a common and poorly understood pain disorder that afflicts an estimated 200 million or more people worldwide. The lack of objective abnormalities detected on physical examination and standard blood and imaging tests has led many physicians to question the existence of this disorder.…
- August 19, 2010
- Yeh G.Y., Kaptchuk T.J., Shmerling R.H.
- N Engl J Med 2010; 363:783-784
Fibromyalgia is a common and poorly understood pain disorder that afflicts an estimated 200 million or more people worldwide.¹ The lack of objective abnormalities detected on physical examination and standard blood and imaging tests has led many ...
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Original Article
A Randomized Trial of Tai Chi for Fibromyalgia
Fibromyalgia is a common and complex clinical syndrome characterized by chronic and widespread musculoskeletal pain, fatigue, sleep disturbance, and physical and psychological impairment. Evidence-based guidelines suggest that fibromyalgia is typically managed with multidisciplinary therapies…
- August 19, 2010
- Wang C., Schmid C.H., Rones R., et al.
- N Engl J Med 2010; 363:743-754
- Free Full Text
In this 12-week, single-blind, randomized, controlled trial, classic Yang-style tai chi was compared with a control intervention (wellness education and stretching) in 66 patients with fibromyalgia. Patients in the tai chi group had significantly greater improvement than those in the control group, with no adverse events.
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Images in Clinical Medicine
“Cotton Wool” Appearance of Paget's Disease
Figure 1.
- August 5, 2010
- Bhargava P. and Maki J.H.
- N Engl J Med 2010; 363:e9
- Free Full Text
A 63-year-old man presented with a long-standing history of sinusitis and 3 weeks of frontal headache. The physical examination was unremarkable. The alkaline phosphatase level was elevated at 434 IU per liter (upper limit of the normal range, 129). The ...
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Clinical Therapeutics
Acupuncture for Chronic Low Back Pain
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…
- July 29, 2010
- Berman B.M., Langevin H.M., Witt C.M., Dubner R.
- N Engl J Med 2010; 363:454-461
- CME
A 45-year-old man with a 7-year history of low back pain asks his physician for a referral to a licensed acupuncturist. Acupuncture involves the insertion of fine metallic needles into the body at specific sites. Clinical trials of acupuncture for chronic low back pain have shown higher rates of symptom improvement with either acupuncture or sham acupuncture than with usual care.
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Clinical Therapeutics
Triptan Therapy in Migraine
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…
- July 1, 2010
- Loder E.
- N Engl J Med 2010; 363:63-70
- CME
A 23-year-old woman presents with migraine headaches that are unresponsive to analgesics. Triptan therapy is recommended. Triptans are serotonin agonists that were originally thought to provide migraine relief by causing cranial vasoconstriction; other mechanisms are now also proposed. Chest pain is a common side effect, but cardiac ischemia is rare and usually associated with known cardiovascular disease or risk factors.
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Perspective
Medical Marijuana and the Law
The U.S. legal landscape surrounding "medical marijuana" is complex and rapidly changing. Fourteen states — California, Alaska, Oregon, Washington, Maine, Hawaii, Colorado, Nevada, Vermont, Montana, Rhode Island, New Mexico, Michigan, and most recently, New Jersey — have passed laws eliminating…
- April 22, 2010
- Hoffmann D.E. and Weber E.
- N Engl J Med 2010; 362:1453-1457
- Free Full Text
The U.S. legal landscape surrounding “medical marijuana” is complex and rapidly changing. Diane Hoffmann and Ellen Weber describe evolving legislation.
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Clinical Therapeutics
Epidural Analgesia for Labor and Delivery
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…
- April 22, 2010
- Hawkins J.L.
- N Engl J Med 2010; 362:1503-1510
A 30-year-old pregnant woman is undergoing induction of labor and is experiencing severe pain despite intravenous opioid administration. Epidural analgesia is recommended. Epidural analgesia involves the injection of a local anesthetic agent and an opioid analgesic agent into the lumbar epidural space. These agents diffuse across the dura and act on the spinal nerve roots. Rates of cesarean delivery are not increased with epidural analgesia.
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Perspective
Focus on Research: Back Surgery — Who Needs It?
Back surgery is not the final common pathway for everyone with persistent back pain. It offers specific therapy for specific anatomical derangements associated with specific complexes of symptoms. When surgery ranges beyond carefully defined situations, we can expect disappointed patients. A…
- May 31, 2007
- Deyo R.A.
- N Engl J Med 2007; 356:2239-2243
- Interactive/Multimedia
Dr. Richard Deyo writes that despite assertions that surgery is only a last resort or is used more selectively than in the past, the rate of spine surgery has steadily increased in recent decades. Are the benefits worth the growing costs and the risks?
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Original Article
Surgery versus Prolonged Conservative Treatment for Sciatica
Sciatica is characterized by radiating pain in an area of the leg typically served by one nerve root in the lumbar or sacral spine; it is sometimes also associated with sensory and motor deficits. The most common cause of sciatica is a herniated disk. The estimated annual incidence of sciatica in…
- May 31, 2007
- Peul W.C., van Houwelingen H.C., van den Hout W.B., et al.
- N Engl J Med 2007; 356:2245-2256
- Free Full Text
This randomized trial of 283 patients with 6 to 12 weeks of severe sciatica compared early microdiskectomy surgery with a strategy of prolonged conservative treatment with eventual surgery if needed. Patients who had early surgery reported faster recovery and more rapid improvement in leg pain. After 1 year, the outcomes in the two groups were similar, and 95% of the patients in both groups reported recovery.
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Correspondence
Case 21-2006: A Man with Left-Sided Facial Pain
To the Editor: The Case Record describing a 61-year-old man with facial pain was a clear presentation of the management of trigeminal neuralgia (July 13 issue). Patients who do not have a response to medical therapy or who have intolerable adverse effects are suitable candidates for surgery.…
- November 30, 2006
- N Engl J Med 2006; 355:2375-2376
- Free Full Text
To the Editor: The Case Record describing a 61-year-old man with facial pain was a clear presentation of the management of trigeminal neuralgia (July 13 issue).¹ Patients who do not have a response to medical therapy or who have intolerable adverse ...
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Medical Meetings Pediatrics Conferences and Meetings

2012 Certifying Examinations of the American Board of Pediatrics

The general pediatrics examination will be held in various cities, Oct. 16-18. Registration for first-time applicants is ongoing through May 3. Registration for re-registrants is ongoing through May 24. The following subspecialty examinations will be held in various cities: "Hospice and Palliative Medicine" (Oct. 4); "Pediatric Transplant Hepatology" (Oct. 11); "Pediatric Cardiology" (Nov. 7); "Pediatric Pulmonology" (Nov. 8); "Medical Toxicology" (Nov. 12); and "Pediatric Critical Care Medicine" (Nov. 14). Registration for first-time applicants is ongoing through April 30. Registration for re-registrants is ongoing through June 15.

Contact the American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC 27514-1513; or call (919) 929-0461; or fax (919) 918-7114 or (919) 929-9255; or see http://www.abp.org .

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