Case Record of the Massachusetts General Hospital: A 76-year-old woman, who had a history of treated hepatitis C virus infection, presented with rapidly progressive kidney failure and a stroke. Palpable purpura on the legs was noted.
A bone marrow core biopsy revealed a moderately hypercellular marrow characterized by maturing trilineage hematopoiesis with myeloid predominance and rare nonparatrabecular lymphoid aggregates. These aggregates were composed mainly of B cells with few plasma cells (Panels A and B) and predominantly expressed IgM (Panel C) and kappa (Panels D and E). Flow cytometry of the bone marrow aspirate identified a small population of B cells (CD19+ and CD10−) with an excess of kappa light chains (kappa:lambda ratio in bone marrow aspirate, 3.6; reference range, 1.0 to 3.0). Plasma cells accounted for 8% of the total cellularity and had kappa predominance (kappa:lambda ratio, 4.4). Flow cytometry of the peripheral blood revealed a concordant population of B cells with monotypic kappa expression (Panel F). These findings are consistent with low-level involvement by a small mature B-cell lymphoma with plasmacytic differentiation — either a marginal-zone lymphoma or lymphoplasmacytic lymphoma. The MYD88 c.794T→C (p.L265P) mutation, which is present in the vast majority of cases of lymphoplasmacytic lymphoma, was not detected.
Read the full case details in “A 76-Year-Old Woman with Fatigue, Rash, and Kidney Failure,” a Case Record of the Massachusetts General Hospital, by F.B. Cortazar et al., from St. Peter’s Hospital (@sphpnews), Massachusetts General Hospital (@MassGeneralNews), and @harvardmed: https://nej.md/4tIpKCw
A 30-year-old man who worked as an agricultural laborer presented with a 2-year history of skin lesions on his right foot. Examination was notable for swelling of the right foot with overlying ulcerated nodules.
Read the full case details in the Images in Clinical Medicine article “Mycetoma,” from the University of Antioquia (@UdeA) and @ClinicaCES: https://www.nejm.org/doi/full/10.1056/NEJMicm2515474
𝗖𝘂𝗿𝗿𝗲𝗻𝘁 𝗮𝗻𝗱 𝗙𝘂𝘁𝘂𝗿𝗲 𝗠𝗮𝗻𝗮𝗴𝗲𝗺𝗲𝗻𝘁 𝗼𝗳 𝗕𝗮𝗿𝗿𝗲𝘁𝘁’𝘀 𝗘𝘀𝗼𝗽𝗵𝗮𝗴𝘂𝘀
Panel A shows the current approach to managing Barrett’s esophagus. The disease is diagnosed on a case-by-case basis, with patients entering a vicious circle of lifetime endoscopy checkups and treatment if dysplasia or early cancer is detected. Patients exit the circle if they become too frail for further checkups, have a missed cancer (i.e., an interval cancer diagnosed before the next cycle of surveillance) warranting systemic treatment, or die from another cause. Panel B shows a future risk-based, population-control approach to managing Barrett’s esophagus. The population to be offered screening is enriched on the basis of risk factors. A triage test determines whether the patients in this population have a low, average, or high lifetime risk of cancer. The approach to management is tailored to each patient to minimize harm and maximize detection of dysplasia or stage I cancer.
Learn more about the management of Barrett’s esophagus in a new Clinical Practice article by Rebecca C. Fitzgerald, MD (@RFitzgerald_lab), from the University of Cambridge (@cambridge_uni): https://nej.md/48nNRxV
A decade’s worth of public data from hospitals in Madrid suggests that value-based hospital outsourcing is associated with improved clinical outcomes, greater efficiency, and increased patient satisfaction.
Learn more in the article “Value-Based Outsourcing in Spain Is Associated with Improved Clinical, Efficiency, and Patient Satisfaction Metrics” by J.A. Álvaro de la Parra et al. in the May issue of @nejmcatalyst Innovations in Care Delivery: https://catalyst.nejm.org/doi/full/10.1056/CAT.25.0208
Explore the full issue: https://catalyst.nejm.org/toc/catalyst/7/5
Amanda Banks, MD, discusses concerns about a potential association between GLP-1 receptor agonists and restrictive eating disorders. Listen to the full interview with NEJM Executive Managing Editor Stephen Morrissey (@srm128): https://nej.md/4twOrC3
Maternal infection, including sepsis, is associated with up to half of in-hospital maternal deaths. The APT-Sepsis multicomponent intervention might help improve outcomes. Research findings are summarized in a new Quick Take video. https://www.nejm.org/do/10.1056/NEJMdo008465/full/
A new review examines the effects of sex hormones on hemostasis and the vasculature and summarizes current evidence on thrombotic risk. Practical guidance on the prevention and treatment of hormone-associated venous thromboembolism is also provided. Read the full review: https://www.nejm.org/doi/full/10.1056/NEJMra2202438
Early results from an international trial of selective decontamination of the digestive tract during mechanical ventilation showed no reduction in in-hospital mortality. Complete SuDDICU trial results are now summarized in a new Quick Take video. https://www.nejm.org/do/10.1056/NEJMdo008447/full/
In the phase 3 OCEANIC-STROKE trial involving patients with noncardioembolic ischemic stroke or high-risk TIA, asundexian added to antiplatelet therapy led to a lower risk of ischemic stroke without increasing major bleeding. Full trial results and Research Summary: https://www.nejm.org/doi/full/10.1056/NEJMoa2513880
"Mushrooms" for depression: new science.
@NEJMClinician Editor-in-Chief Raja-Elie Abdulnour, MD (@BageLeMage), explains a trial investigating the efficacy and safety of psilocybin as a therapy for treatment-resistant depression. Read the key results and comment from Peter Roy-Byrne, MD: https://jwat.ch/3Qc6EWH
Visit http://clinician.nejm.org to see What Matters Most This Week, including:
❤️🔥 Acute Coronary Syndromes in Premenopausal Women
💊 Clopidogrel Beats Aspirin at 10 Years Post-PCI
🫀 Assessing Cardiovascular Risk in Rheumatoid Arthritis
🔬 Long-Term Risk of Cervical Precancer after HPV, Cytology Screening
🧵 Recent technological advances are reshaping the health care landscape and fueling innovation within and outside health systems. Physicians bring critical stewardship to this transformation
Perspective by P. Joseph et al.: Nurse Scientists as Trusted Voices in Health Communication https://www.nejm.org/doi/full/10.1056/NEJMp2518286
#HealthPolicy #PublicHealth
Images in Clinical Medicine: Intraosseous Abscess from Subacute Osteomyelitis https://www.nejm.org/doi/full/10.1056/NEJMicm2514540
#Radiology
Case Record of the Massachusetts General Hospital (@MassGeneralNews): A 70-year-old woman was evaluated at this hospital because of a racing heart, fatigue, dyspnea, and leg edema. 🔗 https://www.nejm.org/doi/full/10.1056/NEJMcpc2513542
Figure 2 from the case illustrates the relationship between the esophagus and targets used in ablation for atrial fibrillation.
Shown are common targets (red X symbols) used in ablation for #AFib and their typical anatomical relationship with the usual course of the esophagus in an approximate left anterior oblique projection. The relationship of the esophagus to the left atrium varies substantially, particularly within the coronal plane. Factors that affect heating of the esophagus (radiofrequency) or cooling of the esophagus (cryotherapy) are multiple and complex. In addition to anatomical proximity, such factors include pericardial fat volume; the number, duration, and sequence of energy applications; contact force; and catheter stability.
Learn more in “A 70-Year-Old Woman with a Racing Heart, Fatigue, and Dyspnea,” a Case Record of the Massachusetts General Hospital, by T.K. Varghese et al., from Huntsman Cancer Institute, University of Utah School of Medicine, Massachusetts General Hospital (@MassGeneralNews), and @harvardmed: https://www.nejm.org/doi/full/10.1056/NEJMcpc2513542
#Cardiology
After inhaling smoke from a forest fire for several hours, an 87-year-old man presented to the ED with difficulty breathing. He rapidly developed respiratory failure, and a flexible bronchoscopy revealed bronchial casts from inhalation of particulate matter from the smoke. Read the full case details: https://www.nejm.org/doi/full/10.1056/NEJMicm2518379
This video is part of an #EarthDay2026 spotlight illustrating the effects of the climate crisis on clinical health. View more resources at https://www.nejm.org/browse/specialty/climate-change
An interactive graphic in a new Review Article summarizes guidelines for management of the risk of venous thromboembolism and cardiovascular disease in persons receiving hormone therapy. Explore the interactive graphic and read the full review: https://www.nejm.org/doi/full/10.1056/NEJMra2202438
Original Article: Randomized Trial of Adjunctive Prednisolone for Kawasaki Disease (phase 3 trial) https://www.nejm.org/doi/full/10.1056/NEJMoa2511478
Editorial: Glucocorticoids in Kawasaki Disease — Refining Indications and the Science https://www.nejm.org/doi/full/10.1056/NEJMe2518759
#Pediatrics #Rheumatology
A new Double Take video reviews the differential diagnosis for a woman with night sweats and unintentional weight loss and how it evolves as new clinical findings are presented. Watch the full video on YouTube: https://youtu.be/-Ty-RKs1TOU
In the SuDDICU trial of patients undergoing mechanical ventilation in the intensive care unit, selective decontamination of the digestive tract did not result in a lower incidence of in-hospital death than standard care alone. Full trial results and Research Summary: https://www.nejm.org/doi/full/10.1056/NEJMoa2506398
“We identified 5055 hospitalizations for Guillain–Barré syndrome. Of these cases, 147 included a documented dengue infection, and the hospitalization occurred within the risk window (1 to 42 days after the onset of symptoms of dengue) in 89 cases. The incidence rate ratio during the period from day 1 to day 42, as compared with the control period, was 16.75 (95% confidence interval [CI], 10.97 to 25.55; P<0.001). Risk was highest in the first 2 weeks and returned to baseline levels by day 43. The attributable risk between day 1 and day 42 was 35.5 excess Guillain–Barré syndrome cases (95% CI, 34.3 to 36.3) per million laboratory-confirmed dengue infections.”
Cerqueira-Silva and colleagues report their research findings in a new correspondence. Read now: https://www.nejm.org/doi/full/10.1056/NEJMc2519008
Original Article: Asundexian for Secondary Stroke Prevention (phase 3 OCEANIC-STROKE trial) https://www.nejm.org/doi/full/10.1056/NEJMoa2513880
Editorial: Asundexian for Noncardioembolic Ischemic Stroke https://www.nejm.org/doi/full/10.1056/NEJMe2601859
#Neurology
Perspective by Amy W. Stimpfel, PhD, RN, and Maja Djukic, PhD, RN: Using Data to Inform Decision Making — Borrowing Limits for Graduate Nursing Students https://www.nejm.org/doi/full/10.1056/NEJMp2600236
#HealthPolicy #MedEd
Phase 3 VAYHIT2 trial: Second-line treatments for immune thrombocytopenia often require long-term therapy. Research evaluating short-course ianalumab plus eltrombopag is summarized in a new Quick Take video. https://www.nejm.org/do/10.1056/NEJMdo008429/full/
In a new Case Record of the Massachusetts General Hospital, a patient had a pentad of symptoms suggestive of narcolepsy type 1, including excessive daytime sleepiness, cataplexy, sleep-related hallucinations, sleep paralysis, and disturbed night sleep. Full case details: https://www.nejm.org/doi/full/10.1056/NEJMcpc2517861
A 74-year-old man presented to the emergency department with a 3-day history of a painful laceration on his right leg that he had sustained while jumping into waters off the Gulf Coast of Florida. Read the full case details and submit your answer or see how others responded: https://www.nejm.org/image-challenge?ci=20260416
In a phase 3 randomized trial involving 3208 children with Kawasaki disease, adding prednisolone to standard primary therapy did not reduce the incidence of coronary-artery lesions at 1 month. Full trial results and Research Summary: https://www.nejm.org/doi/full/10.1056/NEJMoa2511478
Original Article: Ianalumab plus Eltrombopag in Immune Thrombocytopenia (phase 3 VAYHIT2 trial) https://www.nejm.org/doi/full/10.1056/NEJMoa2515168
#Hematology #Immunology
Among patients with moderate or severe PTS, the addition of endovascular therapy to standard care resulted in less severe PTS and better quality of life at 6 months than standard care alone but with a higher risk of bleeding. Full phase 3 C-TRACT trial results and Research Summary: https://www.nejm.org/doi/full/10.1056/NEJMoa2519001
Phase 3 OCEANIC-STROKE trial: Genetically low levels of coagulation factor XI are associated with a reduced risk of ischemic stroke. Asundexian, an inhibitor of activated factor XI, may lower the risk of recurrent stroke. Research findings are summarized in a new Quick Take video. https://www.nejm.org/do/10.1056/NEJMdo008443/full/
A new Double Take video describes a woman who presents with night sweats and unintentional weight loss, and it explores the differential diagnosis of the patient’s presentation and how it evolves throughout the diagnostic evaluation and the patient’s clinical course. 📺 https://youtu.be/-Ty-RKs1TOU
In a patient with metastatic cervical cancer treated with the nectin-4–targeted antibody–drug conjugate bulumtatug fuvedotin, a new hepatic lesion proved to be pseudoprogression and resolved with continued therapy. Read the full case details: https://www.nejm.org/doi/full/10.1056/NEJMc2518316
Amy W. Stimpfel, PhD, RN, discusses a new policy that would cap loans for graduate nursing and other students. Listen to the full interview with NEJM Executive Managing Editor Stephen Morrissey (@srm128): https://www.nejm.org/doi/full/10.1056/NEJMdo008497
Original Article: First-Line Zongertinib in Advanced HER2-Mutant Non–Small-Cell Lung Cancer https://www.nejm.org/doi/full/10.1056/NEJMoa2516969
Editorial: EGFR’s Poor Sibling https://www.nejm.org/doi/full/10.1056/NEJMe2603357
#Oncology
Post-thrombotic syndrome, common after deep-vein thrombosis, can cause severe limb symptoms and impair activity. Studies suggest that endovascular therapy may reduce clinical severity. Research findings from the phase 3 C-TRACT trial are summarized in a new Quick Take video. https://www.nejm.org/do/10.1056/NEJMdo008471/full/
A 74-year-old man presented to the emergency department with a 3-day history of a painful laceration on his right leg that he had sustained while jumping into waters off the Gulf Coast of Florida. Two days after the injury to his leg, skin changes had appeared on his right arm. Physical examination is shown of the right lower leg and right forearm. He had no known history of chronic liver disease or an immunocompromising condition. What is the most likely diagnosis? https://www.nejm.org/image-challenge?ci=20260416
A new Double Take video reviews the differential diagnosis for a woman with night sweats and unintentional weight loss and how it evolves as new clinical findings are presented. Watch “The Devil Is in the Details” on YouTube: https://youtu.be/-Ty-RKs1TOU
In a Brazilian self-controlled case series of 5055 hospitalizations for Guillain–Barré syndrome, laboratory-confirmed dengue was associated with an increased risk of Guillain–Barré syndrome occurring within 42 days. Learn more: https://www.nejm.org/doi/full/10.1056/NEJMc2519008
In the season finale of the Not Otherwise Specified podcast, host and NEJM National Correspondent Lisa Rosenbaum, MD, and her guests elucidate the quiet beauty of good primary care and consider how to induce the U.S. health care system to prize it more highly.
Listen to the full episode: https://not-otherwise-specified-podcast.nejm.org/e/when-no-ones-watching/
Read the full episode transcript: https://www.nejm.org/doi/full/10.1056/NEJMp2514244
Original Article: Selective Decontamination of the Digestive Tract during Ventilation in the ICU (SuDDICU trial) https://www.nejm.org/doi/full/10.1056/NEJMoa2506398
Editorial: Selective Digestive Decontamination — Finding the Way Forward https://www.nejm.org/doi/full/10.1056/NEJMe2602823
📖 Further reading in @NEJMEvidence:
Original Article by N.E. Hammond et al.: Selective Decontamination of the Digestive Tract in Mechanically Ventilated Patients — An Updated Systematic Review with Bayesian Meta-Analysis https://evidence.nejm.org/doi/full/10.1056/EVIDoa2500264
Coronary-artery lesions develop in 10 to 20% of patients who receive standard treatment for Kawasaki disease. Whether adjunctive glucocorticoids reduce lesion formation is unclear. Research findings for a phase 3 trial are summarized in a new Quick Take video. https://www.nejm.org/doi/full/10.1056/NEJMdo008445