NEJM Group

Pancreatic cysts are often found incidentally on imaging tests for other indications. Imaging, symptom assessment, and laboratory tests can help distinguish benign cysts from those associated with a risk of malignant transformation.    The presence of high-risk stigmata (including biliary obstruction, dilatation of the main pancreatic duct of >10 mm, and a solid enhancing mural nodule of ≥5 mm) has a high positive predictive value for advanced neoplasia, ranging from 56 to 89% (shown in panel A). Worrisome features, such as a cyst size greater than 3 cm in diameter, main-duct dilatation of 5 to 10 mm, a contrast-enhancing mural nodule of less than 5 mm, an enhancing or thickened cyst wall or septations, lymphadenopathy, a change in the caliber of the pancreatic main duct with distal pancreatic atrophy, and an increase in cyst size greater than 20% or approximately 2.5 mm in diameter per year, are also associated with an increased risk of advanced neoplasia, albeit a lower risk than that associated with the high-risk stigmata (shown in panel B).    Learn more in the Review Article “Pancreatic Cysts” by Tamas A. Gonda, MD, Djuna L. Cahen, MD, PhD, and James Farrell, MD, from NYU Langone Health, Erasmus MC, Yale School of Medicine, and Yale New Haven Health: https://nej.md/4g4jz5s  

Health care workforces in the United States and Europe are struggling and shrinking at unsustainable rates, write the authors of a new Perspective. One in five doctors and one in four nurses may leave the profession in the next 3 to 5 years. Many observers ascribe this exodus to burnout, which increased during and after the Covid pandemic. Burnout arises when demands surpass worker resources and has proved stubbornly resistant to interventions. In failing to consider the roles of compromised values, ethics, and existential meaning as drivers of distress, however, “burnout” offers an incomplete account of the health workforce crisis. By contrast, “moral injury” describes the values-based distress inherent in forsaking the foundational principle of the healing professions: the covenant of care. This experience is rooted in relational ruptures and ethical dilemmas that reflect the significant personal meaning people ascribe to perceived transgressions and betrayals. Such “meaning attached” experiences are distinct from the “transactional imbalance,” or demand–resource mismatch, of burnout, though they often coexist with that imbalance. Understanding the common drivers of moral injury in various types of health systems is vital for identifying effective solutions to ensure a thriving workforce and optimized patient care.    Continue reading the Perspective “Moral Injury and the Global Health Workforce Crisis — Insights from an International Partnership” by W. Dean et al., from Moral Injury of Healthcare and elsewhere: https://nej.md/4dY99CA 

#ESCCongress 2024 Round Up: 12 Original Articles were simultaneously published in NEJM and presented at this year’s European Society of Cardiology Congress in London. Each article included a podcast with NEJM editors discussing the significance of the trial results.    𝗛𝗘𝗟𝗜𝗢𝗦-𝗕 𝗧𝗿𝗶𝗮𝗹  📄 Vutrisiran in Patients with Transthyretin Amyloidosis with Cardiomyopathy https://nej.md/3X5nl5Q  🎙️ Podcast: https://nej.md/3yY69Y2    𝗔𝗕𝗬𝗦𝗦 𝗧𝗿𝗶𝗮𝗹  📄 Beta-Blocker Interruption or Continuation after Myocardial Infarction https://nej.md/3MeRHOi  🎙️ Podcast: https://nej.md/4dBTJ7g     𝗪𝗼𝗺𝗲𝗻’𝘀 𝗛𝗲𝗮𝗹𝘁𝗵 𝗦𝘁𝘂𝗱𝘆  📄 Inflammation, Cholesterol, Lipoprotein(a), and 30-Year Cardiovascular Outcomes in Women https://nej.md/3Mrh9A8  🎙️ Podcast: https://nej.md/3T9rxjZ     𝗥𝗘𝗦𝗛𝗔𝗣𝗘-𝗛𝗙𝟮 𝗧𝗿𝗶𝗮𝗹  📄 Transcatheter Valve Repair in Heart Failure with Moderate to Severe Mitral Regurgitation https://nej.md/477rpaC  🎙️ Podcast: https://nej.md/4cFK5PO     𝗠𝗔𝗧𝗧𝗘𝗥𝗛𝗢𝗥𝗡 𝗧𝗿𝗶𝗮𝗹  📄 Transcatheter Repair versus Mitral-Valve Surgery for Secondary Mitral Regurgitation https://nej.md/3ACiKk2   🎙️ Podcast: https://nej.md/3Mrb0UY     𝗡𝗢𝗧𝗜𝗢𝗡-𝟯 𝗧𝗿𝗶𝗮𝗹  📄 PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation https://nej.md/3AH5WJo   🎙️ Podcast: https://nej.md/3MqUBzK     𝗦𝗘𝗡𝗜𝗢𝗥-𝗥𝗜𝗧𝗔 𝗧𝗿𝗶𝗮𝗹  📄 Invasive Treatment Strategy for Older Patients with Myocardial Infarction https://nej.md/4fZIG9z   🎙️ Podcast: https://nej.md/4788V9L     𝗣𝗢𝗣𝘂𝗹𝗮𝗿 𝗣𝗔𝗨𝗦𝗘 𝗧𝗔𝗩𝗜 𝗧𝗿𝗶𝗮𝗹  📄 Continuation versus Interruption of Oral Anticoagulation during TAVI https://nej.md/3XllHys   🎙️ Podcast: https://nej.md/3T7FaAc     𝗢𝗖𝗘𝗔𝗡𝗜𝗖-𝗔𝗙 𝗧𝗿𝗶𝗮𝗹  📄 Asundexian versus Apixaban in Patients with Atrial Fibrillation https://nej.md/473TRdc   🎙️ Podcast: https://nej.md/3T8naG2     𝗘𝗣𝗜𝗖-𝗖𝗔𝗗 𝗧𝗿𝗶𝗮𝗹  📄 Edoxaban Antithrombotic Therapy for Atrial Fibrillation and Stable Coronary Artery Disease https://nej.md/3Z1D1d3  🎙️ Podcast: https://nej.md/3T4vqqr     𝗙𝗜𝗡𝗘𝗔𝗥𝗧𝗦-𝗛𝗙 𝗧𝗿𝗶𝗮𝗹  📄 Finerenone in Heart Failure with Mildly Reduced or Preserved Ejection Fraction https://nej.md/470x4ix   🎙️ Podcast: https://nej.md/3T7E2fW     𝗣𝗔𝗟𝗜𝗦𝗔𝗗𝗘 𝗧𝗿𝗶𝗮𝗹  📄 Plozasiran for Managing Persistent Chylomicronemia and Pancreatitis Risk https://nej.md/3YZMBx2   🎙️ Podcast: https://nej.md/3MnsCB1  

𝗙𝗲𝘁𝗮𝗹 𝗵𝗲𝗺𝗼𝗹𝘆𝘀𝗶𝘀 is the rupture of red cells, which causes release of cellular debris and proteins, such as hemoglobin, into surrounding fluids. Fetal hemolysis can lead to fetal anemia and, as a result of heme degradation, the production of bilirubin, which is eliminated by the placenta. Hemolysis during pregnancy can lead to anemia in the fetus and hyperbilirubinemia and anemia in the newborn. To learn more about this NEJM Illustrated Glossary term, read the editorial “Inhibiting IgG in Hemolytic Disease of the Fetus” by Emeline Maisonneuve, MD, Alice Panchaud, PhD, and David Baud, MD, PhD: https://nej.md/3YS7Scb    Explore more terms: https://nej.md/glossary  

One third of Black and Latinx residents in Chicago are food insecure, write the authors of a new Perspective.     Food insecurity was exacerbated by closure of supermarkets during the Covid-19 pandemic, which led to especially low availability of fresh produce on the city’s racially minoritized West Side.    VeggieRx is a produce prescription program anchored by the Farm on Ogden, a 20,000-square-foot urban agriculture facility.    VeggieRx prescriptions are provided by health center clinicians to patients with diet-related diseases such as obesity and diabetes, many of whom are also experiencing food insecurity. To redeem prescriptions, patients are given an appointment at the Farm on Ogden, a 20,000-square-foot urban agriculture facility that is located on the West Side of Chicago, one block from Lawndale Christian Health Center’s main campus, and is accessible by several public bus and train routes. The farm is operated by the Chicago Botanic Garden’s urban agriculture program, Windy City Harvest, and houses a 7300-square-foot indoor greenhouse, a 50,000-gallon aquaponics system, a year-round indoor farmer’s market, commercial and teaching kitchens for nutrition education and local culinary entrepreneurs, an aggregation space for urban farmers, job training for justice-involved residents, and certificate programs in farming, food safety, cooking, and nutrition (shown in photo).    Learn more about this program in the Perspective “An Urban Farm–Anchored Produce Prescription Program — Food as Medicine and Economic Justice” by K.M. Fruin et al., from UCLA, the University of Chicago, the Chicago Botanic Garden, and the Lawndale Christian Health Center: https://nej.md/3WQXIpt 

Acute kidney injury (AKI) is a serious and common complication of cardiac surgery, for which reduced kidney perfusion is a key contributing factor.    Intravenous amino acids increase kidney perfusion and recruit renal functional reserve. However, the efficacy of amino acids in reducing the occurrence of AKI after cardiac surgery is uncertain.    In the PROTECTION trial, researchers evaluated the efficacy and safety of intravenous amino acid therapy in reducing the risk of AKI in adult patients undergoing elective cardiac surgery with cardiopulmonary bypass.    A total of 3511 adults scheduled to undergo cardiac surgery requiring cardiopulmonary bypass were randomly assigned to receive either a balanced mixture of amino acids, at a dose of 2 g per kilogram of ideal body weight per day, or placebo, from the time of admission to the operating room for up to 3 days.     The primary outcome was AKI within 1 week after surgery, with AKI defined according to the Kidney Disease: Improving Global Outcomes creatinine criteria for stage 1 or greater AKI.    Among adult patients undergoing cardiac surgery, infusion of amino acids reduced the occurrence of AKI.    Read the full PROTECTION trial results and Plain Language Summary: https://nej.md/45zYDyF    #ClinicalTrials #MedicalResearch

𝗩𝗼𝗻 𝗪𝗶𝗹𝗹𝗲𝗯𝗿𝗮𝗻𝗱 𝗙𝗮𝗰𝘁𝗼𝗿 is a multidomain adhesive glycoprotein produced in megakaryocytes and endothelial cells that protects factor VIII from degradation and is crucial for primary hemostasis and thus plug (or clot) formation. It forms multimers that circulate in the blood. After endothelial damage, von Willebrand factor binds to the subendothelial extracellular matrix and unfolds to expose platelet-binding sites, capturing platelets and thus contributing to the formation of a platelet plug. It promotes changes in platelet shape and granule release, which contribute to coagulation and hemostasis. Genetic variants in the von Willebrand factor gene result in changes in von Willebrand factor, causing a common bleeding disorder known as von Willebrand disease. To learn more about this NEJM Illustrated Glossary term, read the editorial “Bioengineered Factor VIII — More Innovation for Hemophilia A” by Pratima Chowdary, MD, from the Royal Free London NHS Foundation Trust: https://nej.md/3Y6RTWY    Explore more terms: https://nej.md/glossary  

Free Virtual Event from NEJM AI: AI in Health Care — Putting Patients First    Patients are using #ArtificialIntelligence for a variety of reasons – from second opinions to self-diagnoses, finding appointments, and more. Today, health care organizations have the opportunity to optimize that AI use, not only to minimize risk for patients, but also to enhance engagement and the overall patient experience.    Join us for a free virtual event to hear experts in the field of AI discuss:    🛠️ The ground truth on the tools patients are using independently  🩺 How clinicians can guide patients on optimal AI use despite current constraints and uncertainties  🤖 What meaningful patient engagement can look like with AI   📝 Strategies to leverage patient input to prioritize research and technology development    📅 October 9, 2024  ⏰ 12:00–2:15 PM  🔗 https://nej.md/3AQXCqh    #AIinMedicine #HealthCare 

Because there is no universal definition of normal sexual function, what constitutes sexual difficulty is determined by a person’s subjective definition of unsatisfactory sexual well-being. The condition is usually described as unsatisfactory interest, arousal, orgasm, or other aspects of sexuality (e.g., sexual self-image), and the symptoms often coexist. The term “sexual dysfunction” is used when at least one of the symptoms is of substantial concern to the affected person.     Sexual dysfunction in women impairs quality of life and is determined by multiple factors. Treatment includes lifestyle modification, counseling and psychosexual therapies, and pharmacotherapy.    Learn more in the Clinical Practice article “Sexual Dysfunction in Women” by Susan R. Davis, MB, BS, PhD, from Monash University and Alfred Health: https://nej.md/3yPp3jN 

A storytelling initiative launched by health care, academic, and community organizations produces narrative interventions to help heal and empower the people most deeply affected by gun violence in Boston.     Ruth Rollins, president and founder of We Are Better Together, Warren Daniel Hairston Project (WAB2G), holds a photo of her son Danny, who was murdered in Boston in 2007. Driven by her personal experiences and her expertise as a domestic violence advocate, Ruth founded WAB2G in 2017 to empower women and girls affected on both sides of gun violence in the peacemaking process. Full Perspective in comments.    Read the Perspective “Transforming Narratives of Gun Violence” by P.T. Masiakos et al., from Massachusetts General Hospital, the Louis D. Brown Peace Institute, and Emerson College: https://nej.md/3SSBRgd