Learning/CME

CME activities, cases, challenges, videos, and more teaching and learning tools from the New England Journal of Medicine.

CME

Original Article
Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI
B.-K. Koo and Others
N Engl J Med 2022; 387:779-789
In a randomized trial of fractional flow reserve versus IVUS to guide PCI, the use of FFR resulted in fewer coronary interventions and was noninferior to IVUS with respect to clinical outcomes at 2 years.
Sep 01
Clinical Problem-Solving
Telescoping the Diagnostic Process
C.D. Lee and Others
N Engl J Med 2022; 387:833-838
A 3-year-old boy presented with abdominal pain and vomiting. He had associated chills without fever, nonbloody and nonbilious emesis, constipation, reduced urinary output, and a decreased activity level.
Sep 01
Review Article
Chronic Urticaria
D.M. Lang
N Engl J Med 2022; 387:824-831
Chronic urticaria differs from acute urticaria in characteristics and treatments. The chronic form is spontaneous or inducible, with the latter elicited by cold, heat, pressure, or other precipitants.
Sep 01
Original Article
Olokizumab versus Placebo or Adalimumab in Rheumatoid Arthritis
J.S. Smolen and Others
N Engl J Med 2022; 387:715-726
In patients with rheumatoid arthritis, the monoclonal antibody against interleukin-6, olokizumab, was superior to placebo and noninferior to adalimumab at 12 weeks.
Aug 25
Review Article
Lesions of the Ovary and Fallopian Tube
R.C. Sisodia and M.G. del Carmen
N Engl J Med 2022; 387:727-736
Lesions of the ovary and fallopian tube are common and may be acute or chronic. Diagnostic assessment is designed to distinguish benign from malignant causes. Referral to a gynecologic oncologist is often necessary.
Aug 25

Clinical Pearls

How is chronic urticaria categorized?

Chronic urticaria has been categorized on the basis of consensus criteria and guidelines as spontaneous urticaria (previously designated as chronic idiopathic urticaria), in which urticaria, angioedema, or both occur in an unprompted fashion, or as inducible urticaria (previously designated as physical urticaria), in which urticaria, angioedema, or both are elicited by factors such as cold, heat, or pressure. Patients with chronic urticaria may have an underlying systemic disorder (e.g., rheumatologic disease, infection, or hematologic cancer), but this is rare; most do not have an identifiable exogenous cause.

What is the prognosis of chronic urticaria?

A prospective study showed that 1 year after the start of treatment, 35% of patients with chronic urticaria were free of symptoms, and 29% had reduced symptoms; remission occurred in almost half (47%) of the patients with chronic spontaneous urticaria but in only 16% of those with chronic inducible urticaria. A prolonged duration of chronic urticaria has been associated with the presence of angioedema, greater disease severity, and autoimmune thyroid disease.

What are some of the clinical manifestations of IgA vasculitis?

IgA vasculitis primarily involves the skin, gastrointestinal tract, joints, and kidneys, with involvement in 95%, 70%, 70 to 90%, and 40 to 50% of cases, respectively, in case series; other data suggest that kidney involvement is even more common, with microhematuria present in the majority of patients. Less common manifestations include orchitis (in 14% of male patients) and, in rare cases, central nervous system involvement. Skin involvement is almost universal; a petechial or purpuric rash in dependent areas (typically the buttocks and lower legs) is the classic manifestation, but other skin manifestations, including bullae, edema, and necrosis, can be seen. In infants, the rash may be limited to the arms or face. Biopsy specimens of skin lesions show leukocytoclastic vasculitis with IgA deposition in the vessels.

Is joint or kidney involvement in IgA vasculitis associated with chronic sequelae?

Joint involvement is the second most common manifestation of IgA vasculitis. Large joints in the legs are classically involved, and in 6% of patients, joint symptoms appear more than a week after diagnosis; joint inflammation typically resolves without chronic sequelae. Kidney disease manifests in a way identical to IgA nephropathy, with mesangial deposits of IgA immune complexes on histopathological examination; microscopic hematuria is the most common manifestation (25% of patients), mild proteinuria is seen in 15% of patients, and in 1 to 2% of patients, chronic kidney disease eventually develops. On the basis of epidemiologic studies, the current recommendation is to monitor kidney function and blood pressure for 6 months after diagnosis, but chronic kidney disease may develop years later, especially during pregnancy.