2021 RSNA Outstanding Researcher

US medical researchers brace themselves for budget cuts

Celebrating the Work of William T. Carpenter Jr

Lapses at the New England Journal of Medicine

Editorial introductions

Professional advancement in academic plastic surgery may depend on scholarly activity. The authors evaluate gender-based publishing characteristics in three international plastic surgery journals. A retrospective review of all articles published in 2016 in the following journals was undertaken: Plastic and Reconstructive Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, European Journal of Plastic Surgery, Annals of Surgery, and New England Journal of Medicine. Data were collected on lead author gender (first or senior author) and differences in author gender proportions, by journal, by article topic, and by geographic location were evaluated. Overall, 2610 articles were retrieved: 34.1 percent were from plastic surgery journals, 12.8 percent were from the Annals of Surgery, and 53.1 percent were from the New England Journal of Medicine. There was a lower proportion of female lead authors among plastic surgery journals compared with the Annals of Surgery and the New England Journal of Medicine (31 percent versus 39 percent versus 39 percent; p = 0.001). There were no differences in female lead author geographic location in the Annals of Surgery or the New England Journal of Medicine; within the plastic surgery journals, there were differences (p = 0.005), including a lower proportion arising from East Asia (15 percent) and a higher proportion arising from Canada (48 percent). Within plastic surgery, Plastic and Reconstructive Surgery had the lowest proportion of female lead author (p < 0.001). The proportion of female lead author varied by article topic (p < 0.001) and was notably higher in breast (45.6 percent) and lower in head and neck/craniofacial-orientated articles (25.0 percent). There are gender disparities in three mainstream plastic surgery journals-Plastic and Reconstructive Surgery, the Journal of Plastic, Reconstructive and Aesthetic Surgery, the European Journal of Plastic Surgery-and there are lower proportions of lead female authorship compared with the Annals of Surgery and the New England Journal of Medicine. Further research should focus on understanding any geographic disparities that may exist.

BackgroundThe ORAL-surveillance trial showed a higher risk of major adverse cardiovascular events (MACE) and cancer in patients with rheumatoid arthritis (RA) taking tofacitinib, a Janus kinase inhibitor (JAKi), compared to...

The purpose of this article is to review clinical computed tomography (CT) lung screening program elements essential to safely and effectively manage the millions of Americans at high risk for lung cancer expected to enroll in lung cancer screening programs over the next 3 to 5 years. To optimize the potential net benefit of CT lung screening and facilitate medical audits benchmarked to national quality standards, radiologists should interpret these examinations using a validated structured reporting system such as Lung-RADS. Patient and physician educational outreach should be enacted to support an informed and shared decision-making process without creating barriers to screening access. Programs must integrate smoking cessation interventions to maximize the clinical efficacy and cost-effectiveness of screening. At an institutional level, budgets should account for the necessary expense of hiring and/or training qualified support staff and equipping them with information technology resources adequate to enroll and track patients accurately over decades of future screening evaluation. At a national level, planning should begin on ways to accommodate the upcoming increased demand for physician services in fields critical to the success of CT lung screening such as diagnostic radiology and thoracic surgery. Institutions with programs that follow these specifications will be well equipped to meet the significant oncoming demand for CT lung screening services and bestow clinical benefits on their patients equal to or beyond what was observed in the National Lung Screening Trial.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessSide-Effect Risk Often Tempers Antipsychotic Use for DementiaJim RosackJim RosackPublished Online:3 Nov 2006https://doi.org/10.1176/pn.41.21.0001aA significant number of elderly patients with Alzheimer's disease who are prescribed second-generation antipsychotic medications to treat psychosis, aggression, or agitation associated with the progressive disorder appear to improve while taking the medications. However, significant adverse effects often cause physicians, patients, and their caregivers to decide to stop using the drugs, regardless of possible benefits.These two take-home points, which came from the National Institute of Mental Health's CATIE-AD (Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease) study, were largely reduced by popular press reports to the single conclusion that "the drugs don't work." The actual conclusions arising out of the complex, multiphase study protocol, however, are more complicated.CATIE-AD is a 42-site, randomized, double-blind, placebo-controlled trial on which NIMH has spent $16.9 million. The study is the largest to date to compare the real-world effectiveness of three of the most widely used antipsychotic medications with placebo by taking into consideration the reason for drug therapy failure.The first round of data from the study appeared in the October 12 New England Journal of Medicine"Antipsychotic medications have been used extensively for Alzheimer's patients without enough solid evidence of whether or not they are effective," said NIMH Director Thomas Insel, M.D., in a press release." The study has vital public health implications because it provides physicians and patients with information to more accurately weigh the medications' benefits against their drawbacks, with the needs and unique reactions of individual patients."Some Findings UnexpectedThe team of CATIE-AD researchers followed 421 elderly patients (average age 78) with Alzheimer's disease who were experiencing delusions, hallucinations, aggression, or agitation that disrupted their daily functioning. They were ambulatory and still living at home or in an assisted-living facility. For each patient, a family member or other caregiver who had regular contact with the patient also took part in the study.During phase 1 of the study, each patient was randomly assigned to take olanzapine (average dose 5.5 mg a day), quetiapine (average dose 56.5 mg a day), risperidone (average dose 1 mg a day), or placebo for up to 36 weeks. Study physicians were free to adjust dosing throughout the protocol.The primary outcomes in CATIE-AD were the time to discontinuation of the study drug for any reason and the number of patients with at least minimal improvement on the Clinical Global Impression of Change (CGIC) scale at week 12 of the study. Secondary outcomes included time to discontinuation due to lack of efficacy and time to discontinuation due to adverse effects, intolerability, or death."We thought that overall the drugs would show their effectiveness," Lon Schneider, M.D., the principal investigator for CATIE-AD, told Psychiatric News. "And the answer turned out to be, yes, the drugs are somewhat effective. But overall, that effectiveness is offset by adverse events that resulted in discontinuation of the medications. It was somewhat surprising really, given that the expert opinion upon which this study was built considered these drugs to be particularly useful in treating these very difficult symptoms."Schneider is a professor of psychiatry, neurology, and gerontology at the Keck School of Medicine of the University of Southern California.Different Outcomes = Different ResultsAfter a minimum period of two weeks, a medication could be discontinued if the patient was not benefiting from it or was experiencing intolerable side effects. This "all cause discontinuation" or "time in treatment" outcome was meant to measure an aggregate of patients', caregivers', and clinicians' judgments of efficacy, safety, and tolerability into an overall measure of effectiveness that reflected therapeutic benefits in relation to undesirable effects.In phase 1, Schneider and his colleagues reported, there were no differences among the four treatment groups regarding the length of time that patients stayed on their medication (see chart). The average length of time across the four groups was eight weeks.When the researchers examined the reasons for discontinuation, they found some statistically significant differences between the medications and placebo. Those taking olanzapine and risperidone were less likely to cite lack of benefit as a reason to discontinue use than those taking placebo or quetiapine. However, those taking any of the three antipsychotic medications were more likely to discontinue use because of intolerable side effects than those taking placebo.Schneider noted that the dosage levels of olanzapine and risperidone used in this study were similar to those used in previous studies, but the quetiapine dose was lower than that used in previous studies. The lower dose could have biased the results, if it was too low to have a therapeutic effect.Nonetheless, Schneider pointed out, "the physicians were free to raise it, and the dose was still high enough to cause side effects."Balancing Benefits and RisksMemory loss and disorientation are the most common symptoms of Alzheimer's disease, but many people with the disease experience symptoms such as delusions, hallucinations, aggressive behavior, or agitation. These symptoms are associated with a rapid worsening of the illness and often result in the patient's being placed in a nursing home or other specialized care institution."Clearly some of these patients were benefiting from these three antipsychotics," Schneider told Psychiatric News. "But there is also a large group of patients who found the medications to be intolerable."All three antipsychotic medications were more likely to cause sleepiness and weight gain than placebo (see table). In addition, there were some differences among the three medications with respect to extrapyramidal signs (less likely with quetiapine), confusion (more likely with olanzapine), and psychotic symptoms (more likely with olanzapine). As expected, prolactin levels were markedly elevated in the patients taking risperidone, but not the patients taking the other two drugs. Patients taking any of the three antipsychotics tended to gain about one-half to one pound a month compared with those taking placebo, who tended to lose one pound a month. Overall, there were no significant differences between the three drugs and placebo regarding patients' glucose, total cholesterol, or triglyceride levels.Taken together, Schneider said, the results from this first phase of the study indicate that the overall benefit of these medications is offset by intolerability to the associated side effects."In deciding whether to prescribe atypical antipsychotic medications for their Alzheimer's patients, clinicians need to consider the risks, benefits, and individual needs of a given patient," Schneider concluded in the study report. "Although some patients may benefit greatly from these medications, the evidence from this study suggests these medications hold limited value for the majority of patients."The CATIE-AD protocol also included a second phase in which patients who discontinued their phase 1 medication were randomly assigned to either one of the other atypical antipsychotics or to the SSRI antidepressant citalopram. Researchers hope to report the phase 2 results sometime next year.An abstract of "Effectiveness of Atypical Antipsychotic Drugs in Patients With Alzheimer's Disease" is posted at<http://content.nejm.org/cgi/content/short/355/15/1525>. The accompanying editorial, "Alzheimer's Disease—Clinical Trials and the Logic of Clinical Purpose," is posted at<http://content.nejm.org/cgi/content/full/355/15/1604>.▪ ISSUES NewArchived

Kathy Stern, the Graphic Arts Director at the New England Journal of Medicine (NEJM), is familiar with the adage “A picture is worth a thousand words.” Over her 29-year career with the NEJM, Kathy has drawn and overseen countless images telling myriad stories and has thus contributed millions of “words” to the information shared with NEJM readers. Images range from in-house illustrations drawn by medical illustrators, to line art graphs, photographs submitted by physician-authors, still images captured from videos created in-house, interactive online elements, and more. In this interview, Kathy discusses how she started in the production department back in the days of paste-up layout and now oversees a department of more than 20 employees working with state-of-the-art digital tools. Science Editor: How did you get started with your career at the New England Journal of Medicine (NEJM)? Kathy Stern: I started out working in a production facility that wasn’t even part of the editorial office. We communicated with a production coordinator in Boston (where the NEJM editorial offices are located) who worked directly with the editors. NEJM was one of several products that the production facility of the Massachusetts Medical Society served, but it was, by far, the biggest product. It was a massive amount of detail work. Everything was done with manual layout with precision cutting knives, acetate, and wax. We would create 14 different proofs that went out to 14 different people. Our main focus was the level of detail; everything had to be exactly right. If […]

The hepatitis E virus (HEV), which was identified as recently as 1980 and has caused massive epidemics of acute hepatitis in Asia and outbreaks in Africa and Iraq, has turned...

IntroductionBy 1920, the Rockefeller Foundation had set out to systematically improve medical education and clinical practice. This wealthy, formidable agent for change initially focused on surveying the state of medical education world-wide and then targeting individual research institutes and universities with funding aimed at improving their facilities.ObjectivesThe aim was to increase understanding of how the Foundation’s focus on improving medical education and practice changed over time.MethodsThe Rockefeller Foundation archive documents the philanthropic activities of the Foundation. Employing a social-history methodology, the primary sources utilised involved officer diaries, including that of Alan Gregg who directed support for medical research and education globally throughout the 1930s and 1940s. Also examined were contemporary journals such as The British Medical Journal, the New England Journal of Medicine, and The Lancet; contemporary newspapers such as the New York Times, The Illustrated London News, and the Times of India, among others. The evidence from the diaries was compared with that of journals, newspapers, and other primary sources.ResultsInitially the Foundation employed a disease-control model aimed at eradicating hookworm, malaria, and yellow fever. However, over time the Foundation changed its focus and developed a special interest in building the discipline of psychiatry. Gregg came to firmly believe that the funding of mental health research and teaching should be given the same resources as any other branch of medicine. Gregg supported initiatives to include psychiatry in standard medical school curricula and he also directed Foundation funding toward individual researchers in the field of mental health. He eventually came to serve as an advisor to the National Institute of Mental Health and the psychiatry section of the Department of Veterans Affairs.ConclusionsThe focus of the Rockefeller Foundation changed over time. Using meticulous planning, the Foundation moved from a laboratory-based, disease-eradication model to developing a deep commitment to promoting scientific psychiatry internationally.Disclosure of InterestNone Declared

A year like no other: introduction to a special issue on COVID-19 and pain

On September 28, 1934, at the annual meeting of the New England Surgical Society in Burlington, Vt, John Homans, MD, delivered an address entitled "Thrombosis of the Deep Veins of the Lower Leg Causing Pulmonary Embolism." Its importance was clearly recognized by publication as the lead article in the<i>New England Journal of Medicine</i>just 2 months later.¹In this report, he pointed out the differences between superficial thrombophlebitis, phlegmasia alba dolens, and a disorder that he called primary thrombosis in the calf, which had a more subtle presentation and a high incidence of fatal pulmonary embolism. Patients with this disorder developed calf pain and ankle swelling that were relieved with bed rest, but that recurred with use of the leg. Autopsy findings showed thrombosis in calf veins but an unobstructed femoral vein. Dr Homans' hypothesis, based on his observations at the autopsy table, was that the thrombosis was

Women in Nephrology: The Journey, Barriers, Challenges and the Future

Citations rule the world—at least the world of academic medicine. Because of the importance of the impact factor, medical journals are dependent on being cited as often as possible in other medical journals. This is also true of Deutsches Arzteblatt International, which, after its inclusion in the Science Citation Index in 2009, is expecting its first impact factor in 2011 (1). In this situation, it is easy to forget that citations in the lay press too are important for medical journals. Being mentioned in the general media may not enhance the impact factor, but is a sign of how important the public deems a journal. By studying the German lay press one can gain an impression as to whether the prejudice that medicine is completely anglicized is correct. Is it really true that only English language journals are important in the work of a German medical journalist? We have analyzed how often leading German lay media mentioned German and English language medical journals in the course of the preceding eight years. The analysis was based on six medical journals, which are comparable, as they all appear weekly and all cover a variety of medical subjects: the New England Journal of Medicine, JAMA, the British Medical Journal, Deutsche Medizinische Wochenschrift, Munchener Medizinische Wochenschrift, and Deutsches Arzteblatt (for details of the methods, see the Box). Box The frequency was examined of the citations of the scientific content of the following weekly medical journals: the New England Journal of Medicine, the Journal of the American Medical Association (JAMA), the British Medical Journal (BMJ), Deutsche Medizinische Wochenschrift, Munchener Medizinische Wochenschrift—Fortschritte der Medizin, and Deutsches Arzteblatt. The journals selected were all clinically orientated magazines for general medicine (rather than specialized journals). The survey was based on the results of a search in the online search machines of FAZ, Welt, SZ, Spiegel, and Zeit. The search only covered central printed products, so that, for example, the Frankfurter Allgemeinen Sonntagszeitung (Sunday Newspaper), the SZ Magazin and Spiegel Online were excluded. For reasons of capacity, we could only consider five of the important and serious printed media in Germany. All journal names were searched for under their complete titles (e.g. New England Journal of Medicine, Munchener Medizinische or Munchener Medizinische Wochenschrift—Fortschritte der Medizin) and their conventional abbreviations (NEJM, N Engl J Med, or MMW or MMW Fortschr Med). Different cases (e.g. Deutsche/r Medizinische/n Wochenschrift) or other close variants (e.g. Munchener/Munchner Medizinische Wochenschrift) were considered. A citation was only counted if it was a direct reference to the scientific content of one of the six medical journals. Thus, a reference to the appointments section of Deutsches Arzteblatt or the announcements of its publishers were not counted as scientific citations. The English edition of Deutsches Arzteblatt, Deutsches Arzteblatt International, was excluded from the evaluation. On the other hand, in a subanalysis, the citations for Deutsches Arzteblatt which related to its political reporting were counted seperately. To ensure a reliable check of the citation of a scientific journal, the full text of the lay journal or newspaper was always searched for. The search took place between November 2008 and March 2009.