The Value of Case Reports for Graduate Medical Education.

Lapses at the New England Journal of Medicine

World Health Organization (WHO) published its 22nd edition of WHO Model List of Essential Medicines in 2021. This list presents a list of minimum medications needed for a basic health care system. Their criteria for such a list included the most effective, safe, and cost-effective medicines for priority conditions (with current and estimated future public health relevance).1 Their section on antiseizure medications (ASMs) has not changed compared with the previous edition. Updating this list is especially relevant now, as the WHO Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders (IGAP), unanimously adopted at the 75th World Health Assembly in May 2022, declared that “Essential medicines have a crucial role for both the prevention and treatment of neurological disorders” and recommended the Member States to “promote the inclusion, updating and availability of essential, effective, safe, affordable and quality medicines and health products for neurological disorders in national essential medicines lists, as guided by the WHO Model List of Essential Medicines.”2 For ASMs (called "anticonvulsants/antiepileptics" in their publication), they included the following drugs as the “essential medicines”: carbamazepine, diazepam, lamotrigine, lorazepam, magnesium sulfate, midazolam, phenobarbital, phenytoin, and valproic acid (sodium valproate). They also included ethosuximide and valproic acid (sodium valproate) injection on a “Complementary List.”1 Here, we have tried to critically reappraise this list and make suggestions to improve such a list in the future. In doing so, we have tried to make suggestions based on the efficacy, safety, and other drug-related issues of the available ASMs. Based on the currently available evidence,3-8 one can conclude that levetiracetam is a reasonable alternative to both carbamazepine and phenytoin for patients with epileptic seizures in different age groups.4-6 Levetiracetam is associated with fewer drug–drug interactions compared with both carbamazepine and phenytoin. Furthermore, levetiracetam has oral and intravenous formulations and is not a hepatic enzyme-inducer drug with all the associated consequences (e.g., hyperlipidemia).9, 10 Therefore, it seems a reasonable approach to revise the WHO Model List of Essential Medicines accordingly and to include levetiracetam on the list. One can argue that levetiracetam is not widely available or cost-effective everywhere in the world. However, based on the WHO criteria for such a list (i.e., most effective, safe, and cost-effective drugs), levetiracetam is a reasonable alternative to carbamazepine and phenytoin. Therefore, while older ASMs definitely need to be included on the list (considering their availability and cost), it would be ideal to add levetiracetam to the list. The authorities in WHO and other international organizations (e.g., International League Against Epilepsy and International Bureau for Epilepsy) should educate and convince health policy makers and governments in all the countries in the world that they should provide the minimum requirements of “essential medicines” for their people. As highlighted in the IGAP document, there is a need to reduce stigma and promote the human rights of people with neurological disorders (e.g., epilepsy), and improve their care and quality of life in a way that no person's life is limited by epilepsy.2 Having said the above, a recent study compared the clinical effectiveness and cost-effectiveness of lamotrigine with levetiracetam and zonisamide (new treatment) for focal epilepsy, and compared valproate with levetiracetam (new treatment) for generalized and unclassified epilepsy.11 In focal epilepsy, levetiracetam did not meet the criteria for noninferiority in the primary intention-to-treat analysis of time to 12-month remission, but zonisamide met such criteria. For time to treatment failure, lamotrigine was superior to levetiracetam and zonisamide. In the economic analyses, both levetiracetam and zonisamide were more expensive and less effective than lamotrigine. In generalized and unclassifiable epilepsy, levetiracetam did not meet the criteria for noninferiority in the primary intention-to-treat analysis of time to 12-month remission. Valproate was superior to levetiracetam for time to treatment failure. Levetiracetam was both more expensive and less effective than valproate.11 Therefore, it is noteworthy to clarify that while the authors recommend adding levetiracetam (at this time) to the WHO list of essential medicines, other candidate drugs (e.g., zonisamide) could also be considered in the future. A.A.A.-P.: honoraria from Cobel Daruo, Ronak, and RaymandRad; royalty from Oxford University Press (book publication); grant from the National Institute for Medical Research Development. A.G.: none.

ACGME's Early Adaptation to the COVID-19 Pandemic: Principles and Lessons Learned.

Fellowship Training in Adult Cardiothoracic Anesthesiology: Navigating the New Educational Landscape as a Result of the Coronavirus Crisis

When I was in my teens, I built a small radio transmitter from individual components. It was my first homebrew project, and I was anxious to see whether I could connect with someone far away from my home in St. Louis. After hours on the air desperately sending “CQ CQ CQ this is WAOAJX” in Morse code, I gave up. I had raised no one. Despite my broadcasts, nobody, it seemed, was aware of my work. I set the project aside. A few months later, I received a postcard from Mexico. Someone had picked up my signal, but I could not hear his response. Although I had succeeded in transmitting, the time frame and the mechanism of response were not what I had expected. Article see p 1755 What does this have to do with cardiovascular research? In this issue of Circulation , an article by Ranasinghe and coworkers looks at “poorly cited articles” in peer-reviewed cardiovascular journals.1 The authors’ premise is that articles that are infrequently cited are of limited impact and therefore “may reflect inefficiency and waste in the research enterprise.” Their key assumption is that impact can be measured by citations within the first 5 years from publication. If your work is important to others, they will cite it when they report their own work; this will happen within a few years of publication. This assumption may often be true, but is it also true that if no one rapidly cites your work, it is unimportant? By their statement about “inefficiency and waste in the research enterprise,” Ranasinghe et al seem to think so. But just as I had to wait to learn that my meager radio signal had reached a faraway place, recognition of the …

Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina. editor-in-chief@anesthesiology.orgEFFECTIVE January, 2013, ANESTHESIOLOGY will no longer publish case reports, either as a separate article type or as a letter to the editor. We make this decision with some reluctance, but believe it is appropriate, both for the ongoing role of case reports in advancing the specialty and for the mission of this journal.Before the advent of clinical trials, case descriptions, either those of a single case or a case series, reigned as the primary mechanism to communicate breakthroughs in medical treatment. The case report of general anesthesia by Henry Jacob Bigelow in 18461was recently voted by readers to be the most important article published in the New England Journal of Medicine in its 200-yr history. Roughly 50 yr later, spinal anesthesia was described by August Bier2as a short case series. Nearly all advances in medicine before 1950, from antibiotics to chemotherapy to surgical procedures, moved forward from case reports.Since the advent of the randomized trial design, described and advocated by Bradford Hill in the 1940s,3case reports moved from primacy in shaping medical practice to alerting us to special circumstances. With the explosion of new drugs and techniques in the last half of the 20th century came the description of rare and not-so-rare toxicity associated with these therapies when they were widely applied. Malignant hyperthermia and hepatitis from halothane and other volatile anesthetics, cauda equina syndrome from intrathecal injection of local anesthetics, delayed respiratory depression from epidural or intrathecal injection of morphine, and acute respiratory depression from sufentanil by these routes were unknown as diseases or not predicted to occur before their descriptions as case reports. In addition to informing us regarding toxicity, case reports also contribute to our treatment in special settings. If we are caring for a patient with a rare disease, an Internet search may only yield case reports that provide hints regarding how to approach this care. Similarly, in planning how to handle unusual complications, from epidural hematoma to unable-to-ventilate and unable-to-intubate, we rely on consensus statements often deriving from case reports.The mission of ANESTHESIOLOGY is, “promoting scientific discovery and knowledge in perioperative, critical care, and pain medicine to advance patient care.” During the process of creating this statement, the Editorial Board listed and rated words and phrases that were important to its perception of the central goal of the journal. Words such as “discovery,” “seminal,” and “definitive” rose to the top. We strive to provide both fundamental and practical knowledge that is new and can be trusted. As noted above, case reports were traditionally considered to reflect these characteristics, but one could argue that a century of individual reports has often misled us in a manner that harms patients. There is a role for case reports to inform us of rare toxicities or how to innovatively handle rare circumstances, but ANESTHESIOLOGY strives to present the future of our specialty, and we strive to choose study designs rather than case descriptions to more accurately meet this goal.We will no longer routinely publish case reports, in part because they no longer directly address our mission and in part because a new venue, Anesthesia & Analgesia Case Reports , has been established to highlight them. This new journal, edited by Lawrence Saidman, M.D., former Editor-in-Chief of ANESTHESIOLOGY, will choose the best case reports to generate hypotheses and to inform practice under unusual circumstance.This is not to say that we will turn our back entirely on the description of individual cases. In the Education Section of the journal, the Invited Case Scenario article type will share case-based perspectives from multiple specialties, on the care of challenging clinical problems, the Mind to Mind article type will share individual perspectives of patients and care givers, and the Images in Anesthesiology article type will share visual aspects of clinical problems. We also plan to expand our efforts to highlight specific areas of the specialty with thematic Requests for Submissions, three of which are planned for 2014; case reports relevant to those themes may be submitted for review under the article type Special Articles. But we intend to focus our attention and energy on bringing you trustworthy guidance on scientific advancement and high quality, multispecialty education related to individual patient care. The introduction of Anesthesia & Analgesia Case Reports as a new venue for case reports in anesthesiology is a welcome addition to the specialty, which allows us to focus on our mission. We wish the fledgling journal focused on case reports well, and know that this special article type will continue to advance the specialty.Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina. editor-in-chief@anesthesiology.org

ObjectivesAdherence to pharmacological intervention in clinical trials is crucial for the correct estimation of medication effect and side effects. The Template for Intervention Description and Replication (TIDieR) - a 12-item...

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.

The common wisdom at the end of the 20th century was that the United States was training too many specialists, including cardiologists.1 By 2001, however, there was increasing evidence that the supply of cardiologists was not meeting the growing demand. That year, as president-elect of the American College of Cardiology (ACC), I appointed a task force to evaluate cardiology workforce. The task force undertook a 2-year process of literature review, hypothesis generation, research design, data acquisition, and analysis. This intense effort included a Bethesda Conference at which consensus was achieved on a report that will be published in the Journal of the American College of Cardiology . Based on various types of information and data, the ACC task force concluded that the United States is facing a shortage of cardiologists. This will reduce access to specialty care of proven benefit and will undermine our nation’s vital cardiovascular research effort. The Bethesda Conference report includes 8 working group documents that recommend several short- and intermediate-term strategies to help narrow the growing demand-supply gap for cardiologists (see Table 1). Some recommendations can be implemented at a local practice or institution level. Others will require a series of complex and coordinated actions at a national level. Hopefully, the report will catalyze actions by academic medical centers, regulatory organizations, federal policymakers, professional societies, and others that influence the output of cardiovascular specialists. View this table: TABLE 1. Working Groups of the ACC Task Force on Workforce Several things continue to drive demand for cardiologists. Elsewhere, I have argued that various scientific, social, and demographic “demand catalysts” outweigh factors that might decrease demand for cardiologists during the next decade2 (see Table 2). Although the relative influence of each demand factor will change over time, one thing is certain: the cardiovascular disease burden in the United States …

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project has shifted the focus for accrediting residency training programs from structure and process to documented outcomes. A central part of the ACGME's Next Accreditation System (NAS) is “articulating milestones of competency development in each discipline.”1 Resident achievement of educational Milestones will be an indicator of the educational effectiveness of residency programs. Most specialties have developed their Milestones through a collaborative effort involving representatives from the ACGME, the pertinent American Board of Medical Specialties (ABMS) organization, the pertinent professional specialty society, and the pertinent program directors' association. In contrast, the approach was quite different for Transitional Year (TY) residency programs, which comprise only 1 year of accredited postgraduate medical education, where there is no corresponding ABMS board certification entity or professional specialty society. In addition, graduates of TY training programs are not expected to demonstrate sufficient competency to enter the independent practice of medicine, as is the case with other specialty (categorical) residency programs.

IGG4-RELATED LUNG DISEASE MASKING LUNG CANCER

Impact Factors and Prediction of Popular Topics in a Journal.

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 […]

Is Nephrology Fellowship Training on the Right Track?

The Gastroenterology Core Curriculum, Third Edition