Podcasts about The New England Journal of Medicine

This week, we discuss endovascular therapy for post-thrombotic syndrome, new evidence on prehospital blood transfusion strategies in trauma patients, and a trial of cefazolin for Staph. aureus bacteremia. We examine evolving approaches to thyroid cancer and share a case of a man with pancytopenia after heart transplantation. Perspectives explore psychedelic therapy, the convergence of Down syndrome and Alzheimer's disease, and treating addiction.

Dr. Gillian L. Gordon Perue discusses asundexian and the OCEANIC-STROKE trial. Show citation:  Sharma M, Dong Q, Hirano T, et al. Asundexian for Secondary Stroke Prevention. N Engl J Med. 2026;394(15):1467-1479. doi:10.1056/NEJMoa2513880 

Join the Behind the Knife Surgical Oncology Team as we discuss clinical challenges through case-based examples including the diagnosis, workup, and management of patients with cutaneous melanoma. Learning Objectives:In this episode, we review the workup and management of patients with cutaneous melanoma and both microscopic and macroscopic nodal disease. References used in the making of this episode: Reijers, I.L.M., Menzies, A.M., van Akkooi, A.C.J. et al. Personalized response-directed surgery and adjuvant therapy after neoadjuvant ipilimumab and nivolumab in high-risk stage III melanoma: the PRADO trial. Nat Med 28, 1178–1188 (2022). https://doi.org/10.1038/s41591-022-01851-x Christian U. Blank et al. Neoadjuvant nivolumab plus ipilimumab versus adjuvant nivolumab in macroscopic, resectable stage III melanoma: The phase 3 NADINA trial.. J Clin Oncol 42, LBA2-LBA2(2024). DOI:10.1200/JCO.2024.42.17_suppl.LBA2 Faries MB, Thompson JF, Cochran AJ, et al. Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma. N Engl J Med. 2017;376(23):2211-2222. doi:10.1056/NEJMoa1613210   https://pubmed.ncbi.nlm.nih.gov/28591523/ National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Cutaneous Melanoma. Version 1.2026. Accessed April 8, 2026. NCCN Guidelines PDF   Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listenBehind the Knife Premium: https://behindtheknife.org/premiumOral Board Review: https://behindtheknife.org/oral-boardOral Board Simulator: https://behindtheknife.org/oral-board/simulatorGeneral Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-reviewTrauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlasDominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkshipDominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotationVascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-reviewColorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-reviewSurgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-reviewCardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-reviewDownload our App:Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US

This week, we present new evidence guiding coronary intervention, a molecular mechanism of inflammatory bowel disease, and gene therapy for a recessive disease. We review antidotes for anticoagulation reversal and discuss a case of hypertension in an adolescent patient. Perspectives examine cholera control, gambling-related harms, and race-based prescribing, alongside a reflection on medicine, motherhood, and what clinicians carry with them.

Edward Ryan is the director of global infectious diseases at Massachusetts General Hospital. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. E.T. Ryan, F. Qadri, and J.A. Lynch. Global Cholera-Control Efforts — Progress and Remaining Challenges. N Engl J Med 2026;394:2177-2180.

Whole blood is the current bright, shiny thing in EMS medicine. It works in the hospital and is what our patients are bleeding out onto the road so it just seems to make sense that we should put back what they're loosing. But… is it any better than blood components? That's the question the authors of TOWAR tried to answer. One of those authors, Dr Frank Guyette, joins us for a two episode interview about this trial and about trials in general. Dr Guyette is an EM and EMS physician, medical director for STATMedEvac, and Professor of Emergency Medicine at University of Pittsburgh. He is also a research leaders with the LITES network, the parent network for the TOWAR trial. We discuss the challenges of conducting large, multi-center randomized controlled trials in episode I, including funding and the ethics of prehospital research. In episode II, we'll jump into the details of the TOWAR trial itself.Reference:1. Sperry JL, Guyette FX, Cotton BA, et al.: Prehospital Resuscitation with Type O Whole Blood for Trauma and Hemorrhage. N Engl J Med. doi: 10.1056/NEJMoa2602167 (Epub ahead of print).

Un nouvel épisode du Pharmascope est disponible! Dans ce 178e épisode, Nicolas, Olivier et Amélie tentent de pondre des réponses un tant soi peu intelligentes à vos excellentes questions. Nous discutons d'ajustement de lévothyroxine, du suivi des IECA/ARA, du rôle de la cariprazine et de l'impact des inhibiteurs du SGLT-2 sur le magnésium.   Les objectifs pour cet épisode sont les suivants: Discuter des modalités d'ajustement de la lévothyroxine et de la déprescription potentielle de celle-ci Discuter des suivis de laboratoire suivant l'initiation d'un ARA ou d'un IECA Discuter des évidences portant sur l'utilisation de la cariprazine Discuter de l'impact des  inhibiteurs du SGLT-2 sur le magnésium Ressources pertinentes en lien avec l'épisode Jonklaas J, et coll; American Thyroid Association Task Force on Thyroid Hormone Replacement. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec;24(12):1670-751. Van Uytfanghe K, et coll. Thyroid Stimulating Hormone and Thyroid Hormones (Triiodothyronine and Thyroxine): An American Thyroid Association-Commissioned Review of Current Clinical and Laboratory Status. Thyroid. 2023 Sep;33(9):1013-1028. Ravensberg J, et coll. Discontinuation of Levothyroxine in Adults Aged 60 Years or Older. JAMA. 2026 Apr 6;335(17):1491–8. RPE de néphrologie de l'APES. Place des IECA et des ARA dans le traitement de la maladie rénale chronique. Septembre 2025. Bhandari S, et coll; STOP ACEi Trial Investigators. Renin-Angiotensin System Inhibition in Advanced Chronic Kidney Disease. N Engl J Med. 2022 Dec 1;387(22):2021-2032. Clase CM, et coll. Acute change in glomerular filtration rate with inhibition of the renin-angiotensin system does not predict subsequent renal and cardiovascular outcomes. Kidney Int 2017;91:683-90. Garlo KG, et coll. Association of changes in creatinine and potassium levels after initiation of renin angiotensin aldosterone system inhibitors with emergency department visits, hospitalizations, and mortality in individuals with chronic kidney disease. JAMA Netw Open 2018;1:e183874. Monographie de produit, Abbvie. VRAYLAR (cariprazine). Canada, 6 mars 2024. Barabassy A, et coll. Transdiagnostic Efficacy of Cariprazine: A Systematic Review and Meta-Analysis of Efficacy Across Ten Symptom Domains. Pharmaceuticals (Basel). 2025 Jul 2;18(7):995. Németh G, et coll. Cariprazine versus risperidone monotherapy for treatment of predominant negative symptoms in patients with schizophrenia: a randomised, double-blind, controlled trial. Lancet. 2017 Mar 18;389(10074):1103-1113. Fava M, et coll. Efficacy of adjunctive low-dose cariprazine in major depressive disorder: a randomized, double-blind, placebo-controlled trial. Int Clin Psychopharmacol. 2018 Nov;33(6):312-321. Durgam S, et coll. Efficacy and safety of adjunctive cariprazine in inadequate responders to antidepressants: a randomized, double-blind, placebo-controlled study in adult patients with major depressive disorder. J Clin Psychiatry. 2016 Mar;77(3):371-8. Barabassy A, Csehi R, Dombi ZB, Szatmári B, Brevig T, Németh G. Transdiagnostic Efficacy of Cariprazine: A Systematic Review and Meta-Analysis of Efficacy Across Ten Symptom Domains. Pharmaceuticals (Basel). 2025 Jul 2;18(7):995. Zhang J, et coll. Comparative Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Serum Electrolyte Levels in Patients with Type 2 Diabetes: A Pairwise and Network Meta-Analysis of Randomized Controlled Trials. Kidney360. 2022 Jan 19;3(3):477-487. Toto RD, et coll. Correction of hypomagnesemia by dapagliflozin in patients with type 2 diabetes: A post hoc analysis of 10 randomized, placebo-controlled trials. J Diabetes Complications. 2019 Oct;33(10):107402.

This week, we discuss left atrial appendage closure for atrial fibrillation, oxygen strategies in respiratory failure, an all-oral treatment for acute myeloid leukemia, CAR T-cell therapy enabling kidney transplantation, and a case of a neuroepithelial tumor that developed after gene therapy. We review childhood vaccine hesitancy, follow a complex diagnostic case, and examine Perspectives on corporatization in medicine, famine and war, and the future of health care systems.

Loren Adler is a fellow and the associate director at the Center on Health Policy at the Brookings Institution. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. L. Adler. Regulating Corporate Control in the U.S. Health Care System. N Engl J Med 2026;394:2073-2076.

Dr. Margarita Fedorova discusses the effectiveness of shunting for idiopathic normal pressure hydrocephalus.  Show citation:  Luciano MG, Williams MA, Hamilton MG, et al. A Randomized Trial of Shunting for Idiopathic Normal-Pressure Hydrocephalus. N Engl J Med. 2025;393(22):2198-2209. doi:10.1056/NEJMoa2503109   Show transcript:  Dr. Margarita Fedorova: Welcome to Neurology Minute. My name is Margarita Fedorova and I'm a neurology resident at the Cleveland Clinic. Today we're reviewing a randomized trial that provides high quality evidence for treatment we've been using for decades, shunting for idiopathic normal pressure hydrocephalus. The PENS trial, a placebo controlled effectiveness and iNPH shunting trial was published in the New England Journal of Medicine in December 2025 by Luciano and colleagues. This international multicenter study enrolled 99 patients across the United States candidate in Sweden. While idiopathic normal pressure hydrocephalus or iNPH is characterized by triad of gait impairment, cognitive decline in urinary continence, these findings can be non-specific and we mass factor in radiological findings too. Furthermore, while CSF shunting has long been the standard treatment, its effectiveness has never been rigorously confirmed in a large well-powered randomized trial. In this trial, patients with a clinical improvement in gait velocity after temporary CSF drainage were deemed eligible for shunting and randomizing the trial. What makes this trial particularly elegant is its blending strategy. All 99 participants underwent the same surgical procedure with the same commercially available programmable shunt valve. After surgery, the valve was set either to an open functioning position or to a high resistance placebo setting. Neither patients nor assessors knew who had a working shunt. This is about as close to a true double-blind design as neurosurgery can get. The primary outcome was changing gait velocity at three months. The open shunt group improved by 0.23 meters per second on average, while the placebo group showed essentially no change in 0.03 meters per second. That's a treatment difference of 0.21 meters per second, both statistically significant and clinically meaningful. To put that in perspective, a change of 0.10 meters per second is considered the threshold for substantial meaningful change in the elderly. 80% of the open shunt group exceeded that threshold compared to only 24% of the placebo group.  The Tenet scale, which measures gait imbalance, also showed significant improvement in the open shunt group. However, screening measures for good condition using the MoCA scale and bladder symptoms did not reach significance at three months, though tertiary outcomes for cognitive testing, quality of life and functional independence tended in favor of shunting. Importantly, falls were more common in the placebo group at 46% compared to 25% in the open shunt group. This is a meaningful safety signal given how dangerous falls are in older adults. There were also real risks with active shunting. Subdural hematomas occurred in 12% of the open shunt group versus 2% of placebo and three even required surgical intervention. Positional headaches from low CSF pressure were more common in the open shunt group at 59% versus 28%. The good news is that the adjustable valve allowed non-invasive management of many of these complications. While this trial gives us reasons to be cautiously optimistic about shunting for appropriately selected iNPH patients, it's worth noting that we only have evidence for improvement in gait and follow-up is only three months.  Longer-term data is still being collected so we don't know yet how durable these benefits are. If you want to read more, please find the paper by Mark G. Luciano, et al. It's titled A Randomized Trial of Shunting for Idiopathic Normal Pressure Hydrocephalus published in the New England Journal of Medicine in December 2025. That's your neurology menu for today. Keep exploring and we'll see you next time. 

Dr. Casandra MacLeod discusses central retinal artery occlusions, recent trials, and those anticipated in the future.  Show citation:  Préterre C, Gaultier A, Obadia M, et al. Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4·5 h of severe vision loss (THEIA): a multicentre, double-dummy, patient-blinded and assessor-blinded, randomised, controlled, phase 3 trial. Lancet Neurol. 2025;24(11):909-919. doi:10.1016/S1474-4422(25)00308-4  Poli S, Grohmann C, Wenzel DA, et al. Early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION): Study protocol of a phase III trial. Int J Stroke. 2024;19(7):823-829. doi:10.1177/17474930241248516  Ryan SJ, Jørstad ØK, Skjelland M, et al. A Randomized Trial of Tenecteplase in Acute Central Retinal Artery Occlusion. N Engl J Med. 2026;394(5):442-450. doi:10.1056/NEJMoa2508515 Show transcript:  Dr. Casandra MacLeod Hello, this is Casandra MacLeod, a neurology resident at Cleveland Clinic with today's Neurology Minute. Today we will be discussing central retinal artery occlusions, or CRAOs, and the recent trials that have come out and even those further on the horizon. The 2026 American Heart Association and American Stroke Association guidelines for the early management of patients with acute ischemic stroke were recently published and in them highlight the uncertainty around the treatment of acute CRAOs with intravenous thrombolysis, even when the patient presents within four and a half hours and is otherwise eligible. These guidelines come after two recent trials, which we will further discuss. The thrombolysis in patients with acute central retinal artery occlusion, or the THEIA trial, was published in the November issue of Lancet Neurology. This multicenter trial out of France randomized 70 patients with acute CRAOs presented within four and a half hours of time from last known well to either receive IV alteplase and oral placebo or IV placebo and oral aspirin. While safety measures showed no symptomatic hemorrhage event, although they did have one asymptomatic intracerebral hemorrhage occur, the primary outcomes, which included visual acuity improvement at one month, showed some evidence for a trend of improved acuity in the IV thrombolytic group at 66% compared to 48 in the aspirin group, it did not reach significant. And now more recently, the Tenecteplase in central retinal artery occlusion study, or TenCRAOs, was published in the January 2026 issue of The New England Journal of Medicine. TenCRAOs was a six European country multicenter trial that randomized 78 patients with CRAOs all presenting within four and a half hours of time from last known well to either receive IV Tenecteplase or aspirin, both with placebo-matching as in THEIA. The primary outcomes of TenCRAOs also included visual acuity at one month, but unfortunately this trial also did not show [inaudible 00:02:07]. They showed 20% in the IV TNK group compared to 24% in aspirin. And additionally, there was one fatal intracerebral hemorrhage in the TNK group that should be considered. Overall, the AHA and ASA guidelines state the usefulness of treatment with intravenous thrombolysis is uncertain. And this is based largely on these studies as neither trial showed improved visual recovery. Although both of these trials are underpowered, leading many to believe that the jury is still out on the use of IV thrombolytics in CRAOs. But importantly, stay on the lookout for one last trial. The early reperfusion therapy with intravenous alteplase for recovery of vision and acute central retinal artery occlusion, or the Revision trial, is actively recruiting. Revision is similar in design as THEIA, but with a goal of up to 422 total patients for a goal of a well-powered study to guide decision making. 

MCAS is one of those diagnoses that can make it feel like your body is telling a dozen stories at once—and no one is listening. If you're experiencing GI symptoms alongside flushing, hives, brain fog, fatigue, palpitations, medication sensitivities, or a persistent "fight-or-flight" feeling, this episode is designed to help connect the dots without oversimplifying your experience.In this episode, we sit down with gastroenterologist Dr. Zachary Spiritos to unpack mast cell activation syndrome (MCAS) and explore the connections between immune activation, the gut-brain axis, and symptoms that can affect nearly every system in the body. We discuss why patients are often dismissed, how stress and hormonal changes can amplify symptoms, and what a realistic, stepwise treatment approach looks like when the evidence base is still evolving.In this episode, we discuss:• What mast cells do and why MCAS can affect multiple organ systems • Why MCAS is often missed in siloed medical care and mislabeled as anxiety • Barrier dysfunction, environmental triggers, and intestinal permeability as a useful framework • Histamine as one mediator among many and why antihistamines are not a perfect treatment for all• Links between MCAS, IBS, visceral hypersensitivity, dysautonomia, and POTS • Hypermobility, pelvic floor dysfunction, and neck tension as common clinical clues • Treatment principles including start low and go slow, informed consent, and layered individualized plans • Dietary approaches patients commonly explore, including low-histamine, low-FODMAP, and gluten-free patterns • Hormonal influences across the menstrual cycle and during perimenopause• The role of sleep, nervous system regulation, and stress reduction in decreasing symptom reactivity If you've ever felt like your symptoms don't fit neatly into a single diagnosis, this episode will help you make sense of the bigger picture and explore what healing can look like when the gut, immune system, and nervous system are all part of the conversation. References:Ford AC, Staudacher HM, Talley NJ. Postprandial symptoms in disorders of gut-brain interaction and their potential as a treatment target. Gut. 2024;73(7):1199-1211. Published 2024 Jun 6. doi:10.1136/gutjnl-2023-331833Walker MM, Warwick A, Ung C, Talley NJ. The role of eosinophils and mast cells in intestinal functional disease. Curr Gastroenterol Rep. 2011;13(4):323-330. doi:10.1007/s11894-011-0197-5Pasricha PJ, Talley NJ. Functional Dyspepsia. N Engl J Med. 2026;394(2):166-176. doi:10.1056/NEJMcp2501860Find Dr. Spiritos on IG @drzacspiritosSo please like and subscribe and share the gut health podcast. Don't forget to subscribe, rate, and leave us a comment. Learn more about Kate and Dr. Riehl:Website: www.katescarlata.com and www.drriehl.comInstagram: @katescarlata @drriehl and @theguthealthpodcastOrder Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.  The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment.  Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

In a conversation with CancerNetwork®, Nathan Goodyear, MD, spoke about the role that exercise and lifestyle intervention can play in the treatment of patients with cancer. He described how prescribed exercise may serve as a biologically interventional therapy that can help prolong longevity, reduce the risk of recurrence; and supplement the efficacy of standard therapeutic approaches like chemotherapy, immunotherapy, and surgery.Goodyear, an integrative medicine physician at the Williams Cancer Institute, pointed to literature indicating the potential benefits of structured exercise programs across different cancer populations. For example, data from the phase 3 CHALLENGE trial (NCT00819208) highlighted a lower risk of death and reduced recurrence following a 3-year structured program among patients with stage II and III colorectal cancer. Furthermore, the OPTIMUS trial (NCT02950324) demonstrated that a short-term exercise program that takes place before surgery or alongside chemotherapy can increase CD8-positive T-cell infiltration while decreasing immunosuppressive cells, effectively turning “cold” tumors “hot.”Additionally, Goodyear addressed some preconceptions surrounding the potential role of exercise in oncologic care, defending it as a prescribable therapy that necessitates a deliberate, properly applied approach to achieve success among patients. He discussed the importance of structuring individualized exercise-based regimens by considering performance status and other physical patient characteristics. He also noted how exercise intervention may mitigate immunosenescence and accelerated aging may be associated with one's disease and anti-cancer therapy. “Surgery, chemotherapy, and radiation…have efficacy; there's no question about that. They also promote senescence and accelerated aging. What if we're able to bring in these therapies that can work to break those cycles, like exercise?” Goodyear stated. “If it improves the outcome, helps the patient heal better, empowers their immune system in intended [and] direct ways that are reproducible in the research, and if it helps to block that accelerated aging, we reengage the immune system, countering the immunosenescence that is accelerating that process called inflammation.”References Courneya KS, Vardy JL, O'Callaghan CJ, et al. Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med. 2025;393(1):13-25. doi:10.1056/NEJMoa2502760 Rayner CJ, Bartlett DB, Allen SK, et al. Prehabilitation during neoadjuvant chemotherapy results in an enhanced immune response in esophageal adenocarcinoma tumors: a randomized controlled trial. J Sport Health Sci. 2025;14:101063. doi:10.1016/j.jshs.2025.101063

This week, we present new research guiding treatment of pulmonary embolism, early progress in cardiac regeneration with engineered heart tissue, and treatments for gastroesophageal cancer and Chiari malformation. We review leishmaniasis and follow a revealing neurologic case. Perspectives discuss nutrition policy, tickborne illness, structural competence in medicine, and the arrival of closure.

Deirdre Tobias is an associate professor in the Department of Nutrition at the Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. D.K. Tobias and F.B. Hu. The 2025–2030 Dietary Guidelines for Americans — Progress, Pitfalls, and the Path Forward. N Engl J Med 2026;394:1969-1971.

Whole blood is the current bright, shiny thing in EMS medicine. It works in the hospital and is what our patients are bleeding out onto the road so it just seems to make sense that we should put back what they're loosing. But… is it any better than blood components? That's the question the authors of TOWAR tried to answer. One of those authors, Dr Frank Guyette, joins us for a two episode interview about this trial and about trials in general. Dr Guyette is an EM and EMS physician, medical director for STATMedEvac, and Professor of Emergency Medicine at University of Pittsburgh. He is also a research leaders with the LITES network, the parent network for the TOWAR trial. We discuss the challenges of conducting large, multi-center randomized controlled trials in episode I, including funding and the ethics of prehospital research. In episode II, we'll jump into the details of the TOWAR trial itself.Reference: 1. Sperry JL, Guyette FX, Cotton BA, et al.: Prehospital Resuscitation with Type O Whole Blood for Trauma and Hemorrhage. N Engl J Med. doi: 10.1056/NEJMoa2602167 (Epub ahead of print).

Eric Rubin is the Editor-in-Chief of the Journal. Lindsey Baden is a Deputy Editor of the Journal. Angela Hewlett is Director of the Nebraska Biocontainment Unit. Steven Kornfeld is a physician who was a passenger on the MV Hondius. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. E.J. Rubin and Others. NEJM Outbreaks Update — Andes Hantavirus. N Engl J Med. DOI: 10.1056/NEJMe2505379.

In this World Shared Practice Forum Podcast, Drs. Mark Peters and Scott Weiss provide their expert insight on the methodology and development of the 2026 International Surviving Sepsis Campaign guidelines. They discuss challenges encountered during the process and review notable changes to these guidelines compared to previous iterations. The authors share the recommendations that will most impact their personal practice for patients with sepsis, and reflect on how we can improve global research infrastructure to address salient knowledge gaps in pediatric critical care. LEARNING OBJECTIVES - Understand the design and methodology for the 2026 Surviving Sepsis Campaign guidelines - Review notable changes in the 2026 sepsis guidelines compared to the 2020 edition - Discuss the implications of the altered recommendations for clinical practice changes - Consider methods to improve global pediatric research infrastructure and data organization AUTHORS Mark Peters, MBChB, PhD, MRCP, FFICM, FRCPCH Professor of Paediatric Intensive Care NIHR Senior Investigator UCL Great Ormond St Institute of Child Health Hon. Consultant Paediatric Intensivist Paediatric Intensive Care Unit and Children's Acute Transport Service Great Ormond St Hospital Scott Weiss, MD, MSCE Professor of Pediatrics and Pathology & Genomic Medicine, Division Chief of Critical Care, Vice-Chair of Research for the Department of Pediatrics, Nemours Children's Hospital, Sidney Kimmel Medical College at Thomas Jefferson University Jeffrey Burns, MD, MPH Emeritus Chief Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital Professor of Anesthesia Harvard Medical School DATE Initial publication date: May 26, 2026. ARTICLES REFERENCED & ADDITIONAL REFERENCES - Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatr Crit Care Med. 2026;27(4):379-434. https://pubmed.ncbi.nlm.nih.gov/41869844/ - Balamuth F, Weiss SL, Long E, et al. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock. N Engl J Med. Published online April 24, 2026. https://pubmed.ncbi.nlm.nih.gov/42028918/ - Weiss SL, Balamuth F, Long E, et al. PRagMatic Pediatric Trial of Balanced vs nOrmaL Saline FlUid in Sepsis: study protocol for the PRoMPT BOLUS randomized interventional trial. Trials. 2021;22(1):776. Published 2021 Nov 6. https://pubmed.ncbi.nlm.nih.gov/34742327/ - Steven Pinker "Enlightenment Now” - https://stevenpinker.com/publications/enlightenment-now-case-reason-science-humanism-and-progress - Blood Poison: The Untold Story of Sepsis - https://amplifypublishinggroup.com/product/nonfiction/health-medicine-and-wellness/general-health-medicine-and-wellness/blood-poison/ TRANSCRIPT https://cdn.bfldr.com/D6LGWP8S/at/r9q8w9vhsbpg7wwzn35kbmz/202605_WSP_Peters_and_Weiss_Transcript.pdf Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children's Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge among healthcare providers worldwide who care for critically ill children across all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open-access, thus at no expense to the user. For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu CITATION Peters MJ, Weiss SL, O'Hara J, Burns JP. Pediatric Surviving Sepsis: Insights From the Leadership. 05/2026. OPENPediatrics. Online Podcast. https://soundcloud.com/openpediatrics/pediatric-surviving-sepsis-insights-from-the-leadership-by-m-peters-s-weiss-openpediatrics.

For this episode, we are joined by Kadija Ferryman, an anthropologist who studies equity and policy in health risk prediction technologies. Dr. Ferryman is Faculty at the Berman Institute of Bioethics and Assistant Professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.Dr. Ferryman traces her path into studying technology through a cultural anthropology lens, beginning with an early curiosity about how different cultures define illness and disease. She explains how the cultural anthropology focus on beliefs, values, and power structures shapes the way she examines modern health technologies. Using examples like the sequencing of the human genome, she highlights how different scientific communities drew strikingly different conclusions from the same discovery, revealing deeper tensions about race, biology, and social meaning that continue to influence biomedical research.Building on this foundation, Dr. Ferryman explores how bias becomes embedded in everyday health technologies, from pulse oximeters to clinical risk prediction algorithms. She describes how known inaccuracies of pulse oximeter readings for darker-skinned individuals persisted for decades and became especially visible during the COVID-19 pandemic. Extending these concerns to emerging areas like generative AI, she raises important questions about how biased data can shape both clinical care and healthcare systems more broadly. At the same time, she offers a more nuanced perspective: these flawed technologies can also serve as powerful windows into the inequities of our society and as opportunities to rethink how ethics is integrated into medicine and technological development.Ferryman K, Mackintosh M, Ghassemi M. Considering Biased Data as Informative Artifacts in AI-Assisted Health Care. N Engl J Med. 2023 Aug 31;389(9):833-838.Ethical Guidelines for AI:https://healthaipartnership.org/health-equity-across-the-ai-lifecycle-heaalhttps://www.chai.org/https://nam.edu/our-work/programs/leadership-consortium/health-care-artificial-intelligence-code-of-conduct/Select other publications by Dr. Ferryman:Collins BX, Bélisle-Pipon JC, Evans BJ, Ferryman K, Jiang X, Nebeker C, Novak L, Roberts K, Were M, Yin Z, Ravitsky V, Coco J, Hendricks-Sturrup R, Williams I, Clayton EW, Malin BA; Bridge2AI Ethics and Trustworthy AI Working Group. Addressing ethical issues in healthcare artificial intelligence using a lifecycle-informed process. JAMIA Open. 2024 Nov 15;7(4):ooae108.Shachar C, Drabo EF, Iwashyna TJ, Ferryman K. Addressing Racial and Ethnic Bias in Pulse Oximeters-A Wicked Problem. JAMA. 2025 Feb 18;333(7):563-564.Ferryman K, Crews DC, Drabo EF, Iwashyna TJ, Kane O, Jackson JW. Adherence to FDA Guidance on Pulse Oximetry Testing Among Diverse Individuals, 1996-2024. JAMA. 2025 Feb 18;333(7):631-632Also mentioned on the show: Joy Buolamwini Coded Bias

This week, we present a promising new therapy for dermatomyositis, evolving approaches to stroke care, the prevention of Covid-19 after household exposure, and new treatments for kidney disease. We review inflammatory myopathies and follow a complex case of multisystem illness. Perspectives discuss AI and uncertainty in clinical care, health equity, the forces shaping affordability in health care, and on unpacking the ordinary.

Raja-Elie Abdulnour is the Chief Clinical Innovation Officer at NEJM Group and an associate physician in the Pulmonary and Critical Care Medicine Division at Brigham and Women's Hospital. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. A. Sikora, L.A. Celi, and R.-E.E. Abdulnour. Can AI Say “I Don't Know”? N Engl J Med 2026;394:1873-1875.

We have only recently become aware of the close relationship between the heart and the kidneys. In today's discussion, Dr. Neil Skolnik speaks with Dr. Josephine Harrington to gain insight into these newly-discovered links between cardiovascular risk and CKD. This special episode is sponsored with support from Bayer. Please listen to the episodes by clicking on the podcast player below or by freely subscribing to Diabetes Core Update via Apple Podcasts, Amazon Music, Spotify, or your preferred podcast platform. Presented by: -Neil Skolnik, MD, Professor of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University; Associate Director, Family Medicine Residency Program, Abington Jefferson Health -Josephine Harrington, M.D., Assistant Professor of Medicine in the Division of Cardiology at the University of Colorado School of Medicine. Selected references: -Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2026. The American Diabetes Association's Standards of Care 2026, Diabetes Care 2026;49 (Supplement_1):S246–S260 -Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. N Engl J Med 2020;383:2219-2229 -Dapagliflozin in Patients with Chronic Kidney Disease. N Engl J Med 2020;383:1436-1446 -Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes. N Engl J Med 2024;391:109-121

Candida auris is an emerging fungal pathogen gaining national attention—and for good reason. In this episode of Rounding@IOWA, Dr. Gerry Clancy sits down with infectious disease experts Dr. Karen Brust and Dr. Joseph Tholany to discuss why C. auris is so difficult to eliminate in healthcare settings, who is most at risk and why, the challenges of antifungal resistance, and practical steps clinicians can take to prevent spread. Episode Transcript CE Credit Available  Host: Gerard Clancy, MD Senior Associate Dean for External Affairs Professor of Psychiatry and Emergency Medicine University of Iowa Carver College of Medicine Guests: Karen Brust, MD Hospital Epidemiologist, University of Iowa Health Care Clinical Associate Professor of Internal Medicine-Infectious Diseases University of Iowa Carver College of Medicine Joseph Tholany, MD Clinical Assistant Professor of Internal Medicine-Infectious Diseases University of Iowa Carver College of Medicine Financial Disclosures:  Dr. Gerard Clancy, Dr. Karen Brust, Dr. Joseph Tholany, and Rounding@IOWA planning committee members have disclosed no relevant financial relationships. Nurse: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this activity for a maximum of 1.0 ANCC contact hour. Pharmacist and Pharmacy Tech: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this knowledge-based activity for a maximum of 1.0 ACPE contact hours. Credit will be uploaded to the NABP CPE Monitor within 60 days after the activity completion. Pharmacists must provide their NABP ID and DOB (MMDD) to receive credit. JA0000310-0000-26-047-H01 Physician: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other Health Care Providers: A certificate of completion will be available after successful completion of the course. (It is the responsibility of licensees to determine if this continuing education activity meets the requirements of their professional licensure board.) References/Resources:  Lionakis MS, Chowdhary A. Candida auris Infections. N Engl J Med. 2024;391(20):1924-1935. Doi:10.1056/NEJMra2402635 Casadevall A, et al. On the Emergence of Candida auris: Climate Change, Azoles, Swamps, and Birds. mBio. 2019;10(4):e01397-19. Published 2019 Jul 23. doi:10.1128/mBio.01397-19 Sharma C, Kadosh D. Perspective on the origin, resistance, and spread of the emerging human fungal pathogen Candida auris. PLoS Pathog. 2023;19(3):e1011190. Published 2023 Mar 23. doi:10.1371/journal.ppat.1011190 Dire O, et al. Survival of Candida auris on environmental surface materials and low-level resistance to disinfectant. J Hosp Infect. 2023;137:17-23. doi:10.1016/j.jhin.2023.04.007 Castanheira M, et al. Recent increase in Candida auris frequency in the SENTRY surveillance program: antifungal activity and genotypic characterization. Antimicrob Agents Chemother. 2024;68(10):e0057024. doi:10.1128/aac.00570-24 Pacilli, Massimo, et al. "Regional emergence of Candida auris in Chicago and lessons learned from intensive follow-up at 1 ventilator-capable skilled nursing facility." Clinical Infectious Diseases 71.11 (2020): e718-e725 Rhodes, Johanna, and Matthew C. Fisher. "Global epidemiology of emerging Candida auris." Current opinion in microbiology 52 (2019): 84-89. https://www.cdc.gov/mmwr/volumes/74/wr/mm7425a1.htm  

The FIMAGE study scanned both shoulders of 602 adults from the general population using high-resolution 3-Tesla MRI. Only 7 had a structurally normal rotator cuff. In this episode, I walk through what the study found, why 78% of full-thickness tears were in people with no shoulder pain, and what happens to the diagnostic value of a scan when the finding it detects is near-universal. I challenge the assumption that prevalence equals normality, explore why the word "tear" imports a trauma narrative into what is usually a degenerative process, and make the case that imaging findings deserve a smaller seat at the clinical reasoning table than we've historically given them. Key resources Ibounig T et al. Incidental Rotator Cuff Abnormalities on Magnetic Resonance Imaging. JAMA Intern Med. 2026 Apr 1;186(4):406-414. doi: 10.1001/jamainternmed.2025.7903. PMID: 41697693; PMCID: PMC12910452. Englund M et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008 Sep 11;359(11):1108-15. doi: 10.1056/NEJMoa0800777. PMID: 18784100; PMCID: PMC2897006. Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73. doi: 10.1056/NEJM199407143310201. PMID: 8208267. Register for the complete shoulder online course Register for my Brisbane workshop Connect with Jared and guests: Jared on Instagram: @‌shoulder_physio Jared on X: @‌jaredpowell12 See our Disclaimer here: The Shoulder Physio - Disclaimer

This week, we present research on high-risk coronary intervention strategies, targeted therapy for pancreatic cancer, an mRNA influenza vaccine, and treatments for severe scabies and sickle cell disease. We review cerebral amyloid angiopathy and follow a complex case of a disseminated infection. Perspectives address the impact of corporate medicine on medical training and drug pricing policy.

Jatin Vyas is a professor of medicine and associate dean for academic innovation at the Columbia University Vagelos College of Physicians and Surgeons. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. J.M. Vyas. From Mission to Margin in Academic Medicine — The Impact of Corporate Medicine on Medical Training. N Engl J Med 2026;394:1769-1772.

#腸躁症 與 #消化不良 是臨床上常見的腸胃疾病，最新一集的Podcast將用兩篇《 刺胳針》(The Lancet)以及一篇《新英蘭醫學期刊》(NEJM)發表的文獻，帶大家全面認識這些功能性腸胃疾病，解析這類疾病如何受到生理及心理因素的影響！雖然這些疾病經常跟身心狀態有關，但臨床診斷仍需由「腸胃科」醫師主導，才能判斷實際的病況以及提供更加合適的治療！本集的Podcast將全面的介紹：1️⃣功能性腸胃疾病（Functional Gastrointestinal Disorders, FGID）►在流行病學上，哪像族群的風險較高？有哪些危險因子？►發病機制為何？需要補充益生菌嗎？►真的是心理因素影響到腸道嗎？2️⃣腸躁症（Irritable Bowel Syndrome, IBS） ►甚麼是腸躁症？竟然還分成「便祕型」、「腹瀉型」或「混合型」►全球以及台灣發病的盛行率又是如何？►急性腸道感染、腸道微生物群以及腦腸軸的功能異常，都是可能的致病因素！►有哪些飲食以及藥物的治療建議？ 3️⃣功能性消化不良（Functional Dyspepsia, FD） ►不明原因的上腹痛、灼熱感、餐後飽脹或噁心都是可能的症狀。►心理上的焦慮或憂鬱，以及生理上的腸躁症或胃食道逆流也是常見的共病！►近年來免疫反應的新發現！➡️功能性消化不良與 「TH2 免疫反應」有關，在患者的十二指腸中常觀察到嗜酸性球與肥大細胞增多的發炎現象，這種局部發炎會透過迷走神經影響大腦，引發情緒困擾與疼痛感。►又要如何去鑑別診斷以及治療呢？ 不論您是腸胃疾病相關的專業醫事人員，或是因為這類疾病深受其擾的人，收聽完這集Podcast將會讓您對這些腸胃疾病有更全面的認識，並獲得更明確的改善方向！立即來收聽⬇️探索大腦的會談地圖｜功能性消化不良與腸躁症收聽連結：https://linktr.ee/digital_biolab-

Welcome to the latest episode (May 2026) of Diabetes Core Update, where every month Neil Skolnik, MD and John Russell, MD review the most important articles on diabetes, obesity, and cardiometabolic disease. This month, they discuss: Marston NA, Bohula EA, Bhatia AK, et al. "Evolocumab to Reduce First Major Cardiovascular Events in Patients Without Known Significant Atherosclerosis and With Diabetes: Results From the VESALIUS-CV Trial." JAMA. 2026;335(16):1400–1407. doi:10.1001/jama.2026.3277 Lee YJ, Lee SJ, Kim JW, et al. "Intensive LDL Cholesterol Targeting in Atherosclerotic Cardiovascular Disease." N Engl J Med 2026;394:1365-1375. doi:10.1056/NEJMoa2600283 Nissen SE, Wolski K, D'Alessio D, et al. "Cardiorenal Outcomes With Tirzepatide Compared With Dulaglutide in Patients With Diabetes and Cardiovascular Disease: A Post Hoc Analysis of the SURPASS-CVOT Randomized Clinical Trial." JAMA Cardiol. Published online March 28, 2026. doi:10.1001/jamacardio.2026.0767 Moura FA, et al. "Association Between GLP-1 Receptor Agonists and Ischemic Optic Neuropathy: A Meta-analysis." Diabetes Care. 2026;49(5):724–729. doi.org/10.2337/dc25-1238 Ostrominski JW, Ortega-Montiel J, et al. "Comparative Effectiveness of Tirzepatide Versus Dulaglutide or Semaglutide on Major Cardiovascular Events in Type 2 Diabetes and Cardiovascular Disease: Insights From Two Target-Trial Emulations." Diabetes Care. 2026;49(5):808–817 doi.org/10.2337/dc25-3063 Nicole Napoli, "Shingles Vaccine Drastically Cuts Risk of Serious Cardiac Events." The American College of Cardiology. March 17, 2026 https://www.acc.org/About-ACC/Press-Releases/2026/03/16/19/33/Shingles-Vaccine-Drastically-Cuts-Risk-of-Serious-Cardiac-Events For information about the American Diabetes Association's scholarly journals, visit diabetesjournals.org. For more about this podcast, visit About Diabetes Core Update.

With Liemena Harold Adrian, Syarifah Ambami Rato Ebu General Academic Hospital, Surabaya - Indonesia and Shelley Zieroth, St. Boniface Hospital, University of Manitoba, Winnipeg - Canada. In this episode,Liemena Harold Adrian and Shelley Zieroth discuss heart failure in post–myocardial infarction patients, covering how myocardial infarction leads to the development of heart failure despite advances in reperfusion and acute care. The conversation addresses the epidemiology and underlying pathophysiology, approaches to early prevention and screening, diagnostic tools, as well as key interventions in the acute and early post-MI phases that may alter heart failure trajectories. They outline management with guideline-directed medical therapy, review current studies on heart failure–modifying therapies (such as the DAPA-MI and EMPACT-MI trials), and address indications for advanced therapies in post-MI populations. The episode also highlights the importance of early diagnosis, prompt recognition, and key evidence gaps in the field. Recommended readings: Akhtar KH, Khan MS, Baron SJ, et al. The Spectrum of Post-Myocardial Infarction Care: From Acute Ischemia to Heart Failurehttps://doi.org/10.1016/j.pcad.2024.01.017. Prog Cardiovasc Dis. (2024); 82: 15-25. DOI: 10.1016/j.pcad.2024.01.017. Butler J, Hammonds K, Talha KM, et al. Incident Heart Failure and Recurrent Coronary Events Following Acute Myocardial Infarctionhttps://doi.org/10.1093/eurheartj/ehae885. Eur Heart J (2025); 46: 1540-50. DOI: 10.1093/eurheartj/ehae885. Butler J, Jones WS, Udell JA. Empagliflozin after Acute Myocardial Infarction. N Engl J Med (2024); 390: 1455-66. DOI: 10.1056/NEJMoa2314051. Fioretti F, Butler J, Udell JA, et al. Empagliflozin after myocardial infarction with or without diabetes and chronic kidney disease: Insights from EMPACT-MI. ESC Heart Failure (2025); 12: 3940-3952. DOI: 10.1002/ehf2.15393. Hernandez AF, Udell JA, Jones WS. Effect of Empagliflozin on Heart Failure Outcomes After Acute Myocardial Infarction: Insights From the EMPACT-MI Trial. Circulation (2024); 149: 1627–1638. DOI: 10.1161/CIRCULATIONAHA.124.069217. Jenca D, Melenovsky V, Stehlik J, et al. Heart Failure after Myocardial Infarction: Incidence and Predictors. ESC Heart Failure (2021): 8: 222-237. DOI: 10.1002/ehf2.13144. Lala A, Beavers C, Blumer V, et al. The Continuum of Prevention and Heart Failure in Cardiovascular Medicine: A Joint Scientific Statement from the Heart Failure Society of America and The American Society for Preventive Cardiology. Journal of Cardiac Failure (2026); 32: 75-105. Petrie MC, Udell JA, Anker SD, et al. Empagliflozin in Acute Myocardial Infarction in Patients with and without Type 2 Diabetes: A Pre-specified Analysis of the EMPACT-MI Trial. Eur J of Heart Fail. (2025): 27: 577-588. DOI: 10.1002/ejhf.3548. Zieroth S, Rizi SS. Time Is of the Essence. JACC: Heart Failure (2023): 11(6): 713-714. DOI: 10.1016/j.jchf.2023.03.022 This 2026 HFA Cardio Talk podcast series is supported by Bayer in the form of unrestricted financial support. The discussion has not been influenced in any way by its sponsor.

This week, we feature advances in targeted therapy for HER2-mutant lung cancer, interventions to reduce maternal infection, an emerging treatment for hemophilia A, and a new diagnostic test for tuberculosis. We review Barrett's esophagus and follow a case of systemic illness with kidney failure. Perspectives address GLP-1 drugs and eating disorders, directed blood donation, generic drug safety, and an in-flight medical emergency.

Amanda Banks is a consultant and a physician at the Corporal Michael J. Crescenz VA Medical Center. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. A. Banks. GLP-1 Receptor Agonists and Eating Disorders — Cause for Concern. N Engl J Med 2026;394:1665-1667.

This week, we explore new strategies for blood-pressure control after intracerebral hemorrhage, Covid-19 treatment in higher-risk patients, hormonal therapy for prostate cancer, and anesthesia for tracheal intubation. We review spinal epidural abscess and follow a case of progressive weakness and liver lesions. We examine advances in tRNA research, and Perspectives discuss the use AI in prescribing, pediatric drug research, the impact of pharmaceutical mergers, and the goals of care.

Sara Gerke is an associate professor of law and at the European Union Center at the University of Illinois Urbana-Champaign. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. S. Gerke, R.B. Parikh, and I.G. Cohen. Utah's Prescription-Renewal Pilot Program — Autonomous AI Managing Patient Care. N Engl J Med 2026;394:1561-1563.

少見但可能致命的抗精神病藥物惡性症候群（Neuroleptic Malignant Syndrome，簡稱NMS）的臨床表現是如何？ NMS 典型是在暴露於多巴胺阻斷藥物之後出現（最常見是抗精神病藥物，第一代與第二代抗精神病藥物階可能）；從用藥到出現症狀的中位數約 4 天，但也可能快到 1 天內就發作，或延後到 30 天以上才出現。整體病程常在第 2–3 天達到高峰；而在最早期的臨床症狀，常是血壓變動與肌張力增高。 NMS 的核心臨床特徵是：（1）高體溫（嚴重時可到 40°C 以上，大多也會有脫水的症狀）以及（2）自律神經不穩（dysautonomia）、（3）嚴重肌肉僵硬（muscular rigidity）。 ►NMS 的病理機制可能與交感神經—腎上腺素系統過度亢奮有關，這種亢奮會讓肌肉細胞內的鈣離子濃度（intracellular calcium ions）上升，使肌肉張力更高、更僵硬，同時也會出現心跳快、血壓波動、出汗等自律神經症狀。進一步來說，下視丘的多巴胺受體被阻斷，身體的散熱能力會變差；而當掌管運動中樞的基底核系統裡的多巴胺受體被阻斷，會更直接導致明顯的肌肉僵硬（rigidity）。肌肉強直本身會增加產熱，再加上散熱變差，兩者疊加成 NMS最關鍵的臨床指標——高體溫（hyperthermia）。 ►自律神經不穩的表現常包含：心跳加快、血壓快速波動（可高可低）、大量出汗、呼吸變快等；意識狀態改變也很常見，從譫妄、混亂、嗜睡到嚴重時接近僵直症（catatonia）都可能出現。 ►肌肉僵硬檢查時常被形容為「鉛管樣僵硬」（lead-pipe rigidity）：醫師幫病人把手腳關節慢慢彎直時，會覺得從頭到尾都卡卡的、阻力很平均；有時也會出現像巴金森症「齒輪樣」（cogwheel）那樣「一格一格卡住」的感覺。 -最新一集Podcast將分享在新版的《會談地圖》當中，整理自權威醫學期刊 NEJM 關於抗精神病藥物惡性症候群相關的診斷與治療，除了讓大家更加認識抗精神病藥物惡性症候群，也希望將龐雜的醫學資訊拆解，整理出貼近台灣臨床實務的內容！ 本集的Podcast，將會深入的探討： 1️⃣NMS臨床特徵與病理機制：如何將高體溫（Hyperthermia）、自律神經不穩、肌肉僵硬（Rigidity）等病理生理學症狀串聯起來，更全面的理解NMS的病徵及發病原理？ 2️⃣實驗室檢查：會利用甚麼實驗室檢查的數值來診斷NMS？ 3️⃣治療原則： NMS 需要視為重症（ICU 等級）來處理嗎？根據風險大小有哪些治療的方法呢？ 4️⃣預後與醫病溝通：預後也是不可掉以輕心的階段，停藥後的恢復期大約需要多久？有哪些後期併發症是需要留意的呢？ - 如果您對抗精神病藥物惡性症候群的議題充滿興趣，或是想進一步了解更多《新版會談地圖》的內容，歡迎加入

This week, we present new research on stroke prevention, Kawasaki disease, ICU infection strategies, and immune thrombocytopenia. We review hormone therapy and thrombotic risk. A case highlights an evolving diagnosis of severe fatigue and sleep disturbance. Perspectives explore nursing workforce policy, the role of nurse scientists in rebuilding trust, and the health consequences of environmental rollbacks.

Croup is a clinical syndrome of upper airway obstruction defined by barking cough, stridor, and hoarseness. Management hinges on severity assessment, universal corticosteroid use, and selective epinephrine. The key clinical task is distinguishing typical croup from high-risk mimics that require urgent airway intervention. Learning Objectives Differentiate croup from other causes of pediatric upper airway obstruction using key historical and physical exam features. Apply a severity-based approach to croup management, including appropriate use of corticosteroids and nebulized epinephrine. Recognize clinical features that suggest alternative or life-threatening diagnoses requiring escalation of care. References Cooke A, Conway S, Griffin L. Croup: Rapid Evidence Review. Am Fam Physician. 2026;113(3):254-258. Gates A, Johnson DW, Klassen TP. Glucocorticoids for Croup in Children. JAMA Pediatr. 2019;173(6):595-596. doi:10.1001/jamapediatrics.2019.0834 Bjornson CL, Klassen TP, Williamson J, et al. A Randomized Trial of a Single Dose of Oral Dexamethasone for Mild Croup. N Engl J Med. 2004;351(13):1306-1313. doi:10.1056/NEJMoa033534 Bjornson CL, Johnson DW. Croup. Lancet. 2008;371(9609):329-339. doi:10.1016/S0140-6736(08)60170-1 Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized Epinephrine for Croup in Children. Cochrane Database Syst Rev. 2013;(10):CD006619. doi:10.1002/14651858.CD006619.pub3 Transcript This transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content.  Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I'm your host, Brad Sobolewski. And today we're gonna talk about croup. We're gonna focus on diagnosis, severity based management, and how to differentiate it from scarier high risk conditions that may present similarly, but behave very differently. So croup is best understood as a clinical syndrome of upper airway obstruction caused by inflammation at the level of the larynx and subglottis. So in most cases this is viral laryngotracheitis, most commonly due to parainfluenza virus. But as you'd expect multiple viruses can cause it. The subglottis is the narrowest portion of the pediatric airway. So even small amounts of edema create large increases in airway resistance. So that's why the clinical picture is so consistent. You've got inspiratory stridor, hoarseness, and that characteristic barking cough, which either sounds like a seal or a dog, and yes, of course, I know the difference between the two coughs because I was a biology major. This is primarily a disease of children between six months and three years of age with a peak incidence in the second year of life. It's really, really common, like one and a half percent of all ED visits, maybe 350,000 visits a year, and 85% of these kids have mild disease. Hospitalization is rare. The range is variable, about two to 8% of cases, and return visits occur in about three to 5%. Fewer than 1% of children, a lot fewer, require intensive care or airway intervention. Honestly, most kids do really well. The ones who don't can get sick very quickly, and that's been my clinical experience. In the Northern Hemisphere, we see croup throughout the fall and winter, usually starting in around November and sort of tapering off by April. But that being said, I've seen croup-like symptoms every month of the year over the past couple of decades. Croup is absolutely a classic clinical diagnosis. A typical case begins with 12 to 48 hours of viral prodrome, you know, body aches, fever, congestion, cough, followed by often abrupt nighttime onset of barky cough and stridor. Symptoms fluctuate, and they're generally worse with agitation and get better when the kid is calm. That variability is the key feature. So what you'll have is a child who wakes up after sleeping for a few hours with a barky cough and then noisy stridor. This freaks parents out, and this is not hyperbole. There's this little center in the back of your brain that's like, please don't stop breathing and die. So appropriately, they're worried about the kid, they call emergency medical services, they bring them to the emergency department, and by and large, by the time they get there, the stridor has resolved. The kid is calm, and parents will say, I swear he looked a lot worse at home. Trust me, we believe you parents, this is what croup does. When I'm taking a history of croup, I get all of these details. Are there any sick contacts? If the parents are worried about a foreign body inhalation or ingestion, then I'm worried about a foreign body inhalation or ingestion. Listen to the lungs, inspect their airway. Always check the ears for concomitant otitis and I'll feel their trachea. I'll actually grab and hold the trachea and move it. Kids with croup really don't have a painful trachea. Kids with bacterial tracheitis, aside from looking more toxic, actually have a lot of pain when they move their trachea. Testing for croup is generally unnecessary. Labs and viral studies do not change management, and imaging is really reserved for atypical presentations or when you're considering an alternative diagnosis like a foreign body. If you do get an X-ray, what you're looking for is the classic steeple sign on the AP view. It is seen in croup, but it's not 100% sensitive nor specific. Once you've made the diagnosis of croup, it's important to assess severity, and remember that I said that most kids are mild. So mild croup is defined by the absence of stridor at rest. So they may have some stridor when they're upset or even a little bit of hoarseness or noise. It's important to listen to many, many children with croup to get a sense of this. Moderate croup includes stridor at rest with mild to moderate retractions. So at rest means that the child is in a position of comfort. They're calm with a parent, and they've generally been that way for about 10 to 15 minutes. Sometimes that's how long it can take for the stridor to dissipate once you get the kid calm. Severe croup, which is fortunately rare, involves marked work of breathing, agitation, fatigue, need for oxygen, altered mental status, and this aligns with the Westley croup score. It formalizes stridor, retractions, air entry, cyanosis, and mental status. But really, in practice, most of us get very good at bedside assessment of croup. Management of croup starts with corticosteroids. This is one of the highest-yield interventions that we have in pediatric emergency medicine. Every child with croup should receive dexamethasone. Typically 0.6 milligram per kilogram as a single dose up to a maximum of 10 milligrams. Some places will use 0.15 milligram per kilogram. Locally, we often give the IV formulation orally. It's 10 milligrams per mL. Tastes bad, but pairs reasonably well with apple juice. The oral suspension is 1 milligram per mL, tastes terrible, and pairs nicely with being spit on the ground by toddlers. The evidence behind dexamethasone is very robust. The main benefit is that it reduces return visits and hospital readmissions by about half, and those return visits include doctor's offices and emergency departments. In a Cochrane review of 1,679 children, glucocorticoids reduce return visits or readmissions with a risk ratio of 0.52, so that translates to a number needed to treat of seven. I've certainly seen seven or more croup kids during one shift, so for every seven children treated with dexamethasone, one return visit is prevented. Symptom improvement begins within about two hours and lasts at least 24 hours, but maybe up to a couple of days. Hospital length of stay for kids that get steroids is reduced by an average of 15 hours as well. Serious adverse events are rare. It's well tolerated, and other than the taste, kids do fine with it. And importantly, the benefit is consistent across all severities of croup, mild, moderate, and severe. So when you explain this to families who are very scared about their kids, but now their kid is looking better and you're only giving them a single medicine, not doing any tests or X-rays or anything, I think you have to frame the medicine in terms of what it's going to do for them over the next couple of days. So one way of explaining this to families would be to say something like this is a steroid called dexamethasone. It reduces the swelling in your child's airway that's causing the barky cough and noisy breathing. Most children start feeling better within a couple of hours, and the benefit lasts at least a full day, if not longer. Without this medicine, about one in five children need to come back because symptoms get worse again. You really get two bad days with croup in most cases. With this medicine, the risk of returning drops to about one in 10, so it cuts the chance of coming back in half. We can expect your child's cough to start improving over the next day or two. Most children are feeling a lot better within 48 hours, though a little bit of hoarseness and cough can last for a week to about 10 days. So it's possible that when your child goes to sleep later tonight, they may experience that barking cough and noisy breathing again. They're almost certainly going to be upset. The steroid blunts enough of the swelling so that you are much more likely to have them free of distress and stridor, that noisy breathing, once you get them calm. So if they're upset, get them calm, and if in about 10 minutes the stridor and noisy breathing get better, that's the dexamethasone doing its job and you can safely stay home. For children with moderate or severe croup, we're gonna use nebulized racemic epinephrine. It works fast by reducing airway edema by constricting inflamed blood vessels. You'll see improvement in stridor and work of breathing often within 30 minutes. The effect is transient and largely gone by about two hours, and you need to do a structured reassessment at about 30 minutes after the racemic epinephrine. If the child's clearly better, continue that observation for up to two hours. If they're unchanged or worse, repeat the epinephrine and start thinking more carefully about your diagnosis and disposition. Because it's got such a short duration, that two hours after treatment is the most common time period, though some institutions and some children will need to be observed a little bit longer. If they remain well appearing with no stridor at rest, normal oxygenation, minimal work of breathing, and they can tolerate oral fluids, they can be discharged. If symptoms recur, they require repeated epinephrine, or they fail to improve, then you may have to escalate care and consider admission. Honestly, with croup, supportive care is still one of the most important things. You gotta keep kids calm by minimizing agitation. Parents are experts at this with their own children. Agitation worsens airway obstruction. Airway resistance is fourfold greater when the kid's upset. Give oxygen if the kid's hypoxic. Fortunately, this is rare. Antipyretics and fluids are great, do them. Humidified air has not been shown to provide meaningful benefit, and obviously we should avoid sedatives because they can suppress respiratory drive without improving airway patency. Many parents will say that their kid was better when they were exposed to cool air or mist in the shower. Those can help, but honestly, don't stick your kid's head in the freezer if it upsets them. Keep them calm, hold them, and comfort them. Alright, croup, barking cough, stridor, variable symptoms, easy, right? There are some other diagnoses that can mimic this or overlap that you shouldn't miss. Spasmodic croup is a related phenotype. You've got sudden nighttime onset, often minimal prodrome, and recurrent episodes. These kids are typically well between episodes, and the pattern becomes more apparent over time. Some kids will bark with every mild cold or stuffy nose up until about eight or nine, but they usually don't have stridor and respiratory distress. Bacterial tracheitis is progression to a more severe and dangerous airway infection. These children often start with viral symptoms and then rapidly worsen. They've got a high fever, they appear toxic. Most importantly, they fail to respond to standard croup therapy. Toxic appearance plus lack of response should immediately shift your diagnostic reasoning. These kids may have a lot of pain when you grab and move their trachea. The cough can be more junky because again, they've got purulent mucus in their trachea. Epiglottitis is defined by the absence of barking cough and the presence of drooling, dysphagia, and tripod positioning. These children are very anxious, they're very ill, their airway is at risk, and so your immediate priority is keeping them calm and having the airway managed in the safest environment, generally the operating room. Deep neck space infections, including retropharyngeal cellulitis and abscesses and peritonsillar abscesses, present with fever, neck stiffness, sometimes even torticollis, and lymphadenopathy. Kids won't really have a barky cough and the exam localizes to the neck rather than the airway alone. Acute foreign body aspiration presents with sudden onset symptoms, no viral prodrome, no barking cough, and sometimes some asymmetric exam findings. The diagnosis is frequently missed when clinicians anchor too early on croup. If you have an esophageal foreign body, remember that 70% of these get stuck at the thoracic inlet. So always think about a kid who sounded like they had croup and got croup treatments, but also has some swallowing issues and is the right age to put things in their mouth. This is when you see coins and button batteries and other things stuck not in the upper airway, but in the esophagus right behind it. Alright, now when it comes to disposition, most kids with croup are gonna be sent home. Children who improve, they have no stridor at rest, minimal work of breathing, can be discharged home with clear return precautions. Those with persistent symptoms, need for repeated racemic epinephrine, hypoxia, or concerning features should be admitted. For kids who continue to worsen despite standard therapy, escalation includes high-flow nasal cannula, noninvasive ventilation as a bridge. Heliox can be used as a temporizing measure to reduce work of breathing. Fortunately, needing to intubate a child with croup is rare, but when it's needed, it can be challenging due to subglottic narrowing. You need the best proceduralists, and you should downsize your endotracheal tube by 0.5 to 1 millimeter smaller than usual. And I'll reiterate this again. The natural course of croup is really favorable for most kids. The fear's not gonna go away for the parents, this is a scary diagnosis, but I think with some reassurance, we can help them understand that this is something that is unlikely to cause significant problems and will get better. Most kids improve significantly within 48 hours, though like any other respiratory illness, symptoms can persist for a week or so. Severe outcomes are fortunately rare, and they almost always occur in children whose severity or alternative diagnosis was not recognized early. So again, here's my take-home points. Croup is a clinical diagnosis. Severity determines your management. Steroids, dexamethasone, should be given to all patients. Racemic epinephrine is used for moderate to severe disease with mandatory reassessment and observation. And most importantly, always reassess the diagnosis when the presentation does not fit the expected patterns. Things can get rough when you're barking up the wrong tree and thinking it's croup when it's actually something else. Well, I hope you enjoyed this episode on honestly one of the most classic conditions that we see in the pediatric emergency department. If you've got any feedback on the episode, send it my way. As the kids would say, like, rate, and review. I would love it if you left a review on your favorite podcast site. It helps more people find the show. I do this as a labor of love because I enjoy teaching, and I think that this is a wonderful way to reach my colleagues and learners. If you've got suggestions on other topics or episodes, I'd love to hear them. For PEM Currents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

Amy Stimpfel is an assistant professor at the New York University Rory Meyers College of Nursing. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. A.W. Stimpfel and M. Djukic. Using Data to Inform Decision Making — Borrowing Limits for Graduate Nursing Students. N Engl J Med 2026;394:1457-1459. P. Joseph and Others. Nurse Scientists as Trusted Voices in Health Communication. N Engl J Med 2026;394:1459-1461.

Dr. Jenna Skowronski, Dr. Shazli Khan, and Dr. Alix Barnes discuss the involvement of palliative care throughout the heart failure spectrum with Dr. Sarah Chuzi. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes. In this episode, we discuss utilizing palliative care principles while caring for patients with heart failure, particularly those being considered for advanced therapies. We emphasize utilization of communication frameworks when discussing prognosis and making decisions on pursuing therapies such as palliative inotropes, left ventricular assist devices (LVADs), and heart transplant. Additionally, we discuss when to involve specialty palliative care services. Finally, we highlight the difference between palliative care and hospice and how to help patients navigate the transition from life-prolonging care to hospice. Dr. Jenna Skowronski is the Chair for the CardioNerds Heart Failure Council. Dr. Jenna Skowronski and Dr. Shazli Khan are the Co-chairs for the CardioNerds Advanced Heart Failure Therapies Series. Dr. Alix Barnes is the CardioNerds FIT Ambassador at UPMC and member of the CardioNerds Critical Care Cardiology Council. Enjoy this Circulation Paths to Discovery article to learn more about the CardioNerds mission and journey. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscripts here. CardioNerds Heart Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls Primary palliative care is care provided by a clinician that is not a palliative care specialist, such as a heart failure clinician having a conversation with a patient about their goals and values in clinic.  Taking time to get to know a patient as an individual and learning their goals and values prior to diving into conversations about prognosis and change in treatment plan facilitates more effective goals of care discussions.   Utilizing and practicing a communication framework can improve our skills at goals of care discussions.   Palliative inotropes should be reserved for patients experiencing symptomatic benefit from the therapy that outweighs the associated risks including arrhythmias and infections. The burden of managing these therapies at home should also be considered. Partnerships between cardiologists and hospice agencies can improve the experience for patients with heart failure who enroll in hospice. Cardiologists can continue to see their patients even after hospice enrollment and help with symptom management.   Notes Notes: Notes drafted by Dr. Barnes. 1. What is the difference between primary palliative care and specialty palliative care? Primary palliative care is the delivery of palliative care services that any clinician can deliver. This includes aligning treatment with a patient's goals and basic symptom management. For heart failure patients, symptom management can include cardiac symptoms such as dyspnea and chest pain as well as managing comorbid mood disorders such as adjustment disorder, depression, and anxiety. Advanced palliative care skills take additional training and time to develop. These include leading a difficult family meeting, managing symptoms that are not controlled with standard therapies and responding to emotional and spiritual distress. When these situations are encountered, referral to a specialty palliative care service should be considered. 1 2. How is palliative care integrated throughout the disease trajectory of a patient with heart failure? Heart failure clinicians deliver primary palliative care when assessing a patient's preferences, goals and values or managing symptoms. As a patient's disease progresses, the heart failure team also engages in primary palliative care when delivering news about prognosis. When advanced therapies are being considered, utilization of shared decision-making (SDM) should be employed (see question 3 for further discussion on SDM). For patients being considered for LVAD, the Centers for Medicare and Medicaid Services (CMS) mandates that patients are seen by a palliative care specialist prior to implantation. 2 Despite this, there remains variability in how institutions involve specialty palliative care in this decision-making process. Thoughtful consideration of what palliative care resources are available at your institution should guide how best to integrate specialty palliative care teams into the LVAD decision tree. One example of a model for meeting this mandate is having a small team of heart failure clinicians with additional palliative care training meet all patient's being evaluate for LVAD. 3. What is shared decision-making (SDM) and how is it utilized when evaluating a patient for advanced therapies? SDM is a collaborative process where patients and clinicians work together to make medical decisions that are aligned with a patient's goals and values.3 There are a variety of communication frameworks that can be used to engage in effective SDM. One framework is the Serious Illness Conversation guide. This is an evidenced based framework that can be used to deliver the news about a patient's current condition and then assess their goals, values and preferences for next steps in their treatment plan.4  This framework can be helpful when discussing prognosis prior to introducing the idea of an evaluation for advanced therapies. REMAP is a second commonly used framework which stands for Reframe, Expect Emotion, Map What's Important, Align, and Plan.5 This framework is similarly helpful when starting a discussion about advanced therapies with a patient. Both frameworks prioritize learning about a patient's goals, values, and preferences prior to making a recommendation for a treatment plan. Listening more than speaking and accepting that a patient and their family may choose a path that is different than what you personally might choose for yourself or your loved ones are vital pillars to engaging in these conversations effectively. When discussing LVAD, it is important to avoid framing the decision as “LVAD or no LVAD,” rather LVAD versus best supportive care. The “Best Case, Worst Case” framework is an effective way to create choice awareness for patients when they are faced with making this decision. This is a way to discuss both the best outcomes after LVAD implantation as well as the potential complications so a patient is better able to understand the full spectrum of possible outcomes. 6 4. How do you select which patients would benefit from home inotrope therapy? There is no data demonstrating a survival benefit with use of palliative inotropes. There may be subsets of patients who derive a survival benefit, such as patients whose renal function worsens when the agent is withdrawn, however there is no concrete data proving this. 7 Therefore, the benefit of home inotrope therapy should be based on if the patient derives symptomatic benefit from these agents. Additionally, risks of the therapy such as arrhythmias and infection as well as the burden of managing these therapies at home should also be weighed in the decision.8 Life expectancy for patients being initiated on palliative inotropes likely ranges from 6 to 9 months. Given this prognosis, concordant palliative care efforts should be intensified when starting patients on these agents. This can either be through involvement in specialty palliative care or increasing primary palliative care interventions. 9 5. How do you determine if a patient would be a candidate for hospice and how do you discuss hospice with patients and their families? Hospice is a comprehensive program that provides supportive care to patients at end of life. This includes a team of physicians, nurses, aids, social workers and chaplains that can deliver care in the home, at a nursing facility, or in an inpatient hospice facility. 10 Patients with a prognosis of 6 months or less can qualify for hospice services. Even if a patient qualifies for hospice based on their prognosis, it is important to assess if a patient's goals and values align with hospice. Introducing hospice to patients who still desire life prolonging care can cause mistrust between the patient and their health care team. When introducing hospice, it is helpful to describe the services hospice offers in addition to naming the service as some patients may have a negative connotation with the word “hospice.” 6. How can cardiologists partner with hospice agencies to provide better care for these patients? Heart failure specialists can continue to see their patients even after they enroll in hospice. Partnering in hospice agencies in this way can help improve symptom management for patients while also allowing them to continue meaningful relationships with providers with whom they've developed a longitudinal relationship with. Guideline directed medical therapy (GDMT) and diuretics can be continued while enrolled in hospice as long as they are offering symptomatic benefit. Heart failure specialists can help with adjusting GDMT to cheaper formulations, such as exchanging angiotensin receptor-neprilysin inhibitors (ANRIs) for angiotensin receptor blockers (ARBs). Many hospice agencies cannot accept patients receiving palliative inotropes due to the resources and training required to safely care for these patients. Understanding what hospice agencies in your area can and cannot support allows heart failure specialists to have informed discussions with patients and make appropriate referrals. References Quill TE, Abernethy AP. Generalist plus Specialist Palliative Care — Creating a More Sustainable Model. N Engl J Med. 2013;368(13):1173-1175. doi:10.1056/NEJMp1215620. https://www.nejm.org/doi/full/10.1056/NEJMp1215620 Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Published online August 1, 2013. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=268 Godfrey S, Barnes A, Gao J, Katz JN, Chuzi S. Shared Decision-making in Palliative and End‑of‑life Care in the Cardiac Intensive Care Unit. US Cardiol Rev. 2024;18:e13. doi:10.15420/usc.2024.03. https://pubmed.ncbi.nlm.nih.gov/39494405/ Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care. 2024;14(e3):e2268-e2279. doi:10.1136/spcare-2023-004163. https://pmc.ncbi.nlm.nih.gov/articles/PMC11671901/ Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract. 2017;13(10):e844-e850. doi:10.1200/JOP.2016.018796. https://ascopubs.org/doi/10.1200/JOP.2016.018796 Kruser JM, Nabozny MJ, Steffens NM, et al. “Best Case/Worst Case”: Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions. J Am Geriatr Soc. 2015;63(9):1805-1811. doi:10.1111/jgs.13615. https://pmc.ncbi.nlm.nih.gov/articles/PMC4747100/ Tolia S, Khan M, Khan S, et al. Mortality and long-term outcomes of palliative inotropes in ischemic and non-ischemic cardiomyopathy. Eur Heart J.  2021;42(Supplement_1):ehab724.0915. doi:10.1093/eurheartj/ehab724.0915. https://academic.oup.com/eurheartj/article/42/Supplement_1/ehab724.0915/6392681 Chuzi S, Allen LA, Dunlay SM, Warraich HJ. Palliative Inotrope Therapy: A Narrative Review. JAMA Cardiol. 2019;4(8):815. doi:10.1001/jamacardio.2019.2081. https://jamanetwork.com/journals/jamacardiology/article-abstract/2737414#google_vignette Chuzi S, Gao J, Thariath J, et al. Characteristics and Outcomes of Palliative Continuous Intravenous Inotrope Support Among Medicare Beneficiaries With Heart Failure. J Am Heart Assoc. 2025;14(14):e039397. doi:10.1161/JAHA.124.039397. https://www.ahajournals.org/doi/10.1161/JAHA.124.039397 What is hospice? Published online September 24, 2024. https://hospicefoundation.org/what-is-hospice/

This week, we present new research on intensive LDL cholesterol targets, team-based strategies to improve blood pressure control, emerging therapies for immune and oncologic diseases, and a next-generation yellow fever vaccine. We review celiac disease and follow a compelling case of post-procedural complications. Perspectives explore health disparities and efforts to strengthen care in vulnerable communities.

Danielle Jones is the vice president of accountability, belonging, and culture at the Association of Women's Health, Obstetric and Neonatal Nurses. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. W.T. Moore and Others. From Clinic to Community — The EveryONE Project in Family Medicine. N Engl J Med 2026;394:1353-1354.

We’re excited today to launch our first episode in collaboration with the Irish Thoracic Society and their podcast series. The Irish Thoracic Society represents respiratory professionals throughout Ireland and is dedicated to championing excellence in the prevention, diagnosis, and clinical care of respiratory disease through its work in advocacy, education and research. In today’s episode, we explore the complex and often overlooked world of refractory chronic cough — a condition that can significantly impact patients' quality of life but is frequently misunderstood or underdiagnosed. With insights from leading respiratory specialists in Ireland and the United States, we discuss the latest thinking on diagnosis, management, and emerging treatments aimed at improving outcomes for patients and helping clinicians navigate this challenging area of respiratory medicine. Joining us are renowned experts Professor Lorcan McGarvey and Professor Brendan Canning, both internationally recognised leaders in respiratory medicine and cough research. Together, they share their perspectives on the neurobiology of chronic cough, the considerable morbidity experienced by patients, and how clinicians can approach diagnostic investigations more effectively. We also explore current treatment strategies and promising new therapies on the horizon as chronic cough increasingly gains recognition as a disease in its own right — rather than simply a symptom. Whether you’re a clinician, researcher, or simply interested in advances in respiratory medicine, this episode offers valuable insights into a condition that is finally receiving the attention it deserves. Meet Our Co-Hosts Marissa O'Callaghan is an Irish trained Respiratory fellow currently undertaking a post-doc fellow working in Erasmus MC Rotterdam in the Netherlands. She finished her Irish respiratory and Internal medicine training and Phd in 2025. Her areas of interest are interstitial and rare lung diseases. She enjoys clinical research, Med Ed, and dreaming up new medical innovations. Together with cohost Sandra Green, she founded the ITS podcast series in June 2024. Marissa O’Callaghan –LinkedIn Sandra Green is an Irish-trained respiratory fellow with a strong track record in climate advocacy and multidisciplinary sustainable initiatives, as co-founder of Irish Doctors for the Environment. She has an MSc in Leadership and Innovation in Healthcare at the Royal College of Surgeons Ireland (2023–2025). With Marisssa, she co-founded the Irish Thoracic Society Podcast Productions, launching the platform in 2024 to share knowledge, insights, and innovations in respiratory care. Sandra Green – LinkedIn Meet Our Guests Lorcan McGarvey is a professor of respiratory medicine at the University of Belfast, with a focus on the neurobiology of cough. His research has significantly contributed to the understanding of cough hypersensitivity syndrome and the development of new therapeutic strategies. Lorcan is a respected voice in the field, known for his collaborative work and dedication to advancing respiratory health. Brendan Canning is a distinguished researcher at Johns Hopkins University, specializing in the mechanisms of cough and airway diseases. His pioneering studies on neural pathways and receptor targets have paved the way for novel treatments in refractory chronic cough. Brendan’s expertise and innovative approach make him a key figure in the ongoing efforts to redefine chronic cough management. In This Episode The definitions and classifications of chronic cough, including unexplained, refractory, and unexplained refractory cough The importance of a thorough clinical history and focused diagnostics over exhaustive testing Common causes of chronic cough The role of personalized, multidisciplinary management—combining pharmacologic, speech therapy, and psychological support—to improve quality of life for even the most challenging patients. The concept of cough hypersensitivity syndrome and its role in refractory cases Evidence-based approach to treatment, including pharmacologic and non-pharmacologic options Emerging therapies on the horizon, including novel receptor modulators and neuromodulatory agents and ongoing clinical trials in this rapidly evolving field The impact of chronic cough on mental health, social life, and overall quality of life The importance of reframing chronic cough as a disease entity in its own right References and Further Reading Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of chronic cough. Lancet. 2008;371(9621):1364-1374. Gibson PG, Vertigan AE. Management of chronic refractory cough. BMJ. 2015;351:h5590. Matsumoto H, Kanemitsu Y, Ohe M, Tanaka H, Terada K, Nishi K, et al. Real-world usage and response to gefapixant in refractory chronic cough. ERJ Open Res. 2025;11(4):01037-2024. doi:10.1183/23120541.01037-2024. McGarvey LP, Birring SS. Cough hypersensitivity syndrome: a novel paradigm for understanding cough. Lancet Respir Med. 2014;2(8):647-656. Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Ribas CD, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 2020;55(1):1901136. Parker SM, Smith JA, Birring SS, Chamberlain-Mitchell S, Gruffydd-Jones K, Haines J, et al. British Thoracic Society clinical statement on chronic cough in adults. Thorax. 2023;78(Suppl 1):S3-S19. Smith JA, Woodcock A. Chronic cough. N Engl J Med. 2006;354(2):136-144. Song WJ, Dupont L, Birring SS, Chung KF, Dąbrowska M, Dicpinigaitis P, et al. Consensus goals and standards for specialist cough clinics: the NEUROCOUGH international Delphi study. ERJ Open Res. 2023;9(6):00618-2023. doi:10.1183/23120541.00618-2023. Song WJ, McGarvey L, Cho PSP, Mazzone SB, Chung KF, editors. Chronic cough. Sheffield: European Respiratory Society; 2025.

Bewegungskomplexität – noch nie gehört? Dann wird es Zeit. Denn wie komplex Du Dich bewegst, entscheidet darüber, wie gut Dein Gehirn altert. Und die meisten Trainingspläne ignorieren das komplett.Am Ende dieser Folge weißt Du, warum vielfältige, kognitiv fordernde Bewegung Dein Gehirn besser schützt als jedes Standardprogramm – und was eine Langzeitstudie mit über 8.600 Menschen über den Zusammenhang von Sportwahl und Lebenserwartung herausgefunden hat.Außerdem: Warum chronische Anspannung Dich blind für die Warnsignale Deines Körpers macht. Bock auf eine kleine Challenge? Dann erfährst Du, wie Du Deinen Körper in wenigen Minuten am Tag sofort fühlbar resilienter bekommst – in 30 Tagen oder weniger.____________*WERBUNG: Infos zum Werbepartner dieser Folge und allen weiteren Werbepartnern findest Du hier.____________Vertiefende InhalteFolge 551: Das Weber-Fechner-GesetzSquat Challenge – 10 Min. Hocken/Tag × 30 TageTiefe Hocke, "Stoppuhr" läuft nur im HockenÜber den Tag verteilen (z.B. 10×1 Min.)Anfangs festhalten erlaubt, Fersen dürfen abhebenEinstieg: 2–3 Min./Tag, langsam steigernZiehen okay – Schmerz nichtHanging Challenge – 7 Min. Hängen/Tag × 30 TageAn Stange hängen, über den Tag verteilenWer nicht frei hängen kann: Füße am Boden lassenProgression: Mit Fußstütze → Frei passiv → Aktiv → EinarmigNicht direkt nach dem AufstehenBei Schulterproblemen vorsichtig startenLiteratur:Schnohr P et al. (2018). Various Leisure-Time Physical Activities Associated With Widely Divergent Life Expectancies: The Copenhagen City Heart Study. Mayo Clin Proc 93(12):1775-85.Rehfeld K et al. (2017). Dancing or Fitness Sport? The Effects of Two Training Programs on Hippocampal Plasticity and Balance Abilities in Healthy Seniors. Front Hum Neurosci 11:305.Rehfeld K et al. (2018). Dance training is superior to repetitive physical exercise in inducing brain plasticity in the elderly. PLoS ONE 13(7):e0196636. ← NEUVerghese J et al. (2003). Leisure activities and the risk of dementia in the elderly. N Engl J Med 348:2508-16.Proske U, Gandevia SC (2012). The proprioceptive senses. Physiol Rev 92(4):1651-97.Schiftan GS et al. (2015). The effectiveness of proprioceptive training in preventing ankle sprains. J Sci Med Sport 18(3):238-44.Raichlen DA et al. (2020). Sitting, squatting, and the evolutionary biology of human inactivity. PNAS 117(13):7115-21.Rojas-Jaramillo A et al. (2024). Impact of the deep squat on articular knee joint structures. Front Sports Act Living.Hartmann H et al. (2013). Analysis of the load on the knee joint and vertebral column with changes in squatting depth. Sports Med 43(10):993-1008.Sikirov D (2003). Comparison of straining during defecation in three positions. Dig Dis Sci 48(7):1201-5.Leong DP et al. (2015). Prognostic value of grip strength: findings from the PURE study. Lancet 386(9990):266-73.García-Hermoso A et al. (2018). Muscular Strength as a Predictor of All-Cause Mortality. Arch Phys Med Rehabil 99(10):2100-13.____________Shownotes und Übersicht aller Folgen.Trag Dich in Marks Dranbleiber Newsletter ein.Entdecke Marks Bücher.Folge Mark auf Instagram, Facebook, Strava, LinkedIn. Hosted on Acast. See acast.com/privacy for more information.

In this episode, we discuss the most important annual updates in the American Diabetes Association Guidelines, Standards of Care 2026, particularly focusing on changes in pharmacotherapy recommendations and the supporting evidence. Key Concepts A few existing agents now have ASCVD risk reduction data in patients with existing ASCVD or high indicators for ASCVD. They are: oral semaglutide and tirzepatide.  SGLT2is are still first-line in patients with diabetes and HF including HFpEF, but SC semaglutide and tirzepatide are now recommended for those with symptomatic HFpEF and obesity due to positive outcomes in this population. The GLP-1RA and dual GLP-1/GIP RA are the preferred agents for weight management in patients with T2DM, but use of GLP-1RA can be considered for weight loss in patients with T1DM. The guideline also better defines recommendations for medication-induced hyperglycemia from immune checkpoint inhibitors, PI3Kɑ (phosphoinositidylinositol 3-kinase α) inhibitors, mTOR inhibitors, and steroids.  References American Diabetes Association. Standards of care in diabetes—2026. Diabetes Care. 2026;49(suppl 1):S1-S377. SOUL study. Darren K. McGuire, Marx N, Mulvagh SL, et al. Oral semaglutide and cardiovascular outcomes in high-risk type 2 diabetes. N Engl J Med. 2025;392(20):2001-2012. doi:10.1056/NEJMoa2501006. SURPASS-CVOT. Nicholls SJ, Pavo I, Bhatt DL, et al. Cardiovascular outcomes with tirzepatide versus dulaglutide in type 2 diabetes. N Engl J Med. 2025;393(24):2409-2420. doi:10.1056/NEJMoa2505928. SUMMIT. Packer M, Zile MR, Kramer CM, et al. Tirzepatide for heart failure with preserved ejection fraction and obesity. N Engl J Med. 2025;392(5):427-437. doi:10.1056/NEJMoa2410027. STEP-HFpEF. Kosiborod MN, Abildstrom SZ, Borlaug BA, et al. Semaglutide in patients with heart failure with preserved ejection fraction and obesity. N Engl J Med. 2023;389(12):1069-1084. doi:10.1056/NEJMoa2306963. STEP-HFpEF DM. Kosiborod MN, Petrie MC, Borlaug BA, et al. Semaglutide in patients with obesity‑related heart failure and type 2 diabetes. N Engl J Med. 2024;390(15):1394‑1407. doi:10.1056/NEJMoa2313917.

This week, we present new research on treatment for muscle-invasive bladder cancer, left atrial appendage closure versus medical therapy for atrial fibrillation, gene-editing approaches for sickle cell disease and β-thalassemia, and the safety of discontinuing beta-blockers after myocardial infarction. We also review GLP-1 receptor agonists and discuss a Clinical Problem-Solving case of a man with progressive confusion. Perspectives explore corporatization; biologic, as opposed to chronologic, aging; and a legal case that could affect mental-health policy.

Lawrence Casalino is a professor of population health sciences at Weill Cornell Medicine. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. L.P. Casalino. Physicians, Corporatization, and the Unmeasured Quality of Care. N Engl J Med 2026;394:1249-1251.

Podcast family, welcome to Quickie #4. This one will be fun: A. Medicine changes, and changes fast. I trained with and learned the Grannum grading placental system (grades 0-III based on ultrasound appearance). Is that still a thing? We recently found a “grade III placenta at 34 weeks” as an incidental finding. Is there specific management considerations for this? Listen in for details. B. What do we do when a patient has “two GBS results” in one pregnancy hat are discordant. Listen in for that as well!1. Jaiman S, Romero R, Pacora P, et al. Disorders of Placental Villous Maturation Are Present in One-Third of Cases With Spontaneous Preterm Labor. Journal of Perinatal Medicine. 2021. 2. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2017. Sentilhes L, Sénat MV, Ancel PY, et al. Prevention of Spontaneous Preterm Birth: Guidelines for Clinical Practice From the French College of Gynaecologists and Obstetricians (CNGOF).3. Brink LT, Roberts DJ, Wright CA, et al. Placental Pathology in Spontaneous and Iatrogenic Preterm Birth: Different Entities With Unique Pathologic Features. Placenta. 2022. 4. Chitlange SM, Hazari KT, Joshi JV, Shah RK, Mehta AC. Ultrasonographically Observed Preterm Grade III Placenta and Perinatal Outcome.International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics. 1990. 5. Mirza FG, Ghulmiyyah LM, Tamim H, et al. To Ignore or Not to Ignore Placental Calcifications on Prenatal Ultrasound: A Systematic Review and Meta-Analysis. The Journal of Maternal-Fetal & Neonatal Medicine : The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2018. 6. Quinlan RW, Cruz AC, Buhi WC, Martin M. Changes in Placental Ultrasonic Appearance. II. Pathologic Significance of Grade III Placental Changes. American Journal of Obstetrics and Gynecology. 1982. 7. Karen M. Puopolo Group B Streptococcal Disease. https://orcid.org/0000-0002-5581-8825; Published February 25, 2026 N Engl J Med 2026;394:896-905ACOG 797

This week, we present new clinical trials on immunotherapy for stage III mismatch repair–deficient colon cancer, early surgery for asymptomatic aortic stenosis, an approach to dengue virus suppression, and advances in gene and prime-editing therapies for rare disorders. We also review minipuberty. We follow the case of a 12-year-old girl with altered mental status and persistent hypoglycemia, and we explore Perspectives on corporate influences on health, vaccine communication, antitrust policy, conflicts of interest, and the meaning of the number needed to treat.

Douglas Opel is a professor in the Department of Pediatrics at the University of Washington School of Medicine. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. D.J. Opel and S.T. O'Leary. Communicating about Vaccines in a Politically Contentious Climate. N Engl J Med 2026;394:1145-1147.

Registered dietitian nutritionist Leyla Muedin discusses a New England Journal of Medicine paper (July 2024, cited via Holistic Primary Care) warning about drug-induced magnesium depletion, especially from diuretics, proton pump inhibitors (e.g., Nexium, Prilosec), and certain antibiotics. She notes magnesium is often not routinely measured despite links between deficiency and cardiovascular, metabolic, and neurological problems, including arrhythmias (AFib, long QT, torsades), endothelial dysfunction, and longer ICU stays. Prevalence estimates range from 7–11% (up to 20%) in hospitalized patients and 2–4% among outpatients, with higher rates among long-term PPI and diuretic users. She reviews symptoms and causes, explains limits of serum magnesium testing, highlights associations with diabetes, alcohol use, low potassium and calcium, and outlines evaluation options and oral repletion approaches, favoring better-absorbed forms like magnesium glycinate over oxide due to diarrhea risk.