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An increase in #Lassafever cases was identified in #Nigeria this year. In this analysis of the infecting #viruses, the predominant mode of transmission appeared to be multiple insertions from local rodent populations rather than sustained person-to-person spread. 
Figure 2: Distribution of Lassa Virus Genetic Diversity in Nigeria. Panel A shows a maximum-likelihood phylogenetic tree of the S segment of the Lassa virus genome. The tree incorporates the genomes reported here from 2015 through 2018, along with 193 previously published genomes from Nigeria and the Mano River Union (the latter belong to lineage IV and are depicted as a single triangle). The new samples are colored according to the season in which they were obtained; the outer ring indicates the geographic regions in which the patients reside. (For samples that were obtained before 2015 and for which geographic region is not known, the geographic region is assumed on the basis of its location in the tree.) The inset shows part of lineage II, in which known nosocomial transmissions are indicated with asterisks. (An apparent human-to-human transmission chain in the inset is not supported by time-aware phylogeny analysis: the times to the most recent common ancestor in the chain are between 10 and 20 years.) Panel B shows a map of Nigeria in which the numbers of new genomes are indicated for each state; for seven samples, the state was unknown. Colors are the same as those used in the outer ring in Panel A. We were unable to confirm fine-scale geographic locations of the samples originating from Kogi State, although all samples clustered within the southwestern sublineage of lineage II. Panel C shows a time-aware #phylogeny of the part of lineage II that is shown in the inset in Panel A. Patients who acquired the #infection from a known nosocomial transmission event are indicated with an asterisk, and two possible but unconfirmed transmissions are indicated with number signs. 
Visit the link in our bio to read the brief report Genomic Analysis of Lassa Virus during an Increase in Cases in Nigeria in 2018. #infectiousdisease #viralinfections #globalhealth #meded #medicaleducation #clinicalpractice
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An increase in #lassafever cases was identified in #nigeria this year. In this analysis of the infecting #viruses , the predominant mode of transmission appeared to be multiple insertions from local rodent populations rather than sustained person-to-p

New England Journal of Medicine
Take the latest Image Challenge: A 35-year-old male presented to the emergency #psychiatry service with paranoid delusions and was found to have patchy, irregular #alopecia of the scalp. What is the most likely diagnosis? Tap the link in our bio to take this week's Image Challenge, or head to NEJM.org/image-challenge. 
#primarycare #clinicalpractice #medical #meded #medicaleducation #medicine #emergencymedicine
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Take the latest Image Challenge: A 35-year-old male presented to the emergency #psychiatry service with paranoid delusions and was found to have patchy, irregular #alopecia of the scalp. What is the most likely diagnosis? Tap the link in our bio to t

New England Journal of Medicine
The Undiagnosed Diseases Network, an @nihgov-funded network of seven U.S. sites, accepted 601 patients for evaluation over a 20-month period. Of the 382 patients who had a complete evaluation, 132 (35%) received a diagnosis; 15 of the diagnoses (11%) were made by clinical review alone and 98 (74%) by #exome or #genome sequencing. 
Figure 1: Drosophila Study of NR5A1 p.R92W Variant. Panels A through I show preparations of cuticles from first-instar drosophila larvae. Tap the link in our bio to read the Original Article Effect of Genetic Diagnosis on Patients with Previously Undiagnosed Disease. #ASHG18 #genetics #primarycare #clinicalpractice #medical #meded #medicalscience #medicaleducation #science
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The Undiagnosed Diseases Network, an @nihgov -funded network of seven U.S. sites, accepted 601 patients for evaluation over a 20-month period. Of the 382 patients who had a complete evaluation, 132 (35%) received a diagnosis; 15 of the diagnoses (11%)

New England Journal of Medicine
After a long struggle, the #healthcare team won a victory that bore a frightening resemblance to an ultimatum, and Ms. S.’s sons signed a DNR order for their 70-year-old mother. I chalked up the nauseated feeling in the pit of my stomach to my inexperience in the field. Tap the link in our bio to read A Seat at the Table, by Lisa Caulley, M.D., M.P.H. 
#primarycare #clinicalpractice #medical #meded #medicaleducation #medicalethics #endoflifecare #medicine
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After a long struggle, the #healthcare team won a victory that bore a frightening resemblance to an ultimatum, and Ms. S.’s sons signed a DNR order for their 70-year-old mother. I chalked up the nauseated feeling in the pit of my stomach to my inex

New England Journal of Medicine
Clinical Implications of Basic Research: Neuroblastoma and Histone Demethylation. 
A recent study of inhibitors of histone demethylases in vitro and in an animal model of neuroblastoma underscores the potential of a new pharmacologic approach to treatment. This illustration shows gene expression, histone methylation, and #tumor growth. Histone H3K27 methylation status is regulated by the addition of methyl (Me) groups by the enzyme EZH2 and demethylation by UTX and JMJD3 histone demethylases (Panel A). Lochmann et al. recently reported that an experimental drug called GSK-J4 inhibits histone demethylase, tipping the balance in favor of increased methylation at histone H3K27 (Panel B). In mouse models of #neuroblastoma, this increase in methylation resulted in increased differentiation and diminished tumor growth.

#neurology #braintumor #childhoodcancer #childhooddiseases #cancer #cancerresearch #meded #medicaleducation #medicalscience #science
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Clinical Implications of Basic Research: Neuroblastoma and Histone Demethylation. A recent study of inhibitors of histone demethylases in vitro and in an animal model of neuroblastoma underscores the potential of a new pharmacologic approach to trea

New England Journal of Medicine
Images in Clinical Medicine: Radial Fracture Due to Parathyroid Carcinoma. 
A 45-year-old man presented to the #orthopedic clinic with pain in his left forearm that he had first felt while gripping a railing 1 day earlier. A plain #radiograph of the left arm showed a diaphyseal #radialfracture (Panel A, arrow) and a diffusely low-density, mottled appearance of the radius and ulna. Two months before presentation, the patient had received a diagnosis of primary #hyperparathyroidism, with an intact parathyroid hormone level of 3590 pg per milliliter (reference range, 10 to 65) and a serum calcium level of 13.0 mg per deciliter (3.25 mmol per liter; reference range, 8.5 to 10.2 mg per deciliter [2.12 to 2.55 mmol per liter]). He underwent #parathyroidectomy and was found to have parathyroid #carcinoma, which is a rare cause of primary hyperparathyroidism and can manifest as markedly elevated parathyroid hormone levels. Tap the link in our bio to read the full clinical case. 
#primarycare #clinicalpractice #medical #meded #medicalscience #medicaleducation #orthopedics #oncology #endocrinology #bonedisease
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Images in Clinical Medicine: Radial Fracture Due to Parathyroid Carcinoma. A 45-year-old man presented to the #orthopedic clinic with pain in his left forearm that he had first felt while gripping a railing 1 day earlier. A plain #radiograph of the

New England Journal of Medicine
Data-organizing methods have been in place for centuries, but very large #data sets have come into being relatively recently. The authors describe terminologies, ontologies, and the changes needed to permit analyses of “big data” that might better serve medical decision making. 
Figure 4: Ontology-Based Mechanistic Classification of Disease. Well-structured #clinicaldata can be readily integrated with discovery research data by using ontologies, which make clinical and basic #science observations “computable” in a way that reflects present knowledge and allows new inferences. Integrating the two streams of data enables a mechanistic classification of disease across many data types, making a more refined and dynamic classification of patients possible. Tap the link in our bio to read the full review Classification, Ontology, and Precision Medicine. #ontology #precisionmedicine #bigdata #genetics #clinicalmedicine #biomedical #medicalscience #meded #scientificresearch
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Data-organizing methods have been in place for centuries, but very large #data sets have come into being relatively recently. The authors describe terminologies, ontologies, and the changes needed to permit analyses of “big data” that might bette

New England Journal of Medicine
Case Records of the Massachusetts General Hospital: A 37-year-old man was admitted to the surgical ICU because of a self-inflicted #gunshotwound to the face. 
Figure 2: #CTScan of the Face. A 3D reconstruction of the face (Panel A) shows the #entrywound in the submental region, the estimated trajectory of the #bullet (red arrow), and the #exitwound in the middle of the face. A 3D reconstruction of the facial bones (Panel B) shows loss of the mandibular symphysis, left mandibular parasymphysis, anterior maxillary alveolar ridge, and anterior nasal aperture. Another 3D reconstruction of the facial bones (Panel C) shows scattered bullet fragments along the wound, extending into the paranasal sinuses and right orbit. An axial image (Panel D) shows scattered bullet and bone fragments in the nasal aspect of the right orbit; these acted as secondary projectiles and caused rupture of the globe of the right eye. Coronal images (Panels E and F) show severe comminution of the bones of the middle of the face, with bone fractures extending to the intracranial compartment through the cribriform plate of the ethmoid sinus (Panel E) and the right frontal sinus (Panel F). Visit the link in our bio to read the case details and the management decisions that were made.

#surgery #depression #trauma #primarycare #clinicalpractice #medical #meded #medicalscience #medicaleducation #gunviolence #gunshot #intensivecare
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Case Records of the Massachusetts General Hospital: A 37-year-old man was admitted to the surgical ICU because of a self-inflicted #gunshotwound to the face. Figure 2: #ctscan of the Face. A 3D reconstruction of the face (Panel A) shows the #entrywo

New England Journal of Medicine
Images in Clinical Medicine: Woltman’s Sign of Hypothyroidism. ⠀
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A 53-year-old man presented to the #endocrinology clinic with fatigue and sensitivity to cold. A physical examination showed delayed relaxation of the ankle jerk reflex — Woltman’s sign, as seen in this video — and laboratory evaluation confirmed a diagnosis of primary hypothyroidism. Woltman’s sign is a neurologic manifestation of #hypothyroidism. This delayed relaxation can also be associated with pregnancy, anorexia nervosa, diabetes mellitus, and advanced age. Tap the link in our bio for the full clinical case. ⠀
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#primarycare #clinicalpractice #medical #meded #medicalscience #medicaleducation #thyroiddisease #neurology #neuroscience
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Images in Clinical Medicine: Woltman’s Sign of Hypothyroidism. ⠀ ⠀ A 53-year-old man presented to the #endocrinology clinic with fatigue and sensitivity to cold. A physical examination showed delayed relaxation of the ankle jerk reflex — Wolt

New England Journal of Medicine
Medicine and Society: Men’s Fear of Mentoring in the #MeToo Era — What’s at Stake for Academic Medicine? 
In response to the #MeToo and #TimesUp movements, some men in positions of power say they are afraid to participate in #mentoring relationships with women. This response has serious consequences for women’s career advancement. Tap the link in our bio for the full article. 
#meded #medicaleducation #medicalethics #womeninmedicine #mentorship
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Medicine and Society: Men’s Fear of Mentoring in the #metoo Era — What’s at Stake for Academic Medicine? In response to the #metoo and #timesup movements, some men in positions of power say they are afraid to participate in #mentoring relation

New England Journal of Medicine
Clinical Practice: Acne Vulgaris. ⠀
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Inflammatory #acne is commonly treated with combination therapy including a retinoid and benzoyl peroxide. For moderate-to-severe cases, an oral #antibiotic is also recommended, typically for no more than 3 to 4 months. ⠀
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Panel A shows a patient with mild acne, with limited papules and pustules and a few closed comedones. Panel B shows a patient with moderate acne, with many papules and notable postinflammatory erythema and pitted scarring. Panel C shows a patient with moderate inflammatory and comedonal acne, with postinflammatory hyperpigmentation noted on the forehead, cheek, and chin. Panel D shows a patient with severe acne, with confluent papules, pustules, and deep nodules.⠀
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#dermatology #pediatrics #primarycare #clinicalpractice #medical #meded #medicalscience #medicaleducation #medicine
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Clinical Practice: Acne Vulgaris. ⠀ ⠀ Inflammatory #acne is commonly treated with combination therapy including a retinoid and benzoyl peroxide. For moderate-to-severe cases, an oral #antibiotic is also recommended, typically for no more than 3 t

New England Journal of Medicine
Images in Clinical Medicine: Brittle Nails and Hair Loss in Hypothyroidism. 
A 41-year-old woman presented to the #endocrinology clinic with nail changes that had occurred over several months and hair loss that had progressively worsened over 2 years. Physical examination revealed dry skin, thickened and brittle nails with horizontal ridges (Panel A), marked #hairloss with coarse hair (Panel B), and a diffusely enlarged thyroid gland. The results of laboratory evaluations were notable for a thyrotropin level of 30.5 μIU per milliliter (reference range, 0.5 to 5.0) and a serum free thyroxine level of 0.4 ng per deciliter (5.7 pmol per liter; reference range, 0.9 to 1.7 ng per deciliter [11.6 to 21.9 pmol per liter]). Findings from further testing showed an antithyroglobulin antibody level of 793 IU per milliliter (reference value, ≤55) and an antithyroid peroxidase antibody level of 2439 IU per milliliter (reference value, ≤9). Ultrasonography revealed diffuse goiter with heterogeneous internal echogenicity. Hypothyroidism due to Hashimoto’s (chronic lymphocytic) #thyroiditis was diagnosed. #Hypothyroidism should be considered in the differential #diagnosis of thickened and brittle nails and hair loss, although this extreme presentation is atypical.
#primarycare #clinicalpractice #medical #meded #medicalscience #medicaleducation #dermatology #thyroiddisease
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Images in Clinical Medicine: Brittle Nails and Hair Loss in Hypothyroidism. A 41-year-old woman presented to the #endocrinology clinic with nail changes that had occurred over several months and hair loss that had progressively worsened over 2 years

New England Journal of Medicine