England Journal Of Medicine Research Articles

Hickam's Dictum: An Analysis of Multiple Diagnoses.

Hickam's dictum ("a patient can have as many diseases as he damn well pleases") has been touted as a counterargument to Ockham's razor, which enjoins clinicians to seek a single, simple, or unifying diagnosis. Yet the phenomenon of multiple diagnoses has not been formally analyzed. We evaluated multiple diagnoses using three methods of inquiry: (1) a review of 83 case reports; (2) a review of 220 cases from the New England Journal of Medicine; and (3) an online survey of providers' intuitions. Eighty-three published case reports claimed to instantiate Hickam's dictum or violate Ockham's razor. All reported a primary diagnosis that explained the presenting illness, and one or more additional diagnoses which could be classified into four categories: (1) an incidentaloma (n = 21; 25.3%); (2) a pre-existing disease (n = 26; 31.3%); (3) a disease causally linked to the primary diagnosis (n = 33, 39.8%); and (4) a causally unrelated second disease contributing to the acute presentation (n = 3, 3.6%). Among 220 cases from the New England Journal of Medicine, all reported a unifying final diagnosis. In an online survey, 265 respondents recruited using social media evaluated four hypothetical cases with multiple diagnoses representing this categorization scheme. A majority of respondents (79%; 95% CI, 74-84%) chose the case representing category 4 - a coincident, causally unrelated second diagnosis - as the most unlikely or surprising diagnostic combination. Multiple diagnoses commonly occur. However, the majority of the multiple diagnoses we analyzed were causally linked, or represented incidentalomas or known pre-existing diseases. These diagnostic combinations were unsurprising to a majority of surveyed providers. We show that multiple diagnoses can be arranged in a framework that considers time, probability, and causation. This framework reconciles the alleged conflict between Hickam's dictum and Ockham's razor and has greater practical and pedagogical utility.

Persistent ethnic disparities in authorship within top European and North American medical journals: a serial cross-sectional analysis

ObjectivesWe examined the ethnic origin of authors who published research articles in leading medical journals over the past 2 decades. Study Design and SettingWe carried out a serial cross-sectional analysis of first and last authors who published original research articles in the British Medical Journal, Lancet, Journal of the American Medical Association, and New England Journal of Medicine in 2002, 2012, and 2022. The main outcome was the change in proportion of authors over time according to ethnic origin (Anglo, North/West European, South/West European, Asian, Arab and Middle Eastern, African), gender (male, female), and institutional affiliation in percentage points. ResultsMost authors were of Anglo descent (44%), although the proportion of non-European authors grew between 2002 and 2022. East Asian, South Asian, and Arab and Middle Eastern last authors accounted for a greater proportion of authors over time, gaining between 3 and 6 percentage points, while African authors made no gains. Gains were gender-specific, with non-European men gaining 8 points as first and last authors, but non-European women gaining 5 points as last authors only. Most non-European authors were affiliated with North American (42.9%) or European (22.4%) institutions, while non-European authors from other institutions did not make meaningful gains over time. ConclusionEthnic diversity of authors in leading medical journals has increased somewhat over time, but non-European men account for most of the gains. Non-European women have yet to make comparable advancement as authors.

COVID-19 vaccinations and their side effects: a scoping systematic review.

Introduction: The COVID-19 virus has impacted people worldwide, causing significant changes in their lifestyles. Since the emergence of the epidemic, attempts have begun to prepare a vaccine that can eliminate the virus and restore balance to life in the entire world. Over the past two years, countries and specialized companies have competed to obtain a license from the World Health Organization for the vaccines that were discovered. After the appearance of vaccines in the health community, comparisons and fears of their side effects began, but people don't get an answer to the question of which is the best vaccine. Methods: IEEE Xplore, ScienceDirect, the New England Journal of Medicine, Google Scholar, and PubMed databases were searched for literature on the COVID-19 vaccine and its side effects. we surveyed the literature on the COVID-19 vaccine's side effects and the sorts of side effects observed after vaccination. Depending on data from the literature, we compared these vaccines in terms of side effects, then we analyzed the gaps and obstacles of previous studies and made proposals to process these gaps in future studies. Results: Overall, 17 studies were included in this scoping systematic review as they fulfilled the criteria specified, the majority of which were cross-sectional and retrospective cross-sectional studies. Most of the side effects were mild, self-limiting, and common. Thus, they usually resolve within 1-3 days after vaccination. Factors associated with higher side effects included advanced age, allergic conditions, those taking other medications (particularly immunosuppressive ones), those with a history of type II diabetes, heart disease, hypertension, COVID-19 infection, and female sex. Our meta-analyses also found that mRNA vaccines looked to be more effective, while inactivated vaccinations had fewer side effects. Conclusion: This review shows that the COVID-19 vaccine is safe to administer and induces protection.

Medical Toxicology vs. Emergency Medicine and Internal Medicine — Are We Really Full of Case Reports?

IntroductionCase reports are perceived as having diminished value relative to other study designs. It has been said that medical toxicology (MT) is based largely upon case report literature and thought to be unique in this regard. We sought to quantify recent MT publication of case reports compared with top periodicals from emergency medicine (EM) and internal medicine (IM) journals.MethodsA retrospective review examined 5 years of articles in 6 U.S.-based medical journals–MT (Journal of Medical Toxicology, Clinical Toxicology), EM (Annals of Emergency Medicine, Journal of Emergency Medicine), and IM (JAMA Internal Medicine, New England Journal of Medicine) was performed using on-line resources. Every article in each issue was categorized into Case report vs. Research and Analysis articles vs. Excluded. “Case report” was defined as one (or ≤ 5) individual patients, one patient’s data, etc. Total articles per issue were reported after removing Excluded items.ResultsBetween 2018 and 2022, these 6 periodicals published 522 issues; with 2644 case reports; and 8246 total included articles. Comparison of MT case reports vs. EM revealed a significant difference and odds (Odds Ratio = 1.7, (95% CI: [1.49, 2.03], p < 0.001); MT compared with IM was not significantly different (Odds Ratio = 1.1, (95% CI: [0.96, 1.30], p = 0.150). The percent of case reports increased in the IM and EM journals compared with a relative decrease in the MT journals. Cumulative case report precents were consistently greater in EM and IM than in MT.Conclusion In the past 5 years, MT journals published fewer and had a declining trend of case reports compared with leading EM and IM journals. Future research is needed to determine the effect on MT practice resulting from the diminished body of case report literature.

Trends and Prospects of Low-Density Lipoprotein Cholesterol in Stroke: A Bibliometric Analysis.

Management of low-density lipoprotein cholesterol (LDL-C) in stroke is a crucial component of cardiovascular disease care. Recent years have seen substantial progress in understanding and managing LDL-C in the context of stroke. This study utilized bibliometric methods to analyze and synthesize trends in this area over the past decade, incorporating 2,841 publications from the Web of Science database. The analyses included trend topic analysis, co-authorship analysis, and co-citation analysis. The findings indicate that research had predominantly concentrated on epidemiological studies related to pharmacological management strategies. Future research is expected to continue exploring lipid-lowering therapies, including both established treatments like statins and newer drugs such as proprotein convertase subtilisin-kexin type 9 inhibitors. Assessing residual cholesterol and employing Mendelian randomization techniques may become potential research hotspots. The New England Journal of Medicine is the most globally influential journal, while Circulation holds the most influence within the field, and Atherosclerosis ranks as the most prolific. International collaboration in this research area was strong between the USA and England, followed by the USA and China. However, collaboration between productive institutions in the USA and China remains limited, highlighting the need to strengthen partnerships between these institutions to further advance the field.

Mapping a Decade (2014-2024) of Research on Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A Visual Analysis with CiteSpace and VOSviewer.

Acute Respiratory Distress Syndrome (ARDS) stands as a primary cause of mortality among critically ill patients. Extracorporeal Membrane Oxygenation (ECMO) is increasingly employed in the rescue therapy of ARDS patients. However, the current status of research in the field of ECMO-assisted ARDS remains unclear. This research aims to categorize and evaluate the literature regarding Extracorporeal Membrane Oxygenation (ECMO) support for Acute Respiratory Distress Syndrome (ARDS), offering a comprehensive analysis of bibliometric properties, research hotspots, and developmental trends within the domain of ECMO-assisted ARDS. A literature search was conducted for ECMO-assisted support for patients with ARDS in the Web of Science Core Collection (WoSCC) database from 2014 to 2024. We employed visualization tools such as CiteSpace and VOSviewer to explore and assess connections among nations, institutions, researchers, and co-cited journals, authors, references, and keywords. This study included 1739 publications. The United States leads in publication volume with Columbia University at the forefront of ECMO research. Intensive Care Medicine has been identified as the most cited journal in this field. Alain Combes from France stands out as a key contributor, particularly in his 2018 publication in the New England Journal of Medicine, which is the most cited work in the discipline. Furthermore, keyword analysis identified three distinct research phases: examining complications associated with ECMO therapy, exploring optimal strategies for mechanical ventilation under ECMO support, and compiling insights into the application of ECMO in treating COVID-19 patients and in the development of predictive models for patient outcomes. Using bibliometric visualization techniques, this study revealed significant progress in the use of ECMO for treating ARDS respiratory support, evaluated the impact of these findings, and outlined potential areas for future studies.

Exploring the differences in syntactic complexity between lay summaries and abstracts: A case study of The New England Journal ofMedicine

This study explores the difference in syntactic complexity between lay summaries (LSs) and scientific abstracts holistically and across their common rhetorical moves. Twenty-three syntactic complexity indices were employed to analyze a corpus of LSs and their counterpart abstracts from TheNew England Journal of Medicine. The analyses revealed that the LSs employed significantly shorter production units, more subordinate structures, more verb phrases, but fewer coordinate phrases and fewer complex nominals. Notably, the number of specific noun modifiers within complex nominals did not differ significantly between the two groups, indicating a comparable level of nominal sophistication. Moreover, we observed significant differences in the syntactic complexity of sentences realizing the common rhetorical moves across the two genres. Specifically, sentences introducing background and presenting results were syntactically simpler in the LSs, whereas the syntactic complexity of sentences summarizing methods and drawing conclusions remains largely consistent across both groups. The study contributes to a deeper understanding of the linguistic features of LSs and offers useful implications for LS writing practice.

Advancing Research on Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: A Scientometric Analysis.

Atherosclerosis is characterised by the accumulation of fatty deposits and plaque as a result of a continuously high level of low-density lipoprotein cholesterol (LDL-C) in the blood. The primary objective of this research is to assess the current status of knowledge, research endeavours and developmental trajectories about proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in correlation with atherosclerosis treatment. Additionally, this study aims to compile bibliometric and scientometric investigations within this domain through rigorous scientometric analysis. Analysing the bibliometric landscape and global research trends associated with PCSK9 inhibitors can contribute valuable insights into comprehending atherosclerosis. This is exemplified by examining publications within the Web of Science Core Collection (WOSCC) database from 2008 to 2022. Citespace was used for frequency, co-occurrence, co-citation, grouping and burst analysis, and Microsoft Excel was used to manage descriptive datasets. Eight hundred eighty-five publications available from WOSCC database between the years 2008 and 2022 were extracted and examined. Over the period, 3,138 collaborating institutions from 87 countries, a staggering 7,750 writers involved and 325 distinct journals published about PCSK9 inhibitors studies. Among authors, Sabatine et al. and the journal The New England Journal of Medicine has had the most significant impact. Lipid-lowering therapy and bempedoic acid are the most prominent topical clusters associated with PCSK9 inhibitors, and the most often used keywords are efficacy, safety and PCSK9 inhibitors. We believe this is the first comprehensive analysis of PCSK9 inhibitors research and publications conducted using Scientometric. These results demonstrate the nascence of PCSK9 inhibitors research. They may encourage a wide range of stakeholders, particularly early career researchers from various disciplines, to work together in the future.

A Review of Authorship Inflation and Multicenter Collaboration Trends in Orthopedic, Medical, and Surgical Journals Over the Last 60 Years.

Over the past six decades, authorship numbers in academic publications have increased significantly, a phenomenon known as authorship inflation. This study aims to analyze comparative authorship trends and the influence of multicenter collaborations across major orthopedic, medical, and surgical journals. We reviewed metadata from The New England Journal of Medicine (NEJM), Annals of Surgery (AS), and The Journal of Bone and Joint Surgery (JBJS) from January 1, 1960, to December 31, 2019. The number of authors per publication, the prevalence of multicenter studies, and their correlation were analyzed. Data was visualized using heat maps and box plots, and trends were statistically tested using the Jonckheere-Terpstra, Mann-Kendall, and generalized linear mixed models (GLMMs). A total of 73,062 articles were analyzed, with 1,190 articles identified as originating from multicenter studies. The number of multicenter trials was found to have increased significantly over time (p < 0.001), plateauing in NEJM but continuing to rise in JBJS and AS. There was a significant increase in authorship numbers per publication over time, across all journals (p < 0.0001). There was a significant statistical correlation (p < 0.0001) as indicated by the coefficient of determination (r2), for the association between the proportion of publications with >10 authors and the proportion of multicenter publicationsacross all three journals. Authorship inflation in academic publishing may be attributable to the rise in multicenter collaborations. The rate of increase in authorship was more pronounced in medical and surgical journals compared to orthopedic journals, reflecting differing trends across specialties. These findings highlight the evolving nature of research collaboration and authorship practices in academic publishing.

Reported community engagement in health equity research published in high-impact medical journals: a scoping review

ObjectiveTo assess reported community engagement in the design and conduct of health equity-focused articles published in high-impact journals.DesignScoping review follows guidance from the Joanna Briggs Institute and Preferred Reporting Items...

A bibliometric analysis of cystic fibrosis transmembrane conductance regulators.

Cystic fibrosis (CF), a multisystem disease primarily affecting the lungs, arises due to pathogenic mutations in the CF transmembrane conductance regulator (CFTR) gene. This study embarked on a bibliometric analysis to survey the use of CFTR modulators in CF treatment. Utilizing the Scopus database, a comprehensive search was executed, incorporating terms related to CF and CFTR modulators. Various document types up to July 19, 2023, were included, with citation counts forming the basis of our analyses. Trends, contributor countries, leading institutions, top authors, journals, keywords, and annual citation trends were evaluated. Our search retrieved 2317 records, predominantly articles. The United States dominated in both publications and citations, followed by the United Kingdom. The University of Alabama, Birmingham, and Vertex Pharmaceuticals, Boston, were among the top institutions. Rowe S.M. was identified as a top-cited author. The Journal of Cystic Fibrosis emerged as the leading journal in terms of publication volume, while the New England Journal of Medicine had the highest citation count. The most-cited article addressed a CFTR potentiator's efficacy in patients with the G551D mutation. The keyword "Cystic fibrosis" appeared most frequently. This bibliometric analysis underscores the significant research focus on CF, especially concerning CFTR modulators. The results highlight the pivotal role of certain countries, institutions, authors, and journals in the progression of CF research, offering insights into current trends and future research directions.

Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in medicine

Recent studies indicate that Generative Pre-trained Transformer 4 with Vision (GPT-4V) outperforms human physicians in medical challenge tasks. However, these evaluations primarily focused on the accuracy of multi-choice questions alone. Our study extends the current scope by conducting a comprehensive analysis of GPT-4V’s rationales of image comprehension, recall of medical knowledge, and step-by-step multimodal reasoning when solving New England Journal of Medicine (NEJM) Image Challenges—an imaging quiz designed to test the knowledge and diagnostic capabilities of medical professionals. Evaluation results confirmed that GPT-4V performs comparatively to human physicians regarding multi-choice accuracy (81.6% vs. 77.8%). GPT-4V also performs well in cases where physicians incorrectly answer, with over 78% accuracy. However, we discovered that GPT-4V frequently presents flawed rationales in cases where it makes the correct final choices (35.5%), most prominent in image comprehension (27.2%). Regardless of GPT-4V’s high accuracy in multi-choice questions, our findings emphasize the necessity for further in-depth evaluations of its rationales before integrating such multimodal AI models into clinical workflows.

Trastuzumab deruxtecan in HER2-mutant non-small-cell lung cancer: a plain language summary of the DESTINY-Lung01 study.

This is a summary of the publication about the DESTINY-Lung01 study, which was published in the New England Journal of Medicine in September 2021. The DESTINY-Lung01 study includes 181 adults with metastatic non-small-cell lung cancer (NSCLC) that could not be treated with surgery and who have had previous standard anticancer treatment. The publication includes information and results about 91 of the 181 study participants. These 91 participants had HER2-mutant NSCLC. Researchers wanted to learn if the drug trastuzumab deruxtecan (T-DXd) could help treat participants with HER2-mutant NSCLC. At the time of this publication, this study is ongoing. Results from the study showed that 55% of participants responded to treatment with T-DXd. The median length of time participants continued to respond to T-DXd was 9.3months.After receiving T-DXd, 92% of participants had disease control. After receiving T-DXd, half of the participants lived for at least 17.8months. After receiving T-DXd, half of the participants lived for 8.2months before their cancer got worse.During the study, 97% of participants had drug-related adverse events, with nausea being the most common. There were 20% of participants with serious drug-related adverse events. Based on these results, T-DXd could be a treatment option for people with HER2-mutant NSCLC that has been previously treated.Clinical Trial Registration: NCT03505710 (DESTINY-Lung01) (ClinicalTrials.gov).

Bibliometric and visual analysis of immunisation associated with acute kidney injury from 2003 to 2023.

This study aims to conduct a detailed bibliometric and visual analysis of acute kidney injury (AKI) and immune-related research conducted over the past two decades, focusing on identifying emerging trends and key areas of interest. The Web of Science Core Collection (WoSCC) was utilised for the meticulous examination of various parameters including publication volume, authorship, geographic distribution, institutional contributions, journal sources, prevalent keywords and citation frequencies. Data were intricately visualised and interpreted using VOSviewer, CiteSpace and Excel 365 software. Analysis of the WoSCC database revealed 3,537 articles on AKI and immunisation, originating from 94 countries and regions, involving 3,552 institutions and authored by 18,243 individuals. Notably, the top five countries contributing to this field were the United States, China, Germany, Italy and the United Kingdom, with the United States leading with 35.76% of total publications. Among the 3,552 contributing institutions, those in the United States were predominant, with Harvard University leading with 134 papers and 3,906 citations. Key journals driving productivity included Frontiers in Immunology, Kidney International, Journal of the American Society of Nephrology and International Journal of Molecular Sciences, with Kidney International being the most cited, followed by Journal of the American Society of Nephrology and New England Journal of Medicine. Prominent authors in the field included Ronco Claudio, Okusa Mark D and Anders, Hans-Joachim. Co-citation clustering and timeline analysis highlighted recent research foci such as COVID-19, immune checkpoint inhibitors, regulated necrosis, cirrhosis and AKI. Keyword analysis identified "inflammation," "ischaemia-reperfusion injury," "sepsis," "covid-19," and "oxidative stress" as prevalent terms. This study provides the first bibliometric analysis of AKI and immune research, offering a comprehensive overview of research hotspots and evolving trends within the field.

The endocrine basis of the cardio-renal axis: New perspectives regarding corin.

The central role of natriuretic peptides (NPs) in the complex cardio-renal integrated physiology and organ failure has been revealed over the last four decades. Atrial natriuretic peptide (ANP), the oldest representative of the NPs family, is produced through conversion of proANP to the mature peptide by corin, a trans-membrane protease localized to the cardiac myocyte membrane. Similarly, brain natriuretic peptide (BNP) is generated by furin, which cleaves proBNP to BNP in myocytes. Though the components of NPs system, their synthesis and target organs are well established, understanding their role in the interplay between the heart and the kidney is steadily evolving. In this context, Feldman etal. (New England Journal of Medicine, 389, 1685) recently described patients with hypertension, cardiomyopathy, atrial arrhythmia and left atrial fibrosis, associated with a homozygous loss-of-function variant of the gene encoding corin (Cor-/-). Notably, reduced baseline urinary electrolyte and creatinine excretion have been observed in one of the studied patients. This renal excretory functional impairment could be attributed to the lack of cardiac-derived ANP in these patients, as implied by Feldman etal. Yet, in this mini-review we suggest that this aberrant renal manifestation may principally stem from lack of local ANP production at renal tissue, as corin is normally expressed in proximal tubules, Henle's loop and collecting ducts, with locally produced ANP provoking Na+ and water exertion. Collectively, it seems that beside the classic well-established cardio-renal axis, the renal NPs system functions as local endocrine machinery in the regulation of sodium excretion.

Publication of observational studies making claims of causation over time

To examine methodology characteristics over time and investigate research impact before and after the start of the COVID-19 era, we analyzed original articles published in The New England Journal of Medicine between October 26, 2017 and August 27, 2022. April 1, 2020 was used as the defining date dividing before and after the COVID-19 era. Out of 1051 original articles, 515 (49 %) were before and 536 (51 %) were after the COVID-19 era. Two independent reviewers categorized and reconciled methodology into groups: “randomized trial” (715 articles), “uncontrolled experimental study” (128), “descriptive observational study” (168), and “observational study making a causal claim” (40). We extracted subsequent citations and Altmetric data for each article to assess impact.The median number of social media shares was 2272 (IQR: 743–7821) for observational studies making a causal conclusion, compared to 306 (IQR: 70–606) for randomized trials (p-value=<0.001). The median Altmetric score for randomized COVID-19 trials (2421, IQR: 1063–3920) was not significantly different than that of COVID-19 observational studies making a causal claim (2583, IQR: 1513–6197, p-value = 0.42), but it was significantly lower than descriptive observational COVID-19 studies (4093, IQR: 2545–6823, p-value = 0.04).We conclude that there has been a steady increase in the number and percentage of observational studies that make causal conclusions about the efficacy of an intervention. Research concerning COVID-19, regardless of methodology, has seen a sharp rise in dissemination as measured through Altmetric's social media score and subsequent citations.

Higher autism risk with valproate than topiramate, lamotrigine

A cohort study examining both publicly and commercially insured individuals has found that prenatal exposure to topiramate or lamotrigine is associated with lower risk of childhood autism compared with exposure to valproate. Study results were largely unchanged in analyses limited to women who received the medications late in pregnancy. Results were published March 21/28, 2024, in The New England Journal of Medicine.

Rethinking the academic accounting research model

Current academic incentive systems primarily reward accounting faculty for publishing research articles in elite journals. Faculty members decide what research questions to address and what research methods to use to investigate those re-search questions. Regulators, accounting service firms, and practicing accountants have little input about which research questions are investigated, how the research is conducted, and how and where the results are disseminated. This current ap-proach often results in financial accounting and auditing research that is not rele-vant to the practice of accounting. This commentary proposes a market-driven approach to the conduct of financial and auditing accounting research similar to that used in the medical sciences where pharmaceutical companies and govern-mental entities determine the most pressing medical issues. Besides university-sponsored research, faculty members in the medical sciences apply for grants to support research targeted at improving the treatment of these medical issues, and relevant research findings are quickly disseminated through highly-regarded peer-reviewed outlets such as The New England Journal of Medicine, The Journal of the American Medical Association, the British Medical Journal, and The Lancet so doctors and other medical professionals may quickly implement them into practice.

A comprehensive analysis of patient demographics and disparities in contemporary oncology clinical trials (2022-2023).

e13748 Background: Overcoming disparities in cancer research is a major challenge that needs to be prioritized in clinical trials in oncology. In this study, we aimed to assess the current representation of patient demographics in phase 2 and 3 clinical trials in oncology to illuminate healthcare inequities during clinical trial recruitment. Methods: We identified published phase 2 and phase 3 oncology studies in five medical journals (New England Journal of Medicine, Journal of Clinical Oncology, Lancet, Lancet Oncology, and JAMA Oncology). We extracted data on patient demographics including sex, age, race, and ethnicity. We also extracted information on trial sponsorship (industry vs investigator initiated). Results: We included 381 articles published between 2022 and 2023 (108 investigator-initiated; 273 industry-sponsored). Details on age groups (&lt;65 vs &gt;65) were available in 149 studies (n=78,523 patients) including 47,192 (60.1%) &lt; 65; and 31,331 (39.9%) &gt;65. Data on gender were available in 373 studies (n=159,836 patients) including 73,308 (45.9%) males and 86,526 (54.1%) females (2 patients were listed as other). Race was reported in 214 studies (n=92,562) including 65,876 Caucasian (71.2%), 3,428 (3.7%) Black, 18,235 (19.7%) Asian, and 5,023 (5.4%) other/missing. Ethnicity data were available in 52 studies including 2,570 Hispanics (12.4%) and 18,234 non-Hispanics or unknown (87.6%). Conclusions: While there are efforts being made to diversify the recruitment of clinical trials, inequities in trial recruitment remains a major issue. Caucasian and younger patients represented the majority of patients, which may not be reflective of real-world practice. There is an important need to focus on increasing enrollment of underrepresented populations and understanding barriers to enrollment.

Controversy on the CONVINCE study findings: the PRO take.

The CONVINCE study, recently published in the New England Journal of Medicine, reveals a groundbreaking 23% reduction in the relative risk of all-cause mortality among end-stage kidney patients undergoing high convective volume hemodiafiltration. This significant finding challenges the conventional use of high-flux hemodialysis and offers hope for improving outcomes in chronic kidney disease patients. While some controversies surround the study's findings, including concerns about generalizability and the causes of death, it is essential to acknowledge the study's design and its main outcomes. The CONVINCE study, part of the HORIZON 2020 project, enrolled 1360 patients and demonstrated the superiority of hemodiafiltration in reducing all-cause mortality overall, as well as in specific patient subgroups (elderly, short vintage, non-diabetic, and those without cardiac issues). Interestingly, it was shown that hemodiafiltration had a protective effect against infection, including COVID-19. Future research will address sustainability, dose scaling effects, identification of subgroups especially likely to benefit and cost-effectiveness. However, for now, the findings strongly support a broader adoption of hemodiafiltration in renal replacement therapy, marking a significant advancement in the field.