At NEJM Knowledge+, we’re committed to keeping our content current and aligned with the standard of care in medicine.

We routinely review our question bank in light of new guidelines, and any edits we make as a result are quickly incorporated into your learning experrecience.

We also update our content regularly based on user feedback provided through two key features in the product: “Challenge Us” and “Claim This as a Synonym.”

  • The “Challenge Us” button appears on every question in NEJM Knowledge+ and allows users to tell us if they feel that the question is incorrect or misleading in any way.
  • The “Claim This as a Synonym” button appears on every fill-in-the-blank question in the Recharge section of NEJM Knowledge+ and allows users to tell us if they think the answer they submitted is synonymous with our correct answer.

We review user challenges and synonyms on a weekly basis and update the content as needed.

If you are a current user of NEJM Knowledge+, please sign out and then sign back in to see the updated content.

Below is a list of content updates we’ve made to NEJM Knowledge+ questions. We will add to this list regularly as additional changes are made.

August 2017

  • We reviewed and updated our content to reflect:
  • We edited 47 questions in response to learner feedback. For example:
    • In our pulmonology section, we asked which interventions have been shown to reduce lung cancer mortality risk in high-risk patients. Our correct answer was low-dose chest CT. A learner asked why smoking cessation wasn’t a choice. This question was developed to test knowledge of screening modalities for lung cancer, but we obviously agree that smoking cessation is of the utmost importance. We have edited the question to highlight this point.
    • In a question about graft-versus-host disease, our feedback stated that “Both cryptosporidium and giardia are readily identified on stool examination for ova and parasites.” A learner wrote that while this is true for giardia, evaluation for cryptosporidium usually requires specific stains. We agree and have edited our text accordingly.
    • In a question about initial testing for chronic distal symmetric polyneuropathy, a learner noted that diabetes does not typically cause sensorimotor neuropathy, as we had described in the vignette. We agree and have edited the question accordingly.

June 2017

  • We reviewed and updated our pulmonology content in light of two new sets of recommendations:
  • We edited 67 questions in response to learner feedback. For example:
    • In a question about pain management for a patient with metastatic cancer who developed acute kidney injury while taking morphine, we recommended reducing the morphine dose. Several learners wrote that hydromorphone would be preferable in this setting. We agree and have edited the question accordingly.
    • In a question about recognizing primary HIV infection, we wrote that serologic testing in primary HIV infection is frequently falsely negative. A learner suggested mentioning that fourth-generation serology uses p24 antigen detection, which allows for much earlier detection of HIV disease. While it is certainly true that Ag/Ab testing narrows the window period, RNA testing is still recommended when acute HIV infection is suspected. We have edited the feedback section of this question to clarify this point.
    • In one of our pediatrics questions, we described a 7-year-old boy who knocked over a pot of boiling water and presented with a partial-thickness burn covering the dorsum of the left forearm, as well as scattered superficial burns on the left hand and upper arm. We recommended discharge with a prescription for oral pain medication after covering the left forearm with nonadherent dressing. A learner wrote that admission should be considered until child abuse could be ruled out. In this case, the mechanism of injury was consistent with the physical findings (splatter burns), making nonaccidental trauma less likely. Nonetheless, we have edited the question stem to clarify that the case was cleared by the social worker, and we have edited the feedback to emphasize the importance of evaluating for nonaccidental trauma when evaluating burn injuries in young children.

May 2017

  • We reviewed and updated our content to ensure alignment with new guidelines, including:
  • We edited 96 questions in response to learner feedback. For example:
    • In our cardiology section, we asked about the most appropriate medication change for stroke prophylaxis in a 78-year-old vegetarian man with hypertension, stage 3 chronic kidney disease, and new-onset paroxysmal atrial fibrillation whose heart rate was well controlled while taking aspirin 81 mg daily, lisinopril 10 mg daily, and metoprolol 25 mg twice daily. We recommended starting warfarin, titrated to a target INR of 2.0 to 3.0. Several learners wrote that the patient’s aspirin should be stopped. These comments bring to light the equipoise that still exists in this area. We have amended the question to give the patient a diagnosis of coronary artery disease, which is less controversial regarding continuing the aspirin.
    • In a question about recognizing and choosing appropriate empiric treatment for suspected septic arthritis, a learner wrote that our characterization of the leukocyte count as “extremely high” was not sufficient and that an exact count would have been more helpful. We have edited the question accordingly

March 2017

  • We edited 165 questions in response to learner feedback. For example:
    • In a question about contraception for a 17-year-old female adolescent who had a chlamydia infection 6 months ago, several learners asked whether intrauterine device (IUD) placement was reasonable in this setting as we had suggested. Our senior physician editor and OB/GYN section editor both reviewed this question in light of the learners’ comments and also revisited guidelines on the topic. Their conclusion was that a prior sexually transmitted infection (STI) is not an absolute contraindication to IUD use — but that this patient should be screened for a current STI either before or at the time of IUD insertion. This conclusion is consistent with CDC guidance on contraception, an ACOG report on IUD use in adolescents, and a new NEJM review article on the topic. We edited the question accordingly.
    • In a question about classes of oral diabetes medications that do not cause weight gain or hypoglycemia, a learner noted that SGLT2 inhibitors should be considered as well. We agree and have edited the question and added the following sentence to the feedback: “Injectable glucagon-like peptide-1 agonists, such as exenatide or liraglutide, and sodium/glucose-cotransporter-2 inhibitors, such as empagliflozin and canagliflozin, are also associated with weight loss and do not directly cause hypoglycemia.”
    • In one of our endocrinology questions, we recommended lipid screening for a healthy 17-year-old girl, based on NHLBI recommendations. A learner pointed out that the USPSTF recently issued a statement saying there is insufficient evidence to support screening for lipid disorders in children and adolescents. Given that these two major guidelines are in direct opposition to one another, we are removing this question from NEJM Knowledge+. If and when there is consensus on this topic, we will edit the question and reintroduce it into the product.
    • In our cardiology section, we recommended catheter ablation as the most appropriate management for a euthyroid patient with kidney disease, COPD, beta-blocker intolerance, recurrent symptomatic palpitations that are affecting his quality of life, >30 premature ventricular beats per hour on Holter monitoring, and a normal echocardiogram. A learner wrote that the vignette was not clear about a correlation between the premature beats and the patient’s symptoms. We have edited the question to add that detail.

January 2017

  • We updated our pediatrics questions to align with new guidance from the American Academy of Pediatrics on preventing lead toxicity and on preventing sudden infant death syndrome (SIDS).
  • We edited 55 questions in response to learner feedback. For example:
    • In a question about the most appropriate test to establish the cause of acute kidney failure in an elderly man with dementia, we recommended bladder ultrasound, and a learner pointed out that renal and bladder ultrasound should be performed together for complete urinary tract evaluation. We agree and edited the question accordingly.
    • In a question about the best empiric treatment for suspected septic arthritis, a learner noted that the feedback section should mention the need for urgent orthopedic consultation for irrigation and debridement. We agree and have added that point to the feedback.
    • In our cardiology section, we listed transesophageal echocardiography

(TEE) as the best initial imaging study for a 60-year-old man with suspected acute ascending aortic dissection. A learner pointed out that the study of choice in this setting depends on whether the patient is hemodynamically stable. We agree and have edited the question to clarify that the patient was hemodynamically unstable and thus required TEE.

December 2016

  • We added 50 new questions to NEJM Knowledge+ Internal Medicine Board review. About 20 are on nephrology/urology, 10 are on neurology, and the rest are spread across various subspecialties.
  • We edited 70 questions in response to challenges from our learners. For example:
    • Our most frequently challenged question is about the most appropriate long-term anticoagulation approach in a 49-year-old man with atrial fibrillation and a CHA2DS2-VASc score ≥2. We continue to stand by our correct answer to that question and have revised the feedback to provide further learning.
    • Our second most frequently challenged question is about an incapacitated patient whose medical team and spouse disagree on the most appropriate next step in his care. Given the difficulty of testing on (and learning about) this topic in a multiple-choice format, we have decided to retire the question.

November 2016

  • We edited 78 questions in response to user challenges. In addition, we reviewed our content to ensure alignment with new recommendations including:
    • New IDSA/ATS guidelines on hospital-acquired and ventilator-associated pneumonia
    • A new FDA advisory on restricting fluoroquinolone use to certain uncomplicated infections
    • New ACIP guidance recommending against use of the live attenuated influenza vaccine during the 2016/2017 influenza season

October 2016

  • We added 50 new questions, covering a range of topics across organ systems, to NEJM Knowledge+ Internal Medicine Board Review.
  • We edited 71 questions in response to user challenges. For example:
    • We reviewed all of our content on duration of dual antiplatelet therapy in patients with coronary artery disease, to ensure alignment with the latest ACC/AHA guidelines.
    • In a question about preventing acute exacerbations of chronic obstructive pulmonary disease (COPD), we recommended daily use of azithromycin, but a learner pointed out that the 2016 GOLD report does not support such use. Although daily azithromycin has been shown to reduce the frequency of COPD exacerbations, there is concern about adverse effects (including prolongation of the QT interval and diminished hearing) and, on a population level, antimicrobial resistance. For this reason, we edited our question to recommend the phosphodiesterase-4 inhibitor roflumilast instead of azithromycin.

September 2016

  • We edited 44 questions in response to user challenges. For example:
    • In a question about the best management strategy for a woman at 35 weeks’ gestation who presents with premature rupture of membranes, a learner pointed us to a new ACOG practice advisory on the use of antenatal glucocorticoids in the late preterm period. A single course of glucocorticoids was already recommended for pregnant women between 24 and 34 weeks’ gestation who are at risk for preterm delivery — and can now also be considered for those between 34 and 37 weeks’ gestation. We have edited our question accordingly.
    • In our psychiatry section, a learner suggested that we make a clearer distinction between bipolar I and bipolar II disorder, consistent with the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). We agree and have edited our questions accordingly.
    • Several learners suggested that we were off-base in recommending no further evaluation for an asymptomatic, obese 15-year-old boy with a blood-pressure reading of 134/82 mm Hg on three consecutive occasions. We agree and have changed the correct answer to clarify that ambulatory blood-pressure monitoring (in which the patient has frequent measurements taken by a portable device) is needed in addition to follow-up blood-pressure measurements and therapeutic lifestyle modifications. The question is now in line with recommendations in the fourth report from the National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents.

August 2016

  • We added 119 new questions into NEJM Knowledge+ Family Medicine Board Review. Most are in the areas of child and adolescent health, patient safety, and ambulatory care.
  • We edited 88 questions in response to user challenges. For example:
    • We updated all of our questions on acute respiratory distress syndrome to better clarify the roles of low tidal-volume ventilation, neuromuscular blockade, and prone positioning.
    • Several learners wrote that the image we used in a question about plantar melanoma was not representative of that diagnosis. We agree and have swapped out the image.
    • In light of recent evidence on the management of acute intracerebral hemorrhage (see NEJM Journal Watch [subscription required]), we have disabled our questions on this topic. Once consensus is reached and/or new guidelines become available, we will update our questions and reintroduce them into NEJM Knowledge+.

June 2016

  • We edited 153 questions in response to user challenges. For example:
    • We updated our questions on abscess management to reflect new trial data, showing benefit from the use of adjunctive trimethoprim-sulfamethoxaxole in addition to incision and drainage in patients with uncomplicated skin abscess measuring 2 cm or more.
    • In a question about the most appropriate management for a patient with Barrett esophagus and newly diagnosed low-grade dysplasia, a learner pointed out that endoscopic ablation is now the preferred approach, according to the latest ACG guidelines on Barrett esophagus (published in January 2016). We have edited the question accordingly.
    • In a question about appropriate next steps for a pregnant woman with an elevated TSH level, several learners noted that the next step in pregnancy is measurement of total hormones, not free T4 because of the lack of an accurate reference range for free hormone in pregnancy. We agree that when the reliability of free T4 cannot be certain for a laboratory, measuring total T4 is a viable alternative. We have edited the question accordingly.

May 2016

  • We edited 56 questions in response to user challenges. For example:
    • In a question about first-line treatment for panic disorder, learners suggested that we clarify whether we were asking about acute treatment or longer-term therapy to prevent additional episodes. We have edited the question accordingly.
    • In a question about the most appropriate evaluation for an elderly man with signs of Alzheimer disease, we recommend that MRI of the brain be performed. Several learners argued that MRI is not part of the first-line workup for dementia. We have edited the feedback to more clearly state the recommendations from the American Academy of Neurology: “Structural neuroimaging of the brain with either a noncontrast head CT or MR scan in the routine initial evaluation of patients with dementia is appropriate.” Neuroimaging can serve to rule out structural brain lesions (e.g., neoplasms, subdural hematomas) that can manifest initially with cognitive impairment. MRI is preferable to CT because it has higher resolution, allowing for better detection of atrophy, strokes (including lacunes), white-matter changes, and microhemorrhages.

April 2016

  • We edited 159 questions in response to user challenges. For example:
    • In a question about recognizing corneal ulcer, an observant learner pointed out that we referred to the ulcer being in the left eye – but then showed an image of the right eye. We have corrected this discrepancy.
    • In a question about digoxin toxicity, several learners felt that the 2:1 atrioventricular block in the rhythm strip was too subtle. We have removed the rhythm strip from the question and described the findings instead.
    • In a question about the best next step in evaluating a patient with a low thyroid-stimulating hormone level and a thyroid nodule, we recommended radionuclide scanning with iodine-123, and a learner pointed out that Tc-99m could also be used as a radiotracer in this situation. We have edited the feedback of the question to acknowledge this. A recent review article on thyroid nodules can be found here: Burman KD and Wartofsky L. Thyroid nodules. N Engl J Med 2015 Dec 10).

March 2016

  • We edited 85 questions in response to user challenges. For example:
    • We updated our cardiology content to use the term “heart failure with reduced ejection fraction” (HFrEF), which was previously referred to as “systolic heart failure.”
    • In a question about radiation-induced dermatitis, a learner suggested that the case we described and the image we provided was not representative of radiation-induced dermatitis. We have edited the vignette and replaced the image.
    • In a question about preventing prescribing errors, we recommended incorporating an allergy alert system into the electronic medical record, and learners raised the issue of alert fatigue. We agree that this is an important consideration and revised the question to recommend a tiered alert system, in which only a small subset of very dangerous situations generate alerts that either demand a response from the ordering clinician or, in a few select cases, even force a change to the intended order. Support for this approach comes from studies such as this one: Paterno MD et al. Tiering drug–drug interaction alerts by severity increases compliance rates. J Am Med Inform Assoc 2009 Jan-Feb.

February 2016

  • We edited 98 questions in response to user challenges. For example:
    • In a question about idiopathic pulmonary fibrosis, we described pirfenidone and nintedanib as promising drugs in development – and a user pointed out that they are now FDA approved for IPF treatment. We have added a sentence to the feedback section noting these approvals and also acknowledging that neither drug has been shown to have an effect on mortality, and both drugs have challenging side-effect profiles.
    • In a question about the most appropriate test to establish the cause of acute kidney failure in an elderly man with dementia, several users commented that a bladder scan would be more appropriate than the bladder catheterization we recommended. We agree and have edited the correct answer accordingly.
    • In a question about improving the quality of bowel preparation before colonoscopy, we recommended splitting the preparation, with half given the night before the procedure and half given the morning of. A user questioned the wisdom of drinking 2 liters of fluid the morning of a procedure involving sedation. We have edited the feedback of the question to clarify that the morning dose should be completed at least 4 hours before administration of anesthesia.

December 2015

  • We reviewed all 10 of our questions on diagnosis and treatment of infective endocarditis to ensure alignment with the new AHA/IDSA guidelines on this topic. For a concise summary of what’s new in the guidelines, see NEJM Journal Watch (subscription required).
  • We edited 102 questions in response to user challenges. For example:
    • In a question about the role of lipid-lowering therapy in preventing cardiovascular events in patients with chronic kidney disease, a user felt that we had relied too heavily on the results of a single trial to support our correct answer. We agree and have rewritten the question feedback to acknowledge a 2014 meta-analysis that supports statin therapy in this context.
    • Several users expressed dissatisfaction about a question on treating dry eye syndrome. After careful evaluation, we have deleted the question from our bank.
    • In a question about de Quervain’s tenosynovitis, we described the patient as having tenderness over the base of the thumb, but a user pointed out that the tenderness would be over the involved tendons, not over the entire base of the thumb (which would be more suggestive of early osteoarthritis). We have edited the patient vignette accordingly.
  • We added 37 synonyms to our fill-in-the-blank questions based on user feedback in Recharge.

November 2015

  • We edited 98 questions in response to user challenges. For example:
    • In one of our oncology questions, we asked which additional medication would be appropriate for a 70-year-old woman with stage 3 chronic kidney disease who has bone lesions from multiple myeloma and is being treated with dexamethasone and ortezomib. Our correct answer was (and still is) is to provide an intravenous bisphosphonate for at least 2 years to reduce the risk for pathological fractures. However, we have added clarification to the question about which specific bisphosphonate is best in this scenario. As a user pointed out, pamidronate is a better choice for this patient than zoledronic acid, because zoledronic acid can cause acute tubular necrosis in the presence of renal impairment.
    • Several users inquired about two oncology questions that presented similar scenarios — a patient with cancer of unknown primary — but had different correct answers. Although both questions were technically correct as written, we retired one of them to avoid confusion.
    • In a question about a patient who has acute hemorrhagic colitis related to E. coli infection, a user noted that the vignette described stool testing for Shiga as positive, but the feedback referred to treatment of EHEC. Our gastroenterology section editor explains: “Infections caused by E. coli O157:H7 typically produce Shiga toxins, from the same toxin family as that produced by Shigella dysenteriae type 1. A positive result from a Shiga toxin assay indicates the presence of Shiga toxin produced by either E. coli or S. dysenteriae type 1.” We have added this information to the feedback section of the question and have also clarified in the stem that the stool testing was performed using enzyme immunoassay.
  • 244 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

September 2015

  • We reviewed all 22 of our STD-related questions to ensure alignment with the new STD treatment guidelines from the CDC. For a concise summary of what’s new in the guidelines, see NEJM Journal Watch (subscription required).
  • We edited 108 questions in response to user challenges. For example:
    • Several users asked us about the nystagmus typically associated with benign paroxysmal positional vertigo (BPPV). We reviewed all of our questions to ensure consistency and clarity and also added a new NEJM Clinical Practice review on the topic.
    • In a question about asthma treatment, several users commented that our case vignette described a patient with moderate persistent asthma while the correct answer addressed mild persistent asthma. We edited the vignette to make the case consistent with mild asthma.
    • We replaced or removed four images that users reported to be problematic.

    June 2015

    • 72 questions were edited in response to user challenges. For example:
      • In a question about managing a suspected tension hemothorax in a hypotensive patient, our correct answer is to place a large-bore thoracostomy tube. Several users have written in that needle decompression would be faster or more appropriate in this scenario. We have revised the feedback section of the question to more clearly explain why this is a case of tension hemothorax (and not pneumothorax) and why a large-bore chest tube would be necessary in this case.
      • A user pointed out that our questions on managing cocaine-associated chest pain were inconsistent. We have reviewed these questions in light of the 2014 AHA/ACC guidelines and have edited them accordingly.
    • 8 questions were reviewed to ensure alignment with new guidelines, including those from the AGA on managing asymptomatic pancreatic cysts and those from the AAP on evaluating suspected child abuse and on treating head lice.
    • 92 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

    May 2015

    • 72 questions were edited in response to user challenges. For example:
      • One of our most frequently challenged questions involves choosing an antithrombotic strategy for a 44-year-old man with a CHA2DS2-VASc score of 2 who is currently taking aspirin 325 mg daily. Our correct answer is to stop aspirin and start warfarin, but several users suggested that the patient might benefit from continuing aspirin at a lower dose in addition to starting warfarin. We edited this question to better explain the correct answer: For patients like this one, who do not have a history of ischemic heart disease or stroke, there’s no evidence that the combination of aspirin plus warfarin improves clinical outcomes compared with warfarin alone, and the combination is known to substantially increase the risk for serious bleeding. Thus, the aspirin should be stopped.
      • In a question about a first recurrence of mild-to-moderate C. difficile infection, several users noted that they are now using vancomycin in this setting rather than metronidazole (our correct answer). After several rounds of review and debate, we decided that we will continue to list metronidazole as the correct answer to this question — to align with current IDSA guidelines — but in recognition of changing practice patterns, we have removed vancomycin as a distractor and mentioned it in the feedback as an acceptable treatment option.
      • In a case about managing a 45-year-old woman with lobular carcinoma in situ, two users questioned the wisdom of prescribing tamoxifen without knowing the hormone receptor status first. We revised the feedback to explain that LCIS is nearly always estrogen receptor positive.

    March 2015

    • 78 questions were edited in response to user challenges. For example:
      • In a question about the need for antiviral prophylaxis in a patient with chronic hepatitis B virus infection who is initiating chemotherapy, a user pointed us to a recent clinical trial showing that entecavir was superior to lamivudine in this setting. We have changed the correct answer in our question to reflect this new evidence.
      • Several users pointed out inconsistencies in our questions on anemia in chronic kidney disease. We have edited all five of these questions to ensure both internal consistency and alignment with the 2012 KDIGO guidelines on anemia in chronic kidney disease.
    • 92 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

    January 2015

    • 49 questions were edited in response to user challenges. For example:
      • In a question about the best timing to initiate antiresorptive therapy in a patient who has just sustained a major fracture from low-energy trauma, our correct answer was to initiate bisphosphonate therapy in several weeks. However, users questioned this timing, and our reviewers confirmed that it is indeed a controversial area. In response, we have modified our correct answer to focus on initiating therapy within 90 days, consistent with the results of the HORIZON trial.
      • One of our most challenged questions is about consent for HIV testing in a patient who is not able to consent for herself. Several users commented that the issue of consent for HIV testing is state-specific and therefore not appropriate for inclusion in a general question bank. We agree and have withdrawn the question from NEJM Knowledge+. The Center for HIV Law and Policy provides a summary of state-specific laws related to HIV testing.
    • 166 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

    December 2014

    • 54 questions were edited in response to user challenges. For example:
      • Several users challenged us on a question about the most appropriate initial workup for an intern with blood-borne HIV exposure in the workplace. Our correct answer included testing for HIV antibody, hepatitis B surface antibody, hepatitis B surface antigen, and hepatitis C antibody. Users pointed out that we should have included the intern’s hepatitis B vaccination status in the stem and that testing for hepatitis B surface antigen would not be standard practice for the scenario we described. We have revised the question accordingly.
      • In a question about treating insomnia in an overweight patient with newly diagnosed major depressive disorder, we noted that a sedating antidepressant was an appropriate choice for initial management and specifically listed mirtazapine as the correct answer. Users pointed out that mirtazapine has been associated with weight gain and is not an appropriate choice for a patient who is already overweight. We have revised the question accordingly.
    • 166 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

    October 2014

    • 83 questions were edited in response to user challenges. For example:
      • Several users challenged us on a question about stroke prophylaxis for a 78-year-old man with paroxysmal atrial fibrillation and hypertension. Our correct answer was to start warfarin, and that remains correct — but several users pointed out that the patient’s aspirin should be stopped and also asked why bridging wouldn’t be necessary. We’ve expanded the feedback section of the question to address both of those points.
      • Our most challenged question so far was about preoperative testing in a woman with a heart murmur who was undergoing knee replacement surgery. Our correct answer was to proceed without further testing, but users felt strongly that the patient’s history suggested early symptomatic aortic stenosis and that additional testing would be necessary. We agree with the comments and have revised the case vignette so that “no further testing” could remain the correct answer.

    September 2014

    • 21 questions were edited in response to user challenges.
    • 209 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

    July 2014

    • 86 questions were edited in response to user challenges.
    • 318 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.
    • 1 question was edited to reflect new ASCO guidelines on tamoxifen use.

    May 2014

    • 44 questions were edited in response to user challenges.
    • 19 synonyms were added to fill-in-the-blank questions in Recharge based on user feedback.

    April 2014