Professor Brian Andrews
NEJM Recommendations for Medical Students and Tutors
Week of the October 15th
2015 (#12)
University of Notre Dame
Australia
(Fremantle campus)
Articles Recommended by and for
Medical Students
Early Inhaled Budesonide for the Prevention of
Bronchopulmonary Dysplasia
EDITORIAL
No End to Uncertainty about Inhaled
Glucocorticoids in Preterm Infants
The Editorial summarises the article well. In essence,
this is large, multinational, randomized, placebo-controlled trial treating
extremely preterm infants (< 28 weeks gestation) with inhaled corticosteroid
(budesonide) or placebo to determine if the risk of bronchopulmonary dysplasia
was reduced. The results of the study were positive (27.8 % in the budesonide
group versus 38% in the placebo group) and fewer closures of PDAs and
reintubation. However the overall mortality rate was increased in the
budesonide group over the placebo group (16.9% versus 13.6%) in a condition
where the mortality rate is normally high. These results are well discussed in
the Editorial.
Recommended
learning: Clinical entities associated with prematurity
ORIGINAL ARTICLE
Neonatal Glycemia and Neurodevelopmental
Outcomes at 2 Year
EDITORIAL
Neonatal Hypoglycemia Studies — Is There a
Sweet Story of Success Yet?
This article and Editorial raise as many questions as
they appear to answer regarding the diagnosis of neonatal hypoglycaemia and its
management. The authors monitor not only blood glucose intermittently but also
continuous interstitial glucose (every 5 minutes) by a subcutaneous probe (for
up to seven days). Hypoglycaemia in the neonate is defined as a glucose level
less than 2.6 mmol/L, whereas in children and adults the level is accepted as
less than 3.3-why?
This is a prospective cohort study of neonates with a
gestational age of at least 35 weeks and who were considered at risk for
developing hypoglycaemia. Hypoglycaemia was treated to maintain a BSL above 2.2
mmol/L. Overall 53% of participants developed hypoglycaemia and nearly 25% had
hypoglycaemia only recognised initially by the subcutaneous probe. Even with
treatment (they also trialled an oral glucose gel), 25% of infants had at least
five hours of low glucose levels.
In this cohort, maintaining a BSL >2.2 mmol/L for 48
hours after birth, at two years of age there was no significant neurocognitive
impairment (advanced testing of executive function, visual and processing and
vision) demonstrated. They raise the possibility that BSLs at the high end of
normal or rapid correct of low BSLs to higher levels may be associated with a
poorer neurological outcome. Stay tuned.
Recommended
learning: Types of hypoglycaemia in the neonate, especially
transient hypoglycaemia and its clinical recognition.
ORIGINAL ARTICLE
A Trial of Calcium and Vitamin D for the
Prevention of Colorectal Adenomas
This is a large randomized, double-blind,
placebo-controlled trial in which patients who had a colonic polyp removed were
treated with vitamin D (1000 IU/day), calcium carbonate (1200 mg/day) or
placebo in all combinations to determine if there were any effect(s) upon the
recurrence of future polyps. Over a 3-5 year follow-up period, there was no
change in the recurrence rate at the doses of vitamin D or calcium tested.
Recommended
learning: Review the epidemiology and genetics of colorectal cancer.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 32-2015 — A 57-Year-Old Man with Severe
Pneumonia and Hypoxemic Respiratory Failure
http://www.nejm.org/doi/full/10.1056/NEJMcpc1503830
This CPC reviews the causes of severe,
progressive pneumonia in a patient who lived on the East Coast of the US and
who had travelled in the recent past.
When you consider the reasoning of a CPC
discussant, you find that the least likely diagnoses are considered first, and
excluded, with the provisional diagnosis reached at the end in a climax – it
appears on the surface to be a diagnosis of exclusion.
However, this is not how the clinician reasons
when reaching a diagnosis in clinical practice. The clinician considers first
the most likely diagnosis, based upon the history, the physical examination and
the experience of the physician. In this week’s case, the diagnosis should have
been apparent at the onset. As you take the history and perform the physical
examination, the clinician should be considering the differential diagnoses and
arranging them in a priority list with the provisional diagnosis at the top of
the list at the end. With each diagnosis, the clinician is continually
assessing the pros and cons of each.
Recommended learning: Because of rapid
travel, this patient could have quite easily presented in any city in the
world. Be aware of the differing geographic prevalence of infectious diseases
and how these need to be assessed in the traveller. In this case, an overview
of fungal infections in the non-immunosuppressed patient from various areas in
the US (in general: West coast – coccidioidomycosis; Mid-west – histoplasmosis;
East coast – blastomycosis).
IMAGES IN CLINICAL MEDICINE
Bursitis and Tenosynovitis Due to Mycobacterium
avium Complex
http://www.nejm.org/doi/full/10.1056/NEJMicm1500800
The MAC complex should always be considered as a cause
for a subacute monoarticular arthritis and/or tenosynovitis in the
immunosuppressed patient (in this case the patient had dermatomyositis and had
been on long-term corticosteroids).
Recommended
learning: Review dermatomyositis and atypical mycobacterial
infections.
