Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 17th December 2015 (#21)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial
Comments
In 2016, every two weeks a Video in Clinical Medicine will be recommended for review from the
NEJM video library.
Perspective
Why a GME (graduate medical education) Squeeze
Is Unlikely (in the US).
This relates to the
new medical schools (MD and DO graduates) in the US and the increased number of
new interns generated by the process. Suffice it to say, there does not appear
to be any shortage of basic training positions for US trained graduates
projected through 2023-2024. However the number of IMG (international medical
graduates), both US citizens who trained outside the US (42% of all IMGs who
obtained internships in the US), e.g. in US approved Caribbean medical schools
(first two years), or non-US IMGs will have progressive difficulty obtaining
intern and residency training. Generally, the less sought after training
positions are now frequently filled by IMGs and in the future will likely be
filled by US graduates.
In some ways this is
reminiscent of the current situation in WA. Currently with the marked budget
deficit, it appears that additional intern and residency training positions will
not increase, especially with the short-sighted cutbacks in public funded
hospital teaching positions. Where will the increased number of medical
graduates from the new Curtin Medical School (CMS) be trained? The government
may be forced to fully reopen Fremantle Hospital (before they sell part of it
off for short-term profit) and Royal Perth Hospital.
If the US scenario is followed, one solution
should be that international medical students (IMS) trained at WA medical
schools will have to return to their own country for intern and residency
training and not be guaranteed a postgraduate training position up front; this
will be vigorously opposed by UWA and CMS who regard IMS as a “cash cow” for
their institutions and an absolute fiscal requirement for such institutions as
Syd U and Melb U.
Another area that must
be addressed seriously in the future is an increase in the number of training
positions in rural Australia which would necessitate more teaching staff and
financial investment from the State and approval by the various Colleges.
MUST READ SECTION
None
Articles Recommended for Medical Students
EDITORIAL
Antidote for Factor Xa Anticoagulants
http://www.nejm.org/doi/full/10.1056/NEJMe1513258
ORIGINAL
ARTICLE
Andexanet Alfa for the Reversal of Factor Xa
Inhibitor Activity
Following
on the reversal agent for the thrombin inhibitors (Idarucizumab for Dabigatran Reversal, http://www.nejm.org/doi/full/10.1056/NEJMoa1502000 ), there is now described a reversal agent for the factor
Xa inhibitors e.g. rivaroxaban and apixaban which are approved
for the prevention of stroke in patients with non-valvular atrial fibrillation.
It is also of interest that this extremely expensive agent also reverses the
effects of other factor Xa inhibitors that act through antithrombin, namely
heparin and fonaparinux.
While the science behind the development of
these monoclonal antibodies is wonderful, several points need to be made:
i)
This recombinant monoclonal antibody will be
extremely expensive (as will be idarucizumab) and may not be generally approved
for the Australian market, especially with the approval of the TPP
ii)
Treatment will require at least two IV
infusions
iii)
As non-neutralizing antibodies are produced,
what will happen with rechallenge in the future? Probably if a bleeding
disorder occurs on one of these anticoagulants, the agent will have to be
stopped in the patient.
iv)
Currently the data in human trials in patients
who have bled has not yet been published, but expect this to be published in
2016 with positive results
v)
Look forward to the results of more studies
using these anticoagulants in the prevention of DVT, treatment of DVTs (Oral
Rivaroxaban for Symptomatic Venous Thromboembolism, http://www.nejm.org/doi/full/10.1056/NEJMoa1007903 )
and the treatment of non-life threatening PEs. There is too
much money (billions) to be made by Big Pharma with these anticoagulants and
their reversal agents.
vi)
What happens if you give too much of the
monoclonal antibodies (over-reversal)? Do patients then clot?
Please do not forget
warfarin, an agent we know based on extensive evidence is effective, is cheap,
but clearly has risks in particular intracerebral bleeding. However to monitor
warfarin therapy carefully this takes up too much of the physician’s time and
in the present practice climate of medicine, time is money. The latter may well
end up being a major reason for the change from warfarin to the new oral
anticoagulants.
ORIGINAL
ARTICLE
BRIEF
REPORT
Molecular Evidence of Sexual Transmission of
Ebola Virus
A new sexually
transmitted disease which is extremely well documented in a single case. The
genital tract (and also the uveal tract) may result in a further reservoir for
the virus until it rears its ugly head again in the next epidemic.
IMAGES
IN CLINICAL MEDICINE
Scrub Typhus
An infection spread by
a mite bite. Endemic in parts of Asia. Store this information in your brain
stem but consider scrub typhus in a traveller exposed to mites as it is curable
with doxycycline.
IMAGES
IN CLINICAL MEDICINE
Achalasia with Megaesophagus
This is an extreme
case of achalasia. You may see an occasional case during a GI rotation or for
upper GI surgery, but this is still a very uncommon cause of dysphagia
Recommended learning: Review the causes of lower and upper
oesophageal dysphagia and their management. Dysphagia is a very important area.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
A 22-Year-Old Man with Hypoxemia and Shock
http://www.nejm.org/doi/full/10.1056/NEJMcpc1507212
An instructive case of a patient who presents
with influenza pneumonia and develops acute respiratory distress syndrome
(ARDS) and disseminated intravascular coagulation (DIC) associated with
bacterial sepsis and an unexpected second viral infection which would not have
been diagnosed if the patient had not had an autopsy!
Be careful after you obtain a total white cell
count that you think in terms of absolute numbers of the various populations of
white cells, not the percentage e.g. this patient as well as being markedly
granulocytopaenic is also markedly lymphopenia and immunosuppressed.
Recommended learning: Review influenza A infection and pathology, immunization,
appropriate use of antiviral agents in prevention; septic shock and SIRS,
causes and management of DIC
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other areas which should be of interest to medical students
Perspective
Peer-Review Fraud — Hacking the Scientific
Publication Process
A new trend is the
increasing numbers of scientific articles that are being retracted because of
fake peer reviews. This new type of
fraud is made possible by electronic manuscript submission systems and inspired
by academia's publish-or-perish ethos. What next!!
Interesting Follow-up Correspondence
CORRESPONDENCE
Cancer Screening in Unprovoked Venous
Thromboembolism
This follow-up
correspondence supports the earlier study (http://www.nejm.org/doi/full/10.1056/NEJMoa1506623 ) that suggested that in a patient
with a new onset unprovoked venous thromboembolism in an otherwise asymptomatic
patient that an extensive diagnostic
workup for cancer is unnecessary (that assumes that the patient has had a full
H&P, including a rectal exam, breast exam and a pelvic exam with a Pap
smear, a screening mammogram, FOBT and I believe also a PSA).
