Professor Brian Andrews
NEJM Recommendations for Medical Students and Tutors
Week of the October 1st
2015 (#10)
University of Notre Dame
Australia
(Fremantle campus)
Occasional Editorial Comments
TPP (Trans-Pacific partnership) update: The
Australia High Court ruled last week that a patent could not be applied to
defined biological genetic sequences, specifically addressing the gene and the
product of BRCA1 as a risk factor for breast and ovarian cancer. Will this be
excluded under the TPP? Who knows? The Fremantle Federal Labour Member also
recently asked this question.
Articles Recommended by and for
Medical Students
Perspective
Reduced-Nicotine
Cigarettes — A Promising Regulatory Pathway
SPECIAL ARTICLE
Randomized
Trial of Reduced-Nicotine Standards for Cigarettes
http://www.nejm.org/doi/full/10.1056/NEJMsa1502403
“People smoke for the nicotine but they die
from the tar’ (Russell, 1976)
“Smoking kills half the people who engage in it
long-term, robbing them of 10 to 15 years of life” (CDC, quoted in Perspective)
This is a complex double-blind, parallel,
randomized clinical trial conducted over one year in 10 sites in the US using
840 paid participants (“smokers who did not wish to quit”) over a six week
period.
Seven
groups of subjects were studied using a range of nicotine concentrations in
cigarettes (from 15.4 mg/gram of tobacco to a low of 0.4 mg/gram, and with low
and high tar content in the 0.4 mg nicotine content cigarette).
The overall results indicate that participants
who smoked cigarettes containing 2.4 mg nicotine/gram or less smoked fewer
cigarettes and were exposed to reduced nicotine overall, with minimal features
of withdrawal. Low and high tar content showed no difference in the smoking
habit in the 0.4mg cigarettes.
Caveats: Subjects were allowed to smoke
cannabis and faced no penalty if they used non-study cigarettes. For a complex
study using paid human subjects, there will always be an aspect of the study
that can be criticized, namely that the perfect study in human subjects does
not exist. I congratulate the authors
for this excellent study. What effect will the TTP have on possible changes like
this?
The authors pose the question: “Is it now time
to introduce low nicotine cigarettes to the US market?” (possibly even stop
production of higher nicotine content cigarettes and at least reduce the tar
content significantly). As usual, the public health implications and costs are
obvious but any changes will be fought by the Tobacco industry, their lobbying
groups and campaign donations to the politicians, who represent more than their
constituents in this battle. The data is
out there, all that is needed is the political will and the moral outrage.
ORIGINAL
ARTICLE
Cardiometabolic
Risks and Severity of Obesity in Children and Young Adults
http://www.nejm.org/doi/full/10.1056/NEJMoa1502821
Essentially this a cross-sectional analysis of
cardiovascular risks associated with obesity in children. The difference is the
method of assessment of obesity in the age group 3-19 years using BMI, with
obesity defined at the 85% percentile or higher for that age and sex.
The results indicate that severe obesity( BMI greater than
120% of the 95th percentile for age and sex) in children and young adults is
associated with increased prevalence of cardiometabolic risk factors (TC, HDLc,
LDLc, TG, AIC, glucose and systolic or diastolic BPs).
REVIEW
ARTICLE
DISORDERS
OF FLUIDS AND ELECTROLYTES
Maintenance
Intravenous Fluids in Acutely Ill Patients
http://www.nejm.org/doi/full/10.1056/NEJMra1412877
An excellent review (store the hyperlink in
Evernote) which emphasises the type of routine maintenance fluid replacement
(isotonic rather than hypotonic). Review the three clinical case examples and Figure 1 which
demonstrates the non-osmotic states of arginine vasopressin excess (AVP, ADH) (LO). The journal
has published several excellent reviews this year on electrolyte disorders and
metabolic consequences of diabetic ketoacidosis.
CLINICAL
PROBLEM-SOLVING
Springing a
Leak
This is well written problem solving and demonstrates
excellent clinical reasoning. This is highly
recommended reading from start to finish for all students. It covers numerous important areas including a
review of the nephrotic syndrome, minimal change disease, the physiology of the
thyroid and thyroid binding proteins, hypothyroidism, management and pathology
of thyroid cancer and an overview of stem cell transplantation.
IMAGES
IN CLINICAL MEDICINE
An Acute
Dystonic Reaction after Treatment with Metoclopramide
http://www.nejm.org/doi/full/10.1056/NEJMicm1412207
This is an interesting before and after video.
IMAGES
IN CLINICAL MEDICINE
Pseudoaneurysm
after Transradial Coronary Angiography
http://www.nejm.org/doi/full/10.1056/NEJMicm1406093
I am sure more of these will be described as
the radial artery becomes increasingly utilized by cardiologists. From a point
of interest, recurrent trauma-induced pseudoaneurysms or thrombophlebitis might
suggest the diagnosis of Behcet’s syndrome.
Recommended learning: DD of recurrent mouth and genital ulceration and anterior
and posterior uveitis, in addition to aseptic meningitis and inflammatory bowel
disease
Important Articles Related to
Mechanisms of Disease and Translational Research
CLINICAL
IMPLICATIONS OF BASIC RESEARCH
Hardly
Tendentious — Repairing Like with Like
This is a very interesting review of an article that
appeared in JCI this year. The study
involves severing rat patellar tendon and then injecting the severed tendon
with “stem progenitor cells” in a fibrin gel.
Within two weeks the tendon had healed with realignment of collagen
fibres.
Instead of
utilizing pluripotent stem cells from other sites (e.g. bone marrow or
umbilical cord) to derive mesenchymal stem cells, the authors utilized
pluripotent mesenchymal stem cells derived from rat tendon. They found that
using these cells, with addition of CTGF (connective tissue growth factor), produced
a “stem progenitor cell, relatively specific for rat tendon repair. Will this
be the path to the future using specific tissue derived stem cells?
ORIGINAL
ARTICLE
Phase 3
Studies Comparing Brodalumab with Ustekinumab in Psoriasis
ORIGINAL ARTICLE
Secukinumab
Inhibition of Interleukin-17A in Patients with Psoriatic Arthritis
http://www.nejm.org/doi/full/10.1056/NEJMoa1412679
As a rheumatologist/immunologist I am particularly
interested in these two articles: however as medical students I can understand
how these would not be of particular interest.
Recommended
learning: Provides the student with a mechanism to update
knowledge on Th17 cells, IL-23 and, in particular, IL-17 and its role in
microbial defenses, antibody class switching, ectopic lymphoid follicle
formation, induction of systemic autoimmunity and psoriasis, psoriatic
arthritis, MS, RA and ankylosing spondylitis.
Other areas which should be
of interest to medical students
Perspective
INTERNATIONAL
HEALTH CARE SYSTEMS
