Professor Brian Andrews
NEJM Recommendations for Medical Students and Tutors
Week of the 24th September
2015 (#9)
University of Notre Dame
Australia
(Fremantle campus)
Occasional Editorial Comments
This is the first week that
I am adding an editorial comment. The views expressed here are strictly my own
and do not necessarily reflect those of the School of Medicine (Fremantle) or
the University of Notre Dame Australia.
The Trans-Pacific
Partnership (TPP)
As you may be aware the
Commonwealth of Australia has just signed (New York Times, Tuesday October 6) a
document with far reaching implications for the practice of medicine in
Australia. I have mentioned the TPP before (week #2- new oral anticoagulants)
but final signing of this document has now occurred. This is a trading
partnership established between Pacific-Rim nations (US, Canada, Australia, NZ,
Japan, Vietnam, Singapore, Malaysia, Brunei, Mexico, Peru and Chile) primarily
to counteract the growing dominance of China in world trade and championed by
the Obama administration and multinational corporations.
The duration of patents on biological agents (and
I assume there will be riders for all new medications to be approved by PBS) is
still vague: the multinational consortium (TPP) requested a time frame of 12 years
for patents, whereas the Commonwealth requested the standard five year period:
TPP agreed in its benevolence to a compromise of “eight years” – the final
decision in the document was “between five to eight years”, creating a major
change in Public Health policy. It behoves the medical profession to be aware
of TPP, keep up to date and understand how the TPP will influence both the
availability and cost of new medications in Australia. All areas of contention
once finalized will be arbitrated by an unnamed (secret) committee of
bureaucrats with no further input by the parliament. This TPP document is
totally secret. We do know a few things, for example, on the one hand the
smoking lobby cannot now influence how cigarettes are marketed in various
countries, but on the other hand countries will not be able to market
cigarettes in plain packaging. Stay tuned.
How much to teach medical
students – Grey zone teaching
This week in the Journal is
an article on “The Asthma – COPD Overlap Syndrome” which challenges the
dogmatic teaching concept of distinct clinical entities. The data presented indicate that there is a
significant overlap between the two entities with respect to aetiology,
immunopathology, results of investigations, management and outcomes.
In MED100 and MED200, the preclinical years, much
of the teaching is involved in delivering specific common facts, which most
students indicate they want and undoubtedly is extremely important (especially
for passing examinations). Generally, a relatively small proportion of the
curriculum is devoted to grey zones teaching: this challenges the reader in
this article. It is important for the student to establish a basic knowledge on
which they can build new information. When do you challenge medical students about
thinking “outside the box?” Realistically, there are only about 10-15% of
students who want to be challenged and think in grey zones. As students advance
in knowledge, particularly in the clinical years, they will be exposed to grey
zones. For example, the physical examination is taught in a specific and
consistent way which students are expected to reproduce in medical school
examinations. As students advance into their internship year, they may well
incorporate these new techniques into their own physical exam technique.
Students should be able to accept, learn and understand new techniques and
utilize these if they wish in their internship.
I was recently talking with
my mentor of 49 years, a close friend and colleague, Solomon Posen, Emeritus
Professor of Medicine at the University of Sydney, about the following issue.
He made a statement and raised the following question: “We know
from years of observation that few practitioners have the time or the ability
to read more than the abstract of a scientific paper. Should medical educators
try to alter that?” My answer and that of the School to this question is a
resounding “yes.” While students are encouraged to pick a single article in the
journal each week that interests them, they should be able to analyse and
discuss this article critically and to present this information. The
practitioner, while skimming many abstracts is expected to critically analyse,
interpret specific articles of interest and translate these to their practice
of medicine.
Articles Recommended by and for
Medical Students
ORIGINAL
ARTICLE
Intravascular Complications of Central Venous
Catheterization by Insertion Site
http://www.nejm.org/doi/full/10.1056/NEJMoa1500964
Patients in the ICU were assigned to catheter
insertion in the subclavian, jugular, or femoral vein. Subclavian
catheterization had a lower risk of bloodstream infection and deep-vein
thrombosis, and a higher risk of pneumothorax, than catheterization in the
other two sites.
The
results of this well designed and conducted multi-centre (nine institutions in
France), randomized controlled study is summarized in the accompanying
statement. This is a must save article.
REVIEW
ARTICLE
The Asthma–COPD Overlap Syndrome
http://www.nejm.org/doi/full/10.1056/NEJMra1411863
Although in textbooks asthma and chronic
obstructive pulmonary disease (COPD) are viewed as distinct disorders, there is
increasing awareness that many patients have features of both. This article
reviews the asthma–COPD overlap syndrome
This
article is discussed in the above editorial. There is significant overlap
between the asthma and COPD syndromes and this information is illustrated in
the excellent Figures and the Table of Clinical examples.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 30-2015 - A 50-Year-Old Man with
Cardiogenic Shock
http://www.nejm.org/doi/full/10.1056/NEJMcpc1415169
A 50-year-old man with a history of
cardiomyopathy and progressive muscle weakness was admitted with cardiogenic
shock. Electroencephalography showed total suppression of cerebral activity;
ventilator support was withdrawn, and he died. An autopsy was performed.
Apart from discussing cardiogenic shock, this
CPC describes in detail myotonic dystrophy, the most frequent (but still very
uncommon) inherited myopathy. The CPC discusses the clinical entity, variants,
inheritance and molecular genetics but does not include clinical features such
as infertility, frontal alopecia, cortical cataracts, osteoporosis,
hyperostosis, insulin resistance and hypercatabolism of IgG. Obviously I find
this an interesting entity.
For the very best, scientific and clinical,
authoritative reviews in neuromuscular diseases, I strongly recommend the
Washington University web site for neuromuscular disease http://neuromuscular.wustl.edu/
Recommended learning: Review the causes of proximal myopathy
IMAGES
IN CLINICAL MEDICINE
Oral Manifestation of Crohn’s Disease
Reading the presentation of this case
illustrates how important it is to take a full history and perform a physical
examination, rather than waiting for the results of a biopsy of a mouth ulcer
to diagnose Crohn’s disease.
Recommended learning: Review Crohn’s disease and contrast
this with ulcerative colitis
IMAGES
IN CLINICAL MEDICINE
Osler–Weber–Rendu Syndrome
http://www.nejm.org/doi/full/10.1056/NEJMicm1414035
While uncommon, this condition should always be
considered in a younger patient presenting with clinical and laboratory
features of iron deficiency anaemia who does not have NSAID abuse, coeliac
disease, menorrhagia or had multiple pregnancies. Always examine the patient
and take a family history.
Recommended learning: Causes of iron deficiency anaemia in various age groups
Important Articles Related to
Mechanisms of Disease and Translational Research
EDITORIAL
Monoclonal Antibodies in Multiple Myeloma Come
of Age
http://www.nejm.org/doi/full/10.1056/NEJMe1509419
Multiple myeloma is a cancer of plasma cells
that has an estimated incidence of 26,850 new patients in 2015 in the United
States.1 In
the past few years, dramatic progress has been made in the treatment of this
disease.
ORIGINAL
ARTICLE
Targeting CD38 with Daratumumab Monotherapy in
Multiple Myeloma
http://www.nejm.org/doi/full/10.1056/NEJMoa1506348
Daratumumab was associated with impressive
antitumor responses, including complete and very good partial responses, in
heavily pretreated patients with myeloma. Infusion reactions were the main
adverse effect.
Over
the past year there has been a significant number of original articles on the management
of multiple myeloma, including proteasome inhibitors, immunomodulatory agents
(lenalidomide), autologous stem cell transplantation and, more recently,
immunological agents. This article describes a monoclonal antibody against a
conserved cell surface glycoprotein (CD38). The editorial reviews a variety of
immunological therapies. Maybe there is some light now at the end of the
tunnel. In the editorial, there is an excellent figure indicating how
monoclonal antibodies exert their therapeutic effect.
LO:
review the myeloma PBL case.
Editorial
A Candidate Dengue Vaccine Walks a Tightrope
http://www.nejm.org/doi/full/10.1056/NEJMe1509442
ORIGINAL
ARTICLE
Efficacy and
Long-Term Safety of a Dengue Vaccine in Regions of Endemic Disease
Development
of a vaccine to prevent dengue infection is an unmet global need. In this
report, further data on the safety and efficacy from two phase 3 trials of a
tetravalent dengue vaccine are presented
The concept of the dengue virus vaccine is fascinating. The
yellow fever virus vaccine has been formulated to be expressed on four chimeric
yellow fever 17D vaccine viruses. Surface envelope and prM membrane proteins
from each of the four serotypes of dengue virus (serotypes 1 – 4) are then
engineered to be expressed in this vaccine system and to induce
viral-neutralizing antibodies against all dengue virus serotypes.
These Asian-Pacific and Latin American studies describe
phase 3 vaccine results at three years. The end point was hospitalizations for
dengue virus infection, which would include dengue haemorrhagic fever (usually
occurs with subsequent infections when challenged with a different serotype
from the primary infection). Interesting findings were an increased number of
admissions in the 2-5 year old group (< 9 years) and the lower antibody
response to serotype 2. There is a discussion of these findings in the
editorial.
Other areas which should be
of interest to medical students
Perspective
Politics and Universal
Health Coverage - The Post-2015 Global Health Agenda
What
political, social, and economic factors allow a movement toward universal
health coverage to take hold in some low- and middle-income countries? Can we
use that knowledge to help other such countries achieve health care for all?
Perspective
Deception by Research Participants
Study participants who fabricate, falsify, or
fail to disclose important information can undermine the integrity of clinical
trials, with negative consequences for both future patients and the
participants themselves. What can investigators do to address the problem?
This is an interesting perspective on remunerated patients
or controls participating in various clinical studies. The article discusses
problems which may arise with the patients or controls and provides some
suggestions how to minimize corrupt data. What is the role of the investigator
and their moral and ethical responsibility when they find patients or controls
have been lying about such things as their disease, medications or drug abuse?
