Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 26th November 2015 (#18)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial
Comments
The five articles below on BP control are a MUST
READ with very practical applications and must be considered in the context of
local Australian guidelines. They will be a fertile ground for much discussion
and in all likelihood there may not be an agreed upon practical resolution.
Such is life and you will just have live with it.
Today I could recommend virtually every article in
the Journal, but have to restrain myself to a practical approach and not risk
scaring off the medical student with too much excitement and information.
However, it is a good idea each week to review the
entire contents of the Journal in case I have omitted something of particular
interest to you.
Don’t forget that there are Podcasts each week with
summaries of articles the Editorial Board regard as the most significant and
there is a host of practical procedures demonstrated in the NEJM video library
(this week how to insert an
intracranial-pressure monitor!!!).
MUST READ
Perspective
FOCUS
ON RESEARCH
Time to Reassess Blood-Pressure Goals
Hypertension is a major public health
problem, but experts disagree on blood-pressure targets. For many patients, the
SPRINT study suggests, target blood pressure in treating hypertension should be
lower than is now recommended, but achieving that goal won't be easy
EDITORIAL
A SPRINT to the Finish
EDITORIAL
Redefining Blood-Pressure Targets — SPRINT
Starts the Marathon
ORIGINAL
ARTICLE
A Randomized Trial of Intensive versus Standard
Blood-Pressure Control
Patients at increased cardiovascular risk but
without diabetes were assigned to intensive treatment of systolic BP (target,
<120 mm Hg) or standard treatment (target, <140 mm Hg). After a median of
3.26 years, the rate of cardiovascular events was significantly lower with
intensive treatment.
CLINICAL
DECISIONS
Excellent clinical
vignette on BP control discussing various options based on evidence.
The above five
publications occupying half of the Journal relate to the Spring Research Group
study comparing Intensive (< 120 mm Hg systolic) versus Standard (<140 mm
Hg systolic) BP control in a randomized, non-diabetic, controlled,
open-labelled trial in 102 centres in the US and Puerto Rico.
The overall results
indicate the lower systolic BP group (intensive) had better outcomes, although:
1.
Not all
patients in either group attained the set BP goal
2.
There was
a significant increase in adverse events in the intensive group.
I recommend that you
review the paper, but pay particular attention to the Perspective article written by Chobanian who provides a reasoned
analysis of the study and then read the two Editorials. Most agree that the
lower the BP overall within reason, the better the outcomes. However most of
the disagreement relates to how this is achieved and to what levels.
The Clinical Decision
Making article also makes for interesting reading.
If the standard of
less than 140/90 is sought in the non-diabetic patient, in the US less than 50%
have controlled BP and only 10% in the non-Western world. How can we improve on
this with a lower control level of 120 mm Hg?
Hypertension is the leading cause of death
worldwide. Can the physician expect patients to be compliant with up to three
BP medications to achieve this result? Read the Chobanian Perspective.
Articles Recommended for Medical Students
ORIGINAL
ARTICLE
A Randomized Trial of Progesterone in Women
with Recurrent Miscarriages
This is the first
large multicentre, randomized, placebo-controlled trial looking at progesterone
vaginal suppositories versus placebo for the first trimester in women with
recurrent miscarriage (loss of three or more pregnancies).
There was no difference in pregnancy outcomes
in the progesterone group versus the placebo group.
Recommended learning: Review the physiology of the menstrual
cycle, the role of progesterone during pregnancy and miscarriages in general.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 37-2015 — A 76-Year-Old Man with Fevers,
Leukopenia, and Pulmonary Infiltrates (and non-caseating granulomata on lung
biopsy)
Interesting bedtime
reading and clinical reasoning.
I have seen two cases
of polyarthritis of similar origin, though rare.
Recommended learning: Causes on non-caseating granulomata
Important Articles Related to Mechanisms of Disease and
Translational Research
ORIGINAL
ARTICLE
Empagliflozin, Cardiovascular Outcomes, and
Mortality in Type 2 Diabetes
This is an article
describing a new inhibitor of the sodium-glucose cotransporter 2 in the kidney
which results in increased excretion of glucose by the kidney.
The outcome results of
the study are positive but I would not spend much time reviewing the article
unless you are particularly interested.
I would use this as a
probe to review the following:
Recommended learning:
1. Renal tubular physiology, particularly
reviewing glucose transport in the normal and in DKA (recent reviews in the
NEJM)
2. Review the mechanisms of action and the
underlying physiology of the groups of non-insulin therapies used to treat
diabetes mellitus:
a. Sulfonlyureas
b. Metformin (new data on the MOA in NEJM
search)
c. Thiazolidinediones (data in NEJM 12-12 2015 suggests that these drugs
may also have a place as antagonists of the PPAR- nuclear receptor [glitazone
receptor] in removing resistant stem cell clones in patients with CML treated
with tyrosine kinase inhibitors)
d. DPP-4 inhibitors
e. Glucagon-like peptide-1 analogues
f. Inhibitors of the Na-glucose co-transporter 2
g. Acarbose
By the end of MED200,
you should have a working knowledge of the medication
groups used to treat diabetes mellitus, not just metformin and the
sulfonylureas.
As we learn more about
cell biology and immune-pharmaco-genetics, many more indications for older
therapies will become apparent.
Other areas which should be of interest to medical students
REVIEW
ARTICLE
Treatment of Tuberculosis
This is a good review
article on tuberculosis, particularly involving therapeutic choices. It offers
very little discussion on research advances but discusses all available
medications extensively.
An excellent Figure
demonstrating the cellular Sites of Active of the various medications.
Store this article in
your data base and review when we do the case of TB in the MED300 discussion
cases.
Recommended learning: Review the epidemiology of TB, the
immunohistopathology, medications and public health issues in particular in the
immigrant and Aboriginal populations.
CLINICAL
IMPLICATIONS OF BASIC RESEARCH
Resolvin Infectious Inflammation by Targeting
the Host Response
Of course I had to
bring up this article. A very interesting update on the role of Resolvins in acute inflammation and
targeting host immune responses in patients with sepsis. Not routine reading.
Maybe I will mention Resolvins in passing in the MED100
lecture I give on acute inflammation (you may wish to review the Figure)
Recommended learning: Review SIRS; sepsis and arachidonic
metabolism
