Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 3rd December 2015 (#19)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial
Comments
In this issue (Perspective), there is an overview of the Swiss health care system
(http://www.nejm.org/doi/full/10.1056/NEJMp1508256 ) in the series International Health Care Systems which began in January 2015 in
the Journal. The Australian system was reviewed (http://www.nejm.org/doi/full/10.1056/NEJMp1410737) in the August 6th edition. For those interested in
international health care systems and where Australia rates, these are an
excellent series of Perspective
articles. Check out the Turkish system.
MUST READ
REVIEW
ARTICLE
Cardiac Complications in Patients Undergoing
Major Noncardiac Surgery
http://www.nejm.org/doi/full/10.1056/NEJMra1502824
This is a must read
article for MED300 and MED400 students and for all surgeons, anaesthetists,
intensivists and all who manage pre- and post-operative patients.
It discusses
perioperative cardiac complications in patients undergoing non-cardiac, major surgery.
Cardiac complications
are the major cause of death within the first 30 days after surgery. Figure 1
demonstrates the preoperative, intraoperative and postoperative risk factors
associated with perioperative cardiac complications.
Perioperative
mortality, if it were considered a separate category, would rank as the third
most common cause of death in the US.
Questions are raised
and evidence produced in areas such as:
1. Should BNP
levels be routinely performed preoperatively in asymptomatic patients with
cardiac risk factors as a means to enhance preoperative risk reduction?
2. Should
preoperative and postoperative troponin levels be monitored in asymptomatic
patients with cardiac risk factors to predict postoperative ACS in patients on
analgesics and who do not usually present with chest pain?
This is an article
that should be read in its entirety when appropriate in the medical course,
particularly on the medical, surgical and critical care rotations, as it really
is “full of pearls.”
Recommended learning: Preoperative anaesthetic risk assessment and
diagnosing postoperative ACS.
Articles Recommended for Medical Students
Perspective
Ending the HIV–AIDS Pandemic — Follow the
Science
MEDICINE
AND SOCIETY
Applying Public Health Principles to the HIV
Epidemic — How Are We Doing?
ORIGINAL
ARTICLE
On-Demand Preexposure Prophylaxis in Men at
High Risk for HIV-1 Infection
The above articles bring the reader up to speed on:
1. Current
evidence that indicate that HIV should be treated with ARTs regardless of the
CD4 count and that the benefits far outweigh the risks (The Perspective by Fauci clearly describes
three major large, international randomized trials and progressively addresses
the evidence to support the above statement)
2. The article about on-demand intermittent preexposure prophylaxis using tenofovir +
emtricitabine in HIV negative men having sex with men (high risk exposure)
showed a relative reduction in HIV risk of 86% compared with placebo.
There are various caveats to consider in this short nine month study
(maybe better drug compliance than longer studies) including i) regular use of
condoms (the study indicated that drugs were not a substitute for condom use),
ii) individual risk assessment where prophylaxis was tailored to the perceived
risk (Russian roulette) and iii) the risk of developing drug resistance (not
discussed in the study but alluded to in passing by Fauci). Clearly the current
evidence suggests that preexposure prophylaxis is an effective public health tool
in this high risk group and is cost-effective, though this would be a hard sell
to insurance companies.
Recommended learning: Review public health aspects of HIV
infection
EDITORIAL
Continuous or Interrupted Chest Compressions
for Cardiac Arrest
Trial of Continuous or
Interrupted Chest Compressions during CPR
In this trial, over 23,000 patients with
out-of-hospital cardiac arrest were assigned to standard CPR with a chest
compression-to-ventilation ratio of 30:2 or to continuous chest compressions.
There was no significant between-group difference in survival to hospital
discharge
For those interesting
in analysing the study, read the original article. However, I received more
information and the results of the background studies by reading the excellent Editorial. The study found no difference
in outcomes in out-of-hospital, non-traumatic, cardiac arrests between the use
of continuous chest compressions and chest compression-to-ventilation rate of
30:2. An excellent and comprehensive study with interesting exclusions which
improved the quality of the study.
Recommended learning: Management of cardiac arrest, ACLS protocols
ORIGINAL
ARTICLE
Acetaminophen for Fever in Critically Ill
Patients with Suspected Infection
This is a study in ICU, critically ill
patients with fever, probably due to infection, who were treated with either IV
placebo every six hours or IV acetaminophen 1 g every six hours until either
discharge from the ICU, cessation of the fever, cessation of antimicrobial
therapy or death. The results showed no shortening of time in the ICU and no
change in the 90 day death rate in the acetaminophen treated group over
placebo.
Recommended learning: Management of fever in the ICU patient
CLINICAL
PROBLEM-SOLVING
Back to Nature
http://www.nejm.org/doi/full/10.1056/NEJMcps1407030
The clinical problem
is a presumed infection in an immunosuppressed young male resulting in hilar
adenopathy, a hilar mass and small pleural effusions.
This is a good
exercise in clinical reasoning but with an unusual organism causing the
problem.
Recommended learning: Biological warfare, bioterrorism, causes of
hilar adenopathy in the acutely ill patient
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other areas which should be
of interest to medical students
Perspective
Tenuous Tether
This is a piece of
medical history beginning with Laennec and his use of the first stethoscope,
which was a major improvement over listening directly with the ear to the lungs
(usually in a patient with cavitatory tuberculosis), through echocardiography
and the electronic stethoscope and now visual representation of the murmur and
heart sounds on a computer screen at the bedside! An interesting read.
ORIGINAL
ARTICLE
Intensive Supportive Care plus Immunosuppression
in IgA Nephropathy
This open-label trial randomly assigned patients with IgA nephropathy to supportive care or supportive care plus immunosuppression. The added immunosuppression did not significantly improve outcomes; more adverse events occurred, with no change in the rate of decrease in eGFR.
This is an important
article on the most common cause of glomerulonephritis in the developed world.
This is a three year
study comparing two groups of patients with primary IgA nephropathy after a six
week run-in period with specific
criteria prior to randomization (age 18 to 70 years; proteinuria level between 0.75 – 3.0 /day of urinary
protein excretion plus arterial hypertension (defined by the use of
antihypertensive medication or by an ambulatory blood pressure ≥140/90 mm Hg),
impaired renal function (defined as an eGFR > 30 and < 90 ml/minute/1.73
m2), or both. Exclusion
criteria were secondary and rapidly progressive, crescentic IgA
nephropathy, other chronic renal diseases, and any prior immunosuppressive
therapy). The two groups were either intensive comprehensive supportive therapy
(ACE/ARBs, quit smoking, dietary advice, and statins for lipid control) or
intensive comprehensive supportive therapy + immunosuppression (in 2007when the
study was commenced, corticosteroids for 3 years + oral cyclophosphamide for 3
months followed by azathioprine for the remainder of the 3 years).
The results showed no
difference in outcomes between the groups with no change in the rate of
decrease in the eGFR, but more adverse effects in the immunosuppression group.
Recommended learning: Review pathology and course of IgA nephropathy
and other causes of acute glomerulonephritis
