Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 22nd October 2015 (#13)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial
Comments
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MUST READ SECTION
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Articles Recommended for Medical Students
Perspective
Reducing LDL with PCSK9 Inhibitors — The
Clinical Benefit of Lipid Drugs
Despite limitations in the data on the two
new PCSK9 inhibitors, an FDA advisory committee has voted to approve alirocumab
and evolocumab. But committee members emphatically stated that LDL cholesterol
levels are not a reliable surrogate for cardiovascular benefit.
This is an interesting
Editorial which discusses the use of monoclonal antibodies that prolong the
half-life of the LDL receptor by reducing the breakdown of the receptor by the
enzyme PCSK9. These drugs are very effective but will also be expensive and if,
and when, they are employed in Australia will have to be used very selectively.
IMAGES
IN CLINICAL MEDICINE
Bullous Pemphigoid
An otherwise healthy 73-year-old woman
reported severe itching and intense blisters on her forearms, lower back, and
legs within the previous 2 weeks. Laboratory findings included eosinophilia and
autoantibodies to bullous pemphigoid antigen 230.
Excellent clinical photograph
and accompanying immunopathology.
Recommended learning: MED300 and MED400. Review the blistering
dermatoses, their immunopathology and don’t forget porphyria cutanea tarda in the alcoholic, particularly after sun
exposure.
REVIEW
ARTICLE
Eosinophilic Esophagitis
An excellent review on
a condition that is becoming increasingly recognised in Western countries (as
are allergic conditions in general, especially food allergies) with a
prevalence of around 0.4% of children and adults. A relatively common cause of feeding
difficulties in children and dysphagia and food impaction in adults. The entity
is well discussed and the Figures are great.
Recommended learning: Review causes of feeding difficulties in
children and causes and management of dysphagia in adults (MED300 Clinical
case).
REVIEW
ARTICLE
Drug-Induced Megaloblastic Anemia
http://www.nejm.org/doi/full/10.1056/NEJMra1508861
Many common drugs induce megaloblastic anemia
by interfering with folate or vitamin B12 absorption, altering B12 metabolism,
or blocking pathways in which these vitamins play a role. Supplements to
overcome these effects or discontinuation of the drug may be necessary.
An extensive review on
drugs that can cause megaloblastic anaemia. Good Figures on vitamin B12 and
folic acid absorption with discussion of biochemical pathways involved with B12
and folate metabolism.
Recommended learning: Review causes of folate and vitamin B12
deficiency, the clinical (including the autoimmune disorder Pernicious anaemia) and laboratory
picture (especially the changes on the blood film) produced and the clinical
management.
EDITORIAL
Parachutes and Preferences — A Trial of Knee
Replacement
ORIGINAL
ARTICLE
A Randomized, Controlled Trial of Total Knee
Replacement
In patients with knee osteoarthritis, total
knee replacement followed by nonsurgical treatment resulted in greater pain
relief and functional improvement after 12 months than did nonsurgical
treatment alone, but it was associated with a higher number of serious adverse
events.
This article and the
accompanying Editorial (check out definition of a Parachute study) should be carefully analysed as an example of an excellent
randomized, controlled trial of 100 patients with symptomatic, osteoarthritis
(radiological criteria) of the knee (check the exclusion criteria) who
underwent total knee replacement with follow-up optimal postoperative
nonsurgical care over 12 weeks versus those who elected optimal nonsurgical
care alone (in the 12 month follow-up period in the latter group, 26% requested
surgery).
Important Articles Related to Mechanisms of Disease and
Translational Research
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Other areas which should be of interest to medical students
ORIGINAL
ARTICLE
A Phase 3 Randomized Trial of Nicotinamide for
Skin-Cancer Chemoprevention
Among patients with a history of skin cancer,
nicotinamide treatment was associated with a 23% lower rate of new nonmelanoma
(basal-cell and squamous-cell) skin cancers than placebo, resulted in 13% fewer
actinic keratoses after 12 months, and had similar adverse effects.
This is a significant study
by our colleagues in Sydney who found that oral nicotinamide (vitamin B3) (500
mg twice daily) was helpful in reducing the rates of new non-melanoma skin
cancers and actinic keratoses in high-risk patients practicing preventive
measures.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
