Wednesday, 20 January 2016

NEJM Week of 20th October 2015 (#13)

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

None
                                                                                                                
MUST READ SECTION

 

None


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

None

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

Case 33-2015 — A 57-Year-Old Woman with Hair Loss and Deepening Voice

http://www.nejm.org/doi/full/10.1056/NEJMcpc1413304


A 57-year-old woman presented with hirsutism, hair loss on the scalp, and deepening of her voice. Previous testing had revealed elevated total and free testosterone levels and a normal dehydroepiandrosterone sulfate level. A diagnostic procedure was performed.

 


Recommended learning: Consider the differential diagnosis of hyperandrogenism and virilism in the female