Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 29th October 2015 (#14)
University of Notre Dame Australia
(Fremantle campus)
Occasional Editorial
Comments
I have recently returned from the annual American
College of Rheumatology meeting in San Francisco and one thing that sticks in
my mind, apart from the large amount of new basic science presented and new
therapeutic options, was the use of a new word. We are all only too aware of
new technologies and the new jargon to describe them, such as genomics,
metabolomics and proteomics, but now a new word with a critical meaning has
crept into the vernacular: clinomics
– the art of history taking, the physical examination and clinical reasoning.
This is the most important of the “omics.”
New
thoughts on total knee and hip arthroplasties: Assays are now available to measure the levels of
ceramic and metal ions in serum of patients who have had TKAs and THAs. With
more wear, are the levels higher? What effect will higher levels in the patient
with the appropriate genome and immune response have on your brain or blood vessels?
Stay tuned.
As students are now on vacation, these reviews will
continue but with my recommendations only.
I will catch up with the backlog over the next week
EDITORIAL
Fifteen Year
http://www.nejm.org/doi/full/10.1056/NEJMe1512739
This is a review of
the history on the NEJM by the editor at the helm for the past 15 years. He
relates the changes in content over time with the changing research scene, the
use of randomized clinical trials and the role the journal has played in the
registration of clinical trials and professional disclosures – an interesting
read.
Articles Recommended for Medical Students
Perspective
Trends in Metastatic Breast and Prostate Cancer
— Lessons in Cancer Dynamics
Discordant trends in the incidence of
metastatic breast and prostate cancer since the widespread implementation of
early-detection efforts may reflect distinct disease dynamics or may result
from the different screening strategies used
The authors discuss
the efficacy of screening procedures and their role in breast and prostate
cancer for patients presenting with metastatic disease. Whereas PSA screening
has reduced the incidence of patients presenting with metastatic prostate
cancer, initiating of widespread mammography has had no significant impact on
the metastatic presentation of breast cancer. There is an interesting discussion
based on various biological paradigms as to why this may be so.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 34-2015 — A 36-Year-Old Woman with a Lung
Mass, Pleural Effusion, and Hip Pain
http://www.nejm.org/doi/full/10.1056/NEJMcpc150215
A 36-year-old woman presented with a mass in the middle
lobe of the right lung. Lobectomy was performed, and examination of the
specimens revealed evidence of lipoid pneumonia and fibrinous pleuritis. Six
months later, pain in the right hip developed. A diagnosis was made.
This involves the differential diagnosis of a
right middle lobe mass with bronchial obstruction and an incorrect initial
histological diagnosis.
This entity is becoming increasingly
recognised and may present to the surgeon as an abdominal mass or ureteric
obstruction [ retroperitoneal (and mesenteric) fibrosis], periaortitis,
autoimmune pancreatitis particularly with a mass, a firm thyroid mass and a
sicca complex with major salivary and lachrymal gland enlargement. Read about
the entity in the review below by John Stone. Since the earlier review (it was
recognized first in the Japanese literature), there is more emphasis placed on
the immunohistopathology and vessel involvement and less on the presence of an
elevated serum IgG4 level.
REVIEW ARTICLE
Mechanisms of Disease: IgG4-Related Diseas
http://www.nejm.org/doi/full/10.1056/NEJMra1104650
IgG4-related disease is a newly recognized
fibroinflammatory condition characterized by tumefactive lesions, a dense
lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, storiform
fibrosis, and, often but not always, elevated serum IgG4 concentrations.
Stone
J.H.Zen Y.Deshpande V. N Engl J Med 2012; 366:539-551, February 9, 2012
IMAGES
IN CLINICAL MEDICINE
Sporotrichoid Mycobacterial Infection
Sporotrichosis is a
worldwide dimorphic fungal infection involving an inoculation site usually on
an extremity and is seen most frequently in gardeners (the classic is the rose
thorn lesion), farmers and the immunosuppressed. Usually an ulcerative lesion
develops at the primary site and satellite lesions can then form along afferent
lymphatic vessels.
This, however, is a
patient infected with Mycobacterium
marinum who was being treated with a TNF inhibitor (infliximab) and with
satellite spread from the primary inoculum site because of the inability to
localize the infection by forming stable granulomata.
Recommended learning: review atypical mycobacterial infections
SPECIAL
ARTICLE
SHATTUCK
LECTURE
The Future of Public Health
This lecture addresses
the area of general public health and introduced me to a new pyramid, the concept
of the Health Care Pyramid. This is a good overview on public health and
contrasts infectious diseases with chronic diseases, both in the US and
everywhere else (non-US or around the world, which includes a large number of
players at extremes of the socio-economic scale).
What stood out to me
were two sentences that I could not reconcile:
1.
“Tobacco
use is still the leading underlying cause of death in the United State and
worldwide”, and
2.
“Hypertension
is the only condition that kills more people globally than tobacco use-more
than 9 million per year.” (contrasted with 6 million per year for tobacco use)
Thomas R. Frieden delivered the oration and was the senior author of this
hypertension study.
The reason I mention these two sentences is that when, and hopefully
if, the student reads this article and
comes across the same apparent discrepant statements that they should not
despair, but rather question the way the paper was written for clarity and
consider whether it was peer reviewed and then discuss this with a colleague.
Important Articles Related to Mechanisms of Disease and
Translational Research
CLINICAL
IMPLICATIONS OF BASIC RESEARCH
Fibrinolysis as a Target to Enhance Fracture
Healing
http://www.nejm.org/doi/full/10.1056/NEJMcibr1510090
Actually, this
was my favourite article for the week which was the summary of the work
recently published by Yuasa and colleagues in JCI.
The authors
demonstrate in a murine model, where the healing of fractures is studied, that
in order for vascular channels to develop in the area of endochondral bone
formation in the centre of callus that fibrin must be cleared first by
fibrinolysis. If fibrin is not cleared, VEGF is not produced. The experiments
performed are elegant and should be readily understood by medical students from
MED200 on. This work may well be very important in patients who have delayed or
incomplete healing of fractures, particularly in those patients with early
identifiable risk factors for poor healing.
Could this also play a
role in normal wound healing after any surgical procedure?
Recommended learning: healing of fractures, particularly the
pathology, and all aspects of wound healing
Other areas which could be of interest to medical students
ORIGINAL
ARTICLE
Paclitaxel-Eluting versus Everolimus-Eluting
Coronary Stents in Diabetes
“In patients with diabetes mellitus and coronary
artery disease undergoing PCI, paclitaxel-eluting stents were not shown to be
noninferior to everolimus-eluting stents, and they resulted in higher rates of
target-vessel failure, myocardial infarction, stent thrombosis, and
target-vessel revascularization at 1 year.”
The NEJM, and I assume
the cardiology literature, is inundated with coronary artery stent studies of
all types and the increasing use of noninferiority studies. There will be
several articles with the stent theme over the next three weeks and most will
not be mentioned in this review. But what on earth are we coming to when we
talk in double negatives “not shown to be noninferior.” I interpret this to
indicative (I think) that the everolimus-eluting stent was superior to the
paclitaxel stent in the many parameters of the study.
The study was based on
the original observation that mTOR pathway activation was impaired in diabetes
and that an everolimus (an mTOR inhibitor) stent would be inferior to a paclitaxel
stent.
