Professor Brian Andrews
NEJM Recommendations for Medical Students and Tutors
Week of the October 8th
2015 (#11)
University of Notre Dame
Australia
(Fremantle Campus)
Articles Recommended by and for
Medical Students
CLINICAL
PRACTICE
Insomnia Disorder
http://www.nejm.org/doi/full/10.1056/NEJMcp1412740
“Evaluation of insomnia should include a complete medical
and psychiatric history and assessment of sleep-related behaviors and symptoms.
Therapies for persistent insomnia include cognitive behavioral therapy
(considered the first-line treatment) and hypnotic medications”
This is an interesting review article on insomnia, a common
presentation in all area of medicine, but in particular general practice. I was
interested to find that roughly 50% of individuals with insomnia disorder have
a psychiatric disorder, most likely a mood or anxiety disorder and of the 80%
of patients with depression who have insomnia, the insomnia precedes the
depression in 50%.
The role of CBT is interesting, but I wonder how often this
is utilized in general practice. The approach to treatment seems very simply
laid out, but at the end of the day I wonder what percentage of patients taking
long term benzos in order to sleep and function are ever able to wean
themselves from them. Ideal in theory but harder in practice. Do long term
benzos predispose to early dementia?
Recommended
learning: Review the pharmacology of benzodiazepines; use of lower
doses of nocturnal antidepressants for insomnia and biology of orexin and
melatonin in sleep.
REVIEW
ARTICLE
Invasive Candidiasis
Despite advances in antifungal therapy, the mortality
associated with invasive candidiasis remains as high as 40%. This review
summarizes recent trends and current strategies, including early treatment and
the emergence of resistance against triazoles (eg fluconazole) and
echinocandins (e.g. caspofungin).
This is an interesting review on invasive candidiasis, in
particular the interesting figure on the pathogenesis of invasive candidiasis
(Figure 1). Risk factors are outlined
but I found very interesting the distribution of specific Candida species
producing infection, based on duration of prophylaxis and type of agent used
for prophylaxis.
Recommended
learning: Review the microbiology of Candida species, the
immunogenetics and immunology of candida infections (page 1447), common
infections caused by this fungus in practice and their treatment.
IMAGES
IN CLINICAL MEDICINE
Oral Maxillary Exostosis
A common finding by medical students in patients and the
need to be aware of this relatively common condition and frequently not as
prominent as in this patient. These are regarded as a normal variant in most
patients and not regarded as an osteoma, although histologically identical.
MAGES
IN CLINICAL MEDICINE
Gastric Ascaris Infection
An interesting MRI.
Recommended
learning: Review round worm
infections and their treatment
Important Articles Related to
Mechanisms of Disease and Translational Research
ORIGINAL
ARTICLE
Daclizumab HYP versus Interferon Beta-1a in
Relapsing Multiple Sclerosis
This study compared the therapeutic effects of a
monoclonal antibody to CD25 (the chain of the IL-2 receptor) with standard
IFN-1a in patients with relapsing-remitting MS. While anti-CD25 reduced the
number of new plaques and the size of established plaques on MRI, as well as
reducing the annualized relapse rate, it had no significant effect the
incidence of disability progression. Further adverse events were more common
with the anti-CD25 (rash, eczema, serious infections and elevated liver
function tests. It is unclear from this study what the future use of this agent
will be in MS management.
Recommended
learning: Immunology of IL-2 and the IL-2 receptor; review the
immunopathogenesis of MS and its management (clinical case in MED300).
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 31-2015 — A 29-Year-Old Man with Thymoma,
Diarrhea, and Weight Loss
This is a case of a patient presenting with a malignant
thymoma with profuse diarrhoea and immunodeficiency. It considers infectious
causes of diarrhoea and autoimmune enteropathy, identical with the diarrhoea
seen in chronic GVH reaction.
Recommended
learning: Mediastinal masses on CXR; review thymomas, especially
their association with myasthenia gravis and other autoimmune diseases; review
the PBL case of immunodeficiency and
the causes; review the general concept of transcription factors and the AIRE
transcription factor; review the classification of diarrhoea, investigations
and management.
Other areas which should be
of interest to medical students
EDITORIAL
Remote Ischemic Preconditioning in Cardiac
Surgery — Ineffective and Risky?
Prior to this editorial and the two articles on this
topic published in this issue, I had no knowledge of this area, although I was
aware of ischemia-reperfusion injury. Apart for the fact that remote ischaemic
preconditioning (occlusion of the circulation in the non-vital upper limb with
a BP cuff for 5 minutes and then reperfusion for 5 minutes and repeating this
exercise for a further four cycles) for patients having CABG with or with valve
or aortic surgery on standard bypass, there was no overall difference in deaths
from cardiovascular causes, nonfatal MIs, coronary revascularization or strokes
in patients (occluded or sham) at 12 months or at the time of hospitalization
and up to 90 days after the procedure.
Sub-group analyses would be very interesting, considering that one third of the
patients in one study also had severe aortic stenosis. Here the devil may well
be in the detail.
Previous studies have indicated that a factor(s) may be
released by the repetitive occlusion of the circulation to a non-vital organ
which may then be beneficial to an ischaemic vital organ such as the heart.
This was not demonstrated by these studies but is fascinating is the nature of this
putative substance(s).
EDITORIAL
Support for SUPPORT
SUPPORT (the Surfactant, Positive Pressure, and Oxygenation
Randomized Trial) was conducted in premature newborns.
The editorial (and the perspective) make very interesting
reading.
The following paragraph from the editorial summarises the
legal decision:
“Judge Bowdre put her finger on the key concept in the
SUPPORT controversy, one that many ethicists seem not to have recognized. When people contract an illness (in
this case premature neonates), there is a risk that bad things will happen.
Research undertaken to improve the care of people stricken with such an illness
cannot be expected to eliminate that intrinsic risk. Thus, in calculating the
risk of participation in research about an illness, one should not include the
risk of bad things that may happen as a result of having that illness.
Researchers need to delineate during the informed-consent process the risks
that derive from the intervention that they hope will make treatment better and
safer, but not the risks of the disease itself.”
ORIGINAL
ARTICLE
BRIEF
REPORT
Pregnancy, Primary Aldosteronism, and Adrenal CTNNB1Mutations
http://www.nejm.org/doi/full/10.1056/NEJMoa1504869
An interesting brief
report of three patients (two pregnant) with adrenal adenomata and
hyperaldosteronism. All had activating mutations of the gene CTNNB1 which
encodes for -catenin in the Wnt cell-differentiation pathway and x100 fold
increase in the density of the receptors for LHCG and GNRH within the tumours.
The authors begin by
quoting the results of two studies which are clearly NOT the real world
experience of most treating doctors, but, none the less, need to be reconciled
by further work.
“Systematic screening detects primary aldosteronism in 5 to
10% of all patients with hypertension and in approximately 20% of patients with
treatment-resistant hypertension.1,2”
1. Mulatero
P, Stowasser M, Loh KC, et al. Increased diagnosis of
primary aldosteronism, including surgically correctable forms, in centers from
five continents. J Clin Endocrinol Metab 2004;89:1045-1050
2. Rossi
GP, Bernini G, Caliumi C, et al. A prospective study
of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol 2006;48:2293-2300
Recommended
learning: Review the causes and management of real world
hypertension; hypertension is extensively covered in BTB lectures, in the PBL
case and in at least two clinical cases in MED300; review the Wnt pathway (canonical) and consider the
role of Wnt pathway activation, increased b-catenin and bone formation. Could this be
useful in treating some forms of osteoporosis?
