Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 14th January 2016 (#25)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial Comment
None
Must Read Section
IMAGES
IN CLINICAL MEDICINE
Lancisi’s Sign
http://www.nejm.org/doi/full/10.1056/NEJMicm1502066
Don’t try to remember the name Lancisi. I had
never heard of the individual (one upmanship) nor was the individual mentioned
in one of my favourite books on the evidence basis of physical diagnosis (Art and Science of Bedside Diagnosis by
Sapira).
However, his is a must watch video of
CV waves in the neck of a patient with severe tricuspid regurgitation.
Articles Recommended for Medical Students
ORIGINAL
ARTICLE
Weight Loss and Health Status 3 Years after
Bariatric Surgery in Adolescents
EDITORIAL
The Obesity Epidemic — Understanding the
Disease and the Treatment
Both the article and
the Editorial discuss the “Severe” Obesity
Epidemic in Western society but with specific reference to severe obesity in the
childhood and adolescent populations. The Editorial gives a succinct overview
of the problem and its strong relationship to severe obesity in adults. The
study discusses the results of bariatric surgery (gastric sleeve or roux-en-Y
gastric bypass) in a select subgroup of 242 adolescents with severe obesity at
three years of follow-up. Apart from the side effects which are significant but
expected and predictable, the results of the surgery appear to be remarkable
with an overall weight loss of 27%, remission in type II diabetes mellitus in
95%, hypertension in 74%, dyslipidaemia in 66%, prediabetes in 76% and
improvement in abnormal renal function in 86%. If these results continue over
the longer-term, this appears to be a significant advance in this selected
population.
Perspective
Shared Decision Making — Finding the Sweet Spot
The patient's role in medical decision making
is often not matched to the clinical circumstances: rather than making strong
recommendations when there's greater certainty and allowing patients to decide
when there's greater uncertainty, we should do the opposite.
Important Articles Related to
Mechanisms of Disease and Translational Research
None
Other areas which should be of interest to medical students
ORIGINAL
ARTICLE
Comprehensive Molecular Characterization of
Papillary Renal-Cell Carcinoma
http://www.nejm.org/doi/full/10.1056/NEJMoa1505917
Recommended learning: Review the epidemiology, pathology, presentation and
unusual paraneoplastic syndromes that accompany renal cell carcinoma. I would
not try to read the paper unless you have a specific interest in this topic.
Perspective
Medical Taylorism
http://www.nejm.org/doi/full/10.1056/NEJMp1512402
Under economic pressure, medicine is
increasingly being subjected to the efficiency principles of “Taylorism.” But
applying standardization to certain vital aspects of medicine can result in
inappropriate and unresponsive care, as well as clinician burnout.
This
Perspective is further musing on what is sacrificed in patient care for
“efficiency”
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 1-2016 — An 18-Year-Old Man with Fever,
Abdominal Pain, and Thrombocytopenia
http://www.nejm.org/doi/full/10.1056/NEJMcpc1501306
An 18-year-old man presented with fever,
abdominal pain, and thrombocytopenia. Abdominal imaging studies showed
nonspecific fluid collection and necrotic lymph nodes, and there were elevated
levels of C-reactive protein and ferritin. A diagnostic procedure was performed
An
interesting CPC that reviews the causes of i) marked elevations in serum ferritin
and ii) a normal ESR with elevated CRP.
ORIGINAL
ARTICLE
Intensified Antituberculosis Therapy in Adults
with Tuberculous Meningitis
EDITORIAL
Chemotherapy for Tuberculous Meningitis
The Editorial
by Dr. Donald from Tygerberg, South Africa, provides an interesting discussion
on the ability of specific anti-tuberculosis drugs to cross the blood-brain
barrier and the development of specific drug resistance and their mechanisms.
He describes TB meningitis in his study of children with established TB
meningitis with a mortality rate of 3.8% in contrast to the Vietnamese in adults
with an extremely high 9 month mortality. The essence of the study was to
determine if higher dose rifampin with a quinolone added to standard RIPE
therapy improved mortality in the Vietnamese adult population: IT DID NOT.
However with both data sets, it is all in the details e.g. ethionamide (readily
crosses the BB barrier) is used in the South African study whereas ethambutol was
used in the Vietnamese study where 43% of patients were also HIV positive. When
you try to compare studies it is extremely difficult and all parameters must be
compared. Don’t spend much time on the study, but I would consider reading the Editorial.
Recommended learning: Pathology and sequelae of TB meningitis and
principles of management. Populations more likely to be affected in Australia
–HIV positive, new immigrants and the Aboriginal population.
IMAGES
IN CLINICAL MEDICINE
Squamous-Cell Carcinoma of the Penis with Human
Papillomavirus
A 54-year-old man presented with a polypoid
mass involving the right side of the penis glans that had developed over a
period of about 8 months. The lesion was itchy with purulent secretions and was
associated with a swollen right inguinal lymph node and a weight loss of 9 kg.
REVIEW
ARTICLE
Relationship between Nonmedical
Prescription-Opioid Use and Heroin Use
A large fraction of heroin users now report
that they formerly used prescription opioids nonmedically, a finding that has
led to restrictions on opioid prescribing. Nevertheless, only a small fraction
of prescription-opioid users move on to heroin use.
Perspective
FDA Approval of Flibanserin — Treating
Hypoactive Sexual Desire Disorder
After three reviews, the FDA approved
flibanserin for hypoactive sexual desire disorder in premenopausal women,
concluding that efficacy had been established but requiring a boxed warning, an
alcohol contraindication, and a risk evaluation and mitigation strategy
