Professor Brian Andrews
NEJM Recommendations for Medical Students and Tutors
Week of the 7th
January 2016 (#24)
University of Notre Dame
Australia
(Fremantle Campus)
Occasional Editorial Comments
As you can see, my NEJM weekly review is now in the form of a blog which will allow searching of back reviews. This
will come to you as an e-mail of the current review with access previous issues
by clicking on the bottom of each weekly review to access the blog..
As this is the first issue of the New Year and as the new MED100 class
will be accessing the blog, I would like again to review the reasons I developed my NEJM review, now 24 weeks young.
As you are aware there are many ancillary learning aids associated with the Journal which I am not attempting to
duplicate.
1. The primary aim
is to foster an interest in every Notre Dame medical student and teacher the
need to remain current in all areas of the curriculum and to develop a yearning
for continued long term learning. My recommendations are not compulsory reading
(except for my MED300 tutorial groups) but for those interested. I hope that most students would read my
weekly review and, at the least, explore the NEJM titles to keep abreast of new
developments which will determine the basis of their future practice. Students will
at least become aware of areas they never knew existed.
2. The NEJM is the
most widely read journal internationally with the highest impact factor of any
journal.
3. The weekly
review is in no way an exhaustive review.
Articles are chosen for their specific relevance to the evolving UNDA medical
school curriculum, to update the student particularly in i) basic sciences
(e.g. cell and molecular biology, immunology, genetics, pharmacology), ii) advances
in newer therapies and to iii) explore new and unrealized areas. Please do not
feel neglected if an article related to your specialty or specific clinical or
research interest, which you feel represents a major advance, is not
highlighted. All are encouraged to
review all titles in each issue.
4. I will attempt
to include areas from each of the Medical School Teaching Domains.
a. Perspective:
Covers all domains, but areas related to PPD and PPH are overrepresented. Many relate specifically to medicine in the
US and will not be highlighted unless there is a specific application to
Australian medicine. For many years I skipped the Perspective section and focused on original articles and reviews:
this was my loss.
b. Original Articles: Some articles will interest
you, while others will not. If interested or in doubt, always read the abstract
and the introduction to the paper. The introduction will provide an overview to
the study, why it was performed and you will pleasantly update your knowledge
in several unexpected areas.
c. Review
Articles: State of the Art review articles are always interesting and
encompass wide areas. My suggestion is
that these be stored as hyperlinks in your long term data base learning system,
such as Evernote (free for moderate storage).
You can also include your long cases in in Evernote for future use after
medical school.
d. Clinical
Pathological Conference (CPC) or Case
Records of the Massachusetts General Hospital: It is very interesting to
follow the clinical reasoning of the discussant. As an exercise, sit down with
a colleague, consider the broad Presenting Symptom(s) and develop a list of
differential diagnoses before you read the case.
e. Images in Clinical Medicine: Fun to look
at. Remember, if a consultant or tutor mentions a specific disorder and you
want to see it with the pathology, always check in this extensive data base.
Apart from Figures, videos are also included.
f. Editorials: After reading the
abstract for the original article, I always then check the editorials before I
read the original article in detail.
These should give you an in-depth overview of the results of the study
and comparisons with other study results.
g. Clinical Problem Solving: Usually
always fun, may learn about an unusual disease but will help to develop the
skill of clinical reasoning.
h. Clinical Implications of Basic Research: Usually, I
find this the most interesting area in the Journal.
The author of the article has been solicited by a member of the editorial board
to write a short summary, with a great picture, of a recent cutting edge basic
science article (e.g. from Science, Nature, PNAS) and to hypothesise on the
relevant to future human research.
i. Figures and Tables: These are
extremely well done, easy to understand and can be saved in a Powerpoint format for presentations.
j. Errors: Errors can occur and are
usually mentioned in subsequent Corrections. As a word of general caution when reading any
article or book, if you cannot understand a statement or a Figure, always check
with a colleague as errors can occasionally occur and should not result in you
having a sleepless night.
k. Other goodies: The NEJM has an
extensive Video Collection of most
commonly performed clinical procedures which are extremely well illustrated and
explained. One of these will be suggested for review every two weeks. Enrol in Residents
E-Bulletin where two key articles are reviewed with Morning Report
questions and Clinical Pearls. Further, there is a Weekly Audio Summary as a Podcast of articles chosen as the most
significant by the editorial board.
l. You can also do
searches of back issues for virtually any topic in Medicine about which you may
require information.
m. The entire
weekly issue of the Journal is available through the medical library as an
e-journal and is readily searched.
5. Finally, I must
state that the views expressed are mine alone and you may not necessarily agree
with them. At least this will hopefully provoke discussion between students and
encourage learning. Errors will invariably occur and for these I apologize in
advance. Please do not hesitate to contact me when this happens.
OCCASIONAL EDITORIAL COMMENT
In the
series of articles on International Health Systems, at
least read the two examples of how acute myocardial infarction and normal
pregnancies are managed in each country.
For
last year, my Virus of the Year was Chikungunya, for 2016 the winner is the Zika virus. Both of these mosquito borne
viruses have the future potential to significantly involve the Australian
population. Zika is not only sexually transmissible, like Ebola, but is
associated with microcephaly in pregnant patients and now Guillain-Barre
syndrome: a fascinating virus to work on. It would be fun if you are
considering a future in ID to think about working at the CDC in Atlanta as a
medical detective.
MUST
READ SECTION
CLINICAL IMPLICATIONS OF BASIC RESEARCH
Cardiac
Repair after Myocardial Infarction
http://www.nejm.org/doi/full/10.1056/NEJMcibr1512011
This is
a fascination article on reducing myocardial damage in pigs after experimental
myocardial infarction (Nature 2015, Wei
et al). By suturing a bioengineered collagen patch loaded with purified
human Fstl1 (Follistatin-like 1) which binds to BMP-4 binding protein and TGF-b to the epicardium overlying
the infarcted area, the researchers showed that there was reduced scarring, an
increase in the development of new blood vessels and an increase in the number
of dividing cardiac myocytes. There is much work yet to be done, particularly
functional and outcome studies. However, I can envisage in the not too distant
future that following percutaneous angioplasty after a major MI, if there is
residual significant acute myocardial damage that the cardiologist will either
inject the injured site sub-endocardially with the appropriate cardiac myocyte
stimulant or the surgeon will use a similar epicardial patch to that mentioned
in the study.
Recommended reading: Review the pathology of atherosclerosis and
myocardial infarction
Articles Recommended for
Medical Students
IMAGES IN CLINICAL MEDICINE
Hyperviscosity-Related
Retinopathy in Waldenström’s Macroglobulinemia
http://www.nejm.org/doi/full/10.1056/NEJMicm1501103
An interesting case with great fundal changes. This
retinal phenomenon is also called “cattle trucking” of the blood in the retinal
veins. These changes are also found in the fundus immediately after an
unsuccessful cardiac arrest.
Comment: When a patient with Waldenström’s macroglobulinemia presents with anaemia, the treatment is not transfusion which may well kill the
patient by increasing the hyperviscosity (IgM is an intravascular
immunoglobulin), but plasmaphoresis.
REVIEW ARTICLE
Viral
Bronchiolitis in Children
http://www.nejm.org/doi/full/10.1056/NEJMra1413456
This is
an excellent, comprehensive review of acute viral bronchiolitis and should be
read by all MED300 students doing paediatrics. Keep this hyperlink in your data
base. This is common in general and paediatric practice and will be extensively
covered by Dr. Fleming Nielsen during the paediatric rotation. I am sure he
will also recommend this article as well as mention the association with the
syndrome of inappropriate ADH. There
is a wonderful Figure and tables. Don’t forget: be aware of the Australian
guidelines.
Recommended reading: Acute bronchiolitis, its
clinical presentation and management.
CLINICAL PROBLEM-SOLVING
A
Complementary Affair
http://www.nejm.org/doi/full/10.1056/NEJMcps1404086
A 57-year-old man
with a history of Sjögren's syndrome presented with several weeks of gradually
worsening fatigue and exertional dyspnea. He reported no cough, fevers, chills,
chest pain, palpitations, orthopnea, or paroxysmal nocturnal dyspnea
Recommended
learning: This is an interesting case that explores the
causes of dyspnoea in a logical progression. MED300 and MED400 should read
about Sjogren’s syndrome and review the classification of cryoglobulins (types
II and II are immune complexes) with hepatitis C and active SLE the more common
causes in Australia.
Other areas which should be
of interest to medical students
IMAGES IN CLINICAL MEDICINE
Percutaneous
Rotational Pulmonary Thrombectomy
http://www.nejm.org/doi/full/10.1056/NEJMicm1415847
A 77-year-old
woman was admitted to the emergency department with chest pain, palpitations,
and dyspnea. She received a diagnosis of pulmonary emboli. A video shows
advancement of a pigtail catheter into the embolus site; tissue plasminogen
activator was subsequently delivered directly into the clot.
This shows
the classical ECG for a large pulmonary embolism (S1, Q3T3) which is very
infrequently seen in clinical practice.
Perspective
INTERNATIONAL HEALTH CARE SYSTEMS
Innovation
and Change in the Chilean Health System
http://www.nejm.org/doi/full/10.1056/NEJMp1514202
Chile has had a
two-tiered health system since the 1980s, though successive governments have
worked to strengthen the public tier. Despite improvements in some health
indicators, satisfaction with the system has declined, and the need for reform
is widely acknowledged.
ORIGINAL ARTICLE
Predictive
Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia
http://www.nejm.org/doi/full/10.1056/NEJMoa1414838
The results of this study may or may not pan out in the
future but the study offers an insight into the possible causative mechanisms
of eclampsia.
ORIGINAL ARTICLE
Evaluation
of Convalescent Plasma for Ebola Virus Disease in Guinea
The use of
convalescent plasma to treat Ebola virus disease has been a focus of interest
since Ebola virus was first identified in the 1970s. However, in this report
from Guinea, the use of convalescent plasma did not significantly improve
survival.
While the results of this study indicated that
convalescent serum was not effective, I believe the results are premature and
incomplete. Wait for Part Two where
the titre of anti-Ebola antibody is measured in convalescent serum as well as
the functional type of antibody produced. I am sure this is already in press
and the results may well be different for selected convalescent sera.
