Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 4th February 2016 (#28)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
Perspective
Lost in Translation
Doctors want to be bearers of good news, and
language barriers make it easier to delay difficult discussions, sometimes
indefinitely. But good translators can knit together doctor and patient in a
way that makes the full truth feel like the natural thing to say.
This is an excellent
and concise Perspective describing
the function of the medical translator and problems associated with their use.
It should be read by all medical students to avoid potential pitfalls in the
future.
Recommended learning: Review the PPH LO on the use of translator in
taking a medical history and discussing the illness, treatment options and
outcomes and arranging for follow-up.
Articles Recommended for Medical Students
REVIEW
ARTICLE
The Role of Risk-Reducing Surgery in Hereditary
Breast and Ovarian Cancer
http://www.nejm.org/doi/full/10.1056/NEJMra1503523
The risk of breast and ovarian cancer among
women with mutations such asBRCA1 and BRCA2 mutations can be mitigated by
operations to remove the organs at greatest risk. Data are presented to assist
in deciding what operation should be performed and when it should occur.
This
is an extremely detailed discussion, not only on the role of risk-reducing
surgery in patients with the syndrome of hereditary breast and ovarian cancer,
but also on the current status of hormonal therapy in patients undergoing
surgery and in prevention.
Medical
students should probably just review the first two pages (454-455),
including Figure 1
and possibly the section on Decision Making at the end of the article. There is
an interesting review also on the psychosocial effects on decisions made, or
not.
If
you are looking after a patient who is a BRAC1 and/or BRAC2 carrier, you may
then wish to delve further into the article to answer more specific questions,
if possible. This article provides current state of art knowledge in this area
and the hyperlink should be stored in your data base for the future. It
provides the best current answers for all of those questions that you never
thought existed.
ORIGINAL
ARTICLE
Metformin versus Placebo in Obese Pregnant
Women without Diabetes Mellitus
http://www.nejm.org/doi/full/10.1056/NEJMoa1509819
Metformin improves insulin sensitivity and
was compared with placebo in this study involving obese pregnant women without
diabetes. Antenatal administration of metformin was associated with lower
maternal weight gain but not in lower birth weight of the baby.
This
is an interesting double-blind, placebo-controlled trial study in non-diabetic,
obese (B MI > 35) pregnant women demonstrating that metformin at a dose of 3
gm/day form 12 – 18 weeks gestation reduced maternal weight gain and the
incidence of preeclampsia but had no effect on neonatal birth weight.
It
is revealing to read the later part of the discussion section where the authors
discuss previous similar trials where the metformin dose has been progressively
increased from 1.7 to 2.5 and now 3.0 gm/day; where the time treatment was
initiated in pregnancy has varied; admission BMI from >30 to now > 35 and
finally where “success” of the metformin daily intake in the trials was
regarded by different parameters( where 67% took a minimum of one 500 mg tablet
for 29% of the days compared with current study where 80% of women consumed at least 50% of the
tablets). Finally, a result which was statistically satisfying. As long as you
have pharmaceutical funding, there are no end of clinical trials you can undertake
to obtain a satisfactory result, provided you do not run into significant
adverse events!
IMAGES
IN CLINICAL MEDICINE
Katayama Fever
http://www.nejm.org/doi/full/10.1056/NEJMicm1504536
During an elective in Uganda, a 24-year-old
Dutch medical student swam in the Nile River. Two months after his return, he
presented with a non-productive cough and malaise, as well as diarrhea and
non-pruritic rash. Examination revealed multiple small papules on the trunk
Another reason not to swim the waters in
foreign climes; this time in the Nile, not as previously in the Red Sea without
a face mask (http://www.nejm.org/doi/full/10.1056/NEJMicm1411119 ).
Recommended learning: Review the causes of bladder cancer, including unusual
causes and histology.
IMAGES
IN CLINICAL MEDICINE
Cocaine-Induced Coronary-Artery Vasospasm
http://www.nejm.org/doi/full/10.1056/NEJMicm1503339
A 58-year-old woman presented with
intermittent, non-exertional chest pain. She had been admitted for similar
symptoms 2 months earlier; a coronary angiogram had revealed normal anatomy. A
transthoracic echocardiogram revealed a pericardial effusion. A video is
available at NEJM.org.
Interesting coronary angiograms.
Recommended learning: Review the causes of acute coronary syndrome not due to
atherosclerotic coronary artery disease.
Important Articles Related to
Mechanisms of Disease and Translational Research
None
Other areas which should be of interest to medical students
Perspective
INTERNATIONAL
HEALTH CARE SYSTEMS
Universalism, Responsiveness, Sustainability —
Regulating the French Health Care System
To
secure universal access and better coordinate care, cost containment in France
has been accompanied by reform of the safety net and creation of regional
health agencies. Progress is slower in the ambulatory care sector, where
rural–urban disparities have worsened.
This is an interesting description of the
French healthcare system. I find it interesting to contrast the standard care
of a normal pregnancy and the management and cost of an acute MI, comparing
this with the Australian system.
Also of interest are the salaries of
self-employed GPs and specialists (in US dollars) and salaried physicians in
public hospitals!
CLINICAL
PROBLEM-SOLVING
From Dancing to Debilitated
http://www.nejm.org/doi/full/10.1056/NEJMcps1311794
A 69-year-old man with a history of
hypertension, hyperlipidemia, gastroesophageal reflux, and adult-onset diabetes
mellitus presented with fatigue and a 14-kg unintentional weight loss over the
preceding year.
A
very catchy title, but the diagnosis is not one you would suspect. When you briefly review this clinical
problem, you may wish to store the diagnosis in your brain stem for future
recall.
The
discussion reviews causes of retroperitoneal inflammation, including the
immunological disease of 2015, IgG4-related diseases.
ORIGINAL
ARTICLE
Kidney-Failure Risk Projection for the Living
Kidney-Donor Candidate
This
study examined risk associations calibrated to the U.S. population-level
incidence of end-stage renal disease and death and projected long-term
incidences of ESRD. Risk projections among non-donors were lower than 15-year
observed risks after donation.
EDITORIAL
The Risks of Living Kidney Donation
This study and the accompanying Editorial attempt to answer the question
about the 15 year projected risks in the living-kidney donors compared with age
and sex matched non-donors. While there are many limitations in this study, as
outlined in the Editorial, this is an
attempt to quantify a model-based lifetime projection. The results in this US
suggest a 15-year observed risk after donation of 3.5 to 5.3 times. This
appears highest in black men and lowest in white women.
EDITORIAL
Minimal Residual Disease in NPM1-Mutated AML
One
of the most important discoveries in the treatment of acute leukemia is that
the presence of minimal residual disease is an independent prognostic factor
for the duration of remission and survival.
This
Editorial summarizes the findings of a study in this issue of the Journal (http://www.nejm.org/doi/full/10.1056/NEJMoa1507471 ) which discusses mutations in the NPM1 gene
(which encodes the nucleophosmin protein) in patients with adult acute myeloid
leukaemia (AML). 346 adult patients with
AML and a known mutation in NPM1 completed two cycles of chemotherapy with a histological
remission. Peripheral blood cells were then examined for persistence of the
NPM1 mutation. In adult AML patients, one third exhibit this mutation in
addition to other high-risk predictive cytogenetic abnormalities, while 60% of
all AML patients with no other cytogenetic abnormalities are NPM1 mutation
positive. When analysed after chemotherapy, the presence of the persistent
mutation indicated a significantly greater chance of relapse (82% versus 30%)
and a lower risk of survival at three years (24% versus 75%). This is a significant study whereby the presence
of a persistent single mutation may lead to a different therapeutic approach
using early stem cell transplantation in this patient population.
ORIGINAL
ARTICLE
Routine Amoxicillin for Uncomplicated Severe
Acute Malnutrition in Children
The role of routine antibiotic use in the
treatment of severe acute malnutrition is unclear. In this randomized,
placebo-controlled trial in Niger, amoxicillin did not significantly improve nutritional recovery in 2399 children
with severe acute malnutrition from four rural health centres. These children, with
ages ranging from 6 to 59 months,
were able to be treated at home.
