Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 28th January 2016 (#27)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial Comment
None
Must Read Section
IMAGES
IN CLINICAL MEDICINE
Cannon A Waves
http://www.nejm.org/doi/full/10.1056/NEJMicm1413235
A 65-year-old man presented with an abrupt
onset of heart palpitations and dyspnea during the previous hour. He had had
three similar episodes but had no other known conditions. Examination of the
jugular venous pulsation revealed cannon atrial waves, shown in a video.
This
video should be reviewed by all readers of the blob, but particularly medical
students doing clinical skills or examining patients.
Recommended learning: Review all of
the information you can learn from the jugular venous pulse and relate these to
pathology and the cardiac cycle.
Articles Recommended for Medical Students
Perspective
Opioid Prescribing for Chronic Pain — Achieving
the Right Balance through Education
Groups advocating quick fixes to the
opioid-misuse epidemic seek regulations limiting opioid availability, but
prescriber education is a more finely tuned approach, allowing us to
individualize care appropriately after a careful benefit–risk assessment.
This Perspective emphasises the importance of
education in the role of prescribing opioids for the management of chronic pain
and how important it is to educate medical students, interns and residents in
their appropriate use.
Question: For how long, and should, over the counter (OTC) codeine
remain available in Australia?
IMAGES
IN CLINICAL MEDICINE
Primary and Secondary Syphilis
A previously healthy 68-year-old man
presented with a solid erosive sore on the inside of his upper lip. He also had
sharply demarcated erythematous, scaly plaques on his hands and feet, including
the palms and soles. The lesions had been present for over a year.
In most patients,
primary syphilis is represented by a chancre which can occasionally last up to
6 weeks. The lesion in the mouth of this patient is not the typical “snail
track ulcer seen in secondary syphilis, although the presence of the rash is
typical, especially the palm and sole involvement. This is NOT a typical
presentation with both primary and secondary disease present.
Recommended learning: Review the prevalence of syphilis in
Australia, the association with HIV infection, the pathology and clinical
presentations of the various stages and the management. Contrast the
presentations of syphilis with the stages of Lyme disease.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 3-2016 — A 9-Year-Old Girl with Intermittent Abdominal Pain
A 9-year-old girl with chronic constipation
was seen in the gastroenterology clinic because of increasingly frequent
episodes of abdominal pain with associated non-bilious vomiting. A diagnosis
was made
There is an
interesting discussion of abdominal pain in a 9 year old girl from the
perspectives of both the GP/paediatrician and the gastroenterologist. The
diagnosis however is unexpected.
Recommended learning: Abdominal pain in the paediatric patient
Important Articles Related to
Mechanisms of Disease and Translational Research
None
Other areas which should be of interest to medical students
EDITORIAL
Progress in Chronic Lymphocytic Leukemia with
Targeted Therapy
This Editorial summarizes the results of two
articles in this week’s Journal which describe two second-generation therapies
(i.e. an improvement on first generation therapy and are usually more selective
in targeting and with fewer adverse events) used to treat relapsed or
refractory chronic lymphocytic leukaemia or small lymphocytic lymphoma. These
newer agents basically inhibit intracellular B-cell receptor signalling and
induce apoptosis. The first drug (venetoclax – don’t even try to remember any
new drug names, just try to understand the mechanism of action) works by
selectively targeting the anti-apoptotic protein BCL2 thus rendering the cell more
susceptible to apoptosis. The second drug, acalabrutinib, i) irreversibly
inhibits the Bruton’s tyrosine kinase (BTK), which is immediately downstream
from the B-cell receptor, and thus blocks activation and additionally, ii) BTK
is involved in chemokine-mediated homing and adhesion of CLL cells to the
microenvironment which are responsible indirectly for cell preservation and
proliferation.
Recommended
learning: Biology of apoptosis
and B-cell activation and signalling.
ORIGINAL
ARTICLE
Belatacept and Long-Term Outcomes in Kidney
Transplantation
This
study evaluated the 7-year efficacy and safety outcomes in transplant
recipients assigned to a more-intensive or less-intensive belatacept regimen or
a standard cyclosporine for immunosuppression. Both belatacept regimens were
associated with significantly superior patient and graft survival.
EDITORIAL
The Clearer BENEFITS of Belatacept
This article and Editorial address patient and renal allograft survival in patients
7 years after transplantation with chronic anti-graft immunosuppression by
either high or lower dose belatacept compared with standard dose cyclosporine
(a calcineurin inhibitor). Belatacept is similar to abatacept, a monoclonal
antibody used in the treatment of RA. The
antibody is a fusion protein containing the Fc fragment of human IgG1 to
maintain the T/2 of the antibody and CTLA4 (cytotoxic T-lymphocyte antigen 4) which
blocks co-stimulatory T cell activation signals. The results (see Kaplan-Meier
curves for patient and graft survival- Figure 2 and Figure 3 for mean eGFR)
indicate that for both doses of the monoclonal antibody, patient and graft
survival and eGFR at 7 years are superior to cyclosporine therapy. Cumulative
adverse events are similar with all therapies.
Recommended
learning:
i)
Pathways
and receptors involved in T lymphocyte activation.
ii)
How are
therapeutic monoclonal antibodies produced?
REVIEW
ARTICLE
Neurobiologic Advances from the Brain Disease
Model of Addiction
The
neurobiology of addiction is pointing the way to potential methods of
disrupting the neurocircuitry with both pharmaceutical and behavioral tools.
Altering the reward and emotional circuits may prevent and treat the problem.
This Review
article considers the scientific advances in the prevention and treatment of
substance-abuse disorder and related developments in public policy in the US.
It discusses the prevalence of addiction, the stages of addiction and the
biological and social factors involved in addiction. There is an interesting Figure 1 describing the neurobiology of
the stages of addiction.
I would consider reading this review prior to
a clinical rotation in Addiction Medicine, prior to the Psychiatry rotation in
MED400 or if you have a specific interest in this area.
