Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 18th February 2016 (#30)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
Perspective
The Doctor’s
New Dilemma
http://www.nejm.org/doi/full/10.1056/NEJMp1513708
A central primary care dilemma is that
engaging with patients as people makes us fall behind in administrative tasks
and feel more burned out, but not engaging means avoiding intimacy that would
not only help the patient but keep us from feeling burned out
To chat or not to chat, that is the question?
The above summary of the Perspective is the crux of the matter. Do you engage your patient at
the onset talking generally about the book next to their bed, about their
occupation, about their travels or their family? The presenting complaint may
not be what the patient really wants to talk about. Invariably, after I introduce myself to the
patient and find out their presenting complaint, I will ask a few general questions
such as where they live; where were they born; what do they do; do they have a
family and support system, reading or travel? This only takes a matter of
minutes but allows the process of building early rapport. Frequently with this
“chit-chat” up front, the real reason, if not obvious, for their visit may
become apparent. Unfortunately, in this
day and age, “time is money” which tends to blunt this essential interaction.
As a profession, we must rally against forces
trying to reduce this essential patient-doctor interaction. We must work through our professional
organizations and government to ensure a just remuneration for services
rendered by all primary care physicians (I am excluding most proceduralists and
surgeons) to be based on realist and justifiable time spent with the patient.
Just wait for a politician or their family to be seen and they will both demand
and expect extra time to be spent with them.
IMAGES
IN CLINICAL MEDICINE
Geographic Tongue
http://www.nejm.org/doi/full/10.1056/NEJMicm1502932
A 73-year-old man was referred by his primary
care physician, who noted a “weird” red lesion that had been moving across the
dorsum of the man's tongue for approximately 3 months. The patient was a former
smoker with essential hypertension, hypercholesterolemia, and hyperuricemia.
Students frequently mention geographic tongue,
usually as not being present, when they are describing the tongue in the mouth
examination. Now, I am sure that many
will now be able to recognise this entity when present in their patient.
Articles Recommended for Medical Students
Perspective
Zika Virus in the Americas — Yet Another
Arbovirus Threat
http://www.nejm.org/doi/full/10.1056/NEJMp1600297
The explosive pandemic of Zika virus
infection in South and Central America is the most recent of four unexpected
arrivals of important arthropod-borne viral diseases in the Western Hemisphere
over the past 20 years. Is this an important new disease-emergence pattern?
As
the Perspective indicates, this “explosive
epidemic occurring throughout South America, Central America and the Caribbean,
is now potentially threatening the United States.” Suddenly last week,
President Obama requested the US congress to appropriate $1.8 billion dollars
to combat this epidemic. As the Perspective
indicates, there is much that is unknown about this arbovirus (a virus spread
by arthropods, such as mosquitoes and ticks and probably by sexual intercourse
– why are some and not others affected?). It has been difficult to get an early
handle on this epidemic as the Brazilian Health Authorities have been reluctant
to share their data with the CDC for fear they will lose control of their investigations,
the results of which they fear will be cannibalized in publications and
research dollars by the CDC! Talk about mutual collaboration. As with dengue,
chickungunya and West Nile virus, global warming may well play a role as the
vector travels and mutations occur in the viruses.
An
excellent, large case-control study (pregnant women with and without active
viral infection) is underway with results available within nine months.
If
you have witnessed the quantity of toxins being sprayed, inhaled and ingested
by the inhabitants (they drink the water in buckets that have been sprayed) to
remove the mosquito larvae, how will this toxic exposure be excluded as a risk
factor for disease and foetal abnormalities?
What
is the association between the virus and microcephaly and Guillain-Barre
syndrome? Stay tuned.
ORIGINAL
ARTICLE
Clinical Management of Ebola Virus Disease in
the United States and Europe
http://www.nejm.org/doi/full/10.1056/NEJMoa1504874
Since the beginning of the current Ebola
epidemic, several patients with Ebola virus disease have been cared for in the
United States and Europe. In this report, the clinical course and care of these
27 patients are described.\
This
article describes the management of 27 patients with Ebola infection acquired
in West Africa (#24) and in the US or Europe (#3). Of the 27 patients, 22 were
health care personnel and all were treated in the US or Europe. Compared with
management in West Africa (survival rates from 26 – 63%), the survival rate in
this group was 81.5% (five died). This improved survival rate was attributable
to “close monitoring, and aggressive supportive care that included intravenous
fluid hydration, correction of electrolyte abnormalities, nutritional support
and critical care management for respiratory and renal failure.”
Of
the 27 patients, 23 received a variety of investigational therapies which will
undoubtedly be described in the future in more detail when combined with data
from the West African experiences.
However
if a new drug, biological therapy or vaccine is found to be effective which the
drug companies will be willing to expend the enormous cost of producing a drug
with limited use? If it is a vaccine, who will be vaccinated, when will they be
vaccinated and who will bear the costs?
Maybe,
the WHO could develop its own Pharmaceutical Research and Development Company
to produce drugs and vaccines that multinational Pharma does not deem
profitable for shareholders. Again, who would pay the bill, but just a thought?
REVIEW
ARTICLE
Statin-Associated Autoimmune Myopathy
http://www.nejm.org/doi/full/10.1056/NEJMra1515161
Statins are widely used and lower the risk of
death from cardiovascular causes. In a fraction of patients, an autoimmune
myopathy may develop, characterized by the development of autoantibodies to the
target enzyme, HMG-CoA reductase
This
is an important Review Article on
muscle disease associated with statin therapy. Although the article focuses on
a very rare autoimmune necrotizing myopathy with
antibodies directed against HMG-CoA reductase (incidence of 1 in 50,000
patients treated), the basic information for medical students regarding statin
use is contained in the first paragraph, in particular in reference 1 (Ganga et
al, 2014), which is a large systemic review which found that mild
musculoskeletal symptoms, such as myalgias, occur equally in controls and
patients treated with statins.
This
will raise many discussions between those with extreme views who believe
statins are “poisons” and those that believe statins should be in the water
supply.
ORIGINAL
ARTICLE
A Randomized Trial Comparing Skin Antiseptic
Agents at Caesarean Delivery
http://www.nejm.org/doi/full/10.1056/NEJMoa1511048
In this single-center trial comparing
chlorhexidine–alcohol with iodine–alcohol for skin antisepsis before caesarean
delivery, the use of chlorhexidine–alcohol resulted in a risk of surgical-site
infection that was significantly lower than that associated with
iodine–alcohol.
This is a clearly defined study with defined
outcomes, performed in a single centre, comparing chlorhexidine-alcohol with
iodine-alcohol for preoperative skin antisepsis in patients undergoing Caesarean
section at the University of Washington Medical Center in St. Louis, MO.
The results indicated that
chlorhexidine-alcohol was superior to iodine-alcohol in reducing the rate of
superficial surgical-site infections (3% versus 4.9%) and deep skin infection
(1.0% versus 2.4%).
Can the results of this study be generalized?
The Introduction should be read at a
minimum to provide good background for the study.
A discussion should be generated with your
surgical tutors regarding the results of this study.
Important Articles Related to
Mechanisms of Disease and Translational Research
CLINICAL
IMPLICATIONS OF BASIC RESEARCH
Epigenetic Modulators and the New
Immunotherapies
http://www.nejm.org/doi/full/10.1056/NEJMcibr1514673
A couple of recent studies suggest that DNA
methyltransferase inhibitors, currently used in the treatment of hematologic
cancers, increase the sensitivity of tumour cells to
immune-checkpoint–inhibitor therapy
I must state from the
onset that no student considered this article for review as they believed it
was not important and too difficult to understand. I had to agree with them.
However!
Immune-checkpoint inhibitors in the treatment of melanoma and renal cell
cancer have been introduced in the Journal
over the last six months of 2015 and we will undoubtedly be hearing much more about
them in the future in oncology.
Activated T cells are
capable of killing tumour cells. If T cells express immune checkpoint receptors
on their surface, the T cell is either inactivated (by the binding of CTLA-4 to
its ligand CD80/B7-1 on the tumour cell) or undergoes apoptosis (by binding of
PD-1 to its ligands PD-L1 and PD-L2 on the tumour cells). These interactions thus
render the activated T cell unable to kill the specific tumour cells. If these
checkpoint receptors on the surface of T cells can be blocked by specific
inhibitors (in the reviewed study by Chiappinelli
et al, Cell 2015 by an antibody directed against CTLA-4), the activated T
cell rebounds and is able to kill the tumour cells.
The authors of the
Cell article, in combination with anti-CTLA-4, added a drug (azacitidine –
inhibits DNA methylation) to treat the melanoma cells. This resulted in activation
of endogenous retroviral dsRNA and subsequent release of b-interferon which induced class I MHC expression with
tumour antigen on the surface of the tumour cell. This then resulted in tumour
cell death by the specific activated T cell.
Other articles which should be of interest to medical students
ORIGINAL ARTICLE
Effects of Testosterone Treatment in Older Men
http://www.nejm.org/doi/full/10.1056/NEJMoa1506119
In this study, men 65 years of age or older
with low serum testosterone and symptoms of hypoandrogenism received
testosterone or placebo for a year. Testosterone had a moderate benefit in
sexual function and some benefit in mood but no benefit in vitality or walking
distance
EDITORIAL
Establishing a Framework — Does Testosterone
Supplementation Help Older Men?
http://www.nejm.org/doi/full/10.1056/NEJMe1600196
Neither the students nor I were impressed with the results with
this extensive study, although we all understood the rationale and need for
this study. The major problem with this testosterone replacement study was the
method of selection of patients. It was reminiscent of the biblical quotation: many are called but few are chosen.
Apart from raising the testosterone level with
testosterone replacement therapy (as a gel) over 12 months in this
super-highly-selected group (790 from a pool of 51,085) of men which bore no
semblance to reality, we gleaned the following:
1. This population of men with an average age of 72 did not
represent any valid patient population due to multiple exclusion criteria and
thus limiting any generalizability of any conclusions made,
2. Any improvement in sexual function in this very fit patient
group only lasted for about nine months, then waned, but testosterone could not
compete with the benefits provided by phosphodiesterase 5 inhibitors,
3. There were minimal improvements in physical performance,
mood and depression. Further, any potential long-term benefits such as
improvement in risk of falls and increased bone density were not able to be
studied, and
4. Potential adverse effects of testosterone therapy in the
elderly were not able to be addressed
VIDEOS
IN CLINICAL MEDICINE
Removal of Foreign Bodies from the Ear and Nose
http://www.nejm.org/doi/full/10.1056/NEJMvcm1207469
This video depicts the clinical presentation
of patients with a foreign body in the external auditory canal or the nasal
passage and describes the most effective techniques for smooth and safe
retrieval.
An interesting video, when you finally get it
to work. It should be viewed by MED400 students doing their ENT rotation. Store
this link. You will get very interesting pointers on what to avoid with buzzing
insects and beans in body orifices.
IMAGES
IN CLINICAL MEDICINE
Central Pontine Myelinolysis
http://www.nejm.org/doi/full/10.1056/NEJMicm1504134
A 35-year-old man presented with acute
alcoholic hepatitis and encephalopathy. His sodium level was 119 mmol per
liter. Over the next 5 days his condition improved with supportive treatment,
including lactulose, vitamins and normal saline for hypovolemia
I
have included a link to superior demonstrations of this rare condition should
you be interested.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
