Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of the 3rd March 2016 (#32)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
Perspective
Uber’s
Message for Health Care
Uber
upended the taxi industry by offering an appealing alternative. Its incursion
into a highly regulated market suggests that if consumers gain enough from a
new solution, it can overcome entrenched interests. Is U.S. health care ripe
for disruption by a medical Uber?
The Uber model presents itself as an industry
unencumbered by regulation which therefore is able to offer reliable, faster,
and more user friendly service than the conventional business model. There is much controversy, however as questions
of uneven charging, passenger safety and drivers’ professionalism come under
more scrutiny. While improvements in patient care standards, costs of health
care delivery, safety and improved efficiencies are necessary and achievable,
these should not be at the cost of fragmenting the current system. I do not wish to see an unregulated health
care industry, nor do I wish to lose medical coverage for pre-existing
illnesses to engorge corporate profits should privatization occur.
The conservative government in Australia would dearly
love to dismantle and privatize the health care industry as it continues to be
in the US even with the improvements due to passage of the Affordable Care Act
(Obamacare). Two major goals of the ACA enacted by a Democratic administration
in the US (equivalent to the Labor government in Australia) were to provide
health insurance coverage for all uninsured Americans at a reasonable cost and
to allow coverage for all uninsurable patients with pre-existing conditions.
These goals have been in large part achieved, but should a Republican president
and congress be elected, this system may well as promised be dismantled.
In this conservative, privatizing, cost-containing,
tax-cutting environment in Australia, we must take care when terms like
Uberization are bandied about with the aim of obfuscating true discussions on
the real cost of health care and the preservation of one of the best health
care system in the world.
Must Read Articles
Perspective
Menopause
Management — Getting Clinical Care Back on Track
Use
of systemic hormone therapy has decreased dramatically among U.S. women since
the Women's Health Initiative results were published. But those results are
being misapplied to treatment decisions for women in their 40s and 50s who have
distressing vasomotor symptoms
This is an excellent discussion on menopause management
which emphasizes the concerns that primary care physicians, including
obstetricians and gynaecologists, and medical students in the US, (and I am
sure also in Australia), have in prescribing HRT to women with moderate or
severe menopausal symptoms. In the US, HRT use has fallen by 80% since the
initial findings of the Women’s Health Initiative were published in 2002. This
indicates that there are large numbers of women suffering from treatable
menopausal symptoms because of the incorrect interpretation of the data (well
illustrated in the accompanying Figure).
The Perspective urges that physicians who treat women with menopausal symptoms
interpret the evidence correctly and that medical schools do likewise in
educating students. I am sure that if males suffered from menopausal symptoms,
prescribing habits would be rapidly reversed.
Recommended
learning:
1. Biology
of the menopause and the clinical presentation
2. Review
the complications of the menopause
3. Review
the management of menopausal symptoms and complications
Articles Recommended for Medical Students
CLINICAL PRACTICE
Peripheral
Artery Disease
Atherosclerotic
peripheral artery disease is associated with a high rate of cardiovascular
events and death. Treatment goals include reducing cardiovascular risk and
improving functional capacity. Revascularization is indicated for persistent
symptoms.
This extensive and excellent review article on
peripheral vascular disease is one you need to store in your data base for
years to come. The article begins with a very common clinical problem and then
addresses each treatment strategy with current evidence-based detail that is
not required for the average medical student.
This will be extremely valuable to have on hand when managing a patient
with vascular disease as a MED400 student, intern, or resident in order to
answer your patient’s or consultant’s questions.
Recommended
learning:
1. Pathology
of atherosclerosis and its causes and other unusual causes of peripheral ischaemia
2. Common
causes and basic management of patients with atherosclerotic peripheral vascular
disease
ORIGINAL ARTICLE
Trimethoprim–Sulfamethoxazole
versus Placebo for Uncomplicated Skin Abscess
In
this randomized clinical trial in patients presenting to U.S. emergency
departments with an acute uncomplicated cutaneous abscess, drainage plus
trimethoprim–sulfamethoxazole therapy for a week was associated with modest
clinical benefits as compared with drainage alone.
CLINICAL DECISIONS
Skin
Abscess
This
interactive feature offers a case vignette accompanied by essays that support
either incision and drainage alone or incision and drainage followed by a 7-day
course of antibiotics.
This article features a multicentre (n=5) US randomized,
double-blind placebo controlled trial on 1013 patients who completed the study
and who presented to the ED with cutaneous abscesses (majority 2-5 cm diameter,
not requiring hospital admission) that were all incised and drained. The aim of the study was to determine whether
a 7-day course of trimethoprim-sulfamethoxazole compared with placebo resulted
in higher cure rates, which it did (80.5 versus 73.6%). The causes for cure
failure are indicated in Table 1. Cultures
from these community-acquired abscesses revealed 45.3% were MRSA, a rate that
now appears to have stabilized after an initial sharp rise. Recommended
antibiotics for abscesses treated in GP or in the ED are either
trimethoprim-sulfamethoxazole or doxycycline.
If you do not wish to read the article, I recommended
reading the Clinical Decision article (a point – counterpoint discussion) but focusing on the use of drainage + antibiotics (Howard Gold MD) where practical
recommendations for antibiotics are suggested.
Recommended
learning: Pathology, presentation and management of cutaneous
abscesses, cellulitis and erysipelas.
CLINICAL PROBLEM-SOLVING
Too
Much of a Good Thing
A
54-year-old man presented to the emergency department with a 1-month history of
edema in the lower legs and a 1-week history of upper abdominal pain. He also
reported intermittent nausea, early satiety, and diarrhea but did not have
fevers, chills, or vomiting.
This case discussion focuses on the pathology and
causes of non-cirrhotic portal hypertension, a very uncommon entity. The
selected causes are indicated in Table 2.
The patient under discussion presented with vitamin A
poisoning (hypervitaminosis A) as the cause of non-cirrhotic portal
hypertension. This case emphasizes the importance of taking a detailed history
from the patient, particularly where the cause may not be clinically obvious at
presentation. I emphasize to students that “common things are common”, but with
the proviso that all relevant facts have been gathered from the patient and
that they are compatible the clinical presentation.
I quote from the Commentary in the article: “Delayed
diagnosis of noncirrhotic portal hypertension probably stems from cognitive
errors made during clinical decision making, and particularly from premature
closure (i.e., failure to consider reasonable alternatives after an initial
diagnosis has been made). Arriving at the correct diagnosis in difficult
cases requires that clinicians remain open to alternative diagnostic
considerations and selective further evaluation, including repeat history
taking.”
IMAGES IN CLINICAL MEDICINE
Right
Ventricular Infarction
A
61-year-old man with a personal history of smoking and a family history of
coronary artery disease presented with what he described as a squeezing pain in
the left side of his chest that woke him from sleep. He also had dizziness and
diaphoresis
A good illustration of right ventricular myocardial infarction.
Don’t
forget: The patient who presents with an acute inferior/posterior
myocardial infarction with hypotension (particularly after morphine and/or nitrates),
tachycardia, raised JVP but with clear
lung fields requires IV fluids, not diuretics.
IMAGES IN CLINICAL MEDICINE
Vertebral-Body
Erosion in Thoracic Aortic Aneurysm
A
74-year-old man presented with acute back pain but no neurologic symptoms. He
had a history of hypertension, open repair of an aortic infrarenal aneurysm,
and end-stage renal failure. CT revealed a thoracic aneurysm and
well-corticated erosions of thoracic vertebrae.
An interesting CT scan demonstrating erosion of both
T10 and T11 vertebrae by an atherosclerotic thoracic aortic aneurysm. Note the
sparing of the disk space which would be involved if infection were the cause.
For those interested in the history of medicine, review
the clinical presentations of syphilitic
thoracic aortic aneurysms.
Important Articles Related to Mechanisms of Disease and
Translational Research
CLINICAL IMPLICATIONS OF BASIC RESEARCH
Burning
Fat by Bugging the System
A
recent study of mouse models links cold exposure, the microbiome, and remodelling
of the intestine to the browning of fat.
I found this to be the most interesting article of the
week, unlike the medical students where only 1 in 22 picked this. I was
informed by a student whose mother is a practicing endocrinologist in Sydney
that, “most endocrinologists (in Sydney) consider that taking cold showers and
generally maintaining a colder state overall result in weight loss.”
The study in Cell,
2015, by Chevalier and colleagues,
focuses on the generation of beige fat cells in the mouse exposed to the cold.
These inducible fat cells, also found recently in humans, can transition
between energy dissipation and energy storage. White fat cells, which are associated
with the production of an inflammatory response, are abundant in humans and
responsible for fat storage. Brown fat cells metabolize fat by mitochondrial
activity.
While the data from this study are not yet immediately
translatable to humans, the results are fascinating and are illustrated clearly
in Figure 1. Cold exposure causes
browning of white fat in mice, resulting in increased insulin sensitivity, heat
production, and weight loss. The results of the Cell study report that cold exposure in mice also changes the
composition of the gut microbiota and results in a large increase in the
absorptive surface of the gut. Transplantation of the cold-adapted microbiota
from cold-exposed mice to warm recipient mice is sufficient to promote fat
browning, weight loss, enhanced insulin sensitivity, and increased intestinal
surface area in the recipient mice.
We are in an exponential learning curve about microbiota,
not only in the GI tract but also the respiratory tract.
Changes in microbiota appear to play a role
in autoimmunity, control of infection, malignancy, malnutrition management and
maybe now may offer a light into the control of obesity.
Other articles that should be of interest to medical students
Perspective
HISTORY OF MEDICINE
Stroke
and t-PA — Triggering New Paradigms of Care
Today,
health systems have been reconfigured to permit speedy access to stroke care.
But this response is a recent phenomenon, dating to the 1995 publication of a
research article on recombinant tissue plasminogen activator.
This offers a brief history of stroke, its frequency,
the development of stroke centres and evidence-based optimal stroke management,
particularly the more recent use of tPA and endovascular therapy. It is important
to note that Melbourne (Peter Bladin), together with Boston (MGH) and Sweden
were at the forefront in development of the concept of dedicated stroke units
and research.
EDITORIAL
Induction of Labor and Cesarean Delivery
The Editorial summarizes the study in this week’s issue
of the Journal ( http://www.nejm.org/doi/full/10.1056/NEJMoa1509117 )
and offers an overview of this area together with future studies. The randomized,
controlled trial of 619 primigravid women over 35 years of age and older
without any obstetrical complications were offered either expectant management of
their pregnancy or were induced in their 39th week of gestation. The frequency
of Caesarean section in each group, which was the primary outcome of the study,
did not differ, nor were there any adverse short-term effects on maternal or
neonatal outcomes.
