Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 7th April 2016 (#37)
University
of Notre Dame Australia
(Fremantle
Campus)
Occasional Editorial Comment
None
Must Read Articles
None
Must Save Article
REVIEW ARTICLE
Antiemetic
Prophylaxis for Chemotherapy-Induced Nausea and Vomiting
One
of the most important changes in cancer treatment in recent decades has been
the development of treatment regimens that greatly reduce the incidence and
intensity of nausea and vomiting. The most effective regimens and how they work
are reviewed.
This review article on antiemetic drugs provides an
excellent update on groups of drugs and their mechanisms of action (Figure 1).
It provides the reader with information on the NK1-receptor antagonists and a
chronology of the approval and use of antiemetic drugs. Antiemetic treatment
recommendations are proposed for nausea and vomiting produced by IV
chemotherapy (Table 3) which should be compared with local guidelines.
Recommended
learning: Groups of antiemetic drugs and their mechanisms of
action. This will be particularly useful on oncology rotations.
Articles Recommended for Medical Students
IMAGES IN CLINICAL MEDICINE
Reversible
Loss of Vision in Malignant Hypertension
A
35-year-old man presented with reduced vision in both eyes. He had no relevant
medical history apart from intermittent headaches. Fundus examination revealed
bilateral disk edema, macular edema with lipid exudates, splinter hemorrhages,
and cotton-wool spots.
Recommended
learning: Review the progressive retinal changes and their
pathological basis in patients with hypertension.
IMAGES IN CLINICAL MEDICINE
Creeping
Eruption — Cutaneous Larva Migrans
A
42-year-old man presented with an intensely pruritic eruption on his foot after
a vacation in Nigeria. The eruption was migratory, moving a few millimeters to
a few centimeters daily. Examination revealed a serpiginous, erythematous
raised tract on his right foot.
An excellent clinical photograph of cutaneous larva
migrans. The hookworm life cycle involves entry into the skin by filariform
larvae, migration to alveolar spaces, ascending into the pharynx, swallowed and
maturing into the adult hookworm in the small intestine resulting commonly in
iron deficiency anaemia. If the definitive host is a dog or cat as in this
example, the larva enters the human epidermis but is unable to travel any
further. The serpiginous lesion spontaneously resolves and the larva dies.
However, if the definitive host is human, the hookworm can carry out its normal
life cycle.
Recommended
learning: For those seeking more information, there is an
excellent review of Skin Lesions in the
Returning Traveller in UpToDate.
CLINICAL PROBLEM-SOLVING
A
Deficient Diagnosis
A
previously healthy boy, 2 1/2 years old, presented with a 6-week history of
progressive inability to bear weight on his right leg. His mother noted no
recent trauma. His medical history was notable only for speech delay.
All students should read this article. If an adequate dietary history in this
patient had been performed at the initial encounter, the diagnosis would have
been made much earlier, saving the child morbidity and eliminating unnecessary
health care costs.
The case again
emphasises the importance of taking a detailed history and performing an
appropriate physical examination, especially where the initial diagnosis is not
apparent.
The case reviews the causes of a painful lower
extremity in a child and iron deficiency anaemia.
This diagnosis is not uncommon in the homeless
alcoholic who lives on a nutritionally inadequate diet and is admitted through
the ED and not examined carefully. In the ED, always look for perifollicular
haemorrhages with occasionally cork-screw hairs on the lower extremities as
these lesions disappear within days once the patient receives any vitamin C.
Recommended
learning: Review the biochemical role of vitamin C, particularly
in collagen synthesis, and the clinical presentations of vitamin C deficiency.
Perspective
When
Is It Ethical to Withhold Prevention?
Why
is the value of extending human life the determining factor in treatment
decisions but the cost of an intervention the determining factor in
population-level prevention decisions? The contrast exposes some tangled issues
of ethics, cost, and cost-effectiveness.
This article should be read by all students and tutors
as it highlights the ethical dilemma raised by the allocation of a fixed number
of dollars to either disease prevention, in this case lung cancer, or the
expensive extension of a patient’s life by several months. The author indicates
that that there is a “systemic bias against prevention and that decisions upon
whether to provide or withhold proven preventive actions are not just tough
budgetary choices, but are also ethical ones.”
The other factor apart from having to treat the patient asking for expensive
life-extending therapies, is that patients, their families and friends, and
doctors also vote.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other articles which should be of interest to medical students
Perspective
Finding
Value in Unexpected Places — Fixing the Medicare Physician Fee Schedule
A
substantially improved, carefully managed Medicare Physician Fee Schedule could
pave the way to more fundamental value-based payment reform and improve
performance among physicians, who are likely to be paid according to fee
schedules for the foreseeable future.
This article raises the vexing question of how the
health care system values time spent talking to and examining patients with
increasingly complex medical problems. Clearly the area of cognitive skills and
time taken for clinical reasoning is markedly underfunded and undervalued. In order for clinicians, especially GPs, to
continue to practice high quality, cost effective medicine this area needs not
only to be addressed, but appropriately funded.
While doing bedside teaching rounds, the number of
patients presenting with iron deficiency anaemia associated with metastatic
colon cancer continues to amaze me, particularly patients who have been seeing
their GP for years and who have been treated with oral iron, without having had
a rectal examination or faecal occult blood testing. I would like to believe
that had the clinician spent more time up front with the patient that the cost
of managing metastatic colon cancer and patient morbidity and mortality might
have been avoided. Medical education cannot continue to be the scapegoat.
I visited the GP last week for my annual influenza
vaccination, but instead of just visiting the nurse, I was scheduled an
unnecessary doctor visit, not with my usual GP. After being asked by the GP if
I had any previous allergies, the nurse then gave me the shot.
The article specifically addresses some areas in which
reduced time and work involved has been markedly improved with automation, but
where the fee system has not been updated (i.e. appropriately reduced) (see
Figure). Examples provided include liquid nitrogen freezing of actinic
keratosis and time spent interpreting ECGs, echocardiograms, and CT and MRIs of
the brain. There are many other examples where health care costs could be
contained, but because of powerful specialty lobbying groups, this is unlikely
to occur, leaving the cognitive clinician underpaid for their services.
ORIGINAL ARTICLE
Pioglitazone
after Ischemic Stroke or Transient Ischemic Attack
In
this trial in nondiabetic patients with insulin resistance and a recent
ischemic stroke or transient ischemic attack, pioglitazone was associated with
a lower risk of stroke and MI than was placebo but with a higher risk of weight
gain, edema, and bone fracture.
EDITORIAL
Insulin
Resistance and a Long, Strange Trip
The article and Editorial address the issue of treating
insulin resistance with pioglitazone in the prevention of a further stroke or myocardial
infarction. Insulin resistance, while universal in type II diabetes mellitus
(DM), is found in 50% of patients without DM who have had a previous TIA or
ischaemic stroke. A numerical value for insulin resistance is calculated by utilizing
the fasting serum glucose and insulin level.
Use of pioglitazone in patients who had insulin
resistance and a history of a recent stroke or TIA resulted in a statically
significant improvement in the primary outcome (9% versus 11.8%, p = 0.007) but
without any change in all-cause mortality. It resulted in fewer cases of type
II DM but increases in weight gain, oedema, and serious fractures (cause
undetermined).
Whether the data support the use of pioglitazone in
patients without clinically apparent vascular disease and increased insulin
resistance is not answered by this study. Further, the use of pioglitazone should
be carefully considered in view of the side effects.
EDITORIAL
Antenatal
Glucocorticoids for Late Preterm Birth?
This article (http://www.nejm.org/doi/full/10.1056/NEJMoa1516783)
and the Editorial provide evidence of
the therapeutic benefit for the established practice of treating women between
34 weeks and 36 weeks and 5 days gestation (late preterm delivery) at high risk
for delivery during this preterm period with two injections of betamethasone.
ORIGINAL ARTICLE
Fresh
Fruit Consumption and Major Cardiovascular Disease in China
In
a study involving 451,665 adults in China, higher levels of fruit consumption
were associated with lower blood pressure and blood glucose levels and, largely
independent of these and other dietary and nondietary factors, with significant
reductions in cardiovascular risk.
This is part of an extensive public health study (512,
891 adults over 10 geographic areas in China) in collaboration with the
University of Oxford which demonstrated that regular fresh fruit consumption
(see Table 2) is associated with lower blood pressure and blood glucose
levels. However, this diet was also
associated with an increase in BMI and waist circumference (Figure 1).
When the group who had daily fruit consumption were
compared with those without any fresh fruit consumption, the hazard ratio for
cardiovascular death was 0.6 and with similar hazard ratios for incident major
coronary events, ischaemic strokes and haemorrhagic strokes. The paper should
be read carefully for more specific details.
CLINICAL DECISIONS
Clinical
Effect of Surgical Volume
This
interactive feature offers a case vignette accompanied by essays that support
either undergoing surgery at a lower-volume, local hospital or undergoing
surgery at a higher-volume hospital, even if it's more distant. Share your
comments and vote at NEJM.org.
This is an interesting point-counterpoint discussion on
specific complex surgery performed in the US at highly specialist centres with
higher turnover versus at smaller sites with less turnover but with very
experienced surgeons. The surgery discussed is a Whipple’s procedure performed
for potentially curative surgery for carcinoma of the head of the pancreas.
From the Australian point of view this discussion is
moot, as all Whipple’s procedures are performed in capital cities at centres
with the highest turnover and clinical experience. Currently in Perth,
Whipple’s procedure can be performed and funded only at SCGH and FSH.
I had always assumed that one would automatically have
the procedure at the centre with the highest turnover and most experience,
which I still believe, though the article does provide some interesting
arguments to support alternate points of view which may be more valid for
practice in the US.
