Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 5th May 2016 (#41)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
Food for thought! The Warburg effect. I found this a very stimulating read from the
New York Times that encompasses medical history, demonstrates the scientific
superiority Germany exhibited at the turn of the 19th century and early 20th
century (especially in immunology and cancer), and reinforces the concept that
there are few genuine new ideas except those that can be realized through the
advancement in science and technology.
While the Warburg effect has
implications in the biology and potential management of malignancy, similar
concepts may also be applicable to the management of obesity.
Must Read Articles
CLINICAL PRACTICE
Herniated
Lumbar Intervertebral Disk
Pain
from disk herniation, the leading cause of sciatica, usually resolves within
several weeks with conservative therapy. In patients with sciatica for 6 weeks,
pain relief is faster with surgery than with conservative therapy; however,
outcomes are similar at 1 year.
This is a must read article for all medical students
and tutors regarding an extremely common condition. It provides an evidence
basis for the accuracy of symptoms and clinical findings in patients presenting
with “sciatica” and low back pain and compares these with findings on MRI or
surgery (see Table 1). The roles of conservative and surgical managements are
discussed as well as areas of uncertainty regarding lumbar disk disease.
This is a must keep clinical practice article.
Perspective
Decriminalizing
Mental Illness — The Miami Model
In
a program launched in 2000, Miami-Dade County, Florida, leverages diverse
expertise and resources to divert people with mental illnesses from the
criminal justice system to community-based mental health services, aiming to
improve community outcomes.
Recently I reviewed the scandalous, immoral and illegal
lead contamination of the water supply in Flint Michigan. As you may recall,
lead poisoning was noted and public awareness publicised by an individual
paediatrician-public health physician. It
was this individual who blew the whistle on this tragic and totally avoidable
event which, in spite of opposition by the Republican governor who sanctioned
this crime for fiscal savings, led to the awareness and correction of the
problem.
Similarly, in Miami-Dade County Florida, a single
motivated judge, Steven Leifman, has been able to effect major changes in an
out of control criminal “justice” system. Over 15 years, Judge Leifman developed “a
comprehensive, coordinated response to what’s recognised as a shared community
solution. This effort leverages diverse
expertise and resources to divert people with mental illness from the criminal
justice system to community-based mental health services, aiming to improve
community outcomes.” In five years the
average daily census in the county jail system has fallen from 7200 to 4000.
There are many more interesting specifics in the article which deserve close
scrutiny by the Australian Judicial system, the medical profession, in
particular the mental health community, and Aboriginal community.
What impressed me was the concept that a single, moral
motivated individual is able to make significant change in what may appear to
be immutable system, such as the medical and judicial systems. As Margaret Mead said: “Never doubt that a
small group of thoughtful committed citizens can change the world; indeed, it’s
the only thing that ever has.”
Must Save Articles
None
Articles Recommended for Medical Students
IMAGES IN CLINICAL MEDICINE
Cutaneous
Actinomycosis
A
33-year-old man presented with lesions on his left knee that had worsened over
the course of several years. Five years earlier, he had been in a motor-vehicle
collision that resulted in superficial soft-tissue bruises on his left knee and
no associated fractures.
Actinomycosis, a gram positive anaerobic organism
which may look like sulfur granules in pus, presents as a chronic, slowly
progressive, non-tender, indurated mass which evolves into multiple abscesses,
fistulae, and multiple draining sinus tracts, as is seen in this very unusual
presentation. Although a rare infection, it most often involves the
cervicofacial area (especially in the jaw) and less commonly may present as a
mass in the right iliac fossa, both usually not diagnosed prior to surgery and
microbiological investigation.
Recommended
learning: Review the clinical presentations, microbiology and
management of actinomycosis.
CLINICAL PROBLEM-SOLVING
Eye
of the Beholder
A
47-year-old man presented to an urgent care ambulatory clinic with a 3-day
history of swelling around his left eye and a sensation of tightness in his
throat. It had become difficult for him to swallow solids, and he felt as
though food was sticking in his throat.
This is a moderately interesting case of a patient presenting
with periorbital swelling and tightness in the throat. The differential
diagnosis revolves around atypical angioedema.
The final diagnosis would never have been made on the original
presentation.
Recommended
learning: Review the clinical presentations of inflammatory
muscle disease, their immunopathology, associated autoantibodies and principles
of management. Spend a little time reviewing inclusion body myositis, an underdiagnosed
cause of lower limb wasting and falls risk in the elderly particularly in
nursing homes.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
CORRESPONDENCE
Chewing Gum Test for Jaw Claudication in
Giant-Cell Arteritis
A
clue to the diagnosis of giant-cell arteritis is the development of jaw muscle
pain and weakness after a few minutes of chewing gum.
This is an interesting, simple, clinical test which may
be able to be standardized provided the same chewing gum were used, TMJ
dysfunction and stroke could be excluded and the patient had normal mental
status.
ORIGINAL ARTICLE
Amiodarone,
Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
In
this trial, patients with out-of-hospital cardiac arrest received amiodarone,
lidocaine, or placebo for shock-refractory ventricular fibrillation or
pulseless ventricular tachycardia. There were no significant between-group
differences in survival to hospital discharge
EDITORIAL
Out-of-Hospital
Cardiac Arrest — Are Drugs Ever the Answer?
This is a well conducted, randomized, multicentre,
double blind study (with an accompanying editorial) comparing the use of iv
amiodarone, lidocaine or saline in out of hospital patients with for
shock-refractory ventricular fibrillation or pulseless ventricular tachycardia
with the primary end point the percentage of patients rate for hospital
discharge. It will be important to
determine the short and long term survival in this cohort and their quality of
life after discharge.
The study demonstrated the following:
1. If
a cardiac arrest was witnessed and the patient found to have shock-resistant
ventricular fibrillation or pulseless ventricular tachycardia, IV amiodarone or
lidocaine improved the rate of survival to hospital discharge to 27.2% and
27.8% respectively, compared to saline infusion alone (22.7%).
2. If
a cardiac arrest is not witnessed and the patient found to have shock-resistant
ventricular fibrillation or pulseless ventricular tachycardia, IV amiodarone or
lidocaine or normal saline are equally ineffective effective in the primary
outcome, as are the results of the combined per-protocol groups overall.
The message I got from the study was that:
1. In
any witnessed arrest, there appears to be a statistically significant benefit
in the use of either amiodarone or lidocaine. Another note was the first use of
a new formulation of amiodarone which did not contain a solvent which had
previously resulted in hypotension.
2. No
medication comes close to survival outcome than bystander-initiated CPR which
showed an absolute survival benefit of almost 10%.
ORIGINAL ARTICLE
Ozanimod
Induction and Maintenance Treatment for Ulcerative Colitis
In
a placebo-controlled phase 2 trial involving patients with ulcerative colitis,
ozanimod, an oral agonist of sphingosine-1-phosphate receptor subtypes 1 and 5,
resulted in a slightly higher rate of clinical remission at 8 weeks.
This is a predictable use of an immunosuppressive drug
that blocks the sphingosine-1-receptor inhibiting lymphocytes exiting lymphoid
organs (spleen or lymph nodes) and resulting in lymphopenia. The concept is
important, not the specifics, and this property has been utilized in the
first-generation drug fingolimod in the treatment of progressive multiple
sclerosis resistant to standard therapies.
In the Introduction to the paper when therapies used to
treat inflammatory bowel are reviewed, there is no mention of the use of the
Jak kinase inhibitor tofacitinib. [Tofacitinib, an Oral Janus Kinase Inhibitor,
in Active Ulcerative Colitis. (http://www.nejm.org/doi/full/10.1056/NEJMoa1112168#t=articleBackground )
This Janus kinase inhibitor inhibits both Jak1 and Jak3 kinases].
Recommended
learning: Review the pathology, clinical presentations and management
of inflammatory bowel disease. Don’t forget Behcet’s syndrome.
EDITORIAL
Preventing
Food Allergy in Infancy — Early Consumption or Avoidance?
This editorial reviews the results of the study (http://www.nejm.org/doi/full/10.1056/NEJMoa1514210)
whose primary outcome was to determine if the introduction of six potentially
allergenic foods (peanut butter, egg, cow’s milk yogurt, sesame paste, white
fish and wheat-based cereal biscuits) at 3 months of age, compared with the
standard time of introduction in the UK of 6 months, to 1300 randomly assigned
infants would result in in the reduction in food allergy to one or more of the
these foods when assessed between 1 to 3 years of age.
While the results of the intention to treat analyses
did not support the early introduction at 3 months, there were several
important points:
1. 42.8%
of the early introduction group were non-compliant with the trial protocol for
whatever reason which clearly skewed the real results of the study.
2. If
the early introduction group were analysed according to the protocol (i.e.
those who were compliant only), there was a significant difference at 2.4%
compared with the later introduction group at 7.3%.
3. There
was a significant difference in allergy for early introduction of peanuts and
eggs, but not for the other four food types.
Thus I would regard the results of this study from the
glass half full perspective. The researchers probably expected more significant
results than they achieved, though I regard the results obtained as positive.
Importantly, no safety issues were identified in the early introduction group.
