Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 21st April 2016 (#39)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
Perspective
Zika Virus as a Cause of Neurologic Disorders
As researchers investigate whether and by
what mechanisms Zika virus infections could affect the nervous system, there is
a key question for public health: How can currently available evidence about
causality guide the choice and implementation of interventions?
REVIEW ARTICLE
Zika Virus
Zika
virus is rapidly spreading throughout the Americas and the Caribbean. The
association with microcephaly has led the WHO to declare a public health
emergency. This review describes our current understanding of the
characteristics of Zika virus infection.
The editorial reviews in detail the epidemiological
evidence to support causality between Zika virus, neurological disease,
particularly Guillain-Barre syndrome and fetal infection, most commonly
resulting in microcephaly. The article reviews the critical articles and
discusses the epidemiological principles employed to assess causality.
The review article reviews Zika virus as we understand
it today. It discusses in detail the epidemiology, modes of transmission,
clinical features, diagnosis, virology, treatment, prevention and control and
future directions.
Recommended
learning: Review the flaviviruses dengue, chickungunya, and
Zika, which can be done when studying the MED300 medical infectious disease
cases.
VIDEOS IN CLINICAL MEDICINE
Managing
Procedural Anxiety in Children
This is an interesting and well done video and should
be viewed by all medical students. It describes interactions between the
clinician and children with varying stages of anxiety and provides suggestions
as to how to cope with both the child and the parent. This should be reviewed
by all MED300 students before commencing their paediatric rotation.
Must Save Articles
None
Articles Recommended for Medical Students
Perspective
Reducing
the Risks of Relief — The CDC Opioid-Prescribing Guideline
The
CDC has released a guideline for prescribing opioids for chronic pain to set a
safer, more effective course for pain management and opioid use by supporting
clinicians caring for patients outside the context of cancer treatment or
palliative or end-of-life care.
This is another article on prescribing opiates for
chronic pain. This is written from the
CDC’s perspective, particularly regarding health policy and provides 12 CDC
Opioid-Prescribing Guidelines. Various prescribing strategies are described. Three
key principles are emphasized:
1.
Use non-opioid drugs for chronic pain if at
all possible.
2.
Use the lowest possible dose of opioid to
achieve pain management.
3.
Think twice before using opioids, but if
used, the patient should be monitored closely with outcomes for pain relief
established up front and consider using a pain contract.
1.
All opioids that are full mu-receptor
agonists are just as addictive as heroin.
2.
Prescription-opioid overdose has quadrupled
over the past 15 years in the US.
3.
In the US, 1 in every 550 patients who started
on opioid therapy for chronic pain died of opioid –related causes in the 2.6
years of follow up.
4.
Management of chronic pain is both an art
and a science
Recommended
learning: Review the principles of both acute and chronic pain
management.
ORIGINAL ARTICLE
One-Year
Risk of Stroke after Transient Ischemic Attack or Minor Stroke
In
this international registry study of patients who had a transient ischemic
attack or minor stroke and who were evaluated on an urgent basis by stroke
specialists, the 1-year risk of recurrent stroke was 5.1%, which is lower than
the risk reported in historical cohorts
EDITORIAL
The
Value of Urgent Specialized Care for TIA and Minor Stroke
Both the article and the editorial present and review
the current data on the frequency of developing a stroke at various time
intervals following an earlier transient ischaemic attack (TIA) or minor/mini
stroke. Earlier studies conducted between 1997 and 2003 estimated that the risk
of stroke was between 8 and 20% at 30 and 90 days post-TIA. The current data for
stroke from the period 2009 to 2011 were 1.5% at 2 days, 2.1% at 7 days, 2.8%
at 30 days, 3.7% at 90 days and 5.1% at 365 days. Th study involved 4789 patients, at 61 sites,
from 21 countries, recruited within 7 days of the TIA, assessed at onset for
the risk of stroke using the ABCD2 scoring system and seen by stroke
specialists within 24 hours.
The many aspects of changes in stroke management
between these two study periods are reviewed, with emphasis on the value of
urgent care in specialized stroke units.
Clearly the problem in Perth and throughout Australia
relates to the availability of specialized centres, the time it takes to reach
the centres after a TIA, and the selection of patients to be urgently referred
to a specialist centre or a stroke specialist.
If the clinician uses the ABCD2 scoring
system on a patient who presents with a TIA, who is over 60 years of age, has
type II diabetes mellitus and a BP of over 140/90, the patient receives an
automatic score of 3/7. If the symptoms and/or signs last less than 10 minutes,
say 8 minutes of visual loss or unilateral weakness or aphasia, then the
patient would receive a score of 0 (if the
episode lasts 10-60 minutes they receive 1, if greater than 60 minutes receive
a 2). It takes the art of medicine to determine, in the patient who presents
with a score of <4, whether the patient should be urgently referred for
acute stroke assessment and management. GPs see many patients with TIAs who
present with no residual neurological deficit.
When the patient is seen, a history is quickly taken to exclude obvious
potential causes (bleeding disorders, head trauma, anticoagulant use, severe
hypertension), the pulse and the carotids are examined, an ECG is obtained to
exclude atrial fibrillation at the time, and the patient is started immediately
on aspirin-dipyridamole or clopidogrel before obtaining a CT scan,
echocardiogram, carotid Doppler flow studies, a CT angiogram or referral to a
stroke specialist. The art is in doing what when? Patients assessed with having
an acute intracerebral bleed are referred immediately
On the other hand, if a 38 year old male presents with
a TIA lasting 12 minutes without a history of migraine or any other apparent
cause and with no risk factors for atherosclerotic vascular disease, he may earn
only a score of 1 but should be referred for acute stroke management.
In Australia, particularly in rural areas, we do not
have the trained personnel or facilities to treat every person with a TIA in an
acute stroke centre.
Recommended
learning: Review the pathology and presentation of stroke; how
to use the ABCD2 scoring system; current management of stroke and
review the FAST system used by the Stroke Foundation of Australia (https://strokefoundation.com.au/about-stroke/stroke-symptoms).
Review the MED300 medical clinical case on stroke.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
12-2016 — An 8-Year-Old Boy with an Enlarging Mass in the Right Breast
An
8-year-old boy presented with a mass in the right breast that had been present
for 18 months and had enlarged during the previous 6 months. On examination, a
firm, mobile mass (2 cm by 2 cm) was present under the right areola. Diagnostic
procedures were performed.
Students reported to me that they enjoyed reading this
CPC, not because of the diagnosis of a rare cause of breast cancer in an 8 year
old boy, but for the way gynaecomastia is excellently discussed and managed (see Figure 2) in the prepubertal and
pubertal boy. The development of the differential diagnosis is extremely well
done.
IMAGES IN CLINICAL MEDICINE
Resolution
of Lumbar Disk Herniation without Surgery
A 29-year-old woman presented to the spine clinic with pain in her right leg, accompanied by paresthesia. MRI of the lumbar spine revealed a lumbar disk herniation resulting in substantial spinal stenosis and nerve-root compression.
In last week’s issue of the Journal, the role of
surgery in spinal stenosis was discussed.
In the current issue a 29 year old patient presents with acute lumbar
disk prolapse and recent-onset back pain and paraesthesia in the lower limb.
With conservative therapy her symptoms and the lumbar disk prolapse on MRI
resolved.
The point is emphasized that the natural history of
acute disk prolapse is still unclear and that long-term outcomes overall are similar in patents whether treated surgically or non-surgically.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
IMAGES IN CLINICAL MEDICINE
Esophagogastric
Bypass in Motion
A
60-year-old man who had undergone esophagogastric bypass as a child because of
an alkali burn presented with concerns about the cosmetic results. A video
shows a water-swallowing test, with normal passage through the subcutaneous
colonic segment.
This is an interesting clinical phenomenon
.
ORIGINAL ARTICLE
Coronary-Artery
Bypass Surgery in Patients with Ischemic Cardiomyopathy
Among
patients with ischemic cardiomyopathy, coronary-artery bypass grafting added to
medical therapy led to significantly lower rates of death from any cause and of
cardiovascular death over 10 years than did medical therapy alone.
EDITORIAL
Coronary Bypass — Survival Benefit in Heart Failure
The article and editorial discuss patients with presumptive
ischaemic cardiomyopathy and an EF of 35% or less who also had significant
coronary artery disease amenable to CABG.
1212 patients in this multicentre, international study
were randomly assigned into treatment with CABG plus medical therapy (#610) and
medical therapy alone (#602) with a mean follow-up of 9.8 years. The primary
outcome of death by any cause was less in the CABG group (58.9%) than in the
medical therapy alone group (66.1%) (p = 0.02). Death from a cardiovascular
cause was less in the CABG group (40.5%) than in the medical therapy alone group
(49.3%) (p = 0.006).
The study suggests that appropriate CABG treatment
improves outcomes in patients with CAD and ischaemic cardiomyopathy.
Interesting data would have been the change in EF, if any, produced by the
surgery; this will probably be forthcoming in a further publication.
