Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 16th June 2016 (#47)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
CLINICAL PRACTICE
Upper
Gastrointestinal Bleeding Due to a Peptic Ulcer
Peptic
ulcers, often due to Helicobacter pylori or the use of nonsteroidal antiinflammatory
drugs (NSAIDs), commonly cause upper gastrointestinal bleeding. Endoscopic
therapy, proton-pump inhibitors, therapy for H. pylori infection, and
nonuse of NSAIDs are described.
The days when I was a medical student when bleeding
chronic gastric ulcers requiring gastrectomy and selective vagotomy are long
gone. The demise of surgical intervention was heralded by the early use of
endoscopy, identification and treatment of H. pylori, the extensive usage of
PPIs and the use of specific COX-2 selective NSAIDs. So extensive now is the
long-term use of PPIs that some evidence suggests their use may result in
impaired renal function, osteoporosis and fractures, vitamin B12 deficiency, increased
frequency of C. difficile colitis and
even Alzheimer’s disease. My student groups have the task over their vacation of
reviewing references 48-50 and other relevant articles to ascertain, based on
the evidence, if any of these observations are substantial. I also have talked
with my paediatric colleagues and found that neonates and infants are now being
commonly placed on PPIs, with some children continuing these long-term!
This is an excellent article which is current with an
extensive evidence base. This should be read fully by all medical students and
teachers and the hyperlink stored for future usage where specifics of treatment
are required.
Recommended
learning: Review the causes and management of upper and lower
gastrointestinal bleeding
Perspective
The
Sharing of Loss
The basis for a successful practice, apart from
clinical competence, is excellent communication between patients and families,
staff and in particular colleagues. I remember as an intern at Sydney Hospital
in 1969 the practice of a particular surgeon who, even before he had both
gloves removed, was on the phone to the GP or the referring physician
describing the findings and outcome of the surgery. As a rheumatologist I always regarded the
referred patient as the GP’s patient and attempted to emulate this practice in
all referrals. I attempt to reinforce the importance of communication to
medical students, urging them that when they discharge patients as interns,
that they first call the patient’s GP (the foundation of clinical care in
Australia), and describe the patient’s hospital course and subsequent follow-up.
This is not the primary focus of this article on
“sharing” but the core is communication. I must admit that when I first read
this perspective, I was underwhelmed by this, unlike my four medical student
groups. But then I reflected more upon the interaction between the oncologist and
the intensivist (from Monash) and began to appreciate the perspective of my
students. The sharing of loss is extremely important at all levels of patient
care. A recent experience I had with a student group while doing bed-side
teaching occurred while the student was taking a family history from the
patient. When the patient related the
recent death of her niece, she burst into tears. The further discussion of this
area was an issue to be avoided in front of the patient, but one which was
subsequently discussed with the group.
Articles Recommended for Medical Students
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
18-2016 — A 52-Year-Old Woman with a Pleural Effusion
A 52-year-old
woman presented with a unilateral pleural effusion. Several weeks later,
uterine bleeding, pelvic fullness, and bloating developed. Magnetic resonance
imaging revealed a large pelvic mass. Diagnostic procedures were performed.
This is a case of a patient with a very small pleural
effusion that had remained static for at least 14 years, thus excluding any
major significant pathology discussed in the differential diagnosis. The
patient subsequently developed an ovarian mass which was found to be an ovarian
fibroma and the retrospective assumption was made that this was a case of
Meig’s syndrome. This was in fact self-diagnosed by the patient, a physician,
with the help of the internet. The major initial diagnosis should have been
ovarian cancer in a patient with an incidental pleural effusion and a very
positive family history of malignancy.
Recommended
learning:
1. Review
the types, pathological causes, physical findings and investigations of a
patient with either unilateral or bilateral pleural effusions.
2. Review
the pathology, presentation and principles of management of ovarian
malignancies.
IMAGES IN CLINICAL MEDICINE
Chronic
Splenic Brucellosis
An
86-year-old man in Minnesota presented with fever, dyspnea, and new-onset
confusion. His history was notable for a febrile illness with night sweats and
a weight loss of 23 kg (50 lb) that had occurred while he was in his late 20s,
working in an abattoir slaughtering pigs.
This is an interesting case of reactivation brucellosis
occurring in an 86-year-old male from Minnesota who demonstrated splenic
calcification from a presumed earlier brucellosis infection during his 20s.
Recommended
learning:
1. Common
causes of hepatic and splenic calcification
2. Review
the epidemiology, microbiology, clinical presentation and treatment of
brucellosis
IMAGES IN CLINICAL MEDICINE
Acanthosis
Nigricans and Insulin Resistance
A
27-year-old woman presented with a 2-year history of acanthosis nigricans,
hirsutism, and amenorrhea. Laboratory tests revealed elevated levels of insulin
and testosterone, the presence of thyroperoxidase antibodies, and an
antinuclear antibody titer of 1:64 (normal titer, <1:32).
These are excellent clinical pictures of acanthosis
nigricans and the demonstration of regression of the lesions when the primary
autoimmune disorder was treated. Oral acanthosis nigricans is the form most
frequently associated with malignancy.
I always remember one of the first cases of acanthosis
nigricans I diagnosed as an intern in a homeless Sydney alcoholic. The
consultant made the correct diagnosis by bathing the patient’s axillae with
hydrogen peroxide which removed the cutaneous lesions.
Recommended
learning: Review the distribution and common associations of
acanthosis nigricans.
MEDICINE AND SOCIETY
“Ethics
and Clinical Research” — The 50th Anniversary of Beecher’s Bombshell
Fifty
years ago, Henry Beecher warned about serious problems with human-subjects
research in the United States and exhorted researchers to reform. Research
regulations proliferated in the ensuing decades, but new policies and
procedures have not resolved every dilemma.
This is a somewhat dry historical summary of how we got
to where we are today on human-subject research. It should be read by those
embarking on any research involving human subjects and for all UNDA students
beginning the new MD course.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
ORIGINAL ARTICLE
Low-Dose
versus Standard-Dose Intravenous Alteplase in Acute Ischemic Stroke
This randomized comparison of low-dose and standard-dose alteplase in acute ischemic stroke did not establish noninferiority of low-dose alteplase for the primary outcome of death or disability at 90 days. Fewer patients had intracerebral haemorrhages in the low-dose group.
EDITORIAL
Finding
the Right t-PA Dose for Asians with Acute Ischemic Stroke
The study and the accompanying editorial describe a
study in Asians (predominantly Chinese) presenting with an acute ischaemic
stroke who were treated with either standard dose IV alteplase (0.9 mg/Kg) or
lower dose alteplase (O.6 mg/Kg). This study was coordinated through the RPAH
Global Health Institute in Sydney. The results of the study essentially
demonstrate that the lower dose is as effective as the standard dose regarding
the primary outcome of disability or death at 90 days. Moreover, there were
fewer patients who developed intracranial haemorrhage in the lower dose group
((1.0% versus 2.1%).
Read the editorial for full discussion of the study,
its implications and analysis of the patient demographics. While cost is
usually not a significant deterrent to using the standard dose of alteplase in Australia
and the US, it is a consideration in countries such as Asia and Mexico where
patients are frequently asked to pay for the full cost of the drug prior to
treatment.
SPECIAL ARTICLE
Two-Year
Costs and Quality in the Comprehensive Primary Care Initiative
The Centers for Medicare and Medicaid Services launched
the 4-year Comprehensive Primary Care Initiative to support transformations in
primary care delivery. After 2 years, practices have changed care delivery but
have not yet reduced costs or substantially improved quality.
EDITORIAL
Transforming
Primary Care — We Get What We Pay For
The two year summary of this extensive and complicated
US study of 497 primary care centres is as indicated above. As yet, there has
been no appreciable cost in savings to Medicare or improved quality of patient
care, although several areas show some improvement. This is an article for
those interested in health care delivery and policy, cost containment, and
hospital management.
Maybe there is no more blood left in the stone, GPs
have been bled out and what they really need is a financial transfusion, both
in the US and Australia. This is also illustrated in the accompanying
editorial.
ORIGINAL ARTICLE
Elimination
of Taenia solium Transmission in Northern Peru
Unfortunately none of the students enjoyed this article
as much as I did. In countries where the pork tape worm (T. solium) is endemic and where encystment can occur in the human
brain, cysticercosis is a frequent cause of seizures. This is commonly seen in
Hispanics who have moved to the US.
I found this study fascinating from a public health
perspective. Of particular interest were the ways T. solium was eliminated in both the human and pig population in the
Tumbes region of Peru. I enjoyed reviewing the microbiology and life cycles of
parasites and Figure 2 in the article.
Recommended
learning: Review the life cycles of the pork and fish (for those
sushi eaters) tapeworms, clinical presentations and their management.
