Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 14th July 2016 (#51)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
None
Articles Recommended for Medical Students
Perspective
Beyond
Bathrooms — Meeting the Health Needs of Transgender People
Beyond
bathroom accessibility, discrimination against transgender people is associated
with many adverse health effects. The health care community can help through
clinical care, research, and advocacy. But most clinicians lack expertise in
transgender health
In my opinion, this is a political wedge issue
concocted by right wing Christians in the US to divert attention from truly
pressing problems such as wars and climate change. One solution is unisex
bathrooms. Transgender rights extend far beyond bathrooms.
There are several points I would like to make:
1. The
fastest growing outpatient clinic at Princess Margaret Hospital is the Gender
Diversity Clinic.
2. With
the inclusion of “other” under Gender in the upcoming census, I predict that
there will be a larger number of Australians than predicted who will tick this
box.
3. I
was discussing transgender issues with one of my MED300 student groups last
week when I was told a story. At one of the large GP group practices in the
Perth area, a patient with transgender issues asked for an appointment. The
front office staff did not know to whom to refer the patient but apparently
selected an empathetic physician. This GP has now developed a reputation as the
“transgender GP” in the area and their practice is growing rapidly.
4. Most
students and doctors do not have experience interacting and treating transgender
patients and may feel awkward in interacting with them. This includes even such seemingly simple
issues as to what pronoun to use when addressing the patient.
5. It
is clearly incumbent upon Australian medical schools to consider the
introduction of transgender medicine as another aspect of the medical
curriculum.
The final paragraph distills the essence of the
article:” Being transgender, like being left-handed, may someday be recognized
as merely another inherent human quality, no longer conferring a need for
protection. In the meantime, the health care community can better address
transgender health needs, help ensure that transgender people feel safe in
seeking health care, promote resilience in the face of prejudice, and expand
our knowledge of how best to promote transgender health and well-being.”
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
21-2016 — A 32-Year-Old Man in an Unresponsive State
A
32-year-old man was admitted to this hospital after being found in an
unresponsive state in his jail cell. He had jaundice and encephalopathy;
results of liver-function tests were abnormal, and CT revealed cerebral edema.
Diagnostic tests were performed.
This is a very educational CPC involving a patient with
acute fulminant liver failure and severe hepatic encephalopathy. A discussion
of the causes of acute liver failure are well addressed as is an excellent
discussion of acute viral hepatitis. I learnt about subtle aspects of the
immune response to hepatitis B including the effects of vaccination.
I would also have treated this encephalopathic
patient with lactulose rather than focusing on measures to reduce the raised
intracranial pressure. Apparently lactulose in this situation is of no proven
benefit and, in addition, may worsen dehydration and underlying electrolyte
abnormalities exacerbating cerebral oedema.
Recommended
learning: Review the pathology, clinical presentations and
management of hepatic encephalopathy and portal hypertension.
IMAGES IN CLINICAL MEDICINE
Milk
of Urate Bulla
A
71-year-old man with a history of gout and renal transplantation presented with
a new blister overlying the second interphalangeal joint just distal to a
preexisting tophus on his hand. Examination of the fluid showed sheets of
negatively birefringent crystals.
This is a photograph
of a gouty tophus (A) discharging a thick soup of monosodium urate crystals
which are demonstrated as negatively birefringent on polarizing microscopy (B).
There are several interesting points which need to be
made:
1. The
prevalence of acute gouty arthritis and chronic tophaceous gout has doubled in
frequency over the last 20 years. These are now seen regularly on the wards in
the Perth area and relate to the obesity epidemic (increased lipids, serum
urate and blood sugar and hypertension), an ageing population with more chronic
kidney disease and, increased use of thiazide diuretics.
2. In
Australia, the prevalence in the adult non-Aboriginal population is
approximately 1.4%, but 4% in Aboriginal Australians.
3. Acute
gouty arthritis is the commonest inflammatory arthritis in males.
4. The
mean time for the development of tophi in untreated gouty patients is 11.5
years and 4-5 years in post-transplantation patients.
5. Long
standing hyperuricemia is an independent risk factor (low OR) for atheromatous
cardiovascular disease and chronic kidney disease.
Recommended
learning:
1. Review
the causes and significance of hyperuricemia.
2. Review
pathobiology of acute gout, including the role of the inflammasome.
3. Review
the treatment of acute gouty arthritis and chronic gout.
4. Review
the tumour lysis syndrome and its management.
IMAGES IN CLINICAL MEDICINE
Jejunal
Diverticulosis with Midgut Volvulus and Intestinal Malrotation
A
67-year-old woman with malabsorption and malnourishment was referred for
possible intestinal transplantation. CT showed small-bowel dilatation along
with a whirl sign and numerous collateral veins, suggestive of a midgut
volvulus, shown in a video.
Radiology demonstrates the jejunal diverticula and the
operative finding demonstrate the diverticula on the anti-mesenteric border of
the jejunum. While the patient exhibited bacterial overgrowth diarrhoea,
malabsorption and weight loss, she also developed a midgut volvulus.
What
interested me the most was that after correction of the mechanical volvulus,
the jejunum containing diverticula was removed and the malabsorption corrected
with evidence of progressive weight gain.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
ORIGINAL ARTICLE
Ventricular
Tachycardia Ablation versus Escalation of Antiarrhythmic Drugs
In
patients with ischemic cardiomyopathy and an implantable cardioverter–defibrillator
who had ventricular tachycardia, catheter ablation was associated with a lower
rate of death, ventricular tachycardia storm, or ICD shock at 28 months than an
escalation in antiarrhythmic drugs.
I have found that students will always pick the article
related to cardiology! This specific study population are a group of 259
patients with recurrent ventricular tachycardia who have survived an MI with an
implantable cardioverter-defibrillator.
The question dealt with is which is more effective, either standard antiarrhythmic
drugs + ablation therapy or escalating doses of anti-arrhythmics
(amiodarone/mexiletine) over a mean follow up period of 28 months.
The primary end point was a composite of death, three
or more documented episodes of VT within 24 hours (VT storm) or ICD activation.
The mortality rate was similar in both groups. Thus, the data supporting
ablation therapy relates to fewer VT storms and ICD activation. It must be emphasised that post-MI ablation
is an extremely complicated procedure, is very time consuming, and requires
skilled expertise and equipment.
ORIGINAL ARTICLE
Olanzapine
for the Prevention of Chemotherapy-Induced Nausea and Vomiting
The
addition of olanzapine to a neurokinin receptor blocker, a serotonin receptor
blocker, and dexamethasone markedly improved the control of nausea and vomiting
in previously untreated patients receiving highly emetogenic chemotherapy.
CLINICAL DECISIONS
Chemotherapy-Induced
Nausea and Vomiting
This
interactive feature offers a case vignette accompanied by essays that support
either using a standard premedication regimen or adding olanzapine to prevent
nausea and vomiting. Share your comments and vote at NEJM.org.
The above include an interesting study and clinical
decision making (point-counterpoint) involving the use of olanzapine as an
anti-emetic agent. It gives students a chance to review the drugs used to prevent
chemotherapy-induced nausea and vomiting produced by very emetogenic
chemotherapy (in the study, cisplatin + other drugs or doxorubicin +
cyclophosphamide and, in the clinical decision making case, cisplatin +
paclitaxel + bevacizumab).
Drugs that can be used to reduce nausea and vomiting
include a 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist (ondansetron
group), dexamethasone, and a neurokinin-1 (NK1) receptor antagonist (aprepitant
group). To this mix has been added olanzapine, an atypical antipsychotic drug,
which inhibits numerous neurotransmitter receptors.
The authors found that addition of olanzapine
significantly improved nausea prevention and complete response rate with few
adverse effects, over the group given placebo.
In the clinical decision making, which I believe is
much to do about nothing, the discussants indicate:
1. Weight
gain and type 2 diabetes mellitus are not serious considerations with
olanzapine in the short term.
2. Olanzapine
produces more drowsiness during the first 24 -48 hours of this very aggressive
chemotherapy. To me this is a plus and not a minus. I want to be asleep and not
throwing up.
3. The
most important consideration is the patient with extensive cervical cancer who
needs specific chemotherapy and is scared of nausea and vomiting. One needs to
do everything possible to limit the effects of chemotherapy and allow her to continue
this chemotherapy. This is a plus, not a minus, as I would want to be asleep
and not vomiting. In my opinion, this does not even
warrant an academic discussion in adding olanzapine to the standard regime.
