Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 2nd June 2016 (#45)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
None
Articles Recommended for Medical Students
Perspective
A
Modern Ars Moriendi
“My
father had never heard of the ars moriendi, but I was certain that he would
have wanted it. In his living will and family discussions, Dad had been clear
that he wanted no mechanical ventilation, no resuscitation, no feeding tubes.
And he wanted to die at the ranch.”
“Latin for “art of dying,” the ars moriendi is
a body of literature that originated in Europe during the 15th century, on the
heels of the bubonic plague. Its aim was to provide a practical and spiritual
framework for the preparation for death. It outlined prayers and
protocols for the dying and for their communities. It emphasized the
acknowledgment of human finitude. “
I recommend reading this description by a physician of
her father’s death following a stroke which relates to the dignity and finesse
with which the situation was managed. She relates moving from the role of
daughter, to health care proxy and to physician. Fortunately the patient had a
living will, advanced health care directives and had discussed his wishes with
the family to help protect him from a possibly overaggressive health care
system. He wished to die with dignity in the setting of his home, a wish that
was granted to him by his family. In spite of this, his daughter still had
reservations about whether she had made the right decision.
Today more of us are opting to have our terminal hours
spent at home, if possible, with appropriate care administered by family, by
home palliative care and by the local GP.
IMAGES IN CLINICAL MEDICINE
Gastrointestinal
Complication of Granulomatosis with Polyangiitis
A
48-year-old man known to have granulomatosis with polyangiitis was admitted for
evaluation of an elevated blood creatinine level. Urinalysis was notable for 2+
protein. The patient, who was positive for antineutrophil cytoplasmic antibody,
had taken azathioprine for 7 years before presentation.
I found this case interesting but the treatment unusual.
If I had been consulted on this patient who had acute ischaemia of his duodenum
and jejunum from vasculitis due to granulomatosis with polyangiitis (formerly
Wegener’s granulomatosis), I would have treated the patient with high dose IV
methylprednisolone. As he was already immunosuppressed on azathioprine, I would
have considered substituting IV cyclophosphamide if his total lymphocyte count
on azathioprine was within the normal range. I would also have considered adding rituximab
for the acute process if the patient had remained on azathioprine. I am amazed
that after the surgeon closed the abdomen, the patient was treated with only IV
heparin and maintained on the same dose of azathioprine. I also assume that the
patient had small contracted kidneys at the time of admission and had acute on
chronic renal failure. The illustrations
are excellent.
Recommended
learning (MED300 and MED400): Review granulomatosis
with polyangiitis (Wegener’s granulomatosis) and when to order an ANCA test.
CLINICAL PROBLEM-SOLVING
The
Hidden Lesion
A
24-year-old woman presented to the ED with pain in the left leg. She had been
training for a 5-km race when, 2 days before presentation, she had crampy pain
in her left leg, extending to the left lower abdomen and buttock, plus leg
swelling and exertional dyspnea.
This is the second time in five weeks that the Journal
has described the May-Thurner syndrome in association with venous thromboembolism.
In this case the patient presented with a classical pulmonary embolism, while
in the CPC (NEJM review #40 on blog) the embolus passed through a patent
foramen ovale (PFO) on its way to the brain resulting in an acute ischaemic
stroke. Furthermore, the students
informed me that they had recently managed a patient with this syndrome
presenting with a pulmonary embolism.
How common is this condition and how far does one
investigate the patient presenting with a left lower extremity DVT without an
identified coagulopathy? Suspicion should be aroused when the patient (more
common in females within the age group 10-40) presents with femoral vein
thrombosis with a previous history of left thigh pain. The article quotes a
study indicating that using CT, two thirds of asymptomatic individuals without
thrombosis had greater than 25% compression of the left iliac vein by the right
iliac artery. A full discussion of the entity, investigations, and management
are in the article and the earlier CPC).
Recommended
learning: Review the causes of DVT.
CLINICAL DECISIONS
E-Cigarettes
and Smoking Cessation
This
interactive feature offers a case vignette accompanied by essays that either support
the use of e-cigarettes to aid in smoking cessation or recommend against such
use. Share your comments and vote at NEJM.org.
In the US, the Tobacco Companies (merchants of death #2
,following arms manufacturers) are in the process of requesting the FDA ban
nicotine-containing e-cigarettes owing to the proliferation of numerous
unregulated smaller companies producing e-cigarettes with little quality
control of the contents and differing nicotine contents. These smaller
manufactures are undercutting the profits of Big Tobacco. I am sure Big Tobacco
will prevail in court and then usurp legal e-cigarette production and profits.
I agree with the counterpoint argument in not
recommending e-cigarettes for smoking cessation and refer Australian readers to
an article from the RACGP describing Australian law and reviewing the general
topic (http://www.racgp.org.au/afp/2015/june/e-cigarettes-and-the-law-in-australia/#4,7).
My premise is that we, as doctors at the doctor-patient
interface, do not treat this subject seriously with patients, providing
lip-service only, or spending the necessary time with the patient in ongoing counselling
for smoking cessation. It is very difficult for GPs, especially those that
bulk-bill with a high patient turnover, to spend this financially undervalued
time with the patient who may not yet be suffering from cough, shortness of
breath and early irreversible pulmonary disease. At UNDA we teach students
motivational interviewing. The question is will they have time to accomplish
this successfully in practice? If the GP acquiesces to the patient, and allows
them to continue smoking, are they complicit in allowing the patient’s health
to deteriorate? Further, I believe the “common good” overrides the patients’
right to treatment while they continue to smoke.
If the GP’s time
were reimbursed for seriously educating patients (shock therapy using gruesome
laminated pathology pictures, somewhat like plain cigarette packaging;
reimbursed group cardio-respiratory exercise therapy; formal counselling and
hypnotherapy as well as nicotine replacement, bupropion and varenicline),
tobacco usage should decline. What about the concept of general practices not continuing
to treat patients who continue to smoke after six months (establish a six month
contract) with every effort is expended stop the patient smoking? Could the
Federal Government subsidize these practices for any loss of income? The
profession needs to try harder and advocate for appropriate remuneration for
preventive services as this in the long run will reduce total health care
costs. Whatever the medical profession is doing is not enough and new areas need
to be considered.
Recommended
learning: Review the mechanisms you can employ to stop your
patient smoking.
ORIGINAL ARTICLE
BRIEF
REPORT
Zika
Virus Infection with Prolonged Maternal Viremia and Fetal Brain Abnormalities
In
this case report, the association between Zika virus infection and
teratogenicity is strengthened, with evidence that the latency period between
ZIKV infection of the fetal brain and the detection of microcephaly and
intracranial calcifications on ultrasonography may be prolonged.
This is an excellent detailed single case study of a
pregnant patient infected with ZIKV during her 11th week of gestation. The
patient was closely monitored and a termination performed at 21 weeks. By 21
weeks there was no evidence of microcephaly or intracerebral calcification but
marked brain abnormalities were noted on ultrasound and MRI and extensive neuropathological
features noted in the brain. ZIKV was
identified in and cultured from the fetal brain. If the pregnancy had progressed to term,
would microcephaly and cerebral calcification microcephaly have developed?
MEDICINE AND SOCIETY
Assessing
the Gold Standard — Lessons from the History of RCTs
Randomized,
controlled trials have become the gold standard of medical knowledge. Yet their
scientific and political history offers lessons about the complexity of
medicine and disease and the economic and political forces shaping the
production and circulation of knowledge.
This is an article that should be read by all medical students
and stored in your database.
It describes the history of randomized, controlled
trials (RCTs). Published data from RCTs began in the UK, though now the UK has
the lowest number of these studies (Figure 1). The number of published RCTs in
the US peaked in the mid-60s funded by the Federal Government, particularly the
NIH and the NSF. Now most of the RCTs are funded by industry for drugs and
devices. Currently the EU carries out the largest number of RCTs. This was one
of the arguments used for the formation of the EU 40 years ago to fund this
type of expensive collaborative research most funded by industry with the
exception of the UK (Figure 2). What will happen now with RCTs in the UK post-
Brexit?
I found the section, “The Gold Standard That Wasn’t,”
particularly illuminating, especially when the NIH and NHMRC have accepted the
methodological hierarchy for publication and funding with case reports on the
bottom rung and RCTs at the top of the ladder. There are clearly pros and cons
for each type of study and areas of disagreement. The future and newer concepts
in trial methodologies are discussed.
ORIGINAL ARTICLE
A
Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care
In this study of an educational program to prevent
catheter-associated urinary tract infection, implemented in more than 10% of
U.S. acute care hospitals, both catheter use and catheter-associated UTI rates
were significantly decreased in the non-ICU setting.
EDITORIAL
Catheter-Associated
Urinary Tract Infections — Turning the Tide
“Up to 69% of catheter-associated UTIs are
considered to be avoidable, provided that recommended infection-prevention
practices are implemented,” though in reality these results are never achieved.
This study involved patients on 926 units in the US in
603 hospitals in 32 states (60% non-ICU and 40% ICU patients) and reviewed
catheter usage and catheter-associated UTI rates in these populations. In the
non-ICU setting, catheter use decreased from 20.1% to 18.8% (p<0.001) and
catheter-associated UTI rates decrease from 2.28 to 1.54 infections per 1000
catheter-days (p<0.001). In the ICU, catheter use and catheter-associated
infections did not change significantly.
The argument assumes that two processes are in play: one
is the technical aspects of prevention which have been standard for years and
generally are not felt to contribute to any changes, while the other relates to
behaviour and culture (socioadaptive component of prevention), which due to
greater levels of education and awareness, probably accounts for the changes demonstrated
in the non-ICU population.
Recommended
learning: Review catheter-associated urinary tract infections
and the indications for treating a catheterised patient with increased WBCs in
the urine.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
IMAGES IN CLINICAL MEDICINE
Intrafacial
Synkinesis
A
52-year-old man was admitted to the hospital with progressive weakness.
Examination revealed involuntary unilateral ptosis that coincided with
voluntary contraction of the lower facial muscles (shown in a video), a form of
synkinesis known as the Marin-Amat syndrome.
This unusual and uncommon neurological sequela (see the
video) of previous Bell’s palsy is assumed to be due to erratic reinervation by
damaged facial nerve fibres of different muscle groups resulting in this entity.
Do not try to remember the name of the syndrome.
ORIGINAL ARTICLE
Prospective
Study of Acute HIV-1 Infection in Adults in East Africa and Thailand
An
understanding of the early events in primary human immunodeficiency virus type
1 infection is important to improve treatment and control the spread of the
virus. This study describes early virologic and immunopathologic events in
acute HIV-1 infection.
This complicated study involved 2276 volunteers from
East Africa and Thailand who were at high risk for developing acute HIV-1
infection (see participant criteria in method section and consider any possible
ethical issues).One hundred and twelve participants (5%) developed acute HIV-1
infection. In the African population the majority were heterosexual women,
while in Thailand the majority were homosexual men and transgender women.
Detailed longitudinal measurements over 510 days were
carried out on 50 participants in whom i) at least two simultaneous samples
showed detectable HIV-1 RNA without a nonreactive enzyme immunoassay, ii) at
least one study visit before RNA conversion and iii) quantitative HIV-I RNA
data.
In essence the study showed that the peak viral RNA
load occurred 13 days after the first detection of viral RNA in blood and by
day 31 the viral load had reached a nadir that persisted at a similar level for
510 days (see Figure 2). Symptoms associated with the primary infection were
minimal and transient and occurred during the viral load upstroke and at the
peak level. The numbers of CD4+ T-cells, CD8+ T-cells, NK cells and B-cells over
the time course were illustrated in Figure 4.
Recommended
learning: Review the clinical manifestations of acute HIV
infection.
