Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 6th October 2016 (#63)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
It never ceases to amaze me how important public health,
ethics, and professionalism are in the practice of clinical medicine. I would
estimate that in discussions with students about specific patients that up 40%
of the discussion involves these issues. This is exemplified by articles that
appear in the Journal.
Must Read Articles
Perspective
Vaccine
Refusal Revisited — The Limits of Public Health Persuasion and Coercion
Many
scientific, ethical, and political challenges that physicians and public health
officials face today in dealing with vaccine refusal would be familiar to their
counterparts of past eras. Their task entails balancing the use of coercive and
persuasive approaches.
The bottom line is that unless coercion is added to
persuasion, the public health program will not optimally succeed.
CLINICAL PROBLEM-SOLVING
Testing
Limits
A
previously well 57-year-old woman presented to her internist during the summer
with a 1-week history of achiness, malaise, anorexia, and fevers. She reported
a cough and persistent pain in the right upper quadrant and had no nausea,
vomiting, or diarrhea.
This is a very interesting discussion of a patient with
a pyrexia of unknown origin (PUO) or FUO with the ultimate cause found to be a uterine
leiomyosarcoma which had been mistaken for uterine fibroids.
Articles Recommended for Medical Students
ORIGINAL ARTICLE
A
Measles Outbreak in an Underimmunized Amish Community in Ohio
Two
men returned to Ohio from the Philippines, where they were unknowingly infected
with measles. A measles outbreak subsequently developed in their Amish
community. The importance of high vaccination coverage to measles control is
highlighted.
EDITORIAL
Measles
Elimination — Using Outbreaks to Identify and Close Immunity Gaps
This is a study of an outbreak of measles in an Amish
population in Ohio where the virus from the Philippines was introduced by two
travellers. The population was generally
non-immune and susceptible population but were not adverse to vaccination. It
describes in detail public health measures undertaken with particular emphasis
on the role and effectiveness of measles vaccination in an epidemic.
Recommended
learning: The biology of measles, pathophysiology of the
infection, vaccination and the principles of epidemic management.
IMAGES IN CLINICAL MEDICINE
Worms
in the Eye
A
21-year-old man presented with a 2-week history of itching in his left eye. He
reported “seeing worms” in his eye. He underwent thorough irrigation of the
conjunctival sac and lacrimal duct. A video shows removal of a worm.
Make sure to watch the video.
IMAGES IN CLINICAL MEDICINE
Placenta
Increta
A
38-year-old woman who had undergone three low-segment cesarean sections was
admitted in labor at 36 weeks of gestation. Ultrasonography suggested placenta
accreta, with irregular vascular spaces and loss of retroplacental hypoechoic
stripe. She underwent an emergency cesarean section.
This is an excellent discussion of the types of
abnormal placentation.
REVIEW ARTICLE
The
Health Effects of Electronic Cigarettes
The
use of electronic cigarettes is growing, and some hope that they will replace
what is felt to be the more dangerous nicotine-delivery system — cigarettes.
However, data on the long-term safety of e-cigarettes are still being gathered.
CORRESPONDENCE
Explosion
Injuries from E-Cigarettes
This
report from a single center describes 15 patients with injuries caused by
explosions of e-cigarettes that occurred over a period of less than a year.
Patients had a combination of flame burns, chemical burns, and blast injuries.
Students enjoyed reading the review on electronic
cigarettes.
It is important to examine the clinical photographs of
patients from the University of Washington Medical Center who sustained
injuries related to exploding e-cigarettes. Injuries from exploding
e-cigarettes will be increasingly recognised in populations where e-cigarettes
are commonly used, particularly traumatic tattooing.
Important Articles Related to Mechanisms of Disease and Translational
Research
None
Other Articles which should interest medical students
ORIGINAL ARTICLE
The
Role of PIEZO2 in Human Mechanosensation
Inactivating
variants in PIEZO2, which encodes a stretch-gated ion channel, impair
touch perception and proprioception. Visual cues partially compensate for these
impairments, allowing affected persons to perform complex movements with
greater accuracy.
This fascinating study involves two patients with
autosomal recessive, compound inactivating mutations of the PIEZO2 gene. This gene encodes for a series of proteins
representing stretch-gated, mechanosensory, ion channels which are expressed in
subsets of somatosensory neurons and Merkel cells (epithelial tactile cells).
In the patients, this mutation resulted in impaired vibration and proprioception
and touch discrimination in skin which does not contain hair follicles
(glabrous skin), such as palms and soles of the feet. Both patients were extensively studied. Each was born with hip dysplasia (possibly
due to absence of proprioception in utero), finger contractures, foot
deformities, early progressive scoliosis, and hypotonia. They also had impaired motor skills, delayed
walking and impaired gait but no cognitive impairment.
ORIGINAL ARTICLE
Life
Expectancy after Myocardial Infarction, According to Hospital Performance
In
an analysis of more than 119,000 patients with acute MI admitted to over 1800
hospitals, patients treated in high-performing hospitals (with low 30-day
risk-standardized mortality) had longer life expectancies than those treated in
low-performing hospitals.
New Pharmacological Therapies
ORIGINAL ARTICLE
Daratumumab,
Lenalidomide, and Dexamethasone for Multiple Myeloma
The
addition of daratumumab to lenalidomide and dexamethasone resulted in superior
response rate and progression-free survival, as compared with lenalidomide and
dexamethasone alone, at a cost of more frequent neutropenia and infusion
reactions.
EDITORIAL
Progress
in Myeloma — A Monoclonal Breakthrough
Over the past decade, more advances in the treatment of
multiple myeloma have occurred than with any other cancer. Advancements have
been seen in the understanding of disease pathogenesis, biomarkers, the concept
of minimal residual disease, and new therapies, all of which resulted in the
doubling of overall survival rate. The last has been attributed to the use of
lenalidomide (a cereblon binder, related to thalidomide which had been used
earlier) and bortezomib (the first proteasome inhibitor).
The new drug daratumumab is a monoclonal antibody which
binds to CD38, a cell surface antigen predominantly on lymphoid cells (CD4+,
CD8+, B cells and NK cells). When
combined with either dexamethasone-lenalidomide or dexamethasone-bortezomib,
the combination led to significant higher response rates and longer
progression-free survivals in patients with previously treated, relapsed
myeloma. More new agents will be
trialled in the future.
Other articles which may be of interest to certain students
REVIEW ARTICLE
THE CHANGING FACE OF CLINICAL TRIALS
Data
Monitoring Committees — Expect the Unexpected
Randomized
clinical trials require a mechanism to safeguard the enrolled patients from
harm that could result from participation. This article reviews the role of
data monitoring committees in the performance of randomized clinical trials.
