Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 15th September 2016 (#60)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
While the students are on vacation over the next three months,
I will not spend a lot of time reviewing each article but will continue to
point out what I believe to be high value articles and include the summary of
the article provided by the NEJM. Clearly if the article is exceptional, I may
not be able to restrain myself from comments.
Must Read Articles
VIDEOS IN CLINICAL MEDICINE
Clinical
Examination of the Shoulder
Shoulder
pain leads many patients to see a primary care physician. This video reviews
the anatomy of the shoulder, common shoulder injuries, and the procedures for
obtaining the patient's history and performing a physical examination of the
shoulder.
This is an excellent clinical video of the examination
of the shoulder. It should be viewed by
all students and the hyperlink stored for further reference.
Articles Recommended for Medical Students
ORIGINAL ARTICLE
Efficacy
of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older
In
this trial of a recombinant VZV glycoprotein E subunit vaccine with the
adjuvant AS01B, the risk of herpes zoster and postherpetic neuralgia is shown
to be significantly lower in association with the vaccine than with placebo
among persons 70 years of age or older.
EDITORIAL
Preventing
Shingles and Its Complications in Older Person
ORIGINAL ARTICLE
Intensive
Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage
In
this randomized trial involving patients with intracerebral hemorrhage,
intensive reduction in systolic blood pressure to a target of 110 to 139 mm Hg
did not result in a lower rate of death or disability than standard reduction
to a target of 140 to 179 mm Hg.
This is an excellent study providing guidance for BP
control in patients presenting with a haemorrhagic stroke.
IMAGES IN CLINICAL MEDICINE
Urinary
Tract Tuberculosis
A
76-year-old man with diabetes and mediastinal lymphadenopathy presented with
fever and fatigue. Pyuria was seen on urinalysis. CT of the abdomen showed mild
dilatation of the left renal pelvis and thickening of the ipsilateral ureteral
wall.
IMAGES IN CLINICAL MEDICINE
Cholesterol
Embolization after Transcatheter Aortic-Valve Replacement
An
88-year-old man with a history of MI for which he had required quadruple
coronary-artery bypass grafting presented with mottled purple discoloration of
the toes. One month earlier, he had undergone transapical transcatheter
aortic-valve replacement.
This is an example of what our surgical colleagues
might call “trash foot.” The frequency of sub-clinical cholesterol embolic
disease (CED) after endovascular procedures or thrombolytic therapy, as
indicated in the discussion, is unclear. I would predict that CED is a very
frequent occurrence, excluding the microvascular compromise mainly involving
the brain, kidney, eye, skin and toes. It
is classically associated with the laboratory findings of eosinophilia and
reduced complement levels.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
28-2016 — A 31-Year-Old Woman with Infertility
A
31-year-old Nepalese woman presented with primary infertility. Two cycles of in
vitro fertilization had been unsuccessful. A hysterosalpingogram showed
abnormal narrowing and outpouching of the distal fallopian tubes. Additional
diagnostic procedures were performed.
This is an interesting cause of infertility which
demonstrates that before the fertilized egg can implant into the endometrium
which must be receptive. The discussion involves the investigation and causes
of infertility, in particular recurrent implantation failure and a differential
diagnosis of endometrial granulomas.
Important Articles Related to Mechanisms of Disease and
Translational Research
CLINICAL IMPLICATIONS OF BASIC RESEARCH
A
Wake-up Call for Type 2 Diabetes?
This
study examines an established association between a variant in a
melatonin-receptor gene and type 2 diabetes, yielding insights into how the
variant confers susceptibility to the disease.
This is a fascinating article which reviews two recent
publications on the role of melatonin and pancreatic insulin-secreting b-cell
function. Under normal circumstances, melatonin (one of myriads of peptides
that bind to receptors on b-cells) binds to the MT2 receptor leading to
inhibition of insulin release (intracellular mechanisms well illustrated in
Figure 1). In situations where there is a gain-of-function mutation in the gene
MTNR1B which encodes the surface receptor MT2 (isolated rat b-cells and
individuals harbouring the risk allele), there is increased inhibition of
insulin release.
The good news is that short term use of melatonin for
jet lag or doses less than 4 mg/night for up to three months for insomnia did
not result in significant impairment in glucose tolerance. However, the BSL did
rise after melatonin but returned to normal within two hours.
Other Articles which should interest medical students
REVIEW ARTICLE
Biologic
and Clinical Perspectives on Thyroid Cancer
As
in many cancers, genetic analysis of thyroid cancers has identified subgroups
that differ in their pathogenesis and has defined targets that make the cancer
susceptible to particular therapies. Recent progress leading to new treatments
is reviewed.
N.B.
The page number should read 1054.
This is an extremely detailed review of the biology and
clinical assessment of thyroid cancer.
The article provides an excellent overview of types of thyroid cancer
and the commonly associated genetic mutations (Figure 1). In Fig. 2, the driver mutations of various
papillary carcinomas are indicated together with the histological type and
degree of differentiation, the biochemical pathways, and their relationships to
thyroid differentiated genes and MAPK output. There is a detailed description
of the management of each type of cancer including surgery, use of radioactive
iodine, and use of various kinase inhibitors.
I would not recommend this as reading for medical students
unless they have a specific interest in thyroid cancer, genetic diagnosis in
malignancy, or have a patient they are currently managing. I would recommend
reviewing Figures 1 and 2.
Recommended
learning: Review thyroid cancer covered in the medical clinical
cases (MED300), surgery and the ENT rotation.
New Pharmacological Therapies
None
Other articles which may be of interest to certain students
Perspective
Zero
to 50,000 — The 20th Anniversary of the Hospitalist
In
the past 20 years, the number of hospitalists in the United States has grown
from a few hundred to more than 50,000. Although challenges remain, many stars
have aligned to enable the model to thrive and contribute to high-quality,
efficient inpatient care.
Perspective
Hospitalists
and the Decline of Comprehensive Care
Increasing
reliance on hospitalists in the United States entails a number of risks and
costs for everyone involved in the health care system — most critically, for
the patients that the system is meant to serve.
SPECIAL REPORT
Twenty
Years of Global Surveillance of Antituberculosis-Drug Resistance
The
emergence and dissemination of drug-resistant Mycobacterium
tuberculosis is a global threat to health. In this report, surveillance of
drug-resistant tuberculosis during the past 20 years is described.
