Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 22nd September 2016 (#61)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
REVIEW ARTICLE
Primary
Sclerosing Cholangitis
This review summarizes the current understanding of primary sclerosing cholangitis, a persistent, progressive disease for which there is no definitive therapy. The authors describe the pathogenesis and management of this condition.
This is an
excellent review article discussing the primary and secondary (Table 1) causes
of sclerosing cholangitis, clinical subtypes and all summarised in Figure 1.
This article should be read when the appropriate
patient is seen during the clinical years.
Articles Recommended for Medical Students
ORIGINAL ARTICLE
Trial
of Decompressive Craniectomy for Traumatic Intracranial Hypertension
In
a trial comparing decompressive craniectomy with medical therapy in patients
with traumatic brain injury and raised intracranial pressure refractory to
medical therapy, decompressive craniectomy resulted in lower mortality and
higher rates of vegetative state and severe disability.
EDITORIAL
Intracranial
Pressure Rescued by Decompressive Surgery after Traumatic Brain Injury
This is a twelve month study following traumatic brain
injury and refractory elevated intracranial hypertension (>25 mm Hg). At six months, patients who had decompressive
craniectomy when compared with standard medical treatment, had an increased
survival rate (48.9% versus 26.9%) but had significantly higher rates of
vegetative states (8.5% versus 2.1%) and severe disability.
ORIGINAL ARTICLE
Andexanet
Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors
Andexanet
alfa, a catalytically inactive decoy of factor Xa, successfully reversed the
factor Xa inhibitory effects of rivaroxaban and apixaban in a small study
involving patients with acute major bleeding.
The reality will be that reversal agents used to
counteract the effects of the NOACs (oral Xa and thrombin inhibitors) will
rarely be employed because of cost, availability, complexity of administration,
and time taken to administer the drugs. As is indicated in this study, the mean
time taken to administer andexanet from the time the patient arrived with acute
major bleeding in the ER to the time of administration was 4.8 hours by which
time the biological effect of the NOAC would have been significantly reduced.
Their availability will probably be used as a comforter for those using NOACs,
being there if needed but rarely used.
IMAGES IN CLINICAL MEDICINE
Regression
of Clubbing after Treatment of Lung Cancer
A
59-year-old woman with a smoking history of 60 pack-years presented with
progressive shortness of breath and clubbing of her fingers. CT scan showed a
large mass with cavitation in the left lower lobe of the lung.
IMAGES IN CLINICAL MEDICINE
In
Vitro Exflagellation of Plasmodium vivax
After
recently arriving in Switzerland seeking asylum, a 24-year-old man from Eritrea
presented to the ED with recurrent fevers. He reported having had fevers
approximately every 2 months for the previous 3 years.
CLINICAL DECISIONS
Obesity
and Management of Weight Loss
This
interactive feature on weight loss offers a case vignette accompanied by essays
that support either using an FDA-approved drug as an aid or maximizing
lifestyle modification and nonpharmacologic therapies. Share your comments and
vote at NEJM.org.
This is an interesting discussion on whether
pharmacological therapies should be added to lifestyle modifications and
nonpharmacological therapies.
Recommended
learning: Therapeutic options to treat obesity, including the
role of drugs and bariatric surgery.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
29-2016 — A 53-Year-Old Woman with Pain and a Mass in the Breast
A
53-year-old woman with systemic lupus erythematosus presented with pain and a
lump in the left breast that had persisted for 5 days. Four months earlier, she
had noted a smaller lump in a different location of the left breast. A
diagnostic procedure was performed.
When a CPC begins with, “a 53-year-old woman with
systemic lupus erythematosus with associated nephritis and chronic renal
insufficiency was seen in the gynecology clinic of this hospital because of
pain and a lump in the left breast,” the prediction is that you are dealing
with a diagnosis that will probably not be breast cancer.
ORIGINAL ARTICLE
Nasal
High-Flow Therapy for Primary Respiratory Support in Preterm Infants
This
multicenter trial comparing nasal high-flow therapy with CPAP as primary
support for preterm infants with respiratory distress showed a significantly
higher treatment-failure rate with high-flow therapy.
CPAP therapy is superior to high-flow nasal oxygen
therapy in preterm infants (age >28 weeks 0 days) with early respiratory
distress. Use of CPAP is standard practice in Australia.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
None
New Pharmacological Therapies
ORIGINAL ARTICLE
Antimalarial
Activity of KAF156 in Falciparum and Vivax Malaria
With
the emergence and spread of artemisinin resistance, new therapies for malaria
are needed. This study shows that the imidazolopiperazine KAF156, a new
antimalarial compound, has in vivo antimalarial activity.
Other articles which may be of interest to certain students
None
