Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 29th September 2016 (#62)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
CLINICAL IMPLICATIONS OF BASIC RESEARCH
Mitochondrial
Mobility and Neuronal Recovery
A
recent study of in vitro and in vivo axonal regeneration underscores the
importance of having competent mitochondria at the site of axonal injury.
I found this to be one of the most fascinating studies
of the year (Zhou et al J Cell Biology, 2016). It was reviewed for the Journal
by a pharmacologist in Estonia. The picture (Figure 1) is invaluable for
understanding the various concepts. This type of study demonstrates a direction
in which neuronal recovery may occur.
None of my students read this review spontaneously as
they did not consider this important. However after discussion of the article
and the possible implications of the study, all were equally fascinated.
SOUNDING BOARD
Limits
to Personalized Cancer Medicine
The widespread dissemination of the idea of
personalized oncology has spread faster than the underlying science. The
authors argue that the principles of clinical investigation need to be applied
to address the many unanswered questions.
This is an excellent article to read over vacation time
as it describes the current limitations of the science of providing
personalized medicine, particularly in cancer medicine.
I particularly recommend reading the sections: Molecular Targeted Agents and Tumor Evolution and Intratumor
Heterogeneity.
Articles Recommended for Medical Students
Perspective
Predicting
the Future — Big Data, Machine Learning, and Clinical Medicine
The
algorithms of machine learning, which can sift through vast numbers of variables
looking for combinations that reliably predict outcomes, will improve
prognosis, displace much of the work of radiologists and anatomical
pathologists, and improve diagnostic accuracy.
This is an important Perspective to read as it reviews the area that computers and
algorithms will play in the future of medical practice, whether practicing
clinicians like it or not.
The authors describe three areas where progress will be
important:
1. They
will dramatically improve the ability of health care professionals to establish
a prognosis. It is expected that prognostic algorithms will be available in the
next five years.
2. Computers
will displace much of the work of radiologists and anatomical pathologists. The
time scale for this is years, not decades.
3. Computers
will improve diagnostic accuracy. This changes will occur within a decade.
IMAGES IN CLINICAL MEDICINE
Lymphangitis
on the Abdomen
A
52-year-old woman and a 43-year-old man presented with erythematous and tender
abdominal lesions. Both patients had previously been healthy, without a history
of cancer or immunodeficiency.
These are excellent examples of the practical anatomy
of lymphatic drainage of the abdominal wall.
IMAGES IN CLINICAL MEDICINE
Human
Papillomavirus–Associated Oropharyngeal Squamous-Cell Carcinoma
A
68-year-old man presented with a mass on the left side of his neck. A biopsy
was performed, and histopathological examination revealed squamous-cell
carcinoma that was positive for HPV and overexpressed p16, a tumor-suppressor
gene product.
This emphasises the role of HPV in head and neck
cancer.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
30-2016 — A 63-Year-Old Woman with Bipolar Disorder, Cancer, and Worsening
Depression
A
63-year-old woman with bipolar disorder and a history of cancer was admitted
for electroconvulsive therapy. Chest CT revealed a new invasive breast cancer.
The patient initially declined surgery and cancelled appointments. Management
decisions were made.
This is an important CPC to read as it emphasises the
difficulties that may arise in treating a patient with mental illness who is
unable to cope with serious illness or unable to accept curative therapy.
This area is also the subject of a Medicine and Society article in the coming October 20, 2016
edition: “Closing the Mortality Gap-
Mental Illness and Medical Care.”
CLINICAL PRACTICE
Influenza
Vaccination
Influenza
vaccines confer considerable but incomplete protection and are recommended for
everyone. The Advisory Committee on Immunization Practices does not endorse a
specific vaccine but recommends against the live attenuated vaccine during
2016–2017 in the United States.
This is a current review of influenza vaccination.
Important Articles Related to Mechanisms of Disease and Translational
Research
None
Other Articles which should interest medical students
ORIGINAL ARTICLE
Defibrillator
Implantation in Patients with Nonischemic Systolic Heart Failure
In
a randomized trial, more than 1100 patients with nonischemic heart failure
(left ventricular ejection fraction ≤35%) were assigned either to receive or
not to receive an ICD. At a median of 67.6 months, there was no significant
difference in mortality between the two groups.
EDITORIAL
The
ICD in Heart Failure — Time for a Rethink?
EDITORIAL
Antibiotic
Prophylaxis for Cesarean Delivery — When Broader Is Better
ORIGINAL ARTICLE
Adjunctive
Azithromycin Prophylaxis for Cesarean Delivery
In
this trial involving women who received standard antibiotic prophylaxis for
nonelective cesarean section, the risk of infection after surgery was lower
with the addition of azithromycin than with placebo.
An important study in the future will be to compare
azithromycin directly with standard prophylactic antibiotic therapy to order to
determine if azithromycin is markedly superior to standard therapy. This will
be important in even considering a change and the further risk of developing
antibiotic resistance to azithromycin.
ORIGINAL ARTICLE
Drug-Eluting
or Bare-Metal Stents for Coronary Artery Disease
In
a trial involving over 9000 patients with coronary artery disease who were
assigned to receive either contemporary drug-eluting stents or bare-metal
stents, there was no significant between-group difference in a composite
outcome of death from any cause or nonfatal MI at 6 years.
EDITORIAL
Balancing the Evidence Base on Coronary Stents
All patients in the study received long-term aspirin
and all received clopidogrel for nine months.
Repeat revascularization was lower in the group with
drug-eluting stents.
Perspective
Considerations
for Developing a Zika Virus Vaccine
The
scientific feasibility of developing a safe, effective Zika vaccine doesn't
ensure successful development. An efficient development pathway must be
delineated, including better ways to evaluate vaccine candidates for intended
target populations.
This Perspective outlines extremely well the practical
difficulties involved in producing a successful vaccine, not only for ZIKV but
for any candidate.
New Pharmacological Therapies
None
Other articles which may be of interest to certain students
ORIGINAL ARTICLE
Effectiveness
of Fluticasone Furoate–Vilanterol for COPD in Clinical Practice
In an open-label, randomized trial conducted in 75
general practices, once-daily treatment for chronic obstructive pulmonary
disease with inhaled fluticasone furoate–vilanterol was associated with a lower
rate of moderate or severe exacerbations than usual care
This is a study funded by GlaxoSmithKline to highlight
their new once daily drug combination used to treat COPD, fluticasone furoate –
vilanterol (an ultra-long-acting β2 agonist (ultra-LABA)) recently approved in
the US.
The comparator in the study, which I believe is the
weak link, is an uncontrolled group using a range of disparate accepted
therapies for management of COPD. The study claims it is different from others in that the
comparison is with a group that is closer to usual clinical practice.
