Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week
of 20th October 2016 (#65)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
MEDICINE
AND SOCIETY
Closing the
Mortality Gap — Mental Illness and Medical Care
People
with mental illness die, on average, 13 to 30 years earlier than similar people
without mental illness, mostly from medical conditions such as cancer and
cardiovascular disease. One contributing factor may be that physicians allow
such patients to refuse care.
This article, second in a series on Serious Mental Illness,
involves the management of patients who have significant medical or surgical
disease along with severe mental illness. This is a Must Read article.
I found several statements (with slight amendments)
worth considering:
1.
Doctors assume that because the patient has
mental illness, he/she has no quality of life. You can’t just let him/she
refuse the treatment.
2.
But though coercion is rarely justifiable, the
rationalization that “there’s only so much you can do” risks misrepresenting
laziness as respect.
3.
It’s infinitely easier to document that the
“patient refused” care than to ensure that the care is provided.
4.
We focus on “fixing the broken system,” but do
we stop seeking solutions from within ourselves?
5.
Far harder is overcoming any collective belief
that what mentally ill people truly need is not something we can offer.
REVIEW
ARTICLE
Graves’
Disease
Graves'
disease is an autoimmune disorder in which the thyroid is activated by
antibodies to the thyrotropin receptor. The hyperthyroidism that develops is
one of many somatic and psychiatric manifestations of the disease that can
affect the quality and length of life.
This is an excellent review article particularly on the
pathogenesis (Figure 2) and management (Figure 3, Table 2) of Graves’ disease.
Articles Recommended for Medical Students
CLINICAL
PRACTICE
Chronic
Cough
http://www.nejm.org/doi/full/10.1056/NEJMcp1414215
The
evaluation of chronic cough should address the possibilities of asthma,
gastroesophageal reflux disease, and postnasal drip and may require more
specialized investigations. For patients with refractory chronic cough, other
treatment approaches may be necessary.
This is an important Clinical Practice article on the approach patients with a chronic
cough (persisting for greater than three weeks). After the common causes have been excluded (lingering
viral respiratory tract infection, asthma, GORD, postnasal drip), there still
remains a population of patients who will need management of their symptoms. This
article provides an approach to this group of patients. The Figures are
informative and should be reviewed.
ORIGINAL
ARTICLE
Prevalence
of Pulmonary Embolism among Patients Hospitalized for Syncope
Among
560 patients hospitalized for syncope, 97 (17.3%) received a diagnosis of
pulmonary embolism. In 61 patients, the most proximal location of the embolus
was a main pulmonary artery or a lobar artery or the perfusion defect was
larger than 25% of the total area of both lungs.
2584 patients presented to the EDs in Italy with syncope.
1867 were sent home as the cause was apparent (vasovagal syncope, volume
depletion, drug-induced hypotension, situational syncope, although eight
declined hospitalization). 717 patients were admitted but 157 were excluded for
various reasons, leaving the 560 patients for the study.
560 patients were admitted with their first episode of
syncope, irrespective of the cause. The question posed by the study was what
percentage of the patients were found to have a pulmonary embolus as the cause
of the syncope. Of the 560 cohort, 330 (60%) were excluded from further
analysis because of low-probability for pulmonary embolism (low probability based
on Wells score for PE together with a negative D-dimer). Of the remaining 230
patients (high probability), 42% were found to have a PE. Of the entire 560
patients who were admitted for syncope, the overall risk for PE was 17.3%.
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 32-2016
— A 20-Year-Old Man with Gynecomastia
A 20-year-old man
reported a 3-year history of gynecomastia and a 4-year history of polyuria and
polydipsia that had recently resolved. Evaluation revealed bilateral
gynecomastia, minimal facial hair, small testes, and an elevated serum sodium
level. Diagnostic tests were performed.
The patient presented with gynaecomastia and an
elevated prolactin level.
He was subsequently
diagnosed with hypopituitarism associated with diabetes insipidus (adipsic type
i.e. without thirst). An intracranial germ-cell tumour resulted in damage to cells
in the hypothalamus producing ADH together with the osmoreceptor cells leading
to loss of thirst.
The discussion of pituitary and hypothalamic physiology
and the method of determining the site of the lesions by the
neuro-ophthalmologist is worth reading.
ORIGINAL
ARTICLE
Romosozumab
Treatment in Postmenopausal Women with Osteoporosis
Romosozumab
binds sclerostin, increases bone formation, and decreases bone resorption.
Postmenopausal women with osteoporosis were assigned to romosozumab or placebo
for 1 year, followed by 1 year of denosumab. Romosozumab was associated with
lower vertebral and clinical fracture risk.
EDITORIAL
Building
Better Bones with Biologics — A New Approach to Osteoporosis?
An earlier article comparing romosozumab with
alendronate and teriparatide for the treatment of postmenopausal osteoporosis
(DEXA results only) was published in the Journal in 2014 (review Figure 2) (http://www.nejm.org/doi/full/10.1056/NEJMoa1305224
).
In this issue of the Journal, patients with postmenopausal osteoporosis were treated
with romosozumab (a monoclonal antibody against sclerostin which is produced by
osteocytes and inhibits new bone matrix formation by osteoblasts) for 12 months
followed by denosumab (a monoclonal antibody which inhibits the action of RANKL
leading to decreased bone resorption) for a second 12 months.
The improvement in bone density and reduction in
fracture rate in the lumbar spine were very impressive, but similar changes
were not statistically significant in non-vertebral sites (Figure 3). Moreover
in the 65 patients treated with romosozumab, one developed osteonecrosis of the
jaw and one developed an atypical femoral fracture at 12 months, and one
patient developed osteonecrosis of the jaw at 24 months following both
romosozumab and denosumab. These events
have been previously associated with bisphosphonate use.
The Editorial
provides an historical perspective to bisphosphonate use and a critical
analysis of the study and should be read.
First
Branchial Cleft Cyst
A
3-year-old boy presented to the ED with pain in the right ear and swelling in
the postauricular area. When gentle pressure was applied to the postauricular
area (shown in a video), keratin debris and purulence were expressed into the
osteocartilaginous junction of the ear canal.
This is an interesting case on an inflammatory
post-auricular swelling in a three year old boy, particularly the video.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
ORIGINAL
ARTICLE
Guillain–Barré
Syndrome Associated with Zika Virus Infection in Colombia
The Guillain–Barré syndrome has been associated with Zika virus infection. In this report from Colombia, further evidence of the association is provided, as well as further characterization of the associated neurologic syndrome.
EDITORIAL
Zika Getting
on Your Nerves? The Association with the Guillain–Barré Syndrome
CORRESPONDENCE
Zika Virus
and the Guillain–Barré Syndrome — Case Series from Seven Countries
During the past year and a half, Zika virus
has been spreading rapidly throughout Latin America. In this letter, evidence
for the Guillain–Barré syndrome being temporally associated with Zika virus
transmission is presented.
Comparing the article, the Editorial and the
Correspondence, the most information can be derived from the Correspondence which describes the
chronological association between ZIKV infection and GBS in seven countries.
The Editorial discusses the
requirements for establishing epidemiological causality between the virus and
GBS and the difficulties establishing this relationship.
New Pharmacological Therapies
None
Other articles which may be of interest to certain students
None
