Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 3rd November 2016 (#67)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
I have just returned from the American College of
Rheumatology meetings in Washington DC and am behind in my weekly NEJM reviews.
Over the next two months while students are on vacation, I will attempt to be
brief in my comments and highlight articles which I believe to be the most
important and ones which the students may read for intellectual pleasure over
this period. I would also like to
believe that each week all students and teachers review the titles of all
article on line and read at least the abstracts of interest.
Must Read Articles
Perspective
BECOMING A PHYSICIAN
Tolerating
Uncertainty — The Next Medical Revolution?
When
we become obsessed with finding the right answer, at the risk of
oversimplifying the richly iterative and evolutionary nature of clinical
reasoning, the result is the very antithesis of humanistic, individualized
patient-centered care.
This is a Perspective article that MUST be read by all
students and teachers. It is one of the most significant articles I have read
this year as it focuses on the practice medicine in the grey-zone and accepts
the concept of uncertainty in the diagnosis and treatment of the patient. It
helps offers a way in which medicine can be practiced in parallel with the
black-white interface concept of medicine projected by the computer screen and
clearly stresses the need of the personal doctor-patient relationship. It reinforces
“I really don’t know what the diagnosis is,” especially when it comes from the
consultant and, should we as teachers, pause when a student makes this
statement. On occasions, maybe the
student is correct.
CLINICAL PROBLEM-SOLVING
Just
a Cut
A
51-year-old surgeon lacerated his left ring finger near the volar distal
interphalangeal joint with a fillet knife while cleaning fish after a late
summer day of fishing in coastal New England seawaters. Twelve hours later, he
awoke with throbbing pain in his fingertip.
This is an excellent article describing what can go
wrong if you cut your finger with a knife while filleting fish and you happen
to be a surgeon taking adalimumab (a TNFa
inhibitor) for rheumatoid arthritis. The article involves the anatomy of the
hand, infection involving tendon sheaths and the urgency and aggressiveness in
treating this type of infection.
Articles Recommended for Medical Students
REVIEW ARTICLE
Molecular
and Biochemical Aspects of the PD-1 Checkpoint Pathway
The
PD-1 pathway plays an essential role in maintaining immunologic self-tolerance.
However, cancers can subvert the role of this pathway and blind the immune
system to their presence. The molecular details of the pathway are discussed.
ORIGINAL ARTICLE
BRIEF REPORT
Fulminant
Myocarditis with Combination Immune Checkpoint Blockade
Fatal
autoimmune myocarditis with rhabdomyolysis and refractory arrhythmias developed
in two patients treated with a combination of anti–CTLA-4 and anti–PD-1
blockers. On histologic examination, a myocardial infiltrate similar to that
seen in acute cardiac allograft rejection was observed.
IMAGES IN CLINICAL MEDICINE
Emphysematous
Cystitis
A
72-year-old woman with poorly controlled hyperlipidemia and diabetes presented
to the ED with lower abdominal pain. Examination revealed lower abdominal
tenderness, and blood tests revealed leukocytosis and elevated C-reactive
protein and glucose.
IMAGES IN CLINICAL MEDICINE
Ocular
Flutter in the Serotonin Syndrome
A
46-year-old woman was brought to the ED because of agitation. On arrival, she
had a fever, tachycardia, and ocular flutter, as well as rigidity in the legs
and myoclonus in the arms. Videos are available at NEJM.org.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
None
New Pharmacological Therapies
ORIGINAL ARTICLE
Ribociclib
as First-Line Therapy for HR-Positive, Advanced Breast Cancer
In
patients with advanced HR-positive, HER2-negative breast cancer, the addition
of the cyclin-dependent kinase inhibitor ribociclib to letrozole was associated
with a significantly higher rate of progression-free survival than placebo.
This is ground-breaking therapy whereby a
cyclin-dependent kinase inhibitor (ribociclid) together with letrazole has been
shown to be more effective than letrazole alone in post-menopausal women with
either recurrent or metastatic HR positive, HER2 negative breast cancer.
Other articles which may be of interest to certain students
None
