Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 2nd February 2017 (#80)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
CLINICAL PRACTICE
Long-Acting
Reversible Contraception
This
article reviews methods of long-acting reversible contraception, including IUDs
and hormonal implants. These methods are about 20 times as effective as pills,
patches, and rings and are safe for almost all women, including those in a
postpartum or postabortion period.
Most fourth-year students felt this was a good review
of contraceptive devices, but that they did not learn anything new. This is an
excellent article for third year medical students beginning their O&G
rotation..
Articles Recommended for Medical Students
Perspective
Learning
to Drive — Early Exposure to End-of-Life Conversations in Medical Training
Sent
to visit a chronically ill patient at home, a medical student finds that his
inexperience can be a strength. Instead of worrying about the right words and
how to say them, he learns how to listen — exactly what the patient needs as
she faces end-of-life decisions.
This type of scenario should be considered for inclusion in the first
and second year curriculum. It emphasises the importance of listening carefully
and actively to patients in their home setting even when they talk about topics
that don’t appear to be directly related to their medical condition. My
prediction is that for many students a bond will be established between the
student and the patient and more visits will ensue. For this curricular addition to succeed,
assessment should be kept to a minimum
IMAGES IN CLINICAL MEDICINE
Actinic
Granuloma
A
50-year-old woman presented with asymptomatic, annular plaques on her forehead
and the dorsum of her hands. Over time, the lesions gradually increased in
number and slowly extended centrifugally.
IMAGES IN CLINICAL MEDICINE
Calcific Pancreatitis Associated
with Alcohol Use
A
50-year-old man with alcohol dependence presented with acute symptoms of
hematemesis. Imaging revealed extensive calcification of the pancreas.
CLINICAL PROBLEM-SOLVING
Making
the Connection
A
41-year-old man with a BMI of 49.1 undergoes Roux-en-Y gastric bypass. Eight
years later, he presents to his primary care physician with pain in the
epigastric region and the left upper quadrant of the abdomen that is
exacerbated by eating.
Last week this patient was discussed in a case
presentation format.
It is now time to include indications and complications
of bariatric surgery in the medicine and surgical end of year assessment. UNDA
students doing their electives in surgery in private hospitals are being
exposed to significant numbers of bariatric surgical procedures. General practitioners will be
increasingly managing these patients and their complications long-term.
Recommended
learning: Indications, types, and complications of bariatric
surgery.
Important Articles Related to Mechanisms of Disease and
Translational Research
CLINICAL IMPLICATIONS OF BASIC RESEARCH
The
Antigenicity of the Tumor Cell — Context Matters
When
is a neoantigen not a neoantigen? A recent study suggests that T cells in a
patient with cancer are more likely to “miss” mutant peptides generated by
somatic mutations than are the T cells in a healthy person.
This presents a fascinating concept whereby mutant
melanoma neoantigens, which are unable to be recognized by host cytotoxic T
cells, are isolated and transferred to donor dendritic cells. Dendritic cells are then used to activate
normal donor T cells. T cell receptor genes are then isolated and inserted into
T cells from a healthy second donor and then demonstrated to kill the original
melanoma cells. The possibility exists that isolated specific T cell receptor
DNA from melanoma cells could be inserted into T cells from a patient with
melanoma, the cell population then expanded ex
vivo and infused back into the original patient.
Other Articles which should interest medical
students
ORIGINAL ARTICLE
Radiation
with or without Antiandrogen Therapy in Recurrent Prostate Cancer
With
a median follow-up of 13 years, a randomized comparison of radiotherapy with or
without antiandrogen therapy in patients with a rising PSA level after
prostatectomy showed that 2 years of antiandrogen therapy resulted in a
significantly higher overall survival rate.
EDITORIAL
Improved
Therapy for PSA Recurrence after Prostatectomy
This study focuses on a specific group of 760 patients
with prostate cancer who had stage T2 or T3 disease and were treated by radical
prostatectomy and lymphadenectomy and who subsequently developed detectable
levels of PSA. Within a period of 12 weeks of detecting the PSA, patients were
randomized into two groups. One received
radiotherapy alone and the other received radiotherapy plus 24 months of
antiandrogen therapy (oral bicalutamide). The median follow-up period for
surviving patients was 13 years. The results indicated that for the group
receiving radiation plus antiandrogen therapy, there was a significantly
longer-term survival rate, fewer deaths from prostate cancer, and lower
frequency of metastatic prostate cancer.
The nuances of the study are discussed in the editorial,
together with descriptions of current studies addressing areas which arise from
the study.
New and Novel Therapies
ORIGINAL ARTICLE
Crizanlizumab
for the Prevention of Pain Crises in Sickle Cell Disease
With
a median follow-up of 13 years, a randomized comparison of radiotherapy with or
without antiandrogen therapy in patients with a rising PSA level after
prostatectomy showed that 2 years of antiandrogen therapy resulted in a
significantly higher overall survival rate.
EDITORIAL
Go
with the Flow
While sickle cell crises are not a common occurrence in
WA, patients are occasionally admitted to teaching hospitals. The basis for the
study is that sickled erythrocytes aggregate and bind to endothelial receptors
by P-selectin leading to microvascular occlusion and a sickle cell crisis. The monoclonal antibody described
(crizanlizumab) binds to P-selectin on erythrocytes lessening adhesion
interactions and, in this study, resulted in a 45.3% lower frequency of sickle
cell crises and a longer time period to first or second crises. The long-term
potential complications of this therapy have not yet been defined.
I believe that this monoclonal antibody may well find
another therapeutic niche in the treatment of chronic inflammatory diseases in
limiting movement of inflammatory cells from the circulation into the tissues.
However, remember the use of the monoclonal antibody against a4-integrins (natalizumab), a very effective therapy in
progressive multiple sclerosis which limited the traffic of T cells into the
CNS, however resulted in an increased frequency of the fatal disease,
progressive multifocal leukoencephalopathy.
The editorial provides a brief review of the
pathophysiology of sickle cell disease, reviews the protective role of foetal
haemoglobin and describes the mechanism of action of hydroxyurea in this
disease.
Recommended
learning:
1. Review
the pathophysiology, clinical presentations and management of haemolytic
anaemias.
2. Review
the normal physiology and pathophysiology involved in haemoglobin synthesis.
Articles Some Medical Students Found Interesting
ORIGINAL ARTICLE
A
Fully Magnetically Levitated Circulatory Pump for Advanced Heart Failure
In
a randomized trial, 294 patients with advanced heart failure were assigned to
receive either a new centrifugal-flow pump or an axial-flow pump. At 6 months,
the centrifugal-flow pump was associated with better outcomes
ORIGINAL ARTICLE
Intrapericardial
Left Ventricular Assist Device for Advanced Heart Failure
In
this trial, patients with advanced heart failure were assigned to an
intrapericardial centrifugal-flow LVAD or an axial-flow LVAD. The
intrapericardial device was noninferior to the axial-flow device with respect
to survival free from disabling stroke or device malfunction.
EDITORIAL
Mechanical
Circulatory Support Devices — In Progress
Some students were interested in the two articles and
the editorial involving the current use of left ventricular assist devices in
patients with advanced heart failure. These devices are being used in tertiary
hospitals in Perth. While the data
presented showed little difference in outcomes between the two types of devices
described, what amazed me was the degree of miniaturization that has occurred
over the past thirty years, as demonstrated by the current use of centrifugal
flow-pumps contained within the pericardial sac (Figures 1 in each article).
