Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 9th February 2017 (#81)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
None
Must Read Articles
REVIEW ARTICLE
Approach
to Fever in the Returning Traveler
Travelers may be exposed to a variety of infectious agents that are endemic in the regions they visit. This review presents a systematic approach to the diagnosis and treatment of travel-acquired illnesses.
This is a must save article which students and interns
will be using for years to come.
The article provides a clinical approach to the returning
febrile traveller with fever and also includes an excellent Figure and Tables.
At first sight, the Figure 1 algorithm appears daunting but is a fount of information including clinical
presentations and even antibiotic treatment for patients with fever. It should
be carefully studied.
The simple Quick
Sepsis-related Organ Failure Assessment tool (qSOFA) is described under the
section Recognizing Life-Threatening
Causes of Fever.
Table 2 describes the history that should be taken
(covered in MEDI6300 clinical cases) from a returning traveller with fever.
Table 1 contains a list of life-threatening tropical infections, and Table 3 a
list of serious transmissible infections.
Articles Recommended for Medical Students
SPECIAL REPORT
Middle
East Respiratory Syndrome
The
Middle East respiratory syndrome is caused by a coronavirus that was first
identified in Saudi Arabia in 2012. Periodic outbreaks continue to occur in the
Middle East and elsewhere. This report provides the latest information on MERS.
The Middle East
Respiratory Syndrome (MERS), while uncommon worldwide, is another viral
cause (coronavirus) of an acute respiratory distress syndrome presenting with
shortness of breath, fever, and lung infiltrates. This Special Report provides a state of the art summary on MERS. The history of both exposure to camels on the Arabian
Peninsula (specifically camel saliva) and acquisition from an infected human
contact is important when considering this diagnosis.
Figure 3 outlines the clinical presentation, modes of
transmission, and the immunopathology of the lung infection. MEDI6100 have just
had a lecture on acute inflammation
and should find the diagram informative while providing some relevance to the
topic. Students who have recently studied the pharmacological approach to type
II diabetes mellitus will recall the gliptins and the incretin mimetics. In
MERS, the surface receptor on bronchial epithelial cells and pneumocytes for
MERS viral attachment is the receptor that binds DPP4 (dipeptidyl peptidase 4).
Gliptins inhibit the enzyme DPP4 which degrades the incretins. Incretins are necessary as glucagon mimics
and for reducing gastric emptying, both leading to reductions in blood sugar
levels.
IMAGES IN CLINICAL MEDICINE
Disseminated
Blastomycosis
A
39-year-old man presented with acute hemoptysis, chills, and a traumatized left
finger. Despite treatment with antibiotics, a repeat imaging study performed 8
weeks later showed a persistent pulmonary infiltrate.
The three common fungal infections in the US, Mexico
and extending into central America, are coccidioidomycosis (West Coast and
desert areas - “valley fever’ or “cocci”), histoplasmosis (follows the
Mississippi river and its tributaries), and, as in this case, blastomycosis
(East Coast and upper mid-West). This fungi enter primarily via the respiratory
tract producing lung infiltrates and, in the case of blastomycosis, a
predilection for the upper lube and occasional cavitation.
ORIGINAL ARTICLE
Thromboprophylaxis
after Knee Arthroscopy and Lower-Leg Casting
Two
trials, one involving patients undergoing knee arthroscopy and one involving
patients with lower-leg casting, evaluated low-molecular-weight heparin as clot
prophylaxis. The incidence of symptomatic venous thromboembolism was low, and
anticoagulation did not influence it.
EDITORIAL
After
the Fall — Prophylaxis for All?
CLINICAL DECISIONS
Thromboprophylaxis
after Knee Arthroscopy
This
interactive feature on thromboprophylaxis after knee arthroscopy offers a case
vignette accompanied by essays that support either recommending or not
recommending thromboprophylaxis. Vote and comment at NEJM.org.
The data from the article indicates that overall use of
subcutaneous prophylactic injections of low MW heparin does not change the low
frequency of symptomatic venous
thromboembolism in patients undergoing knee arthroscopy or patients with lower
extremity casts.
The Editorial
provides the specifics of the study and an unbiased analysis of the results.
The Clinical
Decisions article describes a patient undergoing an arthroscopic
meniscectomy and discusses in point-counterpoint format the use of
postoperative thromboprophylaxis. The bottom line is that the decision is usually
made by the treating physician in conjunction with the orthopaedic surgeon based
on the individual risk factors for the patient. While the results of the study provide general
guidelines, each patient and their potential risk factors should be considered
individually.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
CORRESPONDENCE
Acute
Pancreatitis
This is interesting
correspondence on pancreatic cancer as a trigger for acute pancreatitis, the
possible role of incretin mimetics in pancreatitis, fine needle aspiration for
culture of necrotic pancreas to determine antibiotic therapy, and clinical
scoring systems for the severity of acute pancreatitis. There is also a good
discussion of these areas by the author.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
4-2017 — A 2-Month-Old Girl with Growth Retardation and Respiratory Failure
A
2-month-old girl presented with respiratory failure and growth retardation.
Imaging revealed periventricular heterotopia (which her mother and grandmother
also had), architectural distortion of the lungs, and cardiac abnormalities.
Diagnostic procedures were performed.
This CPC involves a 2-month old girl with multiple
defects, including periventricular heterotopia (I had never heard of this
before).
I draw the
reader’s attention to an extremely valuable web site OMIN (Online Mendelian
Inheritance in Man (http://www.ncbi.nlm.nih.gov/omim ) which is an extensive database (pathology, epidemiology,
specific genetics, and treatment) of all diseases, rare and common. This
site had its genesis in the massive classical work on Heritable Diseases by
Victor McKusick (Johns Hopkins).
In 2001, we
published a letter in the Ann Intern Med (Mouradi, B. and Andrews, B.S.
Usefulness of Online Mendelian Inheritance in Man in Clinical Practice. Ann.
Intern. Med.135:70, 2001). This publication involved a patient who had multiple
seemingly disparate pathological conditions. By consulting OMIN, we were able
to determine that all of these disorders were linked to a small region on a
specific chromosome defining a new disease entity.
When the
search terms periventricular heterotopia
and congenital heart disease are
entered, the correct diagnosis is found together with all you ever wanted to
know about previous unusual clinical presentations and associated gene defects.
Perspective
Powerful
Ideas for Global Access to Medicines
The
UN High-Level Panel on Access to Medicines has reframed the access challenge
not only as involving prices in lower-income countries, but also as requiring
systemic changes to the prevailing research-and-development business model for
the sake of all countries.
New and Novel Therapies
None
Articles Some Medical Students Found Interesting
ORIGINAL ARTICLE
Prognostic
Mutations in Myelodysplastic Syndrome after Stem-Cell Transplantation
Prognostic
systems for myelodysplasia rely on clinical factors, but particular genetic
lesions can influence relapse rate, overall survival, and nonrelapse-related
mortality as well as the choice of conditioning regimen for hematopoietic
stem-cell transplantation.
This study further
illustrates the utility of determining specific genetic mutations, in
this case in patients with the myelodysplastic syndrome (MDS) prior to
receiving an allogeneic haematopoietic stem-cell transplantation. Mutations in TP53, the RAS pathway, and JAK2
were able to help predict the responses to allogeneic haematopoietic stem-cell
transplantation as well as which groups would benefit from myeloablative
conditioning regimens rather than reduced-intensity conditioning regimens.
IMAGES IN CLINICAL MEDICINE
Persistent
Pupillary Membrane
A
15-year-old boy presented with diminution of vision in both eyes. Slit-lamp
examination revealed persistent pupillary membranes caused by the presence of
remnants of the blood supply to the fetal lens.
