Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 27th October 2016 (#66)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
Over the past three editions of the Journal, readers
have been fortunate to be exposed to a series of articles written on
"Serious Mental Illness" by NEMJ national correspondent. Dr Lisa
Rosenbaum. I have found these articles
to exhibit an uncommon sense of humanity in their discussion of doctor/patient
relations. The descriptions of the
personal level of interactions with patients from all walks of life by the
staff, particularly psychiatrists, at the MGH is an example of patient care
that members of the medical profession should seek to emulate.
I regard these articles as an essential component of
the unwritten curriculum for all medical students and teachers at the
University of Notre Dame Australia.
Must Read Articles
MEDICINE AND SOCIETY
Unlearning
Our Helplessness — Coexisting Serious Mental and Medical Illness
Patients
with coexisting serious mental and medical illnesses often don't recognize that
they need treatment, and those who do may be unlikely to complete it. Caring
for such patients successfully requires dedication, flexibility, collaboration,
persistence, and love.
I will not attempt to summarize the article but rather draw
attention to the concept of “learned helplessness” and how it may be recognised
and managed in the physician. This is a quote from the final three sentences of
the article: It entails recognizing that
a disease doesn’t define a person, without pretending that it doesn’t exist or
warrant treatment. It requires understanding that autonomy may be achieved not
in an instant but over time (in a patient with serious mental illness).
And it means knowing when a refusal of care is a symptom and when it’s a
dying wish.
Articles Recommended for Medical Students
ORIGINAL ARTICLE
A
Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation
In this trial, long-term supplemental oxygen treatment
did not result in longer survival over no use of supplemental oxygen among
patients with stable COPD and moderate resting desaturation (SpO2,
89 to 93%) or moderate exercise-induced desaturation.
EDITORIAL
Clinical
Usefulness of Long-Term Oxygen Therapy in Adults
Long-term oxygen therapy has been previously
demonstrated to improve prognosis in patients with COPD and chronic severe
hypoxaemia (PaO2 less than or equal to 55 mm Hg and a SaO2 <88%, breathing
ambient room air) or moderate hypoxaemia with signs of right heart failure or
polycythaemia.
This article addresses the question of long-term oxygen
therapy in patients with stable COPD and resting pulse oximeter readings (SaO2)
from 89-93% (compared with a group receiving no supplemental oxygen). In order
to increase the number of patients in the study, the researchers added a group of
patients with stable COPD who exhibited moderate exercise-induced desaturation.
The study group that desaturated only with exercise received supplemental
oxygen only during exercise and sleep.
The results of the study on 738 patients from 42
centres over a period ranging from 1-6 years showed that the group receiving
supplemental oxygen did not differ from those who did not receive supplemental
oxygen with respect to time to death or time to hospitalization. Further, oxygen supplementation did not result
in improved secondary outcomes (incidence of COPD exacerbations, adherence to
oxygen regimen, 6 minute walk distance, severe exercise-induced severe
desaturation or quality of life and well-being).
ORIGINAL ARTICLE
Child–Parent
Familial Hypercholesterolemia Screening in Primary Care
This
study assessed child–parent screening for familial hypercholesterolemia in
primary care practices. For every 1000 children screened, 8 persons who had
positive screening results for familial hypercholesterolemia were identified.
EDITORIAL
What
Should Be the Screening Strategy for Familial Hypercholesterolemia?
10, 095 children between the ages of 1 to 2 years were
screened when they attended their PCP for routine immunizations. Blood was
removed by heel prick and screened for familial hypercholesterolaemia. The
children were considered positive if they had either an elevated cholesterol
level (above the 99.2th percentile) on two occasions three months
apart, or if they had an elevated cholesterol level together with a familial
hypercholesterolaemia mutation. If they were positive, their parents were also
screened.
The mutation prevalence was 1 in 273 children (not all had an
increased cholesterol level at the time). For every 1000 children screened, 4
children and 4 parents were positive and considered at high cardiovascular risk
in the future.
The Editorial
provides an overview of the study and an in-depth analysis of screening
methodology including advantages and disadvantages. Universal screening,
selective universal screening and cascade screening are explained in the
context of this disorder. Whether o screen or not to screen all comes down to a
cost/risk-benefit analysis which is what we do in the everyday practice of
clinical medicine.
REVIEW ARTICLE
Hepatic
Encephalopathy
The
brain dysfunction associated with liver failure can have diverse
manifestations. The main pathogenesis is metabolic derangement of cell function
and brain edema. Prompt recognition and treatment may reverse, at least
partially, some of the abnormalities.
This is an excellent clinical review on hepatic
encephalopathy. Figures and Tables provide a summary of the article. The
section on current treatment is particularly worth reading.
IMAGES IN CLINICAL MEDICINE
Emphysematous
Pyelonephritis
A
51-year-old man presented with fever and general malaise of 2 weeks' duration.
He had poorly controlled diabetes mellitus at the time of presentation. Imaging
studies revealed gas collection in the parenchyma and perinephric space of the
left kidney.
This case of emphysematous pyelonephritis due to E. coli,
in a patient with diabetes mellitus and a neurogenic bladder, was treated with
IV antibiotics and did not require nephrectomy. This is second in the series of
emphysematous infections involving the urinary tract either due to E. coli or K. pneumoniae.
IMAGES IN CLINICAL MEDICINE
Clonus
Associated with Tropical Spastic Paraparesis
A
53-year-old woman with tropical spastic paraparesis reported several months of
worsening weakness of the legs and feet. On examination, she had severe
spasticity and weakness of both legs and feet, bilateral Babinski sign, and
bilateral patellar clonus, shown in a video.
The video should be reviewed to see bilateral patellar
clonus. This patient suffered from tropical spastic paraparesis (human
T-lymphotropic virus–associated myelopathy) which results in progressive
spastic paraplegia.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
33-2016 — A 30-Year-Old Woman with Severe Lower Abdominal Pain and Chills
A
30-year-old woman presented to this hospital with abdominal pain, nausea, and
chills. Evaluation showed tachycardia, bilateral lower-quadrant abdominal
tenderness, leukocytosis, and an elevated CA-125 level. Imaging studies showed
adnexal cysts. A diagnosis was made.
This 30-year-old patient had fever, lower quadrant
abdominal pain and was found to have bilateral pelvic masses on CT. Excellent differential
diagnoses were presented together with a discussion of the causes of an
elevated CEA level.
Important Articles Related to Mechanisms of Disease and
Translational Research
CLINICAL IMPLICATIONS OF BASIC RESEARCH
The
Hypoxia Response Pathways — Hats Off!
This
year's Lasker Award for basic medical science recognizes the work of
investigators who uncovered a pathway that has a central role in effecting the
myriad cellular responses to hypoxia.
In MED100 pathology, the role of HIF (hypoxia-inducible
factor) in the pathogenesis of the acute inflammatory process was discussed.
This article summarises the research on HIF which was the basis for the 2017
Lasker award.
The following is the final paragraph of the article:
All
three of these 2016 Lasker awardees have been involved in efforts to exploit
such oxygen-sensing pathways for therapeutic gain. For example, Semenza did
early groundwork showing the salutary effects of HIF in preclinical ischemia
models, Kaelin and Ratcliffe established that the PHDs (prolyl hydroxylase
domain enzymes) could be inhibited with drug-like molecules, and all three have
probed the role of HIF in cancer. First-generation PHD inhibitors, which
stabilize HIF, are being developed for renal failure, tissue ischemia, and
tissue regeneration. Conversely, HIF inhibitors are being developed for cancer
(especially clear-cell renal carcinoma) and specific diseases such as pulmonary
arterial hypertension (see Fig. 1 for the biology of HIF under
normal and low oxygen conditions and in the von Hippel-Lindau syndrome).
Other Articles which should interest medical students
Perspective
Days
Spent at Home — A Patient-Centered Goal and Outcome
If
“high-value, patient-centered care” is to be more than rhetoric, health care
organizations need to measure outcomes that matter to patients, such as days
spent at home in the last 6 months of life. There is substantial variation in
this patient-centered outcome.
The following is a quote from this article:
Health
policy often stumbles when there is uncertainty about what we are trying to
maximize in health care. It is clear that one goal is to minimize costs, but
there should be counterbalancing measures to be maximized. Mortality is not a
sufficient measure to define excellence in care; in fact, no single performance
metric will suffice. Outcome measures that reflect what truly matters to
patients can define performance in ways that increase the engagement of
patients, clinicians, and provider organizations in the redesign of care.
In US studies, patients in their last six months of
life (180 days) spent between 120 -146 days at home depending on the region of
the country (Fig. 1). In a large UK study, the Camden Commissioning Group
(CCG), unusual data was produced (Fig. 2). The more patients accessed home
hospice and home-health care, the fewer the days the patients spent at
home. This result was attributable to
the findings that: when providers did
more of one thing, they did not do less of another. There is a difference
between doing more and doing better. The Camden CCG experience indicates,
however, that when health care providers and community groups collaborate with
the goal of increasing days spent at home, progress can be made.
Results of surveys indicate that:
1. 86%
of patients want to be at home in their final days under ideal circumstances,
but some prefer to be in a medical care facility for many reasons e.g. not
having a supportive family, not wanting to be a burden, and preferring hospitals,
for such reasons as perceived better pain relief and care.
2. Patients
do want to be placed on a respirator to gain an extra week of life.
3. Patients
are not opposed to drugs that relieve symptoms but ultimately may shorten their
lives.
SPECIAL ARTICLE
Public-Access
Defibrillation and Out-of-Hospital Cardiac Arrest in Japan
In
Japan, the use of public-access defibrillation for patients with
out-of-hospital cardiac arrest increased substantially from 2005 to 2013. The
rate of 1-month survival with favorable neurologic outcome was significantly
higher with than without public-access defibrillation.
Between 2005 and 2013, there were 43,762 documented
bystander witnessed cardiac arrests in Japan. 4499 (10.3%) were treated with
public-access defibrillators. Usage of
defibrillators increased from 1.1% in 2005 to 16.5% in 2013 due to increasing
public access. The primary outcome assessed was survival at one month with
favourable neurological outcomes. This was 38.5% for patients treated with
public-access defibrillators compared with 18.2% for those not treated with
early defibrillation (adjusted odds ratio of 1.80). The number of
neurologically functional survivors increased from 6 in 2005 to 201 in 2015
(P< 0.001).
New Pharmacological Therapies
ORIGINAL ARTICLE
Levosimendan
for the Prevention of Acute Organ Dysfunction in Sepsis
In
a randomized trial, over 500 patients with sepsis received levosimendan or
placebo in addition to usual care. Levosimendan did not result in a lower
likelihood of organ dysfunction or lower mortality.
Levosimendan, a calcium-sensitizing drug with inotropic
and vasodilatory properties, was added to usual standard of care for adults
with sepsis. The aim was to determine if addition of the drug reduced the frequency
of severe organ dysfunction and mortality rate. The results indicated that
levosimendan did not reduce the risk of severe organ dysfunction or the
mortality rate but did lead to a higher risk of supraventricular tachycardia
and a lower likelihood of successful weaning from the respirator. A brief
summary of the physiological effects of sepsis is contained within the Introduction.
Other articles which may be of interest to certain students
None.
