Recommended Readings

(1). Cecilia Lazea, et al. ROHHAD (Rapid-onset Obesity with Hypoventilation, Hypothalamic Dysfunction, Autonomic Dysregulation) Syndrome-What Every Pediatrician Should Know About the Etiopathogenesis, Diagnosis and Treatment: A Review. Int J Gen Med. 2021;14:319-326.

https://www.dovepress.com/rohhad-rapid-onset-obesity-with-hypoventilation-hypothalamic-dysfuncti-peer-reviewed-fulltext-article-IJGM

Abstract: Rapid-onset obesity with hypoventilation, hypothalamic dysfunction, autonomic dysregulation (ROHHAD) syndrome is a rare disease with unknown and debated etiology, characterized by precipitous obesity in young children, hypoventilation and autonomic dysregulation with various endocrine abnormalities. Neuroendocrine tumors can be associated in more than half of the cases. This rare condition has a severe outcome because of high morbidity and mortality. We provide a comprehensive description of the etiopathogenetic theories of the disease, clinical presentation, diagnostic workup and treatment possibilities.

(2). Alberto Mantovani. Humoral Innate Immunity and Acute-Phase Proteins. N Engl J Med 2023; 388:439-452.

https://www.nejm.org/doi/full/10.1056/NEJMra2206346

The broad term “inflammation” encompasses a diverse set of tissue reactions classically triggered by microbial recognition and by tissue damage.1,2 More recently, it has been recognized that dysmetabolic conditions, ranging from diabetes to obesity, elicit overt or subclinical inflammatory reactions. The general role of inflammatory reactions is in the amplification of innate resistance and tissue repair, leading to a return to homeostasis

In this documentary video from the New England Journal of Medicine, physicians and scientists from across the world discuss the epidemiology of malaria and outline key strategies for prevention and treatment of the disease.

(3). Lindsey Baden. Malaria – Epidemiology, Treatment, and Prevention. N Engl J Med 2023; 388:e9

https://www.nejm.org/doi/full/10.1056/NEJMp2216703

The narrative takes a deep dive into prevention of the disease, including strategies to control mosquito vectors, new vaccines, and monoclonal antibodies. The video anticipates the challenges of eliminating malaria, given the emergence of drug-resistant strains, and looks to promising new therapies on the horizon

(4). How one virus can block another

https://www.bbc.com/future/article/20230210-can-you-get-two-viruses-at-the-same-time

Three years into the pandemic, Covid-19 is still going strong, causing wave after wave as case numbers soar, subside, then ascend again. But this past autumn saw something new – or rather, something old: the return of the flu. Plus, respiratory syncytial virus (RSV) – a virus that makes few headlines in normal years – ignited in its own surge, creating a “tripledemic”.

(5). Alessandro Sturiale, et al. Safety and efficacy of topical drug-free cream in subjects with hemorrhoidal disease: a randomized, double blind, clinical trial. Minerva Gastroenterology 2022;68(4):407-14

https://www.minervamedica.it/en/journals/gastroenterology/article.php?cod=R08Y2022N04A0407

Abstract

Background: Hemorrhoidal disease (HD) is one of the most common anorectal benign disorder affecting millions of people around the world. Grade I-II HD are generally treated with a conservative approach with topical products such as creams and ointments considered a safe and effective option to treat mild symptoms. The aim of the present study was to assess the safety and efficacy of a topical medical device (Lenoid; International Health Science [IHS] – Biofarma Group, Mereto di Tomba, Udine, Italy) in patients affected by symptomatic HD.

Methods: This study is a randomized, double blind, placebo-controlled, 2-weeks clinical trial. Patients affected by I-II grade symptomatic HD were enrolled in the study and then randomly assigned to Lenoid arm (LA) or placebo arm (PA), respectively. Patients were evaluated before and after intervention through clinical examination and disease-specific questionnaires assessing symptoms such as pain, tenesmus, pruritus and anal discharge.

Results: A total of 68 patients were screened and 60 (30 in each group) were enrolled into the study. All patients belonging to LA showed a statistically significant improvement of each symptom after 7 and 14 days of treatment when compared to PA (P<0.001). Furthermore, subjective improvement of change in overall assessment of disease was observed in the LA but not in the PA. No serious adverse events were recorded.

Conclusions: The tested product was found safe and effective in improving clinical signs and symptoms in patients with grade I-II HD.

(6). Luigi Muratori, et al. Diagnosis and management of autoimmune hepatitis. BMJ 2023; 380

Abstract

Autoimmune hepatitis is an inflammatory disease of the liver of unknown cause that may progress to liver cirrhosis and end stage liver failure if diagnosis is overlooked and treatment delayed. The clinical presentation is often that of acute hepatitis, sometimes very severe; less frequently, it can be insidious or completely asymptomatic. The disease can affect people of any age and is more common in women; its incidence and prevalence seem to be on the rise worldwide. An abnormal immune response targeting liver autoantigens and inducing persistent and self-perpetuating liver inflammation is the pathogenic mechanism of the disease. A specific set of autoantibodies, increased IgG concentrations, and histological demonstration of interface hepatitis and periportal necrosis are the diagnostic hallmarks of autoimmune hepatitis. Prompt response to treatment with corticosteroids and other immunomodulatory drugs is almost universal and supports the diagnosis. The aims of treatment are to induce and maintain long term remission of liver inflammation. Treatment can often even reverse liver fibrosis, thus preventing progression to advanced cirrhosis and its complications. Most patients need lifelong maintenance therapy, and repeated follow-up in experienced hands improves the quality of care and quality of life for affected patients.

(7). Low-value Care

https://lowninstitute.org/lown-issues/low-value-care/

We must ensure that patients get all the care they need, and none that they do not.

In health care, more is not always better. Unnecessary or ineffective procedures, tests, scans, and medications cause substantial physical harm to patients and waste money and resources. Such “low-value care” ranges from useless CT scans and repeated lab tests, to unnecessary prescriptions, major surgeries, and the implantation of poorly tested medical devices

(8). Brian Olshansky. Placebo and Nocebo in Cardiovascular Health. J Am Coll Cardiol. 2007;49(4): 415-21.

https://www.sciencedirect.com/science/article/pii/S0735109706026969?via%3Dihub

Despite treatments proven effective by sound study designs and robust end points, placebos remain integral to elicit effective medical care. The authenticity of the placebo response has been questioned, but placebos likely affect pain, functionality, symptoms, and quality of life. In cardiology, placebos influence disability, syncope, heart failure, atrial fibrillation, angina, and survival. Placebos vary in strength and efficacy. Compliance to placebo affects outcomes. Nocebo responses can explain some adverse clinical outcomes. A doctor may be an unwitting contributor to placebo and nocebo responses. Placebo and nocebo mechanisms, not well understood, are likely multifaceted. Placebo and nocebo use is common in practice. A successful doctor-patient relationship can foster a strong placebo response while mitigating any nocebo response. The beneficial effects of placebo, which are generally undervalued, hard to identify, often unrecognized, and frequently used, help define our profession. The role of the doctor in healing, above the therapy delivered, is immeasurable but powerful. An effective placebo response will lead to happy and healthy patients. Imagine instead the future of healthcare relegated to a series of guidelines, tests, algorithms, procedures, and drugs without the human touch. Healthcare, rendered by a faceless, uncaring army of protocol aficionados, will miss an opportunity to deliver an effective placebo response. Wise placebo use can benefit patients and strengthen the medical profession.

(9). Talal Hilal. In the trenches. Art Of Medicine. Lancet 2023;10(3):E164.

https://www.thelancet.com/pdfs/journals/lanhae/PIIS2352-3026(23)00038-8.pdf

When I look back at the most influential clinicians who have taught me clinical reasoning and how to interact with patients, they had several traits in common. They often were enormously respected by their peers, emulated by learners, and loved by their patients. But they also seemed to have a very modest bibliography, often avoided administrative roles, and, unless their institution bestowed upon them an academic rank commensurate with their years of service, they did not feel the need to jump through senseless hoops to get promoted. Despite the high clinical burden of their practice, they remained genuinely curious and compassionate towards patients. However, they seemed to have been overlooked by their institutional leaders, seemingly inundated by clerical work without the reward and recognition they deserved.

(10). John P. Higgins. Ten Traits of Great Physicians. Am J Med. 2022;000:1-5.

There are certain traits that differentiate great doctors from good doctors. This article will discuss some of these traits along with tips you can incorporate to go from good to great. By applying these tips, I hope you will enhance your ability to practice medicine and improve your patients’ experience.

(11). Margaret M. Redfield. Heart Failure With Preserved Ejection Fraction. JAMA. 2023;329(10):827-838.

https://jamanetwork.com/journals/jama/article-abstract/2802310

Heart failure with preserved ejection fraction (HFpEF), defined as HF with an EF of 50% or higher at diagnosis, affects approximately 3 million people in the US and up to 32 million people worldwide. Patients with HFpEF are hospitalized approximately 1.4 times per year and have an annual mortality rate of approximately 15%.

Risk factors for HFpEF include older age, hypertension, diabetes, dyslipidemia, and obesity. Approximately 65% of patients with HFpEF present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF with overt congestion (volume overload) at rest. Approximately 35% of patients with HFpEF present with “unexplained” dyspnea on exertion, meaning they do not have clear physical, radiographic, or echocardiographic signs of HF. These patients have elevated atrial pressures with exercise as measured with invasive hemodynamic stress testing or estimated with Doppler echocardiography stress testing. In unselected patients presenting with unexplained dyspnea, the H2FPEF score incorporating clinical (age, hypertension, obesity, atrial fibrillation status) and resting Doppler echocardiographic (estimated pulmonary artery systolic pressure or left atrial pressure) variables can assist with diagnosis (H2FPEF score range, 0-9; score >5 indicates more than 95% probability of HFpEF). Specific causes of the clinical syndrome of HF with normal EF other than HFpEF should be identified and treated, such as valvular, infiltrative, or pericardial disease. First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials. Compared with usual care, exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials. Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms. Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation.

Approximately 3 million people in the US have HFpEF. First-line therapy consists of sodium-glucose cotransporter type 2 inhibitors, exercise, HF self-care, loop diuretics as needed to maintain euvolemia, and weight loss for patients with obesity and HFpEF.