Charité Clinical Journal Club by Fred Luft - 16.07.2014

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• published: 21 Jul 2014
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The N Engl J Med image of the week shows a man with a red face. You are offered auriculotemporal nerve syndrome, carcinoid syndrome, mastocytosis, pheochromocytoma, and rosacea. We go over each condition. We revisit the case from last week with sternal tuberculosis and review his CT scan. Exemestane is an aromatase inhibitor that blocks the conversion from testosterone to estrogen. Adjuvant therapy with an aromatase inhibitor could improve outcomes, as compared with tamoxifen, in postmenopausal women with hormone-receptor--positive breast cancer. Investigators randomly assigned premenopausal women with hormone-receptor--positive early breast cancer to exemestane plus ovarian suppression or tamoxifen plus ovarian suppression for a period of 5 years. Suppression of ovarian estrogen production was achieved with the use of the gonadotropin-releasing-hormone agonist triptorelin, oophorectomy, or ovarian irradiation in both groups. Exemestane reduced disease recurrence, but not overall survival. Clomiphene is the current first-line infertility treatment in women with the polycystic ovary syndrome, but aromatase inhibitors, including letrozole, might result in better pregnancy outcomes. Letrozole beat clomiphene in these BMI 35 ladies. Dupilumab, a fully human monoclonal antibody, which blocks interleukin-4 and interleukin-13, has shown efficacy in patients with asthma and elevated eosinophil levels. The blockade by dupilumab of these key drivers of type 2 helper T-cell (Th2)--mediated inflammation could help in the treatment of related diseases, including atopic dermatitis. The findings provide evidence that allergic asthma and atopic dermatitis might have related drivers — in particular, interleukin-4 and interleukin-13 — and that these diseases may benefit from the same therapeutic approach. In the Total Body Hypothermia for Neonatal Encephalopathy Trial (TOBY), newborns with asphyxial encephalopathy receiving hypothermic therapy had improved neurologic outcomes at 18 months of age, but it is uncertain whether such therapy results in longer-term neurocognitive benefits. Now we are certain. The recent outbreak of Exserohilum rostratum meningitis linked to epidural injections of methylprednisolone acetate has brought renewed attention to mold infections of the central nervous system (CNS). Although uncommon, these infections are often devastating and difficult to treat. We review the topic. The mystery case of the week is a 68-year-old man with ANCA vasculitis who develops diplopia and other CNS manifestations. In the Lancet, evidence suggests that brief physiotherapy programs are as effective for acute whiplash-associated disorders as more comprehensive programs; however, whether this also holds true for chronic whiplash-associated disorders is unknown. Turns out that brief treatment is as good as comprehensive physiotherapy for long-term whiplash results. Postoperative surgical site infections are one of the most frequent complications after open abdominal surgery, and triclosan-coated sutures were developed to reduce their occurrence. The aim of the PROUD trial was to obtain reliable data for the effectiveness of triclosan-coated PDS Plus sutures for abdominal wall closure, compared with non-coated PDS II sutures, in the prevention of surgical site infections. Unfortunately, triclosan did not help. Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users (heroine addicts) are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programs is poor. Investigators aimed to assess whether contingency management (paying them to complete vaccination) delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy. Bribes generally work. We then inspect an important meta-analysis of breast cancer patients treated with neoadjuvant chemotherapy (more advanced disease given chemotherapy before surgery). A "pathological complete response" is deemed to be an important prognostic indicator. We learn the prognostic value and limitations of this pathological result. The Lancet case is a 92 year-old lady with knee pain that turns out to be an obturator hernia. We review this treacherous diagnosis.