Guest Articles

The development of professionalism and professional identity: the recognition and roles

A/Prof Stuart Lane:

“In the most recent edition of AMSJ, I discussed the concepts of professionalism and professional identity, and encouraged medical students to consider what they understood by them, and how they might influence their future practice. In this edition of AMSJ, I will discuss some of the other concepts that were mentioned: intellectual humility, growth mindset, and situational awareness. These concepts are integral to how students and doctors develop their beliefs and attitudes towards professionalism and professional identity, and I will outline in this article how they relate to clinical decision making, life-long learning, and working relationships.”

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Guest Articles

A (Constructive) Criticism of Medical Curricula: Mileham Hayes

Dr Mileham Hayes reflects on how the medical curriculum has changed and evolved over time; and how this has affected new doctors.

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Review Articles Articles

Molecular Mechanism of Depression: A narrative review of the leading neurobiological theories of Depression

Affective disorders, notably major depression and anxiety, are a significant cause of mortality and morbidity in society today, with the prevalence of depression estimated to be 10-16% in the general population and it is important to have effective treatments available for potentially life-threatening affective disorders. Yet, our understanding of the pathophysiology of depression and anxiety disorders has traditionally been limited due to the difficulty in investigating the brain in vivo. Thus, the molecular bases of these medication targets remain unclear. Recent advances in neuroscience have allowed us to gain a better understanding of  the pharmacological basis of medical treatments for affective disorders. This new knowledge may pave the way for improved management of depression and anxiety. This review summarises some of the leading theories surrounding the neurobiology of depression and link them with both current and potential pharmacological treatments for depression.

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Book Reviews

Book Review: Dermatology truly made easy

A review of Dermatology Made Easy by Dr. Amanda Oakley; a concise resource and perfect introductory companion for any medical student with a dermatological disposition.

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Case Reports

A patient with right striatocapsular stroke complicated by relative adrenal insufficiency

Introduction: Relative adrenal insufficiency can occur throughout the progression of critical illness and is generally transient.

Case: This case report describes a 74 year-old male with right hemispheric stroke syndrome on a background of multiple cardiovascular risk factors. A CT scan showed no acute change.
An MRI scan revealed an acute right striatocapsular infarction. No acute therapies (thrombolysis or endovascular clot retrieval) were performed, as the time of symptom onset was unknown (patient awoke with symptoms). One week later, hyponatraemia was noted with a concurrent decline in function. A repeat MRI showed no interval change or haemorrhagic transformation to account for the functional decline. Complications included relative adrenal insufficiency, diagnosed presumptively and managed with cortisone, and gait instability managed with rehabilitation and allied health input.

Discussion: We review the literature concerning the association between acute ischaemic stroke and adrenal insufficiency and the clinical and biochemical overlap in our patient. This case report aims to increase awareness of relative adrenal insufficiency following a stroke and provide a discussion of possible mechanisms.

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TGA Reform and Why You Should Care About It

The bill to amend the Therapeutic Goods Act was referred to the Senate for enquiry in late 2017, and since has been passed with further amendments. The bill triggered outcry by stakeholders who voiced concern that some of the proposed amendments may make the already widely criticised system, even worse.

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Original Research Articles

The association between pre-pregnancy body mass index and gestational weight gain (GWG) among women in rural NSW, Australia

Background: Pre-pregnancy body mass index (BMI) and excessive gestational weight gain (GWG) are associated with adverse outcomes of pregnancy. The Institute of Medicine (IOM) provides recommendations for weight gain during pregnancy based on pre-pregnancy BMI.

Objectives: To evaluate the proportion of pregnant women in a rural medical practice not meeting the IOM guidelines and to assess a link between pre-pregnancy BMI or excessive GWG and delivery method in this population.

Methods: A clinical audit of 168 patients in a rural NSW Medical Centre with a search criterion of ‘pregnancy’ was performed. Relevant patient details were collected and linked to patient files; pre-pregnancy weight, height, weights recorded during pregnancy, and delivery method.

Results: Among the 87% of gestating women who did not meet the current GWG recommendations, 57% gained weight excessively and 30% inadequately. There was a statistically significant association between pre-pregnancy BMI and excessive GWG with overweight women more likely to gain excessively (Fisher’s exact test 29.04, p<0.001). Pre-pregnancy BMI was also associated with delivery method, with normal weight women more likely to have a normal vaginal delivery and obese women more likely to have an instrumental delivery or planned Caesarean-section (Fisher’s exact test 20.89; p<0.001). Gestational weight gain was not associated with delivery method, regardless of pre-pregnancy BMI.

Conclusion: Given that the majority of women in this rural medical practice showed gestational weight gains outside the recommended limits and that pre-pregnancy BMI was associated with delivery method, there is a role for pre-conception and antenatal programs educating women regarding healthy pre-pregnancy weight and GWG.

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Original Research Articles

Xanthomas seen on capsule endoscopy: What are they saying about your patient’s health?

Background: There is long-standing evidence of an association between cutaneous xanthomas and underlying lipid metabolism disorders, impaired glucose tolerance, secondary hyperlipoproteinemia and diabetes mellitus. Since the advent of capsule endoscopy (CE), substantial numbers of endoscopies have shown evidence of small bowel xanthomas. These have unknown significance to the patient and, consequently, are not routinely reported when identified. Our research is the first study to investigate the significance of small bowel xanthomas identified on CE with underlying lipid disorders or diabetes mellitus.

Methods: 54 patients participated in this prospective cohort study. We recorded patients’ demographic details, medical history, medication list, height, weight, and waist circumference measurements. A blood sample for fasting lipids, fasting glucose and HbA1c was collected. A blinded gastroenterologist reported whether xanthomas were present and quantified the number of xanthomas.

Results: 37% of participants had small bowel xanthomas visualised during CE. The presence of xanthomas was associated with a previous diagnosis of hyperlipidaemia currently treated with anti-lipid medication (IRR 4.43; 95%CI 1.32 to 14.9; p=0.048) and was also associated with increasing units of alcohol consumption (IRR 1.91; 95%CI 1.32 to 2.78; p=0.0007).

Conclusion: This demonstrates an association between the presence of small bowel xanthomas with hyperlipidaemia, mainly in patients with hyperlipidaemia controlled by medication. We also detected an association between small bowel xanthomas and increased alcohol intake. The presence of small bowel xanthomas might trigger lipid evaluation, in future clinical practice.

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Feature Articles

Nanoparticle administration across the blood-brain barrier using MRI-guided focused ultrasound

A vast array of medical conditions affects the central nervous system (CNS), implying a tremendous scope of therapeutic interventions that must target the brain. However, all medical therapy to the brain faces the inherent physiological obstacle of the blood-brain barrier (BBB). Furthermore, after the BBB, drugs must navigate the additional barrier of the brain extracellular space (ECS), which presents its own unique biochemical obstacles. Both the BBB and brain ECS present considerable difficulties for drug therapy to treat diseases affecting the brain. With advancing technology, there has been significant progress towards the goal of overcoming these barriers. An exciting development is the use of MRI-guided focused ultrasound (MRIgFUS) to deliver drug-loaded nanoparticles (NP).

This article describes and explores the use of MRIgFUS and NPs, together as a novel method in CNS drug therapy. First, the basic scientific principles underlying the approach are described. Then, studies that demonstrate key concepts, advancements, strengths, and limitations are discussed to outline directions that have been pursued towards the goal of implementing MRIgFUS NP delivery in practice.

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Review Articles

Efficacy and Safety of Allergen Immunotherapy to Treat House Dust Mite Allergic Asthma in Children

Allergic asthma is a significant disease of childhood, of which, house dust mite is the most common trigger. There have been many investigations into the role of allergen immunotherapy in preventing the development of allergic asthma, and potentially its treatment following formal diagnosis, as evidenced by studies demonstrating significant improvements in medication use, asthma symptoms, and respiratory function. However, there is a paucity of research into specific populations – significantly, paediatric populations. This article reviews the recent literature regarding the efficacy and safety of allergen immunotherapy in the treatment of house dust mite-allergic asthma, with a focus on paediatric populations.

This review suggests that immunotherapy effectively improves asthma symptoms and severity in paediatric populations. While adverse reactions may occur, serious or life-threatening reactions are rare. More research is required to investigate immunotherapy in populations who are polysensitised or who have severe or uncontrolled asthma – preliminary evidence suggests immunotherapy may have a role in the treatment of these patients.

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