Professor Brian Andrews NEJM Recommendations

Week of the 27^th August 2015 (#5)

University of Notre Dame Australia Fremantle

Articles Recommended for Medical Students

Perspective

Shifting Vaccination Politics -The End of Personal-Belief Exemptions in California

http://www.nejm.org/doi/full/10.1056/NEJMp1508701

This is an issue that not only involves the US but also Australia. A recent measles epidemic, which spread from Disneyland, appeared to be the flame that ignited the passage of a recent bill by the Californian Senate (SB 277). This bill requires that all children attending schools, child-care centres and day nurseries MUST be fully vaccinated before they are allowed to enter the school with the only exemption being medical conditions (I hope legitimate only). Support for passage of the bill came from the parents of a 7 year old with leukaemia who asked that the school bar unvaccinated student from attending at the school.

This is a must read perspective which has immediate public health applications for WA and Australia and is a polarising issue, but with only one answer-all children attending schools should be vaccinated (medical exceptions) in order for them to attend. This is a Public Health priority.

EDITORIAL

Overcoming Impediments to Global Implementation of Early Antiretroviral Therapy

http://www.nejm.org/doi/full/10.1056/NEJMe1508527

This is a well written summary on the Global Health issues surrounding the treatment of HIV, particularly in the third world. Unfortunately due to pragmatic reasons that are discussed in the review, HIV infection is treated based on the absolute CD4 count and WHO recommendations.

I have placed the two reviewed original articles in the Optional reading for those interested.

Fortunately in Australia, when HIV is first diagnosed, irrespective of the CD4 count, the patient is treated at the onset with ART (anti-retroviral therapy).

The Editorial should be read by any interested student, particularly those with an interest in Global Health issues.

ORIGINAL ARTICLE

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

http://www.nejm.org/doi/full/10.1056/NEJMoa1501035

This is a very important, large randomized, double-blind, placebo-controlled trial (US and Canada) which asked the following question: Is bridging anticoagulation with low MW heparin required in patients on warfarin for atrial fibrillation undergoing elective surgery or other elective invasive procedure?

Using this non-inferiority study, the answer appears to be no. While there was a similar incidence of arterial thromboembolism in both the bridging (0.3%) and non-bridging groups (0.4%), the other two key points of the study were:

1. Major bleeding in the bridging group (3.2%) was significantly higher than in the non-bridging group (1.3%) group, and

2. No rebound hypercoagulability was demonstrated in the non-bridging group recommenced postoperatively on warfarin without heparin.

Of course, the results of this study may only be useful for the next year or two when direct oral anticoagulants (DOAs – this should not be the expected outcome) will be the most commonly used anticoagulant for this clinical scenario and pharmaceutical companies will be asked again to front the bill for a similar study using DOAs.

Read this article carefully, in particular review the Study Design.

CLINICAL PRACTICE

Primary Care for Men Who Have Sex with Men

http://www.nejm.org/doi/full/10.1056/NEJMcp1401303

This is an important and well written clinically relevant article for all medical students to read. It particularly emphasises the importance of taking a detailed and specific sexual history and to determine the patient’s sexual identity (in some cultures, men may not regard themselves as “gay” if they have sex with other men).

It describes the clinical interaction between the treating physician and the patient. Clinical Points are well documented as are the primary care recommendations and the preexposure prophylaxis in men who have sex with men. Recommended vaccination protocols are discussed.

Further, the article discusses controversial issues such as preexposure prophylaxis for HIV and routine screening for anal cancer.

IMAGES IN CLINICAL MEDICINE

A Child with Gross Hematuria

http://www.nejm.org/doi/full/10.1056/NEJMicm1410250

This is a very interesting case which is seen infrequently in Australia but can be seen in travellers and recent immigrants from endemic areas. This is associated with SCC of the bladder. The video is “cool.”

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL

Case 27-2015 - A 78-Year-Old Man with Hypercalcemia and Renal Failure

http://www.nejm.org/doi/full/10.1056/NEJMcpc1310003

An interesting CPC which provides an excellent discussion on the relationship between renal failure and hypercalcaemia. It discusses the 1-hydroxylation of 25OH vitamin D by granuloma cells in a similar manner to the kidney resulting in hypercalcaemia. In particular, the discussion should be read by MED300 and MED400 students.

Optional Articles for Medical Students

ORIGINAL ARTICLE

Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

http://www.nejm.org/doi/full/10.1056/NEJMoa1506816

ORIGINAL ARTICLE

A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa

http://www.nejm.org/doi/full/10.1056/NEJMoa1507198

Both of the above articles have been reviewed in the above Editorial.

SPECIAL ARTICLE

Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work

http://www.nejm.org/doi/full/10.1056/NEJMsa1415994

This study should provide some reassurance for surgeons, patients, medical administrators, insurance companies and students considering a future in surgery.

Tuesday 19 January 2016

NEJM Week of 27th August 2015 (#5)

Overcoming Impediments to Global Implementation of Early Antiretroviral Therapy

This is a well written summary on the Global Health issues surrounding the treatment of HIV, particularly in the third world. Unfortunately due to pragmatic reasons that are discussed in the review, HIV infection is treated based on the absolute CD4 count and WHO recommendations.

I have placed the two reviewed original articles in the Optional reading for those interested.

Fortunately in Australia, when HIV is first diagnosed, irrespective of the CD4 count, the patient is treated at the onset with ART (anti-retroviral therapy).

The Editorial should be read by any interested student, particularly those with an interest in Global Health issues.

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

Using this non-inferiority study, the answer appears to be no. While there was a similar incidence of arterial thromboembolism in both the bridging (0.3%) and non-bridging groups (0.4%), the other two key points of the study were:

1. Major bleeding in the bridging group (3.2%) was significantly higher than in the non-bridging group (1.3%) group, and

2. No rebound hypercoagulability was demonstrated in the non-bridging group recommenced postoperatively on warfarin without heparin.

Read this article carefully, in particular review the Study Design.

Primary Care for Men Who Have Sex with Men

It describes the clinical interaction between the treating physician and the patient. Clinical Points are well documented as are the primary care recommendations and the preexposure prophylaxis in men who have sex with men. Recommended vaccination protocols are discussed.

Further, the article discusses controversial issues such as preexposure prophylaxis for HIV and routine screening for anal cancer.

A Child with Gross Hematuria

This is a very interesting case which is seen infrequently in Australia but can be seen in travellers and recent immigrants from endemic areas. This is associated with SCC of the bladder. The video is “cool.”

Case 27-2015 - A 78-Year-Old Man with Hypercalcemia and Renal Failure

Optional Articles for Medical Students

Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa

Both of the above articles have been reviewed in the above Editorial.

Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work

This study should provide some reassurance for surgeons, patients, medical administrators, insurance companies and students considering a future in surgery.

Community Trust and the Ebola Endgame

Perspective

Ebola in the United States — Public Reactions and Implications

Perspective

Invisible Colleagues

Initial Use of Ambrisentan plus Tadalafil in Pulmonary Arterial Hypertension