Professor Brian Andrews NEJM Recommendations
Week of the 27th 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
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.
Other areas not reviewed but may be of interest
Perspective
Community Trust and the Ebola Endgame
http://www.nejm.org/doi/full/10.1056/NEJMp1508413
Perspective
Ebola in the United States — Public Reactions
and Implications
http://www.nejm.org/doi/full/10.1056/NEJMp1506290
Perspective
Invisible Colleagues
http://www.nejm.org/doi/full/10.1056/NEJMp1506873
ORIGINAL
ARTICLE