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The BMJ Today: Improving vaccination rates

30 Jul, 14 | by BMJ

peter_doshiIn the United States, the Centers for Disease Control and Prevention (CDC) held a press conference to discuss a recent survey, which found that rates of HPV vaccine coverage did not reach the 80% target. This in itself is not a surprise given the vaccination levels of previous years.

But at the press conference, The BMJ reports, officials delivered a message for doctors: forego a conversation with parents about whether or not to get the HPV vaccine, and instead just recommend it outright. US assistant surgeon general Anne Schuchat said “she thought that doctors were recommending the vaccine, just not forcefully enough.” more…

Richard Lehman’s journal review—28 July 2014

28 Jul, 14 | by BMJ

richard_lehmanNEJM 24 July 2014 Vol 371
371  Long ago I had a patient who kept having odd things happen to her. She infarcted part of her cerebellum, and then did the same to two fingers on her right hand. She was full of pains, her kidneys were failing, and her erythrocyte sedimentation rate (ESR) stayed high. When CRP became available in our little hospital, that stayed high too. Then, finally, somebody ran a brand new test on her—anticardiolipin antibodies. At last we had a diagnosis—antiphospholipid syndrome! Getting this label made absolutely no difference to her since she had already been given all the usual “empirical” treatments, like aspirin which made her bleed, and steroids which made her even huger and more diabetic. She died long ago, but for the last 25 years, I have been reading pieces about antiphospholipid syndrome in the hope of discovering (a) that somebody understands it and (b) that there is an effective treatment. Now a little bit of my hope has been fulfilled. Twelve years ago, some patients whose kidneys had been destroyed by this syndrome received renal transplants and were given sirolimus as an anti-rejection drug. Now 70% of them have functioning allografts, whereas for those who did not get sirolimus the percentage is 11. So sirolimus urgently needs investigating as a treatment for the more severe forms of the syndrome. And from biopsy and autopsy samples, it seems that the destructive process is driven by mTORC through the phosphatidylinositol 3-kinase (PI3K)–AKT pathway, which sirolimus suppresses. Serves me right for wanting to know. more…

Mayank Singh: The euthanasia debate in India

28 Jul, 14 | by BMJ

Mayank_singhThe case of Aruna Ramachandra Shanbaug was a landmark moment for the euthanasia debate in India. Aruna was a nurse working in the King Edward Memorial Hospital (KEM) in Mumbai. On the evening of 27 November 1973, Aruna was brutally raped. She survived, but asphyxiation had cut the blood and oxygen supply to parts of her brain, which resulted in her being in a permanent vegetative state (PVS) ever since. She cannot walk, eat, or even move, and relies on the services of the staff nurses of KEM who have, for more than 40 years, cared for and looked after Aruna. more…

The BMJ Today: More on transparency

24 Jul, 14 | by BMJ

BirteIn recent years, The BMJ has campaigned on transparency—the focus of our Open Data campaign, and an issue of vital importance if modern medicine is to retain the trust of doctors and the public, writes Trevor Jackson in this week’s Editor’s Choice.

Dabigatran was the first of the new oral anticoagulants licensed to prevent stroke in patients with non-valvular atrial fibrillation. It was approved by the US Food and Drug Administration in 2010 and by the European Medicines Agency for this use a year later. The drug’s unique selling point, said its manufacturer, Boehringer Ingelheim, was that it would need no monitoring, unlike warfarin. more…

The BMJ Today: Time to rethink your assumptions about sepsis, Minerva

23 Jul, 14 | by BMJ

When I first arrived at the University of Bath, to study history and philosophy of science, our first lecture was about Sulis-Minerva: the combination of Minerva, Roman goddess of wisdom, and Sulis, the Celtic goddess who lived in the hot springs that gave the city its name.Sulis_Minerva_head_Bath

Sulis-Minerva became the goddess of health in Roman Britain, so it it seemed appropriate when working at The BMJ to ritually read her summary of the big journals each week. The latest edition is called “The progression of rheumatoid arthritis and other stories . . . ” but it’s the note about Chickenpox that makes this worth a read. The virus used to kill 100 US residents of all ages every year, but that number’s dropped after concerted vaccination programmes. And, the fear that this may push the virus into older populations, where shingles is much more severe, hasn’t manifested. more…

Richard Lehman’s journal review—21 July 2014

21 Jul, 14 | by BMJ

richard_lehmanNEJM 17 July 2014 Vol 371
203  Niacin is an abundant natural B vitamin, which lowers bad cholesterol and raises good cholesterol. What’s not to like? Well, niacin, unfortunately. In doses that make any difference to lipid levels, it is very likely to make you feel sick, get flushes and/or rashes, and/or feel muscle pains. So Merck decided to market it in combination with laropripant, a prostaglandin antagonist that is meant to combat its unpleasant effects. Even so, a third of people who were recruited to the present trial could not continue past the run-in phase with the active combination. And now that the full results are out, we have confirmation that this dual agent definitely does not offer any cardioprotection despite its “favourable” effect on lipids. Worse still it causes bleeding, raises blood sugar, and shows a tendency to increase mortality in those who can tolerate taking it for three years. The Clinical Trials Support Unit (CTSU) at Oxford did a great job of running this trial with funding from Merck, following its usual rules of independence. In doing so, it provides a great illustration of the fact that lipid fractions are very unreliable surrogates for cardiovascular outcomes. But we knew that already, and it seems a great pity to me that many superb researchers were tied down for so long on a project that has made such a small contribution to clinical knowledge, whatever it may have contributed to the funds of CTSU. more…

The BMJ Today: Talking shit again

21 Jul, 14 | by BMJ Group

By the end of next month rural India could have an extra 5.2m toilets as part of a pre-election pledge by Narendra Modi, now prime minister, to build “toilets first and temples later.”

Readers of The BMJ will no doubt be heartened by the Indian government’s announcement, coming seven years after sanitation topped a reader poll as the greatest “medical milestone” in the past 166 years  more…

The BMJ Today: Laws on money and sex

16 Jul, 14 | by BMJ

kristina_fisterBeing a doctor can sometimes feel glamorous. Soon after graduating from medical school, I found myself on a high floor of a fancy hotel in downtown Chicago, waking up to the sun rising over Lake Michigan, a perfect view through a glass wall. Yes, not a window, a wall. Plush carpets, marble bathroom, you know—the works. It was beautiful, and someone else was paying for it.

It might have been at that editorial congress that I learned: disclosure is panacea. Get as many “free lunches” as you want, from whomever you want, but let people to whom it might matter know about it. more…

Shalini: India needs those vaccines

15 Jul, 14 | by BMJ

shaliniIndia has just introduced three new paediatric vaccines to its Universal Immunization Program (UIP), extending protection to its children against deadly and crippling diseases (rotavirus, rubella, and polio through an injectable polio vaccine). With an estimated 27 million children born in India each year, this is an unprecedented policy leap by the new government, which is flexing its muscles. Rotavirus diarrhoea alone costs the country 300 crore rupees (£29m; €37m; $50m) each year in terms of healthcare costs. It also causes 80 000 deaths, and up to a million hospitalizations, in children each year. One episode of rotavirus treatment costs 7-8% of annual income for low income Indian families. The situation couldn’t have been more urgent. more…

The BMJ Today: Explaining telomeres

15 Jul, 14 | by BMJ

georg_roegglaTelomeres are getting a lot of attention at the moment. At the 64th Nobel laureate meeting in Lindau two weeks ago, Elizabeth Blackburn (who won the 2009 Nobel prize in medicine) drew my attention to the role of telomeres in the cellular aging process. more…

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