Now that the MRCP exam is out of the way, I've been catching up on few interesting articles which have featured in the BMJ over the past few weeks.
Measles
This can is a disease which can be effectively prevented by vaccination, yet most of the UK has not reached the levels of immunity necessary to achieve herd immunity (estimated to be around 95% of the population immunised). The number of people not immunised may in fact be greater than known, particularly in the age group of children who should have received vaccination around the time of the widely spread reports about a possible link with autism (a link which has now been rebuked and disproved). Indeed I found out recently that I did not have immunity to measles, and have begun my MMR vaccination schedule to ensure that my risk of catching the disease is diminished. In Swansea this year there has been a surge in the number of cases, and in the north of England there have been 354 cases so far this year (2013). The condition is largely self-limiting but complications can occur including permanent disability and death, and it is highly infectious. And yet an effective vaccine is available. So should we be doing more to prevent this disease? In the US, cases of measles are treated as an emergency, and this may be a contributing factor which has led to the elimination of endemic measles in the Americas. Any child death due to measles should be a 'never' event because it is avoidable. It would be reasonable for me to expect that global eradication of measles will be achieved in my lifetime but we cannot be complacent and must do more as doctors to help eradicate the world from measles permanently.
Acne Vulgaris
Acne vulgaris is a distressing condition which commonly affects adolescents and can have a profound impact on quality of life. It shouldn't be underestimated how often the condition continues into adulthood and permanent scarring may occur. Acne is considered to be severe if there are nodules and cysts present. It is an inflammatory condition of the pilosebaceous unit where there is abnormal keratinocye proliferation, an androgren driven increase in sebum production, proliferation of Propionibacterium acnes and inflammation. Topical retinoids are the mainstay of treatment although oral isoretinoin is the most effective treatment.
Are Anti-Depressants Overprescribed?
There is a strong feeling amongst many doctors that anti-depressants are over-prescribed and a recent poll on the BMJ's website saw 79.3% of respondents vote in agreement. The reasons why are suggested to be due to influences of the pharmaceutical industry, the broad definition of depression and perceived 'quick fix' solutions from patients and doctors. There are however explanations for the increase in anti-depressant prescribing, according to one psychiatrist (who does declare receipt of payment in an advisory role to a pharmaceutical company). He gives the counter-side of the argument in the BMJ this week. His arguments (amongst others) are that anti-depressants are effective in treating depression, and that the increasing numbers of patients taking the medications may reflect improving practice amongst doctors in understanding that patients need to take the medications for at least 6 months for an effect to be seen.
Investigating Suspected Heart Failure
A review article on the initial investigation of heart failure places a strong emphasis on the use of B-type natriuretic peptide (BNP) as a predictor of disease. A normal 12-lead ECG and BNP has a high negative predictive value for excluding heart failure although this is recommended for use in a non-acute setting. A BNP result of >400pg/mL confers a poor prognosis and it is recommended that these patients are reviewed by a cardiologist within 2 weeks. Echocardiogram does however remain the investigation of choice in confirming the diagnosis of heart failure. It has to be noted though that there are a number of other causes for a modestly raised BNP result, such as COPD, hypoxia and diabetes therefore results need to be interpreted with caution.
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