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July 29, 2016

Safe travels

The story

It's a great big world out there, when you're the doctor responsible for providing travel advice. And while some stuff is obvious – maybe your pregnant patient should pass on those Olympic tickets in Rio – it's tough to prepare yourself and your patients for overseas travel.

The advice

Over a billion folks traveled overseas in 2015, and a quarter to a half of them got sick on their journey. Tell your patients to see you 4 - 6 weeks before departure. Give appropriate vaccines and think about what education they may need, like instructions on how to avoid mosquitos or what to bring with them in medical kits. Here's a quick guide on how to structure your visit, and a cheat sheet for some common international destinations. Want more? Watch an animated robot suffer tropical diseases as he walks you through the international medical consultation.
NEJM

That whole Zika thing

Your friends are going to ask you, so you might as well have something to say. This week, Brazilian researchers question whether microcephaly can be explained by Zika alone, since it's mostly seen in the country's northeast despite a nationwide outbreak. And a new report found Zika RNA in amniotic stem cells in the early miscarriage of a pregnant woman with confirmed Zika infection.

The takeaway

Whether your patients are visiting their home countries or you and your friends are heading for adventure, a little research and some simple tools can help you give appropriate travel guidance.

Say it on rounds

When your last admission arrives 5 minutes before signout

If only you could know ahead of time. To glimpse at the future of kidney transplants, researchers looked at transplant biopsies to see if genes could predict allograft fibrosis at 1 year. They discovered a 13-gene set that predicted fibrosis more accurately than current clinical and pathological variables. The gene set was also predictive of early allograft failure. 
Lancet

When the air conditioner is down and the fans are broken

Sweat it out, and consider telling your patients with knee pain to do the same. Though 2 million meniscus repairs are performed globally each year, surgery provides only marginal benefit. A Norwegian RCT comparing partial meniscectomy with an observed exercise regimen found no differences in knee function at 2-year follow-up. The exercise group also had greater thigh muscle strength – thought to be protective against osteoarthritis – at 3 months.
BMJ

When your white coat doubles as a nap time pillow

It's great to use an old tool for new tricks, so consider using statin therapy in patients with hepatitis B without access to antiviral treatment. A population-based cohort study from Taiwan found that statins were associated with a dose-dependent reduction in the risk of cirrhosis in chronic hep B patients. 
Am J Gastroenterol

Brush up

Chronic obstructive pulmonary disease (COPD)

Use spirometry to diagnose COPD. Look for a FEV1 / FVC ratio of less than 0.7, though normal values don't rule out disease. Treatment with a long-acting muscarinic antagonist or long-acting beta agonist (LAMA / LABA) is indicated when FEV1 is less than 60% of predicted or if patients are regularly symptomatic. Give active smokers advice on how to quit, and make sure your patients are up to date with influenza, pertussis and pneumococcal vaccines. GOLD guidelines can help you keep up with evolving diagnosis and management.

What's the evidence

For macrolides in COPD? The antibiotics are often used to treat acute exacerbations because of immunomodulatory and anti-inflammatory effects, but they can also be effective preventative agents. A large 2011 RCT found that daily azithromycin prompted a significant decrease in the frequency of acute exacerbations and improved quality of life in COPD patients at increased risk of exacerbation. Note that the azithromycin group was more likely to have airway colonization with macrolide-resistant bacteria.

Fond memories

Those who miss the Step 2 CS exam can always reminisce, but over 16,000 people that paid big bucks for the infamous medical licensing exam have signed a petition to end it. Medical students pay $1.1 million in aggregate test fees to find one person who cannot pass the exam.
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