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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 20-January-2012, Vol 125 No 1348

Efficacy of a herpes simplex vaccine?

Both herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) can cause primary infection of the genital tract, and HSV-1 infection has become an increasingly frequent cause of genital disease. Recurrence of genital disease in people with HSV-2 antibodies happens in some 10–25% and is distressing. Even more distressing is transmission of HSV from infected women to neonates as this may lead to severe neurologic disease or death in the newborn. Current strategies to prevent such include condom usage and antiviral drugs. However, a prophylactive vaccine would be better.
In this trial in 8323 women, a candidate HSV vaccine containing glycoprotein D was found to be ineffective in preventing HSV-2 infection. However it was effective in preventing HSV-1 genital disease. Good but not good enough.
N Engl J Med 2012;366:34-43

Systematic screening for occult cancer in elderly patients with venous thromboembolism

A controversial topic explored in a prospective study from France. Fifty consecutive elderly patients (median age 80 years) with proven deep venous thrombosis and/or pulmonary embolism were screened for occult cancer by clinical, laboratory (including tumour markers) and radiological investigations (abdominal ultrasound, chest X-ray and a thoraco-abdominopelvic computed tomography scan).
The screening strategy did not detect several cancers that became overt clinically over the next 12 months. They conclude that a full history, clinical examination and routine laboratory investigations might be the optimal first-line strategy to detect cancer after the diagnosis of venous thromboembolism in elderly patients, but regular clinical examinations during follow-up are warranted. They do not favour blood tumour markers with the exception of PSA in elderly men.
Int Med J 2011;41:769-75.

Blood pressure targets recommended by guidelines for high-risk patients: <140/90 or <130/80?

Hypertension treatment guidelines recommend that blood pressure (BP) be lowered to <140/90 mmHg, but that a reduction to <130/80 mmHg be adopted in patients at high cardiovascular (CV) risk because of diabetes mellitus, renal disease or prior cardiovascular event. This study involved 12554 such hypertensive patients with a high CV risk. Patients were divided into four groups according to the proportion of in-treatment visits before the occurrence of an event (<25% – >75%) in which BP was reduced to <140/90 or <130/80 mmHg). And their conclusions were that the more frequent achievement of the BP targets recommended by guidelines led to cerebrovascular and renal protection, but did not increase cardiac protection.
Overall, CV protection was favourably affected by the less tight but not by the tighter BP target. In an editorial it is noted that at the present time only a minority of patients with hypertension meet the current recommended targets in either the general hypertensive population or the high risk group. So he recommends that the current targets should not be revised until further evidence is presented.
Circulation 2011;124:1727-36 & 1700-02.

2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm

Apparently the optimal excision margins for such melanomas are controversial. This randomised study involved 936 patients, half of whom had a 2-cm excision margin and the other half a 4-cm margin. After a median follow-up of 6.7 years the authors report no significant difference in overall survival or recurrence-free survival. There was also no difference in the death rate from melanoma in the two treatment groups. The authors also note that those having the wider excision may have worse cosmetic results and may need skin grafts which may lead to complications. Consequently they conclude that their findings suggest that a 2-cm resection margin is sufficient and safe for patients with cutaneous melanoma thicker than 2 mm.
Editorial commentators noted that the trial findings are welcome. However, as the trial was planned as an equivalency trial with 2000 patients but only recruited 936 patients they believe the study should be classed as an unplanned non-inferiority trial, which showed that a 2-cm margin was not inferior to a 4-cm margin.
Lancet 2011;378:1635-42 & 1608-9.

Treatment of recurrent pericarditis with colchicine

Recurrence of pericarditis is common—up to 30% and up to 50% after a first recurrence. Colchicine has been reported to be useful and this randomised placebo controlled trial sets out to elucidate. 120 patients with a first recurrence of pericarditis were randomly assigned to receive either placebo or colchicine, 1.0 to 2.0 mg on the first day followed by a maintenance dose of 0.5 to10 mg/d for 6 months. At 18 months the recurrence rate was 24% in the colchicine group and 55% in the placebo group. These results represent an absolute risk reduction of 0.31 and a relative risk reduction of 0.56 (number needed to treat, 3). In addition colchicine reduced the persistence of symptoms at 72 hours and the mean number of recurrences. Hence, such treatment is recommended. Presumably colchicine treatment effects in pericarditis are analagous to the benefit seen in treating the synovitis of gout. The authors caution that pericarditis of proven bacterial or neoplastic causes were excluded from their trial.
Ann Intern Med 2011;155:409-14.
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