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24 December 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Unprecedented but Justified. Princeton meningitis outbreak calls for “compassionate use” of unlicensed vaccine

In the wake of Princeton University’s meningitis outbreak, healthy individuals on campus who are at risk for infection will be offered voluntary immunization with Bexsero (Novartis), a vaccine that has not been approved for use in the United States. Since March 22, 2013, health officials have confirmed eight cases of Neisseria meningitides serogroup B (MenB) meningitis among students and visitors at Princeton University. Bexsero is the only vaccine in production that protects against MenB. While the media have expressed concern about using an “experimental” vaccine on students, the authors of an article being published in Annals of Internal Medicine say “compassionate use” of the unlicensed vaccine is justified because epidemiologic evidence suggests that all Princeton University meningitis cases are related and that transmission is ongoing. They argue that the vaccine is not experimental, as it has been approved for use in Europe and Australia. A plea for broader access to the vaccine has been made by advocacy groups, but the vaccine is being limited to Princeton University students based upon policy and epidemiology. While more than a third of total cases in the U.S. are due to MenB, a monovalent MenB vaccine would need to be administered along with the current quadrivalent conjugate meningococcal vaccine to optimize protection against all of the serogroups that cause the majority of disease in the U.S. The authors suggest that a vaccine that prevents MenB still should be available in the U.S. They write, “our ability to mobilize resources in response to this situation should compel us to take measures to ensure access to this prevention tool with proven safety and efficacy to all who are at risk.” Full text of this article is available at

2. Task Force recommends BRCA mutation screening for high-risk women

According to a new guideline being published in Annals of Internal Medicine, the United States Preventive Services Task Force (USPSTF) recommends that primary care providers screen asymptomatic women with a family history of breast, ovarian, tubal, or peritoneal cancers to determine if that family history may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes BRCA1 or BRCA2. Women who screen positive should have genetic counseling and, if indicated after counseling, BRCA testing. The Task Force recommends against routine genetic counseling or testing for average-risk women. The Task Force identified specific screening tools that can be used in primary care to guide referral to genetic counselors. In general, the tools present a series of questions designed to elicit information about factors associated with increased likelihood of BRCA mutations. While the tools are all estimated to be more than 85 percent sensitive, there was not enough evidence for the Task Force to recommend one test over the other. This recommendation is reaffirms the Task Force’s 2005 recommendation on BRCA testing. The full recommendation is free to the public and can be found at

3. The American College of Physicians explains how Medicaid expansion will help the poor

The American College of Physicians (ACP) explains how Medicaid expansion will benefit poor citizens and their physicians in an article being published early online in Annals of Internal Medicine The authors write that under the provisions of the Affordable Care Act-mandated Medicaid expansion, patients who have historically been denied Medicaid coverage will now have access to a healthcare plan equivalent to a benchmark plan chosen by the state. The Medicaid plan will be required to cover 10 essential benefit categories, including regular health screenings. While Medicaid expansion should benefit physicians by reducing the volume of uncompensated care, some patients may have difficulty finding a physician who is willing to accept new Medicaid patients. Another looming challenge is that patients in states that are unwilling to expand Medicaid are likely to remain uninsured and hospitals in those states will continue to absorb uncompensated care costs. According to the authors, states that refuse to expand Medicaid coverage “are forgoing an opportunity for their poor citizens to achieve financial peace of mind, obtain a regular source of medical care, and receive preventive services to help stave off serious complications.”