Women's Healthcare
HRT Shown to Lower Sensitivity of Mammography
Chlebowski RT, Anderson G, Pettinger M, et al. Estrogen plus progestin and breast cancer detection by means of mammography and breast biopsy. Arch Intern Med. 2008;168:370-377.
Women who take estrogen plus progestin may need additional screening for breast cancer. Findings from the Women's Health Initiative study show that use of these hormones makes breast cancer more difficult to detect by means of mammography as well as breast biopsy.
In the study, the mammograms for the women who took hormone therapy were less sensitive for cancer detection. Those who took the hormones for 1 year were 4% more likely to have an abnormal mammogram. Women who took hormone therapy for 5 years were 11% more likely to have an abnormal mammogram. Repeat mammograms, and/or biopsies were necessary in these cases. In addition, this higher frequency of abnormal mammograms continued after the therapy was stopped.
The researchers concluded that not only did the use of estrogen plus progestin increase risk for breast cancer, it also mars the diagnostic efficacy of mammograms and breast biopsies. Healthcare practitioners are encouraged to discuss this information with all patients considering hormone therapy, even for short-term use.
Pros and Cons of Fibroid Treatments
Hehenkamp WJK, Volkers NA, Birnie E, et al. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy-results from the randomized clinical Embolisation versus Hysterectomy (EMMY) trial. Radiology. 2008;246:823-832.
There are two main courses of action to take for uterine fibroids or heavy menstrual bleeding: uterine artery embolization and hysterectomy. Both approaches have their advantages and drawbacks, which were examined in a Dutch trial involving 177 women with uterine fibroids and heavy menstrual bleeding who had been scheduled for hysterectomies. After informed consent, 88 of the women were randomly chosen to have uterine artery embolization, and the remaining 89 went on to have hysterectomies as planned.
The trial found that the health-related quality of life (HRQOL) outcomes improved in both groups, with no differences observed between the groups at the 24 month follow-up. However, a higher level of overall satisfaction was reported by the patients in the hysterectomy group. The researchers concluded that based on the HRQOL results, uterine artery embolization is an interventional alternative to hysterectomy.
HRT Increases Lobular Breast Cancer Risk
Li CI, Malone KE, Porter PL, et al. Relationship between menopausal hormone therapy and risk of ductal, lobular, and ductal-lobular breast carcinomas. Cancer Epidemiol Biomarkers Prev. 2008;17:43-50.
In 2003, the Women's Health Initiative examination revealed that hormone replacement therapy (HRT) increases risk of breast cancer in postmenopausal women. A new study of more than 1,500 women supports those findings, now specifically linking combination HRT use to increased risk of lobular carcinoma. The report is published in the January issue of Cancer Epidemiology, Biomarkers & Prevention.
Postmenopausal women who take HRT for even as little as 3 years have four times the risk of developing lobular breast cancer than those who do not.
These findings are significant because lobular breast cancer is considered to be more treatable than ductal cancers, although it only accounts for 15% of all invasive breast cancers.
Women who are considering HRT and their providers must weigh these risks versus the benefits. If it is decided that the patient should take HRT, then she should take the lowest possible dosage for the shortest possible time.
Emergency Care
Racial-Ethnic Bias in Pain Management in the ED
Pletcher MJ, Kertesz SG, Kohn MA, et al. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299:70-78.
A recent survey of U.S. ED visits, the National Hospital Ambulatory Medical Care Survey, has revealed a disparity in the pain treatment received by minorities.
Though the overall usage of opioids for pain management increased over the 13 year time period of the study (from 1993 to 2005), black, Hispanic, and Asian patients were less likely to receive them than were non-Hispanic whites. These data are reported in the January 2 issue of the Journal of the American Medical Association.
It is estimated that 42% of all ED visits are pain related. Of the patients who were administered opioids for pain, 31% were white, 28% were Asian, 24% were Hispanic, and 23% were black. These differences did not change over time.
The study was limited, in that it included only limited clinical details about each case; such as whether or not the patient actually requested pain medication, and what quantity was administered. Nevertheless, an inequality of pain management in minority patients was evident.
Pediatric Care
Updated Pediatric Immunization Guidelines
American Academy of Pediatrics. Committee on Infectious Diseases. Recommended immunization schedules for children and adolescents-United States, 2008. Pediatrics. 2008;121:219-220.
The American Academy of Pediatrics, the CDC's Advisory Committee on Immunization Practices, and the American Academy of Family Physicians have recently recommended three main changes in the pediatric immunization schedule. These new guidelines were published in the January issue of Pediatrics, and are as follows:
* All healthy children ages 24 to 59 months should receive a single dose of the pneumococcal conjugate vaccine if they are not already completely immunized.
* The age limit for the live-attenuated influenza vaccine has been reduced from age 5 years to age 2 years. In addition, a second dose, when indicated, can be given 4 weeks after the initial dose, instead of 6 weeks.
* All 11- to 18-year-olds should receive a single dose of quadrivalent meningococcal vaccine if they have not already received it. This vaccine is preferred by the 2006 Red Book over the quadrivalent polysaccharide vaccine for children 2 to 10 years of age.
Psychiatric Care
Combination Therapy for Teenage Depression
Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299:901-913.
New research shows that a combination treatment strategy is often effective when dealing with adolescents with depression who did not respond to initial treatment. The Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study revealed that a combination of cognitive therapy and a selective serotonin reuptake inhibitor (SSRI) was more effective in combating depression than simply switching from one SSRI to another.
This study included 334 adolescent patients whose depression had failed to respond to at least 2 months of treatment with an SSRI. They were randomly switched to a different SSRI or venlafaxine (Effexor), plus cognitive psychotherapy. After 12 weeks of this combination therapy, more than one-half of the participants saw an improvement in their depression than those who were on a medication alone.
Dermatologic Care
'Ugly Duckling' Moles Likely to be Cancer
Scope A, Dusza SW, Halpern AC, et al. The 'ugly duckling' sign: agreement between observers. Arch Dermatol. 2008;144(1):58-64.
Many people have irregularly shaped or pigmented moles that are completely benign. However, when there are several on the same person, and one is more irregular than the others, there is cause for concern. These moles, termed "ugly ducklings," are often malignant melanomas.
In a small study, 34 examiners studied baseline back images of 12 patients. All 12 patients had at least eight atypical moles on their backs. Five of the patients were diagnosed with melanomas.
Of the 34 examiners, 8 were pigmented-lesion specialists, 13 were general dermatologists, 5 were dermatology nurses, and 8 were members of the nonclinical staff. If one of the moles was perceived as different from the others by at least two-thirds of the examiners, it was considered an ugly duckling.
Of the 145 moles studied, all 5 of the confirmed melanomas and 3 of the benign moles were considered to be ugly ducklings.