Journal of the New Zealand Medical Association, 08-August-2008, Vol 121 No 1279
The Women’s Health Initiative trial—comparing combined hormone replacement therapy (HRT) with placebo—showed a significant increase in the risk of breast cancer, coronary heart disease, venous thromboembolism and stroke among women using HRT. As expected, HRT use subsequently declined, but what else happened? After the report was published in 2001, the incidence of breast cancer in US women aged 50 years or older dropped by 11% between 2001 and 2004.
HRT use tends to increase the risk of oestrogen receptor (ER)-positive tumours, and the fall in breast cancer incidence in the US after 2001 was largely confined to ER-positive tumours.
This paper reports on the Australian situation—a 6.7% fall in age-standardised incidence of breast cancer in Australian women aged ≥ 50 years in 2003 compared with 2001. The authors estimate that this equivalent to 600 fewer cases in this age group (out of a total of about 9000).
It is widely believed that blood pressure levels are strongly and directly related to the relative risks of stroke and heart disease but that the strength of the association declines with increased age. This meta-analysis from Australia sets out to examine these hypotheses. No less than 31 trials, with 190,606 participants, were included in the systematic review. Approximately half of the patients were 65 years of age or older and the gender mix was about equal.
And the conclusions were that blood pressure reduction produces similar proportional reductions in the risks of vascular events in younger (<65 years) and older (≥65 years) adults. And there was no clear evidence to support recommendations for particular drug classes in older or younger adults.
Eradication of this organism is recommended because of its possible sequela—rheumatic heart disease. In the past this was achieved with a single intramuscular dose of long-acting penicillin and more recently with a 10-day course of penicillin V orally in 2 or 3 divided doses. Difficulties with compliance and the need to take it 1 hour before food mar its effectiveness.
In this report from Auckland the conventional oral penicillin treatment has been tested in a randomised trial with a single daily dose of amoxicillin (750mg–1500mg depending on the weight of the child).
353 children were involved and the once daily amoxil was found to be not inferior to twice daily penicillin V, both in curing the pharyngitis and eradicating the streptococcus.
Arch Dis Child 2008;93:474–8
Two papers in a recent NEJM address this proposition. In one, patients with type 2 diabetes who had either established cardiovascular disease or additional cardiovascular risk factors were randomised to receive intensive therapy (targeting a glycated haemoglobin level below 6.0%) or standard therapy (targeting a level from 7.0% to 7.9%). Unexpectantly, the use of intensive therapy to target normal glycated haemoglobin levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events. An editorial commentator wonders whether such intense treatment would benefit the majority of type 2 patients who do not have high cardiovascular risk factors.
The other paper goes some of the way to answer this, as it reports on a less selected group in its trial—lowering the glycated haemoglobin value to 6.5% yielded a 10% relative reduction in the combined outcome of major macrovascular and microvascular events, primarily as a consequence of a 21% relative reduction in nephropathy.
N Engl J Med. 2008;358:2545–72 & 2633–5
Bleeding has now emerged as one of the most common complications after PCI—its incidence ranging from 3–9% in various reports.
The site of bleeding is most frequently related to the femoral access site (52–73% of events). However a significant minority of bleeds, unrelated to arterial access, occur including GI bleeds, intra-cerebral bleeds and large haemoglobin drops without a clinically obvious bleeding site.
The need to prevent restenosis is paramount hence the use of low-dose aspirin and clopidogrel. On the other hand, these drugs are clearly culprits in the bleeding issue. In this meta-analysis the focus is on gastrointestinal bleeding and how to prevent it. Prophylactic usage of proton pump inhibitors is supported by trial evidence because of its gastroprotective effect but does not help prevent lower gastrointestinal bleeding.
Q J Med 2008;101:425–33
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