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This Week in JAMA
July 17, 2002

This Week in JAMA

JAMA. 2002;288(3):277. doi:10.1001/jama.288.3.277
JAMA-EXPRESS: Estrogen Plus Progestin in Postmenopausal Women

The Women's Health Initiative (WHI)Article launched a series of clinical studies in the 1990s to assess several preventive strategies in postmenopausal women. The combined estrogen and progestin component of the WHI, a placebo-controlled primary prevention trial in healthy postmenopausal women with an intact uterus, was stopped early because risk of invasive breast cancer exceeded the stopping boundary in the estrogen plus progestin group after a mean follow-up of 5.2 years and because overall health risks exceeded health benefits. At the time the trial was stopped, risks of coronary heart disease, stroke, and pulmonary embolism were significantly increased in the estrogen plus progestin group. Risks of colorectal cancer and of hip fracture were decreased, and mortality risk was not significantly different. In an editorial, Fletcher and ColditzArticle consider the results of this WHI trial and other studies on the effects of combined estrogen and progestin and conclude that estrogen plus progestin should not be used to prevent chronic disease in postmenopausal women.

HRT and Risk of Ovarian Cancer

To determine whether hormone replacement therapy (HRT) is associated with ovarian cancer risk, Lacey and colleaguesArticle analyzed follow-up data from women enrolled in the Breast Cancer Detection Demonstration Project, a nationwide breast cancer screening program, who were menopausal or became menopausal during follow-up. Ever use of estrogen-only replacement therapy, especially long-term use of 10 or more years, was significantly associated with increased risk of ovarian cancer. Use of combination estrogen-progestin–only therapy was not associated with increased risk of ovarian cancer, and there was no evidence of a duration response. In an editorial, NollerArticle recommends weighing the benefits and risks of estrogen replacement therapy on an individual basis, noting that risks of estrogen-only therapy now include ovarian cancer.

Triage of Patients With Possible Acute Cardiac Ischemia

Patients with suspected acute cardiac ischemia may be admitted unnecessarily to cardiac care units or improperly triaged to less intensive care settings. Reilly and colleagues developed a clinical rule for emergency department (ED) triage decisions based on an adaptation of a risk-stratification algorithm from a previously validated prediction rule for major cardiac complications in patients with suspected acute cardiac ischemia. During a 14-week intervention period during which the rule was used, the proportion of patients without major complications who were triaged to an ED observation unit or an unmonitored ward increased compared with the preintervention period, and the proportion of patients with major cardiac complications admitted to a coronary care or inpatient telemetry unit was not significantly different.

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β-Blocker therapy continues to be underused in patients with cardiovascular disease, perhaps because of concerns about the development of depressive symptoms, fatigue, and sexual dysfunction. In this quantitative review of randomized trials of β-blocker therapy in patients with cardiovascular disease, however, Ko and colleagues found that β-blocker therapy was not associated with a significantly increased risk of reported depressive symptoms. Risks of reported fatigue and sexual dysfunction were only slightly increased.

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Issues in the Conduct of Clinical Trials

Halpern and coauthorsArticle counter arguments that support underpowered clinical trials and conclude that underpowered trials are ethical in only 2 specific situations. Partridge and WinerArticle examine implications of offering results of clinical trials to study participants and issues that need to be addressed before results could be routinely provided.

A Piece of My Mind

"Old age has been constricting and sometimes lonely. Lucy's genius is surviving a world that would move past her." From "A Survivor's Way."

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Medical News & Perspectives

Lack of physician training, poor reimbursement, and few clinical studies to establish treatment standards are preventing people with mental retardation and developmental disabilities from gaining access to quality health care. Will heightened federal attention help close the gaps?

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Commercial Filming of Patient Care Activities

Filming of patient care activities in hospitals for commercial purposes: potential positive and negative aspects, ethical and legal considerations, current standards, and recommendations.

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Residents' Prescription Writing for Nonpatients

On Call: Issues in Graduate Medical Education
In a survey of internal medicine and family practice residents in community-based teaching hospitals, 85% of respondents reported having written a prescription for persons who were not their patients, and, based on responses to hypothetical vignettes, up to 95% would write a prescription for a person who is not their patient under certain circumstances.

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JAMA Patient Page

For your patients: Information about ovarian cancer.

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