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.
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.
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.
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.
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.
"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."
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?
Filming of patient care activities in hospitals for commercial purposes:
potential positive and negative aspects, ethical and legal considerations,
current standards, and recommendations.
On Call: Issues in Graduate Medical EducationIn
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.
For your patients: Information about ovarian cancer.
This Week in JAMA. JAMA. 2002;288(3):277. doi:10.1001/jama.288.3.277