Journals Watch - Breast cancer, diabetes and SLE

A review of this week's medical research. By GP Dr Sally Hope

A study has found a link between invasive breast cancer and HRT (Photograph: Zephyr/SPL)
A study has found a link between invasive breast cancer and HRT (Photograph: Zephyr/SPL)

Breast cancer incidence in relation to HRT use

Maturitas 2012; 72: 317-23

Since the huge trials of the Women's Health Initiative and the British Million Women study, the incidence of breast cancer has fallen, as has the use of combined HRT. There is still controversy about how risky taking HRT is for women less than 60 years old.

This study looked at invasive breast cancer rates in Belgian women aged 50-69 years. There was a significant association (p <0.001) between invasive breast cancer incidence and HRT rate in the previous year. This group calls for a prospective European registry to assess the adjusted breast cancer risk associated with HRT, in different populations and with different regimens.

Women really do need to understand the breast cancer risk associated with taking combined HRT and, as GPs, we need to write in their notes that it has been discussed.

Burnout and satisfaction among US physicians

Arch Intern Med 2012; doi: 10.1001/archinternmed. 2012.3199

This national study in the US evaluated doctors using the Maslach Burnout Inventory. They achieved a 26.7% response rate (7,288 completed surveys). Nearly half of the physicians who replied (45.8%) reported at least one symptom of burnout.

There were substantial differences across different specialties, with the highest rates in front-line care: family medicine, general internal medicine and emergency medicine.

Pathology, dermatology and occupational health had the lowest rates of burnout, and the best satisfaction in their work/life balance.

Not surprisingly, specialties with the least satisfaction with work/life balance were general surgery, obstetrics/gynaecology and internal medicine.

Compared with US adults in other walks of life, physicians were more likely to have symptoms of burnout (37.9 versus 27.8%) and to be dissatisfied with their work/life balance (p <0.001).

The conclusion of this survey is that burnout among US physicians is at 'an alarming level'.

Bariatric surgery for prevention of type 2 diabetes

N Engl J Med 2012; 367: 695-704

In this Swedish study, 1,658 people aged 37-60 with a BMI >34 in men or >38 in women, received bariatric surgery and were followed up for 15 years, along with 1,771 controls, to see what percentage developed type 2 diabetes mellitus.

None of the participants had diabetes at baseline.

In the control group, the incidence rate of diabetes was 28.4 cases per 1,000 person-years, but the intervention group had an incidence of 6.8 per 1,000 person-years (p <0.001). The postoperative mortality was 0.2%.

Current NICE guidelines recommend a BMI >40 or BMI >35 plus other risk factors before considering bariatric surgery.

This paper adds to the evidence that bariatric surgery is a more efficient way of preventing diabetes in the morbidly obese than 'usual care'. It might be useful to quote this when we fill in PCT application forms for funding for these patients.

Genetic risk factors for thrombosis in SLE

J Rheum 2012; 39(8): 1603-10

The authors of this study wanted to investigate whether genetic variants implicated in thrombosis pathways were associated with thrombosis among two ethnically diverse systemic lupus erythematosus (SLE) cohorts.

Thirty-three single-nucleotide polymorphisms (SNPs) known to be implicated in the thrombosis pathway were tested in a large cohort enrolled in the San Francisco Lupus Genetic project.

Of the SLE patient cohort, 23% had experienced a thrombotic event.

Leiden V factor and methylenetetrahydrofloate reductase abnormalities were more common in the white ethnic group. In Hispanic Americans, the fibrinogen gamma gene variants were more common.

This is a useful reminder that the same disease in different ethnic groups can have an increased risk of thromboembolism, but the underlying genetic defect might be different.

Certainly when referring these patients for elective surgery or other high-risk, thrombogenic procedures, they need to be flagged up for antithrombogenic prophylaxis, and patients themselves need to understand this.

Frontal thalamocortical circuits in schizophrenia

Arch Gen Psychiatry 2012; 69 (8): 766-74

One disappointment of the past 30 years has been the lack of progress in schizophrenia.

We know a lot more about the genetics and there are more medications available, but it is still a terrible disease.

In this paper, 20 patients with schizophrenia and 20 age-matched controls had high-density EEG recordings taken during transcranial magnetic stimulation of four cortical areas.

The schizophrenia patients showed a slowing in the natural frequency of the frontal/prefrontal regions and the thalamocortical circuits compared with controls. This prefrontal natural frequency can predict some of the symptoms and cognitive dysfunctions of schizophrenia.

Gluten-free diets: are they vital or just a vogue?

Am J Gastroenterol 2012; doi: 10.1038/ajg.2012.219

In this American study, about 8,000 people were screened for coeliac disease; 82% of those with a diagnosis did not previously know they had coeliac disease. Seemingly, 1.6m people in the US follow a wheat-free diet as a lifestyle choice: many of my patients who do this say they feel much better, with more energy and fewer headaches and joint pains.

I believe my patients when they say they feel better. I think we are so primitive in our understanding of how wheat/gluten affects us that over the next few decades, we will discover why gluten seems to make some people ill, even when they do not have endomesial antibodies.

  • Dr Hope is a GP in Woodstock, Oxfordshire, and a member of our team who regularly review the journals.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review the practice protocols on communicating to women the risks of breast cancer when using combined HRT, and how you record this in the patient notes.
  • At the end of your next practice meeting, discuss as a partnership how you can all improve your work/life balance.
  • Audit how many coeliac patients you have in your practice and how many you might expect to have.

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