Journal's watch: Breast cancer, migraine and Down's syndrome

A review of this week's research impacting primary care. By GP Dr Louise Newson

Study could not provide evidence that HRT causes breast cancer (Photograph: SPL)
Study could not provide evidence that HRT causes breast cancer (Photograph: SPL)

No definitive evidence that HRT causes breast cancer
J Fam Plann Reprod Health Care 2012; 38: 102-9

Many women and healthcare professionals are reticent to take or prescribe HRT in view of the possible increased risk of developing breast cancer. This analysis looked at the evidence for HRT (estrogen and progestogen and also unopposed estrogen treatment) causing breast cancer in the Million Women Study (MWS).

The researchers found that despite the massive size of the MWS, the findings for both types of HRT did not adequately satisfy the criteria of time order, information bias, detection bias, confounding, statistical stability and strength of association, duration-response, internal consistency, external consistency or biological plausibility.

The conclusion of this study was that HRT may or may not increase the risk of breast cancer, but the MWS did not establish that it does.

MI risk raised among elderly antipsychotic users
Arch Intern Med 2012; doi:10.1001/archinternmed. 2012.28

It is well accepted that there is an increased risk of cardiovascular disease in elderly patients with dementia who receive antipsychotic medication.

This study looked at patients aged over 66 years with dementia who were receiving a cholinesterase inhibitor. From this cohort, new antipsychotic users were matched with a random sample of non-users.

Their results found that within one year of initiating antipsychotic treatment, 1.3% of antipsychotic users experienced incident MI.

The risk of MI was greatest in those who had most recently been prescribed antipsychotic medication. Antipsychotic users had a 2.19-fold increased risk for MI at 30 days compared with a 1.15-fold increased risk at one year.

It is possible that the increased risk of MI could be increased by the agitation, aggressiveness or potentially exhausting motor behaviours associated with their condition.

However, we should be limiting our prescribing of antipsychotic drugs to dementia patients and instead use other techniques.

Cardiovascular anomalies in Down's syndrome
Arch Dis Child 2012; 97: 326-30

Although the prevalence of cardiovascular anomalies in Down's syndrome is well described, there is a lack of data on spectrum, management and outcome. This study from Newcastle was undertaken to provide this information for infants with Down's syndrome in a defined population over a 22-year period.

The authors found that 42% of infants with Down's syndrome had a cardiovascular anomaly. The most common anomaly was complete atrioventricular septal defect.

Reassuringly, there was found to be a significant reduction in postoperative mortality and improvement in one-year survival in these patients. The one-year survival in Down's syndrome patients with a cardiovascular anomaly improved from 82% in 1985-1995 to 94% in 1996-2006.

This is likely to continue to improve as advances continue to be made in surgical techniques.

Telephone intervention and bisphosphonates compliance
Arch Intern Med 2012; 172: 477-83

Many patients are not keen on taking bisphosphonates and I wonder how good (or bad) their compliance with these medications is.

This study examined the effectiveness of a telephone-based counselling programme designed to improve patients' adherence to a medication regimen for osteoporosis.

An RCT was undertaken involving patients who had recently been prescribed medication for osteoporosis.

They were randomised to either telephone-based counselling using a motivational interviewing framework or a control group that received mailed educational materials.

The results found that there was no statistically significant improvement in compliance between the two patient groups.

Improving mobility in patients with type 2 diabetes
N Engl J Med 2012; 366: 1209-17

Many patients with type 2 diabetes mellitus have limitations in mobility. This study randomly assigned more than 5,000 overweight or obese adults between the ages of 45 and 74 years with type 2 diabetes to either an intensive lifestyle intervention or a diabetes support and education programme.

The primary outcome of this study was self-reported limitation in mobility, with annual assessments for four years.

Their results demonstrated that weight loss and improved fitness slowed the decline in mobility in overweight adults with type 2 diabetes. However, it should be noted that around one in five patients (20.6%) in the lifestyle intervention group had severe disability after four years. This compares with 26.6% in the support group.

This is a US study, so it may be these figures are higher than in the UK. However, this is yet another reason to encourage overweight, unfit patients with type 2 diabetes to lose weight and improve their fitness.

A potential new treatment for migraines
Lancet 2012; doi:10.1016/S1474-4422(12)70047-9

5-HT is implicated in the aetiology of migraine as well as many other diseases, including depression and obsessive compulsive disorder. Lasmiditan is a new, centrally acting, highly selective 5-HT1F receptor agonist without vasoconstrictor activity. Its efficacy and safety have been assessed in this trial when given for the acute treatment of migraine.

It was given to patients with migraine with and without aura and who were not taking prophylactic medication.

The results showed that oral lasmiditan seemed to be safe and effective in the acute treatment of migraine. The authors recommend that further assessment in larger placebo-controlled and triptan-controlled trials is needed to determine the potential role of lasmiditan in acute migraine therapy.

  • Dr Newson is a GP in the West Midlands and a member of our team who regularly review the journals

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

  • Arrange a meeting with a local HRT expert to discuss their views about the risk of breast cancer in women taking HRT.
  • Undergo a search of your patients who are being prescribed a bisphosphonate. Find out how many of them are not requesting enough medication in a given period, which may suggest there are compliance problems.
  • Perform a search of your patients with dementia who are taking a cholinesterase inhibitor. Ensure that none of these patients has also been prescribed an antipsychotic medication.


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