Journals watch: Hip replacements, HRT and cardiac arrest

Too busy to read all of the research? Dr Raj Thakkar selects some papers of interest to GPs.

Artificial hip joint: 90 day mortality risk fell during eight-year study period

Mortality following total hip replacement for osteoarthritis

Lancet 2013; 382(9898): 1097-1104

Although deaths after hip surgery for osteoarthritis (OA) are rare, it is important to review the deaths that have occurred in case there are lessons to be learned.

This study looked at 409,096 operations for OA of the hip between 2003 and 2011. In that period, 1,743 patients died within 90 days of their operation.

Mortality risk fell over the study period. This was attributed to some simple clinical management strategies: a posterior surgical approach, thromboembolic risk mitigation (mechanical and chemical) and spinal surgery. Perhaps every unit should adopt this approach.

Health outcomes in women taking HRT in the menopause

JAMA 2013; 310(13): 1353-68

It is probably fair to say that there is confusion about the safety of HRT. Advising patients has not been easy and a consensus is needed. This publication reviewed patients from the Women's Health Initiative trials.

More than 27,000 women were involved in the study. Women with an intact uterus received estrogens plus medroxyprogesterone acetate. Others did not require medroxyprogesterone due to hysterectomy and received estrogen alone.

The women received combination HRT for an average of 5.6 years or estrogen only for 7.2 years.

In patients with combination HRT, there was no statistically increased risk of CHD, although there was a small but increased risk of developing breast cancer. The risk of breast cancer continued after HRT had been discontinued.

The researchers also stated there was an increased risk of stroke, pulmonary embolism, dementia, gall bladder disease and urinary incontinence, but a reduction in osteoporosis and diabetes risk.

The risk of CHD and breast cancer was not significant in women who required estrogen only. Interestingly, all-cause mortality was not influenced by combined or estrogen-only HRT.

The results for quality of life and all-cause mortality are variable and age-dependent in some cases.

The study concludes that HRT is not effective enough to be used for disease prevention and should be used for symptom control only. Care should be taken where breast cancer is of concern.

Bystander intervention in cardiac arrest management

JAMA 2013; 310(13): 1377-84

This study in Denmark reviewed nearly 20,000 cardiac arrests between 2001 and 2010 considered to have a cardiac cause and not witnessed by medical personnel.

They learned that most cardiac arrests occurred in men. The chance of a bystander intervening with CPR increased over the study period (21% in 2001 and 45% in 2010). This may have accounted for the increase in one-year survival in these patients from 3% in 2001 to 10% in 2010.

Bystander defibrillation did not increase over the study period, which may be explained by the availability of equipment and training.

This is another clear indication that educating the public to take responsibility for health is critical in achieving better outcomes.

Planned caesarean section or vaginal delivery for twins

N Engl J Med 2013; 369:1295-1305

Patients often ask questions we cannot answer because the evidence is not available. One relates to twin pregnancy and whether caesarean section is safer than vaginal delivery.

This study included women with the presenting twin in cephalic position and randomised them to caesarean section or vaginal delivery. More than 2,800 women were included.

There was no significant difference in neonatal adverse outcomes between the two groups. As expected, a significant number of women in the vaginal delivery arm eventually delivered by caesarean section.

Coffee drinking and all-cause and cardiovascular disease mortality

Mayo Clin Proc 2013; 889(10): 1066-74

Cardiovascular disease prevention is high on the agenda, not only to protect patients, but also to protect the future health economy.

Hypertension, smoking, cholesterol, diabetes and obesity are classic risk factors; however, the search for novel risk factors is critical.

This massive longitudinal study aimed to find out if coffee consumption related to mortality risk.

Bad news for coffee lovers - the study concluded that consumption of more than 28 cups a week raised all-cause mortality in females and in males below the age of 55.

Of course there could be confounders that were not considered in the study, but either way, if you or your patients drink a lot of coffee because you need or like it, perhaps it would be best to review your intake.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, 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 your local orthopaedic unit to understand the measures they are taking to reduce mortality risk.
  • Consider if you are up-to-date with HRT prescribing. Update your knowledge of different preparations and at-risk groups.
  • Organise a roadshow for your patients on cardiovascular disease, including how to manage the collapsed patient.

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

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