Journals Watch - Thyroid cancer, pre-eclampsia and mammography

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

Thyroid cancer: lower-dose radioiodine therapy was investigated (Photograph: SPL)
Thyroid cancer: lower-dose radioiodine therapy was investigated (Photograph: SPL)

Low-dose radioiodine in thyroid cancer
N Engl J Med 2012; 366: 1674-85
The incidence of thyroid cancer has tripled from 2.7 to 7.7 per 100,000 cases in the past 40 years. This may be due to better detection of low-risk cancers by modern imaging.

The standard treatment is high-dose radioiodine (3.7GBq (100mCi)) after total thyroidectomy.

This research group asked if lower-dose radioiodine (1.1GBq (30mCi)) might be equally as effective, either with recombinant human thyrotropin (thyrotropin alfa) or thyroid hormone withdrawal. In more than 420 patients treated, ablation success rates were similar with high-dose radioiodine at 88.9% and low-dose radioiodine at 85%.

The proportion of patients with adverse events was 33% in the high-dose group and 21% in the low-dose group.

The conclusion is that low-dose radioiodine is as effective as high dose, but with fewer side-effects.

Are maternal deaths from pre-eclampsia avoidable?
Lancet 2012; 379: 1686-7

The huge strides in the developed world towards improved mortality and morbidity for childbirth over the past 100 years mean that fortunately, maternal death is an extremely rare event.

The UK triennial report of the Confidential Enquiries into Maternal Deaths found that 20 of 22 deaths relating to pre-eclampsia involved substandard care.

What this paper points out is that of these women, 63% fell into the category of 'major substandard care'. These deaths were described as 'undoubtedly avoidable'. This paper is a blunt reminder that we can all do better: constant vigilance in detecting pre- eclampsia is needed in primary care, with immediate referral to specialist secondary services.

The third stage of labour and controlled cord traction
Lancet 2012; 379: 1721-7

Active management of the third stage of labour involves a prophylactic uterotonic (oxytocin), early cord clamping and controlled cord traction to deliver the placenta. The idea is that this reduces postpartum haemorrhage (>1,000ml blood loss).

In a multicentre trial, women were randomised to standard active management (oxytocin plus cord clamping plus cord traction) or a simplified package (oxytocin plus cord clamping only; no traction). Midwives were also allowed to perform uterine massage.

Although the study did not prove that the simplified management was not inferior, stopping cord traction had little effect on the risk of severe haemorrhage (trial endpoint risk of severe haemorrhage was 1.09 for the simplified package).

There was one case of uterine inversion in the full active management group. The authors concluded that it is the oxytocin that is life saving, and in the developing world this is the action that will save maternal lives.

Transcatheter or surgical aortic valve replacement
N Engl J Med 2012; 366: 1686-95

Transcatheter aortic valve replacement (TAVR) has been hailed as a safer method for valve replacement. But is it?

In this Harvard study, the death rates were 33.9% in the TAVR group and 35% in the surgery group at two years. At 30 days, strokes were more frequent with TAVR than with surgical replacement (4.6% versus 2.4%, p = 0.12).

Paravalvular regurgitation was more frequent after TAVR (p <0.001), and even mild paravalvular regurgitation was associated with increased late mortality (p <0.001). So reading this study at present, it is slightly safer to stick to conventional open-heart surgery.

Postnatal contraception in HIV-positive women
J Fam Plann Reprod Health Care 2012 doi:10.1136/jfprhc- 2011-100220

Traditionally, after giving birth all women have an in-depth discussion about contraceptive options at their postnatal check.

In 26 years of general practice I have seen three women come to the six-week postnatal check pregnant again. I changed my practice and now go through contraceptive choices at the first home visit.

With HIV-seropositive women the need for effective contraception to prevent an unwanted pregnancy and minimise transmission to possible HIV-negative partners is essential. This clinic in Berkshire looked at women with HIV who had received postnatal care from it.

A total of 20% of women did not return to the clinic post-partum for contraceptive advice. Of the 80% who did come back, all were advised to use condoms and a high percentage wanted a second contraceptive option in addition; 26% chose a depot contraceptive, 27% chose an intrauterine contraceptive, 12% had been sterilised at caesarean section, one chose an implant and 7% opted for the combined oral contraceptive pill.

With HIV-positive patients we must ascertain their knowledge of barrier methods and offer additional contraception as appropriate.

Screening mammography at 40 years of age
Ann Intern Med 2012; 156: 609-17

I always thought that mammography was designed for the postmenopausal breast, which is why screening in the UK starts at the age of 50 years, although an extension of the breast screening programme has begun and full roll-out to women aged 47-49 years and 71-73 years is expected to be completed after 2016.

This model from Harvard Medical School was looking at false-positive findings/life-years gained in the standard biennial screening for US women aged 50-74 years, and found that women aged 40-49 with a twofold increased risk of breast cancer would have the same harm/benefit ratio as an average woman in the standard US screening programme.

The harm/benefit ratio for film mammography is better than digital mammography because film has a lower false-positive rate.

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

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

  • Consider presenting or organising a quick update on spotting pre-eclampsia and its management for your practice, including the receptionists, so they understand how to manage a telephone call about this.
  • Consider reviewing your past year's postpartum patients and see how many did not come to a postnatal check to discuss contraception.
  • Review the guidance on managing women who are at high risk of breast cancer.

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