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MD-FM Thursday March 13 , 2014



Sarah:

MD-FM, the latest medical news from around the world. Here’s Peter Goodwin.

 

 

P1:  Androgen deprivation therapy: no survival benefit in early prostate cancer

 

PETER:

Hello, first: for patients with early prostate cancer the idea that hormone therapy could be used instead of watchful waiting has not been supported by the facts.  And that’s even though randomised trials have shown that when it’s given as adjuvant therapy for locally advanced disease, it improves survival. Sarah Maxwell is here with me.  What’s the latest on this then?

 

SARAH:

Well, according to a study, reported in the Journal of Clinical Oncology, a group in the USA looked at 15 000 patients and found no survival advantage in those who opted for androgen deprivation therapy rather than watchful waiting.  They didn’t look at quality of life but it’s important to remember that ADT has quite a number of side effects, and, of course, it has a price-tag..

 

PETER

Yes, principal author Arnold Potosky from Georgetown University in Washington DC said they found no benefit from Androgen Deprivation as a whole as primary therapy.  But they looked at sub-groups within their cohort:

 

POTOSKY:

“We did find a slightly decreased risk in the sub group of men who were diagnosed with so called high risk clinically localised prostate cancer, in other words these were men at a higher risk of progression based on their baseline factors such as stage and PSA and their Gleason score, which is a measure of their histology. So in that group we found a small benefit with a hazard ratio of 0.88. So that’s a pretty small benefit, but it was statistically significant.”

 

SARAH:

Dr Potosky thought the question of balancing the potential harm of ADT with these small survival benefits needs to be looked at, but that for now, the message seems to be clear: 

 

POTOSKY:

“Even in the subgroup with high risk disease the benefit that we found, while significant statistically, was relatively small.  Therefore I think the bottom line is that any benefit that we found should be weighed against the existing evidence from other studies that show an increased risk of these serious side effects from ADT.” 

 

SARAH:

Dr Arnold Potosky from Washington DC.

 

We turned to consultant urologist Dr Keith Kowalczyk who did not participate in the trial, for his take on the clinical implications of the study:

 

KOWALCZYK

“It reaffirms that it is safe just to do active surveillance or watchful waiting in patients that have low risk prostate cancer, that you don’t have to give them androgen deprivation therapy just to say: well at least we’re doing something!  Some patients may see it as just a shot every three months, and what’s so harmful about that? The fact is: its very harmful. It can be harmful to your bone health to your heart health. On the other hand it does help patients at high risk of prostate cancer and that was shown in this study”

 

SARAH

Keith Kowalczyk from Georgetown University Health Centre in Washington DC.



P2: Endoscopic resection safe and effective for mucosal adenocarcinoma of the esophagus           

 

PETER:

There might soon be guidelines for using endoscopic resection to treat patients who have mucosal adenocarcinoma of the esophagus, judging from data published in the journal: Gastroenterology. In a large study from Germany 1000 patients with Barrett’s Esophagus, who had their diagnoses narrowed down to non-invasive adenocarcinoma, were treated with endoscopic resection. There was a 96 per cent complete remission rate and three quarters of the patients lived for 10 years with few complications. The authors conclude that endoscopic therapy is highly effective and safe.



P3: Pregnancy: at risk from un-encapsulated haemophilus influenzae 

 

PETER:

Pregnant women are almost 20 times more likely to become infected with a strain of the bacterium Haemophilus influenzae, compared to non-pregnant women, and the infection is associated with poor pregnancy outcomes…

 

SARAH:

Yes, un-encapsulated haemophilus influenzae infection, although rare, poses a serious threat to mothers and their babies. That’s according to a large surveillance study carried out in England and Wales, reported in JAMA, which further backs up previous study findings. It gathered information on all cases of the infection in women of childbearing age between 2009 and 2012 and found that even though the women had no other medical problems, just the fact they were pregnant put them at an increased risk. Study author Shamez Ladhani:

 

LADHANI:

“What hadn’t been reported before is actually, nearly all the pregnant women when they got the infection ended their pregnancy. So if that happened in the first half of the pregnancy, then that resulted in miscarriage. And then if it happened in the second half of their pregnancy, most of them were either born very prematurely and then had all the complications of prematurity, or were stillbirth and very few were born on time, because the women got the infection when the baby was nearly born.”

 

SARAH:

Dr Shamez Ladhani of Public Health England.

 

PETER:

Hmm, these findings are intriguing but there are still a lot of questions aren’t there…

 

SARAH:

Indeed, and Dr Ladhani stressed that more awareness and information is still needed to understand why this bacterium, which normally only causes respiratory tract infections, is ending up causing very serious illness in mothers and newborn babies.

 

And Morven Edwards, who wrote an accompanying editorial, said the findings are provocative. Un-encapsulated haemophilus influenzae hasn’t previously been considered a hazard to pregnancy outcomes, and she had this recommendation for practitioners:

 

EDWARDS:

“If there’s a threatened pregnancy loss, a blood culture should be taken, particularly if the woman is febrile, and a laboratory should be alerted to do cultures that optimise isolation of this bacteria to see if the findings are replicated in other global areas. This may be a widespread finding that we just did not properly document, so ongoing investigation at other sites is certainly indicated.”

 

SARAH:

That was Morven Edwards, professor of pediatrics at Baylor College of Medicine in Houston, Texas.

 


P4:  Aortic aneurysms: trans-atlantic outcome differences 

 

PETER:

For patients with ruptured abdominal aortic aneurysms, a study has compared practice between the USA and England…

 

SARAH:

That’s right, the study, published in the Lancet, looked at data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA, comparing patients between 2005 and 2010…

 

PETER:

So, how did practice appear to differ between these two countries then?

 

SARAH:

Well, in-hospital mortality was actually lower in the states than in England. Meanwhile, intervention rates and uptake of endovascular repair are lower in the UK than in the USA.

 

PETER:

And these are quite large patient numbers we’re talking about here aren’t they?

 

SARAH:

That’s right, nearly 12,000 patients with rAAA in England and nearly 24,000 in the USA.

 

PETER:

But, there were some similarities weren’t there…

 

SARAH:

Yes, the lowest mortalities for ruptured abdominal aortic aneurysm were in teaching hospitals with greater bed capacity and greater proportions of cases with endovascular repair and that was for both countries. Which all goes to show, that centres of excellent are paramount in this branch of medicine.




P5: Hemicraniectomy in older patients increased survival without severe disability  

 

PETER:

For older patients with malignant middle-cerebral-artery infarction, hemicraniectomy increased survival without severe disability, according to a randomised study looking at 13 centres across Germany, reported in the New England Journal of Medicine

 

SARAH:

Yes, 112 patients aged 60 years and older were assigned to either: conservative treatment in an intensive care unit or surgical treatment. Previous pooled analysis looking at younger patients had shown, surgery had a significant survival benefit. In this study, hemicraniectomy decreased mortality from about 70% to 33% at six months.

 

PETER:

Sounds encouraging for such a devastating disease. So what about the rates of disability then?

 

SARAH:

Well, 38% of the patients who had surgery survived without a severe disability versus 18% in the control group and the authors say this is regarded as acceptable:

 

UNTERBERG:

“If you ask these patients later on about their consent to the trial, more than 70% of patients and relatives say they would again participate in the trial and they accept the result of the treatment.” ‘15secs

 

SARAH:

That was lead study author professor Andreas Unterberg from Heidelberg University.

 

PETER:

So, what are the recommendations now then for these patients? Because despite the mortality benefit, survivors do still need some assistance with their daily bodily needs don’t they…

 

SARAH:

Yes, and professor Unterberg stressed that doctors need to communicate with patients and their relatives and caregivers alike:

 

UNTERBERG:

“You can talk to them and say well, we can at least reduce mortality by half, on the other hand, please also keep in mind that your disability may be significant. This is a concern and this has to be discussed with patients and the families and caregivers and whatsoever.” 

 

SARAH:

Andreas Unterberg from Germany.



B1: Children with glomerular kidney disease more likely to have hypertension as adults

 

PETER:

Finally, in brief:

Men who had glomerular disease when they were children were found to face double the risk of hypertension later in life in a study from Israel of 38 000 healthy young men published in JAMA. Even though their kidney disease had been completely resolved in childhood, it continued to have a long term effect, bringing a 13.6 per cent additional risk of hypertension, which the authors believe could be the result of kidney injury initiated during the childhood illness, and an early warning, perhaps, of further kidney disease to come.



And...

 

B2: Metabolomic biomarkers in serum and urine in women with preeclampsia

 

Predicting pre-eclampsia, now.  A set of biomarkers in blood and urine have been identified which are different in women who have pre-eclampsia as compared with those who don’t, and different again from women who are not pregnant.  The authors, from Norway, found biomarker abnormalities similar to those in cardiovascular and inflammatory diseases. They conclude that the observed differences could potentially help detect underlying preeclampsia phenotypes in urine and serum samples early, before they can go on to harm expectant mothers and their babies.

 

 

That’s all from MD-FM for now.  Sarah Maxwell and I will be back next week with more, so until then, from me Peter Goodwin, Good-bye.

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