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Permanente
Abstracts
Abstracts
of Articles Authored
or Coauthored by Permanente Physicians
Selected
by Daphne Plaut, MLS, Librarian, Center for Health Research
From Southern
California:
The relationship of sex to asthma prevalence, health care utilization,
and medications in a large managed care organization.
Schatz
M, Camargo CA Jr. Ann Allergy Asthma Immunol 2003 Dec;91(6):553-8.
background:
Age-related sex differences in asthma hospitalizations and emergency department
(ED) visits have been reported, but relationships of these differences
to disease prevalence and outpatient management have not been defined.
objective:
To define the relationships of sex to asthma-related health care utilization
and medications, accounting for age-related differences in asthma prevalence.
methods:
Computerized data from Southern California Kaiser Permanente were used
to identify asthmatic patients, aged 2 to 64 years, enrolled continuously
during 1999 and 2000. Age-specific asthma prevalence in 1999 was calculated
to identify ages of male or female predominance. Males and females were
compared with regard to asthma-related health care utilization outcomes
(outpatient clinic visits, ED visits, and hospitalizations) and medication
use (beta-agonists, inhaled steroids, and oral steroids). Hospitalizations,
ED visits, and oral steroid use were considered markers of disease severity.
results:
Of the 60,694 subjects, the female-male prevalence ratio was approximately
35:65 at each age between 2 and 13 years, it was inverse (65:35) between
the ages of 23 and 64 years, and prevalences were relatively similar at
the ages of 14 to 22 years. In patients aged 2 to 13 years, most utilization
and medication variables were significantly greater in males (p < .01).
Females aged 14 to 22 years had more outpatient and ED visits and used
more oral steroids than males. In patients aged 23 to 64 years, all utilization
variables were significantly greater in females, except beta-agonist use
and mean inhaled steroid dispensings.
conclusions:
Asthma utilization and severity appear greater in males aged 2 to 13 years,
somewhat greater in females aged 14 to 22 years, and definitely greater
in females aged 23 to 64 years. The mechanisms for these striking sex
differences merit further investigation.
clinical
implication: Asthma is known to be more common in males under age
15 and in females older than age 15. It has been less clear that disease
severity follows the same age distribution, above and beyond the effect
of prevalence. The most important finding in this study is that adult
women experience more severe asthma, even after accounting for prevalence,
management, and other severity factors. Female gender needs to be considered
an independent severity marker in adults and management intensity adjusted
accordingly. MS
From the
Northwest:
Income inequality and pregnancy spacing.
Gold
R, Connell FA, Heagerty P, Bezruchka S, Davis R, Cawthon ML. Soc Sci Med
2004 Sep;59(6):1117-26.
We examined
the relationship between county-level income inequality and pregnancy
spacing in a welfare-recipient cohort in Washington State. We identified
20,028 welfare-recipient women who had at least one birth between July
1, 1992, and December 31, 1999, and followed this cohort from the date
of that first in-study birth until the occurrence of a subsequent pregnancy
or the end of the study period. Income inequality was measured as the
proportion of total county income earned by the wealthiest 10% of households
in that county compared to that earned by the poorest 10%. To measure
the relationship between income inequality and the time-dependent risk
(hazard) of a subsequent pregnancy, we used Cox proportional hazards methods
and adjusted for individual- and county-level covariates. Among women
aged 25 and younger at the time of the index birth, the hazard ratio (HR)
of subsequent pregnancy associated with income inequality was 1.24 (95%
CI: 0.85, 1.80), controlling for individual-level (age, marital status,
education at index birth; race, parity) and community-level variables.
Among women aged 26 or older at the time of the index birth, the adjusted
HR was 2.14 (95% CI: 1.09, 4.18). While income inequality is not the only
community-level feature that may affect health, among women aged 26 or
older at the index birth it appears to be associated with hazard of a
subsequent pregnancy, even after controlling for other factors. These
results support previous findings that income inequality may impact health,
perhaps by influencing health-related behaviors.
Reprinted
from Social Science and Medicine, volume 59, Gold R, Connel FA, Heagerty
P, Bezruchka S, Davis R, Cawthon, ML, Income inequality and pregnancy
spacing, 1117-26, Copyright 2004, with permission from Elsevier.
From the
Northwest:
Cost-effectiveness of a tailored intervention to increase screening in
HMO women overdue for Pap test and mammography services.
Lynch
FL, Whitlock EP, Valanis BG, Smith SK. Prev Med 2004 Apr;38(4):403-11.
background:
Research has established the societal cost-effectiveness of providing
breast and cervical cancer screening to women. Less is known about the
cost of motivating women significantly overdue for services to receive
screening.
methods:
In this intent-to-treat study, a total of 254 women, aged 52-69, who were
overdue for both Pap test and mammography, were randomized to two groups,
a tailored, motivational outreach or usual care. For effectiveness, we
calculated the percent of women who received both services within 14 months
of randomization. We used a comprehensive cost model to estimate total
cost, per-participant cost, and the incremental cost-effectiveness of
delivering the outreach intervention from the health plan perspective.
We also conducted sensitivity analyses around two key parameters, target
population size and level of effectiveness.
results:
Compared with usual care, outreach (p = 0.006) screened significantly
more women. The intervention cost US $167.62 (2000 US dollars) for each
woman randomized to outreach, and incremental cost-effectiveness of outreach
over usual care was US $818 per additional woman screened. Sensitivity
analyses estimated incremental cost-effectiveness between US $19 and US
$90 per additional woman screened.
conclusions:
Larger health plans can likely increase Pap test and mammography services
in this population for a relatively low cost using this outreach intervention.
Reprinted
from Preventive Medicine, volume 38, Lynch FL, Whitlock EP, Valanis BG,
Smith SK, Cost-effectiveness of a tailored intervention to increase screening
in HMO women overdue for Pap test and mammography services, 403-11, Copyright
2004, with permission from Elsevier.
From the
Northern California, Southern California, Northwest, Hawaii, and Colorado:
Reason for late-stage breast cancer: absence of screening or detection,
or breakdown in follow-up?
Taplin
SH, Ichikawa L, Yood MU, et al. J Natl Cancer Inst 2004 Oct 20;96(20):1518-27.
background:
Mammography screening increases the detection of early-stage breast cancers.
Therefore, implementing screening should reduce the percentage of women
who are diagnosed with late-stage disease. However, despite high national
mammography screening rates, late-stage breast cancers still occur, possibly
because of failures in screening implementation.
methods:
Using data from seven health care plans that included 1.5 million women
aged 50 years or older, we conducted retrospective reviews of chart and
automated data for three years before 1995-99 diagnoses of late-stage
(metastatic and/or tumor size 3 cm; case subjects, n = 1347) and early-stage
breast cancers (control subjects, n = 1347). We categorized the earliest
screening mammogram during the period 13-36 months before diagnosis as
none (absence of screening), negative (absence of detection), or positive
(potential breakdown in follow-up). We compared the proportion of case
and control subjects in each category of screening implementation and
estimated the likelihood (odds ratio [OR] with 95% confidence intervals
[CIs]) of late-stage breast cancer. We also evaluated demographic characteristics
associated with absence of screening in women with late-stage disease.
All statistical tests were two-sided.
results:
Absence of screening, absence of detection, and potential breakdown in
follow-up were distributed differently among case (52.1%, 39.5%, and 8.4%,
respectively) and control subjects (34.4%, 56.9%, and 8.8%, respectively)
(p = .03). Among all women, the odds of having late-stage cancer were
higher among women with an absence of screening (OR = 2.17, 95% CI = 1.84
to 2.56; p < .001). Among case patients, women were more likely to
be in the absence-of-screening group if they were aged 75 years or older
(OR = 2.77, 95% CI = 2.10 to 3.65), unmarried (OR = 1.78, 95% CI = 1.41
to 2.24), or without a family history of breast cancer (OR = 1.84, 95%
CI = 1.45 to 2.34). A higher proportion of women from census blocks with
less education (58.5% versus 49.4%; p = .003) or lower median annual income
(54.4% versus 42.9%; p = .004) were in the absence-of-screening category
compared with the proportion for the other two categories combined.
conclusions:
To reduce late-stage breast cancer occurrence, reaching unscreened women,
including elderly, unmarried, low-income, and less-educated women, should
be made a top priority for screening implementation.
Taplin
SH, Ichikawa L, Yood MU, et al. Reason for late-stage breast cancer: absence
of screening or detection, or breakdown in follow-up? Journal of the National
Cancer Institute 2004; 96(20):1518-27, by permission of Oxford University
Press.
clinical
implication: One advantage of integrated health plans like KP is
existence of data such as information enabling us to identify women
who have not had mammography screening for two years. These women can
be reminded to get their mammogram or to come in for a discussion of
mammography with their physician. Our study suggests that such activity
may be the most important one for reducing late-stage cancer and require
less correspondence than sending reminders to all age-eligible women.
Our study also suggests that more should be done to improve radiologist's
interpretations. ST
From Hawaii:
Dairy intake is associated with lower body fat and soda intake with greater
weight in adolescent girls.
Novotny
R, Daida YG, Acharya S, Grove JS, Vogt TM. J Nutr 2004 Aug;134(8):1905-9.
Body fat
and weight of 9- to 14-year-old girls (n = 323) from KP were studied in
relation to age, ethnicity, and physical activity. Mean age, calcium intake,
weight, and iliac skinfold thickness were 11.5 ± 1.4 years, 736.5
± 370.7 mg/d, 44.6 ± 13.0 kg, and 12.4 ± 6.1 mm, respectively.
Multiple regression with age, ethnicity, height, Tanner breast stage,
physical activity, energy, soda, and calcium intake explained 17% of the
variation in iliac skinfold thickness. Calcium intake, age, and physical
activity were significantly negatively associated with iliac skinfold
thickness whereas height, Tanner breast stage, and Pacific Islander ethnicity
were significantly positively associated (p < 0.0001, R(2) = 0.165).
Substituting total calcium with dairy and nondairy calcium in separate
models accounted for 16 and 15% of the variance, respectively (p <
0.0001, both models); 1 mg of total and dairy calcium was significantly
associated with 0.0025 mm (p = 0.01) and 0.0026 mm (p = 0.02) lower iliac
skinfold thickness. Thus, one milk serving was associated with 0.78 mm
iliac skinfold thickness. The interaction of Asian ethnicity and dairy
intake was significant (p = 0.027). Nondairy calcium was not associated
with weight or iliac skinfold thickness. Soda intake was significantly
positively associated with weight in both models (p = 0.01, both models).
Decreasing soda and increasing dairy consumption among Asians may help
maintain body fat and weight during adolescence.
Reprinted
with permission from The American Society for Nutritional Sciences.
clinical
implication: Our study suggests that replacing soda with dairy and
other calcium-rich foods may help prevent overweight, especially of
the midregion of the body, which is known to be important to prevent
chronic diseases. This association was true for adolescents and especially
for Asians and was stronger for dairy than nondairy foods. Potential
for a slim waist provides another reason to recommend calcium and dairy
intake to young people of diverse backgrounds. RN
From Southern
California:
Rates of multiple birth before and after fortification of food with folic
acid, 1994-2000 [abstract].
Lawrence
JM, Watkins M, Chiu V, Erickson JD, Petitti DB. Am J Epidemiol 2004 Jun
1;159(11 Suppl):S86.
background:
Fortification of foods with folic acid (FA) began in 1998. The potential
effect of fortification on rate of multiple births continues to be a source
of concern.
methods:
Women who had a live birth in 11 hospitals of a large managed health care
organization from January 1, 1994 through December 31, 2000 were identified
using the perinatal services system (PSS) database. We ascertained multiple
births and the use of ovulation-inducing drugs (clomiphene citrate and
menotropins) by reviewing computer-stored data. A random sample of medical
records was reviewed to determine whether the use of other assisted reproductive
technologies (ART) had changed during the same period.
results:
There were 224,963 live births during the study period; births per year
ranged from a low of 27,119 in 1994 to a high of 35,408 in 2000. We identified
3035 multiple births for a rate of 1.41 multiple births per 100 live births
during the seven-year study period. The rate of multiple births per 100
live births remained stable over the seven years of the study (1.36, 1.40,
1.44, 1.42, 1.34, 1.41, and 1.48, respectively). When women who had a
prescription for an ovulation-inducing drug filled within 12 months of
the birth (9.6% of the multiple births) were excluded, the overall rate
of multiple birth was 1.27. (1.27, 1.26, 1.32, 1.32, 1.24, 1.24, 1.26,
respectively). Use of ART increased through 1997 but decreased thereafter.
discussion:
This study shows that there is no temporal relationship between the multiple
birth rate and the implementation of food fortification with folic acid
in the United States in this large population-based study.
Lawrence
JM, Watkins M, Chiu V, Erickson JD, Petitti DB. Rates of multiple birth
before and after fortification of food with folic acid, 1994-2000 [abstract],
American Journal of Epidemiology 2004; 159:S86 by permission of Oxford
University Press.
From Southern
California:
Differences in serum folate values at first prenatal visit by race/ethnicity,
vitamin use, and body mass index, 1999-2000 [abstract].
Lawrence
JM, Watkins M, Chiu V, Erickson JD, Petitti DB. Am J Epidemiol 2004 Jun
1;159(11 Suppl):S76.
background:
Fortification of foods with folic acid (FA) began in 1998. The effect
of fortification on folate levels in women in different demographic groups
is of interest.
methods:
Serum folate was quantified using the ADVIA Centaur, Immunoassay System
on 12,526 women entering prenatal care at five KP medical centers from
1999-2000. Information on use of vitamins containing FA, body mass index
(BMI), race/ethnicity, and age was obtained from a survey and from the
infant's birth certificate. Women who used vitamins when they became pregnant
and at the time of first prenatal visit were considered vitamin users;
women who did not use them at either time were considered vitamin non-users.
results:
The median folate value was 19.7 ng/mL in the study population (mean age
28±6 years; range 13-45 years). The median folate value for vitamin
users was 24.0 ng/mL, compared to 16.7 ng/mL for non-users. Among vitamin
non-users, Caucasian women had the highest folate values (median = 17.7
ng/mL). African-American women had the lowest values (median = 15.9 ng/mL).
Values for Hispanic and Asian/Pacific Islander women were intermediate
(median = 16.5 ng/mL). Among vitamin non-users, the median values decreased
slightly as BMI increased (17.4 ng/mL, 16.7 ng/mL, 16.2 ng/mL for average
weight, obese and very obese women respectively), but these differences
are not likely to be clinically significant.
discussion:
Other data show that food fortification with FA has had a significant
impact on serum folate values nationally. This study shows that racial
differences in folate status of women of childbearing age persist.
Lawrence
JM, Watkins M, Chiu V, Erickson JD, Petitti DB, Differences in serum folate
values at first prenatal visit by race/ethnicity, vitamin use, and body
mass index, 1999-2000 [abstract], American Journal of Epidemiology 2004,
159, S76, by permission of Oxford University Press.
From the
Northwest:
Diagnoses and outcomes in cervical cancer screening: a population-based
study.
Insinga
RP, Glass AG, Rush BB. Am J Obstet Gynecol 2004 Jul;191(1):105-13.
objective:
This study was undertaken to examine routine cervical cancer screening
diagnoses and outcomes on an age-specific basis in a US population.
study
design: We conducted an observational cohort study using 1997-2002
health plan administrative and laboratory data for women enrolled at KP
Northwest (Portland, OR) in 1998.
results:
Across all female enrollees (n = 150,052), the annual rate of routine
cervical cancer screening was 294.7 per 1000, with cytologic abnormalities
detected at a rate of 14.9 per 1000. The annual incidence of cervical
intraepithelial neoplasia (CIN) 1 was 1.2 per 1000 with a rate of 1.5
per 1000 for CIN 2/3. CIN 1 incidence peaked among women aged 20 to 24
years (5.1 per 1000), with CIN 2/3 rates highest among those 25 to 29
years (8.1 per 1000). From among 44,493 routine cervical smears, results
were normal for 94.5%, with abnormal diagnoses of atypical squamous cells
(3.3%), atypical glandular cells (0.2%), low-grade squamous intraepithelial
lesion (1.2%), high-grade squamous intraepithelial lesion (0.3%), and
inconclusive/inadequate (0.5%). Of women with abnormal routine smears,
CIN or cancer was detected on follow-up in 19.4% of cases, 51.5% were
found to have had a false-positive smear, and 29.0% incomplete follow-up
as defined by published management guidelines.
conclusion:
These are the first comprehensive age-specific estimates of routine cervical
cancer screening diagnoses and outcomes to be reported within a US general
health care setting. Overall, 5% of routinely screened women were found
to have an abnormal cervical smear with an annual incidence of CIN across
all female enrollees of 2.7 per 1000.
Reprinted
from American Journal of Obstetrics and Gynecology, v191(1), Insinga RP,
Glass AG, Rush BB, Diagnoses and outcomes in cervical cancer screening:
a population-based study, 105-13, Copyright 2004, with permission from
Elsevier.
clinical
implication: Approximately 1 in 20 women receiving routine cervical
cancer screening will require follow-up for an abnormal Pap smear. The
widespread adoption of Pap screening has been successful in reducing
the incidence of cervical cancer in the US. However, this study also
suggests that opportunities exist for improving the quality and efficiency
of patient management, such as by reducing the number of women with
an abnormal smear who have incomplete follow-up and by decreasing Pap
screening among women over the age of 65 who are at low risk for cervical
cancer. RI
From Colorado,
Georgia and Northwest:
Prescription drug use in pregnancy.
Andrade
SE, Gurwitz JH, Davis RL, et al. Am J Obstet Gynecol 2004 Aug;191(2):398-407.
objective:
The purpose of this study was to provide information on the prevalence
of the use of prescription drugs among pregnant women in the United States.
study
design: A retrospective study was conducted with the use of the automated
databases of eight health maintenance organizations that are involved
in the Health Maintenance Research Network Center for Education and Research
on Therapeutics. Women who delivered of an infant in a hospital from January
1, 1996, through December 31, 2000, were identified. Prescription drug
use according to therapeutic class and the United States Food and Drug
Administration risk classification system was evaluated, with the assumption
of a gestational duration of 270 days, with three 90-day trimesters of
pregnancy, and with a 90-day period before pregnancy. Nonprescription
drug use was not assessed.
results:
During the period 1996 through 2000, 152,531 deliveries were identified
that met the criteria for study. For 98,182 deliveries (64%), a drug other
than a vitamin or mineral supplement was prescribed in the 270 days before
delivery: 3595 women (2.4%) received a drug from category A; 76,292 women
(50.0%) received a drug from category B; 57,604 women (37.8%) received
a drug from category C; 7333 women (4.8%) received a drug from category
D, and 6976 women (4.6%) received a drug from category X of the United
States Food and Drug Administration risk classification system. Overall,
5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received
a category X drug after the initial prenatal care visit.
conclusion:
Our finding that almost one half of all pregnant women received prescription
drugs from categories C, D, or X of the United States Food and Drug Administration
risk classification system highlights the importance of the need to understand
the effects of these medications on the developing fetus and on the pregnant
woman.
Reprinted
from American Journal of Obstetrics and Gynecology, v191(2), Andrade SE,
Gurwitz JH, Davis RL, et al. Prescription drug use in pregnancy, 398-407,
Copyright 2004, with permission from Elsevier.
10th Annual HMO Research Network Conference
Abstracts
from the HMO Research Network
In the Fall
2004 issue, we published the first abstract from the HMO Research Network
annual meeting in May 2004. In this issue we present several more. I believe
publishing these abstracts creates an opportunity for Permanente physicians
and clinicians to learn from the research findings in like integrated
groups and health systems from other parts of the country. We will continue
to share this important research in future issues.
--Tom Janisse, MD, Editor-In-Chief
May 3-5,
2004 Dearborn, MI
Evaluating Care Delivery
From: HealthPartners
Research Foundation
Screening clinical breast examination sensitivity, specificity, and predictors
of accuracy.
Rolnick
SJ, Fenton JJ, Elmore JG on behalf of the CRN PROTECTS Group.
background:
Although many US women receive regular screening clinical breast examination
(CBE), the accuracy of CBE in the community setting remains uncertain.
methods:
We determined the accuracy of CBE among asymptomatic female health
plan enrollees in five states (WA, OR, CA, MA, and MN). Among women who
received a screening CBE within one year of breast cancer diagnosis and
who subsequently died of breast cancer (N = 485), sensitivity was estimated
as the proportion of women whose most recent CBE was abnormal. Among women
without a breast cancer diagnosis in the year following a screening CBE
(N = 1427), specificity was estimated as the proportion whose screening
CBE was normal. Bivariate and logistic regression analyses identified
patient characteristics associated with CBE accuracy.
results:
Among women who subsequently died of breast cancer, the sensitivity
of screening CBE was 21.6% (95% CI: 18.1%, 25.6%). Decreased sensitivity
was associated with: estrogen use at the time of CBE (OR 0.23; CI = 0.07-0.80)
and concurrent receipt of a Pap smear (OR 0.45; CI = 0.27-0.72). There
were non-significant trends toward decreased sensitivity among women with
a family history of breast cancer and increasing chronic disease comorbidity.
Specificity of screening CBE was 98.6% (95% CI = 97.8%, 99.0%). Both a
family history of breast cancer (OR: 0.31, CI = 0.13, 0.78) and history
of breast biopsy (OR 0.22, CI = 0.09, 0.55) were independently associated
with decreased specificity.
conclusions:
Screening CBE provided in the community is less sensitive but more specific
than in clinical trials of breast cancer screening.
From: The
Henry Ford Health System
Hormone replacement therapy utilization pre- and post- women's health
initiative HRT trial termination.
Wegienka
G, Havstad S.
background:
In July 2002, the Women's Health Initiative Study published their conclusions
that led to the early termination of the hormone replacement therapy (HRT)
trial of estrogen plus progestin in postmenopausal women with an intact
uterus. In JAMA, they reported an increased risk of breast cancer,
but also a decreased risk of osteoporosis. While the findings were headline
news across the nation, it is not clear whether they impacted clinical
practice or the health behavior of women.
methods:
Using claims data from 15,493 women ages 50-79 continuously enrolled in
the Health Alliance Plan HMO from January 2001 through November 2003,
we examined the counts of HRT prescriptions filled by this fixed cohort
in the 18 months before and after the WHI results were published. Using
the claims data, we were not able to determine whether each woman had
an intact uterus or their exact menopausal status.
results:
Overall, the number of HRT prescriptions filled decreased over time. However,
in the months immediately after July 2002, there was a steep drop in the
number of HRT prescriptions filled by the fixed cohort. In January 2001,
2320 HRT scripts were filled, 1973 in June 2002, 1837 in July 2002, 1617
in August 2002, 1467 in September 2002 and 742 in November 2003. The number
of new HRT users increased through the first half of 2002 and dropped
continuously after peaking in June 2002. The patterns observed were similar
for the most commonly filled prescription, Premarin (estrogen plus progestin/Wyeth-Ayerst),
and all other HRT medications.
conclusions:
It appears that the publication of the WHI results and their subsequent
discussion in the press affected the use of HRT in our study population.
It is not clear whether the women, their clinicians, or both were the
driving forces behind this reaction. However, the symptoms of menopause,
such as hot flashes, sleeplessness and bone loss, can be disabling, while
some women have no symptoms. Future research should study the appropriateness
of HRT given the different circumstances women may encounter with menopause.
From: HealthPartners
Research Foundation
Women and hormone use in the light of new evidence.
Rolnick
S, Kopher R, Kelley M.
background:
Prior to the findings of the Women's Health Initiative (WHI), it was
believed that hormone therapy (HT) provided numerous health benefits.
With WHI, however, considerable doubt was raised regarding prior assumptions.
To better understand what women who were using HT are doing and thinking
in the light of recent findings, we conducted a survey. Its purpose was
to assess HT usage (maintenance, discontinuation or change), health behaviors,
symptom control and overall concerns.
methods:
Women who had a prescription for HT (PremPro or FemHTR) between 1/1/2002
and 6/30/2002 were identified through pharmacy records and stratified
by duration of hormone use (recent users [<1 year], women with 1-5
years of use and long-term users [>5 years]). A random sample of 10%
from each stratum was selected for a total of 1200 subjects. Surveys were
mailed with questions on hormone use, awareness of study findings, changes
in medication use or health behaviors, what influenced changes, symptoms,
use of alternative medications and overall concerns.
results:
The response rate was 70%. Of these, 69% claimed they discontinued HT.
The main reasons stated for starting HT were symptom relief (70%), and
bone health (46%). Many women (35%) did not consider how long they would
take hormones. However of those that did, only 21% thought it would be
short term. Most assumed they would continue on HT "as long as they
felt okay." When asked how they learned of the new study findings,
twice as many cited television and magazines than their health plan. Only
19% claimed to make no changes, others discontinued, stopped then restarted,
or changed their HT. Minimal change was reported in use of alternative
medications or in lifestyle.
conclusions:
Women appear to be heeding the warnings and taking initiative for changes
regarding HT, rather than being encouraged at the initiation of their
providers. They are concerned about current symptom control and also if
past usage puts them at risk for future health problems.
From: Kaiser
Permanente Southern California and Harvard Pilgrim Health Care
Procedures and complications after bilateral prophylactic mastectomy.
West
CN, Barton MB, Liu AI, Geiger AM for the Cancer Research Network PROTECTS
Group; Southern California Permanente Medical Group, Pasadena, CA: Harvard
Pilgrim Health Care, Boston, MA.
background:
While highly efficacious, little is known about the complications
or subsequent procedures needed to rectify complications or cosmetic problems
after bilateral prophylactic mastectomy. Complications and procedures
occurring after bilateral prophylactic mastectomy were the focus of the
study.
methods:
We used automated hospitalization and cancer registry records to identify
women who underwent bilateral mastectomy without breast cancer at one
of six health maintenance organizations between 1979 and 1999. Confirmation
of bilateral mastectomies being done for prophylactic reasons, identification
of the timing of initial reconstruction and ascertaining complications
and subsequent procedures were done by structured medical record review.
results:
During the study period, 270 women underwent bilateral prophylactic
mastectomy. Median age of women at surgery was 44 years (range 23 to 74)
and the majority (90%) were Caucasian. The majority of women (179, 66%)
had simultaneous reconstruction but 36 (13%) had delayed reconstruction
and 55 (20%) had none. After bilateral prophylactic mastectomy 466 complications
occurred in 171 (63%) women, with a median of two per woman (range 1 to
13). More than half (55%) required repair, including excessive scarring
and implant leakage or rupture. About a third (167, 36%) were temporary,
including hematoma, hemorrhage and infection. The remaining 42 (9%) complications
were permanent or psychological, including lymphedema and depression.
A total of 822 subsequent procedures were performed in 167 (62%) women,
with a median of four per woman (range 1 to 22) and the majority (766,
93%) were cosmetic in nature. Complications and subsequent procedures
were less common in women with no reconstruction (c square p = 0.067 and
p < 0.001, respectively) but occurred in nearly identical proportions
among women with simultaneous or delayed reconstruction (c square p =
0.764 and p = 0.958, respectively).
conclusions:
Women undergoing bilateral prophylactic mastectomy may experience
a range of complications and after reconstruction additional procedures
may be required. The risks and the potential benefits of bilateral prophylactic
mastectomy need to be weighed by women and their physicians.
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