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Harms and benefits of estrogen therapy among women with a hysterectomy appear to depend on age when

Embargoed news from Annals of Internal Medicine

American College of Physicians

1. Harms and benefits of estrogen therapy among women with a hysterectomy appear to depend on age when therapy was started and whether women still had their ovaries

Patients who started estrogen over the age of 60 did not derive a mortality benefit and experienced more adverse effects particularly among those 70 and older, regardless of whether they had their ovaries removed

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0274
Patient Summary: http://annals.org/aim/article/doi/10.7326/P19-0011
URLs go live when the embargo lifts

While no statistically significant benefit was seen in the initial study average follow-up period of 7 years, women in their 50s who had a hysterectomy and their ovaries removed appear to experience a mortality benefit from estrogen therapy during long-term follow-up (average of 18 years) and did not seem to have harmful health effects. The same was not true for women who started estrogen therapy in their 60s or 70s, whether or not they still had their ovaries. Findings from a randomized double-blind trial are published in Annals of Internal Medicine.

About one third to one half of women who undergo hysterectomy also have their ovaries removed (a procedure called bilateral salpingo-oophorectomy) at the same time to reduce their risk for ovarian cancer in the future. These procedures lead to early menopause and loss of estrogen, which is associated with other health risks. This is the first study to assess, in a randomized trial setting, whether health outcomes of menopausal estrogen therapy differ between women with or without their ovaries.

In a study led by researchers at Brigham and Women's Hospital, Harvard Medical School, 9,939 women aged 50 to 79 years with prior hysterectomy were included to examine whether estrogen therapy outcomes differed by whether or not the participants' ovaries were also removed. They also assessed whether the effect was different based on the age at which the women began estrogen therapy. Women were randomly assigned to receive estrogen hormone supplements or placebo pills and the researchers documented whether women developed heart disease, breast cancer, or death from any cause, among other measures. They found that menopausal estrogen-alone therapy for a median of 7.2 years was associated with reduced mortality over the long-term (18 years) and had a generally favorable safety profile when initiated before the age of 60 in women who had their ovaries removed. Whether or not their ovaries were intact, older women did not derive this benefit. Women who had their ovaries removed and were above age 70 experienced adverse effects of treatment.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the corresponding author, JoAnn E. Manson, MD, Dr.PH, please contact Haley Bridger at hbridger@bwh.harvard.edu or Elaine St. Peter estpeter@bwh.harvard.edu.

2. For poor Americans, living in a more affluent area is associated with better health

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2800
URLs go live when the embargo lifts

Low-income, older adults living in more affluent areas of the country have lower prevalence of most diseases and chronic conditions, suggesting that geography matters for the poor. Findings from a cross-sectional study are published in Annals of Internal Medicine.

Recent studies have found that there are substantial differences in life expectancy and in causes of death across U.S. geographic regions, even after accounting for differences in age, sex, and racial composition. Researchers have documented that poor adults living in more affluent areas have higher life expectancies. Less is known about the relationship between the affluence of a geographic area and morbidity of the low-income population there.

Researchers from Stanford University School of Medicine studied more than 6 million Medicare beneficiaries with a history of low-income support under Medicare Part D to evaluate the association between the prevalence of 48 chronic conditions among low-income, older adults and the economic affluence of the local area. They found that the prevalence of chronic conditions in low-income, older adults varied substantially across local areas in the United States. Adults living in more affluent areas were healthier, with fewer chronic conditions compared with low-income persons living in less affluent areas. According to the researchers, these results suggest the likely importance of local location-based public health efforts that target the general health of the population rather than any specific conditions.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with author, Maria Polyakova, PhD, please contact Beth Duff Brown at bethduff@stanford.edu or Becky Bach at retrout@stanford.edu.

3. Hemophilia significantly more prevalent than previously reported

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1208
Editorial: http://annals.org/aim/article/doi/10.7326/M19-2535
URLs go live when the embargo lifts

The prevalence of hemophilia is higher than previously estimated and patients with hemophilia still have a life expectancy disadvantage. A meta-analysis using national registry data is published in Annals of Internal Medicine.

Hemophilia results when mutations in either of the genes that code for the coagulant proteins factor VIII or factor IX cause abnormal blood clotting. Because these genes are located on the X chromosome, hemophilia is a sex-linked disorder that mainly affects males. Patients with the most severe disease can have repeated bleeding into large joints that causes chronic and disabling joint disease. Bleeding into organs and intracranial hemorrhages can lead to disability and death. Effective treatment is key, but not all patients have access. Understanding the global burden of hemophilia can hope towards addressing the gap in care access.

Researchers from McMaster University, North Carolina State University, Aix-Marseille University, University of Sheffield, and the World Federation of Hemophilia conducted a meta-analysis of registry data in countries with comprehensive registries (Australia, Canada, France, Italy, New Zealand, and the United Kingdom) to estimate the prevalence and prevalence at birth of hemophilia and the associated life expectancy disadvantage for male patients with hemophilia A or B. They estimated that approximately 1,125,000 persons have hemophilia worldwide, of whom about 418,000 have severe and mostly undiagnosed disease. This estimate is significantly higher than previously reported. The authors suggest that their analytic approach and results constitute a solid base for the future assessment of burden of disease in specific settings and worldwide.

According to the author of an accompanying editorial from the National Center on Birth Defects and Developmental Disabilities of the Centers for Disease Control and Prevention and Synergy America, the magnitude of the global gaps in care for persons with hemophilia is daunting. However, these data provide important information that can inform efforts aimed at improving the lives of persons with hemophilia no matter where they live.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with author, Alfonso Iorio, MD, PhD, please contact Veronica McGuire at vmcguir@mcmaster.ca.

4. C auris linked to panophthalmitis in human patient

Abstract: http://annals.org/aim/article/doi/10.7326/L19-0323
URLs go live when the embargo lifts

Clinicians warn that Candida auris, could cause panophthalmitis (acute inflammation of the eye) in an immunosuppressed patient. They report the case of a 30-year-old man with panophthalmitis caused by C auris in Annals of Internal Medicine.

Candida auris was first identified in Japan in 2009 and has since been associated with hospital-acquired infection outbreaks on several continents. Researchers from Lennox Hill Hospital, New York, NY, have identified another infection caused by C auris. A 30-year-old patient diagnosed with both HIV infection and syphilis went to the emergency department complaining of vision loss and irritation in his right eye, which quickly progressed to complete vision loss in the right eye and difficulty opening both eyes. While his heart rate was elevated, he did not have a fever. Laboratory testing confirmed the presence of yeast-like C auris cells and the patient was treated accordingly.

According to the authors, their case confirms that panophthalmitis with C auris may occur in an immunocompromised patient without a history of trauma and that the infection may have a severe course, resulting in loss of vision and structural integrity of the eye.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with author, Matthew Ballenberger, MD, please contact him at mballenber@northwell.edu.

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David J. Whellan, MD, MHS
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M19-1656

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