15th October 2010, Volume 123 Number 1324

Antidepressants and pregnancy

The authors of this study and an editorial commentator agree that pregnancy is often complicated by depression. This may require pharmacological treatment and the issue addressed here is whether antidepressant drugs increase the risk of spontaneous abortion. They used a nested case-control design, whereby they obtained data on 5124 women who had a spontaneous abortion. Of the 5124 women, 284 (5.5%) had had a prescription filled for an antidepressant. Each case was matched by randomly selecting 10 controls from their data bank. They report that the use of antidepressants (especially paroxetine, venlafaxine or the combined use of different classes of antidepressants) during pregnancy was associated with an increased risk of spontaneous abortion.
The overall odds ration (OR) was 1.68, but the OR for combined use of antidepressants was 3.51. The editorial commentator was not overimpressed pointing out that a filled prescription does not necessarily mean that the drug was taken. On the other hand she mentions a prospective randomised trial, which featured her as an author, which reached identical results.
CMAJ 2010;182, 1031–7, & 10107–18.

Screening mammography—benefit and harm analysis

This paper reports the results of the Norwegian breast cancer screening programme which was started in 1996. Screening was offered every 2 years to women aged 50–69 years. The authors report that the death rate from breast cancer has been reduced by 7.2 deaths/100,000 person years. However they produce data to show that only one-third of this is due to screening, the other two-thirds is due to advances in breast cancer awareness and treatment.
An editorial commentator offers a benefit-harm analysis based on the relative reduction in mortality reported in this paper (10%). His analysis—if 2500 women have screening over 10 years, one woman would avoid dying of breast cancer. Up to 1000 women will have at least one false alarm and about half of these will have a biopsy.
And breast cancer will be overdiagnosed in 5–15 women and treated needlessly.
NEJM 2010;363:1203–10 & 1276–8.

Various treatments for rotator cuff tears

A common complaint in the elderly. The authors of this review suggest that more than half of all adults over 60 years of age may have a partial or complete rotator cuff tear at some time.
Their review is based on 137 studies in which patients with imaging-confirmed lesions were treated in a variety of ways. They conclude that functional outcomes did not differ between open versus mini-open repair, mini-open versus arthroscopic repair, arthroscopic repair with versus without acromioplasty, or single-row versus double-row fixation, whatever that means.
However non-operative treatment involving analgesia and physical therapy had similar outcomes. So they reach the conclusion that evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive.
Ann Intern Med 2010;153:246–55.

Exposure to oral bisphosphonates—a cause of oesophageal pathology?

Bisphosphonates inhibit osteoclast-mediated bone resorption and are mainly used to prevent or treat osteoporosis, especially in postmenopausal women. Consequently, a lot of older women are on such treatments, aledronate most commonly. It is known that this medication can cause serious oesophagitis in some.
Indeed, crystalline material that resembles ground alendronate tablets has been found on biopsy in patients with bisphosphonate-related oesophagitis. It is known that these abnormalities persist after the inflammation has subsidised. It has been suggested that this may predispose the patient to develop oesophageal cancer.
This review of data from the UK General Practise Research Database compares the incidence of oesophageal cancer in more than 40,000 subjects who were taking oral bisphosphonate with the incidence in a similar number not taking bisphosphonate. They found no significant association between the use of oral bisphosphonate and oesophageal cancer.
JAMA 2010;304(6):657–63.

Homeopathy and the UK National Health System (NHS)

In February this year the House of Commons Science and Technology Committee concluded that homeopathy is a placebo treatment that deceives patients and could therefore damage the implicit trust between doctor and patient (BMJ 2010;340:c1091). Furthermore they recommended that the NHS should no longer fund such treatments and that such products should no longer be licensed.
The government noted the report but passed the buck to the local primary care trusts. And there the matter rests, with the homeopaths happy and others outraged. In particular, Professor Ernst, the professor of complementary medicine at the Peninsula College of Medicine is quoted as saying—“This is utterly incomprehensible and makes a mockery of the principles of evidence based medicine.” Gilbert and Sullivan could make something of this.
BMJ 2010;341:c4073.