Management of iron-deficiency anemia following acute gastrointestinal hemorrhage: A narrative analysis and review.

Many patients experiencing acute gastrointestinal bleeding (GIB) require iron supplementation to treat subsequent iron deficiency (ID) or iron-deficiency anemia (IDA). Guidelines regarding management of these patients are lacking. We aimed to identify areas of unmet need in patients with ID/IDA following acute GIB in terms of patient management and physician guidance. We formed an international working group of gastroenterologists to conduct a narrative review based on PubMed and EMBASE database searches (from January 2000 to February 2021), integrated with observations from our own clinical experience. Published data on this subject are limited and disparate, and those relating to post-discharge outcomes, such as persistent anemia and re-hospitalization, are particularly lacking. Often, there is no post-discharge follow-up of these patients by a gastroenterologist. Acute GIB-related ID/IDA, however, is a prevalent condition both at the time of hospital admission and at hospital discharge and is likely underdiagnosed and undertreated. Despite limited data, there appears to be notable variation in the prescribing of intravenous (IV)/oral iron regimens. There is also some evidence suggesting that, compared with oral iron, IV iron may restore iron levels faster following acute GIB, have a better tolerability profile, and be more beneficial in terms of quality of life. Gaps in patient care exist in the management of acute GIB-related ID/IDA, yet further data from large population-based studies are needed to confirm this. We advocate the formulation of evidence-based guidance on the use of iron therapies in these patients, aiding a more standardized best-practice approach to patient care.

Correction to: Risk of dementia among postmenopausal breast cancer survivors treated with aromatase inhibitors versus tamoxifen: a cohort study using primary care data from the UK.

The article Risk of dementia among postmenopausal breast cancer survivors treated with aromatase inhibitors versus tamoxifen: a cohort study using primary care data from the UK, written by Susan E. Bromley, was originally published electronically on the publisher's internet portal.

Risk of dementia among postmenopausal breast cancer survivors treated with aromatase inhibitors versus tamoxifen: a cohort study using primary care data from the UK.

PURPOSE: Among a cohort of postmenopausal breast cancer survivors, we aimed to compare the risk of dementia associated with aromatase inhibitor (AI) therapy versus tamoxifen. METHODS: Using UK primary care electronic health records, we identified 14,214 postmenopausal breast cancer survivors (aged ≥ 54 years) with a first AI or tamoxifen prescription between January 2002 and December 2015 and no previous dementia diagnosis. Women were followed-up to identify incident cases of dementia. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) to quantify the association between AI exposure (vs. tamoxifen) and dementia, adjusted for confounders. RESULTS: A total of 368 incident dementia cases was identified over 57,102 person-years of follow-up. The crude incidence rate of dementia was 7.46 per 1000 person-years (95% CI 6.43-8.65) among women starting endocrine treatment on an AI, and 6.32 per 1000 person-years (95% CI 5.34-7.47) among women starting on tamoxifen. After accounting for age differences and assessing other potential confounders, there was no evidence of a difference in dementia risk between exposure groups (HR for AI vs tamoxifen 1.04, 95% CI 0.83-1.03). There was no evidence of effect modification by age. CONCLUSION: There was no evidence for a difference in dementia risk between AI and tamoxifen users among postmenopausal breast cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Our findings suggest that there is no reason for concern about a difference in dementia risk with AI vs. tamoxifen, which is relevant to postmenopausal breast cancer patients recommended these treatments.

Hormone replacement therapy and risk of acute myocardial infarction : a review of the literature.

Many animal studies and studies on intermediate clinical endpoints have shown hormone replacement therapy (HRT) to be associated with both favourable and unfavourable cardiovascular effects. We reviewed the literature regarding HRT and the distinct endpoint of acute myocardial infarction (AMI) in peri- and postmenopausal women. Searches of the MEDLINE and EMBASE databases were conducted. Fifty papers were identified as eligible for inclusion: eight randomised controlled trials, 18 cohort studies, 23 case-control studies and one case-control and cohort study. The single large primary prevention randomised controlled trial on HRT and the risk of AMI in generally healthy women (Women's Health Initiative trial) reported a small yet significantly increased risk of AMI in postmenopausal women receiving combined HRT. This contrasts with a large number of observational studies that suggested a protective effect, although in many of these studies the results were not statistically significant. Inconclusive evidence on the effect of duration of use does not support the notion that a possible protective association is causal. Detection bias and residual confounding are alternative explanations for the associations observed in the randomised controlled trial and observational studies. No studies on groups of women with existing cardiovascular disease or with diabetes mellitus, including the only large secondary prevention trial (Heart and Estrogen/Progestin Replacement Study), reported a significant change in AMI risk between HRT users and non-users. There is insufficient evidence to suggest that HRT is associated with a change in the risk of AMI in the majority of women. However, certain subgroups of women with specific genetic polymorphisms may be more susceptible to a change in the risk of AMI with HRT use.

Tibolone and endometrial cancer: a cohort and nested case-control study in the UK.

OBJECTIVE: Case series and spontaneous reports of endometrial cancer have raised the question as to whether the use of tibolone (introduced into the UK in 1991) is associated with an increased risk of endometrial cancer. This study set out to evaluate whether tibolone use is associated with an increased risk of endometrial cancer. METHODS: Age-adjusted incidence rate ratios (IRRs) of endometrial cancer were calculated for tibolone use compared with the use of other hormone replacement therapy (HRT). Separate sets of controls, matched for age and general practice, were compared with cases, all nested within a cohort of HRT users identified from the UK General Practice Research Database (GPRD). Conditional logistic regression analysis, adjusted for potential confounders, was used to study the association between tibolone use and the risk of endometrial cancer. RESULTS: 4995 women used tibolone as their first HRT product; 10 783 (4.3%) of the users of combined HRT had changed to tibolone at some time during the study period. Amongst women whose HRT began with tibolone, the age-adjusted IRR relative to those who started with combined sequential HRT was 1.83 (95% CI 1.19, 2.82). The nested case-control study comprised 162 cases, each matched to two sets of 972 controls. There were 43 tibolone-exposed subjects, 28 of whom had used other HRT before or after tibolone. The adjusted odds ratio of the risk of endometrial cancer in women who had ever used tibolone, compared with users of combined sequential HRT, was 1.54 (95% CI 1.03, 2.32) in the age-matched set and 1.58 (95% CI 1.01, 2.47) in the practice-matched set. Sensitivity analyses did not decrease the risk estimates found. DISCUSSION: Tibolone may be associated with an increased risk of endometrial cancer compared with conventional forms of HRT, but our data are fragile. Residual bias and uncontrolled confounding cannot be excluded, and follow-up time is insufficient to draw any firm conclusions with respect to the endometrial safety of tibolone.