Risk-Reducing Salpingo-oophorectomy in Women with BRCA Mutations

In this study of 170 women with a BRCA1 or BRCA2 mutation that greatly increases the risk of ovarian and breast cancer, 98 elected to undergo salpingo-oophorectomy and 72 chose to undergo surveillance. During a follow-up of about two years, the risks of both breast and ovarian cancer were considerably lower among the women who underwent the surgical procedure than among those who chose surveillance.

The findings of this prospective study complement those of a retrospective study in risk-reducing oophorectomy in women with a pathogenic mutation in the BRCA1 or BRCA2 gene (see page 1616). Physicians now have persuasive support for a recommendation to remove the target tissue from women who carry such mutations.

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Prophylactic Oophorectomy in Women with BRCA Mutations

Among 551 women with a disease-associated mutation in the BRCA1 or BRCA2 gene who were followed for at least eight years, the at least incidence of ovarian cancer was significantly lower in the group that underwent prophylactic bilateral oophorectomy than in the comparison group of women who did not undergo the surgery. In a subgroup of these women, prophylactic oophorectomy also reduced the risk of breast cancer.

This retrospective analysis of a large group of women at high risk for ovarian cancer provides persuasive evidence in favor of prophylactic oophorectomy for women with a disease-associated mutation in the BRCA1 or BRCA2 gene. For the individual woman with such a mutation, counseling about the risks and benefits of the procedure and about the maintenance of fertility is imperative. This study complements the prospective analysis by Kauff et al. (see page 1609).

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Ghrelin Levels after Diet-Induced Weight Loss or Gastric Bypass

Patients who undergo gastric bypass surgery have dramatic and sustained weight loss. They feel less hungry after eating, although they still perceive foods with high caloric value as enjoyable. Ghrelin is an orexigenic hormone whose levels in normal subjects increase before meals and decrease after meals. In this study of patients who achieved stable weight after gastric bypass surgery, circulating ghrelin levels were low and did not show meal-related periodicity.

Ghrelin may affect both the desire to eat and satiety. If the investigators' hypothesis is proved correct, inhibition of the synthesis or action of ghrelin could serve to inhibit appetite and aid in weight loss.

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Salmeterol for the Prevention of High-Altitude Pulmonary Edema

High-altitude pulmonary edema occurs in otherwise healthy persons when they are at high elevations. Since -adrenergic agonists increase clearance of alveolar fluid and attenuate pulmonary edema in animal models, these investigators studied the effect of inhaled salmeterol (a -adrenergic agonist) or placebo in 37 subjects who were prone to high-altitude pulmonary edema. In addition, nasal transepithelial potential difference, a marker of fluid clearance in distal airways, was studied in 33 mountaineers who were susceptible to this condition and 33 who were resistant to the condition. Prophylactic inhalation of salmeterol halved the incidence of high-altitude edema in susceptible subjects. Nasal transepithelial potential difference was significantly lower in susceptible subjects.

Defective sodium-driven clearance of alveolar fluid may be important in the genesis of high-altitude pulmonary edema in humans and may provide a target for therapy.

Related Perspective

End-of-Life Decisions by Patients with Amyotrophic Lateral Sclerosis

Physicians in the Netherlands described on a questionnaire the deaths of their patients with amyotrophic lateral sclerosis. Of the 203 patients, 35 (17 percent) had chosen euthanasia and died that way. An additional six patients died as a result of suicides that involved assistance from a physician. The choice of euthanasia or physician-assisted suicide was not associated with the patient's income or educational level.

In the Netherlands, physician-assisted death is allowed if strict guidelines are followed. This study documents the fact that one in five patients with this progressive neurologic disease chose death either by euthanasia or by physician-assisted suicide.

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Clinical Practice: Head Lice

An eight-year-old girl is sent home after the school nurse detects head lice. She will not be permitted to return to school until the absence of infestation is documented. What treatment strategy is most likely to allow her to return to school with a minimal risk of infecting her classmates?

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