As we head into the New Year, let’s take a look back and see what lessons we should have learned from medical science in 2015.
The New England Journal of Medicine’s publication Journal Watch provides physicians and other health care providers with expert analysis of the most recent medical research. Below is a brief synopsis of what the Journal Watch editors felt were the most important stories in general medicine for the year 2015. While you likely heard about a couple, others probably escaped your radar.
Getting Aggressive with Strokes
We’re familiar with the idea of a cardiologist performing an angioplasty, where a tiny tube called a catheter is threaded into a coronary artery and a balloon on the end of the catheter is inflated to open the blockage that’s causing a heart attack. One would think a similar “endovascular” intervention might work well for a blocked cerebral artery causing a stroke, but it hasn’t worked out that way… until now.
A new device called a “stent retriever” expands out into the offending arterial clot, allowing it to be removed. Five trials published in 2015 showed a clear benefit for this new technique, but the procedure needs to be performed quickly, and at high-level stroke centers.
Testosterone for the Old(er) Man?
Testosterone levels decline naturally as men age, and there’s never been any proof that artificially boosting testosterone levels with medication improves anything but the bottom line of the companies who are selling the stuff. Several 2015 studies confirmed this.
Peanut Allergies and Your Grandkids: An About-Face
In 2000, The American Academy of Pediatrics (AAP) recommended that children at high risk for food allergies (those with severe eczema or an egg allergy) avoid peanuts until age three. The AAP withdrew the recommendation in 2008, after finding that peanut allergy rates had doubled.
In 2015, after a U.K. study showed that early peanut introduction to high-risk infants lowered peanut allergy rates by 80 percent, the AAP took note and recommended the same: Start ‘em early. The expert reviewer recommended that infants with severe eczema or another food allergy eat their first PB&J in the doctor’s office, and that all children be exposed to all foods in their first year.
Unfortunately, dense bones aren’t necessarily strong: The Titanic’s hull was thick but brittle.
What Constitutes ‘High’ Blood Pressure?
Current recommendations suggest treatment should be initiated when blood pressure is 140/90 mm Hg or higher; we let that number slide to 150/90 mm Hg or higher in adults 60 years and older, except in patients of any age who have hypertension and diabetes, where treatment should be started at the lower number of 140/90 mm Hg.
But when a 2015 SPRINT trial (a large federally funded blood pressure study) took patients at high risk of a stroke or heart attack and aimed for a blood pressure goal of 120, not the usual 140, the researchers found a significant benefit.
How does this study apply to people who are at low-to-moderate risk of cardiovascular disease, and how will it affect future hypertension guidelines? Time will tell.
Who Should Be on the Almighty Statin?
If you’ve had a heart attack or stroke, being on a class of cholesterol-lowering drugs called statins (Lipitor is the most widely recognized of these) is a critical part of making sure you don’t have another. But here’s the rub: It’s sometimes hard to predict who should be on a statin to prevent a heart attack from happening in the first place. With the idea that those at the highest risk will get the largest benefit, doctors use a variety of cardiovascular risk calculators to help decide who is “statin-worthy.”
A risk calculator published in 2015 from the American College of Cardiology and the American Heart Association stirred controversy because it classified a much higher proportion of patients as being eligible for statins. Several studies showing a small but statistically significant increase in diabetes among statin users cast a “no” vote on statins for the masses.
One Older Medication Is Best for Some Hypertensive Patients
Patients with uncontrolled blood pressure despite being on three medications are said to have “resistant” hypertension. In 2015, several studies found that an oldie-but-goodie medication called spironolactone (commonly sold as Aldactone) seemed to do the trick for these people.
Immune System Overdoing It in Sepsis?
Patients with serious infections can develop a process called sepsis, where blood pressure drops and organ failure and death can ensue. It remains controversial as to whether sepsis is caused directly by the virus or bacteria causing the infection or by a zealous immune response — a cellular version of collateral damage. New research suggests the latter: Patients with severe pneumonia did better if they were treated with corticosteroids, which tone down our immune response.
Help for Hospital Patients with COPD
Breathing is about exhaling carbon dioxide and inhaling oxygen. So patients hospitalized with COPD (emphysema, chronic bronchitis) sometimes need help moving enough air in and out of their lungs to get rid of excess carbon dioxide and we fit them with a mask that uses pressure to push more air into their lungs. These pressure masks don’t always work for patients with low oxygen levels; but 2015 brought the advent of high-flow oxygen generators.
The new devices can comfortably deliver the oxygen flows these patients require, with the goal of avoiding the dreaded, last ditch option: being on a ventilator, with a tube down your throat in the ICU.
Comparing 2 Tests for Chest Pain
For patients with chest pain, there are two general ways to discern whether their pain is due to blockage of the coronary arteries. Functional stress tests force the heart to work hard (either via exercise on a treadmill or by using an intravenous medication to accomplish the same thing) and then most commonly use a radioactive tracer to see if the heart stumbles under the rising physiological demands. Functional stress tests have been around for some time, but they only detect bigger blockages, and they’re being challenged by new CT scan technology that allows us to see even small amounts of coronary artery disease. Several 2015 trials that pitted the old test against the new test drew pros and cons for both, so either is fine. For now.
How Best to Treat Spontaneous Blood Clots in the Legs?
Blood clots often develop in the leg veins during periods of trauma or inactivity — a knee surgery or a long plane ride, for example — and patients like this need to be on blood thinners for several months until the clot and the immobility that triggered it resolves. But some patients develop venous clots out of the blue and experience recurrences. How should doctors treat those?
Several 2015 studies tried — and failed — to identify testing that would accurately indicate when it would be safe for these people to stop their blood thinners. For the time being, it appears they’ll need to be on them indefinitely.
Calcium Is No Elixir for Strong Bones
Bone is a bit like a concrete roadway: It’s a network of collagen fibers (metal rebar) and calcium salts (concrete/cement). We’ve chosen to quantify bone strength in terms of bone density, a measure of calcium salts more than of the collagen fibers. Unfortunately, dense bones aren’t necessarily strong: The Titanic’s hull was thick but brittle.
Two 2015 studies reviewed many of the previous trials that had looked at the relationship among dietary calcium, calcium supplements, bone mineral density and fractures. Increased calcium intake via food or pills did lead to small increases in bone density, but did not translate into clinically significant reductions in fracture risk. As the expert reviewer concluded, stick with weight-bearing exercise and the RDA of calcium and vitamin D, and avoid smoking and excessive alcohol — both of which thin the hull.