The brainiacs at the New England Journal of Medicine (NEJM) offer physicians in various specialties a product called “Journal Watch,” which provides updates on the newest information and research from medical journals. Here’s a brief summary of what NEJM Journal Watch General Medicine thought were the most important medical stories of 2016 and why those stories matter to you:
Prince and the Opioid Crisis
In my home state of Minnesota, our beloved Prince died from an overdose of fentanyl, a narcotic he was reportedly using for a severely arthritic hip. Although Prince was truly one of a kind, he joined 90 other Americans who die every day from a prescription narcotic or heroin overdose, according to the Centers for Disease Control and Prevention (CDC).
Here in the U.S., if a statistic involves narcotics, the number is going up. Since 1999, sales of prescription opioids and deaths from opioids have both quadrupled. Heroin use is up, and heroin-related deaths tripled from 2010 to 2015.
As sad as all that it is, opioids don’t really work — for acute pain, yes, but not for chronic pain, which is where most of these opioids are being used. You’re saying, “Why don’t doctors stop prescribing them if they are ineffectual and potentially lethal?” and I am saying, “I have no idea.”
SIRS Dropped for SOFA (Septic Shock)
The field of medicine is FULL (Fairly Unlimited LoL) of acronyms, but I’ll make this SIMPLE (So Intuitive Minded PLEase). A task force of intensive care unit doctors decided to swap SIRS (Systemic Inflammatory Response Syndrome) for SOFA (Sequential Organ FAilure).
Early recognition and treatment of a looming and potentially serious infection can turn things around.
When an infection turns bad, really bad, blood pressure drops and organs begin to fail. This process — what we call “septic shock” — has a certain amount of momentum. Early recognition and treatment of a looming and potentially serious infection can turn things around, but delays can lead to what quite literally can become a death spiral. Hopefully the new SOFA guidelines, which accompanied the acronym change, will improve the treatment of serious infections and save lives. [As Next Avenue wrote, actress Patti Duke died of sepsis last year; septic shock is the most severe form of septis.]
Overdoing It on the Oxygen
Many patients with chronic obstructive pulmonary disease (COPD) use oxygen to improve their oxygen levels, and since we all need oxygen to live, shouldn’t more be better, particularly if one is low to begin with?
A multi-center U.S. trial found no benefit for home oxygen use in COPD patients with mildly to moderately decreased oxygen levels. And an Italian study found that goosing oxygen levels up to 97 to 100 percent in critically ill patients only increased their mortality risk. Shucks. For reference, a normal oxygen level is somewhere between 95 and 100 percent, with older folks tending to be on the lower side of that (yes, the lungs get older too).
CPAP and Cardiovascular Events
Obstructive sleep apnea occurs when the muscles of the upper airway relax during sleep, to the point where they can close off the airway. Carbon dioxide levels subsequently rise, rousing these patients awake and thereby temporarily correcting the problem — until they fall back to sleep.
A pressurized mask therapy (continuous positive airway pressure, or CPAP) can help keep the airway open and restore normal, restful sleep. Patients with obstructive sleep apnea are at increased risk for heart attacks and strokes, and the use of a pressurized CPAP mask has always been felt to lower that risk.
Two 2016 studies cast doubt on that particular benefit — although both studies were weakened by the fact that some patients had a hard time tolerating the mask. The average CPAP usage in one of the studies was just 3.3 hours per night, and like a raincoat, it can’t work if you’re not wearing it.
Rethinking Fainting Episodes
The most common reason why people suddenly pass out is a rapid drop in blood pressure, or pulse, or both. As dramatic as passing out can be, often the event is of little consequence, particularly for younger patients; with a little education, the person who faints can become better aware of the circumstances and warning signs leading up to the event, and avoid a repeat episode.
But an Italian study found that 17 percent of older adults (with a mean age of 76) hospitalized for their first syncopal (fainting) event had suffered a pulmonary embolism. That’s where a blood clot from the leg veins breaks loose and flows back to the heart, plugging the pulmonary artery, which brings blood to the lungs. Chest pain and shortness of breath are common symptoms of a pulmonary embolism; prior to this study, passing out was thought to be rarely triggered by a pulmonary embolism.
Take-home lesson: if you’re older and pass out for the first time, ask your emergency room doctor to consider a pulmonary embolism — and to maybe order a D-Dimer level and a Wells score. They’ll know what you’re talking about, even if you don’t.
Prostate Cancer Treatment Still Controversial
Most men who live long enough will develop prostate cancer, but what kind? The kind that spreads out from the prostate gland and eventually becomes lethal? Or the more common, slow-growing kind, which stays confined to the prostate and can only be detected by a urologist with a biopsy needle, or by a pathologist at autopsy — that is, after some other disease process has claimed the top line on the death certificate?
The “Protec T” trial in the U.K. randomized 1,600 men age 50 to 69 with low-grade prostate cancer to either surgical removal of the prostate, a combination of radiation therapy and drugs to deprive the cancer (and the rest of the body) of testosterone, or to surveillance with a PSA blood test every three to six months.
A decade later, half of the men in the surveillance group ended up getting surgery or radiation because their PSA was on the rise. Widespread (“metastatic”) prostate cancer occurred infrequently, but was more common with surveillance (6.1 percent) and less common with radiation (2.9 percent) or surgery (2.4 percent). Think about those numbers: in 2.4 percent of cases where physicians concluded that the cancer was low grade and isolated to the prostate gland, surgical removal of the prostate cancer did not provide a cure because, on a microscopic level not detectable by current testing methods, the cancer had already left the prostate gland.
Opting for treatment sounds like a no-brainer until one considers treatment risks and side effects, and the fact that all three groups had the same overall mortality rate (10 percent) and the same chance of dying of prostate cancer (1 percent).
For any individual, it is hard to make sense of all the risks and odds, so be sure to take your bookie with you when you talk with your physician about prostate cancer screening.
New Diabetic Drugs Lower Risk of Heart Attack and Stroke
Insulin is the most well-known treatment for diabetes, but there are a host of other drugs — some in pill form, some injectable — that can improve blood sugar levels. Poorly controlled diabetes makes people feel bad, but it also leads to premature cardiovascular disease such as strokes and heart attacks.
For unclear reasons, some diabetic treatments improve blood sugars but don’t reduce cardiovascular disease. Two newer diabetic drugs — liraglutide and empagliflozin — were shown to reduce the risk of dying from a stroke or heart attack in diabetic patients at high risk for such.
But the drugs are — you guessed it, expen$$$$ive — and although everyone who takes the medications will see their blood sugar control improve, not everyone will see a cardiovascular benefit. In fact, a fairly high number of patients have to be taking these drugs in order to prevent a stroke or heart attack in one individual, which only adds to their overall cost. Here’s another fiscally rooted area in which President Trump can intervene and make something beautiful or “yuge” happen.
Zika, Zika, Zika
Have you heard of it? Most Zika virus infections are so mild as to cause no symptoms, and serious illness or death are very rare. But nothing digs deeper into our fear psyche than a mosquito-borne virus that can infect expectant mothers and cause neurological birth defects. So much so that even dysfunctional Congress, after only eight months of deep contemplation, was able to sign a bill appropriating $1.1 billion to fight the virus.
The first two trimesters of pregnancy are the riskiest time for Zika infection, because that’s when the fetal brain is most actively developing. The virus can be sexually transmitted, and it can persist in semen for months, so Deep Woods Off can’t help you there.
Black End-of-Life Matters
Several 2016 studies added to previous studies showing that black patients receive more aggressive medical treatment than whites as they near the end of life. And that’s probably not a good thing, as Americans have come to better understand that a “do everything, no matter what” approach for the dying and threadbare elderly is not only futile, but it can unnecessarily promote suffering.
Misplaced empathy (we don’t want them to die — but that’s not the question we get to answer) can prolong the death process, and it can increase the chance that a dying loved one will spend the last few weeks (or months) of their life in a hospital, mortally exhausted, in pain and surrounded by hospital staff rather than family members.
I will stick my neck out here and suggest that the reasons for the disparity are likely “multi-factorial.” As a hospital-based physician (and as a son, and then also as a brother), I have been involved in a lot of these end-of-life discussions. They can be very complex and nuanced.
They are heart-wrenching: patients and family members are trying to communicate their deepest thoughts and often unspoken wishes, and cultural/social differences — even subtle ones — can loom large. Patients and family members who have come to feel that The System is against them can easily interpret any suggestion of withdrawing care as a question of worthiness rather than compassion, and who can blame them?
We’ve got work to do.
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