Every January, the New England Journal of Medicine’s publication Journal Watch selects the top medical stories from the previous year. Think of it like the Grammys, except there are no acceptance speeches, bold fashion statements, or entertainment — unless you find research statistics to be entertaining.
Of course, COVID-19 could have swept the awards — “Virus of the Year,” “Pandemic of the Year,” “Best Performance by a Coronavirus” etc. — but because we’re sick of hearing about the virus, the editors spread the prizes around. Here is a brief explanation of the winners.
Angioplasty versus medication for stable coronary artery disease
When an artery to the heart muscle — a coronary artery — becomes blocked by atherosclerosis, that’s a “heart attack,” and it’s typically treated by ballooning open the clogged artery and inserting a wire mesh tube — a stent — to keep it open. A recurring question has been whether there is any benefit to using angioplasty to open blockages that are not causing a heart attack, but are causing angina — chest pain that typically comes with activity. A seminal 2020 trial found that for people whose stress test showed moderate-to-severe blockages, angioplasty offered only modest improvements in the amount of angina compared to therapy with medications. And angioplasty didn’t change the risk of heart attack or cardiovascular-related death either. Pills don’t offer the razzamatazz of a complex procedure, and they need to be taken daily, but they do work. And besides, patients need to be on medications after angioplasty too.
What about gout?
Gout is caused when uric acid forms crystals inside of joints. The pain can be excruciating. A study found that naproxen — an over-the-counter pain medication — worked as well as a prescription medication called colchicine, which can be reserved for patients who can’t take naproxen (because they have stomach ulcers, or weak kidneys). The American College of Rheumatology also issues guidelines about which gout sufferers would benefit from being on medication to lower their uric acid levels and thereby avoid these painful attacks.
What’s in a pain number?
Pain is both real and subjective. To try and objectify it, caregivers have long asked patients to rate their pain on a scale of 1-10, with 10 being the worst. A June study found a poor correlation between a patient’s chosen pain number and their description of their pain as either tolerable or intolerable. In fact, almost half of those who placed their pain in the 7-10 range also said that their pain was tolerable. Given that higher pain numbers typically lead to more pain medication dosing, ditching the pain scale for the simple question “Is your pain tolerable?” might avoid overmedication.
Bad knees? Start with physical therapy before you get an injection or surgery
Chronic knee pain is most often due to osteoarthritis or tears of the meniscus — a thin wafer of cartilage that pads the knee joint. Physical therapy can help both of those conditions, but patients often feel attracted to more aggressive treatment options, which may seem more modern and definitive. One study found that over a year’s time, 12 sessions of physical therapy led to more improvement in arthritic pain and knee function than did 2-3 steroid injections into the knee. Another study found that for those with both arthritis and a meniscal tear, arthroscopic surgery to repair the tear brought improved pain relief for the first three months in comparison to physical therapy. Beyond that, pain scores were equal for the next five years, and those who had had surgery seemed to progress more quickly to a total knee replacement.
Zowee! Bulging discs, and pinched nerves
Low back pain can turn into leg pain when a disc herniates and pushes on a nerve that is exiting the spine and headed down to the leg. What patients call “Zowee!” physicians call “sciatica.” With time, a herniation often resolves on its own, but it can be a long and painful wait. So how long should one wait? A new study suggests that after 4 months, a microdiscectomy, in which a surgeon removes the bulging portion of the disc, is a beneficial move. A second study suggested that physical therapy provided minimal relief for sciatic pain.
Atrial fibrillation: to convert or not convert?
Atrial fibrillation is the most common heart arrhythmia, and is characterized by an irregular and often fast heart rate. Atrial fibrillation (AF) is bad because it makes the heart work inefficiently (particularly when it is beating too fast) and it increases the risk of having a stroke. There’s a longstanding debate about whether it’s better to a) leave people in AF, using medications to keep the heart rate down and blood thinners to reduce the risk of stroke; or b) force the heart out of AF using medications, a controlled electrical shock (“cardioversion”), or an ablation procedure, in which a catheter is slipped into the heart to knock out the “loose wire” that is triggering the AF. In a study that looked at patients who had had AF for a year or less, those randomized to therapy aimed at getting them back into a normal rhythm did better (less cardiovascular deaths, strokes, heart attacks) than those who remained in AF.
Many penicillin allergies aren’t
More than 10% of the U.S. population believes they are allergic to penicillin, but most of them are likely mistaken. Often they confused a side effect (diarrhea) with an allergy, or the rash they thought was from amoxicillin (a commonly used derivative of penicillin) was actually caused by the viral infection in their throat (for which the amoxicillin was inappropriately prescribed). And dimly recalled decade-old stories of a possible allergic reaction in childhood usually end up being more folklore than fact. The most common symptoms of a bona fide allergic reaction to a drug include a skin rash, hives (an itchy, raised welt), runny eyes and nose, fever. Less common but more serious symptoms include a drop in blood pressure, altered mentation or seizures, or swelling of the lips, tongue, throat, and airways that can lead to breathing problems. In a study of patients whose potential penicillin allergy had occurred more than a year ago, and was not accompanied by any serious symptoms or a classic drug rash, 97% tolerated a challenge dose of amoxicillin.
Can antibiotics replace surgery for appendicitis?
For most of my medical career, an appendectomy for appendicitis was dogma. A swollen and infected appendix can rupture and spew bacteria into the abdomen, a truly sickening and serious event. But a steadily increasing amount of evidence suggests that as many as 70% of people with appendicitis can successfully be treated with antibiotics alone. That number drops off for those with an appendicolith — a hard, pebbled accretion of stool plugging the appendix — and an appendectomy remains the right choice for some patients. But it’s no longer the only choice.
Chasing down microscopic amounts of blood in the urine
A patient with obvious blood in the urine (hematuria), but without any pain, raises the concern for a cancer in the kidney or bladder. Microscopic amounts of blood in the urine can still be a flag for cancer, but it can also be due to something benign or so small as to be undetectable. Several studies indicate that patients with microscopic hematuria who are low risk for cancer (primarily non-smokers, women under age 50, men under 40) can be screened with just a repeat urinalysis in 6 months, or with an ultrasound of the kidneys and bladder. A CT scan or a cystoscopy — wherein a urologist passes a fiberoptic scope into the bladder to look around — can be reserved for those at higher risk.
Some diabetic medications improve heart failure
There’s a newer class of diabetic drugs called SGLT-2 inhibitors that not only improve diabetic control, but also help people with heart failure (a ginormous ad campaign has made Jardiance the most recognized SGLT-2 inhibitor). Two large studies show that these diabetic medications improve heart failure outcomes even in patients without diabetes. That’s the good news. The bad news is that these medications are mighty spendy, with non-discounted costs of $600 a month.
Drug therapies for COVID-19
I recall a scene from the movie “Pirates of the Caribbean” where the crew loads silverware into the cannons: When you’re in a pinch, you go with what you’ve got and hope it will work. Unfortunately, we’ve yet to find a magic cannonball, or even a magic bullet, against SARS CoV-2. The two drugs currently in use — decadron (a steroid) and remdesivir (an anti-viral medication) — appear modestly effective. Transfusing the sick with antibodies from the blood of those who have recovered seemed like a sure thing. How could it not work? And yet it doesn’t seem to. Research continues on better therapies against the scallywag SARS CoV-2, with no lack of trial participants.
Caring for critically ill COVID-19 patients
Although SARS CoV-2 has thrown us plenty of surprises—large numbers of asymptomatic spreaders, and people who are profoundly low on oxygen but don’t look all that short of breath—it appears that when the infection gets serious enough to warrant ICU care, lungs damaged by SARS CoV-2 respond to the same measures we use to treat a more common lung injury called Acute Respiratory Distress Syndrome (ARDS). Patients with ARDS often require mechanical ventilation, where the trick is to deliver adequate amounts of oxygen without causing further injury to the damaged lungs.
What?! No mention of COVID vaccines!?! I can only surmise that they appeared too late in 2020 to be considered in this year’s voting. If these novel vaccines do what we hope they will, they and those who created them will surely sweep next year’s awards — which will hopefully be held in person and without masks.