Year in Review

IMG_2235Reflecting on the medical literature of 2013, I’m reminded of what my tennis coach always preached before a match. “If they knew who was going to win the tournament, they’d just give the trophy to the first seed.”

Medical knowledge is, like a win-loss record, built incrementally. Sometimes the results of one study contradict another, yielding whipsawing recommendations that leave everyone (including physicians) a bit confused. And year after year, the research almost always produces a surprise or two, knocking a long-held conclusion off its perch. Here are our picks for the most important primary care studies and revelations of 2013.

1. Frequency of bone mineral density (BMD) testing can be extended. The BMD is an important predictor of fracture risk. But once it’s assessed (by a DEXA scan) at baseline, what is the ideal interval for retesting? This study showed that an average retesting interval of four years added little to the fracture risk calculation. In other words, the extra measurement did not help to determine who is at risk for developing a fracture or osteoporosis. These results add to an earlier 2012 paper showing that the BMD testing interval could be stretched to 15 years for women with normal baseline BMD at age 65.

2. Regular pelvic exams may be unnecessary. Earlier research showed that the bimanual pelvic exam produces a lot of unimportant findings that nevertheless then need followup. There are easier ways to determine vaginal health (pH paper) and presence of STDs (urine tests or vaginal swabs). Now a growing number of experts are recommending we discard the practice of regular pelvic exams altogether.

3. Routine cholesterol tests for those on statin medication are unnecessary. New guidelines instruct that once the decision has been made to treat, documenting the amount of cholesterol lowering achieved is immaterial. This is because statins lower heart attack risk by altering other biological processes (such as inflammation) in addition to simply lowering LDL cholesterol. Case in point: cholesterol medications lower cardiovascular risk even in persons with normal LDL levels.

4. Our government is still not doing enough to prevent contamination of the food supply with harmful bacteria. This study showed most chicken, including samples from organic brands, was tainted with everything from E. coli to salmonella. Even worse, widespread antibiotic use in farming promotes the development of bacteria that are resistant to treatment. Foodborne infections cause up to 23,000 deaths annually — comparable to the annual number of deaths caused by leukemia. The FDA acted just last month to tighten antibiotic use in food production, but many say the rules are not strong enough.

5. Prostate cancer screening continues to frustrate both patients and physicians alike. Should we or should we not check prostate specific antigen (PSA), the blood test by which most prostate cancer is diagnosed? The data are so conflicted, “You can find support for just about any position you take on screening,” one of my favorite urologists opined recently. This new study suggests we might get by with far fewer PSA tests during a man’s lifetime than previously thought.

6. Overdiagnosis and overtreatment, and the recognition of the harms they cause, continue to be a hot topic in the popular press. Take a look at what the medical profession is doing to try and change provider (and patient) understanding of this important concept.

7. Daily multivitamin use is worthless. This strongly worded editorial drew on several recent studies showing lack of benefit for daily multivitamin use. While some specific subgroups do need supplementation (folic acid for pregnant women, for example) the majority of us don’t need a supplement.

8. Arthroscopy (knee scope) may be overutilized. More than a third of randomly selected people over the age of 50 have evidence of knee cartilage injury. Additionally, surgical trimming of torn knee cartilage is one of the most common orthopedic procedures. In this study, individuals with persistent knee symptoms, and evidence of cartilage damage, underwent surgical meniscal trimming or sham (“pretend”) surgery. There was no difference in patient reported symptoms at one year post-procedure, suggesting that surgery offered no additional benefit.

Happy New Year, and best wishes from Baskin Clinic for your good health.

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