The top 8 health stories of 2008
The year's top 10 list is a reminder that so much of health and medicine seems to reside stubbornly in the details.
1. Blood sugar limbo: How low should it go?
People with type 2 diabetes are encouraged to keep their blood sugar levels low, and the usual goal is a glycated hemoglobin (HbA1c) level of 7% or lower. But is 7% ambitious enough? Results from three clinical trials showed that the single-minded pursuit of low blood sugar levels is probably not the best approach to type 2 diabetes, particularly in people ages 60 and older.
People with diabetes should not give up blood sugar control. Data show that it lowers the risk of kidney disorders, eye disorders, and other problems related to damage of small blood vessels (microvascular disease).
But 2008's bumper crop of diabetes research has shown that it's unwise to be overzealous about blood sugar lowering — moderation in all things! — and certainly not without also attending to risk factors like high blood pressure and cholesterol.
2. 80 ain't old
The age limit for controlling high blood pressure — usually with medication — has crept up as research results have shown that it prevents strokes, heart attacks, and heart failure in the old and young alike.
Results from the Hypertension in the Very Elderly Trial (HYVET) topped off that trend by showing that for those 80 and older reining in high blood pressure pays off. After two years, the treated group in the study had lower rates of heart failure, strokes, and overall mortality, which was especially important because previous research suggested a decrease in strokes might be offset by an increase in deaths from other causes.
HYVET is more evidence that the age for effective medical intervention — be it pills, surgery, or devices — is getting older and older.
3. Gene tests: Progress and Pandora's box
In 2008, personalized medicine (or pharmacogenomics, as it is sometimes called if drug choices are involved) inched closer to becoming part of everyday medicine. Doctors have started to order gene tests to assess how sensitive people are to warfarin (Coumadin), the anti–blood clotting drug. Researchers reported that heart-failure patients with a certain genetic profile responded well to bucindolol, a beta blocker that had fallen out of favor because it wasn't very effective in the average patient. And results from a substudy of a large blood pressure trial traced differences in the response to diuretics back to a particular gene.
Meanwhile, many direct-to-the-consumer genetic tests hit the market. Several companies are using the same DNA chips as researchers to sell genome scans, readouts of several hundred thousand genetic variations that have been associated with diseases and other traits.
The commercial tests have raised some concerns. Will they be done correctly? And even if they are, at this stage, the predictive powers may be oversold, unduly scaring some while giving false assurances to others. Moreover, the take-home message would be the same: lose weight, exercise, eat more fruit and vegetables.
4. Seeing right through you and its dangers
A half-dozen imaging technologies allow doctors to see what's going on inside the body. The workhorse, though, is computed tomography (CT), which uses a computer to assemble multiple cross-sectional x-rays into remarkably detailed pictures. A new generation of machines, called multidetector CT scanners, are making the pictures even faster and incredibly sharp.
By some estimates, doctors in the United States ordered over 60 million CT scans this year, double the number ordered in the late 1990s.
But are we going to pay a price for all these pictures? The radiation from CT scans is much higher than from traditional imaging tests. Starting in 2007 and continuing into 2008, researchers at Columbia University have published several provocative papers about the cancers that these CT scans may cause. According to their projections, our current exposure to CT scans might be responsible for between 1.5% and 2% of all cancers a few decades from now (it takes years for the cancers to develop).
Doctors need to eliminate unnecessary do-overs. And using other imaging tests when possible could reduce radiation exposure.
5. War wounds that don't show
One of the grim aspects of the wars in Iraq and Afghanistan has been the widespread use of small-scale bombs — in military jargon, improvised explosive devices (IEDs) — in suicide attacks and roadside booby traps. Many American soldiers survive these explosions because of protective gear, but by no means do they escape unscathed. In addition to terrible leg, arm, and other sorts of obvious physical injury, there are brain injuries that may have long-lasting effects.
Psychiatrists at the Walter Reed Army Institute of Research reported the results of a study that counted the number of mild traumatic brain injuries — or, more simply put, concussions — among returning troops. About 15% (384 of 2,525) gave answers that suggested they had suffered a mild traumatic brain injury of some kind. Probing a bit further, the Walter Reed researchers found that almost half (54 of 123) of the soldiers whose concussions had caused a loss of consciousness met the criteria for post-traumatic stress disorder (PTSD), and about a quarter of them were suffering from major depression.
It's difficult to separate the concussions suffered in a war from the life-threatening stress under which they occur. The Army researchers believe that there's a great deal of overlap between PTSD and the ill-defined consequences of wartime concussions. Regardless if the cause is stress, concussion, or some mixture, the veterans of these wars who have memory problems, difficulty concentrating, headaches, and other "invisible" injuries must get the care they need and deserve.
6. Generic Rx: Shopping for health care in the global village
Once the exception, generic drugs are now the norm. In 2008, about two-thirds of the prescriptions written by doctors were for generic drugs.
Generic drugs have taken off for many reasons. Brand-name blockbusters (Fosamax, Pravachol, Zocor, Zoloft) have lost their patent protection in recent years. Cost shifting by insurers and tiered pricing have steered doctors and their patients to the generic script. Large retailers like Wal-Mart have used generics as loss leaders simply to get people into their stores. And the Medicare Part D prescription plans have loaded up their formularies with generics with only a sprinkling of brand-name drugs in between.
But a crucial, and largely underappreciated, factor has been the role of low-cost suppliers, many of them in India. All the problems with contaminated Chinese products don't need to be recounted here. So far, nothing as serious has occurred with Indian drugs, although the FDA has promised to step up its overseas inspections.
7. Awareness test doesn't make the grade
Being awake during surgery after being given general anesthesia is one of those bad dreams that does, very occasionally, come true. Several studies have found "anesthesia awareness" to be a 1-in-1,000 occurrence, although one study put it more in the hen's teeth territory of 1 in 15,000. The bispectral index (BIS) is a formula that uses the values of measurements of the brain's electrical activity to come up with a single number that's supposed to measure "anesthetic depth." But it's been controversial, partly because the company that sells it has kept the formula a proprietary secret.
Researchers at Washington University in St. Louis reported the results of a study that tested the BIS monitoring in a 2,000-person randomized trial. Four people in the study experienced anesthesia awareness, two in the BIS-monitored group and two in the control group, and five others were rated as possibly being awake during their operations (false memories can occur), four in the BIS-monitored group and one in the control group. The investigators concluded that BIS-guided anesthesia was no better at identifying anesthesia awareness than another kind of monitoring.
This is another case when the results of an independent clinical trial have called into question the value of a widely adopted medical practice.
8. Health care reform: If not soon, when?
Some argue that the new political leadership will be hard pressed to take on something so organizationally and politically complicated as health care reform during an economic downturn. The counterpoint: health care reform is essential for any kind of durable recovery.
Regardless of how reform efforts play out in the long run, here are a few, quite gloomy predictions about the short term:
- The health care building boom will wind down in 2009.
- The number of Americans without health insurance will increase as the economy sheds jobs and employers look for ways to cut costs. The ranks of the underinsured — people with bare-bones policies with exclusions and high deductibles — will grow.
- Investment in projects that might save money in the long run and make health care more efficient — electronic medical records, prevention programs, and the like — will be put off during the scramble to make ends meet.
January 2009 update