Update From the Medical Journals: July 2011 - What Your Doctor Is Reading - Harvard Commentaries

What's the latest news in the medical journals this month? Find out what your doctor is reading.

Massage Helps Back Pain
Heart and High Blood Pressure Patients Have Extra Risk If Taking NSAIDS
Stem Cells May Soon Treat Worst Cases of Coronary Artery Disease
More News in Brief: At-Home Blood Pressure Numbers Matter More than Readings In a Doctor's Office, New Drug Delays Lung Cancer Progression, and U.S. Obesity Epidemic Is Still Growing

On July 5 the Annals of Internal Medicine published a study on massage treatment for back pain. The study included 401 people with chronic (long-term) symptoms of low back pain. They were divided into three groups. One group got medicines and physical therapy to relieve their pain — this is "usual care" for back pain. The other two groups had massage treatments for one hour each week. The massage treatments lasted for ten weeks.

By the end of the treatments, one in three people from the massage groups said their pain was gone or much better. Only 1 in 25 people from the "usual care" group had this improvement in pain. People in the massage groups used less pain medicine, too. The difference between the groups was still seen six months later, when the study researchers did follow up interviews. After one year, however, there was no noticeable difference in comfort between massage and no-massage groups.

The two massage groups had different types of massage work done, but both seemed to reduce pain. One group had "structural massage," which focuses on tight muscles or poorly aligned bones or ligaments in the back. The other group had "relaxation massage," also known as "Swedish massage," which focuses on rest and relaxation, not on treating pain in a particular location.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are generally safe over-the-counter and prescription pain medicines, but they do carry some risks. They can irritate the digestive tract, sometimes resulting in an ulcer with bleeding. They may also be dangerous for people with coronary artery disease, high blood pressure or heart failure.

In May 2011, a study from Circulation: Journal of the American Heart Association showed a link between NSAID medicines and the risk for death or repeat heart attack among heart attack survivors and heart disease patients.

A new study about NSAID risk was published in the July issue of the American Journal of Medicine. This study has more bad news about NSAID risk for people with heart disease. More than 30,000 patients who had both high blood pressure and coronary artery disease were included in the study. Of these, 882 patients took NSAIDs frequently, on a long-term (chronic) basis. The rest of the patients took them rarely or not at all. During the three years of the study, researchers recorded health events among the subjects. Researchers found that there was a higher-than-average rate of heart attack, stroke and death in the group of people who frequently took NSAIDs. We don't know whether the extra risk came from the NSAID, or whether it came from inflammation. Often, pain in joints or other tissues from inflammation is the reason a person takes NSAID medicine for pain.

Still, it is concerning to see this extra risk associated with such commonly used medicines. If the risk is caused by NSAIDs, why would they have this effect? NSAIDs that are primarily used for pain don't prevent blood clotting as well as aspirin does. People who take an NSAID are less likely to take a daily aspirin. Aspirin does not work as well in the presence of other NSAIDs. Also, NSAIDs block a natural substance called prostaglandin. This can lead to higher blood pressures, tighter arteries and mildly-reduced kidney function when using NSAIDs.

People who have had a heart attack, heart failure or coronary artery disease should minimize use of NSAIDs (other than aspirin). If you do have to take aspirin and non-aspirin NSAIDs, take the aspirin at least two hours before the other medicine.

A small study gives hope to people with advanced coronary artery disease that continues to cause symptoms despite treatment with stents, bypass surgery, angioplasty and medications. This study found that injecting stem cells into the heart muscle improved patients' symptoms. The study was released July 7 by Circulation Research: Journal of the American Heart Association.

There were 167 patients included in this study. Some had stem cell injections and some had placebo injections. The stem cells were harvested and purified from the patient's own blood after a medicine was used to stimulate their release from bone marrow. Researchers guessed that the stem cells would create new small arteries in the heart muscle, which helps blood flow. The results of the study suggest they may have been right.

Improvements were seen in both chest pain and exercise abilities. Six months after the injections, patients who got the stem cells had fewer chest pain attacks per week and needed less nitroglycerin. This benefit was still present at 12 months. Exercise tolerance at six months was roughly doubled (although these patients were still quite limited in their ability to exercise).

This treatment is not yet approved by the U.S. Food and Drug Administration. Larger studies are needed to confirm safety. The study will be expanded to include more than 400 patients later this year, so safety information can be collected.

Home Blood-Pressure Numbers Matter More than Readings In a Doctor's Office. Home blood pressures (also called "ambulatory" blood pressures) are more important than the blood pressure readings in your doctor's office. Home blood pressure is better at predicting your risk for complications from hypertension. This is the finding from a study released June 27 by the Archives of Internal Medicine. The study involved 436 patients in a kidney clinic. These patients had kidney disease but were not on dialysis. The patients went home with a device that recorded their blood pressure every 15 to 30 minutes for 24 hours. For the next 4 years, the study researchers tracked serious health events that can result from high blood pressure: death, heart attack or new kidney failure that needs dialysis. Researchers also looked at people's blood pressure history. These health crises were more likely to happen to people who had shown a pattern of high blood pressure at home. This could be either the top (systolic) or bottom (diastolic) part of the blood pressure readings. By contrast, blood-pressure readings in the doctor's office didn't predict at all which people would have these events. For some people, medicine taken once a day wears off before the next day's dose. Home blood pressures can show this. For other people, high blood pressure in the office comes from anxiety called "white coat hypertension." White coat hypertension may be treated with more medicine than is needed. Measurement of blood pressure at home could help doctors to avoid under-treatment and over-treatment of patients with high blood pressure.

New Drug Delays Lung Cancer Progression. For some people with lung cancer, a new drug can delay the growth of the cancer almost three times longer than standard chemotherapy. The medicine is erlotinib (Tarceva). Lancet Oncology published the results of a small (165 patients) study July 21. The study compared the drug to a placebo (fake medicine). This is a breakthrough in treatment for lung cancer, although it is not a cure. The most common kind of lung cancer is non-small cell lung cancer. Some forms of this cancer have a mutation called an "epidermal growth factor receptor (EGFR)" mutation. The mutation is found by testing cancer tissue from a biopsy. About half of never-smokers who get lung cancer have an EFGR mutation, but the mutation is less often seen in smokers. The medicine did not cure the cancer, but stalled the growth of lung cancer with this mutation for 13 months, before the cancer progressed. Standard chemotherapy stalled cancer growth for only 4 to 5 months in most patients.

U.S. Obesity Epidemic Is Still Growing. A study reported on July 7 by the Robert Wood Johnson Foundation and the Trust for America's Health makes it clear that the U.S. obesity epidemic is continuing to grow. The obesity study reported rates of obesity from 2010. In states with the lowest rates of obesity, one out of every five people (20%) is obese. In 12 states (including many states in the South), 30% or more are obese. This is an increase from previous years.

Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.