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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: July 2014

July 31, 2014

By Mary Pickett M.D.

Harvard Medical School

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

Heart Monitoring May Prevent a Second Stroke

Many strokes have no clear cause. This is unsettling to doctors and patients. Three new studies looked at one known cause — atrial fibrillation. This is an irregular heart rhythm.

Atrial fibrillation causes the upper chambers of the heart (the atria) to stop pumping. Blood can still travel through the atria, but blood flow is sluggish. And blood can form into a clot. A clot in the heart is very risky. It can travel into your large arteries, such as a brain artery. This can cause a stroke.

The new studies found that atrial fibrillation is a probably a much more common cause of stroke than we had known. With careful heart monitoring, however, doctors can detect atrial fibrillation in many stroke patients. Medicine to prevent blood clots can help prevent future strokes.

Two of the studies were published by the New England Journal of Medicine on June 26. They looked at how well heart-rate monitoring detects atrial fibrillation.

The first study included 572 patients with a recent unexplained stroke. Researchers randomly assigned half the patients to a single 24-hour session of heart monitoring in a lab. The other half wore a portable monitor for 30 days. This kind of recording is called an "event monitor."

Atrial fibrillation episodes were found in about 3% of the 24-hour monitoring group. They were found in 16% of the patients monitored for 30 days. In the end, more people in the 30-day monitoring group were treated with anticoagulant medicines.

In the second study, doctors surgically implanted a heart-rate monitor in half of 441 people. The other half got regular post-stroke care. This included doctor visits and electrocardiograms. Patients were followed for 6 to 12 months. Again, heart-rate monitoring found more patients with atrial fibrillation.

Finally, a study published online on July 23 by Neurology looked to see if taking a wrist pulse regularly could detect atrial fibrillation in patients who had a previous stroke. The study included 253 people. They or a family member were taught to tell the difference between a normal pulse and an irregular one. According to the results, slightly more than half of the patients detected an irregular pulse. Many of these patients were experiencing atrial fibrillation.

Detection of atrial fibrillation is important. It is a major cause of stroke in younger patients. Treating atrial fibrilliation can prevent stroke. Guidelines will likely change soon to include better monitoring for atrial fibrillation after a stroke.

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Steroid Inhalers for Asthma Slow Growth in Children

The most effective drugs for controlling asthma are corticosteroids. People take these with an inhaler. Compared with steroid medicines in pill form, inhalers expose the body to very low doses of steroid medicine overall. But a small amount of the drug is absorbed into the bloodstream.  A new review of the evidence shows that inhaled corticosteroids slow children’s growth. The Cochrane Library published the review online on July 17. The news concerns doctors and parents. But the overall effect on growth seems small, compared with the benefit of treating asthma.

Researchers reviewed 25 published studies. They combined data from 8,471 children under 18. Researchers monitored their height as they got older. Children who were not getting inhaler treatments grew an average of 6 centimeters (cm) to 9 cm each year. Children and teens who used corticosteroid inhalers grew about 0.5 cm less than other children did, but only in the first year they used an inhaler. After that, the differences between the groups of children were not significant. 

The review also suggested that lower doses of inhaled corticosteroids had less of an effect on children's growth spurts. Based on the research, it seems important to use the lowest possible dose of steroid medication to control asthma symptoms.

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More News In Brief

  • Tamoxifen Breast Gel May Be Better than Tamoxifen Pills. Tamoxifen slows the growth of some breast cancers and protects against cancer recurrence. But it causes distressing side effects, including menopause symptoms and an increased risk for blood clots. Researchers tested a skin gel that contains the active ingredient in tamoxifen. The study included 26 women with the mild form of breast cancer called ductal carcinoma in situ (DCIS). They were randomly assigned to take tamoxifen pills or to rub the gel into the affected breast every morning. After 6 to 10 weeks, the women had breast surgery to remove the areas with DCIS. The results suggest that both forms of tamoxifen suppressed cell growth. Breast tissue in both groups had approximately equal concentrations of tamoxifen, but there was less tamoxifen in the bloodstream of the women who used the gel. Women in both groups still had menopause-like side effects. Based on blood test results, the researchers predict that the gel is likely to cause fewer blood clots. Clinical Cancer Research published the study July 15.

    Additional study will be necessary to know whether the gel has true advantages over tamoxifen in pill form. For now, the gel will be used only in study patients who are closely monitored.

  • Insulin Pumps Perform Better than Injections in Type 2 Diabetes. Type 2 diabetes is usually treated with oral medicine. But about one-third of people with type 2 diabetes need injections of insulin, usually several a day, to control of blood sugar. Insulin pumps are an alternative to injections. These small devices send insulin through a catheter into the skin. They often are used to treat type 1 diabetes. Patients with type 2 diabetes rarely use insulin pumps. In general, lower doses of insulin are needed to treat type 1 diabetes compared with type 2 diabetes.

    So the results of a new study may seem a bit surprising. The study included 495 adults who had poorly controlled type 2 diabetes. Doctors treated the patients with insulin injections for a couple of months. But 331 of these patients still had trouble with blood-sugar control. So doctors divided the patients into two groups. One group got insulin through an insulin pump. The other group continued to get injections. The group using the insulin pumps had fewer episodes of high blood sugar. There were no differences between groups in the number of low-sugar episodes. Hemoglobin A1C test results (another way to look at sugar control in diabetes) were better in the insulin-pump group. This group used about 20% less insulin each day, compared with the group getting injections.

    This study is likely to make insulin pumps more popular for type 2 diabetes treatment. Until now, it has not been clear that they offered a treatment advantage. The Lancet published the study July 2.

  • New Guideline Says Women Should have Fewer Pelvic Exams. The American College of Physicians is recommending that doctors stop doing routine pelvic exams during a woman's annual visits, unless a Pap test is due. The new recommendation also says pelvic exams don't need to include the bimanual (two-handed) exam. During this exam, the doctor feels the position and size of your pelvic organs with one hand. With the other hand, he or she presses gently on your abdomen to guide your uterus and ovaries into a position where they can be easily felt.  The ACP says there is not much evidence to show that this examination finds important conditions when a woman does not have pelvic symptoms. The recommendation was published in the Annals of Internal Medicine on July 1.

    Some doctors find that a bimanual exam helps them to know the location of the cervix. This may help doctors to do a Pap test. During the test, they insert an instrument called a speculum into the vagina. The bimanual exam also helps to diagnose certain problems, such as infections in the fallopian tubes or uterus. Some patients feel reassured by having a doctor check the size and shape of their pelvic organs. Doctors will continue to do a bimanual exam if a women is having symptoms. Many doctors will choose to do the bimanual exam when doing a Pap test. The new recommendation is controversial, but it will probably change usual practice for many doctors.

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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.

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