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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: November 2012

November 29, 2012

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.

Epidural Injections for Sciatica Pain Help Only Slightly

Sciatica is pain in the leg that is triggered by a pinched or irritated nerve in the back. It often occurs along with back pain. It can be an aching or burning pain. And it can be severe. For some people, sciatica goes away on its own. For others, it is long lasting.

Doctors commonly treat sciatica with an injection of steroid medicine into the spine (epidural injection). A new report looked at how effective this treatment is. It was published online November 13 by the journal Annals of Internal Medicine.

Researchers combined the results from 14 previous studies that compared steroid injections to placebo injections. Altogether there were 1,316 patients. For some people, an epidural injection gave good relief from pain for several months. This allowed them to work again. But for most people, the benefit was quite small.

On a scale of 1 to 100, on average epidural injections only improved pain by a score of 6.2 in the first two months after the injection. Doctors usually consider a change of 10 to 30 points to be a pretty significant improvement. In addition, the pain relief did not last. There was no difference in pain between placebo and treatment groups one year after the injections. Steroid injections do have some risks, including a small risk for serious infection. Recently there was an outbreak of fungal meningitis caused by contaminated steroid solution.

Doctors will still offer epidural injections to patients with severe sciatica pain. But both doctors and patients (as well as insurers who can approve or deny treatments) should be aware that they only offer a small and short-lasting benefit.

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Fasting May Not Be Needed for Cholesterol Tests

It's standard practice to fast (avoid eating and drinking) for at least 8 hours before a blood test to check your cholesterol. But a new study is calling this into question.

Researchers collected test results for more than 209,000 people. They were asked how long they had fasted before their test. Then the researchers compared the cholesterol levels of people who fasted with those of people who didn't fast. They found that levels of total cholesterol and HDL cholesterol (high-density lipids or "good" cholesterol) varied only about 2% whether a person fasted or not. LDL levels (low-density lipids or "bad" cholesterol) varied less than 10% with and without fasting. Triglycerides varied the most, but by less than 20% with and without fasting.

We can't say anything certain about how fasting affects cholesterol tests based on this study. That's because this study did not randomly assign patients to fasting or not fasting. However, it is likely that this study will prompt new research. If new studies have similar results, cholesterol testing could become much more convenient. The journal Archives of Internal Medicine published the study online on November 12.

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Alcohol Makes Up 5% of Our Total Calories

A new study from the National Center for Health Statistics finds that about 5%, on average, of all the calories U.S. adults consume come from alcohol. The study and a news brief were published online by the Centers for Disease Control and Prevention on November 15.

Soda and other sweetened drinks, by comparison, make up 6% of calories. Like soda, alcohol has "empty" calories. It has no nutritional value. This is a good reason to drink less – or not at all.

This study suggests that another good reason to reduce drinking is obesity. A soda has about 140 calories. A typical beer has about 150 calories. And a 5-ounce glass of wine has about 100 calories.

If you drink an average of one drink per day, you'll have to exercise an extra 30 minutes about 3 days a week to burn your alcohol calories. This is relative to the amount of exercise you might need if you drank no alcohol, and if you were watching your weight.

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More News in Brief

    • HIV Tests Recommended Once for Every Adult. The U.S. Preventive Services Task Force (USPSTF) has issued a "draft" recommendation that all adults ages 15 to 64 get tested for HIV, whether or not they are at risk for exposure. Previous recommendations have not included testing low-risk people. The task force points out that 20% to 25% of people who have HIV don't know they are carrying the virus. Testing all adults will allow people to get treated, and will reduce the spread of HIV.

      Draft recommendations by the USPSTF are typically made into formal recommendations after the task force collects and considers comments from doctors for several months. The draft recommendation was published November 21 on the USPSTF website. When this task force makes recommendations, doctors usually follow them. The USPSTF also affects patient costs for testing. Under the Affordable Care Act, insurance must cover preventive-care tests that the task force strongly recommends at no cost.

    • Steroid Treatment Helps Recovery from Bell's Palsy. When one side of a person's face suddenly droops, it could be a sign of a stroke. But when it's the only symptom, it's usually caused by an inflamed nerve. This is called Bell's palsy. It's common, especially in older adults. And it almost always goes away on its own. But 15% of people who get Bell's palsy do not fully recover, and their facial expressions can remain uneven.

      A guideline, published November 7 in the online issue of the journal Neurology, recommends giving patients a short course of steroid treatment (prednisone) for the condition. The guideline is based on a review of studies that looked at the effectiveness of various treatments. The steroids increase the chances of a good recovery. Doctors suspect a virus may cause the nerve inflammation. So many also prescribe antiviral medicines to treat the condition. According to the guideline, studies have shown that antiviral medicine only has a very minor benefit.

    • Aspirin Does Not Prevent a Second DVT. Deep venous thrombosis (DVT) is a blood clot in a large vein. People with DVT need treatment with a blood thinner (anticoagulant), such as warfarin (Coumadin), for several months. This helps prevent serious complications, including a blood clot that travels to the lungs (pulmonary embolus).

      Researchers wanted to see if long-term daily use of aspirin might prevent a second DVT. Their study included 822 patients who had finished their treatment for DVT. Half of them took a placebo pill. The other half took an aspirin. The results were published online November 22 by the New England Journal of Medicine. (Brighton, TA, et al. "Low-dose aspirin for preventing recurrent venous thromboembolism." The New England Journal of Medicine. 2012; 367:1979-1987.) They were not too impressive.

      Among patients who took a placebo pill, 6.5% per year had another DVT. Among those who took aspirin, 4.8% per year had a second DVT. This difference was not scientifically significant. However, there were unrelated benefits. Aspirin prevented some strokes and some heart attacks, but there was also an increased risk for side effects, such as bleeding.

      Your doctor can help you to weigh the risks and benefits of taking aspirin. Your decision should probably be based on your risk for heart disease, stroke and intestinal bleeding. Not on preventing a second DVT.

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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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