2023 in Review: Other Important Research

Educational Objectives

Summary

2023 in Review: A Synopsis of Other Important Research

In 2023, NEJM Journal Watch Audio General Medicine covered many studies that are not included in our detailed Year in Review feature but still were important contributions to the clinical literature. Here are brief synopses of some of those studies.

New colorectal cancer screening guideline

Several years ago, the U.S. Preventive Services Task Force and the American Cancer Society recommended that people at average risk should begin colorectal cancer screening at age 45 instead of age 50 (https://doi.org/10.1001/jama.2021.6238). But in 2023, the American College of Physicians issued a “guidance statement” in the Annals of Internal Medicine (https://doi.org/10.7326/M23-0779) and argued that net benefit was insufficient to justify routine screening starting earlier than age 50. Those who favor the age-50 threshold now have a guideline supporting that view.

Managing intermittent claudication

A large observational study in the Journal of Vascular Surgery (https://doi.org/10.1016/j.jvs.2022.10.025) showed that clinically stable patients with intermittent vascular claudication should receive noninvasive medical management rather than early invasive intervention (i.e., angioplasty, stenting, or atherectomy). During several years of follow-up, several adverse outcomes were more likely with early invasive intervention. And in a meta-analysis of randomized trials in the Annals of Surgery (https://doi.org/10.1097/SLA.0000000000005793) comparing exercise therapy to early revascularization in stable patients with claudication, several outcomes favored exercise therapy.

Statins for primary prevention in people with HIV

Because people with HIV have excess cardiovascular (CV) risk, researchers examined the effect of statin therapy in 7700 patients who were taking antiretroviral drugs, whose 10-year CV risk was low (mean, 4.5%) and whose median LDL cholesterol level was 108 mg/dL. Findings appear in the New England Journal of Medicine (https://doi.org/10.1056/NEJMoa2304146). Compared with placebo, pitavastatin lowered the incidence of major adverse CV events significantly — from 7.3 to 4.8 events per 1000 patient-years. Pitavastatin was chosen because it has fewer interactions with antiretroviral drugs than do other statins, but other statins presumably would confer similar benefit.

Pitfalls in management of cellulitis

A meta-analysis of 7 studies in the Journal of Hospital Medicine (https://doi.org/10.1002/jhm.12977) suggested that an initial diagnosis of cellulitis often is incorrect. And an observational study in Open Forum Infectious Diseases (https://doi.org/10.1093/ofid/ofad488) of lower-extremity cellulitis showed that full resolution of signs and symptoms often takes 1 to 2 weeks — even when treatment is correct. The take-home messages are (1) we shouldn’t forget to think about potential alternative diagnoses when we suspect cellulitis, and (2) we shouldn’t necessarily assume treatment failure when symptoms and signs of correctly diagnosed — and appropriately treated — lower-extremity cellulitis are slow to resolve.

Vitamin D and fractures

In 2022, the landmark VITAL trial (https://doi.org/10.1056/NEJMoa2202106) showed that routine vitamin D supplementation did not prevent fractures in healthy community-dwelling older people in the U.S. Now in 2023, a large randomized 5-year trial in The Lancet: Diabetes & Endocrinology (https://doi.org/10.1016/S2213-8587(23)00063-3) has yielded the same outcome in a similar population in Australia. Vitamin D didn’t lower the incidence of fractures, even among participants with baseline 25-hydroxyvitamin D levels lower than 20 ng/mL.

Treatment for patients with Alzheimer disease

In a large study in the New England Journal of Medicine (https://doi.org/10.1056/NEJMoa2212948) of patients with Alzheimer disease, the anti-amyloid antibody lecanemab resulted in slightly less worsening on a dementia rating scale than did placebo, but many observers doubted whether this difference was clinically important. Although the U.S. FDA approved lecanemab based on this trial, controversy persists about the role of this drug — and the other approved anti-amyloid antibody, aducanumab — in treating patients with Alzheimer disease.

Pulmonary embolism probably is underdiagnosed

Two studies addressed the prevalence of pulmonary embolism (PE) in two distinct patient populations. One study in the Journal of Thrombosis and Haemostasis (https://doi.org/10.1016/j.jtha.2022.09.007) showed a surprisingly high prevalence of PE in patients hospitalized with exacerbations of chronic obstructive pulmonary disease. The other study in the International Journal of Chronic Obstructive Pulmonary Disease (https://doi.org/10.2147/COPD.S410954) showed a high prevalence among patients with new-onset exertional dyspnea, even when the initial clinical impression was that other diagnoses were more likely. These studies suggest that PE probably is underdiagnosed when it occurs in certain clinical settings.

Weight loss in patients with advanced cancer

In a trial in the Journal of Clinical Oncology (https://doi.org/10.1200/JCO.22.01997) that involved patients with advanced cancer, weight loss, and chemotherapy-related anorexia, several outcomes (e.g., weight gain, quality of life) were better with low-dose olanzapine than with placebo. This trial’s findings led the American Society of Clinical Oncology to recommend olanzapine as first-line therapy to improve weight gain and appetite in patients with advanced cancer (https://doi.org/10.1200/JCO.23.01280). However, keep in mind that no drugs (including olanzapine) are FDA-approved for this purpose.

Allan S. Brett, MD

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Acknowledgements

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