Harvard Medical School's Sharon K. Inouye, MD, MPH, is editor in chief of JAMA Internal Medicine and a leading voice in American gerontology. We asked her to choose five of the influential journal's most impactful studies from 2023 and highlight important take-home messages for internists and their colleagues.
Q: One of the studies you chose suggests that the antiviral nirmatrelvir (Paxlovid) can ward off long COVID. Could you recap the findings?
A: Researchers followed a group of more than 280,000 Department of Veterans Affairs patients who were seen in 2022, had a positive COVID test, and had at least one risk factor for severe COVID. They focused on those who survived to 30 days after their COVID infection and compared those who received the drug within the first 5 days of a positive test with an equivalent control group.
They found that 13 long COVID symptoms were all significantly less common (relative risk = 0.74) in those who received nirmatrelvir. This was true no matter whether they'd ever had a COVID vaccination.
Q: How should this research affect clinical practice?
A: You can't generalize from this to everyone because, of course, not everyone was included in this study. But it is highly suggestive that this drug is very effective for preventing long COVID.
Nirmatrelvir was touted as being able to shorten duration of illness and prevent hospitalization. But if you were low risk or you were already well into your COVID course, it wasn't like rush, rush, rush to the doctor to get it.
This changes that equation because we know long COVID is such a huge issue. The vast majority of doctors who work with COVID patients and know this are now being more aggressive about prescribing it.
Q: What about patients whom the CDC considers to be at less risk — people with up-to-date vaccinations who are under 50 with mild-to-moderate COVID and no higher-risk medical conditions? Should they take nirmatrelvir?
A: The evidence is not 100% in yet. A study like this one needs to be repeated and include younger people without any risk factors to see if we see the same thing. So it's a personal choice, and a personal calculus needs to be done. A lot of people are making that choice [to take the drug], and it can be a rational decision.
Q: You also chose a study that links high thyroid hormone levels to higher rates of dementia. What did it reveal?
A: This study looks at patients who had thyrotoxicosis — a thyroid level that's too high — from hormone produced endogenously and exogenously. Researchers tracked almost 66,000 patients aged 65 and older and found that thyrotoxicosis from all causes, whether it was endogenous or exogenous, was linked to an increased risk of dementia in a dose-response relationship (adjusted hazard ratio = 1.39).
Q: Is there a clinical take-home message here?
A: When we start patients on thyroid medication, they don't always get reassessed on a regular basis. Given this finding, a TSH [thyroid-stimulating hormone] level is indicated during the annual wellness check that patients on Medicare can get every year.
Q: Is TSH measured as part of routine blood tests?
A: No it's not. It has to be ordered. I think that's why we're seeing this problem to begin with — because it's not something we all have awareness about. I wasn't aware myself that mildly high levels of thyroid could increase the risk of cognitive impairment. Certainly, I'm going to be much more aware in my practice.
Q: You also picked a study about silicosis in workers who are exposed to dust when they make engineered stone countertops, also known as quartz countertops. What were the findings?
A: Silicosis is a very serious lung condition that develops from exposure to crystalline silica. Essentially, sand gets inhaled into the lungs. Workers can be exposed when they're making engineered stone countertops, the most popular countertops now in the United States.
This study is based on statewide surveys from 2019 to 2022 that the California Department of Public Health does routinely. They gathered cases of silicosis and found 52 — all men with an average age of 45. All but one were Latino immigrants, and most either had no insurance or very poor insurance.
Q: The study found that "diagnosis was delayed in 58%, with 38% presenting with advanced disease (progressive massive fibrosis), and 19% died." What does that tell you?
A: It's a very serious condition. Once it gets to the advanced stage, it will just continue to progress, and the person will die. That's why it's so important to know that it's absolutely preventable.
Q: Is there a message here for internists?
A: If you treat a lot of immigrants or work in an area where there are a lot of industrial workers, you're going to want to have a very high suspicion about it. If you see an atypical pattern on the chest X-ray or via diffusion scoring, have a low threshold for getting a pulmonary function test.
Doctors need to be aware and diagnose this very quickly. When patients present, you can pull them out of that work environment or put mitigation systems into place.
Q: California regulators were expected to put emergency rules into place in late December to protect workers. Did this study play a role in focusing attention on the problem?
A: This article, along with a commentary and podcast that we put out, really helped with advocacy to improve health and safety for workers at stone-cutting and fabrication shops.
Q: You were impressed by another study about airborne dangers, this one linking air pollution to dementia. What did researchers discover?
A: [This analysis] of more than 27,000 people in the Health and Retirement Study, a respected and rich database, found that exposure to air pollution was associated with greater rates of dementia — an increase of about 8% a year. Exposure to agricultural emissions and wildfire smoke were most robustly associated with a greater risk of dementia.
Q: How are these findings important, especially in light of the unhealthy air spawned by recent wildfires in the United States and Canada?
A: Studies like this will make it even more compelling that we are better prepared for air quality issues.
I grew up in Los Angeles, where smog and pollution were very big issues. I was constantly hearing about various mitigation strategies that were going into place. But after I moved to the East Coast, I almost never heard about prevention.
Now, I'm hoping we can keep this topic in the national conversation.
Q: You also highlighted a systematic review of the use of restraints in the emergency department. Why did you choose this research?
A: At JAMA Internal Medicine, we're really focused on ways we can address health disparities and raise awareness of potential unconscious bias.
This review looked at 10 studies that included more than 2.5 million patient encounters, including 24,000 incidents of physical restraint use. They found that the overall rate of use of restraints was low at below 1%.
But when they are used, Black patients were 1.3 times more likely to be restrained than White patients.
Q: What's the message here?
A: This is an important start to recognizing these differences and then changing our behavior. Perhaps restraints don't need to be used as often in light of evidence, for example, of increased rates of misdiagnosis of psychosis in the Black population.
Q: How should physicians change their approach to restraints?
A: Restraints are not to be used to control disruption — wild behavior or verbal outbursts. They're for when someone is a danger to themselves or others.
Dr Inouye has no conflicts of interest.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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