As the first decade of the 21st century comes to an end, it is interesting to look back and reflect on the most significant medical advances we’ve seen. I’d like to present 12 medical advances that I consider to have been the most important over the past decade, and I’d like to ask you, the wider world, to contribute in two ways:
– Add your nomination in the comment field regarding anything I’ve overlooked.
– Visit The Examining Room of Dr. Charles in 1 week to vote on what you think is the top medical advance of the past decade.
So, here is a list I’ve put together, both off the top of my head and with some research. If you had to choose one now, which would you consider the most important?
Battlefield Medicine (2001-present) – Improvements in trauma care have reduced mortality from gun assaults from 16% in 1964 to just 5% today, yet the numbers are more impressive in wars. According to an article in the NEJM by Dr. Atul Gawande: “Though firepower has increased, lethality has decreased. In World War II, 30 % of the Americans injured in combat died. In Vietnam, the proportion dropped to 24 %. In the war in Iraq and Afghanistan, about 10 % of those injured have died.” Forward Surgical Teams that operate closer to the battlefield, Combat Support Hospitals, and improved trauma stabilization techniques have contributed to this decrease in mortality.
WHI Study, and recent fall in breast cancer rates – The Women’s Health Initiative was perhaps the largest and most significant study to be published this decade. A full discussion of the results can be found elsewhere, but compared with the placebo, women taking estrogen plus progestin had a mild but significant increased risk of heart attack, stroke, blood clots, dementia over 65, and breast cancer. On the positive side they were found to have a reduced risk of colorectal cancer and fewer fractures. These evidence-based results changed prescribing behavior among doctors overnight. Since the first results of the WHI were published, there has been a considerable drop (~15%) in breast cancer incidence, attributed to decrease in hormone replacement therapy.
HPV vaccination – Gardasil will prevent the 2 types of HPV that cause most cervical cancers (about 70%), and also protect against the 2 types of HPV that cause most genital warts (about 90%) in females who have not already been exposed to these types of HPV. Long term trends wait to be seen, but it would seem intuitive that rates of cervical cancer, cervical biopsies, and other high risk HPV-related cancers such as genital, anal, and head and neck cancers should further decrease, marking the greatest impact on cervical cancer disease since the Pap smear was introduced.
Cardiac Arrest Hypothermia Protocol – It has been demonstrated since the 1950’s that cooling the body after cardiac arrest can have therapeutic benefits in terms of preventing or minimizing anoxic brain injury. Restoring oxygen circulation to a brain too quickly can trigger a series of reactions that includes the production of damaging free radicals. But it was not until this decade that several major studies confirmed the benefits of cooling protocols, and major institutions started cooling comatose victims after cardiac arrest with encouraging results, and are now applying the science to other problems such as newborn birth asphyxia.
Better Clot-Busting Drugs – Fibrinolytic clot dissolving medications like tPA (tissue plasminogen activator) have improved the treatment of ST-elevation myocardial infarction, acute ischemic stroke, and acute massive pulmonary embolism. Although PCI (percutaneous coronary intervention) has been shown to be superior to fibrinolytic drugs, less than 25% of acute care hospitals have the cardiac infrastructure to be able to offer it, and so fibrinolytics open a lot of arteries that would otherwise have remained closed with clots. According to a review of studies published in Chest: “…benefits of thrombolysis translate into absolute benefits of 26 lives saved per 1,000 patients with acute MI treated, and 126 fewer dead or dependent stroke patients for every 1,000 thrombolysis-treated patients within 3 hours of symptoms onset.”
The Human Genome Project and gene therapy – The international effort to sequence every gene in the human genome was completed ahead of schedule in 2003. While gene therapy has not yet realized its full promise, researchers are able to share gene specific knowledge across the entire human genome database, and the project is credited with catalyzing the multibillion dollar U.S. biotechnology industry. The scale, cooperation, and long term promise of the project are remarkable.
Near eradication of Guinea Worm – From 3.5 million cases in 1986 to only 3,000 in 2009, Guinea Worm has been 99% eradicated from the globe. Nigeria, once the worst affected country, has not had a case in 12 months. The Guinea worm is ingested as larvae in contaminated drinking water and within a year can grow to be three feet long before slowly burrowing out of the skin and causing excruciating pain for months. Credit the efforts of the Carter and Gates Foundations and the WHO. Humans are the only host for the parasite, and with the last case of human infection the worm will have lost its parasitic life cycle “habitat.” The introduction of mesh filters for drinking water, and pipe filters that can be worn around the neck by nomadic peoples, has Guinea Worm disease poised to be the first disease eradicated without vaccines or medications, and the next since smallpox to vanish from the Earth.
Drug-eluting stents improve the success of angioplasty in treating coronary artery disease – The 2007 COURAGE Trial showed that the outcomes of intensive medical management (lifestyle, pills, etc.) of patients with stable angina or narrowed coronary artery are comparable to more invasive placement of stents. But as this Harvard Medical School guide states: “For a sudden blockage of a coronary artery, emergency artery-opening balloon angioplasty followed by the placement of a stent is the best remedy around.” Restenosis rates have fallen from 30 to 40 % after balloon angioplasty to 20 to 30 % after bare metal stents to less than 10 % with drug-eluting stents, according to Up To Date.
Online health knowledge, and the patient education revolution – free, publicly accessible sites such as the NIH, CDC, WebMD, Mayo Clinic, Up to Date, emedicine, medical and patient blogs present a modern day Great Library of Alexandria. Never in the history of the world have patients with diseases been more empowered to help themselves and participate in their medical care. The downsides include many self-proclaimed “experts” with misleading information, dubious “cures”, and undue anxiety for those who use the internet to attempt to self-diagnose. But the benefits are clear in terms of education, prevention, community support, continuing physician education, transparency of evidence and clinical studies, and sometimes even physicians are helped by Dr. Google.
Treatment of HIV/AIDS – in the past decade HIV continues to decline from being a universally feared and inexorably fatal disease to a somewhat manageable chronic disease. Although antiviral drug resistance is becoming more problematic, and less fear of the disease threatens to ease its spread, the fact remains that people like Magic Johnson are still here today. In the U.S. in 1993 over 50,000 people died of AIDS, while in 2008 the number dropped to around 14,000. There are still more than 460,000 people in the U.S. living with HIV/AIDS. Whereas a person diagnosed with HIV in the past had a life expectancy of 10-12 years, according to an article on Web MD: “An HIV-positive person who started on combination antiretroviral drug therapy at age 20 can expect to live to age 63.” Assuming we stay ahead of the shifty retrovirus, perhaps we will see a successful vaccine in the coming years.
Smoking bans and consequent fall in community cardiovascular disease – the advent of smoking bans in public picked up steam in this decade, and many large cities now ban smoking in bars. A recent study showed this has benefited non-smokers even more than anyone might have guessed. According to the BBC: “Bans on smoking in public places have had a bigger impact on preventing heart attacks than ever expected, data shows. Smoking bans cut the number of heart attacks in Europe and North America by up to a third, two studies report… the results of numerous different studies collectively involving millions of people, indicated that smoking bans have reduced heart attack rates by as much as 26% per year.” But maybe including this one shows I’m just partial to getting a beer without my clothes stinking?
Pandemic Planning and Coordination of Response – While it may seem like a lot of hype at times, the H1N1 pandemic has infected an estimated 50 million Americans, and contributed to the deaths of 10,000. Considering that the seasonal flu often kills 35,000 per year, this pandemic could have been much worse. The production, distribution, and coordination of the vaccine, combined with stockpiling of antiviral medications, took tremendous effort. Yet many feel we are terribly unprepared, and had this disease been more virulent we would be looking back with Katrina-like indignation. Well done, or damned if you do/don’t?
These are my nominations for medical advance of the decade. Please share any others you can think of, along with the reasons the advance you cite is important.
Then visit The Examining Room of Dr. Charles next week and check out the amended list and vote. I think it will be fun.
Of course an obsession with advancements can make us devalue the time-tested basics such as living a healthy lifestyle, sanitation, and not smoking as we chase the latest expensive hype promised to change the world. Yet medical progress does provide us with hope that we might still overcome those basic human experiences of suffering and disease, and better our lives and the lives of others.
May the best advance win!
Dr. Charles is a family physician who blogs at The Examining Room of Dr. Charles.
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