TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include differences in donor heart acceptance by race and gender, medication for self-managed abortion, aspirin and MASH, and diagnosing Parkinson’s with a skin biopsy.
Program notes:
0:40 Aspirin for fatty liver disease
1:40 Low dose aspirin for 6 months
2:40 Primary prevention?
4:03 Just shy of 14,000 donors
5:03 More likely to have antibodies
5:45 Diagnosing Parkinson’s with skin biopsy
6:45 Could detect in between 92-100%
7:45 Diagnosis of Lewy body dementia
8:45 Medication abortion before and after Dobbs
9:46 Provisions increased
10:46 Sued the FDA
12:12 End
Transcript:
Elizabeth: What are the differences in donor heart acceptance by race and gender?
Rick: Diagnosing Parkinson’s disease with a skin biopsy.
Elizabeth: Taking medications for self-managed abortion.
Rick: And can low-dose aspirin help fatty liver?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, this week it’s all JAMA all the time. Why don’t we start — because I see so many patients who have liver failure secondary to what we’re now calling metabolic acute steatohepatitis. Can aspirin help with that?
Rick: This is called metabolic dysfunction-associated steatotic liver disease, or fatty liver due to metabolic syndrome. That’s usually obesity associated with abnormalities in cholesterol and triglycerides, and hypertension and prediabetes. That’s the metabolic syndrome.
This can contribute to fatty liver disease. Up to one third of those individuals progressed to develop frank inflammation, fibrosis, and unfortunately that can lead to cirrhosis, liver cancer as well, and to death.
In preclinical studies, they have shown the thing that initiates this is platelets — that’s our blood cells that are usually involved in clotting — infiltrate the liver and when they do they promote inflammation. Aspirin is an antiplatelet agent and also treats inflammation as well. The question is, can aspirin reduce fat in people that have this metabolic-associated fatty liver disease?
This is a phase 2 randomized clinical trial; 80 individuals that had metabolic-associated fatty liver disease and half of them received just low-dose aspirin (81 mg) for 6 months and half of them received placebo, and measured the fatty content in the liver. What they found is that those that received aspirin had a reduction in the fat, and those that received placebo had a slight increase, so overall there was about a 10% difference in fatty content.
Elizabeth: With regard to this syndrome, starting at the beginning, employing weight loss and blood sugar management, changes in diet, improvements in exercise, and so forth are really strategies that are well worth trying. How would you say that low-dose aspirin fits into this? Then the other question is, what about the risk of bleeding in these folks?
Rick: When these people have evidence of cardiovascular disease or increased risk, we put them on low-dose aspirin anyway. At least in a small group of patients, there were no increased safety issues. This actually needs to be confirmed in a larger trial.
Elizabeth: Right. I would like you to, though, still comment on this notion of what I’m going to call primary prevention with regard to this, which is let’s just deal with all of those factors relative to metabolic syndrome.
Rick: We need to control these other things: cholesterol, reduce obesity, increase physical activity, and control diabetes. But this is another thing in the armamentarium. It’s inexpensive, it’s readily available, and it’s safe. Now, this may be primary prevention of steatohepatitis.
Elizabeth: Let’s turn now to differences in donor heart acceptance by race and gender of patients who are on the transplant waiting list. This study attempted to evaluate whether race or gender of a heart transplant candidate is associated with the probability of a donor heart being accepted by the transplant center team with each offer.
I was educated a bit on this whole process. Clearly, what happens is a heart becomes available and then it’s offered to different people who are matched by a number of different parameters. The question is, will the transplant center team accept the offer, and that’s the people who actually make this decision.
This is a cohort study that used the United Network for Organ Sharing (UNOS) datasets to look at this organ acceptance with each offer for non-Hispanic Black, non-Hispanic white adults, and males and females from 2018 through 2023. They had almost 160,000 heart offers with just shy of 14,000 donors. They were pretty distributed in terms of races and genders.
If you take a look at this heart offer acceptance by the transplant center team, it was consistently lower for Black candidates than for whites of the same gender and higher for women than for men. They corrected for all the rest of the variables that they could think of and found that this was still persistent. It looks like — and the editorialist comments — that there are some persistent biases that are probably not even at the level of awareness on the transplant center team’s side that are allowing these things to persist.
Rick: I don’t think anybody in the transplant world intentionally refuses transplants based on anything other than the need. That’s one possible explanation is there is unconscious bias. The second is that there was some important difference in these two groups that just wasn’t measured. African Americans are more likely to have antibodies that make them less likely to be a good match. Even when we look at heart transplants, Black patients are clustered within centers. It’s possible that the center-specific acceptance rates are just different. That may be because they are willing or unwilling to assume risk because all of the centers want to have really good outcomes.
Elizabeth: Well, one that they did measure, of course, and that they report is that Black men had the highest proportion of ventricular assist devices at listing and this is a factor that does have something to do with the acceptance of a heart.
Rick: Yep, the hearts are supposed to go to the sickest individuals and they measure that with a number of different ways. The fact that there are disparities, that leads us to the fact that we’ve got to figure out why that is.
Elizabeth: Let’s turn to your next one.
Rick: Can we diagnose Parkinson’s disease with a skin biopsy? Parkinson’s disease is one of a number of different neurologic conditions called synucleinopathies. There is a particular protein called synuclein that’s deposited either in the peripheral nerves or in the central nervous system. Things like Parkinson’s disease, Lewy body dementia, multisystem atrophy, and pure autonomic failure — these are all in that same category and it’s the deposition of this protein. They are typically diagnosed just on the basis of the clinical manifestations and unfortunately there is overlap with other neurologic conditions. And sometimes it can be very difficult to distinguish — in rare individuals, it’s actually not diagnosed until autopsy.
These investigators said, “Well, gosh, maybe we can detect these synuclein proteins on routine skin biopsies.” They took a skin biopsy above the ankle, the thigh, and they took one on the back of the neck. They just looked for synuclein. In each of these conditions, they were able to detect the synuclein protein in the skin biopsy in between 92% and 100% of each of these four conditions. They took individuals that didn’t have these neurologic conditions and did the same skin biopsies, and detected synuclein in only 3%.
There were 343 patients in this, 220 met the diagnosis of a synucleinopathy and 120 were controls. We need to confirm this, but it seems like it’s going to have really broad application. If we can confirm this in larger trials, it could give us great insight into whether a person has one of these neurologic conditions or doesn’t.
Elizabeth: As you know, there is a very prominent researcher at Hopkins who has been looking at this aberrant alpha-synuclein for quite a long time. One hypothesis is that this, by retrograde transport, makes its way from the gut into the central nervous system and that could be the precipitating event that gets the whole thing started.
The other part of it that’s interesting to me is that, for example, with Lewy body dementia in the absence of Parkinson’s disease, it can be a real struggle to make that diagnosis with any precision. I’m wondering two things. What in the world is aberrant alpha-synuclein doing in the skin? Then the question is, what do we need to do about this? Do we scavenge all of the alpha-synuclein that’s in the body?
Rick: These conditions affect about 2.5 million people in the United States — 180,000 new cases each year. Here is the value of being able to identify the skin biopsy, to be able to establish a definitive diagnosis. What we’d like to do in a disease like this is begin treatment early to see if we can alter the course and perhaps this would be a good way to follow, by the way, because the more synuclein protein in each of these biopsies, the more severe the disease.
Elizabeth: If we have treatments. Once again, back to my question of, do we scavenge it and if we do what happens then?
Rick: That’s a great question. Is it really a marker or is it the cause? We know that amyloid is deposited in certain brain tissues with certain conditions. We’ve treated amyloid for a long time. It doesn’t seem to change the ultimate course.
Elizabeth: Finally, let’s turn to this look at the provision of medications for self-managed abortion before and after the Dobbs decision. This is a look at, gosh, the Supreme Court, we all know overturned the right to choose abortion in the United States and 16 states subsequently implemented abortion bans or 6-week gestational limits.
Research that’s already been done indicates that in the 6 months after this decision, about 32,000+ fewer abortions were provided within the U.S. formal healthcare setting. What happened, then, with medication abortions for self-managed abortion outside of this particular setting?
They looked at, cross-sectionally, data from sources that provided abortion medications outside the formal healthcare setting to people in the United States from March 1 to December 31st, 2022. Those include online telemedicine organizations, community networks, and online vendors.
The total number of provisions of medication for self-managed abortion increased by almost the same number as the number of medically formalized abortions: 27,838. Just because somebody gets it doesn’t mean they take it. Then they try to get their arms around the actual use of this medication, and they say it increased by an estimated 26,000+.
Rick: Elizabeth, the FDA approved mifepristone for medication abortion in about 2000 and there is a large amount of scientific data around that. But they restricted it on prescribing and to patient access. In 2016, again based upon a vast amount of experience, the FDA determined that those restrictions were no longer necessary. We reported not too long ago that this can be administered safely. There are very, very few side effects. As a result of those lack of restrictions, a large number of women had access to it.
Well, in 2022 a number of physicians sued the FDA and sought to revoke this, the use of it, or dramatically restrict it because of their concerns about safety issues. But as we talked about, the data indicate there really weren’t any safety issues. This is more about politics. That’s kind of where we sit at the crossroads now. I must say that if you look at the scientific evidence, these can be used safely without restricting access to them.
Elizabeth: Right, and there are a lot more women who are doing it.
Rick: The value of this particular study is, it went outside the traditional ways of identifying medical care to figure out how often this happened.
Elizabeth: The authors note that — and this was a pathway that I never really considered before — sometimes people cross over and go to Mexico in order to purchase these medications. They can also get them in community settings such as flea markets in border towns, and provisioned by community home abortion providers, which I was unaware of.
Rick: Yep. The former — that is, getting medications from Mexico — I’m familiar with. El Paso is on the border. Whenever you do that, you worry that the medications that individuals get may not be regulated. They may be tainted with other things as well.
Elizabeth: More coming on this, no doubt. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.
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