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
Texas
Tech
Health
El
Paso,
look
at
the
top
medical
stories
of
the
week.
This
week’s
topics
include
ADHD
and
CVD,
hospice
care
in
the
city
and
the
country,
CTE
and
dementia,
and
anemia,
cardiac
surgery
and
IV
iron.
Program
notes:
0:37
CTE
and
dementia
in
NFL
players
1:37
Post
mortem
CTE
presence
and
stage
2:35
Past
look
at
brains
of
players
who
died
3:35
Lesion
is
perivascular
tau
4:34
Warning
on
repeated
head
trauma
5:14
IV
iron
for
anemia
before
cardiac
surgery
6:14
Anemic
before
surgery?
7:17
Hospice
in
rural
and
urban
areas
8:18
People
66
years
or
older
who
died
9:20
Length
of
stay
shorter,
private
or
nursing
homes
10:20
Doesn’t
limit
hospice
care
10:33
ADHD
and
CVD
11:33
About
a
30%
increase
in
CVD
12:45
End
Transcript:
Elizabeth:
What’s
the
difference
in
hospice
care
between
rural
and
urban
settings?
Rick:
Patients
undergoing
cardiac
surgery,
is
there
a
benefit
of
IV
iron
if
they
have
anemia?
Elizabeth:
What’s
the
relationship
between
chronic
traumatic
encephalopathy
and
dementia?
Rick:
And
is
there
an
association
with
ADHD
and
cardiovascular
events
in
people
with
hypertension?
Elizabeth:
That’s
what
we’re
talking
about
this
week
on
TT
HealthWatch,
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
Health
El
Paso.
Elizabeth:
Rick,
I’d
like
to
start
first
with
this
issue
of
chronic
traumatic
encephalopathy
at
death
in
National
Football
League
players
and
the
relationship
between
the
presence
of
that
and
dementia
in
their
lifetime.
And
this
is
in
The
BMJ.
This
has
been
an
ongoing
issue
that
we’ve
been
talking
about
for
quite
a
long
time.
This
notion
that
repeated
head
trauma
results
in
a
condition,
CTE,
chronic
traumatic
encephalopathy,
and
that
that,
of
course,
results
in
a
bunch
of
deleterious
outcomes.
And
in
this
case,
they’re
looking
more
closely
at
dementia.
They
had
among
their
participants
over
1,700
former
NFL
players
who
died
in
the
time
period
2008
to
2021,
of
whom
338
donated
their
brains
for
neuropathological
evaluation.
They
were
able
to,
of
course,
access
lots
of
personal
information
and
causes
of
death
in
these
folks.
And
they
asked
neuropathologists
who
were
masked
to
their
clinical
and
playing
histories
to
look
at
their
postmortem
CTE
diagnosis
and
stage
of
CTE.
Among
that
338
whose
brains
were
studied,
315
had
a
diagnosis
of
CTE.
When
they
run
that
backwards
and
they
look
at
the
potential
prevalence
of
CTE
among
all
of
those
NFL
players
who
died,
I
love
this,
they
estimate
a
range
between
18.5%
and
98.7%.
Among
the
brain
donors,
about
31%
of
them
did
have
stage
4
CTE.
About
60%
of
them
had
study
clinician-diagnosed
dementia
with
an
age
of
onset
at
63.4
years.
They
definitely
seem
to
land
on
this
space
that
if
you
have
CTE,
you
have
a
high
risk
of
having
dementia
also.
They
don’t
really
nail
down
very
well,
though,
what’s
the
risk?
Rick:
Yeah.
And,
Elizabeth,
that’s
difficult.
Here’s
why.
In
the
past,
we
took
NFL
players
that
died
of
dementia,
we
looked
at
their
brain,
and
they
had
CTE.
What
you
really
want
to
know
is
let’s
make
sure
we
look
at
all
the
brains
of
all
the
NFL
players
that
die
over
a
certain
period
of
time.
CTE
can
only
be
diagnosed
in
an
autopsy,
and
you
have
to
have
a
pathologist
that
knows
what
they’re
looking
for.
And
that’s
why
it’s
been
very
difficult
to
nail
down.
The
great
value
of
this
particular
study
is
they
had
a
large
number
of
NFL
players
that
had
had
a
postmortem
exam.
Now,
not
every
NFL
player
did
and
that’s
why
this
big
range.
Their
estimate
is
that
about
a
quarter
of
the
individuals
have
CTE,
but
it
actually
could
be
higher
because
you
don’t
know
about
the
ones
that
died
that
you
never
examined.
The
flip
side
is
oftentimes
people
have
dementia,
but
it’s
not
recorded
on
their
death
certificate.
So
trying
to
link
these
two
together
has
been
very
difficult.
And
that’s
why
this
particular
study,
I
think,
adds
some
value.
Elizabeth:
I
have
some
questions
about
why
can’t
we
diagnose
CTE
when
someone’s
still
alive?
They
say
that
the
lesion
that’s
present
in
CTE
is
perivascular
accumulation
of
hyperphosphorylated
tau
in
neurons
at
the
depths
of
the
cortical
sulci.
So
I
get
it.
It’s
way
down
in
there.
But
gosh,
I
would
think
that
with
PET
or
with
something
else,
we
would
be
able
to
come
up
with
something
that
would
be
able
to
say,
yeah,
there’s
an
aberration
here.
Rick:
Well,
you
can
detect
tau.
It’s
a
particular
deposition
in
particular
areas
of
the
brain.
Current
imaging
techniques
we
have
for
looking
at
tau
aren’t
that
specific
yet.
Elizabeth:
I
will
note
that
dementia
was
common
among
these
donors,
and
it
was
dementia
of
all
kinds
of
different
types.
And
there
did
seem
to
be,
if
you
had
stage
1
CTE,
how
many,
and
so
forth,
with
90%
plus
of
those
with
stage
4
CTE
having
dementia
at
death.
So
that
relationship
seems
to
be
pretty
substantial.
The
authors
come
to
this
lukewarm
conclusion
that
for
right
now,
we
ought
to
be
advising
people
who
are
going
to
play
American-style
football
that
repeated
head
injury
might
result
in
an
increased
rate
of
this
inflammatory
condition,
as
well
as
dementia
and
early
death.
Rick:
We’ve
known
about
CTE
in
football
players
for
a
number
of
years
now
and
still
it’s
a
lot
of
people
playing
it.
Is
it
related
to
duration?
Is
it
related
to
when
you
play?
Is
it
in
high
school
or
college
or
later
in
life?
Is
it
related
to
the
number
of
head
blows
you
have?
Because
of
the
glamour
and
glitz,
and
money
associated
with
football,
there
are
people
that
are
willing
to
do
that,
much
in
the
same
way
as
boxing,
for
example.
All
the
information
we
can
provide
is
valuable
to
individuals
that
are
considering
either
playing
that
particular
sport
or
maybe
going
to
something
different.
Elizabeth:
Speaking
of
different,
why
don’t
we
stay
in
the
BMJ?
But
let’s
look
at
this
notion
of
intravenous
iron
infusions
to
treat
anemia
before
cardiac
surgery.
Rick:
For
individuals
who
have
cardiac
surgery,
somewhere
between
20%
and
50%
need
to
have
transfusions
as
a
result
of
the
surgery
because
there’s
some
blood
loss.
The
risk
is
higher
if
you
go
in
and
you’re
anemic
to
begin
with.
Oftentimes,
if
a
person
is
going
to
have
elective
cardiac
surgery,
they’ll
tell
the
patient
to
take
oral
iron
a
month
beforehand.
Some
individuals
can’t
tolerate
it.
It
takes
a
little
while
for
the
iron
to
work.
The
alternative
is
to
give
one
single
dose
of
intravenous
iron.
Does
giving
IV
iron
improve
their
outcome?
Specifically,
are
they
able
to
spend
more
time
at
home
in
the
first
90
days
after
surgery?
That
means
either
they
get
out
of
the
hospital
earlier
or
they’re
less
likely
to
be
readmitted.
They
took
920
individuals
who
were
undergoing
cardiac
surgery
and
randomized
them
to
either
receive
placebo
or
intravenous
iron
about
a
month
before
the
procedure.
And
then
they
had
cardiac
surgery.
They
measured
what
their
blood
loss
was.
They
measured
whether
they
were
anemic
before
the
surgery
or
not,
and
then
they
followed
them.
How
many
days
did
they
spend
at
home
over
the
next
90
days?
There
was
an
improvement
with
IV
iron,
but
it
was
pretty
minimal.
Those
that
received
IV
iron,
they
were
at
home
81
of
90
days
afterwards.
Those
that
didn’t,
80
days.
However,
during
surgery,
the
individuals
that
received
IV
iron
were
less
likely
to
receive
a
transfusion,
about
33%
versus
43%.
The
estimate
was
that
they
would
save
44
units
of
blood
over
the
course
of
100
patients
having
cardiac
surgery
if
they
gave
IV
iron.
There
was
no
downside
to
it.
There
wasn’t
an
increased
risk
of
complications,
no
infections
associated
with
it.
Elizabeth:
It
sounds
to
me
like
it’s
a
useful
strategy
because
getting
a
transfusion
is
not
a
free
lunch.
And
I’ll
say
one
of
my
colleagues,
who
is
a
hematologist
and
an
expert
in
this
area,
[mentioned]
that
it
is
like
a
liquid
transplant.
Rick:
You’re
right.
If
we
can
save
44
units
of
blood
for
every
100
people
that
have
surgery,
and
all
we
have
to
do
is
give
them
a
15-
or
30-minute
IV
infusion
of
iron,
it
sounds
like
a
pretty
good
tradeoff.
Elizabeth:
Okay.
Let’s
turn
to
JAMA.
This
is
an
issue
near
and
dear
to
my
heart,
of
course,
hospice.
And
I
actually
think
this
research
letter
provides
us
with
some
really
good
news.
What
it’s
looking
at,
of
course,
is
a
disparity
that’s
between
the
provision
of
hospice
services
between
rural
and
urban
areas.
Previous
studies
have
determined
that
rural
residents
are
more
likely
to
die
in
nursing
homes,
less
likely
to
receive
paid
caregiving
support
at
home,
and
have
a
higher
reliance
on
unpaid
family
caregivers.
So
this
study
was
looking
at,
well,
what
about
hospice
care?
How
does
that
vary
across
the
rural-urban
continuum
in
terms
of
length
of
stay,
setting
of
care,
visits
by
hospice
staff,
and
rates
of
higher-level
hospice
care?
Because
as
we’re
both
aware,
as
people
progress,
sometimes
they
need
to
go
on
to
an
inpatient
unit,
or
sometimes
they
get
provided
with
24-hour
care
at
home
by
the
hospice.
So
they
looked
at,
from
2013
to
2022,
the
master
beneficiary
summary
file
identifying
people
who
had
died
66
years
or
older
within
1
year
of
Medicare
claims
and
a
sub-cohort
of
those
who
had
a
hospice
claim
within
the
last
year
of
their
life.
They
linked
zip
codes
with
that
particular
data,
and
they
assessed
the
calendar
year,
age,
Medicaid
enrollment,
Medicare
Advantage
enrollment
at
time
of
death,
sex,
race,
and
ethnicity.
They
also
looked
at
cancer
and
dementia
diagnoses.
What
they
found
was
that
in
a
cohort
of
21
million
folks
who
died,
51.5%
had
a
hospice
claim
in
the
last
year
of
life.
And
from
somebody
in
the
chaplain
role,
the
fact
that
over
50%
of
people
accessed
hospice
services
is
actually
a
really
good
thing.
When
they
took
a
look
at
814,000-plus
folks
who
died
in
isolated
rural
zip
codes,
they
found
out
that
they
had
lower
hospice
use,
but
not
that
much
lower
hospice
use.
They
also
found
out
that
their
length
of
stay
was
shorter,
their
location
of
hospice
care
was
more
often
in
private
or
nursing
homes,
less
often
in
assisted
living,
and
that
their
use,
and
this
is
the
place
where
there
is
a
big
disparity
of
inpatient
hospices,
hospitals,
and
other
facilities,
when
they
needed
more
intensive
care
was
significantly
lower
at
about
14%
versus
21%
if
you
were
in
an
urban
area.
As
I
said,
though,
I
think
that
in
general,
the
fact
that
they’re
not
that
dissimilar,
except
for
that
one
factor,
is
really
pretty
good
news.
Rick:
Yeah.
Not
only,
as
you
mentioned,
Elizabeth,
it’s
not
very
dissimilar,
that
gap’s
been
narrowing.
The
difference
between
hospital
care,
rural
versus
urban,
was
about
an
8%
difference
in
2013
and
narrowed
to
about
4%
difference
in
2022.
A
lot
of
rural
areas
don’t
have
inpatient
facilities.
I’m
thinking
about
places
in
rural
Texas,
counties
that
not
only
do
they
not
have
any
hospitals,
they
oftentimes
don’t
have
any
healthcare
providers
at
all.
It’s
nice
to
know
that
that
doesn’t
limit
hospice
care.
It’s
provided
in
a
different
way
in
rural
areas,
but
it
doesn’t
mean
individuals
can’t
get
it.
Elizabeth:
Actually,
I’m
somewhat
encouraged
by
it,
and
I
like
those
notes
of
encouragement.
Let’s
finally
turn
to
The
Lancet.
Rick:
In
individuals
with
hypertension,
does
ADHD
increase
the
risk
of
cardiovascular
events?
There
are
studies
that
have
shown
that
ADHD
is
associated
with
increased
risk
of
cardiovascular
events.
People
think
it’s
because
of
the
comorbidities
associated
with
it.
If
you
have
ADHD,
you’re
more
likely,
for
example,
to
have
hypertension,
to
smoke,
to
have
a
sedentary
lifestyle.
You’re
more
likely
to
have
obesity.
Are
all
those
things
the
things
that
contribute
to
it,
or
does
ADHD
in
and
of
itself
increase
the
risk
of
cardiovascular
disease?
If
you
have
a
group
of
individuals
that
are
being
followed,
seven
different
settings
—
like
Australia,
England,
Denmark,
Netherlands,
Norway,
Sweden,
and
even
the
USA
—
for
hypertension,
we
know
that
they’re
going
to
be
treated.
Does
the
presence
or
absence
of
ADHD,
in
addition
to
that,
confer
an
increased
risk
of
cardiovascular
disease?
In
almost
6
million
adults
that
were
undergoing
first-line
antihypertensives
in
these
seven
countries
that
I
mentioned,
ADHD
was
associated
with
a
higher
risk
of
major
adverse
cardiac
events,
about
a
30%
increase,
about
a
threefold
increase
in
all-cause
mortality.
There’s
some
concern
that
treating
ADHD
with
medications
increases
the
risk
of
cardiovascular
disease.
So
then
they
looked
at
those
treated
with
ADHD
medications,
those
without,
and
what
they
discovered
was
that
the
use
of
medications
did
not
make
that
any
worse
at
all.
Elizabeth:
The
authors,
of
course,
suggesting
that
this
is
a
factor
that
clinicians
need
to
be
aware
of
when
they’re
managing
their
patients.
Outside
of
that,
though,
what
about
a
mechanism?
I
don’t
get
it.
Rick:
We
also
know
that
there
are
behavioral
or
psychosocial
things
that
also
increase
the
risk.
So
is
there
something
with
regard
to
ADHD,
regarding
the
behavior
or
psychological
issues,
that
if
we
treat
those,
we
can
lower
the
risk?
The
real
answer
is
we
don’t
know
the
mechanism.
Elizabeth:
No
doubt
there’s
more
coming
since
this
is
such
a
prominent
condition
all
around
the
world.
Rick:
Yeah.
Elizabeth:
On
that
note
then,
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.
Please
enable
JavaScript
to
view
the