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 long COVID and variants, treatment of asymptomatic kidney stones, a new blood marker for diabetes and cancer, and managing intracranial atherosclerosis.
Program notes:
0:45 Post-COVID syndromes associated with variants
1:45 Systemic inflammatory cluster
2:43 Treatment of asymptomatic kidney stones
3:45 Time to relapse 75% longer with treatment
4:45 New techniques and equipment
5:45 Millions of people with stones
6:05 Two studies in intracranial atherosclerosis
7:05 Also got an additional antiplatelet agent
8:05 Risk of recurrent stroke
9:00 Novel risk marker plasma prostasin
10:01 Significantly associated with both diabetes and cancer
11:30 End
Transcript:
Elizabeth: Do we have a new blood risk factor for cancer and diabetes?
Rick: Associating long COVID symptoms with different variants of the virus.
Elizabeth: Should small asymptomatic kidney stones be removed if someone is already been identified with the stones?
Rick: And strategies for treating atherosclerosis of the blood vessels to the brain following a stroke.
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, how about if we turn straight to, of course in our way, this notion of, “Hmm, what kind of post-COVID syndromes might you have if you have a different variant of COVID?” That’s in medRxiv.
Rick: This was a really interesting study conducted in the United Kingdom in which they tried to do a couple of things. One is they try to see whether there was an association of different long COVID symptoms and relate them to either people who were vaccinated or unvaccinated and the various variants of the COVID virus — the wild type, the Alpha variant, and the Delta variant — and they looked at the various symptoms in over 9,300 individuals.
They were able to identify three common patterns. There was a central neurologic cluster associated with the Alpha and Delta variants that caused things like brain fog and confusion.
There was a second cluster. It’s called a cardiorespiratory cluster. It was typically linked to more severe symptoms, such as severe shortness of breath, cardiac issues, and lung problems associated primarily with the wild-type variant.
Then there was a systemic inflammatory cluster that often had immune-related symptoms. This transpired across all three different variants. These clusters weren’t affected by the vaccination status of the individual. It didn’t appear to alter the profile or the type of long COVID symptoms associated with these different ones.
Elizabeth: There is a paper that we are not discussing this week, but that just came out in The Lancet, that looks at the risk of developing long COVID among quite a large cohort and establishes that as 1 in 8 will end up with these long COVID symptoms. I guess I’m still struggling a little bit with all of this and what its clinical impact might be.
Rick: It’s not rare. What these authors hope to do by clustering these things is try to find some common etiologies or causes that would help direct prognostication, identification, or treatment. But I think we’ll be talking about this more in the future.
Elizabeth: Unquestionably, we’ll be talking about it more. Let’s turn from here to the New England Journal of Medicine. This is a study that addresses this very common condition and that’s kidney stones. It looks at whether, when somebody has a symptomatic kidney stone that’s being treated if, “Oops, while you’re at it should we take a look at other small stones, those that are smaller than 6 mm, but that are asymptomatic? Should we also attempt to remove those? What does that do in terms of recurrence?”
They did a multicenter randomized controlled trial. However, in that trial they only got 38 patients in their treatment group and 35 patients in their control group. They looked at endoscopic removal of stones in the ureters or contralateral kidney stones. The remaining small asymptomatic stones, again, were removed in 38 of these patients and then they followed up these folks for a mean time period of 4.2 years.
They were able to show that the time to relapse was 75% longer in the treatment group than in the control group. The risk of relapse was 82% lower in the treatment group than the control group. They also looked at the financial aspects of this and they determined that it was actually less expensive to go ahead and treat these asymptomatic stones than it was to let this person go on and then get symptomatic later.
The editorialist makes the argument that this is, “Okay and probably a good idea to go ahead and do this,” although they did note that only one-fourth of the patients in both groups were prescribed preventive medications to try to assist with this recurrence risk.
Rick: Elizabeth, as you said, this is an interesting study because if you’ve had kidney stones and they have been treated there is about a 50% chance that you’ll have a relapse within the next 4 to 5 years. As you said, these are individuals who are already going to be treated for kidney stones. It comes on the fact that the treatment has gotten really much better. The urologist have newer techniques and newer equipment. It’s overall a very safe procedure.
Now, the real question is, “Okay, what about in individuals that aren’t having asymptomatic kidney stones? Should we be doing something for their asymptomatic stones?” But if a person is having treatment for symptomatic kidney stones, the urologist should at least consider removing the smaller ones that are asymptomatic in the same patient.
Elizabeth: Right. I also wonder, though, in this extremely common problem, whether screening would be appropriate in people who have already had an issue. Then finally, the editorialist makes the statement that an alternative to pre-emptive surgical intervention would be to figure out how to make small stones detach and pass spontaneously.
Rick: You’re right. The options are medications to decrease the formation of new stones or dislodgement of one. Secondly is trying to dislodge them and keep them asymptomatic. That sounds like a pretty noble, but difficult goal. Or the third is to remove them at the time of a procedure. There are millions of individuals that already have symptomatic kidney stones, and removing the additional stones only takes about 25 minutes longer.
Elizabeth: What about this idea of screening? What do you think of that?
Rick: I would only screen if we are going to do something about it. Do you treat their stones? That’s really what a study should address. In that case, if it’s proven to be beneficial, then screening should be pursued.
Elizabeth: Let’s move on to your next one. That’s in JAMA and actually there were quite a few of them.
Rick: Elizabeth, we’re going to talk about two studies together. Both of these are treatment strategies for people that had intracranial atherosclerosis blockage in the blood vessels in the brain that cause stroke. Approximately 12% of white patients with a history of an acute ischemic stroke, or what’s called a transient ischemic attack, have some form of intracranial atherosclerosis. If you actually look at people under the age of 55, about one-third of them have intracranial atherosclerosis.
At the time of stroke, how do you best treat it to minimize neurologic dysfunction and to reduce the risk that there will be a recurrent stroke? Removing the thrombus or the clot that’s causing the stroke is one of the most effective therapies.
Can we combine additional therapies to that to make it even more effective? One of which is to use more intensive antiplatelet agents that would potentially reduce the risk of recurrent stroke.
In one of the studies they did that. Patients underwent thrombectomy. They removed the clot. They received aspirin and then half received a very potent antiplatelet agent called tirofiban intravenous for 20 hours after the procedure.
Unfortunately, what happened was it didn’t really improve the neurologic deficit, but it did increase the risk of bleeding inside the brain. The second study looked at, “OK, what about afterwards, after you have done the thrombectomy either doing a balloon angioplasty or a stent where there was a blockage there?”
They took 358 patients that had a stroke. They did a thrombectomy. They waited for 3 weeks to 12 months afterwards and then randomized them to either put in a stent and a balloon or just continue medical therapy. What they found out was, that was not the case. The addition of stenting or balloon angioplasty didn’t reduce that risk at all. In fact, it increased it slightly initially and even over the course of years there was no improvement in survival.
Now, that’s partly, Elizabeth, because our medical therapy is so good now. They’re using intensive statin therapy and aspirin therapy, and we lower their blood pressure. In that setting the risk of recurrent stroke was really pretty low, about 7% over the course of a year, and the overall mortality at 3 years in the medical group was 1.3%.
Elizabeth: Yeah, and I wouldn’t be me without saying that I think we even need to go further back than that, and let’s prevent any of these events to begin with and not have to institute all of this by paying really careful attention to everything — blood pressure, sodium, and so forth — so that we can avoid the whole problem for most people.
Rick: Elizabeth, we know the risk factors: diabetes, cigarette smoking, and high blood pressure that’s not treated. There is a genetic component as well. The average age of these individuals is only 56 years old. You’re right, preventing stroke is really much more effective than treating stroke.
Elizabeth: Since we are talking about — you already mentioned a risk factor for that — diabetes, then let’s turn to Diabetologia. This is a look at a novel risk marker for diabetes and cancer mortality. This is called plasma prostasin. I hadn’t heard of this before. Had you?
Rick: No. It’s news to me.
Elizabeth: This was a study that was conducted in the Malmö Diet and Cancer Study cardiovascular cohort; that’s in Sweden. They had in this particular study 4,600+ participants and they excluded a few of those folks because they didn’t have sufficient data for all of them.
What they were looking at was this blood marker, prostasin, and blood glucose levels and other covariants. This marker, interestingly, is associated with epithelial sodium channels. There is a relationship there between those sodium channels and ultimately with diabetes and this cancer risk.
They followed them up for quite a while — 22 years more or less. During that time, several of these people developed diabetes and also died from cancer. They were able to show that prostasin was significantly associated with the incidence of diabetes and with cancer, especially strong association in individuals with impaired fasting blood glucose levels at baseline. They are suggesting that this might be a marker that we could start paying attention to.
Rick: Studies like this I find are fascinating, but I’m going to talk about the limitations. There was a single measurement of prostasin in these individuals. You want to follow this over a long period of time. For example, we don’t even know if prostasin levels fluctuate in the normal population.
Whenever you see these, you ask yourself, “Is there an association at all? Secondly, is it causal or not? Is this a marker or not? Is it a byproduct? Is it related or not?” These are all things that need to be identified. An interesting hypothesis, but a lot more to be done.
Elizabeth: I would finally note, however, that we have talked a lot — and I have talked a lot it seems like — about this relationship between diabetes and different kinds of cancers. I think trying to find a smoking gun in here is something that I’m really very interested in.
Rick: Yeah, and that’s an association many of our listeners may not be aware of. It’s clear that diabetes is associated with an increased risk of cancer and there is no question about that.
Elizabeth: More to come. No doubt. 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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