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 pain and functioning, planned delivery to prevent preeclampsia, an artificial intelligence (AI) decision support for stroke treatment, and the efficacy of rotator cuff surgery.
Program notes:
0:35 Shoulder surgery efficacy
1:30 10 year follow of ASD surgery
2:30 Exercise does relieve pain
3:00 Association of pain with intrinsic capacity and inflammation
4:00 Domains including locomotion and others
5:01 Pain impacts a number of capacities
6:01 Aspirational to figure out pain
6:30 Scheduling birth at term to avoid preeclampsia
7:30 High risk pregnancy delivered at term
8:35 Is there impact on the infants?
9:18 AI decision support for large vessel stroke
10:20 71,000+ patients with ischemic stroke
11:25 U.S. data also not impressive
12:54 End
Transcript:
Elizabeth: How can artificial intelligence inform stroke treatment?
Rick: Scheduling birth to prevent preeclampsia.
Elizabeth: What does pain have to do with functioning in multiple domains across the lifespan?
Rick: And how effective is rotator cuff surgery?
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 Health El Paso.
Elizabeth: Rick, we were talking before we started to record about shoulders and about how prominent shoulder pain is. I cited the fact that I heard recently that, second to knees, shoulders are the second most common reason people seek orthopedic help. This study in The BMJ takes a look at that.
Rick: As you mentioned, shoulder surgery ends up being the second most common orthopedic surgery behind knee replacement. I call it rotator cuff surgery. It’s people that have arm pain, either at rest or with activity. It’s a combination of having injury to the tendons and a bone spur on a portion of the scapula called the acromion. And what the surgery does is it goes in there to remove the bone spur and to decompress the area.
How effective is it? In the United Kingdom, over 30,000 rotator cuff surgeries done. And in the United States, more than 75,000 done. These are called arthroscopic subacromial decompression or ASD surgery.
This is a 10-year follow-up of a study that compared ASD surgery, a sham surgery, and exercise. And in these 200 adults, age 35 to 65, that had rotator cuff pain, there was no benefit at all with either of the surgeries compared to exercise. This is a remarkable study in that about 90% of the people completed the 10-year follow-up and at no time was the surgery better at preventing pain at rest or pain with activity compared to exercise or the sham surgery.
Elizabeth: I always find these results to be somewhat disappointing in that I think we all, and I would include myself in this number, would like to have some kind of a solution that would help to deal with pain that is often relentless. And it’s limiting. A lot like a lot of knee arthroscopy, a lot of spinal surgeries. When we look at long-term follow-ups, oops, it looks like not doing anything other than exercise is just as good.
Rick: Yep. So Elizabeth, I agree with you. You want to have something that relieves the pain. The exercise therapy does and it’s effective early on. It was effective, but more importantly it was effective even out to 5 and 10 years later. This is a scoring system that rates your pain at rest and with exercise. Over the course of time, that pain decreased substantially, decreased according to the score by about 90% with activity, 80% at rest.
Elizabeth: Since we’re talking about pain then, let’s move to The Lancet because this is a study from France that’s looking at association of pain with what’s called intrinsic capacity and the moderating role of inflammation.
They have a study that’s called the INSPIRE-T cohort. It’s an ongoing 10-year observational study in Toulouse, France, that recruited people 20 years of age and older who were not affected by severe illness that could compromise their life expectancy within 5 years. What they were looking at was whether two different factors, whether pain can actually amplify inflammation, and then they were also looking at the moderating role of the inflammatory aging clock in this association. They also wanted to look at whether pain-intrinsic capacity associations varied as a function of age and/or sex.
They had 971 participants from this cohort. They assessed their pain on self-reported presence over the previous 8 days. They had a composite intrinsic capacity score and intrinsic capacity domains, including locomotion, cognition, vitality, psychology, and sensory capacity, including both visual and hearing capacities. If you report pain, is it messing with these various capacities that you might have?
Unsurprisingly, both moderate and intense pain were negatively associated with their intrinsic capacity values. Intense pain was also associated with lower scores in the psychological domain. The only thing that was really increased, and this doesn’t surprise me at all, was the sensory domain. Of course, the more pain you have, the more tuned in you’re going to be to your sensorium.
Interestingly, they found that there was no evidence of a moderating role of this “age clock” in their association with pain and reduced intrinsic capacity. What they conclude is, “Gosh, we need to assess this and see whether effective pain management would help to prevent these declines that they perceive in intrinsic capacity.”
Rick: Yeah. It was interesting that pain affected a number of those different variables that go to the intrinsic capacity. The other thing that was interesting is that that occurred whether you were young or old. And that implies that if it starts at a young age, cumulatively, the results are worse with regard to intrinsic capacity.
Elizabeth, here’s the major issue I have. In the past, we spent a lot of time controlling pain using narcotics and opioids. What we have now experienced, the opioid crisis, just because we called pain one of the vital signs, like blood pressure and heart rate, and our goal was to control it. And in doing so, we actually made a new medical problem. I’d like to hear your thoughts on that.
Elizabeth: I am gratified that there are many people who are working on non-opioid pain relievers, and some of them have actually gotten approved. So that’s kind of interesting. And clearly, we need to figure that out. I agree that pain as a fifth vital sign was not a good thing, and started off a whole cascade of things that now we’re trying to deal with. I also think that based on this study, that it is aspirational to try to figure out how to ameliorate pain, particularly since this study shows that it does impact on people’s ability to function.
Rick: And it is graded, by the way, and the people that are most severely affected are those that have the most intense pain, compared to those that have moderate or mild pain. So I’m not saying that people should suffer, but I think we need to make sure that we direct our efforts to addressing inflammation, pain, and intrinsic capacity, at the same time not creating a new medical issue or a new medical problem.
Elizabeth: I agree. We’re staying in The Lancet, and we’re going to look at, “Gosh, does it help to schedule birth at term to prevent preeclampsia?”
Rick: And preeclampsia is a leading global cause of both maternal and child perinatal mortality and morbidity. On average, about 1 in every 30 pregnancies are complicated by preeclampsia. About a fourth of those occur preterm, that is, in the last trimester of pregnancy, and about three-fourths of them actually occur at term, about 40 weeks of pregnancy. And it’s responsible for more than half of maternal and at least a quarter of fetal or newborn deaths or major morbidity.
If it’s detected preterm, and we detect it by looking at protein in the urine, we look at blood pressure, is that aspirin is effective in the preterm. At term, aspirin is not effective and so it exposes the mother and the baby to these risks. We have ways of predicting who is at high risk of developing preeclampsia, and those individuals, delivering them at term before they develop preeclampsia can be beneficial.
So that’s exactly what these investigators tried to do. They tried to identify high-risk pregnancies, randomize them to either continuing to deliver the child, just whenever they went into labor, or offering birth, trying to induce labor as a way of preventing preeclampsia.
There were over 8,100 women who were randomized in this trial and what they discovered was those that participated in the scheduled birth had decreased the risk of preeclampsia by about 30%, from 5.6% to 3.9%. Were there any serious complications? Those that delivered at scheduled birth, were they more likely to have complications or their babies? The answer was no. Were they more likely to have caesarean sections? The answer was no as well. So this looks like scheduled birth for the prevention of preeclampsia is a very good way, effective way, and safe way of preventing preeclampsia at term in at least 30% of women who are at a high risk.
Elizabeth: Clearly, that’s an objective that we’d love to see come to a reality. I’m wondering about — and it sounds like a follow-up study is going to need to look at — in the babies, is there any risk or is there anything that changes for the babies as they develop? Another thing I would be interested in would be second pregnancies, or subsequent pregnancies, in these women who have this intervention.
Rick: Yep. Great question. So even though they were delivered early, they were all past 35 or 36 weeks of gestation. The baby is normally formed. Previous studies have suggested that children born after 36 weeks do perfectly fine.
And then your other question is a good one. Since women who have had preeclampsia, or [are] at high risk, are at even increased risk with multiple pregnancies, will this be effective in those individuals? And that’s a great question that requires a follow-up study.
Elizabeth: No doubt we’ll see it.
And finally then, remaining in The Lancet, this study taking a look at artificial intelligence imaging decision support for acute stroke treatment in England. We’ve talked about many times that endovascular thrombectomy is the standard of care with patients who have large vessel occlusion stroke. What these folks wanted to see was, can artificial intelligence imaging software used to support the identification of this particular subset of strokes and the selection of patients who would then go on for thrombectomy, is that helpful?
They were looking at data from stroke units in England’s National Health Service and all patients 16 years of age and older who were admitted to the hospital with a primary diagnosis of stroke were collected. That endovascular thrombectomy rates and inter-hospital transfer times, and this is a really important fact, for all 107 National Health Service hospitals admitting patients with acute stroke in England were included in this from January 2019 through December 2023. They had patient-level data available for 71,000+ patients with ischemic stroke during this time period.
And what they showed was that before they implemented the AI-driven software to help with this identification of these patients, their endovascular thrombectomy rate was 2.3% in evaluation sites and the post-implementation rate was 4.6%. For the non-evaluation sites among these hospitals, the pre-implementation rate was 1.6% and it improved to a post-implementation rate of 2.6%. Lots more folks who were eligible to have endovascular thrombectomy were able to undergo this as a result of using this AI imaging software.
I just have to note that I was chagrined by these numbers that still they were only having just less than 5% of these folks who were eligible having this intervention. Here in the U.S. actually, when we take a look at folks who have a stroke that would be eligible for this intervention, we’re still only looking at less than 10% of them getting it. Gosh, I hope AI can help.
Rick: So Elizabeth, the percentage of individuals that actually present with large vessel occlusion is actually relatively small. Secondly is you have to present with a certain time window and that’s why this particular study is important. In the U.K., there were 107 hospitals that admit people with strokes. There’s only 20 that are considered to be primary stroke and only 6 that are comprehensive that actually offer thrombectomy. So you need to identify those individuals quickly and correctly, then get them transferred to a center. And the use of AI decreased the time from when the patient came to the hospital to when they got transferred out by an hour. And that’s the great value of AI, particularly when you have a hub-and-spoke way for treating strokes as they do in the United Kingdom.
Elizabeth: And I would also say it sure looks like there’s plenty of room for improvement and I hope that AI is able to inform that.
Rick: Yep, and so I would say it’s not just unique to the United Kingdom, but we have a hub-and-spoke way of treating strokes here in the United States as well, where there are comprehensive stroke centers that we need to get people to quickly when they present to an outlying hospital, so they can have the best therapy as quickly as possible.
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.
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