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 deaths related to tropical cyclones, treating low-risk thyroid cancer, continuing steroids after COVID hospitalization, and using tablets for screening in primary care.
Program notes:
0:40 Continuation of steroids after COVID hospitalization
1:40 90% required oxygen during hospitalization
2:40 Can be associated with decreased immune response
3:10 Screening in primary care with tablets
4:10 Given a tablet with an app
5:13 These are issues that warrant immediate clinical attention
6:00 Low-risk thyroid cancer treatment
7:01 Radioiodine after thyroidectomy or not
8:03 Isn’t risk-free
8:25 Increased mortality after tropical cyclones
9:27 In the month following increased deaths
10:35 Accrue over time
11:53 End
Transcript:
Elizabeth Tracey: Excess deaths associated with tropical cyclones.
Rick Lange, MD: Do you need to give radioiodine therapy to people with low-risk thyroid cancer?
Elizabeth: Can we use tablets in primary care practices to find out more about patients?
Rick: And refining steroid therapy in patients that have COVID infection.
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, let us turn first to JAMA Internal Medicine. Of course, this is our COVID material. Is there any benefit to the continuation of steroids when somebody who has had COVID is discharged from the hospital?
Rick: Steroids were actually the very first medication class to demonstrate a mortality benefit among patients with COVID-19 who are being hospitalized, and is now our cornerstone of COVID-19 therapy.
Now, the recommendations are to use steroids for up to 10 days or until discharge for patients that are hospitalized with COVID-19. Now, what about patients that are hospitalized for less than 10 days? Do you need to continue steroids or not? That was the focus of this particular study.
It’s a retrospective cohort study conducted in 15 different medical centers within the Kaiser Permanente system in Southern California. These were individuals who were hospitalized for COVID and received less than 10 days of steroids, specifically dexamethasone.
There were 1,164 of these patients and most of them were Hispanic — about 71% — and about 60% male. The vast majority, 90%, required oxygen support during hospitalization. Almost 60% continued dexamethasone to discharge. They compared those to the 40% that were not continued on it. They were asking the simple question, whether continuing dexamethasone treatment was associated with a reduced readmission rate or mortality after discharge from the hospital.
After following these individuals for up to 30 days, there was no associated reduction in all-cause readmission or mortality, even when they looked at different subgroups. Those that were hospitalized for a shorter period of time, 1 to 3 days, versus those for up to 10 days, those that needed oxygen or not, or those that had longer duration of disease, as opposed to that have shorter duration of disease. That means when you’re discharged from the hospital the steroids can stop and there doesn’t seem to be any benefit to continuing them.
Elizabeth: I am wondering about possible negative side effects of continuing on dexamethasone post-discharge.
Rick: That’s really the rub. If you don’t need them, why take them, especially because they can be associated with issues? Things like decrease in the immune response to the secondary infections, other complications, especially in people with diabetes with increased sugar. There doesn’t appear to be any benefit.
These are high-dose steroids. It’s surmised that even though they are stopped at the hospital discharge, [with] their long half-life, there still continues to be some benefit.
Elizabeth: Big fans, of course, of discontinuing things that aren’t needed. This is good news study.
Let’s turn to JAMA Network Open. The reason I picked this study, this is universal screening in primary care practices by self-administered tablets versus asking one’s nursing staff to conduct screening. We were talking last week about the burden on primary care practices of saying, “Hey, you really need to exercise,” and it sure enough had an impact. I’m really interested, or I have had my antenna picked up, regarding this issue of screening and then being prescriptive ultimately.
In this study, what they did was they created an app that was called mPATH. Patients could access this thing on a tablet at their primary care office, ostensibly to assist with colorectal cancer screening.
While they were at it, they decided, to encourage using all of that, they had screening questions for depression, fall risk, and intimate partner violence. These were questions that the participating health system requires nursing staff to ask at every visit.
When patients came in for their check in, the adult patients, they were given this tablet with the app on it and said, “Okay, hey do you mind taking a look at this thing and filling it out for us?”
This is a kind of an interim analysis of a study that I think we’re going to see something more about. They had 6 participating practices, 3 family medicine and 3 internal medicine. They had 23,000 + patients who were included in the study.
It’s interesting the level of participation of use of the app, it varied between 10% and 60%. They accounted for that because of differences in how the front desk office staff handed the tablet to the patients — or not, presumably.
This self-administered screening with a tablet detected more than twice as many patients with concerns relative to these issues than would have been otherwise identified. It seems like a pretty powerful way to engage people in their own care and also to discern a whole lot more of potentially concerning issues.
Rick: This self-administering screening was significant because these are issues that warrant immediate clinical attention. The fact that the self-administration doubled the detection of these things is really a significant finding.
Elizabeth: And easy to do.
Rick: Very easy. The nice thing is it didn’t take any time from the physician or the nurses. I mean, usually we ask nurses to ask these questions. Oftentimes, because they are cramped with regard to time, they don’t get through all these things. Now we know that actually self-administering a tablet is twice as effective. I’m really glad you picked this particular study.
Elizabeth: I think all we have to do now is figure out what’s the barrier regarding getting the office staff to hand the person the tablet. Let’s turn to the New England Journal of Medicine.
Rick: We’re going to turn our attention to low-risk thyroid cancer. Most thyroid cancers would fall into this particular category and you determine that low risk — that means the low risk of recurrence — based on a number of different pathologic features. What’s the size of the tumor? Has the tumor invaded the capsule or involve any of the blood vessels? Involvement of the cervical lymph nodes. Are there different mutations? Then finally, there are some blood tests, one called thyroglobulin, that elevated levels predict recurrence of thyroid cancer.
But interestingly enough, most low-risk thyroid cancers actually don’t recur. Nevertheless, the current therapy is to do a total thyroidectomy — you take all the thyroid out — and then you follow that with radioactive iodine.
Well, you ask yourself, “If it’s low risk recurring, does the radioactive iodine really do anything in terms of preventing a recurrence?” That’s what this study tried to address.
They took 776 adult patients. They had low-risk papillary thyroid cancer and they had already undergone a total thyroidectomy. These were tumors that were less than 2 cm in size, and then they assigned half of them to receive radioiodine therapy or the other half to receive no radioiodine therapy. They followed these individuals with evaluations at 10 months and 3 years, looking for what are called “disease-related events.”
There were no clinically meaningful differences in any of the endpoints between the two groups, with about 96% of the patients in either group experiencing no evidence of recurrence. This suggests that in these low-risk patients, thyroidectomy and careful monitoring afterwards, is sufficient and you don’t need to combine that with radioiodine therapy.
Elizabeth: Talk to me about why did we ever implement radioiodine therapy to begin with.
Rick: The initial thought was the radioiodine therapy would ablate or take care of any tissue that may still be remaining after the thyroidectomy. Now, that could be in the area of the thyroid or if there was any thyroid tissue outside of it that has metastasis.
Elizabeth: This sounds to me like this is a real kind of change in practice study.
Rick: It is Elizabeth. You know, for example, that my wife had thyroid cancer — and it was low-risk and had thyroidectomy — but that was followed with radioactive iodine. Again, this was over 15 years ago and the therapy was standard of care at the time.
But radioactive iodine therapy isn’t risk-free. The patient has to be isolated in the hospital for a while and at home as well. Knowing that you don’t have to undergo this type of therapy for low-risk thyroid cancer is really a game-changer.
Elizabeth: Good news. Let’s turn to JAMA. This was one I picked because we are talking so much about climate change, of course, and about its impact on human health. This study takes a look at tropical cyclones — interestingly, what we normally call in this country hurricanes, and they call elsewhere in the world cyclones — and its relationship to increased mortality in the United States.
This is one of those absolutely gigantic databases where they took a look retrospectively at data collected from the National Center for Health Statistics over 31 years, from 1988 to 2018. Many, many deaths taking place during that time, over 33 million. They also looked at that relationship with how many tropical cyclone days were experienced during this time and then they looked at this down to the level of 1,206 U.S. counties.
The upshot of this whole study is that, sure enough, cyclone days were associated with increased death rates in the month following the cyclone. These included a 3.7% increase in injuries, a 1.8% increase in infectious and parasitic disease-related deaths, a 1.3% increase in respiratory disease deaths, a 1.2% in cardiovascular disease death, and finally 1.2% also in neuropsychiatric conditions.
One thing I would be really interested in seeing is if there is a dose-response. What I mean by that is if there are more days of tropical cyclone activity, is that increased more? I think it’s something we need to be concerned about if we are seeing this relationship.
Rick: The official records of the tropical cyclone deaths generally include only deaths from direct exposure to the cyclone hazards that occurred when the cyclone hit land. That’s in the first several hours in the first days after a storm. Typically, they include things like blunt trauma from wind-borne debris and electrocutions from downed power lines, or drownings in vehicles attempting to navigate the flooded roadways.
But as this study suggests, these tropical cyclone deaths really don’t cease once the wind and water hazards abate. These cyclone deaths accrue over several months as deaths among the survivors are revealed. Things like environmental exposures, disrupted health systems, some of the conditions you mentioned, cardiovascular, neurovascular, or respiratory. Furthermore, they don’t just occur in the counties that are immediately hit by the cyclone, but in the surrounding counties as well. The virtue of this particular study is, it really expands our knowledge of how cyclones affect health not only in the first days, but in the several months after the cyclones hit.
Elizabeth: I know you would agree with the assertion that we’re probably going to be seeing a lot more of this rather than less.
Rick: In fact, the climate change has influenced the cyclone behavior in that they are now stronger, have more rain, they are wetter, and they are slower-moving, so they’re more likely to be more damaging, destructive, and deadly as the editorialists mentioned.
Elizabeth: On that note, since we are about to be entering the cyclone season, 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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