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 a look at congenital syphilis, a way of treating some people with congestive heart failure, palliative care in two different populations, and breast cancer outcomes over fifty years.
Program notes:
0:32 Long term outcomes in heart failure
1:32 Defibrillator with pacing
2:30 Like putting in a pacemaker
2:50 Congenital syphilis
3:50 Consequences for neonate dire
4:50 Time sensitive treatment
5:50 Almost 4,000 cases in 2022
6:30 Breast cancer mortality in last 50 years
7:30 Hormone negative screening very important
8:15 Palliative care in two populations
9:15 Nurse intervention with social worker effective
10:15 Needs to be resourced
11:15 Resistance by some clinicians
12:30 End
Transcript:
Elizabeth: A look at soaring rates of congenital syphilis.
Rick: Long-term outcomes of a treatment for heart failure.
Elizabeth: Palliative care in both large and small populations.
Rick: And breast cancer mortality in the United States.
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 a soft toss for this morning? Let’s turn to the New England Journal of Medicine, this heart issue, long-term outcomes of resynchronization and defibrillation for heart failure.
Rick: We’ve talked before about the different types of drugs or medications that can treat heart failure. There are also devices that can be useful in improving long-term survival. There are two types of therapy that can be useful. One is called an implantable cardio-defibrillator and we know that that’s useful for individuals that have irregular heart rhythms that could be fatal.
But there is another therapy called cardiac resynchronization therapy. That’s individuals whose heart function is severely depressed and when you look on their EKG we can determine that the QRS is wide. What that means is, the electrical activation of the heart doesn’t occur all at the same time. It’s very dyssynchronous. If we can resynchronize that with the pacemaker, we can actually improve heart function. What these investigators did was they extended that short-term study of about 3½ years and now extended it to 14 years.
There are over 1,000 individuals included in this long-term study. Half of them got the defibrillator. The other half got the defibrillator with the CRT, the cardiac resynchronization therapy, a type of pacing. By the way, they all got optimal medical therapy.
At the end of the 14 years, mortality was very similar. It was about 80%. Those individuals that had the resynchronization therapy, the time to death actually appeared longer. They were more likely to be alive at 5 and 7 and 10 years, although at 14 years the mortality was fairly high.
Elizabeth: You say, “in specific individuals.” Talk to me about those specifics.
Rick: Okay. They have to have heart failure due to depressed function of the left ventricle. The EKG has to show that there’s dyssynchrony. That’s the key that the heart is not synchronized in terms of its pumping ability. If you can do that, those individuals receive a benefit.
Elizabeth: What’s it take, and how uncomfortable, unpleasant, and expensive is it?
Rick: It’s no different than putting a pacemaker in. The overall complication rate is fairly low. It’s less than 1% or 2%. It’s usually a same-day procedure.
Elizabeth: It’s sounding to me like this is a pretty significant change that ought to be employed.
Rick: The addition of this to regular therapy improves overall outcome and it should be the standard of care.
Elizabeth: Staying in the New England Journal of Medicine, this is a review paper. It’s taking a look at syphilis complicating pregnancy and congenital syphilis. Lots of things I learned in this paper. One is that syphilis, congenital syphilis, was first described in 1497 by Gaspar Torella, which I did not know. We know, of course, the causative organism Treponema pallidum and its transplacental passage.
Here is the bad news and this is why I picked this particular paper. In 2021, the rate of congenital syphilis in the United States was the highest it has been in nearly 30 years. These cases of syphilis, of course, rising among persons of reproductive age globally. Congenital syphilis has increased by 755% from 2012 to 2021. One in 1300 live births is affected.
This review paper, I think, is important because of course the consequences of congenitally acquired syphilis are pretty dire. What do we need to do? We know that we’re supposed to have serologic testing in the first prenatal visit. It’s mandated by most states in the United States and recommended by health authorities worldwide. STI guidelines from the CDC recommend repeat screening at 28 weeks of gestation, particularly in high-prevalence areas and among women who are considered to be at increased risk for syphilis because of sex with multiple partners, sex in conjunction with drug use, or transactional sex.
The authors note that a large review of gestational syphilis has shown that nearly half of the patients did not report any risk factors for having had syphilis. They note that the clinical presentation of syphilis is not different between pregnant and non-pregnant women. Either the traditional or what’s called the reverse sequence algorithm is okay when you’re going to look for it. They also say effective syphilis treatment during pregnancy is time-sensitive. The treatment is parenteral benzathine penicillin G — that’s an IM administration. They do say that right now this drug is in short supply.
Rick: Elizabeth, you alluded to the fact that it severely affects the newborn. I mean, it can cause neurosyphilis. It can affect the blood system, the liver, skin, and bones. Prevention and or early detection and treatment is absolutely necessary.
They looked at why congenital syphilis is occurring in the United States right now. They noted that delayed or no prenatal care was associated with 42% of the neonatal syphilis, inadequate treatment of the mother about 31%, late identification of the mother during pregnancy — that is, she was initially negative and then her test turned positive, and nobody found that out — that was about 14%. Then prenatal care without any syphilis testing at all, about 8%. We’ve already had in 2022 almost 4000 cases of congenital syphilis reported.
Elizabeth: The other thing that I thought was rather disconcerting is that diagnosing this syphilis in the neonate is really not standardized at all.
Rick: Although testing in the mother is mandated, testing in the neonate isn’t.
Elizabeth: There is also a bunch of challenges, of course, that they identified. One of them, of course, is treatment of male partners because that’s an important contributor to breaking this chain of maternal infection and reinfection that’s contributing to this problem.
Rick: A significant problem. It’s worse now than it was in the last 30 years and something our listeners need to be aware of.
Elizabeth: Let’s turn on to your next one that’s in JAMA.
Rick: I’m happy to report that the breast cancer mortality has declined precipitously in the past five decades. In 1975, mortality about 48 per 100,000 females; it’s down to about 27 per 100,000 females in 2019. There are a lot of reasons why that is and what these authors attempted to do was to do modeling based upon a study funded by the National Cancer Institute. This is a multi-institutional, collaborative, modeling consortium. Using aggregated, observational, clinical data, what this consortium did was look at breast cancer mortality in the United States, again, during that five-decade period.
Breast cancer screening and treatment was associated with a 58% reduction in breast cancer mortality compared to 1975. Treatment for stage 1 to stage 3 breast cancer was associated with about half that mortality reduction. About a fourth of the reduction was due to treatment for metastatic cancer, and about 25% was due to the screening itself. For individuals that had hormone-negative [breast cancer], prevention — that is, screening — played a much more important role than treatment did.
Elizabeth: I’ll point to the notion that catching it early is going to be the best strategy.
Rick: You want to catch it before it’s metastasized, so I would agree with that. It’s particularly important in those that are more resistant to treatment. Preventive screening ends up being a very important part to reducing mortality.
We still have things that we need to address. People that live in rural parts of America, people that are not White, people that are uninsured, they still remain at the greatest risk of dying from breast cancer. Their outcome hasn’t been quite as good, but overall the fact that breast cancer mortality has decreased almost 60% over the last five decades is a good news story.
Elizabeth: We like good news. Finally, let’s remain in JAMA. We’re going to treat two studies together. These were two studies that were taking a look at palliative care provision in very different populations.
One study, they had a primary outcome of quality of life, and that was the smaller study of the two. It had 306 participants. The other one, their outcome was length of stay in the hospital, and that had 24,000 + participants.
They did different interventions in these folks. In the smaller study, they had an intervention that involved a nurse and a social worker, each of them making six phone calls, focusing on symptoms, psychosocial needs, and healthcare navigation with regard to the patient. The second one was in the VA population, where they mandated a default order for palliative care consultations in 11 hospitals across eight U.S. states — 15,000+ older inpatients with either advanced dementia, COPD, or kidney disease.
What they basically found in the smaller study was that the nurse intervention with the social worker was effective with these folks in reducing anxiety, depression, and their disease-specific quality of life. With regard to the default order for palliative care consultation, what they showed was that it did increase the consult rate from 17% to 44% and reduced the time to a palliative care consultation among hospitalized patients by 1 day. It did not reduce the length of stay.
However, something that is very meaningful to me is that this default order was associated with increased odds that the patient would institute a do-not-resuscitate order at discharge, and that they were discharged to hospice. Among that group, the much bigger group, there was also no difference in in-hospital mortality. The editorialist notes that this palliative care — hmm, we really need to resource it. The nurse/social worker strategy does seem to really be helpful, and once again, how are we going to resource that?
Rick: As you mentioned, two different studies, one an outpatient study, the other inpatient. Importantly, did they resource it? Again, in the outpatient study they added a nurse and a social worker. In the hospital, they didn’t add additional resources. They just told the people at the hospital, “Work a little bit harder and see some more patients.” The goal was to actually get the people out of the hospital quicker and it didn’t do that.
That’s sort of good news from my standpoint, because the point of palliative care isn’t to get the person out of the hospital, by the way. It’s actually to provide palliative care, end-of-life care. As you mentioned, one of the things that’s important to that is making sure that we have do-not-resuscitate orders so we’re not doing unnecessary things in individuals that are at end of life.
Obviously, you help deliver palliative care as a champion. What do you want our listeners to take away from these studies, Elizabeth?
Elizabeth: Well, it’s so interesting that you should ask that question because it’s always been something that’s garnered my attention: resistance on the part of some clinicians to employ palliative care and particularly to employ it early. As you stated, palliative care, its whole goal is to allow somebody with a chronic health condition to experience the best quality of life they can at the moment that they are. That’s largely symptom management and amelioration when that’s possible, and so bringing palliative care in early is really an important thing.
That’s what I would say about both of these studies. Bringing these palliative care folks in early, even among this VA population that was hospitalized, if they get discharged to hospice that’s a really good outcome as far as I’m concerned.
Rick: And bringing them in early with what desired outcome, Elizabeth?
Elizabeth: With ameliorating their symptoms so that they can experience the best quality of life they can experience.
Rick: I think you’ve just defined what palliative care is, Elizabeth. Thank you.
Elizabeth: Oh, you’re welcome. Let’s hope more and more clinicians start bringing it on board and that we resource having it available on an outpatient basis.
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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