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 an insulin pump for type 2 diabetes, nudges for critical care physicians, statins and liver disease, and rates of Parkinson’s disease worldwide.
Program notes:
0:40 Statins, liver cancer and liver fibrosis
1:40 Over 16,500 participants
2:40 Lipophilic statins more effective
3:17 Nudging clinicians to serious illness communication
4:16 Decrease length of stay?
5:15 22 other measures
6:15 Prefer to spend more time at home?
6:40 Automated insulin delivery in type 2 diabetes
7:40 HbA1c decreased more with pump
8:40 Implantable pump?
8:56 Parkinson’s disease projections worldwide
10:00 Middle fifth sociodemographic index impacted most
11:00 Association with cigarette smoking
12:00 New model of predicting disease
13:08 End
Transcript:
Elizabeth: Just how many people are going to have Parkinson’s disease in the next 25 years?
Rick: Is automated insulin delivery helpful in people with type 2 diabetes?
Elizabeth: Can we nudge intensive care medicine practitioners toward looking at comfort care?
Rick: And using statins to prevent liver cancer.
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, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I’m going to turn straight to you in JAMA Internal Medicine, this idea that statin use might actually be beneficial in liver cancer and liver fibrosis when people have a chronic liver disease.
Rick: Well, Elizabeth, this is really important because the incidence of liver cancer is increasing steadily not only in the U.S., but across the globe. Now, it used to be due primarily to chronic viral hepatitis, but now it’s more commonly due to metabolic and alcohol-related fatty liver. We know that statins have many positive attributes in individuals. Not only do they lower cholesterol, but they’re anti-inflammatory. They can actually inhibit chronic scarring or fibrosis. For people that already have some underlying steatohepatitis or fibrosis, can the administration of statins decrease the risk of cancer, limit worsening fibrosis, or actually cause regression of fibrosis?
To answer that question, the investigators looked at the 10-year cumulative incidence of liver cancer and liver decompensation, as well as the transitions in liver fibrosis or scarring in over 16,500 participants who were part of the Research Patient Data Registry from 2000 to 2023. These are people that have chronic liver disease and they followed them. And of that group, about a fourth of them used statins and three-fourths didn’t, and they followed their outcome. What they discovered was the individuals that used statins, it lowered their risk of liver cancer by about 35% and the liver decompensation by about 22%, and some actually had regression as well.
Elizabeth: So my question, of course, is for those folks who had pre-existing liver disease, they must have also had an aberrant cholesterol profile or some other indication to put them on a statin?
Rick: Interesting you mention that because they looked at individuals that had dyslipidemia and those that didn’t to say, “Was there a benefit in one and not the other group?” The answer was no. There was a benefit in both groups. I can’t tell you exactly why they were on statins, but I can tell you that not all individuals had dyslipidemia.
There were some statins that were more effective than others, those that are called the lipophilic statins: atorvastatin, fluvastatin, lovastatin, pitavastatin, and simvastatin. The higher the cumulative dose — if you’re on it for a longer period of time — the more benefit you got.
Elizabeth: We have quipped, of course, in the past that, gosh, we ought to be putting statins in the water. Now, I’m thinking is GLP-1 agonists. How does this expand the criteria? What should primary care providers be looking at with regard to prescribing a statin for folks when they walk in the door?
Rick: I think for this particular group, this is pretty convincing data. It’s a drug that’s been around for decades and it has very few side effects, and if I had chronic liver disease, I would be on a statin.
Elizabeth: Let’s stay in JAMA Internal Medicine and let’s take a look at this study that’s entitled “Nudging Clinicians to Promote Serious Illness Communication for Critically Ill Patients.” This study looked at 3,500 encounters of adults with chronic serious illness who were receiving mechanical ventilation for at least 48 hours at 10 hospitals comprising 17 medical, surgical, specialty, or mixed ICUs in community, rural, and urban settings. They had two clinician-directed electronic health record “nudge” interventions that were provided to these clinicians in these ICUs, and they were each compared with usual care alone and in combination. Their main outcome measure was hospital length of stay.
The basic question: if we nudge clinicians to have these critical care conversations, do we decrease the hospital length of stay? Then they had a large number of secondary outcomes.
They were able to see that their overall intervention document completion rate for all patients was 75%. Among these 3,500 encounters, hospital mortality was just shy of 36% and their median observed length of stay was almost 9 days. They were not able to show that there was any difference between the intervention and the usual care groups with regard to length of stay.
They did see that, compared with usual care, a higher percentage of patients were discharged to hospice and it also led to earlier comfort-care orders in the hospital. They suggest that this might be an effective thing to do and it’s kind of a low bar, so might be well worth implementing.
Rick: To me, this study was disappointing — the results were. It did nudge the physicians to do what they wanted to do: to identify individuals that had a poor prognosis and to talk to the family, and in 75% of the time they did that.
It didn’t change length of stay. They looked at 22 other measures and there was really a minimal effect. To me, what’s disappointing is that despite all of this nudging, it didn’t change the overall outcome for the patient, and that’s the primary thing.
Elizabeth: It was disappointing, but it’s moving in the right direction, I would say that, and that’s not just my inherent optimism speaking here. I think that this is a lot like turning the Titanic. It’s not going to happen overnight or with a single intervention that’s just directed at the ICU physicians.
The authors themselves cite that there is a whole culture, and you’re well aware of this, that surrounds critical care. Changing all of those factors and getting the patient out of the hospital sooner is sometimes not consonant with that whole culture that’s in place.
Rick: I wouldn’t disagree with that, but what the study does show is just nudging the physician doesn’t change things. We need to move on and look at other processes, just as you mentioned.
Elizabeth: I agree with that. I would also note that the authors assert that length of stay is important to patients with serious illness and their families who prefer to spend more time at home. I would say that in my own experience with this, there are patients who really don’t want to go home, who would rather stay in the ICU or stay in the hospital because of their fears relative to the whole management of their conditions. So that’s also something that I think we need to look at a little bit more closely.
Rick: You’re right because nudging the physician isn’t going to change that and we need to communicate better with the patient and their family.
Elizabeth: Let’s turn now to the New England Journal of Medicine. Does automated insulin delivery help in people with type 2 diabetes?
Rick: Elizabeth, I was really surprised because using an automated insulin delivery system, or an AID system, has been shown to be beneficial for people with type 1 diabetes. But we really haven’t had good randomized controlled trials regarding the management of using AID systems in people with type 2 diabetes.
In this study, it was a 13-week multicenter trial, adults that had type 2 diabetes, and they were randomized to the usual treatment of administering insulin based upon continuous glucose monitoring. Or they use an automated insulin delivery system, where they had an insulin pump, it communicated with the continuous glucose monitoring, and it automatically adjusted the insulin.
They followed 319 patients over this 13-week period and what they discovered was, compared to usual care, hemoglobin A1C level decreased substantially more in those that used the automated insulin delivery system — glucose between 70 and 180 — and it did not result in increased hypoglycemia. That occurred in just one patient.
Elizabeth: So, let’s talk about some of the adverse side effects of using this device.
Rick: Really — none. Do people not tolerate it? Actually 94% of the people that started on it continued on it. How often does the device malfunction? Very rarely. This is a device, it’s called a tandem, and it’s been FDA-approved. You wear a continuous glucose monitor on your arm. It connects via Bluetooth with the insulin pump, which is worn on a belt and has a subcutaneous injection.
Elizabeth: I’m just wondering about the discomfort that might be associated with that, so, it still involves an injection.
Rick: It does, so that’s not any different.
Elizabeth: So we’re not, at least with these folks, where we are with some of the people with type 1 diabetes where they get an implantable pump that automatically works on its own.
Rick: These individuals didn’t use that particular pump.
Elizabeth: I’m just wondering if we’re going to transition to something that’s going to be even more hands-off for people.
Rick: Certainly possible. That would be a nice study.
Elizabeth: Finally, let’s turn to the BMJ and this is a look at the global projection for prevalence of Parkinson’s disease and the factors that drive Parkinson’s disease all over the world. This is based on the Global Burden of Disease Study 2021.
Parkinson’s disease, I learned, is the second most common neurodegenerative disease in the world and it’s increasing, and so this study is particularly important in trying to help folks all over the globe to put things in place to deal with what looks like is going to be an increasing burden of that.
They project that 25 million+ people are thought to be living with Parkinson’s disease worldwide in 2050, representing a 112% increase from 2021. The primary factor that has to do with this is population aging — so clearly there’s nothing we can do to intervene there — followed by population growth, and then finally these changes in prevalence.
This increase is going to impact countries that have different economies differently and they have divided these economies into fifths. They say that the middle fifth of this socio-demographic index is going to have the highest percentage increase in all age prevalence of Parkinson’s disease — that’s 144%. East Asia to have the highest number of Parkinson’s disease cases in 2050. These are, of course, things that are only actionable with regard to policy and we’re trying to get things in place to deal with this burden.
Finally, at the very end of the paper, they talk about some of the things that are thought to be involved in this — exposure to pesticides and herbicides, and to other environmental toxins as being an important factor.
They also talk about air pollution as having something to do with this increasing development. Type 2 diabetes, which increases the risk and the rate of progression for Parkinson’s disease, and then physical activity, coffee, tea, and vitamin E as also things that could potentially be beneficial. Very interestingly, it turns out that there is an association with cigarette smoking that counters one’s risk of developing Parkinson’s disease and, of course, they say we’re not advocating for cigarette smoking in order to avoid Parkinson’s. But, boy, isn’t that intriguing?
Rick: The burden is increasing because the population is growing; we’re getting older. If you get older, you’re more likely to develop Parkinson’s as the numbers show. It’s not surprising that people that smoke cigarettes are less likely to develop Parkinson’s because they die earlier than everybody else, and with regard to the socio-demographic information that Parkinson’s is associated with many of the things associated with urbanization. So as those middle-income countries become higher-income countries, they’re more likely to have an increased incidence of Parkinson’s as well.
But the reason this is important is we’ve seen the number of people with Parkinson’s double over the last 25 years and it’s going to double again. That means we need to look at healthcare resources that we need to provide these individuals, look at causes, treatments, those kinds of things. We just need to get ready for it because it’s coming.
Elizabeth: I would say that the editorialist also points out something for the nerds among us that I think is really interesting. They identify this thing called the illness-death model and this is a representation of disease dynamics that incorporates transitions between different health states. So in this case, it models movement from a healthy state to Parkinson’s, from a healthy state to death without developing Parkinson’s, and to death from Parkinson’s disease. And that that integration or the utility of this model is way more profound than the current models that are used to take a look at this.
Rick: They use this because it’s better suited for long-term healthcare planning. I agree with you, the illness-death model provides additional information and all of those projections are trying to get us ready. So if we know we’re going to need more care for Parkinson’s patients, because we’re going to have more of them, let’s start getting ready for it.
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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