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 ablation for hypertension; paid sick leave and cancer screening; physical activity, mortality and other outcomes; and alcohol screening in primary care.
Program notes:
0:40 Renal artery denervation to treat hypertension
1:40 150 randomized
2:40 Durable over months
3:40 Daytime, nighttime, and during sleep
4:40 May have an important place
4:55 Physical activity and health outcomes
5:55 Reduce all cause mortality by 30%
6:45 Paid sick leave and cancer screening
7:45 Cancer screening rates modestly higher
8:45 We need to improve cancer screening across the board
9:49 Alcohol-related screening and primary care
10:49 Number screened went up substantially
11:49 Doesn't show where we fall down
12:15 End
Transcript:
Elizabeth: How does paid sick leave influence cancer screening?
Rick: How important is out-of-work physical activity in preventing chronic disease and improving mortality?
Elizabeth: Should we use a pretty invasive way to treat hypertension?
Rick: Can we integrate alcohol-related prevention and treatment into our primary care?
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: AndI'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: I'd like to start with JAMA. Last week we talked about ablation of a part of the brain called the globus pallidus to help people with Parkinson's disease improve the tremor that's associated with that condition. This week we're talking about endovascular ultrasound to denervate this blood vessel that goes into the kidneys to treat people with hypertension, or high blood pressure. To me, this seems like a pretty invasive way to do this.
It turns out, of course, that we have lots of people whose hypertension is intractable. That we put them on a bunch of different meds and it still doesn't come down to within guidelines that we think are appropriate and that will help to avoid some of the long-term consequences of having hypertension. In this case, they are looking at efficacy and safety of this ultrasound renal denervation -- removing the sympathetic innervation to that particular area in bringing down people's hypertension.
They have a bunch of people that they screened for this trial, which I thought was really interesting, over 1,000. Of that number, 150 were randomized to this ultrasound procedure and 74 to a sham procedure. Of this number, about a third of them were female and about 16% self-identified as Black or African American. This is important, of course, because we see way more intractable hypertension in this population than we do in others.
These people were between 18 and 75 years of age. Their systolic blood pressure seated in the office was greater than 140 mm Hg and their diastolic greater than or equal to 90. They were taking up to two antihypertensive meds at the time. They had them take a 4-week washout of their medications before they underwent this procedure and then they had this ablation procedure.
What they found was that they were able to achieve a reduction in their daytime ambulatory systolic blood pressure of about almost 8 mm Hg versus the sham procedure. That appeared to be fairly durable. They also had secondary outcomes that were things like if you measured it at home, if you looked at it over 24 hours, and 6 out of the 7 were also significantly improved with this ultrasound procedure.
Rick: This has been studied before and the results have been fairly inconsistent. This is one of several trials that, first of all, compare this procedure to a sham procedure because the earlier trials didn't, and we know that sometimes there can be a placebo effect. In fact, in the sham treated group here, their blood pressure went down about 2 mm Hg versus 8 mm in the procedure group. Doing properly controlled trials is really important.
The other thing this trial did was they took individuals that had modestly elevated blood pressure. They wanted to pick a fairly low-risk group that could tolerate hypertension for 3 months, did this procedure, and then monitored the blood pressure over the course of the next 1 to 2 months. Overall, it looked like it reduced the blood pressure throughout the entire day by the way, at nighttime, daytime, and even during sleep. I think the results are fairly robust.
Elizabeth: I'm just wondering, though, why you would choose this? What are the long-term consequences of ablating sympathetic innervation to the kidneys?
Rick: They're going to follow these people out to 5 years, so we won't have an answer for a little while. They did do studies looking at the renal artery to make sure that the procedure didn't cause stenosis or blockage of the artery, or other consequences. It looks like it's a pretty safe procedure.
Where might it be applicable? Well, for individuals that can't take medications because of side effects, for individuals that have resistant hypertension despite a couple, for people who have trouble with compliance with medications. It's not likely to replace medications altogether, but it is likely to be a supplement.
Elizabeth: We know that people are famously indifferent to taking their antihypertensive meds. Maybe this is going to be one of the things that can be helpful. It just seems like it's a pretty drastic measure to me.
Rick: If it's a one-time procedure that can render someone's hypertension either easier to control or easier to manage, then it may have a very important place in the control of the millions of individuals that have hypertension.
Elizabeth: Why don't we turn to the BMJ and take a look at this non-occupational physical activity and risk of cardiovascular disease, cancer, and mortality? I would note, of course, exercise as a well-known way to help to keep one's blood pressure under control.
Rick: It's interesting. We've talked before about how important exercise can be in terms of preventing cardiovascular disease, mortality, and even cancer mortality. What these investigators attempted to do was to estimate the dose-response association between a non-occupational physical activity, i.e. physical activity outside of work, and several chronic and disease mortality outcomes in the general adult population.
They found over 196 articles or studies that address this, over 30 million participants. This is the largest study to date. They categorized physical activity based on each of these different studies into a single measure: how many metabolic units, or how vigorous was your activity, and how many minutes were you involved?
Here is what they found out. If you average about 150 minutes of low to moderate exercise, or even 75 minutes of moderate to high exercise, you could reduce all-cause mortality by 30%. You could reduce cardiovascular disease by about 30%. You could reduce mortality from cancer by about 15%. In fact, they said if all those individuals did 150 minutes per week of moderate to vigorous aerobic physical activity it would reduce premature deaths by about 16%.
Elizabeth: So you really just have to do your exercise in order to maintain your body's health. It just seems so straightforward to me.
Rick: Yeah. If we had a medication that we said could reduce your chance of dying or heart disease by 30% and prevent premature death, we could probably charge a lot for it.
Elizabeth: Worth doing it. I'll also note that we have also just recently reported on exercise "snacks" and so if you don't have an unrelieved amount of time to devote to exercise, you can get up and just do stairs, or get up and do other kinds of things for a short period of time, not break a sweat, and still have an impact.
Let's turn to the New England Journal of Medicine. This is a special article that's taking a look at cancer screening after the adoption of paid sick leave mandates. They note that at the end of 2022, nearly 20 million workers in the United States gained paid sick leave coverage from mandates that required employers to provide benefits to qualified workers, including paid time off for the use of preventive services.
What they wanted to look at was the association between these paid sick leave mandates and screening for breast and colorectal cancers. They looked at that by looking at changes in 12- and 24-month rates of screening for those particular conditions between workers residing in what they call the metropolitan statistical areas (MSAs) that have been affected by these paid sick leave mandates versus those that were not.
They found that there were paid sick leave mandates in 61 of their MSAs. Cancer screening rates were higher among those workers who were in those particular areas.
They were not huge differences, however. They were just over 2% for 24-month mammography, but other than that, all less than 2% increases in those areas where they were covered. However, the authors conclude that this is an important addition to getting people to get their preventive services, including cancer screening.
Rick: As the authors point out, we know that cancer screening is particularly important for colorectal cancer and breast cancer, which is what they were looking at, yet less than 70% of individuals actually adhere to the guidelines and have it. But just because of the sheer volume, although the percentage improvement was relatively small, the authors note that over a 2-year period, paid sick leave would have resulted in about 300,000 additional people having colorectal cancer screening over a 24-month period, and almost a quarter of a million women would have had breast cancer screening.
What that tells me is we actually need to improve cancer screening among all populations. The populations that are most at risk are those that are underserved, low-income populations. These are the ones that not only are least likely to be screened, but also the ones in whom paid sick leave can actually make the biggest difference.
Elizabeth: Right, and who are also most unlikely to have it. They note in this article that nearly 30% of our nation's workforce lacks paid sick leave coverage.
Rick: In fact, I was unaware that we're one of only two developed countries that doesn't have paid sick leave. Within the U.S., there are about 17 different states or counties, 18 cities, that mandate paid sick leave. Then there are 18 states that actually prevent municipalities from doing that.
Elizabeth: It also occurs to me, of course, that if we take a look at even costs to the healthcare system, the benefits of early detection that we achieve by screening are clearly less expensive to the system than having somebody present with a fulminant cancer.
Rick: Absolutely. We're saving costs as well as saving lives.
Elizabeth: Let's go to your last one and -- talk about saving lives -- that looks at, can we integrate alcohol-related prevention and treatment into primary care? That's in JAMA Internal Medicine.
Rick: About 20% to 25% of U.S. adults drink alcohol at an unhealthy level and about 14% have an alcohol use disorder where it actually impairs their daily activity. Since most individuals will see a primary care physician, it makes sense that we could potentially screen for this, and if the screen shows positive, we introduce brief interventions at the physician's office that have been shown to be effective, and then importantly, for those that have the most severe alcohol use disorders, refer them for more serious treatment.
These investigators assessed the ability to do that. This was done at 22 primary care practices in an integrated health system in Washington State over a 3-year period. When they looked at almost 335,000 patients who visited their primary care physician, the number of individuals that were screened went up substantially, from about 20% to about 83%. Those that were introduced to brief intervention also increased substantially, about 4- to 5-fold.
But then when they looked at treatment initiation for those that had the worst alcohol use disorder, surprisingly it really didn't have any benefit at all. A very intensive attempt to increase screening, addressing this in the doctor's office, which they did, but in terms of long-term treatment it really wasn't very successful.
Elizabeth: Of course, this is just such a thorny problem and also one that's so incredibly common. The strategy of trying to intervene in a primary care setting where people are already going there for other issues just makes a lot of sense to me. How would you change it so that it would actually have an impact on people who have the most severe problems?
Rick: Elizabeth, that's a great question. How do you get individuals plugged in and having effective treatment for the most severe alcohol use disorders?
One of the things the study doesn't show is, it doesn't show where we fall down there. Were people referred and didn't go? Do they go and not continue? We know that there are some medications that can be very helpful, and were medications prescribed? I think taking this study to show how we might more beneficially treat those with the most severe alcohol use disorders is probably the next step.
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.