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 respiratory syncytial virus (RSV) vaccine in older adults, gun deaths at the scene, training to prevent falls in elderly, and COVID and flu deaths among hospitalized veterans.
Program notes:
0:38 Flu and COVID deaths in hospitalized
1:38 COVID mortality about 6%
2:33 Outpatient therapy helps
3:08 RSV vaccination in older adults
4:08 Single intramuscular vaccination
5:08 Vaccine is efficacious
6:08 Severity of illness acute
6:40 Cognitive training for reducing falls in older adults
7:40 Speed of processing, and other types
8:40 Physical activity and processing
10:15 Removed self-inflicted
11:15 Guns being used more lethal
12:28: End
Transcript:
Elizabeth: If you're over 65, are you going to be taking an RSV vaccine soon?
Rick: Is the risk of death being hospitalized for COVID different than being hospitalized for flu?
Elizabeth: What do we know about gun deaths?
Rick: And does cognitive training reduce the risk of falls in older individuals?
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's turn right to JAMA. If you have the flu or if you have COVID, what's the likelihood that you're going to die while hospitalized?
Rick: We've previously reported on this early on in COVID, about 2020. At that time, if you looked at an older population -- for example, the VA population -- the risk of dying with COVID if you were hospitalized was about 17% to 20%. The risk of dying with flu is about 3.5% to 4%.
Well, fast-forward to 2023 and now several things have happened. One is obviously we have a lot of people that are vaccinated. We're much better with caring for individuals that are hospitalized and also there are different variants. Is the mortality of patients hospitalized with COVID still as high as it was? We can use the flu by the way, as a reference, because that really shouldn't have changed over the last 3 or 4 years.
This is a study again of VA patients' electronic health databases. These are all individuals that were hospitalized with either flu or COVID and they followed their mortality. The mortality with COVID was about 6%. The mortality with flu was again about 3.5% to 4%. COVID mortality has decreased substantially.
It was higher in certain groups, over 65 and particularly higher in those who were unvaccinated. Across the whole group, it looks like the risk of COVID death was about 60% higher, but if you were unvaccinated it was 130% higher. Another reason for those individuals that either aren't vaccinated or haven't been boosted to consider doing so.
Elizabeth: What about comorbidities? Because certainly we fingered those as being really important in COVID mortality.
Rick: They adjusted for different comorbidities. They didn't identify how that affected -- they looked primarily at age, vaccination status, whether it was a primary infection or reinfection, and whether the person received outpatient COVID treatment or not, but they didn't actually look at it by comorbidities.
Elizabeth: What about this thing of outpatient treatment with things like Paxlovid, for example, since you mentioned that?
Rick: It looks like it did have a difference. For example, those who received outpatient therapy, the risk was about 27% higher, and those that did not, about 63% higher. To your point, usually the individuals who get outpatient therapy are those with more comorbidities. Whether this was the fact that the antiviral treatment lowered the risk of mortality or whether it was because those who received it had higher comorbidities, we really can't tell.
Elizabeth: In view of the fact that it sounds like boosters are going to be offered to those 65 and older, I would say if you haven't had a vaccine you need to get one, and if you are over 65 keep on getting those boosters.
Rick: Absolutely. I mean vaccination helped, but boosting helped even more.
Elizabeth: Let's turn to the New England Journal of Medicine since we're talking about older adults and their risks. It turns out that another infectious disease, respiratory syncytial virus or RSV, that we've talked about a number of times in the past and that children just had a huge spike in those kinds of infections as the pandemic started to wind down.
This is a look at an RSV vaccine that has already been tested, actually, in younger kids. It's a bivalent, prefusion F vaccine. What that refers to is the protein that the virus actually uses to dock and to fuse with cells so that it can initiate infection. We've discussed this vaccine previously in pregnant women.
This is a phase III trial and they randomly assigned 1:1 adults older than 60 years of age to receive a single intramuscular injection of this RSVpreF -- that's the abbreviation -- vaccine at a dose of 120 mcg, or a placebo.
They looked at two primary endpoints: They were seasonal RSV-associated lower respiratory tract illness with at least 2 or 3 signs or symptoms. The other endpoint was RSV-associated acute respiratory illness. They had quite a few folks in this; 17,000+ got the vaccine and 17,000+ the placebo.
For RSV-associated lower respiratory tract illness with 2 signs or symptoms, they had 11 participants who were infected in the vaccine group and 33 in the placebo group. For the people they were looking for 3 signs or symptoms, they only had 2 cases in the vaccine group and 14 cases in the placebo group.
With regard to RSV-associated acute respiratory illness in the vaccine group, 22 versus 58 in the placebo group. So their ends are very low for people who ended up with infection, but they were able to say, "Yep, the vaccine is really pretty efficacious."
Rick: Specifically, it looks like it reduces the risk of infection by about 60% to 70%. It's interesting because we mostly think about RSV as infecting young kids. In the U.S., there are about 177,000 hospitalizations and 14,000 deaths each year in older adults that get RSV infection. Having a vaccine that's available, that's efficacious, without significant side effects -- by the way, we didn't talk about that; there were no significant side effects -- is important. For 50 years we have been trying to get an effective vaccine. When they looked at subgroups, it was just as effective in those over 80, in those younger, and those who had high risk factors.
Elizabeth: I think we definitely are going to be seeing this thing get approved and we're going to be rolling up our sleeves and getting this vaccine.
I think it's worthwhile mentioning that not only are there about 14,000 deaths each year in the United States, but when people who are older get RSV their severity of illness among those who are hospitalized with it is actually really acute; 18% are admitted to ICUs, a third receive home health services at discharge, and 26% die within a year after that admission, which harkens to me to data relative to falls, broken hips, and death. That also is that straight-line kind of relationship. They also say that older adults shed the virus at higher levels and for longer durations than younger adults.
Rick: Elizabeth, I'm going to transition to the next study because you mentioned falls. One of the studies that was published in the International Journal of Environmental Research and Public Health -- I think this is the first time we've reported for this particular journal -- asks a question: "Does cognitive training reduce falls in older individuals?" It goes without saying that older adults have an increased risk of falling. When they do fall, they have a higher mortality and morbidity associated with it than younger individuals. Once an individual has fallen, that's a big predictor of their chance of falling again and injuring themselves.
There was a study called the ACTIVE study. It's known as the Advanced Cognitive Training for Independent and Vital Elderly. It's a randomized controlled trial looking to see whether different types of cognitive training can improve lifestyle and overall lifespan in older individuals. In this particular one, we're going to focus just on whether cognitive training affects the fall rate or not.
This involves older individuals, ages 65 to 94, who are randomly assigned to cognitive training, which involves either speed of processing, memory, or reasoning training versus those that received no training. So almost 3,000 individuals, half of whom received some cognitive training and half of them who didn't. They followed them over 10 years.
When they looked overall at all their participants, the cognitive training didn't seem to decrease the risk of fall. But then they looked at the group according to whether there was a low risk for falling and a high risk. High risk is those that had a previous fall within 2 months prior to entering the study. The cognitive training, specifically the speed of processing, did decrease the risk of fall about 30% in that particular group.
Elizabeth: Well, let's talk about speed of processing training. What does that involve?
Rick: It's both a process and computer training that focuses on recognizing different displays and be able to make a decision based upon that. They flash up things like two objects and ask somebody to make a decision based upon that. You're talking about how quickly can you process things.
Then you say, well, how does that translate into falls? When we're walking, there are two things going on. There is obviously the physical activity, but also the processing we have to do to make sure we avoid objects. If we're walking on a carpet, things aren't level anymore. Perhaps by improving that is it can also decrease fall risk as well.
Elizabeth: It sounds like this would be fairly easy to implement and also fairly easy to scale.
Rick: It's easy to implement in that it is computer-based training. Obviously, it's fairly inexpensive and it ought to be fairly easy to do. The nice thing about this study is this was a long study. This went over a 10-year period.
Elizabeth: Let's turn now to JAMA Surgery. This is a look at something that I think is really important and I want to illustrate it, not just because it gives us really important numbers, but also because I think we really need to be looking very hard at gun-related death in the United States and how we're going to intervene here. This is a research letter in JAMA Surgery and it's looking at deaths at the scene of injury versus those who get transported to the hospital and die there or die during surgery.
They look at data between 1999 and 2021, looking at patterns in the location of death from firearm injury in the United States. There is a database called the Multiple Cause of Death file of the Centers for Disease Control and Prevention WONDER. That's Wide-ranging Online Data for Epidemiological Research. Wow, I'm glad they have an acronym for this one.
This is using publicly available, anonymous data. They removed from this number self-inflicted firearm deaths because, of course, most such deaths do occur at the scene where this takes place and their primary outcome was location of death. The one that they focused in on was deaths at other place and decedent home. Those were combined and classified as deaths at the scene.
Those deaths at the scene increased from just shy of 52% in 1999 to just shy of 57% in 2021, indicating that more deaths are taking place before there is even the ability to transport anyone. In the ED, they also saw an increase over that time period from just shy of 26% to just shy of 30%. Deaths on arrival decreased during that time and that's of course because more take place before anybody can get there.
The authors of this study are people who specialize in trauma surgery and often that kind of surgery relative to gunshots. They opine that a lot of this has to do with the fact that the guns that are being used to render these injuries are so much more lethal than the guns that were widely available in 1999.
Rick: Unfortunately, the information we don't have in this particular study is actually the weapons that were used or the patterns of injury, variations by race, ethnicity, age, and those kinds of things. I hope the follow-up study will provide more insight into that because those are the things that will help us decide what the most appropriate action is.
Elizabeth: I think so. I hope that any of the prohibitions and the lack of funding relative to looking more closely at all of these issues evaporate.
Rick: I couldn't agree more. I applaud the authors for using, as you mentioned, publicly available, anonymous data. Let's use that and additional data. Let's be honest, look at the data and say, "What can we do to solve this -- I'm going to call it a pandemic -- firearm-death pandemic?"
Elizabeth: I couldn't agree more. 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.