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 the benefits of weightlifting, neurologic long COVID, syphilis screening guidelines, and a bionic pancreas.
Program notes:
1:38 42% increased risk
2:38 Across all ages increased risk
3:00 USPSTF syphilis screening update
4:00 Women's rate has nearly tripled
5:00 Make individuals aware
5:55 Bionic pancreas
6:55 Type 1 diabetes
7:55 Didn't quantitate carbohydrate
8:35 Weights in addition to aerobic exercise
9:35 Additional mortality benefit in addition to aerobic
10:35 Doesn't look at duration of activity
11:35 Usually less than 10% meet activity guidelines
13:00 End
Transcript:
Elizabeth: What are the benefits of weightlifting in addition to aerobic activity?
Rick: Long-term neurologic outcomes of COVID-19.
Elizabeth: Updated guidelines on syphilis screening.
Rick: And is a bionic pancreas more effective than usual therapy for people with type 1 diabetes?
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 the dean of the Paul L. Foster School of Medicine.
Elizabeth: And we're going to start of course with the COVID material and that's in Nature Medicine.
Rick: We've reported before -- and it comes from observational studies that have been relatively short-term -- that is, 3 to 6 months of people that have COVID -- but we've really not looked at the full panoply of different neurologic outcomes and for a longer duration after people who have COVID-19.
That's what this study does in a population of 154,000 individuals that are part of the U.S. Department of Veterans Affairs and compares it to two different cohorts, a contemporaneous cohort of about 5 million people and then also a cohort before COVID was available of about another 5 million. Overall, this is a study of about 11 million individuals in the post-acute phase of COVID-19 -- that is, after 30 days after the infection there was an increased risk of things like a stroke, both ischemic and hemorrhagic, cognition and memory disorders, peripheral nervous system disorders, migraine and seizures. They estimated that the increased risk was about 42%. The burden of that was there were about 71 neurologic events per 1,000 persons at 12 months. If you were in the ICU, you were more likely to have a neurologic event than if you were just hospitalized, and if you were hospitalized more than if you weren't hospitalized.
Elizabeth: This cohort of course started -- wasn't it at the beginning of the pandemic, is that correct?
Rick: You're right, Elizabeth. This is a cohort that did not get vaccinated. Many of them didn't have access to some of the newer treatments as well. Further, because it's a VA cohort, it's primarily men. Your point is well taken. Now that we're vaccinated and now that we have other treatments, if we look at a wider range of individuals does this still hold up?
Elizabeth: Well, and frequently also, the VA population is going to be older and possibly have significant comorbidity.
Rick: In fact, what they did was they looked over the range of ages. They had individuals as young as 40 and then obviously individuals over the age of 70. There were some differences based upon age about what neurologic events you had, but nevertheless, even across all ages, the risk was increased.
Elizabeth: I think we're going to be seeing a whole lot more of this, I'm sure, as we see more time elapse and we'll be able to identify what is possible post-vaccination.
Rick: Yeah, and I agree. It would be nice to repeat this study in the post-vaccination era. You ought to be able to do that with a very similar population.
Elizabeth: Let's turn now to JAMA, and since we're talking about infectious diseases, a look at what are the screening guidelines for syphilis infection in non-pregnant adolescents and adults. This is the USPSTF of course, and this is basically an interesting thing. It's more or less a reaffirmation of the guidelines that they had already identified. It basically establishes that they have an A recommendation for screening for syphilis infection in persons who are at increased risk for infection.
There is a lot of background relative to syphilis, however, that I think is noteworthy. In 2000, we were at a record low for transmission of 2.1 cases per 100,000 population. In 2019, now we're at almost 12 cases per 100,000. There are certain populations, of course, that are really more at risk. These are men who have sex with men, and men in general are the folks who get syphilis, although they cite that women have experienced nearly triple the rate of syphilis infection between 2015 and 2019. Although back to this men who have sex with men, their risk was 106 times the rate among men who have sex only with women, and 168 times the rate that's just among women by themselves.
There are other things that are associated with this too: sociodemographic and behavioral factors, use of illicit drugs, especially methamphetamine, and diagnosis of another STI. These are all reasons to raise the index of suspicion. They finally say that for those who are at risk, like men who have sex with men, the screening interval, rather than just being annually, might be more frequent -- even every 3 to 6 months among people who engage in those behaviors.
Rick: Elizabeth, you hit the nail on the head. The reason to bring this out, again, is two things. One is obviously to inform clinicians because the rate has gone up as you said in men and women. We haven't even talked about congenital syphilis as well. -- that rate has almost gone up 3-fold. But it's also to make individuals aware. Individuals that are a higher risk ought to be a part of this solution and they ought to be the ones saying, "Listen, I think that I'm in a high risk category based upon what I have heard, and I want to make sure that I get tested."
Elizabeth: Of course, we still, thankfully, have effective treatment. People should go forward and go ahead and get tested if they feel that they're at risk.
Rick: Treatment is incredibly effective and the diagnosis is relatively easy. It does require the individuals to present at a place that can collect the appropriate tests and interpret them. But we have decades of experience with this and with treatment that can be effective.
Here is the trouble. People get a primary syphilis infection and then it appears to go away, but really it's in a latent phase and it can affect multiple organs. That's why making that diagnosis and making sure that people are adequately treated is incredibly important.
Elizabeth: Let's turn now to the New England Journal of Medicine.
Rick: Elizabeth, let's talk about what's called a bionic pancreas. It's for people that have type 1 diabetes and the treatment of that is insulin. We're oftentimes going to an automated system now -- what's called a "closed-loop system" -- a device that can actually test what the glucose is and then allows the individual to adjust their insulin levels.
They have been effective. They are more effective than just giving intermittent doses of insulin, but they require that you have to input the basal insulin rate, identify what the insulin sensitivity ratio is, the carbohydrate-to-insulin ratios, the total dose of insulin, and, by the way, if you have a meal, to estimate how many carbohydrates.
But there is a new device out called the "bionic pancreas." All you do is you put the patient's previous insulin regimen and put their weight in. If they eat a meal, you just say, "Is it the usual amount for the meal, or is it more or less?" and the bionic pancreas takes over. It's really much easier for the patient to manage.
There were 219 participants aged 6 to 79 that had type 1 diabetes. A third of them got standard care, two-thirds got the bionic pancreas, and they followed them over a 13-week period. The usual care group the hemoglobin A1c did not change. It was about 7.7. For those that were in the bionic pancreas [group], it went down from 7.9 to 7.3.
When they looked at the overall where did they want them to be in terms of their overall sugar levels, they were more likely to remain in that range 2½ hours more per day than those that received standard care. Did it cause more hypoglycemia? The answer is no. It did not.
Elizabeth: Clearly, one of the things I want to know is what does this device cost, and then secondly, since we're sort of rolling into the holidays, I'm thinking a lot about those intermittent times when one might consume a much higher carbohydrate load than normal. What about modification of it under those circumstances?
Rick: Yeah. Well, two things. One is there has not been a cost established because it's not FDA-approved. As all these devices improve, other devices come on that have very similar characteristics and everything gets cheaper. I can't address the issue with what happens during Thanksgiving or Christmas. They didn't actually quantitate the carbohydrate doses here.
Elizabeth: I'm just thinking about people I know who have insulin-dependent diabetes, who sometimes have to supplement their automated devices if they are in a situation where they consume a whole lot more carbohydrate.
Rick: I guess we'll have to have additional studies to address whether that's a big issue. It also depends on how many days you're going to celebrate for Christmas and Thanksgiving, Elizabeth, okay? A single day or we're going to draw this out over a month?
Elizabeth: As for me, I'm thinking a month sounds really attractive and would end up having to make me lift weights in addition to my robust already aerobic exercise regimen. That's in the BMJ British Journal of Sports Medicine.
An interesting cohort here. They were taking a look at independent and joint associations of weightlifting and aerobic activity, with all-cause and cardiovascular disease and cancer mortality in the prostate, lung, colorectal, and ovarian cancer screening trial.
They had a sample that included 90 to almost 100,000 people who completed a follow-up questionnaire assessing weightlifting, and were followed up through 2016 for a median of 9 years. Their mean age at their follow-up questionnaire was 71.3 and about half of them are women. Their BMI wasn't that high. It was just shy of 28.
What they found was that weightlifting was associated with a 9% lower risk of all-cause mortality and cardiovascular disease mortality after they adjusted for moderate to vigorous physical activity, and joint models where they looked at both of these things in adults who met aerobic moderate to vigorous physical activity recommendations, but did not weight lift. They had a 32% lower all-cause mortality while those who also reported weightlifting one to two times per week had a 41% lower risk. This is incredibly impressive and I have to reveal I don't do a lot of weightlifting, and I'm going to start.
Rick: I'm going to confess the same thing. I mean, you and I both do a lot of aerobic exercise, usually on a bicycle. I was surprised that weightlifting one to two times per week would lower mortality even more. I mean, again, 32% with aerobic activity -- I'm not surprised -- but 40% when you do aerobic activity plus one to two times of weightlifting per week.
A couple of things. One is this is an older population. Remember, at the end of the study, these were 71-year-old individuals. It's nice that it applies to them. Does it mean the same thing in a 40- or 50-year-old? I'm not sure that it does.
It really doesn't talk about what the duration or intensity of the weightlifting was. We talked about moderate to vigorous physical activity in terms of aerobic. This just reported that they did some weightlifting.
We know weightlifting is good. It's good for balance. You have less fractures. It's good for muscle tone. It's good for bone density. I'm just surprised -- pleasantly surprised -- that it also improves overall and cardiovascular mortality as well. Elizabeth, like you, I think it's going to change my exercise habits.
Elizabeth: Oh, absolutely, and I agree with you though. The question is how much of those things do I have to lift and how long do I have to do it? It's not that I object so much to it. It's just that I don't have that many weights and I don't know if this means that I need to go out on a shopping trip.
I will say that something I found a little bit suspect in here was the number of respondents who said they already met both aerobic and the weightlifting guidelines. It was 24%, so 1 in 4 people are saying that they do this already? I find that really challenging to believe.
Rick: Yep. I mean, the statistic show us is usually less than 10%. This is either a particularly motivated group or like a lot of older individuals, kind of maybe even yourself or myself, we overestimate exactly what we do.
Now, one of the downsides of this particular study, one of the limitations, is it's just a single report. It doesn't follow the duration -- did they continue this? -- but it was a survey and these individuals are being screened for cancer, saying, "How much exercise do you do?" and then following their mortality.
Elizabeth: The other thing, let me just add this too, that I thought was a little bit questionable was that they also looked at education, smoking, BMI, race and ethnicity, and report that they did not significantly modify associations between weightlifting and all-cause mortality. They also found a stronger association for a benefit of weightlifting and mortality in women than in men. I would like to see this study, even though it's a big study, followed up with a bigger study and with a longer-term study.
Rick: Your point is well taken. Again, Elizabeth, this is at best an association. I think you're right, it does need to be collaborative, but I don't think any of us would disagree the overwhelming evidence is that exercise does improve overall survival.
Elizabeth: So get out those weights folks. 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.