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Valve Surgery and Opioids; Hospital Alarm Fatigue: It’s PodMed Double T! (with audio)


PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, 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. A transcript of the podcast is below the summary.

This week’s topics include prostatectomy versus watchful waiting, flu vaccines and heart failure, preventing alarm fatigue in the hospital, and a dramatic rise in heart surgery and the opioid crisis.

Program notes:

0:44 Valve surgery and the opioid crisis

1:44 Don’t undergo detoxification

2:45 High index of suspicion in IV drug users

3:09 Flu vaccines and heart failure death

4:09 Adjusted risk reduced by 18%

5:09 Important for increasing survival

5:42 Telemetry cessation

6:44 Reduced unnecessary monitoring over 60%

7:43 Radical prostatectomy versus watchful waiting

8:46 Having a procedure done

9:45 Can be just as successful without the side effects

10:30 Helps personalize treatment

11:11 End


Elizabeth Tracey: What are long-term outcomes for prostate cancer when men have a prostatectomy?

Rick Lange, MD: Preventing alarm fatigue in the hospital.

Elizabeth: What are the benefits of the flu vaccine outside of preventing flu?

Rick: And how drug abuse has dramatically increased heart operations.

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on December 14th, 2018.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, why don’t we turn first, actually, to one of yours? You did a little changeup on me, and so therefore, I’ll have you start in Annals of Internal Medicine, a look at, gosh, what is causing endocarditis, that infection of the heart?

Rick: Elizabeth, this was a very interesting study, a statewide study, done in North Carolina where they noticed there was an increased incidence of heart operations, particularly valve operations. So they examined this over a 10-year period, that is from 2007 to 2017, and what they noted was a 12- to 13-fold increase in hospitalizations for heart valve infections due to drug abuse and subsequently needing surgery. This is clearly associated with the increased incidence of opioid use and heroin use as well.

In fact, when they looked at these particular patients, those that had their heart valve infections that needed to be replaced, they were fairly young. There was a higher incidence of females than in individuals that had their heart valves replaced for other reasons, and the alarming thing is that many of these patients don’t undergo outpatient or even inpatient detoxification, that is, adequate treatment of their drug use. What that means later on is this is a group of individuals that have a high risk for subsequently needing additional heart valves, either because of infection or even because the heart valve deteriorates because they received these at such a young age. This was an alarming report.

Elizabeth: I’ve been seeing a whole lot more of this in the hospital, just in circulating through the different ICUs. I’m not exactly sure what can be done to stem this tide.

Rick: We need to address the opioid-use problems. This is just one of the sequelae, but it has, obviously, implications with regard to health care. For example, treating these individuals costs about a quarter of a million dollars just during that hospital stay. It’s usually a longer hospital stay because they have to receive IV antibiotics, and there’s concern that if they leave the hospital they won’t receive the full treatment. So obviously, we want to prevent it first. In a number of states, a number of initiatives around the U.S. are trying to address this. Early on, sometimes, these people respond to IV antibiotics. Later on, as more of the valve is compromised, it does result in surgery.

Elizabeth: I guess I would say that this says to me there should be a high index of suspicion when somebody admits to using drugs IV that this is a possibility.

Rick: Absolutely. It usually results in fever and systemic symptoms as well. It needs to be looked for before a patient is put on antibiotics, because once a person is put on antibiotics, it’s sometimes difficult to detect it using routine blood cultures.

Elizabeth: Well, since we’re talking about the heart, let’s turn to the journal Circulation. I served this up as another benefit of influenza vaccination outside of preventing influenza itself. This Danish study took a look at a lot of people. We, of course, always love these studies because they have such robust data on their entire population. This was a nationwide cohort study, all patients who were older than 18 years of age and diagnosed with heart failure in Denmark from 2003 to 2015. That’s pretty amazing. The end was 134,000+.

They had follow up in 99.8% [LAUGHTER] of the people. Again, really remarkable median follow up of 3.7 years. And basically what they showed was that, gosh, if you had an influenza greater than or equal to one influenza vaccination during follow up, initially in unadjusted analysis, they showed an increased risk of death, but after they adjusted for comorbidities, medications, household income, education, it was actually associated with almost a 20%, an 18% reduced risk of death from heart failure. So, yet one more reason why everybody really needs to get out there and do it, and also, the earlier these folks got it in the year, from September to October, the greater the benefit.

Rick: You’re right, Elizabeth. Over this 12-year period, a countrywide study with 99.8% follow up, it just doesn’t get any better than that. If you received any vaccinations, it reduced the risk of not only cardiovascular mortality, but all-cause mortality by about 20%. That goes in line with many of the medications we give to prevent mortality in these individuals. But if you did it on an annual basis instead of missing some, you had an even higher reduction in mortality. As you mentioned, the earlier in the year as well. This is very clear evidence, the best evidence we have to date, that for people with heart failure, getting a flu vaccine and doing it on an annual basis is important for increasing survival.

Elizabeth: Let us just tail on to the end of that the fact that we have discussed the benefit of influenza vaccination in women who are pregnant, in people with other cardiac issues, so I think it sounds like it’s a no-brainer. You just really need to get the vaccine.

Rick: Absolutely, and Elizabeth, when I see patients in clinic, especially during the summer as we approach the fall months, every patient that comes into the clinic, because I see heart patients, I ask them, “Have you had your flu vaccine?” And if not, we administer it before they leave the clinic.

Elizabeth: Very good. Let’s turn to the Journal of the American Medical Association. This one is yours. This is regarding telemetry monitoring and when it can be safely discontinued using an electronic health record.

Rick: Most of our listeners should be familiar with this. When people are either suspected or concerned they may have some sort of irregular heart rhythm, they’re put on a monitor in the hospital. That monitor is transmitted, usually wirelessly, into some central receiving area where, if there’s an abnormal heart rhythm, an alarm goes off. Well, oftentimes, those alarms go off not because of an irregular heart rhythm, but because the patient moves or the wires are taken off. The alarms go off. They’re constantly going off. It results in alarm fatigue. Can we reduce the use of unnecessary telemetry by doing something incredibly simple?

What happened in this particular study was they took a bunch of inpatient hospital units, and they said, “If we send an alert to the right doctor at the right time with the right information, can we stop the telemetry when it’s no longer useful?” They studied that over about a 6-month period, and what they determined was they reduced unnecessary monitoring by about 62%. In fact, overall they reduced 50 hours to about 41 hours, and all they did was when the physician would sign into the medical record, they said, “Do you know it’s been going on for a week now? Do you need to continue it? Do you want to stop giving this alert or do you want to continue it?” The doctor chose, and two-thirds of the time they said, “You know what? We haven’t really used it. The patient is doing fine, and we can discontinue it.”

Elizabeth: I bet it also resulted in improved quality of life for people while they’re in the hospital, because the fewer alarms and monitors that are going on for them, the less disruptive that is for their healing.

Rick: You’re absolutely right, Elizabeth, and you have experience with that in the hospital. The other thing is that oftentimes there’s not enough access to telemetry units. People are wearing them unnecessarily. It prevents other people that need them, so oftentimes they stay in the emergency room because they can’t get access to the telemetry unit up on the floor.

Elizabeth: And yet one more practical implication of the electronic health record, so that’s a good thing, too. Let’s turn finally, then, to the New England Journal of Medicine, this ongoing issue of what is the best treatment for guys with prostate cancer? In this study, they had almost 700 men with localized prostate cancer who were assigned to watchful waiting or active surveillance, or radical prostatectomy, having their prostate gland removed, between October 1989 through February 1999, and then follow-up data through 2017.

So, they found these guys. They said, “Are we going to either just keep an eye on them? We’re going to go ahead and take their prostate gland out.” They found, in the long haul, that men with clinically detected localized prostate cancer, so that was cancer that was detected with a digital rectal exam rather than with PSA screening and the long-life expectancy, benefitted from radical prostatectomy with almost 3 years of additional life gained in comparison to the men who were assigned to active surveillance.

Rick: We’ve talked a lot about prostate cancer and watchful waiting versus having a procedure done. This seems to indicate that having a procedure done is really the way to go. However, as you mentioned, this study started about 30 years ago, and we weren’t using PSA to detect prostate cancer. We were using clinical means that usually involved doing a digital examination. We didn’t have the advanced blood tests that we have. We didn’t have the advanced imaging we have. So this was a group of men that had advanced prostate cancer, oftentimes outside what’s called the “capsule,” and it was considered to be “more malignant,” that is, a higher Gleason score.

In those men, radical prostatectomy was, in fact, helpful, as this study shows. But this is not applicable directly to the kind of patients we’re seeing now where they have a modestly increased PSA, no clinical evidence of prostate cancer, that are in the very early stages. In those individuals, as we’ve talked before about, a more watchful, waiting strategy can be just as successful as a more radical strategy with less side effects.

Elizabeth: Right, and so I think that we could also land on some of those side effects worth repeating — oftentimes, urinary incontinence, sexual dysfunction, sometimes fecal incontinence.

Rick: Absolutely, so if we’re going to subject a man to those possible complications, we want to make sure that it would benefit. What this study suggests is for individuals with a higher Gleason score, those that have extra-capsular involvement, and those that are expected to live at least 10 years, that a more radical approach can be helpful. But again, we’re not talking about the men that have a minimally increased PSA and none of those other features.

Elizabeth: Ending on a positive note, I would say this study helps to further stratify treatments and really personalize them depending upon the constellation of symptoms and tests that a man comes with.

Rick: I’m glad you mentioned that, Elizabeth, because this really is what personalized medicine means. You take the data to the individual, explain the risk and the benefits and the information we have, and you let that person be involved in the decision-making process. That’s more personalized to me than doing any genetic testing.

Elizabeth: On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.