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 causes of death among U.S. children, lifetime risk of stroke, sleeping more in Seattle, and a new treatment for pancreatic cancer.
0:35 Sleeping more in Seattle
1:35 Looked pre and post study
2:35 Change in infrastructure needed
3:25 Do better once they get there
3:40 Causes of death for kids in the U.S.
4:40 Guns second most common cause
5:42 Thirty-six times more common in U.S.
6:02 Adjuvant therapy for pancreatic cancer
7:02 Overall survival better
8:02 Median survival of 54 months
9:01 Risk of stroke globally
10:01 Hypertension major factor
Elizabeth Tracey: The benefits of sleeping more in Seattle.
Rick Lange, MD: The major causes of death in children and adolescents in the United States.
Elizabeth: Hope for pancreas cancer.
Rick: The lifetime risk of stroke.
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 21st, 2018.
Rick: 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, let’s turn first to the journal Science Advances. This is a new one on us, but a research article that we thought was really interesting that you quipped, of course, “Sleep More in Seattle.” The authors also quipped the same thing based, of course, on the movie Sleepless in Seattle. Some may remember that. This was a look at, gosh, if we allow teenagers to sleep later, what happens to their school performance? So pretty powerful stuff, I think, an idea that we have actually talked about a lot, about that adolescents have a circadian clock that results in them wanting to actually naturally stay up later, but then remain sleeping much later than the rest of us do.
So, of course, this had to be in Seattle, where they seem to do a lot of these kind of social interventions. What they did was delay the secondary school start time by nearly an hour. Actually, they looked at this pre-research study and said, “OK, what are these kids doing as far as their sleep goes? And what about their grades?” Then afterwards. When they delayed the start time for school, there was a daily median sleep duration increase of 34 minutes and a 4.5% increase in the median grades of the students who had this intervention and an improvement in their attendance. So leave your sleeping teenagers lie.
Rick: This is a win-win-win. The students are happier because they sleep later. Teachers are happier because the students are better prepared and do better on testing, and then the parents are happier as well. This goes to the fact that normal sleep really plays an important role in learning and memory consolidation. And Elizabeth, you had mentioned the normal circadian rhythm that actually changes during puberty so that there is a delay in the normal circadian rhythm — that is, kids want to stay up later and they want to sleep later, and that’s just a part of the normal biology. Being able to accommodate that in Seattle improved outcome. This is a terrific story.
Elizabeth: I like it. Also, one concern I have is when I look at all of the infrastructure relative to getting kids to school. Around here, it’s school buses and they pick them up at 6:20 in the morning. Wow! Really early. Not for you and me, but for many people, really early. I’m just wondering about shifting that whole thing so that it picks them up later, but it also brings them home later, and that might be right in the middle of rush hour.
Rick: As you mentioned, there are a lot of infrastructure things that one has to consider. Again, these are high school students, so while some of them are on buses, about half of them are already driving at this particular time. One can make the case and it’s been shown before — partly as a result of using daylight savings time — that when you pick up kids later and it’s lighter, it’s safer for them as well. In fact, the interesting thing about this is this particular study showed that sleeping later, actually attendance improved. So, although it may take a change in getting kids to school, they’re more likely to get to school and to do better once they get there.
Elizabeth: Note to national policymakers. Maybe it’s time to change that school start time for kids in secondary school. Since we’re talking about kids, now we’re going to turn to something a good deal more sobering. In the New England Journal of Medicine, a look at the causes of death for children in the U.S.
Rick: This looks at the year 2016, where we have the most recent data. The data comes from the CDC, and it’s derived from U.S. death certificates looking not only in 2016, but in the previous several decades as well. And here is the sobering fact. The leading cause of death is motor vehicle accidents. Now, while over the course of the last about 20 years, it’s decreased about 38%, motor vehicle accidents resulting in death have actually increased over the last 3 years, and that’s been attributed partly to the fact that teenagers are now distracted — distracted by being on the cellphone and distracted by having other people in the car as well.
The second leading cause of death is firearms. This is from kids ages 1 to 19. It’s not usually the child playing with a firearm that results in death. That’s only about 2% of these, but it’s more commonly homicide and suicide — homicide in the young children and suicide in the older children, the adolescents. The third most common cause of death has to do with malignancy, and that’s gone down about 32% over the last several years as a result of better detection and better treatment. Of the leading 10 causes, six of them end up being what’s called “accidental.” Things like suffocation and drowning and drug overdose, fire and burns.
When we call them accidental, unfortunately that implies that we can’t improve the outcome. What I want our listeners to know is these are things that we have under our control, and the only way to improve this, because there were over 20,000 childhood deaths in the U.S. last year, is to recognize where they are and begin to address it.
Elizabeth: It’s just so very, very distressing to me, especially some of the data regarding these increases, because this motor vehicle death — and that we can attribute to cellphones, to texting while driving and to distractions, is really actionable and preventable. Of course, the gunshots, also.
Rick: Yeah, so with regard to motor vehicle accidents, from 1997 to about 2013, it decreased 50% and now over the last 3 years has gone up a little bit higher. With regard to firearms, if you look at other developed countries, we are 36 times more likely to have a firearm-related death than the other developed countries. We can bury our heads in the sand and try to deny it, or we can actually look at data and studies that look at firearm-related deaths and address it in this age population.
Elizabeth: And I couldn’t have put it better myself. Since we’re in the New England Journal of Medicine, let’s turn to something more hopeful. In this case, this is a look at a strategy for dealing with pancreas cancer — of course, a very serious problem. People with pancreas cancer, when they’re diagnosed, many of them, the vast majority, are usually dead within a couple of years. So in this case, they took a look at two different strategies for what’s called adjuvant therapy for pancreas cancer. They resected first the tumor and then the patients were treated with the combination of several agents that’s known as FOLFIRINOX. That includes fluorouracil, leucovorin, irinotecan, and oxaliplatin vs gemcitabine therapy.
They took a look at almost 500 patients who had had their pancreas cancer resected, and then they put them on these two regimens. At a median follow up of almost 34 months, the median disease-free survival was almost 22 months in the FOLFIRINOX group and 12.8 months in the gemcitabine group, so clearly much better. Also, overall survival was better. That overall survival at 3 years was 63.4% in the FOLFIRINOX group and almost 50% in the gemcitabine group. However, adverse events were higher in almost 76% of the patients in the FOLFIRINOX group vs 53% in the gemcitabine group. But clearly this regimen provides hope for people with pancreas cancer.
Rick: This new therapy, adjuvant therapy, is based upon treating individuals with metastatic pancreatic cancer where the mortality is very high. The question is, in people that have resectable pancreatic cancer, does this same new adjuvant therapy provide a benefit? The reason why this is important is, in the absence of an adjuvant therapy, just resecting it, the 5-year survival rate is less than 10%, and it has not improved over the last several decades.
In fact, it’s estimated that by 2030 this is going to be the second leading cause of cancer death. To be able to take this group of individuals, to resect their cancer, and give them this new therapy and to achieve a median survival of about 54 months, which is about 4½ years. Again, about a year and a half longer than the gemcitabine, this is really remarkable and I’m glad you picked this particular study.
Elizabeth: Yeah, it’s such a dismal prognosis associated with pancreas cancer, so I, too, am really, really happy that it appears that we have something that can actually impact on survival.
Rick: And as you highlighted, more intense chemotherapy oftentimes leads to more side effects, but these weren’t generally the most severe side effects, grade 4 side effects. They were the same between the new treatment and the old treatment. Most of the side effects were reversible. You could decrease them by decreasing the dose of the medication, and they weren’t sustained. This is a tremendous advance. Obviously, the future is going to be to look at targeted therapy to identify specific targets that render specific therapy, whether it be immunotherapy or targeted chemotherapy towards these patients. But, again, this is a great step in the right direction.
Elizabeth: Let’s turn to our last one, then. This is taking a look at the risk of stroke globally.
Rick: This is what’s called looking at the lifetime risk of stroke, and it looked at the regional, at the country, and the global level using data from 2016, the Global Burden of Disease Study. When we talk about the risk of developing stroke — the lifetime risk — that’s looking at other competing causes of death as well. For example, if one looked at the turn of the century and what the leading causes of death were, they were pneumonia, tuberculosis, infectious diseases, diarrhea as well, but not stroke. As we’ve addressed these infectious diseases, the risk of stroke has increased, and that’s what this study shows.
Globally, it looks like the lifetime risk of stroke is about 25%. Over the last 3 or 4 years, that’s increased from about 22%, a relative risk of about 9%. There’s a huge disparity between different countries or different regions. For example, in East Asia, it’s as high as 39%. In Central Europe, about 32%. It’s low in sub-Saharan Africa. It’s only about 10%, but that’s because they die of other things at a younger age. In the U.S., it’s about 24%. They also identified from previous studies what are the leading causes or contributors. It looks like worldwide it’s hypertension. In low-income countries, it’s the lack of adequate diet and the United States, obviously, obesity and diabetes contribute to that as well.
Elizabeth: Of course, we know that this hypertension risk is increasing all over the place.
Rick: It is and there are a substantial number of people that are not diagnosed, that is they don’t have their blood pressure taken. That’s more in developing countries and in the U.S., but even in those individuals that have hypertension, it’s not as often controlled as we’d like it to be. If it is controlled, it obviously decreases the risk of stroke, heart attacks, and kidney disease as well. But I would think a 25% lifetime risk of stroke would get people’s attention and urge them to have healthy lifestyles, eat good diets, and if they have hypertension, to have it adequately treated.
Elizabeth: Yeah, that last one we’re seeing so much expansion of that with that criteria now that tips so many more people over into that category.
Rick: Yeah. It’s addressing it earlier and it’s addressing it more fully.
Elizabeth: On that note, then, 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.