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 decolonizing people with MRSA, perinatal depression guidelines, active surveillance for prostate cancer, and reducing opioid use after hip surgery.
0:41 Active surveillance for low risk prostate cancer
1:42 SEER database for prostate cancer
2:45 Personalized approach
3:13 Perinatal depression guidelines
4:14 CBT or interpersonal therapy helpful
5:17 Psychotherapy via telemedicine
5:50 Effect of acetaminophen and ibuprofen on morphine use
6:50 Combination reduced morphine use
7:51 Doesn’t increase adverse side effects
8:21 Reducing MRSA among carriers
9:23 Use cleansing techniques after discharge
10:24 All done at home
Elizabeth Tracey: More men with prostate cancer are choosing active surveillance.
Rick Lange, MD: Preventing perinatal depression.
Elizabeth: Can we help people to choose something other than opioids after they’ve had hip replacement?
Rick: Reducing resistant staph infections after hospitalization.
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 February 15th, 2019.
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, I’d like to turn first to the Journal of the American Medical Association, taking a look at this issue of active surveillance for men who have prostate cancer. As we know, lots of bodies have been recommending that when men have low-risk prostate cancer they ought to enter something that used to be called “watchful waiting.” Now it’s being called “active surveillance” to just watch their disease and periodically assess it. If it looks like it’s advancing, then other treatments might be employed. This has been kind of a moving target, and as we know, when these recommendations come out, the USPSTF, for example, got into this fray also. It takes a while for it to penetrate practice.
In this research letter, they took a look at this whole issue. This one looked at all men with localized prostate cancer who were diagnosed between 2010 and 2015 as part of the surveillance epidemiology and end result. Prostate active surveillance watchful waiting database or SEER, that, of course, for health care providers is well known and monitors bunches of diseases and conditions. They said, “How many of these guys are actually choosing active surveillance or watchful waiting instead of having a radical prostatectomy or other kinds of treatment, especially external beam radiation?” From 2010 to 2015, sure enough, in men who have low-risk disease, many more of them percentagewise, just shy of 50%, are choosing to go ahead and watch instead of having treatment.
Rick: That was the first part of this study. The other part of this, they also looked at individuals that had intermediate or high-risk prostate cancer, because in those individuals, active surveillance is not recommended. They were concerned that these recommendations might adversely affect the proper therapy of these individuals. But what they determined was that in the intermediate and high risk, active surveillance was only applied to less than 2% of individuals.
Elizabeth: This is excellent news, also, because it suggests that this personalized approach, that this is what your disease looks like. This is what’s appropriate for you is being employed.
Rick: Over the same time period, for those that did have intermediate or high risk, more individuals underwent radical prostatectomy and fewer underwent radiation therapy. That could be because that’s the physician’s choice. The other possible alternative answer is they actually involve the patient in the decision-making process. Let’s move from this to looking at perinatal depression. Is that okay?
Elizabeth: Sure, that works for me, in this same journal.
Rick: Specifically, this is the U.S. Preventive Services Task Force or USPSTF’s recommendation concerning intervention to prevent perinatal depression, which affects about 1 in 7 women. We’re talking about women that develop depression either during pregnancy or in the first six to 12 months after pregnancy. They reviewed about 50 studies that incorporated over 22,000 women looking at a variety of therapies that were tried. Cognitive behavioral therapy, interpersonal therapy, there were some pharmacologic therapies, and there were alternative or complimentary therapies, as well.
What they determined, we don’t have a very good way of screening which women are likely to develop perinatal depression. However, we do know what the risk factors are. But then when they looked at the therapies, the ones that were most tested and had good data for preventing perinatal depression were those that involved cognitive behavioral therapy or interpersonal therapy, and it could reduce the risk of perinatal depression by 40%. The USPSTF is recommending that we use these preventative techniques in women that fall in the high-risk category.
Elizabeth: All right, so then, of course, you already foreshadowed and an obvious question is what constitutes the high-risk category?
Rick: They are women that either have a history of depression or a family history of depression, those that have depressive-type symptoms and certain socioeconomic risk factors like low income or being a young mother or being a single parent. Those individuals would benefit from counseling interventions because they’re considered a risk of depression.
Elizabeth: What about the pharmacology?
Rick: They looked at three different agents and only one of them was potentially useful, that was sertraline, but that was a small study of just 22 patients. It reduced the risk of depression from 50% to 7%, but again, they didn’t feel comfortable making that recommendation on the basis of that one small study. They also noted, by the way, that that carries some side effects, the medication does. Whereas cognitive behavioral therapy and interpersonal therapy does not.
Elizabeth: I would add, also, that increasingly we’re seeing that CBT and other forms of psychotherapy are being administered via telemedicine.
Rick: Absolutely, and one of the programs they looked at was one, in fact, that was a web-based program. Why this is important is we don’t have enough trained individuals at all the geographic locations we have to meet the needs of the over 400,000 women that are going to develop perinatal depression. If it can be done online or web or via telemedicine, then we can apply it to a broader spectrum of women. Thanks for bringing that to our listeners’ attention.
Elizabeth: Surely. Let’s turn now to another study in JAMA. This one is taking a look at the effect of the combination of paracetamol, which I love that word, or acetaminophen, of course domestically, and ibuprofen versus either alone or a patient-controlled morphine consumption in the first 24 hours after total hip arthroplasty or total hip replacement. This is a Danish study, and of course, we’re persuaded by those studies because they’re so vigilant in gathering all the data relative to this.
They had six Danish hospitals with 90-day follow up. It included 556 patients who had a total hip replacement between December 2015 and October 2017. They were randomized to receive either acetaminophen plus ibuprofen, acetaminophen plus a matched placebo, ibuprofen plus a matched placebo, or half-strength acetaminophen plus ibuprofen orally for 24 hours postoperatively starting one hour before surgery. They said, “What happens with these people with regard to their morphine consumption?”
What they found was that the acetaminophen plus the ibuprofen significantly reduced the morphine consumption compared with acetaminophen alone in the first 24 hours after surgery. There was no significant increase in adverse events in the pooled groups receiving ibuprofen alone versus acetaminophen alone. However, this combination did not result in clinically important improvement over ibuprofen alone, so suggesting that ibuprofen alone might be very efficacious in this particular circumstance.
Rick: Again as you highlighted, these are patients having hip surgery and they’re put on self-administered morphine after that to just try to relieve the pain. We’ve talked about the importance of trying to decrease opioid dependence by decreasing opioid use. What this shows is using a non-steroidal anti-inflammatory medication early on can decrease morphine use without significantly increasing adverse side effects.
Elizabeth: I think it’s a really great goal to try to reduce that morphine use because patients don’t even like it themselves.
Rick: Obviously, it decreases pain, but some of the side effects is it affects both bladder retention, inability to urinate, and also the inability to move your bowels as well, which are problems after surgery. If we can get people off of morphine, but feeling just as well, then that’s what we want to do.
Elizabeth: Now let’s turn to your final one, shifting to the New England Journal of Medicine, the worthy goal of trying to reduce methicillin-resistant Staph aureus among carriers when they get discharged from the hospital.
Rick: I’m going to abbreviate this MRSA because that’s what methicillin-resistant Staph aureus is typically called. It causes more than 80,000 invasive infections in the United States each year. In fact, if you look at people that are discharged from the hospital, about 5% or 1.8 million individuals in the U.S. are discharged with MRSA. It’s colonized. That is it sits on the skin or sits in the nasal passage or in the oral passageway. We know that if someone is admitted to the hospital and has it, we can decrease the risk of infections, that is usually skin infections or surgical infections or pneumonia by beginning to treat it while they’re in the hospital by giving them cleansing baths and using a topical antibiotic in the nose. But the question is when people get discharged from the hospital, can you use these same cleansing techniques to decrease the risk that they’ll develop a MRSA infection after the hospitalization? That’s what this study did.
They looked at over 2,000 patients being discharged from the hospital and half of them they gave what we usually give. They educated them about hygiene and laundry and things like that. The other half they used topical cleansing with chlorhexidine, mouthwash, and nasal application of mupirocin. They did that for two weeks every month for six months, and they just followed them for a year. What they found out was those that had the decolonization, the cleansing, and the antibiotic administration topically to the nose, it decreased their risk of having an MRSA infection by about 30%, and it decreased hospitalization for that. Not only that, by the way, it decreased other hospitalizations related to infections as well, mostly related to skin infections and to pneumonia. I think this is terrific news for, again, the 1.8 million individuals that are discharged from the hospital every year and are known to be colonizer carriers of MRSA.
Elizabeth: Yeah, I think it’s a really good idea. I’m wondering about the time invested on the part of nursing, I suspect.
Rick: Elizabeth, so this was all done at home, and so they instructed the individuals and the next question you ask is, “How compliant were they? How many of the individuals were able to actually do this?” 65% were able to follow it fully. By the way, for those that followed it fully, it decreased the risk of an infection by 40%, so it’s very effective. Where they had trouble was in nursing homes, that is getting individuals to be able to do this because you do it for five days in a row, twice a month for a total of six months. Those nursing home inhabitants were less likely to be fully compliant, but most outpatients, it was no issue.
Elizabeth: Very interesting. One more thing to do when you get home.
Rick: If you’re an MRSA carrier, you should consider it.
Elizabeth: Which many people are. I’m waiting for the study that’s going to take a look at a strategy like this for health care providers who are also carriers, which we know is a pretty large number.
Rick: That will be a very interesting study.
Elizabeth: Indeed. 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.