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Early Tx in MS; Push-ups and Mortality: 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 push-ups and mortality, primary care physicians and mortality, osteoporosis in men, and early initiation of multiple sclerosis (MS) therapy.

Program notes:

0:41 Early use of treatments for MS

1:43 Disease modifying therapy complex

2:43 Several studies relative to MS

3:00 Primary care physician supply and outcomes

4:01 Change in population distribution

5:00 Address risk factors

5:35 Push-ups and mortality

6:35 Mean age almost 40 years

7:36 Cardio fitness was predictive

8:37 Any measure of cardiovascular fitness good

9:00 Osteoporosis in older men and women

10:00 Risk factors, DEXA scans, and treatment

11:00 Oral steroids and other factors still didn’t predict screening

11:47 End


Elizabeth Tracey: Can how many push-ups you do tell when you’re going to die?

Rick Lange, MD: Does providing more primary care providers improve mortality?

Elizabeth: Employing treatments earlier in MS can help reduce disease progression.

Rick: Diagnosing and treating osteoporosis in men.

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.

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 JAMA Neurology. This is a study that’s taking a look at early initiation of treatments that heretofore have been held off until slightly later in people who are diagnosed with MS. There’s lots of questions about this, of course, in MS — when it’s either the relapsing-remitting type or the chronic type — about when is it most appropriate to initiate these different therapies.

In this case, they had 592 patients. They looked at whether they should initiate what is called high-efficacy DMT, right, so disease-modifying therapy as a second-line treatment or standard-issue treatment. They said, “How long is it going to take for this to progress?” Basically, in this real-life setting, the long-term outcomes were better following early, intensive therapy versus just the regular moderate efficacy disease-modifying therapy. It sounds like initiating that early is better in terms of staving off disease progression.

Rick: Disease-modifying therapy or DMT has the highest efficacy, but it’s associated with more complex safety profiles and more monitoring requirements and oftentimes a need for a hospital or day-unit admission to administer these. As a result, they’ve been considered second line, and what you described as a progressive, intensive therapy has been first line. This study implies that early application of the DMT, the disease-modifying therapy, is useful. The alternative is we don’t have very good ways of identifying when we should be stepping up more intensive treatment. I agree. Earlier treatment, more intensive treatment seems to delay progression of multiple sclerosis.

Elizabeth: This is a very thorny problem, of course, and for folks who have this condition, it’s really scary because the prospect of being disabled over the long haul is real. The authors, of course, conclude that a prospective, randomized clinical trial is in order here based on these observations.

Rick: I agree. We have several reports about multiple sclerosis over the last several months and years. Again, we’re honing in and perfecting therapy so that we can prevent some of the progression of multiple sclerosis.

Elizabeth: Good news! Let’s turn to one of yours. Which one would you like?

Rick: Let’s talk about primary care physician supply. As you are aware, the U.S. health care system incentivizes improving population outcomes and primary care functions, but it really remains unclear how much improving primary care physician access or supply can improve population health. That’s independent of other healthcare and socioeconomic factors.

To study this, these authors identified the primary care physician supply changes across U.S. counties over a 10-year period from 2005 to 2015 and correlated such changes with population mortality. To do that, they evaluated U.S. population data and individual claim data from over 3,000 U.S. counties and associated the primary care physician supply with changes in life expectancy and different causes of mortality. Over that 10-year period, the primary care physician supply actually increased from a little over 196,000 primary care physicians to over 204,000, but we also had an increase in the population and a change in the distribution. Overall, there were many counties that ended up with fewer primary care physicians per 100,000 population.

What they discovered, for each 10 additional primary care physicians, there were per 100,000 in population, there was an associated 51.5 day increase in life expectancy. Now there were places that had additional specialists as well, but the specialists had less of an impact. That increase in life expectancy with 10 specialists per 100,000 was only a 19.2-day increase. This clearly shows that the greater primary care physician supply is associated with lower mortality over this 10-year period.

Elizabeth: I know that this is speculation because they don’t really assess this. What exactly are the factors that are related to a density of primary care physicians that result in greater life expectancy?

Rick: The two major causes of death are cardiovascular disease and cancer, and primary care physicians address those issues. They address the risk factors for cardiovascular disease like hypertension, cholesterol lowering, obesity, and those things affect cancer as well, including cigarette smoking and physical activity.

Elizabeth: It’s hard to say what exactly we’re going to be able to do about this problem. There are already programs to incentivize primary care physicians to move to rural areas.

Rick: I think we need to do two things. We need to increase the number of primary care physicians and we need to double-down on our efforts to allow them to practice not only in rural areas, but there are many underserved areas in urban areas as well.

Elizabeth: That last one was in JAMA Internal Medicine. Now let’s turn to JAMA Network Open. I thought this one was really interesting, the association between push-ups and future cardiovascular events among active adult men. I thought this was very interesting because it was firefighters, and we have reported before about mortality among firefighters and that it’s actually increased in comparison to age-matched controls over the long haul. We have speculated and studies have speculated it’s because of the occupational exposures that they experience.

I’m looking at this in a little bit of a jaundiced way, but in any case, what they did was look at these firefighters between January 2000 and December of 2010 and they asked them all to do push-ups. They had 1,562 participants who underwent baseline examination with 1,100+ with data that were included at the end of the study. The mean age was 30 to almost 40 years at the beginning of this study, so young people, and then about 10 years of follow up. Basically what they were able to show was that the number of push-ups that these guys could perform predicted their mortality over that 10-year period with, obviously, higher push-up capacity associated with a lower incidence of cardiovascular events.

Rick: Of the over thousand that they had data on, there were only 37 that had cardiovascular events, so it was a fairly small number. But as you mentioned, the more push-ups they were able to do, the lower their mortality. They estimated that for the men that could perform over 40 push-ups in a one-minute period, their mortality was decreased by 96%. Now interestingly enough, it related not only to push-ups, but the fact that the men who were able to do push-ups had healthier lifestyles. They had lower blood pressure, lower cholesterol, they were less likely to smoke, but independent of that, their cardio fitness as assessed by this very simple, easy measure, that is the number of push-ups, was predictive. Now, they also did stress tests on these men. That was also predictive. The difference is anybody can tell you how many push-ups they do. The stress test takes supervised tests to determine how fit someone is cardiovascular wise. I agree with you. I think this is a very interesting study.

Elizabeth: It’s interesting in lots of ways. One thing that we’ve talked about before has been this predictive ability of push-ups to assess just general fitness, and I have to say that from my own perspective I consider myself fairly fit, but I’m not great at push-ups. I’m wondering if that’s really equally predictive for men and women, and I would also say depending on your sport, is it predictive?

Rick: Elizabeth, that’s a good point. You and I ride cycles and so our ability to perform push-ups is less than our ability to cycle. The firefighters, however, are very active not only with their lower body, but their upper body, so I think this is just a surrogate measure. Any measure of cardiovascular fitness would be a good way of determining whether someone’s mortality is higher or lower than it should be.

Elizabeth: I have to admit it kind of tickles me to think about a primary care kind of an exam where somebody says, “Drop to the floor and give me 20.”

Rick: [LAUGHTER] Good point, Elizabeth.

Elizabeth: Okay, [LAUGHTER] let’s turn to your final one and that’s in …

Rick: In this particular British medical journal called the Journal of Investigative Medicine, they studied over 13,000 older men and women who were receiving care at a VA medical center over a 10-year period from 2000 to 2010. The reason they studied them was because there are clear recommendations about screening for osteoporosis in men and women with the thought being if you could screen for it and determine it, you can begin to treat it to prevent fractures because that’s really where the major issue is. There are over 10 million people in the U.S. that have osteoporosis and 2 million fractures due to osteoporosis each year.

Their hypothesis, based upon their observation, was that we do a much poorer job of identifying and screening men that are considered to be at high risk for osteoporosis, and because we do a poor job with screening, we do a poor job of treating them. By looking at these over 13,700 older men and women, they looked at whether they had risk factors for osteoporosis, and if they did, were they likely to get a DEXA scan and get treated with vitamin D?

They determined that compared with older women, fewer older men underwent DEXA scan (12% of men vs 63% of women), fewer had measurements of vitamin D level (18% in men and 39% in women), and fewer men received calcium or vitamin D prescriptions (20% vs 63%) or received bisphosphonates (5% vs 44%). This shows we do a really poor job of screening men, measuring their vitamin D, and treating men compared to women.

Elizabeth: Yeah, and this is extremely concerning. The good news, of course, is that we have this fast-growing population of octogenarians, and clearly in octogenarian men, osteoporosis and subsequent fracture is a problem.

Rick: We know that there are several risk factors, age being one of them, but men that have had a previous fracture, men that are on chronic oral steroids or that have had androgen-deprivation therapy are all at risk. Even these individuals had a markedly reduced screening and treatment.

Elizabeth: I guess our take home then, for older men, is to advocate for yourself when you’re out there and suggest that maybe some kind of a DEXA scan is a good idea.

Rick: Especially for those risk factors. Again, men over the age of 70 or 75, those receiving androgen-deprivation therapy, steroid use, or with a previous fracture.

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.