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 vaccines and autism, the effects of low-dose aspirin after prostate cancer diagnosis, wearable technologies and surgery recovery, and a report of a patient cured of HIV infection.
0:47 Report of HIV remission in man who tested positive
1:49 After bone marrow transplant, no reported HIV infection
2:45 Autism spectrum disorders and vaccines
3:40 Relationship between vaccines and autism a resounding “no!”
4:20 Two-decade old controversial paper retracted
5:36 Unvaccinated individuals have caused measles outbreaks
6:41 Low-dose aspirin not associated with improvement in mortality
7:40 Wearable devices
8:30 Technology might result in benefit
9:17 Physicians not good at predicting ambulation
Elizabeth Tracey: What I’m hoping is the final word on vaccines and autism.
Rick Lange, MD: Using low-dose aspirin after prostate cancer diagnosis.
Elizabeth: Can wearable technologies help us avoid bad outcomes for people who had surgery?
Rick: And a patient cured of HIV infection.
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 March 15th, 2019.
Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also the Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I think that we should start first with the HIV remission in the treatment of this one man who was HIV positive. That was in Nature.
Rick: It’s interesting because it was about a decade ago that there was a reported case of an individual cured. This individual lived in Berlin and is referred to as the “Berlin Patient.” So this is the second such report. This individual that had confirmed HIV, and as a result of therapy, developed lymphoma, which is not terribly uncommon. The person underwent different types of chemotherapy for the lymphoma, but it was unsuccessful in causing it to have remission. So he underwent a bone marrow transplant.
Now it’s interesting because the bone marrow he received had cells in it that were deficient for a receptor that the HIV infection can bind to. As a result, this person repopulated his bone marrow with the cells from the bone marrow transplant. The HIV virus could not bind to it, and over the course of 18 months, the person has no reported HIV infection.
Elizabeth: These are really great proofs of concept in my mind, but having borne witness to the consequences of bone marrow transplantation, it’s hard for me to imagine given the really great medicines that we have right now to render HIV infection a chronic disease that doesn’t really impact too much on somebody’s lifespan or on a lot of what’s going on, that this would actually be something we would want to undertake.
Rick: So Elizabeth, your point is very well taken. I mean it has serious consequences as such with bone marrow transplant, side effects as well. It’s very costly, prolonged hospitalization. But what it does do is it shows that this particular receptor that was missing in the bone marrow donor — that’s called the CCR5 receptor — plays an important role, and perhaps there are other ways we can use this knowledge to cure HIV in the future — perhaps doing genetic changes in the same receptor that do not require a bone marrow transplant.
Elizabeth: That would absolutely be a better outcome. Let’s turn from here in Annals of Internal Medicine to what I served up as, “Wow, I really hope this is the last word with regard to autism spectrum disorders and vaccines.” That old thing, that skeleton that keeps emerging from the closet, or whatever we want to call it. It’s just we’ve got to put this thing to rest and I really think this study might be the way to do it.
I hardly ever cite the exact numbers, but in this case, it was 657,461 Danish children who were born in 1999 and they followed them through August 2013. During that time, 6,517 — which is so crazy that that [is the] percentage — were diagnosed with autism spectrum disorders. They said, “Was there a relationship between vaccination with MMR and the development of autism spectrum disorders?” and the answer was absolutely a resounding no. There was no relationship. And even among groups that were at risk — so kids who had a family history and they already had a sibling who had an autism spectrum disorder — even among that group, there was no increased risk. I’m convinced. How about you?
Rick: You’re absolutely right. This should be the end of this story and for a number of reasons. I’ll remind our listeners that it was over two decades ago that the controversial paper was published in The Lancet suggesting there might be a correlation between the mumps, measles, and rubella [MMR] vaccination and autism. That paper was retracted because it was scientifically wrong. Well, this is the largest study done to date. This same group, by the way, did a study on over 300,000 Danish kids previously.
As you said, this is over 657,000 kids and it puts to rest the issue if people said, “Well, it may not cause autism in all kids, but those that are susceptible, those are the kids it does.” This shows that it does not. Then the other thing was they said, “It depends on when you receive it — if you receive it at a young age versus an old age.” This says it doesn’t matter what age you receive it; there’s no association with autism. I agree with you, Elizabeth, the MMR vaccination has no correlation with autism, and this is the final word in this very big study.
Elizabeth: In view of the fact that we are witnessing measles outbreaks all over the world, in countries where the vaccine is freely available, I think that this is compelling evidence that there ought to be actually legislation that says, “You must vaccinate your child if they’re going to be in a public place.”
Rick: In fact, Elizabeth, it was in 2000 where they thought measles was eradicated from the United States, but because individuals have not been vaccinated recently, we’ve had outbreaks over the last several years and at least five this year already, with several hundred people in the United States developing measles.
Elizabeth: And [its] not a benign disease. It has sequela.
Rick: And leading all the way up to death.
Elizabeth: Let’s remain in Annals and let’s turn to your second one, that’s prostate cancer. Does low-dose aspirin do any good whatsoever?
Rick: There was some suggestion that regular aspirin use would improve prostate cancer survival. The reason for that is aspirin has several properties that could be considered beneficial. It causes death of cells. It’s anti-inflammatory and in some suggested studies, it prevented metastasis of prostate cancer. But what these investigators asked is, “Is there an association between the post-diagnosis use of low-dose aspirin and prostate cancer mortality?”
These are men that have known prostate cancer, some of whom take low-dose aspirin, some of whom who don’t, and does aspirin improve the mortality? This is over 29,000 men, average age or median age 70 years. They were followed up for a median of 5 years. What they discovered was that the post-diagnosis use of low-dose aspirin was not associated with an improvement in mortality. That is disappointing.
Elizabeth: Yeah, it is disappointing. I know we keep struggling to try to see something that’s going to prolong survival and have some help in that disease.
Rick: Again, the virtue of this study was although it was a nationwide cohort study from Denmark, it was a large number of individuals. So I think the study is a fairly robust study.
Elizabeth: Let’s turn finally to JAMA Network Open. This, I thought, was a rather provocative study, a small study, where they took 100 patients who were having eight different operations between July 2016 and August 2017 at Cedars-Sinai. The mean age of these patients was 53. There … 53% of them were also women, and their mean length of stay in the hospital was 4 days. They used a wearable device to take a look at the number of steps that these folks took postoperatively. Their physicians had written a scrip saying, “Hey, I’d like you to get up and start moving around.”
They basically found that a higher step count on postoperative day #1 was associated with decreased odds over a prolonged length of stay, to 1,000 steps. If the patient took 1,000 steps, up to 1,000 steps, and there was this linear relationship, a benefit, and then it plateaued and there was no further benefit after that. Basically, they were able to use this technology and identify patients who might be at risk for poor outcomes or a prolonged length of stay after an operation. I’m encouraged by this study. I think it’s part of the incremental movement toward the use of these wearable technologies that might actually result in some benefit.
Rick: And Elizabeth, the nice thing about this particular study, again, it was a wearable technology. It uses a supercomputer, i.e. a smartphone, to document how many steps they’re taking, and the physician typically writes an order that says something like this, “Ambulate with assistance.” When they looked at the patients, some of them ambulated zero steps and some ambulated up 7,600 steps. With that, they were able to document that if they ambulated more than 1,000 steps it decreased their length of stay. They recovered faster. They had fewer complications.
By the way, the physician did a poor job of estimating how much the patient was ambulating based upon what the wearable monitor showed. The physician would say, “Yeah, I know the patient is getting up and getting out of bed.” The answer was they weren’t necessarily very good at predicting that. This is a nice use of a very minimally expensive technology that’s readily available that gives quantitative data that’s much better than the physician guessing what’s going on.
Elizabeth: Yeah, and what I’d like to see is further analysis of let’s take a look at post-operative steps and pre-operative condition and see what that looks like, and then also look at their comorbidities and see how they correlate with their ability to actually get up and ambulate following an operation. I’d also like to see post-discharge, a longer-term follow up on … do steps predict readmissions, for example.
Rick: For example, you could use this technology before the operation to figure how often the patient is ambulating. The patient can tell you, “Yeah, I’m really active.” When you look at their wearable monitor, you realize, “Listen, you may think you are, but you don’t walk very much. If you did that, it would make your operation safer.” Your point is well taken.
Elizabeth: I think one of these days, unfortunately or fortunately, we’re going to have Big Brother leaning over our shoulders all the time looking at those kinds of things. On that note, 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.