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Alcohol Deaths; A Video Game for ADHD: It’s TTHealthWatch!

TTHealthWatch 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 a COVID-19 update, a video-like game for ADHD, alcohol-related deaths in the U.S., and stroke treatment with clot busting agents.

Program notes:

0:42 COVID-19 update

1:41 Did test positive for coronavirus

2:42 Communities need to prepare

3:00 Rate of alcohol-related deaths

4:00 Certain groups had largest increase

5:00 Need a screening mechanism

6:02 Outcomes with use of higher-dose clot-busting drugs in stroke

7:04 Over 300 patients with stroke in a large vessel

8:04 Important to recognize signs and symptoms

8:15 A digital intervention for ADHD symptoms

9:16 Either the digital intervention or a control game

10:15 At home on your own time

11:30 End


Elizabeth Tracey: The rate of alcohol-related deaths in the United States.

Rick Lange, MD: Does giving more intravenous clot-busting medications improve stroke outcome?

Elizabeth: A video-like game for the management of attention deficit hyperactivity disorder.

Rick: And transmission of the coronavirus — COVID-19 — by someone without symptoms.

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

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, since it’s remaining in the news and it’s extremely prominent, why don’t we turn first to COVID-19 and where are we with that right now?

Rick: This is the first known reported case of an individual that transmitted the virus to family members and the person had no symptoms and no abnormalities on a chest x-ray. This is a report from January of 2020, where they enrolled a familial cluster of five patients that all had fever and respiratory symptoms and one asymptomatic family member that apparently gave them the coronavirus.

This is a lady that traveled from Wuhan to Xinyang, China, and then over the course of the next several days to two and a half weeks, five family members this person came in contact with all had proven coronavirus infection. They had fever and abnormalities on their chest x-ray. This particular patient — the index case — never had symptoms of respiratory issues, had no abnormal findings on a chest CT imaging, and in fact, did test positive for the coronavirus.

Elizabeth: How does this inform us further about any intervention efforts relative to containment?

Rick: Elizabeth, it’s disappointing because a lot of the containment has been centered around identifying individuals that have symptoms — that is a fever or a cough — and making sure we either test them for the coronavirus or isolate them. This suggests that people can be carriers of it and not have symptoms, and that makes it much more difficult to contain.

Elizabeth: Well, I guess the question really devolves to how often does this happen?

Rick: It’s very difficult to say. This is the first reported case. There are undoubtedly going to be many more to follow, but how often it happens is not known. These are people that are known as superinfectors. They’re more likely to come in contact with a large number of people because they don’t have symptoms. This could potentially have a single person contacting hundreds of individuals over the routine course of the 1 to 2 weeks that they actually have the infection.

Elizabeth: More to come, no doubt. In fact, just today, the CDC has warned that there will be domestic spread community-wide here in the United States and that communities ought to be preparing for that. It’s unclear to me exactly how they should be preparing, but sounds like we ought to be.

Why don’t we turn to the Journal of the American Medical Association. This was a look at the rate of alcohol-related deaths in the United States, and it’s really very, very concerning. This study took a look at a tremendous amount of data and looked at alcohol-induced mortality rates from 2000 to 2016 using U.S. national vital statistics from all of those years for all U.S. residents older than 15 years. They looked at trends in alcohol-induced mortality by sex, race, ethnicity, age, county level, socioeconomic status, rurality level — or how rural was this area that they were examining — and U.S. state. There were 425,000+ alcohol-induced deaths during this time period. The vast majority, 76%, were in men.

When they broke this down into different ethnicities, socioeconomic classes, and sex, they found out that the largest increases by race, ethnicity were observed among American Indian and Alaskan-native men, American Indian and Alaskan-native women, and white women. This is a trend that appears to be increasing. The largest absolute increases occurred in midlife, and among women, it was women aged 50 to 54 years. What this is suggesting, at least to me, is that we are not even coming close to paying attention to alcohol-related deaths in a way that speaks toward intervention.

Rick: It is disappointing news because over this time period — early on, for example, there was a decline in alcohol-related deaths, specifically among the African American population — but over the last 4 or 5 years, that trend has reversed and they’ve had an increase in alcohol-related deaths as well. So this cuts across all socioeconomic backgrounds, all age groups. For example, we saw it in individuals in midlife and even in younger individuals — that is under the age of 35 — men and women as well. As you said, very disappointing.

Elizabeth: Does it sound to you like we ought to institute some kind of a screening mechanism when people interact with the healthcare system at all to identify if there might be a problem with alcohol? Because the authors also point out that drinking alcohol is sort of one thing, but there is a far larger spectrum of deaths that’s probably not represented by this dataset, including traffic collisions and cancer that may not actually even be represented here.

Rick: You’re right. In fact, most primary care physicians should be screening for alcohol-related misuse or alcohol abuse that can contribute to secondary conditions such as liver disease, mental health issues. By the way, these are very easy things to screen for. Now the next question is once you’ve screened for them, then it’s getting people into appropriate care.

Elizabeth: And having that therapy available, which is something else they point out, that, in fact, it’s pretty tough to access some of that.

Rick: And especially for some of the groups that they identified. It starts with recognizing it’s an issue, identifying that it’s an issue across all these socioeconomic groups and is increasing, and that we need to address this.

Elizabeth: Let’s stay in the Journal of the American Medical Association and talk about the outcomes of a trial taking a look at interventions for stroke.

Rick: And specifically, Elizabeth, we’re talking about ischemic stroke — that is people that have a clot in one of the large arteries to the brain that results in stroke. We know that an effective therapy is to identify these individuals early on — that is within the first 4 or 4½ hours — and to give them intravenous clot-busting drugs followed by what’s called endovascular thrombectomy, removing the clot with a device. So a clot-busting drug followed by the device.

Now, there are several different clot-busting drugs. The initial one that was used for stroke was called alteplase, but that needs to be infused over the course of about an hour. There’s a newer one. It was a bolus over a 5-second period and studies showed that that was more effective in terms of initially opening the artery before the procedure was done than the older alteplase medication.

What this study did was it looked at what the conventional dose of tenecteplase is and said, “Listen, if the standard dose — 0.25 mg/kg, a total of 25 mg — is successful, what about using a higher dose?” To establish that, they had over 300 patients that had stroke in a large vessel, gave them either 0.25 mg/kg of the tenecteplase or 0.4 mg/kg and then did a picture afterwards to see if the artery was open prior to doing the endovascular thrombectomy. What they determined was the higher dose was not any more beneficial. In about 1 in 5 patients, the artery was, in fact, opened with a less than a 50% occlusion and there was no difference in stroke outcome either.

Elizabeth: What are the adverse events relative to the higher dose?

Rick: The major adverse event was a higher bleeding rate, although it wasn’t statistically significant in this group because of the small number of patients. No benefit with a higher dose and a potential harm.

Elizabeth: I think it’s great that we’re examining this because we know that the positive aspects of treating these strokes is really profound with regard to long-term sequela.

Rick: That’s important if the stroke is established early. You want to receive treatment in the first 4 to 4½ hours, if possible. That’s why it’s important people recognize the signs and symptoms of a stroke so they can seek treatment very early on.

Elizabeth: Let us end, then, for this week by turning to the Lancet, specifically in the Lancet Digital Health, one of the Lancet journals. A novel digital intervention for actively reducing severity of pediatric ADHD symptoms — a randomized controlled trial — so I really loved this because I’m one of those folks who looks at video games with judgment. They seem like a waste of time and they seem like they can’t be really very helpful, although we’ve reported about surgeons improving their dexterity by using these things. The other thing that I find appealing about this study is that it’s non-pharmacologic, that they used this digital intervention in kids who are not on ADHD meds.

They’ve developed this video intervention. It’s called AKL-T01. It’s an investigational digital therapeutic that’s designed to target attention and cognitive control. They do it on an iPad at home for 25 minutes per day, 5 days per week for 4 weeks. They had 348 kids in this group who were randomized to either receive this particular intervention or a controlled intervention which was a challenging kind of word game. Among those who used the AKL-T01, I know they’re going to come up with a better name for this — median age 9.7 years — and were able to use it for the period of time that was specified.

It improved their ability to pay attention to things. They have an outcome measure that’s called TOVA, T- O-V-A. That’s the Test of Variables of Attention. That improved among those kids who used this specific intervention. The authors come at the end and say, “This could probably be used in conjunction with other methods such as cognitive behavioral therapy or pharmacotherapy to help these kids with ADHD.”

Rick: This was interesting. As you know, ADHD affects over 37 million children worldwide, so having some treatment, especially one that’s portable, one that you can do at home on your own time, can use different devices, is all very attractive. I would note a couple things about this study. One is it’s a relatively short intervention. It’s 4 weeks. The results of the TOVA tests were relatively modest. They looked at some secondary outcomes as well, including the parent rating and the clinician rating of the ADHD symptoms and the functional impairment, and none of those things improved at all with the test. It’s interesting, so there’s a lot of work to be done to show whether this can be sustained and whether there’s actually improvement in functional impairment.

Elizabeth: Right. One of the things that was interesting about it was that 83% of the sessions were completed among kids who had the intervention, while it was almost 100% among the kids who were playing the challenging word game, which says to me, “Maybe you need to make the intervention more attractive or engaging or interesting for these kids.”

Rick: In fact, the nice thing about the intervention is they reported no harm, but they did report that about 5% of the kids were frustrated and about 3% of the kids had a headache after doing the test. Future studies will ascertain whether this is actually beneficial in the long term.

Elizabeth: On that note, then, 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.