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 treatment of patients lacking health insurance, transplant of organs infected with the hepatitis C virus (HCV), alcohol use and health impact, and how nutrition affects non-communicable diseases worldwide.
1:42 Donors had high viral load
2:42 Longest followed for a year
3:30 Insurance status and access to hospital care
4:32 Target those seen for pulmonary issues
5:31 Weighs heavy on inner city hospitals
6:33 Alcohol and cigarette comparison
7:35 Run counter to a lot of studies on alcohol
8:33 Cancer just one of the conditions
9:27 Global burden of suboptimal diet
10:27 25% of deaths globally due to this
11:25 Transition to a Western diet
Elizabeth Tracey: What’s the negative health impact of alcohol consumption?
Rick Lange, MD: Are emergency department patients more likely to be discharged or transferred based upon their insurance status?
Rick: And health effects of dietary risk across the globe.
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 April 5th, 2019.
Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso and Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, how about if we turn to the New England Journal of Medicine? This is a study that resonates for me this week because at Johns Hopkins we just had a historic transplant, and that was a kidney transplant among two people who were both HIV positive. The idea clearly is two-fold. One is that we can control HIV really well with medications and transplanting an organ from someone who’s already infected into someone else who’s infected is unlikely to result in increased risk.
So this study in the New England Journal of Medicine took a look at folks who were infected with hepatitis C virus. In this case, they had 44 patients enrolled. 36 received lung transplants and eight received heart transplants. These were folks who took organs from people who were infected with hepatitis C virus. This was with the idea that, as I suggested with HIV, hepatitis C virus cannot only be controlled, it can be cured with the medications that we have right now. And so it turns out that these infected donors had really quite a lot of virus that was detectable, but the folks who received these particular organs were given the two drugs that can cure hepatitis C virus both previous to the transplant and following the transplant. And their outcomes were really good.
Rick: This is an attempt to increase the supply of organs. Last year, we had over 113,000 people waiting for transplants and only about 36,500 actually received them, to a large extent because we don’t have enough donors. Now the interesting thing about these donors that are HCV positive — that is, hepatitis C positive — is they’re younger and they have less comorbidities. Oftentimes, these were individuals that had become donors because of the opioid crisis. In some respects, their organs could be better for transplant except for this hepatitis C infection. And as you note, we now have medications that can treat it, so this is very promising. I would note, however, it’s relatively small and also it’s relatively short time for follow-up. The longest patient with one of these organs was followed for a year, so we still have more information, but this is still very promising.
Elizabeth: Well, it’s promising. One of the things that was brought up again to draw the parallel with the HIV transplant is that we have different serotypes, if you will, of these viruses, so the question is, “Are we going to be transplanting a virus that is resistant?” I think that as we use these HCV medicines more broadly, globally, we’re going to see the emergence of resistant viruses.
Rick: Right, and this is obviously early in the treatment phase. As you know, the treatment has gotten better, and of course, there were four different genotypes represented in these donors as well. So you’re right. There’s still a lot we have to learn. Kudos to the investigators for taking this on.
Elizabeth: I agree. Now which of yours would you like to turn to?
Rick: Let’s talk about this association between insurance status and access to hospital care. That’s reported in JAMA Internal Medicine. Our listeners may not be aware that in 1986, the U.S. Congress enacted what’s called the Emergency Medical Treatment Active Labor Act or [as it’s] called, EMTALA. It actually requires all U.S. hospitals that accept Medicare to provide emergency-department care to all patients regardless of their ability to pay. So a person gets to the emergency department and they have to be stabilized, but it doesn’t require the hospital to admit them, or if the hospital admits them, it doesn’t require them to continue to receive care.
What these authors hypothesized, they were concerned there was some disparity about how people were treated based upon their insurance status. So they did a cross-sectional analysis from 2015 of a national emergency department sample. That’s about 20% of emergency department admissions across the United States. So it looked at over 30 million emergency department visits to over 953 hospitals and specifically they wanted to target those individuals that were seen for pulmonary issues, because most hospitals can take care of those.
They determined there were over 215,000 visits for acute pulmonary diseases to over 160 hospitals that had an ICU that should have been able to care for them. But what they discovered was if the patients were uninsured, they were about 67% more likely to be discharged from the hospital than they were to be admitted, and if they got admitted, they were more likely to be transferred, about 2½ times more likely to be transferred to another hospital compared to patients that had insurance or even compared to those that had public pay, that is Medicaid.
Rick: They have a mandate they have to stabilize the patient in the emergency department, and although hospitals would like to say, “Yes, we take care of individuals regardless of pay,” this shows that, that in fact, is not the case. This weighs particularly heavy on inner-city hospitals where they have a large catchment area of uninsured patients, because the private hospitals take these non-paying patients and they transfer the cost of those to the insured patients, but a lot of inner-city hospitals don’t have the ability to do that. Some proponents of a national health system would say, “EMTALA demands that the hospitals stabilize the patients, but it provides no funding at all, and it doesn’t demand that they actually admit them and prevent them from being transferred,” so we need to address this on a national basis.
Elizabeth: We sure do. And what would you say to the individual right now who might be facing this sort of thing?
Rick: One of the things we need to avoid is encouraging the uninsured patients to receive their primary care in the emergency department setting. That’s not the proper place to do it. So we need to provide access to them through federally qualified health centers, through other funding mechanisms so they can receive primary care to prevent them from using the emergency department as their source of primary care.
Elizabeth: Agreed. All right, so let’s turn from here to the British Medical Journal. This was a study that I picked largely because there has been so much press relative to it. And this is basically just a giant mathematical puzzle, as far as I’m concerned, where they took a look at data relative to alcohol and tobacco use, and then they compared the risks that were associated with either smoking or the consumption of one bottle of wine per week.
And they said — their conclusion, ultimately, was one bottle of wine per week is associated with an increased absolute lifetime risk of alcohol-related cancers in women by 1.4%. That’s driven by breast cancer, largely. Then that is an absolute cancer risk that would also be seen if they smoked 10 cigarettes per week. For men, it was an absolute increase of 1%. As I said, this was a lot of fancy figuring and a lot of statistics — numbers jump and letting these conclusions be drawn. They run counter to a lot of the studies that we’ve been reporting that take a look at alcohol use.
Rick: I’m going to quote directly from the first sentence or two of their conclusions because I think it’s important. It says, “We must first absolutely be clear this study is not saying that drinking alcohol in moderation is in any way equivalent to smoking.” That’s because smoking not only increases the risk of cancer, but it increases the risk of cardiovascular disease and stroke, as well. This is a very narrow focus. If we were to say, “There’s an increased risk of cancer with alcohol and it’s relatively modest and an increased risk with smoking,” how can we compare the two? A cigarette-equivalent alcohol study. That’s why, as you said, drinking alcohol increases the risk in men about 1%. That’s the lifetime risk attributed and in women higher because of breast cancer.
But this doesn’t address the other issues. Obviously, with cardiovascular disease and modest alcohol use, there’s a decrease in cardiovascular disease with moderate alcohol use, but an increase in cardiovascular disease and stroke later, as well. Cancer is just one of the diseases or one of the conditions looked at in this particular study, but it doesn’t look at the overall impact of alcohol on health and mortality.
Elizabeth: Right, I do think it’s important for us to acknowledge that we do know that alcohol consumption is related to a slightly increased risk of breast cancer for most women and that maybe there are some other alcohol-related increases even among men that haven’t really been discerned yet.
Rick: And in men, it’s mostly related to the risk of GI cancer. And by the way, this was talking about moderate alcohol use, but it’s clearly graded. If you increase the alcohol use, there’s an increase or you double the risk of cancer in men and women as well. I think most people would say if you’re not drinking alcohol, they don’t encourage you to drink it for the health benefits. But if you are drinking, is to make sure you do it in moderation to lower your risk of cancer in both men and women and also to get the maximal benefit with regard to cardiovascular disease.
Rick: We know that suboptimal diet is an important, preventable risk factor for non-communicable diseases. However, its impact on the burden of that hasn’t been systematically evaluated partly because we can’t do randomized, controlled trials with it and short trials just look at intermediate outcomes. We have this huge database now called the Global Burden of Diseases, Injuries, and Risk Factors Study, and this study allows us to estimate the burden of mortality and disability attributed to a specific dietary risk by looking at 84 different behavioral, environmental, occupational, and metabolic risks in over 195 different countries and their territories.
They looked at 15 specific dietary risks for their effects on mortality and disability from cancer, cardiovascular disease, and diabetes. What they discovered was there are about 11 million deaths or about 25% of deaths globally attributed to suboptimal diet. Eleven million people — that’s pretty huge. And by the way, they found out they were related primarily to three factors: high intake of sodium, low intake of whole grains, and low intake of fruit. That accounted for about 50% of the deaths. This won’t be surprising: there was a disproportionate burden in low-income settings.
Elizabeth: Of course, it’s really important for us to get our arms around this. I guess I’m a little bit surprised by the magnitude of this burden.
Rick: I must say I wasn’t expecting this either. That’s why I thought it was particularly important to talk about it. This suggests that 1 in 5 is attributed to suboptimal diet, but in many countries, unfortunately, that are developing and low-income countries, those changes in diets can consume as much as 50% of their annual income. So we need to make these more available to developing countries.
Elizabeth: Also, we’ve seen that rather depressing trajectory, I would note, that when a country starts to accrete wealth, it also seems to transition to a more Western diet, very similar to what we have in the United States, and concomitant in obesity and sedentary lifestyle.
Rick: Yeah, and unfortunately this study didn’t address those particular things. It did make a point, though, that maybe we’ve missed the boat because we’ve been focused on nutrients, but this focuses on food groups, and that’s much easier to do. You don’t have to get nutrient value of different food groups. You just say, “Listen, we need to lower our sodium intake and increase our intake of whole grains and fruit as well.” So changing it from nutrients to foods may be of great value.
Elizabeth: 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.