TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, 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.
This week’s topics include neurologic sequelae of vaccination for or infection with COVID-19, lack of benefit for those with COVID on aspirin or other antiplatelets, the safety of history-based prescription of medications to terminate pregnancy, and quit attempts by adolescents using combustible and e-cigarettes.
Program notes:
0:44 Neurologic outcomes and COVID infection or vaccination
1:45 Bell’s palsy, transverse myelitis
2:46 What is the background rate?
3:45 Even with variants prevent severe disease
4:00 Failed attempts to quit cigarettes among teens
5:00 Monitoring the Future study
6:00 Regulate e-cigarettes to not target this group
7:01 Antiplatelet agents in COVID infection
8:01 Wasn’t effective in critically ill patients
8:44 Outcomes and safety of history-based prescription of medication abortion
9:44 Looked at adverse events
10:42 Approved up to 70 days of pregnancy
11:44 Meets six domains of healthcare quality
12:45 End
Transcript:
Elizabeth Tracey: What’s the impact of electronic cigarette smoking cessation on teens?
Rick Lange, MD: Do critically ill patients with COVID-19 benefit from aspirin and other anticoagulant agents?
Elizabeth: What do we know about the safety and the outcomes of history-based screening for medication abortion?
Rick: And do COVID-19 vaccinations result in neurological events?
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 Texas Tech University Health Sciences Center in El Paso where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Let us talk, Rick, from the BMJ about this association you teased up as, “Is there a relationship between vaccination, SARS-CoV-2 infection, and neurologic events?”
Rick: As of January, there have been over 9.2 billion doses of COVID vaccine administered. As you’re aware, there are at least five that are approved by the European Medicines Agency. Those include the two mRNA vaccines, the two viral vector vaccines, and one recombinant spike protein nanoparticle vaccine.
Initially, there was some concern that they may cause neurologic events that are mediated by immune complexes. So what this study attempted to do was to look at individuals that either received one or more of those vaccines, individuals that had COVID infection and then no vaccination, and then the general population, to determine whether the vaccines were associated with an increased incidence of these neurologic events. We’re talking about things like Bell’s palsy where there is facial droop, encephalomyelitis, Guillain-Barre Syndrome, and transverse myelitis. All of those are immune-mediated neurologic events.
They looked at over 8 million people that received at least one dose of these COVID vaccines, three-quarters of a million people that were unvaccinated but developed COVID, and there were over 14 million people just from the general population. There was no increase in any of these with any of the vaccines. However, those people that developed COVID infection were more likely to develop one or more of these neurologic events.
Elizabeth: This seems like ancient history, of course, but I recall — and I know you do also — that when we first started vaccinating people we did think we saw an increase in the transverse myelitis.
Rick: And Bell’s Palsy as well. What happens is when you’re giving vaccine, and somebody has any type of event — whether it’s neurologic or cardiac or pulmonary — you report that. But what you have to do is say, “Okay, what’s the background history?” There are going to be some people that even if they didn’t receive a vaccine would develop one or more of these conditions. What a study like this does is when you’re looking at over 25 million people, you can say, “OK, how much of this due to the vaccine, how much of is due to the COVID infection, and how much of it just occurs in the general population?” With this data, we’re able to say with confidence that these vaccines really don’t elicit these neurologic complications.
Elizabeth: I’d like to hear your opinion about how persuasive you feel any of this burgeoning data really eliminating concerns about untoward side effects of vaccination is going to be for the general public.
Rick: Elizabeth, people that have not gotten vaccinated — we have tried a number of different educational and learning events to try to inform them of the safety of these vaccines. Unfortunately, they still remain unconvinced.
Elizabeth: I would just note, and I know we’re also watching this data that the BA.2 variant seems to be gaining some ascendancy, and if we are model, as they are seeing in Europe, we could be seeing an increase again.
Rick: Fortunately, the vaccines and the boosters really do a terrific job of preventing hospitalizations and deaths, even for those individuals that develop COVID infection, even with some of the variants. If we have any listeners that haven’t received booster or haven’t received the initial vaccine, let me encourage you to do so.
Elizabeth: Let’s turn to JAMA. This is a research letter and it’s taking a look at failed attempts to quit both combustible cigarettes and e-cigarettes among U.S. adolescents. This, of course, is a really important issue because this letter notes that nicotine use usually starts and then becomes well-established during adolescence. It’s declined, this use of cigarettes among adolescents, from 57% in 1997 to only 16% in 2020.
They wanted to take a look at well, gosh, if you are one of the people who is using either combustible or e-cigarettes, have you made an unsuccessful attempt to stop using nicotine? They use this as their metric for nicotine addiction and loss of autonomy relative to the use of this substance. They also note something that I didn’t know before, and I don’t know if you did — that both combustible cigarettes and e-cigarettes deliver similar levels of nicotine with similar addiction potential.
These were respondents from the 1997 to 2020 Monitoring the Future study, which surveys nationally representative samples of 8th, 10th, and 12th grade students in person. Amazing response rate of 86% over all of these years.
They asked them, “Hey, first of all, are you using these things, and have you tried to quit?” They have over 800,000 respondents, including about 9,000 + in 2020. E-cigarette use was broken out separately. The percentage of adolescents who reported an unsuccessful quit attempt for cigarettes declined from just shy of 10% in 1997 to 2.2% in 2020. However, for e-cigarettes, unsuccessful quit attempts was just shy of 6%.
What they are pointing out is that e-cigarette unsuccessful quit attempts demonstrates that this is a very addictive substance among adolescents; it’s a substantial problem. We really need to start thinking about how we formulate our policies to regulate e-cigarettes so we don’t allow them to target this population.
Rick: From 2007 to 2020, there was a significant decline until the most recent reported events. Basically, we have erased 13 years of decline, just since we have introduced e-cigarettes into the adolescent population. That’s very concerning.
Elizabeth: Yeah, I mean, I think we have made some progress with regard to these e-cigarettes. All those flavors like bubblegum, spice, and what have you that were out there are no longer there for the most part, although some of these manufacturers are strategizing on ways to get around those particular constraints. I just think there is no reason at all for these things to be available to adolescents.
Rick: Clearly, it shows that they do have addictive potential and the fact that it’s now increased more so now than in the last 13 years. These unsuccessful attempts to stop using nicotine are a risk factor for long-term chronic cigarette or nicotine use. If we don’t get this under control now, it’s going to plague us for decades to come.
Elizabeth: Staying in JAMA, then, on to your next one.
Rick: This has to do with whether antiplatelet agents — aspirin and other agents — can be useful in individuals that have COVID-19 infection and are critically ill. This stems from the fact that thrombotic events are very common. COVID infection causes inflammation, that inflammation affects most of the blood vessels, which makes them stickier and more likely for platelets to adhere, and to clump, and to clot. In non-critically ill patients, the use of anticoagulants like heparin has been shown to be useful, but not in critically ill patients by the way. The question is can antiplatelet agents be helpful in these critically ill patients?
They looked at over 1,500 critically ill adult patients from 105 sites in eight different countries and they were followed up for 90 days. What they were looking at are individuals that didn’t die and they were free of intensive care unit based respiratory or cardiovascular organ support. They looked at open-label aspirin, other antiplatelet agents, and also control — about a third in each group.
The use of antiplatelet agents really wasn’t effective in terms of looking at organ support-free days in critically ill patients. It did increase the risk of bleeding, by the way. The proportion of patients surviving the hospital discharge were actually slightly higher in the aspirin group, 71.5% versus 67.9%. But overall, when you look at the totality of the information, it doesn’t appear that aspirin is beneficial overall.
Elizabeth: Is there any speculation on biological mechanisms in here? Because I would hypothesize to you that somehow being able to interrupt this clotting is really a good idea.
Rick: Is there a biologic plausibility? Clearly blood vessels are damaged or inflamed, but the aspirin and related agents aren’t beneficial enough to prevent that from recurring.
Elizabeth: Let’s turn to JAMA Internal Medicine. This is a look at outcomes and safety of history-based screening for medication abortion. This is a retrospective multicenter cohort study.
This, of course, is an important issue right now. There has been lots of transitions in abortion services nationally and a lot of political energy behind changing many things. Previously, when women were prescribed medications to terminate pregnancy, they were required to have either pre-abortion ultrasonography or a pelvic examination. With COVID, that was taken away and there were a whole lot more history-taking and then prescription of these medicines in order to terminate pregnancy.
What were the outcomes relative to that? They had an effectiveness measure that was defined as complete abortion after 200 micrograms of mifepristone and up to 1,600 micrograms of misoprostol without additional intervention. They also looked at major abortion-related adverse events defined as either hospital admission, major surgery, or blood transfusion.
They included data on just about 3,800 patients with eligible abortions and they were racially and ethnically diverse. For most of these patients, it was the first time that they had asked for a medication abortion. They represented 34 states and the vast majority of them lived in urban areas.
In 66% of them, these medications were dispensed in person and the others were mailed to the patient. What they found when they followed them up was that the adjusted effectiveness rate was just about 95%. These complications that I mentioned were rare. The editorialist says it’s really time for us to consider this as standard practice.
Rick: The reason why ultrasonography and physical exam was initially mandated was concerns about these medications are approved for use up to 70 days of pregnancy and to make sure that there weren’t individuals that were later than that.
The other is because it would be a certain number of women that have ectopic pregnancy, those we want to be detected rather than treated with medications. At least in this study, that was pretty rare. It’s about 2 out of every 1,000 pregnancies. The author suggests that even though the screening procedures used by the participants won’t triage these patients that the potential benefits of expanded use outweigh the concerns about this.
One of the things the authors recommend is that the clinicians really should explain this to the patients if they are going to allow this to happen because it’s rare, but it is a significant issue. In terms of informed consent, it’s important to let the mothers know.
Elizabeth: The editorialist brings out the fact that many of these women are low-income and they are otherwise in marginalized groups that may have a lot of difficulty trying to get to some kind of an in-person situation in order to obtain care. They cite the Institute of Medicine, having identified six domains of healthcare quality, which include safety, effectiveness, and patient centrality; it happens in a timely, efficient, and equitable fashion — and that this change in practice would meet all of those standards, it would reduce burdens, and it is an evidence-based model for medication abortion care delivery.
Rick: That’s why the authors were keen on reporting this is because even though COVID had allowed a relaxation of how these mothers were evaluated prior to receiving the medications, because you want to be able to look at the data and say, “Is it safe for the mothers?” At least in this retrospective study, it appears that they were. I would say that it was a little disappointing that about a fourth of the patients weren’t followed up. I hope this leads to more robust studies with better follow-up.
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.