Palliative Care in the ED; Eyeing Risk Factors for Stroke

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 palliative care in the emergency department (ED), attempting to improve outcomes in large strokes, lung and associated cancers worldwide, and eyeing risk factors for stroke.

Program notes:

0:40 Eyeing up stroke

1:40 How does it compare to traditional risk factors?

2:40 Large language models to analyze

3:14 Evolving trends in lung cancer worldwide

4:15 Air pollution-associated cancers increased

5:15 25% of lung cancers with air pollution

6:15 Less fruit consumption

6:30 Improving outcomes in large strokes

7:30 Use of clot busting agents didn’t help

8:27 Palliative care initiated in ED

9:30 Gagne comorbidity score

10:30 Same rate of admission to hospital

11:30 Most palliative care teams available during business hours

12:30 End

Transcript:

Elizabeth: Can we initiate palliative care in the emergency department?

Rick: Can we improve on the outcome of people with large strokes?

Elizabeth: What’s it looking like in terms of lung cancer and other types of respiratory cancers worldwide?

Rick: And eyeing risk factors for stroke.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, 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: Okay, Mr. Pun Master. With that idea of eyeing up stroke, why don’t we turn first to TheBMJ?

Rick: This is a really interesting study. It looked at retinal pictures to predict the risk of stroke. Traditional risk factors we use are things like your age, your gender, and blood pressure. All of those things affect the blood vessels. Blood vessels are the cause of most strokes, and the best place to actually visually look at blood vessels is in the back of the eye, in the retina.

Well, in the United Kingdom they have the big Biobank, almost 70,000 different retinal pictures. They decided to take a look at all of these retinal pictures and then follow people up for over 12 years and ascertain which had strokes, and then look at different measures of the retina. We’re talking about blood vessels — looking at their caliber, their density, their tortuosity, their branching angles, almost 120 different characteristics.

The first thing they said is, “Okay, can we identify blood vessel changes in the eye based upon pictures that predict the stroke?” They were able to do that. Importantly, they said, “Okay, how does this compare to traditional risk factors?”

What they found was it was just as good if you looked at age and gender, that’s all you knew, and you had a picture of the eye, it was just as good at predicting stroke as having all of those risk factors together. Traditional risk factors involve getting blood pressure and blood tests. In some low- and middle-income resource countries, they may not have access to that. But almost everybody has access to a camera. You can take a picture of the back of the eye. It can be analyzed not by an individual, but by this large language model that they used here.

Elizabeth: This notion of assessing health by looking at the retina and the vasculature that’s back there is gaining a lot of traction. We have talked before about things like MS and being able to discern those lesions by looking at the back of the eye. I have certainly had one of these things that was easy and painless. Probably if we capture them over time they will be even more good at prognostication.

Rick: The ability to use artificial intelligence or large language models and advanced computers to analyze these — we can do things now we couldn’t do 5, 10, or 15 years ago.

Elizabeth: There will be economies of scale too, as this model is improved over time so that people will be able to implement it all over.

Rick: Absolutely. If we identify those individuals, can we modify their risk factors to actually reduce their risk? That’s where the next step is after this.

Elizabeth: And seeing whether the reduction in risk factors is reflected also in this tortuosity and other aspects of their vasculature. Most interesting; we’ll be watching.

Let’s turn then to The Lancet. This is a look at evolving trends in lung cancer risk factors in the 10 most populous countries in the world. I said this was “beyond lung cancer” because they also looked at the bronchi and the trachea. They looked at the Global Burden of Disease database.

There are three factors important, of course, in the development of these kinds of cancers: tobacco use; occupational exposure to asbestos; and air pollution. They looked at those three factors and their associated cancer mortality data.

What they found is that this cancer mortality, relative to these types of lung cancers — let’s call them a catch-all term — has decreased by 8%, with a decrease for males, but an increase for females. Globally, both tobacco- and air pollution-associated cancers have decreased, while tobacco-associated has increased in China and Indonesia. Air pollution-associated cancers of this type have also increased in China, India, Pakistan, and Nigeria.

We have talked many times about this PM2.5, these tiny little particles that people inhale and that get way down inside the lung. That PM-associated mortality has increased by 25% globally. China is weighing in as the place with the highest PM-associated burden of death and disease, while the U.S., unfortunately, has remained twice higher than the global average for asbestos-associated cancers.

Rick: Yep, so some good news in the U.S. that tobacco-associated lung cancer has decreased substantially. It’s disappointing that it’s increased in other countries, as you said, particularly China. But still, tobacco accounts for about two-thirds of the lung cancer risk globally. As you mentioned, about 20% of it is now due to pollution — to ambient air pollution, in China, but it’s also on the increase in India, Pakistan, Bangladesh, and Nigeria, where more than 25% of lung cancers are associated with it.

In the U.S., as you mentioned, asbestos-related lung cancer is decreasing, but it still remains twice as high than in other countries. Now that we have banned asbestos altogether, I expect that to continue going down, but in other countries that risk is going up.

To me, the most alarming thing, Elizabeth, is overall in males the risk is decreasing, but in females it’s increasing primarily due to the fact that the tobacco companies are focusing attention on them to try to get them to smoke. Unfortunately, women are more susceptible to the carcinogenic effects of cigarette smoking than men are.

Elizabeth: Back to this issue of ambient particulate matter. One of the things that they identify as a factor that’s related to this, in addition to household air pollution — which sometimes is relative to cooking methods that are used — was also low-fruit diets. I would love to know what that relationship is. That factor, less fruit consumption, is actually increasing in lower socio-demographic regions.

Rick: Whether that’s due to fruit consumption or whether that’s a marker, what it clearly demonstrates is there is a complex interplay of both society and environmental factors when we talk about lung cancer.

Elizabeth: So true. Let’s turn now to JAMA.

Rick: Can we improve outcomes in individuals that have large strokes? We know that in the vast majority of individuals, stroke is caused by a clot in one of the arteries that supplies blood to the brain, and the major treatment is to dissolve that clot. The most effective way is to do that by mechanically going in there — we disrupt it, extract it, and restore blood flow. Even though we’re successful in doing that in about 90% of individuals with large strokes, still half those individuals end up with a significant neurologic defect. The thought is that even though we’ve removed the clot from that large blood vessel, in the small blood vessels, blood flow hasn’t been restored adequately.

There are two studies that were done looking at two different agents, but with the same thought. It’s that once we have had extracted the clot, let’s insert in the carotid artery a medicine to dissolve any remaining clot, one called tenecteplase and the other one called urokinase. They’re both effective and unfortunately, in neither of these studies, it didn’t matter which agent you use — after a successful embolectomy, putting a catheter in the artery and trying to dissolve any remaining clot really wasn’t the answer to improving outcomes.

Elizabeth: Very disappointing, but an important piece of information, of course. Again, one of those things that a priori I’m sure that it looked like this would be effective and it would be a good strategy. I’m wondering about other medications that might be taken, either given IV or taken orally, that might help to improve that microclotting, if you will.

Rick: Well, Elizabeth, as you mentioned, there was a rationale behind this because there were some smaller studies that suggested it could be helpful. If this isn’t the answer, the question, as you say, is, are there other medications that can help preserve the brain tissue? These are potential studies in the future, but unfortunately these show that the addition of a thrombolytic agent after thrombectomy isn’t beneficial.

Elizabeth: Another negative study and also remaining in JAMA, this is a look at palliative care that was initiated in the emergency department. We know, of course, that palliative care is an attempt to try to help people who have chronic disease live as well as they can with all the symptomatology that they have. I would just remark that, of course, it’s appropriate for anyone with chronic disease to have a palliative care consult because it can really help people deal with their symptoms better and improve their quality of life. In this case, they are wondering whether the provision of palliative care in the emergency department when older adults present there might help improve a couple of things, especially admission to the hospital, but also short-term mortality.

This was patients 66 years or older who visited 1 of 29 EDs across the U.S. over a 4-year period and had been receiving Medicare benefits 12 months prior to this. There was also the application of the Gagne comorbidity score, which is, “Gosh, how much do you have going on?” That score had to be greater than 6, which represents a risk of short-term mortality greater than 30%, and no nursing home patients were included in this.

Previous to this study, what they did was train clinicians in the emergency department with what they called the primary palliative care for emergency medicine intervention. This included evidence-based multi-disciplinary education, simulation-based workshops on serious illness communication, clinical decision report, and audit and feedback for the ED clinical staff. They had almost 100,000 initial ED visits during this study period. About 50% of their patients were female, 13% Black, and 78% white.

Basically, looking at all of their metrics, the rate of hospital admission was essentially the same. There was no difference in their secondary outcomes including admission to the intensive care unit. It really did not impact on these outcomes at all.

Rick: If you look at individuals over the age of 65, half of them visit an emergency department during the last month of life. In general, both patients and their families are more satisfied if they receive their care at home. We know that palliative care teams have decreased the use of hospitalizations and improved patient and family satisfaction. This is the first where we attempt to train emergency department individuals to deliver that care. Why, in your opinion, was this not successful when we know all the other things I’ve mentioned have been shown in previous studies?

Elizabeth: I think it’s really hard to say what exactly went wrong here and it was disappointing.

Rick: Does this close the door on expecting emergency department personnel to be trained to deliver adequate palliative care?

Elizabeth: I think you put your finger on this idea about training in palliative care. In the study, they cite the fact that most palliative care teams are on duty from 9:00 to 5:00 Monday through Friday. Does this suggest that palliative care ought to be expanded in general? I would say unquestionably I think that’s true. I think taking that global approach to people, particularly with a lot of comorbidities, is the right thing to do. Adding this burden to emergency medicine personnel and having an expectation that they are going to deliver a high level of intervention might be an unreasonable expectation.

Rick: Well, I appreciate your thoughts. Many of our listeners are unaware that you, in addition to what you do for the communications at Hopkins, and obviously you and I doing the podcast, is that you’re also a certified chaplain. You’re providing palliative care to many individuals at the Hopkins hospitals and other hospitals. Thank you, Elizabeth.

Elizabeth: Oh, you’re welcome. I’m very disappointed, of course, in the outcome of this study, on at least two levels. 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.

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