Prosthesis for Hip Replacement; Testing for Respiratory Viruses in Nursing Homes

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 Texas Tech Health El Paso, look at the top medical stories of the week.

This week’s topics include a dual-action prosthesis for hip replacement, a new inhaled agent for idiopathic pulmonary fibrosis (IPF), testing nursing home residents for respiratory viruses, and online prescribing of GLP-1 receptor agonists.

Program notes:

0:40 Online prescribing of GLP-1 agonists

1:44 Physician asks a number of questions

2:44 Interaction to approval about 5 minutes

3:30 Respiratory outbreak mitigation in nursing homes

4:30 Using polymerase chain reaction (PCR)-based test in the nursing home

5:30 No difference in outbreak number or size

6:35 Avoid 64,000 emergency department (ED) transfers in U.S.

7:32 Residents reap many benefits

8:00 Inhalation treatment for pulmonary fibrosis

9:00 Clinical worsening in fewer patients

10:01 Dual-mobility total hip replacement

11:04 Substantially reduced risk of dislocation

12:05 Substantial number required revision previously

13:15 End

Transcript:

Elizabeth: Should we be testing nursing home residents for respiratory viruses right there in the facility?

Rick: Inhalation treatment for idiopathic pulmonary fibrosis.

Elizabeth: Is there a way to improve total hip replacement to avoid revisions?

Rick: And online prescribing of GLP-1 receptor agonists.

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 Health El Paso.

Elizabeth: Rick, I’d like to turn first to JAMA and talk about this issue of prescribing of GLP-1s. That’s because they’re just, as we know, feeling ubiquitous out there. And gosh, are there checks and balances to their use?

Rick: Yeah. Elizabeth, until reading this article, I was unaware that nearly 20% of adults taking a GLP-1 receptor agonist obtain the prescriptions actually online. And they usually do that by getting compounded versions that are sold through telehealth platforms. The GLP-1 has the same active ingredients as the prescribed ones, but they have different inactive ingredients. And they’re not approved by the U.S. Food and Drug Administration. But because of the high demand and the shortage of prescription drugs, oftentimes people receive it through these online methods.

So what this investigator did is they pretended they were a secret shopper and they studied the characteristics of the prescription process. They attempted to obtain prescriptions from August to December of 2025 from previously identified websites. They looked at what information they asked for, because if you see the physician, the physician wants to know, why do you need it? Is it just for weight loss? Are we using it for diabetes? Do we have other conditions that anyone needs to be concerned about? Other medications you have?

They looked at 49 different websites; 98% prescribed and 69% mailed the medication. All the websites used a questionnaire. Only about 80% asked about what the weight loss goals were. About two-thirds asked about prior nonpharmacologic weight loss attempts and only about half asked anything about the diet and physical activity. One hundred percent asked about medical conditions, about 94% about medications and allergies. Only 27% required a video visit or 6% required a call. That video visit, by the way, was to confirm that you needed it, because as you know, there’s some people that have eating disorders, will take a GLP-1 receptor agonist, and they don’t even need it. And the median time from when you did this to when you got the prescription was 1 day or less. That’s when you got the prescription, but from the time you interacted to the time it was approved, average time about 5 minutes.

Elizabeth: One of the questions that springs to my mind right away is, and how much do these things cost when they’re compounded for you? And are people paying out of pocket?

Rick: Well, the median price per month was about $217 and it ranged from about $160 to $290. These are usually paid for out of pocket.

Elizabeth: The other criticism I’ve heard about this is that, as we both know, it’s foundational for weight loss to consider diet and exercise and employ those alongside the GLP-1s. And it sounds like there’s a sad lack of that.

Rick: Absolutely. I mean, these things don’t require any clinician interaction. And we’ve talked before, once you stop these medications, unless you address these other issues, you gain the weight back and you gain it back very quickly.

Elizabeth: Let’s turn to JAMA Internal Medicine. This study takes a look at respiratory outbreak mitigation with point-of-care testing in long-term care facilities, otherwise known as nursing homes.

We both know, and I’m sure many of our listeners know also, that respiratory viruses in nursing homes or long-term care facilities are legendary and are often the proximal cause of death for residents. Because of the nature of having so many people in these spaces, pretty closely living next to each other, the rate of spread is really high. And this is a vulnerable population.

What has been done in the past in many of these long-term care facilities is that if somebody is suspected of having a respiratory infection, they send it out to get it tested. And in this case, they were looking at the effect of an on-site point-of-care respiratory multiplex polymerase chain reaction, or PCR, instrument on assessing outbreaks among nursing home populations. It’s important, of course, that this is a PCR-based test because it’s much more accurate than a lot of the other ones, and it returns the answer really quickly.

So their primary outcome was COVID, influenza, and RSV [respiratory syncytial virus] outbreak size and number in 20 participating nursing homes. And their secondary outcomes included the rate of resident emergency department, or ED, transfer and death. They had just shy of 4,000 beds that were represented among their participating nursing homes. What they had to do was, of course, obtain this device and then train their staff how to use it. It did have an upfront cost, if you will, and a level of participation among the staff that was needed in order to allow this intervention to go forward. Interestingly, there was one nursing home that could not get their staff trained and participatory, and dropped out of this study.

What they basically found was that there was really no difference in outbreak numbers or size in the intervention group versus the control group. However, ED transfers were reduced among the intervention group. There was no difference in death. The other positive about the point-of-care PCR test was there was a shorter time to the initiation of antiviral therapy. So the authors basically recommend that seasonal adoption of this type of testing would probably be beneficial and would result in an estimated four fewer ED transfers per 100 beds.

Rick: There was an 11% absolute reduction in the probability of having an emergency department transfer.

When you look at the cost of it — and by the way, this particular study did not — you have to weigh the upfront cost against the savings you get from fewer ED transfers. And the estimated, according to the authors, approximately 8,000 transfers avoided across Canada, 19,000 in the U.K., and 64,000 across the U.S. each season.

As you mentioned, this polymerase chain reaction is both more sensitive and more specific than the current rapid antigen testing that we do. And because rapid antigen testing is not very sensitive, we usually only apply it to people that we suspect already have one of these viral infections. Whereas the PCR, you can actually do it in asymptomatic individuals. Nursing homes are much more likely to use the PCR testing than the rapid antigen testing. That and the early antiviral therapy has probably resulted in fewer ED transfers.

Elizabeth: The other thing that the editorialist brings out is that avoiding a hospital transfer is also beneficial to the residents. It enables them to maintain their cognitive abilities. We have both borne witness many times to the development of delirium when someone is transferred from a long-term care facility into the hospital. They also reap psychological benefits of staying in their familiar and home-like, if it’s home-like, in their long-term care facility environment. It also reduces, I was unfamiliar with this term, iatrogenesis and other adverse events that are associated with hospitalization.

Rick: An area where we have difficulty with healthcare capacity to begin with, things that we can do to prevent ED transfers that are beneficial for the healthcare system and the patient, sounds like a win-win.

Elizabeth: Let’s go on to your next one. That’s in the New England Journal.

Rick: Inhalation treatment for idiopathic pulmonary fibrosis, people that have scarring of the lung for reasons that are inexplicable. And it’s a progressive fibrotic or scarring disorder. There are now three approved therapies. But despite that, the prognosis still remains pretty poor.

What we’re going to talk about is treprostinil [Tyvaso], which is an inhalation therapy. It’s a pulmonary vasodilator. In individuals that have idiopathic pulmonary fibrosis and are already receiving other treatment, does the addition of this particular therapy provide additional benefit? It not only dilates the pulmonary blood vessels, but it has activity against fibrosis, vascular, and inflammatory pathways.

This was a 1-year study in two different stages. This is a report on TETON-1 of 600 patients, 434 of which completed the assessment for the entire year. There was a significant improvement in preventing decline of pulmonary dysfunction measured by forced vital capacity, or FVC. Clinical worsening occurred in fewer patients in the treated group. Clinical worsening occurred in 32% that received the active therapy and 45% that were receiving the baseline therapy … . There was no difference in observed time to when there was exacerbation. The major side effect from it was cough. About a fourth of the individuals had to stop it because of the cough and as many as 40% discontinued it for other reasons, compared to about 33% in placebo.

Elizabeth: And, of course, pulmonary fibrosis, it’s just such a crazy condition, having seen many patients with it and not much to offer in terms of hope. So it seems like this would be a worthwhile strategy.

Rick: It is, Elizabeth. And as you’re aware, my father passed away with IPF about… it’s been almost 10 years. And it’s progressive. There aren’t a lot of really good therapies. This study that shows that combining therapies can prevent clinical worsening deterioration is really good news. It’s very important.

Elizabeth: Finally, then, let’s turn to The Lancet.

This is a study that’s taking a look at a device that’s called a dual-mobility total hip replacement. I didn’t realize that dislocation is the most common early surgical complication in patients with hip fractures who’ve been treated with total hip replacement. And this dual-mobility total hip replacement device was developed to increase joint stability.

Well, all right. How do they compare if we just do the regular one versus utilizing this device? This study included people who were 65 years or older with a displaced femoral neck fracture in 20 Swedish and 24 U.K. hospitals. They were eligible for total hip replacement and randomized to this 1:1 ratio to either standard total hip or the dual-mobility device. And their primary outcome was dislocation of the index joint, and that was ultimately treated either with closed reduction or open surgery within 1 year.

[There were] 1,600 participants, 64% of whom were female. They had 1,566 included in the analysis. This dual-mobility device substantially reduced the risk of dislocation. It is also significantly more expensive than total hip replacement utilizing other devices.

Rick: Typical total hip replacement is you have this metal stem that is drilled into the thigh bone and it has a little ball on it, and that ball fits into a socket. In about 5% to 10% of individuals, within 2 months after surgery, that will dislocate.

So what the dual-mobility is, it’s that same socket, but it has a polyethylene capsule that surrounds it that fits into the socket. So it can move or articulate in two different directions. That’s why it’s called dual mobility. This study was important in that it demonstrated, in these older individuals, it didn’t have an increased risk of infection. There were actually fewer complications, fewer dislocations.

Elizabeth: I’ve always considered “revision” to be rather a euphemism for having to redo a surgery. It’s a distressingly large number of folks who end up having that outcome. So if there’s a way to avoid that, that’s pretty good. I will say that to include people in this particular study, they had to have few or none comorbidities and no cognitive dysfunction. If we exclude those folks from possibility, it’s going to include a large number of people who require a total hip replacement.

Rick: That’s true. And, Elizabeth, let’s put some numbers. With the dual hip replacement, the dislocation rate was 1%. And for the regular otherwise hip replacement, it was 4%. Fortunately, for those in whom there was dislocation, most of the time they were able to put it back into place without surgery, three-fourths of the time. But you’re right, there are some people that needed to have the surgery revised.

Elizabeth: Yes, you use that euphemistic “revision.”

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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