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 will be available next week.
This week's topics include sinusitis treatment, low back pain management, waning mumps immunity, and e-cigarettes and quitting attempts.
Program notes:
1:32 A booster should be assessed
2:33 Sequelae of mumps in adults
3:10 Use of e-cigarettes to assist in quitting smoking
4:12 Those using e-cigs were 50% or more less likely to quit
5:12 Damning evidence on e-cigs
5:46 Low back pain management
6:46 Call out to global health community
7:45 First line of therapy is nonpharmacologic
8:28 Sinusitis and antibiotic use
9:28 How should a patient approach this?
10:24 End
Transcript:
Elizabeth: A disturbing resurgence in mumps.
Rick: Does the use of e-cigarettes help people quit smoking?
Elizabeth: How should we manage the worldwide scourge of low back pain?
Rick: Are we treating sinusitis appropriately with antibiotics?
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. This is posted on March 30th, 2018. I'm Elizabeth, a medical journalist at Johns Hopkins.
Rick: I'm Rick Lange, President of Texas Tech University Health Sciences Center in El Paso and Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, let's turn right to science translational medicine, this thing I served up as a very disturbing recurrence of mumps. These scientists took a look at a lot of data, actually, and basically came to the conclusion that on average immunity to mumps wanes 27 years after vaccination. They said, "Okay, we're seeing this come back, then. Is something changing about the virus?" and they determined that the virus was not mutating and that, in fact, this was a frank loss of immunity among populations that had been vaccinated.
This is extremely disturbing, of course, because mumps can be associated with sequelae, especially in adults, and I really love their conclusion, which is that a booster, perhaps throughout adulthood may be a strategy to prevent mumps reemergence and should be assessed in clinical trials. This, of course, is something that we've been advocating for years every time we look at the annual vaccination schedule.
Rick: Elizabeth, as you mentioned, they looked at outbreaks prior to vaccination. That was in the 1980s and determined that most of the mumps infections occurred in young schoolchildren. In 2006, there's been a reemergence of mumps infection, and that occurred primarily in individuals between the ages of 18 to 29. It wasn't because the vaccine was ineffective because the virus had changed. It was because we have waning immunity, putting the individual at risk for developing a mumps infection, especially in a community where many of the kids aren't getting vaccinated because parents are concerned about it. Again, the recommendation based on this is that we get a third dose sometime after age 18. Now there have been no studies, but when they do the mathematical modeling, it suggests that it would be effective.
Elizabeth: As for me and I think for you, also, as a result of international travel, I have received a booster dose and would certainly advocate for that practice. Let's talk about the sequelae of infection especially in adults.
Rick: The clinical course in children is usually pretty mild. There's fever and a little bit of swelling of the parotid gland that is right near the ear, but in older individuals who get it, about 10% can have serious sequelae that includes orchitis, the serious inflammation of the testes that actually can render males sterile. In addition, meningitis and deafness can occur in individuals, so it can be a very serious issue. It's not just a mild viral infection, but 1 in 10 individuals have a more serious complication.
Elizabeth: So you heard it here first, folks. [Laughter] Let's turn from here to another very important public health message, at least in my mind, a look at the use of e-cigarettes to assist people in their quitting efforts. That's in Annals of Internal Medicine.
Rick: This becomes an issue because many smokers report using e-cigarettes to help them quit smoking, but there haven't really been any studies to show whether that strategy is effective or not. This study suggests it's not an effective strategy. They determined that by looking at over 1,350 hospitalized patients who planned to stop smoking. They were enrolled in one of two treatment arms. Either they received counseling about how to do that or they received counseling and nicotine-replacement therapy. In that setting, they followed these individuals for 6 months and noticed that a fourth of the individuals in either group said, "You know what? This isn't going to be effective enough alone. I need to also use e-cigarettes to help me stop cigarette smoking."
What they found is in those individuals that used e-cigarettes, they were much less likely to stop smoking than those that didn't, regardless of whether they received education or nicotine replacement, and it was a substantial difference. In fact, those that received e-cigarettes were somewhere between 50% and 75% less likely to stop smoking than those that did not use e-cigarettes.
Elizabeth: For right now, what would you suggest to folks when they're hospitalized, and of course, they're obligatorily removed from their smoking habits, whether that's electronic or combustible cigarettes, who would really like to continue that when they are discharged?
Rick: The first thing you mentioned is it has to be self-motivated. A person has to want to quit. But if they do, the strategies that seem to be most effective do involve education before they leave the hospital, nicotine-replacement therapy, or pharmacologic agents to decrease nicotine withdrawal symptoms, and then finally, follow up. In this particular study, when those three things were administered, about 30% of individuals had stopped smoking 6 months after their hospitalization.
Elizabeth: I do have to reflect that we are reporting pretty often on pretty damning evidence relative to e-cigarettes and transition to, frank, combustible cigarette smoking and hooking youth on nicotine addiction using flavorings and I just am very concerned that the horse is out of the barn here.
Rick: You highlighted some of the issues. You recall within the last several weeks we also talked about inhaled volatile substances as well that are carcinogenic. Although it's touted as being safer than cigarette smoke, it carries its own issues, and among them, targeting young individuals with flavored vaping that actually gets them hooked on nicotine and has them advance to cigarettes as well.
Elizabeth: Okay, let's turn from here to another major public health issue, this one global. In fact, cigarette smoking, of course, is global, but this one also. Low back pain and the major challenges it represents. In fact, low back pain is the major cause of disability worldwide. In The Lancet, they took a look at this in a very comprehensive way, identifying this increasing problem largely due to a lot of factors we would have already talked about: sedentary occupations, smoking, and obesity, and also including low socioeconomic status as a risk factor for people developing low back pain.
This affects all countries all over the world, but the evidence for the management of low back pain and its treatment comes from high-income countries like the United States, and therefore may not be terribly practical with regard to its utility in low- and middle-income countries. Moreover, a lot of those treatments I would note aren't terribly effective even by themselves. This is really a callout to the global health community, "Hey, what should we do with regard to the management of this very important and disabling problem?"
Rick: In fact, some of the routine practices that occur both in high-income, middle-, and low-income countries are not effective and sometimes counterproductive. Some of those things are the use of specialists when, in fact, most low back pain should be cared for by a primary care physician, overuse of radiologic procedures like CT scan and MRI, overuse of pharmacologic agents as a first-line therapy, especially opioids. The things that we know that are effective: exercise, remaining active, returning to work early, education are rarely prescribed or rarely given enough time to be effective. I think the value of this particular paper was it highlights we're doing the things that have been shown not to be effective. We're neglecting the things that are effective, and that's in countries throughout the world.
Elizabeth: For right now, for the many people who are suffering with low back pain, what would you say?
Rick: The first line of therapy is non-pharmacologic. It's bio-psycho-social, education, letting people know that it's short lived, it's self-resolved. They should remain active. They should continue to exercise. They should return to work early to avoid unnecessary procedures, imaging, even things like injections and spinal surgery are really not effective strategies for most people with low back pain.
Elizabeth: I guess I would also add weight loss in a long-term strategy.
Rick: Absolutely, in terms of prevention, weight loss and also regular exercise. Since this recurs frequently, once a person has had an episode of low back pain, being involved in those secondary prevention methods is really important.
Elizabeth: Great point. Since we've just covered the most common cause of disability worldwide, now let's turn to the most common reason people seek antibiotics or are given an antibiotic prescription. That's in JAMA Internal Medicine -- sinusitis.
Rick: As you said, the most common reason for outpatient antibiotic therapy in the United States. What this study addressed is once they are prescribed, are we prescribing the right antibiotics and using them for the appropriate duration of therapy? What they discovered is in the vast majority of individuals in the United States, that's not the case. We're prescribing them too long, and we’re oftentimes not using the right antibiotic.
They determined this by looking at almost 4 million antibiotic prescriptions for sinusitis. The recommended duration of therapy is 5 to 7 days. When they looked at the antibiotic duration, they discovered in over two-thirds of individuals they were prescribed for longer than 7 days. With regard to use of azithromycin or a Z-pak, it's not recommended because of antibiotic resistance. Yet, a large number of individuals were getting that antibiotic.
Elizabeth: For someone who goes to their physician with sinusitis, what would be your recommendation with regard to this particular interaction with their physician?
Rick: The typical antibiotic prescription should be with penicillin, a tetracycline, or a group called fluoroquinolones, and they should be for 5 to 7 days. If your prescribing physician doesn't use one of those three classes of antibiotics or prescribes for longer periods of time, then what I would suggest the individual say is, "I'm aware that the guidelines recommend a shorter duration of therapy and that's what I'd like to try," and ask the physician, "Are we using the antibiotics that are recommended by the Infectious Disease Society?"
Elizabeth: Empowering the patient. On that note, I'm going to talk about the mumps this week on the blog. That's a look at this week's medical headlines from Texas Tech. I'm Elizabeth.
Rick: I'm Rick Lange. Y'all listen up and make healthy choices.