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 new screening methods for colorectal cancer, a drug-coated balloon for blocked stents in the heart, delta-8 tetrahydrocannabinol (THC) use, and mortality and treated attention-deficit/hyperactivity disorder (ADHD).
Program notes:
0:39 How to treat blocked stents
1:40 Over a year does reblockage occur?
2:40 Bypass may be more durable in some
3:00 Treating ADHD with medicines and mortality
4:00 Mean age at diagnosis 17.4 years
5:00 Still, questions remain
6:00 6% of youths worldwide
6:25 THC and marijuana use in youths in the U.S.
7:25 About 11% use over preceding year
8:25 Similar to tianeptine and kratom?
9:10 Screening for colorectal cancer
10:10 Genomic alterations detection
11:10 Stool sample collected
12:06 End
Transcript:
Elizabeth: Can we improve noninvasive colorectal cancer screening?
Rick: Treating blockages in the heart arteries after a stent has been placed.
Elizabeth: What is the mortality impact of treating ADHD?
Rick: And adolescent THC and marijuana use in the United States.
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: 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: Rick, I'm going to toss the ball to you. Which would you like to start with?
Rick: How to treat blockages in the coronary arteries that have occurred and those that have had stents placed. We have placed over a million stents in the United States in the coronary arteries, and overall those stents are fairly effective in not only immediately relieving the blockage, but in long-term durability.
Ten percent of the time tissue grows inside the stent and a blockage can recur in the first year after the stents have been placed. In Europe, that's treated with a drug-coated balloon. Once the balloon has been inflated, that material adheres to the inside of the artery and it's meant to prevent growth of new tissue again. But studies of this particular treatment have never been performed in the United States. Even in Europe, the acceptance of this has been based on relatively small studies.
This is the largest study of what's called a paclitaxel-coated versus an uncoated balloon in arteries with a blockage after stent placement. They looked at 600 patients; about two thirds of those got the drug-coated balloon and a third got the regular balloon. They looked over the course of the next year to see how often they had evidence of reblockage, chest pain, or they had a heart attack or cardiac death in that artery. It happened in about 18% of those that received the coated balloon and about 29% in the regular balloon.
When they looked at individual components, it decreased the recurrence of chest pain caused by recurrent blockage by about 50% and it reduced the risk of heart attack in that particular vessel by about 50%.
Elizabeth: Let's just mention that this is in JAMA. This seems like one of those "duh" moments to me in a lot of ways because these paclitaxel-coated stents have been out there for a while. I would like to talk about restenosis with respect to stents. Is there a stent that allows this to happen more often than not?
Rick: We used to have what are called bare-metal stents. There were no drugs on them and the restenosis rate in them was 30%.
Elizabeth: When is it appropriate to just do a revascularization versus placing a stent?
Rick: You're talking about bypass surgery. There are specific circumstances where the durability of bypass surgery is better than a stent -- for example, in diabetics that have multivessel disease -- and then there are certain blockages that are a better approach to the bypass surgery than they are with stents.
Elizabeth: Remaining in JAMA, let's turn to this issue that was rather astonishing to me, the relationship between treating attention-deficit/hyperactivity disorder with medicines and mortality. This is a study that was conducted in Sweden. Of course, we've given them kudos many times for the robustness of their collection of data on their population.
They used a strategy that's called target trial emulation framework, which was also a novel notion for me. They had people who were ages 6 through 64 with a diagnosis of ADHD from 2007 through 2018 and no ADHD medication dispensation prior to their diagnosis. Their follow-up started from their diagnosis until death, emigration, 2 years after their diagnosis, or December 30th, 2020, whichever came first. They looked at all-cause mortality, then natural-cause mortality, and unnatural-cause mortality in this population.
They had almost 150,000 individuals with ADHD. Their median age at diagnosis was 17.4 years, which sounded a little old to me. They looked at mortality risk, which was lower in the treatment group. They also were able to discern that they lowered their mortality in women; it was natural causes of mortality among all those individuals diagnosed with ADHD. The medication initiation was associated with lower all-cause and in the guys unnatural-cause mortality.
Rick: Mortality risk is about twofold with ADHD. Elizabeth, I was surprised as well because in the past we've reported that in adults with ADHD the medications that are used, particularly the stimulants and/or amphetamines, may increase the risk of cardiovascular death. This was a relatively short-term study. It really didn't identify which treatment was the best. It also did not look at comorbid conditions. It suggests that treating individuals can reduce short-term mortality, but this still leaves a lot of things unanswered.
Elizabeth: The editorialist notes that adult ADHD is also associated with adverse behavioral and neuropsychiatric outcomes, and some of the non-fatal problems that are things like injuries, accidents, and substance use in previous studies do appear to be mitigated by treatment with the medications. I thought this was another startling finding. Among those who received stimulant and non-stimulant ADHD meds, most of them discontinued taking it within a few months.
Rick: Yeah, that was surprising as well because they are trying to make an association between treatment and decreased mortality, but individuals rarely took these for a long period of time. I think that more studies need to be done to show is there a benefit, how long does the benefit last, and what drugs are most beneficial.
Elizabeth: I finally would just like to say this statistic that they begin with they say that internationally, according to the World Federation of ADHD International Consensus Statement from 2021, about 6% of the youths and 2.5% of adults worldwide have ADHD. However, in the United States the prevalence is estimated to be just shy of 10% among children and adolescents and 4.4% among adults. I find that a curious statistic, but also a much higher incidence and clearly something that we need to get our arms around.
On to your next one, still in JAMA.
Rick: THC and marijuana use in adolescents in the United States. There are two cannabinols -- 8-tetrahydrocannabinol and 9-tetrahydrocannabinol -- which are active components of marijuana.
It's the 9-THC that most likely produces intoxicating effects and is a focus of several laws limiting its use, especially in younger individuals. The delta-8 THC is thought to be less hypnotic, but it binds to the same receptors.
Delta-8 THC is not regulated in the United States. As a result, there are a number of products that are sold online that have it. We're talking about things like gummy bears and flavored vaping devices. It's primarily derived from hemp rather than marijuana and hence the reason why it's not under legal regulation.
How often is delta-8 THC and marijuana used in adolescents in the United States? They surveyed about 2,200 12th graders from 27 different states. What they found is that about 11% use delta-8 THC over the preceding year and about 35% of those individuals used it multiple times. When they looked at the states, those that didn't regulate marijuana were more likely to have adolescents use delta-8 THC as well.
Elizabeth: This is really concerning. As we have talked about so many times, their CNS [central nervous system] is still in the formative stages and is about to undergo a period of pretty profound neuronal sprouting. Under the influence of this particular drug, it seems like it's unclear what the impact would be over the long haul.
Rick: Yep. Delta-8 THC is not as well studied as regular cannabis, but the users often report that it still produces intoxication, slurred speech, and impaired coordination. In kids, where there is still neural development, it increases the risk of psychosis and other psychiatric conditions at an early age, so very concerning.
Elizabeth: You say that they are buying this stuff online. Is this also similar to these other two unregulated things that we have fingered recently, tianeptine and kratom, and is it sold in convenience stores, for example?
Rick: Oh, yeah. You can buy it in convenience stores via the web. It's fairly ubiquitous. Now the other thing I should mention, Elizabeth, is that even these products that sell delta-8 THC -- because it's not regulated -- you don't know how much is in it or if there is any in it at all. There are also some adulterants as well.
Elizabeth: I'm feeling like there is just an awful lot out there that is unregulated that has a high potential for harm that somehow we need to figure out how to regulate it or intervene.
Rick: Yep, the effect is not regulated. It is an unintended consequence of the , which was meant to not regulate .... We need to take another look at this and especially its accessibility to adolescents.
Elizabeth: Finally then, let's turn to the New England Journal of Medicine, and we're going to treat two studies together. These are both describing studies relative to noninvasive colorectal cancer screening tests.
The first study is the acronym , and this evaluated a next-generation, multi-target, stool DNA test that has updated DNA biomarkers from their first-generation test. They compared this with FIT [fecal immunochemical test], which we're familiar with already, in more than 20,000 participants at average risk who were undergoing screening for colorectal cancer. Where it sort of falls down, and so does the other one, is in detection of advanced precancerous lesions, where it only showed a 43.4% sensitivity.
The second study is called [Evaluation of the ctDNA LUNAR Test in an Average Patient Screening Episode]. This is a study using cell-free DNA from whole blood -- a very attractive target for cancer screenings of all types right now -- that's attempting to detect genomic alterations, aberrant methylation, and DNA fragment changes. This is in just shy of 8,000 screened participants.
This, as compared with colonoscopy, showed a sensitivity of 83.1% for colorectal cancer, a specificity just shy of 90% for advanced cancer, and 13.2% sensitivity for the advanced adenomas. In some, these are great things and they seem like they are steps along the way to getting really robust tests for this. Clearly, we want to increase the rate of colorectal cancer screening, especially as we're seeing a demonstrable increase in younger people. Trying to remove barriers to screening with tests that one can conduct at home -- specifically with regard to the first study -- is very attractive.
Rick: A lot of people don't want to undergo routine colonoscopy or it's not available or their insurance sometimes doesn't cover it. You'd like to have a noninvasive way of being able to assess it. Hence, the collection of a stool sample. Once we detect this, then we have to go to the next step and that's to do colonoscopy, where we're actually visualizing and looking for either precancerous lesions or polyps, and we can treat them as well.
Elizabeth: I think there is a lot more work that needs to be done actually on both of them and on this strategy just in general. The editorialist points out that the good news about the blood test is when somebody comes in for a routine annual or biannual exam, you could just draw blood and do these cancer screening tests also. I think that that's a very attractive target and I'm sure we're going to see more about that.
Rick: That doesn't make it easier than collecting a stool sample.
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.