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 is below the summary.
This week’s topics include beta blockers and COPD, soccer players and cognitive function, long term exposure to disinfectants, and survival without comorbidities in premature birth.
Program notes:
0:44 Heading the ball in soccer
1:44 Three times higher rate of death with neurodegeneration
2:45 Some association with professional players
3:46 Asymptomatic events important
5:00 May cause exacerbation
5:45 Disinfectant use in nurses and COPD
6:45 A number of types of disinfectants
7:45 Develop strategies to reduce exposure
8:40 Survival without comorbidities in premature birth
9:47 Kids born before 27 weeks gestation only 22%
11:01 Overall have a high quality of life
12:13 End
Transcript:
Elizabeth Tracey: Do soccer players need to worry about the long-term impact of heading?
Rick Lange, MD: Outcome of adults that were born prematurely.
Elizabeth: What are the occupational hazards of exposure to disinfectants?
Rick: And should beta blockers be used in people with COPD?
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. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on October 25th, 2019.
Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, how about if we turn first to the New England Journal of Medicine, the one I served up as, “Wow, do soccer players need to worry about heading a ball?” We’ve been covering for several years now, of course, the chronic traumatic encephalopathy (CTE) that plagues professional football players. It seems like there’s a pretty clear relationship there. In this case, they took a look at 7,676 — so I’m tickled by that number, so that’s why I’m reporting it exactly — professional soccer players in Scotland and matched those folks to 23,000+ controls from the general population. They were matched on sex, age, and degree of social deprivation, which I thought was a really interesting factor to include.
They took a look at mortality among these folks over a median of 18 years. All-cause mortality was lower among former soccer players than among controls up to the age of 70 years and then was higher thereafter. However, mortality with neurodegenerative disease listed as the primary cause was significantly higher, three times higher, among the former soccer players than it was among those who had not played. Also, they talked about the specific dementias — for example, Alzheimer’s disease also higher. Interestingly, Parkinson’s disease in there, also. The use of dementia-related medications was seen more often with regard to the former soccer players than among controls. So to me, at least, this looks like there’s some concern relative to heading the ball among soccer players.
Rick: When they looked at people that played out in the field versus the goalkeepers, there was no difference in terms of the neurodegenerative conditions that you mentioned. You would suspect it would be higher in those that were out in the field because the goalkeepers very seldom had the ball. I don’t want people to be dissuaded from playing sports because, as you noted, overall people that are involved in sports — whether amateur or professional — have lower cardiovascular mortality and a lower mortality overall. But as you allude to, even though overall mortality was decreased to age 70, there does appear to be some association in these professional players with neurodegenerative disease.
Now, a couple things. One is it doesn’t necessarily talk about people that are involved with recreational sports. It doesn’t talk about people with regard to amateur sports and there was no imaging to see whether CTE was higher in this population as well. So there’s some more data, but I’ve wondered about this as well. As you know, our son played soccer competitively up through the college level and I was always concerned that going to the professional level might increase the risk. This is certainly preliminary information that needs to be followed up.
Elizabeth: One thing the editorialists noted was, perhaps, it’s the chronic subacute injury that may be taking place in soccer players in contrast to those really profound acute events that football players experience.
Rick: You’re right. In fact, even when we look at football players, we think about the major concussive events as being those that predispose to CTE. But as you noted, it looks like it’s not related to major concussive events. Many of those subsymptomatic or asymptomatic events may be more important. So more to come on this story.
Elizabeth: No doubt. Which of yours would you like to turn to?
Rick: Let’s talk about beta blockers first, particularly in people that have COPD.
Elizabeth: That’s also in the New England Journal of Medicine.
Rick: And I thought this was interesting because people with heart disease oftentimes have an indication for a beta blocker. In people that have heart failure, we know beta blockers lower mortality. People that have had heart attack benefit from it as well. There was some suggestion that people with COPD could benefit because beta blockers reduce inflammation and also reduce mucous secretion. This was an interesting study because it took 532 patients that had moderate to severe COPD and randomized them to a long-acting beta blocker, metoprolol, or placebo with the intention of decreasing the time to exacerbation and hopefully decreasing hospitalizations.
Unfortunately, what happened is that the study was stopped prematurely for futility because it looked like beta blockers weren’t going to be helpful, but more importantly because there appeared to be a serious adverse event or some hint of that. The patients who received beta blockers were twice as likely to have a severe exacerbation leading to a hospitalization and intubation with mechanical ventilation.
So where do we stand with regard to beta blockers? If someone has COPD and an indication from a heart standpoint, please continue the beta blocker. Those observational studies showed that those people benefit, but if you’re taking a beta blocker only to help with COPD — that is, there’s no heart indication — it’s not beneficial and it looks like it may actually be harmful.
Elizabeth: Help me to understand this just a little bit further. I don’t know if there’s any speculation in there on the mechanism by which this creates an exacerbation of COPD.
Rick: Elizabeth, there’s some concern that beta blockers may actually cause constriction of the airways and that’s why there was always concern about should we be giving them to individuals that have COPD?
Elizabeth: OK. Let’s turn now to JAMA Network Open, a population, of course, I’m very interested in and that’s nurses. That’s because in my chaplain role I just think they’re the heroes of the health care system. No criticism of you, of course, intended at all, Rick.
In this study, they took a look at data from the Nurses Health Study, and this, just as a review, has 116,000+ female registered nurses from 14 states who were enrolled in 1989 and they’ve been followed up for quite a while. In this case, they included almost 74,000 women in this analysis and their mean age at baseline was 54.7 years, so fairly young. They took a look at weekly use of disinfectants to clean surfaces. They also adjusted for age, smoking, race, ethnicity, and body mass index. So I thought it was pretty impressive in trying to get rid of the potential confounders.
They also looked at specific disinfectants and those included glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds. And they said, “Gosh, are these women developing COPD more often?” That was COPD that was diagnosed by a physician. In fact, they did find that exposure to these agents did increase the risk of COPD after correcting for all of the potential confounders, suggesting to me, at least, that this is an important area we need to examine more closely.
Rick: One thing that our listeners should be aware of is the incidence of COPD in this population was really pretty low. Of the over 73,000 women, only 582 of the nurses developed COPD. But as you note, it clearly was related to disinfectant use. We’ve previously known that disinfectant use can increase the risk of asthma in people that are predisposed. This is the first time it’s actually been linked to COPD, and as you identified, specific agents as well. Our listeners should also note this was independent of smoking status. To me, that tells me we need to develop strategies to reduce the exposure, at the same time making sure we adequately disinfect materials and places that need to be disinfected.
Elizabeth: Yeah, I think among all the occupational exposures people in health care experience it would be really great if we could strategize on ways to reduce this one.
Rick: Right. Now, unfortunately, the data here doesn’t get granular enough to know what sort of protective gear they were wearing, if any. Were they using gloves, for example? Or were they using masks or things like that? Unfortunately, the data doesn’t tell us whether that helped prevent it at all or whether the nurses were wearing it. But again, I think this is a really important study and I’m glad it focused on nurses because there are actually more nurses in the health care profession than physicians. And what we do wouldn’t be possible without nurses. We need to protect them.
Elizabeth: Let’s turn to your final one, then, and first remind me where again that is.
Rick: This is in the Journal of the American Medical Association that talks about the survival without major comorbidities among adults that were born prematurely. We know when children are born prematurely, there’s an associated incidence of cardiometabolic disease and respiratory disease, even neuropsychiatric disorders. However, we haven’t really studied what the survival is without major comorbidities in adults that were born prematurely.
And so to address that, this is a study done in Sweden using a cohort of over 2.5 million persons born between 1973 and 1997 who had follow-up for almost 30 years. They assessed the incidence of major comorbidities and survival in those born prematurely and matched it to children that were not born prematurely. What they discovered, overall about 6% of the Swedish children were born prematurely, and at the end of 30 years’ follow-up, about 55% of them were alive without major comorbidities.
Now, compare that to 63% in the general population. It was clearly a little bit lower, but the population that drove most of that were kids that were born before 27 weeks of gestation. That’s really extremely premature. In those individuals, only 22% survived without major comorbidities. When we talk about major comorbidities, we’re talking about things like hypertension and chronic kidney disease, asthma, and diabetes and things like that.That’s why even in the general population a third of them have one or more of these conditions even in early or mid-adulthood.
Overall, what we can say is that among the premature children born in Sweden between 1973 and 1997, the vast majority of them survived to early to mid-adulthood without major comorbidities. However, those born extremely premature had the highest incidence of comorbidities.
Elizabeth: Right. In spite of all of our best efforts to intervene and to try to prevent some of these things, there’s been ongoing research and we pointed out many of these outcomes in the past. I guess one of the questions I would ask is, this is a very resource-intensive and emotional time for people when they have a child who’s born that early. And I guess I’m wondering what would you do if you were the king of the forest with regard to the probability that these kids are going to be disabled as they grow up?
Rick: I wouldn’t call them disabled. I’m glad you brought that up, because overall when you look at it, most of them have a high quality of life. The comorbidities we’re talking about doesn’t necessarily mean the quality of life is poor or they’re disabled. Many of these things are treatable. I think what we need to do is we need to have increased surveillance among those children born extremely prematurely to recognize that they’re at increased risk and be able to treat those and to provide the quality of life that you and I know they can achieve.
It’s interesting. When they look at this over the different decades — again, this study went from 1973 to 1997 — it looked like there wasn’t a huge difference in outcome between those several decades. In other words, as you noticed, we’ve been doing a much better job of getting premature children both through early infancy and into adulthood, and overall, we’ve done a very good job of that. Now we need to make sure we provide surveillance and treatment of these comorbidities.
Elizabeth: 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.