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 reanimating hearts for transplant, suicidality among older adults, opioid use disorder (OUD) treatment in primary care, and ductal carcinoma in situ (DCIS) outcomes without surgery.

Program notes:

0:44 Reanimating hearts for transplantopens in a new tab or window

1:44 Allow heart to sit for two to four minutes

2:34 Outcomes in DCIS without surgery

3:34 Free of breast ca six months after diagnosis

4:34 Numbers who went on to develop invasive disease low

5:34 May change how we approach DCIS

6:09 Suicidality around the world in older adults

7:09 Guns, pesticides, hanging

8:10 Increase primary care diagnosis of OUD

9:10 Three clinics in four U.S. states

10:10 6 million adults with OUD

11:10 Many physicians unaware of medicines

12:43 End

Transcript:

Elizabeth: What happens to ductal carcinoma in situ if surgery is not undertaken?

Rick: Suicide rates and methods in older adults.

Elizabeth: Can electronic intervention help primary care treat opioid use disorder?

Rick: And reanimating hearts to make them suitable for transplant.

Elizabeth: That's what we're talking about this week on TT HealthWatch, 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: Rick, I'd like to turn first to the New England Journal of Medicine and this look at two studies that are talking about reanimating hearts because, of course, we have a huge shortage of organs for transplant. Could this help?

Rick: We're talking about harvesting hearts from individuals that have been determined to have circulatory death. Currently, there are a couple of techniques. One of the more common ones is called normothermic regional perfusion. After the person has been declared dead, they use the aorta and inject fluid, run it through a machine that oxygenates blood, try to maintain perfusion. But there are some ethical issues because at that time you've re-established circulation. There are a lot of countries and hospitals that prefer not to do that.

What this study in the New England Journal, [of] 3 adults' hearts and 1 pediatric heart, instead of doing normothermic perfusion, is allowing the person to be declared dead and then waiting for a short period of time after that -- 2 to 5 minutes -- and then putting oxygenated fluid through the heart. That avoids the ethical issues of reestablishing circulation. If you allow the heart to sit without working for 2 to 5 minutes, does it recover and how does it perform when it's been transplanted?

The heart did perfectly fine. One month, 3 months, and 6 months afterwards, the heart function was entirely normal. This particular technique is pretty simple. It's economically more feasible. It can improve the availability of organs.

What it shows is that there's a reversibility of cellular death that commences after circulatory death. You can preserve a heart even after someone's been called dead from a circulatory standpoint. It can actually make cardiac donation more available.

Elizabeth: I think this probably opens up that window into how many times, when the heart has stopped, could we actually harvest it and use it in transplant.

Rick: Yep. I agree.

Elizabeth: Let's turn from here to The British Medical Journal, and this is a study that's looking at what happens with ductal carcinoma in situ, the most common type of breast cancer in women, when surgery is not performed. And I'm going to foreshadow here. We've been talking in prostate cancer for a long time about active surveillance, that somebody doesn't have a bunch of invasive and potentially disabling techniques performed on them. We just watch their cancer to see what happens, and what does that tell us about how the cancer advances and all kinds of longevity issues.

My guess is that this kind of study clearly is headed in that direction with breast cancer. So this was a look at ipsilateral invasive breast cancer development in women who already had a breast cancer diagnosed, but who did not receive upfront surgery. They had 1780 women with a diagnosis of primary DCIS on needle biopsy, who were alive and free of invasive breast cancer on the same side they originally had their first tumor at 6 months after diagnosis.

They followed up these folks, 53.3 months median follow-up, and the number of ipsilateral invasive breast cancer events was 6.5% and the number of deaths from breast cancer was 1.6%. Their 8-year cumulative incidence of breast cancer occurring on the same side was just shy of 11%. Their 8-year cumulative incidences of breast cancer on that same side varied from 8.5% among women at low risk up to just shy of 14% among those considered to be at high risk. So they could stratify those women who chose not to have any surgery subsequent to their diagnosis as high risk or low risk. And even so, the numbers who went on to develop more invasive disease were really pretty low.

The authors cite the statistic that more than 50,000 women in the U.S. receive a diagnosis of DCIS every year. Is it possible for us to de-escalate their treatment through actively monitoring them for cancer recurrence? And based on this study and some of the historical data that they also cite, it sure seems like the answer is yes.

Rick: Yeah. In fact, this accounts for about a third of all lesions that are detected by mammography. Ductal carcinoma in situ, it's a precursor lesion of invasive breast cancer. It doesn't mean it will necessarily always turn into invasive breast cancer, but it can.

Well, the current guidelines say if you detect it, you need to do surgery. If it rarely develops into breast cancer and it's not likely to cause death, maybe we don't need to be doing surgery on all these individuals. As this study highlights that over a course of 53 months of follow-up, about 90% of women did not develop invasive breast cancer that had ductal carcinoma in situ, and so this may change how we approach it. Now, this is an observational study and it needs to be confirmed in a randomized controlled trial.

Elizabeth: Also in this study, a third of these women had one or more comorbidities at the time of diagnosis and I, for one, would like to see what's the intersection of comorbidity with recurrence of cancer.

Rick: Yeah. You're right. I mean, and again, these are either comorbidities or risk factors that would be helpful in identifying those people at low risk, where you just ought to observe them, and those that are at high risk. Very similar to prostate cancer, as you mentioned.

Elizabeth: On to your next one.

Rick: This is an article that's in The Lancet. It looks at, unfortunately, suicide in 47 different countries and territories over the course of about 25 years. Most of our listeners may not be aware that suicide rates are highest among older adults over age 65. How has that changed over the last 25 years? Is it going up or going down? What are the specific methods and then what are the risk factors associated with that?

They used data from the WHO Mortality Database. It looked at over 10 million individuals, of whom about 670,000 who died by suicide, three-fourths men and one-fourth women. The mortality rate among those over age 65 was about 16 deaths per 100,000 individuals, whereas across all ages, it was a little bit under 11.

The most common methods were firearms, frequently used by older adults, in about 15%, as opposed to 10% in the younger population. For women, poisoning was more common. Oftentimes, it was associated with pesticide use. Unfortunately, another form that did not change was hanging. And although over 25 years the incidence decreased, an older aging population means that the total number of individuals actually increased, even though the rate had decreased somewhat. Factors associated with suicide mortality in the older population include higher poverty rates, mental disorders, alcohol use disorders, and an increasing age.

Elizabeth: Really, pointing to a need for awareness certainly among older adults about their mental state, maybe some kind of screening tool that might specifically ask about suicidal ideation.

Rick: Yeah. For those of us that take care of older individuals, we need to be aware of how prevalent this problem is. Individuals that have attempted suicide, but not been successful, 90% of them never attempt suicide again. So if we can remove some of these methods that are very successful, like firearms or poisoning, we can actually probably decrease the mortality overall.

Elizabeth: Finally, let's turn to JAMA Internal Medicine. Can we increase primary care diagnosis and treatment of opioid use disorder using a clinical decision support system and electronic intervention?

The authors cite that nearly 727,000 individuals in the United States died of opioid overdoses between 1999 and 2022. We do have to add parenthetically, of course, that this number, while it was very high a couple years ago, has been declining. So, that's good news. In any case, they also cite that the current workforce of addiction medicine specialists is completely inadequate. Is there a way that we can engage primary care clinicians to treat opioid use disorder?

They developed an electronic health record-integrated clinical decision support system and assessed whether it could increase opioid use disorder diagnosis and treatment in primary care. This was a cluster randomized clinical trial using primary care clinics and three health systems in four U.S. states. They either received or did not receive this electronic health system that was aimed at improving opioid use disorder diagnosis and treatment. They had almost 11,000 patients.

Patients in the intervention group had more naloxone orders and orders for treatment referrals. These were modest. It was still not that much overall in either group. When they followed these folks out for a while, they did not see that there was any difference in opioid use disorder treatment over 90 days, overdose, or death rates during the intervention period. So basically, they come to the modest conclusion that this electronic intervention can help to improve access to opioid use disorder treatment in primary care, but it's not a panacea and it's not that efficacious.

Rick: No, not really when you consider the fact there are almost 6 million adults in the U.S. with opioid use disorder. There are less than 2,000 U.S. physicians that are actually trained in addiction medicine, so we have a huge need. We've got over half a million primary care physicians -- by the way, most of them that don't want to deal with this. They're either not trained, they don't feel comfortable with it, they don't want to be associated with this treatment, or they don't have time.

But if we could use the electronic health record and clinical decision support, can we actually improve care of these individuals? And what this shows is it's really not very beneficial. In fact, more than 80% of individuals with opioid use disorder, even using the electronic health record, are never even referred. Benefits are modest, if any at all.

Elizabeth: And also, we saw that same old persistent problem with various subgroups that they examined, including American Indian, Alaska Natives, Black patients. What is that persistent stigma, I guess, that's associated with treating opioid use disorder? I guess I would like to examine that a little further.

Rick: Well, some of it's stigma, and some of it is that many physicians are unaware that the three medications that we have available have all been shown to improve survival. We live in a world where there are decreasing number of healthcare providers. There's more and more expectations of them of what they need to do, limited time to spend with a patient. If you don't have expertise in this particular area, you're not willing to treat patients. And, unfortunately, there's not enough physicians to refer them to, even if you identify them.

Elizabeth: I think it's very daunting, if you look at these numbers, that the referral rate to specialty addiction treatment compared to usual care was only 14% versus 9.4%, so still a very low rate. And their use of buprenorphine orders, 15.2% in the intervention group versus 10.3% in the usual care group. So, you're right. There's this huge barrier that's present in primary care. The editorialist says, "Should we make it an expectation that expertise in treating opioid use disorder is part of that expected scope of care in primary care?"

Rick: And you can try to add another thing onto primary care physicians. But unless one gives them the training, unless someone gives them the additional time, you can make it an expectation, but it's simply not going to happen.

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.