Geriatric Update July 15, 2024
Conjunctivitis is a symptom of COVID and also of H5N1 bird flu. Over the last 27 years >900 bird flu cases have been identified with 52% fatality. As of today, 7 cases have been identified this year in the US with one fatality in a patient with multi-morbidity. It is treatable with oseltamivir.
I was surprised to read that only 47% of surveyed Americans knew that raw milk is less safe to drink than pasteurized milk.
A systolic blood pressure (BP) of <120 vs. a BP of <140 improved outcomes: a composite of myocardial infarction, revascularization, hospitalization for heart failure, stroke, or death from cardiovascular causes. The mean BP was 119.1 mm Hg (SD 11.1) in the intensive treatment group and 134.8 mm Hg (10.5) in the standard treatment group. Over 3.4 years of follow-up, the primary outcome event occurred in 547 (9.7%) participants in the intensive treatment group and 623 (11.1%) in the standard treatment group (hazard ratio [HR] 0.88, 95% CI 0.78–0.99; p=0.028), regardless of diabetes status, duration of diabetes, or history of stroke. Serious adverse events of syncope occurred more frequently in the intensive treatment group (24 [0.4%] of 5624) than in standard treatment group (eight [0.1%] of 5631; HR 3.00, 95% CI 1.35–6.68). Making sure our patients drink enough fluids will mitigate side effects, especially drinking early in the day, when arising shifts >1 quart of blood to our legs.
Sodium intake of >6 g/d was associated with 10% increase in atrial fibrillation risk for each additional 1 g of sodium consumed, in 28,800 individuals (91.6%), avg age 55, assessed with a fasting morning urine sample. A J-shaped curve indicates likely higher risk patients instructed to limit sodium intake for co-morbidities.
People who were exposed to the most light between 12:30 AM and 6 AM, as recorded by a wrist-worn sensor, were 1.5 times more likely to develop diabetes than those of the 84,790UK Biobank individuals, age= 62.3, who remained in darkness during that timeframe.
Weekly semaglutide 2.4 mg showed a 22% reduction in renal outcomes (HR 0.78; 95% CI, 0.63–0.96; P = .02): estimated glomerular filtration rate (eGFR) reduction of more than or equal to 50%, eGFR of less than 15 mL/min/1.73 m2, macroalbuminuria, kidney replacement therapy (dialysis or transplant), and death from kidney disease. This was mainly driven by the reduced deterioration of the eGFR and macroalbuminuria and beyond glucose contro,l in the 8,803 patients with obesity, but not diabetes. In the subgroup on RAS inhibitors, ACE inhibitors and Angiotensin receptor blockers, the improvement was similar at 26%, indicating that it was a different mechanism.
A retrospective propensity matched cohort study showed a higher hazard ratio for the incidence of nonarteritic anterior ischemic optic neuropathy (NAION) in patients on semaglutide, during 36 months of follow up (hazard ratio [HR], 4.28; 95% CI, 1.62-11.29) in a specialized Boston eye clinic, avg age 47 years. 17 NAION events occurred in patients prescribed semaglutide vs 6 in the non–GLP-1 RA antidiabetes cohort, and for patients who were overweight or obese, 20 NAION events occurred in the prescribed semaglutide cohort vs 3 in the non–GLP-1 RA cohort. The overall incidence is rare, at 2.3-10.3 per 100,000 in the United States and higher in whites (95%) and uncommon in other races, higher in those with sleep apnea, PDE5-inhibitors. Given the overall benefits of GLP-1s, this risk is exceedingly low.
After reports of depression with GLP-1 meds, this study looked for increased risk of psychiatric events, but instead found less cognitive deficit with semaglutide compared to sitagliptin (HR 0.72, 95% CI 0.64–0.80) and glipizide (HR 0.72, 95% CI 0.63–0.81), dementia compared to sitagliptin (HR 0.52, 95% CI 0.40–0.68), and nicotine misuse compared to glipizide (HR 0.72, 95% CI 0.61–0.85); against empagliflozin (HR 0.77, 95% CI 0.65–0.90).
While the risk of early onset dementia <65 yo, in World Trade Center responders is low, <1%, it increased with exposure severity, per 1000 person-years: low, 2.95 [95% CI, 1.07-11.18]; mild, 12.16 [95% CI, 10.09-14.79]; moderate, 16.53 [95% CI, 13.30-20.81]; high, 30.09 [95% CI, 21.35-43.79]; and severe, 42.37 [95% CI, 24.86-78.24]). Adjusting for social, demographic, and relevant medical factors, each unit increase in exposure severity was associated with increased incidence of dementia (adjusted hazard ratio, 1.42 [95% CI, 1.18-1.71]; P < .001; mean risk difference, 9.74 [95% CI, 2.94-32.32] per 1000 person-years; P < .001).
Plant-based meat alternatives, despite being ultraprocessed, may be healthier for the heart than meat, a new report suggests. A systematic review found that risk factors for heart disease, including total cholesterol, LDL cholesterol and body weight, improved when various animal-based meats were replaced with a substitute made from plants.
A Dutch study of nearly 2000 women with finger polyarthritis was presented at the European Alliance of Associations for Rheumatology (EULAR) 2024 Annual Meeting. New erosions first appeared in 9 joints in the osteoporosis med denosumab group, compared with 38 in the placebo group over 4-8 years, denosumab or placebo were administered every 12 weeks for 48 weeks.
Systemic Lupus Erythematosus is more common in women, and the Nurses Health study showed an association with diet: A higher cumulative average daily intake of ultraprocessed foods was associated with a 56% increased risk for SLE (95% CI, 1.04-2.32). Sugar or artificially sweetened beverages were associated with a 45% increased risk for SLE (95% CI, 1.01-2.09), without significant interactions with body mass index.
Daily Aspirin use lowers the risk for colorectal cancer (CRC) by about 1/3 and this article describes the proposed mechanisms of action:
Inhibits cyclooxygenase (COX) enzymes
Immune microenvironment in that aspirin directly boosts the presence of antigens on gastrointestinal epithelial tumor cell, especially in patients with BRAF mutations, and in proximal (right-sided) colon cancer vs distal (left-sided), leading to fewer nodal metastases and metastatic lymph nodes.
Higher levels of tumor-infiltrating CD8+ and CD3+ lymphocytes.
Higher expression of CD80 on the surface of their rectal epithelial cells, which the tumor downregulates, allowing T cells to identify the tumor cell as foreign and kill it.
However, aspirin boosted expression of PD-L1 genes in the CRC cells, which serves as an "off" switch for patrolling T cells, protecting the tumor cell from being recognized.
During hospitalization, significantly more females experienced ≥1 adverse drug reaction (ADR) compared to males (28% and 21%, respectively; odds ratio 1.40, 95% CI 1.10–1.78, p < 0.005). Nine of the 11 STOPP-criteria PIMs showing a significant sex difference occurred more often in females. Of the four START-criteria, all occurred more often in females. Some differences are due to higher prevalence of health conditions in older women, requiring medications. The START and STOPP criteria are a European version of the Beers criteria of potentially inappropriate medications (PIMs), and potential prescribing omissions (PPOs).
A new hormone has been identified to protect bone during lactation’s high calcium demand: brain-derived cellular communication network factor 3 (CCN3) secreted from KISS1 neurons of the arcuate nucleus (ARCKISS1) fills the void that estrogen leaves after delivery, and functions as a potent osteoanabolic factor to build bone in lactating females. This study showed benefits in mice, and might be a future treatment for humans.
A full bladder during endometrial biopsy was better than routine care: Insertion failure rate was significantly lower: 25 of 107 (23.4%) compared with 45 of 107 (42.1%) (relative risk 0.56, 95% CI, 0.37-0.84; number needed to treat to benefit 6.0, 95% CI, 3.20-15.70). Pain score (median) during the procedure (interquartile range) was 4 vs. 5; patient satisfaction score was 8 vs. 7; and mean procedure duration was 3.0 compared with 4.7 minutes. Other secondary outcomes of cervical laceration, analgesia use, and adequacy of endometrial tissue for histopathologic assessment were not significantly different between groups.
The march-in rights law of 1980 allows the government to demand an invention developed with government dollars be licensed to a third party, then the public should enjoy the benefits of using the invention, when necessary to meet societal health needs. The federal government has never exercised its march-in rights. In December, the administration proposed a framework for US agencies to utilize march-in, laying the groundwork for the federal government to assist in the generation of pharmaceutical and other goods that the public cannot sufficiently access, and will likely impact US drug prices.
The House Appropriations Committee voted 31-25 to cut CMS by 11% below the Fiscal Year 2024 effective spending level, 15% below the President’s Budget Request. Thus, we will be facing another 2.93% cut in physician reimbursement for FY25. It will also prohibit any funding from being used to implement or enforce the final rule issued by the Administration relating to minimum staffing levels for long-term care facilities. At the same time, the Medicare Economic Index — a measure of practice cost inflation — is expected to rise by 3.6% in 2025.
Here is my Commentary in Primary Care Practice Update: Antibiotics for Delirium in Older Adults with Pyuria or Bacteriuria.
The CDC has a COCA Webinar on Avian Flu today, Tuesday, July 16, 2024 at 2:00 PM – 3:00 PM ET, the recording will be available for viewing on the COCA Call webpage a few hours after the live event ends.
The OMDA Call on Thursday at 8 am this week is Moving Forward Update, by Alice Bonner, PhD, RN, Institute for Healthcare Improvement.
This is an excellent Leadership TedTalk.
