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Athletes and Hearts; Best Meds for ADHD: It's PodMed Double T!

— This week's topics include secondhand smoke and adolescents, labor induction, screening young athletes for cardiac problems, and ADHD medicines.

MedpageToday

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 secondhand smoke and adolescents, labor induction, screening young athletes for cardiac problems, and ADHD medicines.

Program notes:

0:36 Screening young athletes for cardiac problems

1:36 Spent over $8 million to screen

2:36 Labor induction in low risk women

3:34 Sweet spot of delivery

4:32 Okay to induce at 39 weeks

5:12 Adolescent exposure to cigarette smoke

6:13 Much higher incidence of respiratory problems

7:18 Best ADHD medicines

8:18 Methylphenidate for adolescents and children

9:18 Tolerated better than placebo

10:21 End

Transcript:

Elizabeth Tracey: What's the best ADHD medicine?

Rick Lange, MD: How does secondhand smoke affect adolescents?

Elizabeth: When should labor be induced in women who haven't given birth before?

Rick: Does routine screening of student athletes prevent sudden death?

Elizabeth: That's what we're talking about this week on PodMed Double T, 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 August 10th, 2018.

Rick: 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, I'd like to turn right to your roundhouse. In the New England Journal of Medicine, a pretty significant study, in my mind, of student athletes and cardiac screening for those folks in an attempt to see, gosh, can we identify them and prevent sudden cardiac death?

Rick: Elizabeth, we don't have very good or reliable information about the incidences and causes of sudden cardiac death in young athletes. This particular routine screening that occurred in the English Football Association, that is, soccer players in England, allows us to examine this. In over a period of about 10 years, they screened over 11,000 adolescents. They did a routine history, an EKG, and they did an echocardiogram, and then if those were abnormal, they could do follow-up testing as well.

What they determined was there were 42 deaths, only eight of which were sudden cardiac death, so sudden cardiac death was really infrequent. Most importantly, six of those individuals had normal cardiac testing. The cost of this, by the way, they spent over $8 million during this time period in all this screening. It really didn't do a very good job of predicting which student athletes were going to have sudden cardiac death.

Elizabeth: My impression is that when people have experiences such as witnessing a sudden cardiac death in someone who's really young, which is a totally, of course, unexpected event, it really informs decision-making going forward. We've reported over the years on lots of initiatives to try to screen athletes in an attempt to prevent sudden cardiac death. What's your thought about the practicality of that, just in general?

Rick: I think what this study shows is despite the fact that we certainly want to prevent it, is that the routine screening we have doesn't do a very good job. Now if someone has a history of sudden cardiac death or symptoms, that's a different matter.

Elizabeth: And clearly points to the need for something more practical.

Rick: I'm not sure what that would be right now. Again, targeting high-risk individuals is a different matter than routine screening.

Elizabeth: Since we're in the New England Journal of Medicine, let's take a look at this recurrent issue of labor induction versus just kind of hanging out and hoping that the woman is going to go into labor on her own in low-risk women who have not given birth before. In this study, they took a look at over 3,000 women who were going to be assigned to labor induction and just over 3,000 who were assigned to what they called "expectant management." Let's watch, let's see, and let's just see if she goes into labor on her own.

They took a look at a bunch of different outcomes, obviously, maternal and fetal health and also the frequency of cesarean delivery. It was really interesting to me that induction of labor at 39 weeks in these women did not result in a significantly lower frequency of adverse perinatal outcomes, but it did result in significantly lower use of cesarean delivery. So when I look at this, I think to myself, "Hmm, it looks like 39 weeks induction is probably a pretty good thing."

Rick: We know that kind of the sweet spot of delivering is the 39th or 40th week. When women go 41 to 42 weeks, there's a higher risk to the baby and to the mother. Do you just wait and see and hope the mother delivers before week 42 or induce labor? The concern was with induction of labor there'd be a higher risk of having cesarean section. What this shows is that's not the case. And in fact, it looked like in women who were getting induced, although not statistically significant, there was a 20% decrease in the composite outcome primarily related to less children having respiratory distress and being on an incubator. It looks like induction actually improved outcome for the babies, although marginally statistically significant.

Elizabeth: I think that when we juxtapose this against other information we know about things like the degeneration of the placenta after 41 or 42 weeks and also our ability to really determine just how long this pregnancy has been going on much more accurately, I think it does argue for it's okay to induce at 39 weeks. And at least from my perspective, I was induced and I really liked it.

Rick: Elizabeth, your point is well taken. The next thing we have to ask is is this representative of most women who deliver babies? In fact, the group that they studied was a little bit younger, about 4 years younger. They didn't have very many women who were over the age of 35, and it had a much larger population of women who were Hispanic or black. But what they do indicate right now is that the induction does not increase perinatal bad outcomes, and it doesn't appear to increase the risk of cesarean sections.

Elizabeth: More to come. Let's turn back to you and let's look at another age or stage of life in Pediatrics. What happens when children and adolescents are exposed to cigarette smoke in the home?

Rick: There is some data about adolescents who have asthma and how smoking affects them, but there's really a paucity of data about adolescents who don't have asthma and does exposure to secondhand smoke adversely affect them with respect to either respiratory symptoms or their presentation to the urgent care or emergency room for respiratory symptoms.

This was a secondary analysis of almost 7,400 adolescents who had completed what was called the Population Assessment of Tobacco and Health study, the PATH study. These are individuals who didn't smoke. They didn't have asthma or respiratory issues, but they were exposed to secondhand smoke either because they had a relative who didn't smoke at the house, a relative who did smoke at the house, or in some cases, exposed to a relative who smoked and did so for more than an hour per week exposed to it, so a whole spectrum.

The individuals who, in fact, were exposed to secondhand smoke had a much higher incidence of having respiratory symptoms, shortness of breath, finding it hard to exercise, a dry cough at night, and they were less likely to report excellent or overall good health. In fact, they were about 50% more likely to present to an urgent care center or emergency department with respiratory symptoms. And by the way, this was true whether the individual smoked in the home or outside the home.

Elizabeth: Lending credence, of course, to this idea that when people smoke, all of those chemicals cling to their clothing and their hair and all that, and then they bring them back into their home environments, even if they do go outside.

Rick: That's true, again, with clothing or related to the car and transportation as well. Now the article makes an excellent point. When these adolescents presented at the urgent care center or emergency department, that may be the time to bring this revelation to light, not only to the adolescent, but to their parent or relative as well to encourage them to stop cigarette smoking, if not for their own health, at least for the health of their adolescent.

Elizabeth: Great public health message. We don't have to say very much about smoking, of course, because we talk about that a lot. Finally, then, let's turn to The Lancet, also talking about largely adolescents, those people who are frequently diagnosed with ADHD, although we do see it also diagnosed in children and adults. This was a very comprehensive look at all the literature out there looking at benefits, safety, efficacy for ADHD treatment in all of these populations: children, adults, and adolescents.

They had 133 double-blind, randomized, controlled trials they included in the analysis. They were looking at comparing amphetamines with each other, the whole bunch of them -- and I won't list them all -- or with placebo. First of all, they chortle that their findings represent the most comprehensive available evidence base to inform patients, families, clinicians, and guideline developers, as well as policymakers, on which is the best ADHD med across age groups. That's a pretty broad claim, I think, and maybe it's true. But once they take a look at all of the evidence, they support the use of methylphenidate in children and adolescents and amphetamines in adults as preferred, first-choice medications for short-term treatment of ADHD. And they also add the caveat that we need to take a look at long-term effects of these drugs very urgently.

Rick: This is an important health message because 5% of school-age children and 2.5% of adults suffer from ADHD. They looked, as you mentioned, at what are called psychostimulants and also non-psychostimulants. They looked at efficacy, tolerability, and acceptability. As you noted, this was probably the most comprehensive analysis. It's called a network meta-analysis. This involved almost 20,000 children and adults. It's as robust a study as we've ever seen, robust meta-analysis, and it shows methylphenidate because it had the best effect of kids and the lower side effects. In adults, the same thing. Amphetamines, most efficacious and also the only medication that was tolerated better than placebo.

Elizabeth: I'm really interested in this idea, though, of short-term treatment because I believe we've reported on studies that show that people tend to get on these meds and they stay on them.

Rick: They highlighted this. All the studies they looked at, they have pretty good data for the first 12 weeks, and they tried to look at 26 and 52 weeks of medication use, and there aren't enough studies to draw any conclusions. Although this study tells us which medications are best, it doesn't tell us when to initiate them. It really doesn't tell us how long to use them, so we need additional studies to determine those things.

Elizabeth: No question because those large numbers of people who are taking all of these meds, I guess that they're just being prescribed them and are taking them kind of on a long-term basis without really any data.

Rick: Precisely. I mean there's still a lot of work to be done.

Elizabeth: On that note, I'm going to talk about induction of labor this week on the blog. 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.