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Robots and Surgery; Alcohol and Death: It's PodMed Double T!

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 Parkinson's disease and metabolic syndrome, lorcaserin and heart problems, the global burden of alcohol related disease, and robotic surgery costs.

Program notes:

0:40 Metabolic syndrome and Parkinson's disease

1:40 Corrected for many confounders

2:40 Some biological reasons

3:30 Robotic surgery costs

4:31 Substantial costs for almost any procedure

5:26 Lorcaserin and heart problems

6:26 Downward trend with diabetes

7:30 Primary care doc intervention

7:48 Alcohol use and burden

8:47 Tuberculosis, road injuries, and self harm

9:41 Cancer increase

10:34 End

Transcript:

Elizabeth Tracey: What does metabolic syndrome have to do with Parkinson's disease?

Rick Lange, MD: Alcohol use and burden across the globe.

Elizabeth: How about that obesity drug, lorcaserin, and its heart impact?

Rick: And the cost of robotic surgery.

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. This will be posted on August 31st, 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 start first with PLOS Medicine, the Public Library of Science Medicine. This study that I don't think we've ever seen a larger N. I'm so impressed with it. It's the relationship between metabolic syndrome and Parkinson's disease, a national cohort study. Here's the numbers. Health check of data of 17,163,560 individuals older than 40 years of age. They had a mean follow-up of 5.3 years, and they looked at just over 44,000 cases of Parkinson's disease during their follow-up period. They also looked at people with metabolic syndrome. That comprised about 5 million folks. Compared to those without metabolic syndrome, over 11 million people, and they also adjusted for these confounders: age, sex, smoking, alcohol consumption, physical activity, income, body mass index, estimated glomerular filtration rate, and history of stroke. So pretty powerful attempts to correct for everything.

Basically what they found was that each metabolic syndrome component, including abdominal obesity, hypertriglyceridemia, low high-density lipoprotein, high blood pressure, all of these were positively correlated with the ultimate development of Parkinson's disease. Even though in toto this wasn't a huge increase, Parkinson's is an incredibly important problem for people all around the world. I think identifying the relationship with metabolic syndrome is important.

Rick: This is a study, really, of over 15 million individuals and that's in the country of South Korea, because they're all a part of the national health system. And you're right. Individuals that had metabolic syndrome had a 24% increased risk of incident Parkinson's disease than individuals without. Each of the individual components of the metabolic syndrome, which you highlighted, were also associated with an increased incidence of Parkinson's disease. It does show that there's an association. There's some biological reasons why that may occur, and we know that metabolic disease has a higher incidence of having inflammation in reactive oxygen species. Those also are associated with an increased risk of Parkinson's disease as well.

Elizabeth: Parkinson's disease, of course, an incredibly common movement disorder and interestingly is also associated with a constellation of other things like depression. And so, getting our arms around ways to be vigilant, in terms of prevention, to me seems like an important goal.

Rick: 1 out of 800 individuals will get Parkinson's disease. Over 9 million people are going to be estimated to have it by 2030 because it's doubling in incidence. Now the real question is if you treat the metabolic syndrome components, do you lower that risk? We don't know that yet, and that's where future studies should go.

Elizabeth: OK. Let's turn to yours, then. Which one would you like to do first? I kind of like the robotic surgery.

Rick: All right, let's do that first. It's not nearly as big a study, but this was an attempt to estimate the acquisition and operating cost for robotic surgery, because there's some minimal data and it's not very inclusive. The authors thought this would be pretty easy to do. There's only one company that makes the robotic surgery platform. In 2017, there were over 4,400 of these things installed across the globe -- by the way, about two-thirds of them in the United States. Globally, there were 877,000 robotic procedures done. Based upon the revenue that the company generated -- that was $3.1 billion -- they estimated that the cost per robotic procedure was $3,568 in the United States. Of that, about $1,900 was due to the equipment. About $1,700 dedicated to the purchasing and maintaining the system. Those costs are novel to the robotic syndrome and the instruments are also novel, as well.

Elizabeth: One thing that was really interesting to me about this study was these substantial costs clearly that are associated with the use of robotics for almost any procedure. I know that there's a sexy, high technology aspect to this and that patients sometimes are attracted to those procedures that are done robotically. Would you say this accounts for the popularity, because I think even when we look at outcomes, I don't know that we're persuaded by the use of robots.

Rick: Elizabeth, you're right. Evidence really questions the clinical benefit of the use of robotic surgery. Now there are some benefits associated with it. There's some reduction in downstream expenses such as reduced length of stay, but whether those offset the cost of this, we really don't know. So we're using robotic surgery not because it's been clearly beneficial across the board, but because it is high tech. Nobody has really done, in my opinion, an effective cost-benefit analysis.

Elizabeth: We'll call out to folks, "Hey, anyone who's listening. This sounds like a study that needs to be done."

Rick: Agreed.

Elizabeth: While we're looking at benefits, then, let's turn to the New England Journal of Medicine. Obesity, another really big, global health problem and an agent called lorcaserin. What happens with that with regard to cardiovascular disease in folks who take it? In this study, they had 12,000 people. They took a look at what are the cardiovascular outcomes relative to folks who used lorcaserin? It turns out that there was already kind of a rationale for that, because when we take a look at the binding site for lorcaserin, it has some kind of relationship to the cardiovascular system.

They had, essentially, the group who took it and the group who didn't. The same long-term cardiovascular outcome with regard to valvular heart disease. There was a trend toward a difference in aortic valve insufficiency and pulmonary hypertension, but they weren't really able to get that totally statistically validated. Finally, they took a look at diabetes and there was a tendency toward a downward trend in diabetes in the folks who took the lorcaserin, but again, not sufficient numbers to really validate that. The editorialist, at least, is sort of +/- with regard to the use of this agent.

Rick: The primary cardiovascular outcome they examined was a composite of cardiovascular death, heart attack, or stroke. Lorcaserin was no different than placebo. However, there was a sub-study that you mentioned in which they did an echocardiography study to look at the valves, and the reason they did this because this particular agent is a serotonin receptor antagonist, and ones in the past have affected the heart valves. In this study, those that took lorcaserin had a 1.8% incidence of having aortic valve problems as opposed to 1.3% in those that received the placebo. So there's a hint, but again, this study is early. It's short term and the question is, over a longer period of time, will this cause valve problems as did some of the earlier agents? But what I would say is I think it's something that needs to be followed up.

Elizabeth: I think it needs to be followed up, and as we've talked about so many times, I think that the best thing for obesity is prophylaxis, and it's catching it early. When a primary care physician interacts with a patient and notices a trend toward increasing BMI, I think they need to really land on that pretty hard.

Rick: Yeah. Let me correct myself. I called it a serotonin antagonist. It's actually a serotonin agonist and it works in the brain to decrease appetite, so more to come.

Elizabeth: Let's turn to your final one.

Rick: This talked about the alcohol use and burden for 195 countries and territories around the globe between the years of 1990 and 2016. This is a systematic analysis of what's called the Global Burden of Disease Study. This studied over 28 million individuals when they looked at 694 different data sources and 592 perspective and retrospective studies on the risk of alcohol use. What they determined was alcohol use is the seventh-leading risk factor for both deaths and what's called DALYs, disability-adjusted life years. About 10% of excess deaths was attributed globally to alcohol use. It's particularly centered in the ages 15 to 49, where it's the most common cause of premature death. It's about three times more common to be problems in men than women. There clearly is a dose relationship. The three major causes of death associated with alcohol use were tuberculosis, road injuries, and self-harm. Is there a safe dose of alcohol? They tried to discern that and what they determined was that the safest dose of alcohol was actually abstention from alcohol ingestion.

Elizabeth: This is such an ongoing controversy, and I guess just like things like aspirin, probably if we had known what all the impacts of alcohol were before alcohol ever became [LAUGHTER] so prevalent in our society, we may have said, "Let's turn away from this," or maybe not. I don't know. That might be too optimistic a view. We certainly are still looking pretty carefully at the reported health benefits of alcohol consumption as well as the harms. Cancer, on the one hand, but potentially less cardiovascular disease on the other.

Rick: You look at a particular disease endpoint. For example, very modest alcohol intake decreases the risk of cardiovascular disease. Many studies have suggested that, but not all, especially some of the recent ones. However, there's a clear increase in the risk of infectious diseases like tuberculosis and cancer, so that even modest alcohol intake increases the risk as well, so you're balancing one health benefit versus other health harms associated with it. That's why the authors here came to the conclusion that gosh, if you want to prevent alcohol-related deaths, the best way to do it is to not drink alcohol.

Elizabeth: And is that going to be your take home from this?

Rick: Elizabeth, I think it's a very compelling story. We would never encourage people to drink alcohol to improve their health. Those that drink, we would say, "Drink as little as possible." I think that's the take-home message. Would you agree?

Elizabeth: I think I would agree. On that note, I'm going to talk about the robotic surgery study this week on the blog. 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.