PTSD After Intensive Care; When to Take Blood Pressure Medicines; New USPSTF Recs

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 the U.S. Preventive Services Task Force (USPSTF) on screening for syphilis in pregnancy, when to take blood pressure medicines, comparing weight-loss drugs, and a narrative intervention for post-traumatic stress disorder (PTSD) after an intensive care unit (ICU) stay.

Program notes:

src:4src New England Journal of Medicine publication of comparison of obesity medications

1:4src Tirzepatide (Mounjaro, Zepbound) versus semaglutide (Ozempic, Wegovy) for 72 weeks

2:41 Also had reduction in blood pressure

3:26 Rise in congenital syphilis and screening

4:26 Disparities among various groups

5:26 Highest incidence in the last 3src years

6:26 In 2src23, 21src,srcsrcsrc cases of syphilis

7:srcsrc When to take blood pressure meds

8:srcsrc Monitored blood pressure in a subset

8:4src Intervention for PTSD after ICU stay

9:4src Self reported PTSD symptoms

1src:4src Must learn to deliver intervention

11:4src Physician needed to spend 45 minutes per visit

12:42 End

Transcript:

Elizabeth: A disturbing rise in congenital syphilis and what we should do about it.

Rick: Comparing two highly effective medications for obesity management.

Elizabeth: Use of a brief intervention for people who experience PTSD after being in an ICU.

Rick: And whether you take your medications in the morning or night, does it matter in the treatment of hypertension?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, 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 think we should turn to the one that’s garnering huge media attention. It’s a look at these medicines that are used to treat obesity and it’s a head-to-head comparison.

Rick: And this is what we’ve been waiting for, Elizabeth, because we know we have a number of what I say are very highly effective medications on the market already for treating obesity. These were medications originally used to treat diabetes. We subsequently noted they also decreased weight not only in people that have diabetes, but in people that don’t.

The two medications are tirzepatide and semaglutide. The semaglutide is what’s known as a GLP-1 receptor agonist. The tirzepatide has that same action, but it also has another action in what’s called GIP. These are receptors in the brain that control our desire to eat and satiety. So they compared tirzepatide to semaglutide straight up and they used the maximum tolerated dose of both of those medications. They started [on a] low dose with both, and then every 4 weeks they increased it until they got to the maximum dose, and they followed these individuals that received once-weekly injections for 72 weeks.

Of the 75src+ participants, the ones that received tirzepatide had about a 2src% reduction in their weight. Those that received semaglutide had about a 14% reduction. The individuals that [received] tirzepatide had a bigger reduction in their waist size, their waist circumference, than those that took semaglutide. They were both tolerated pretty well. The major side effects were gastrointestinal [GI] side effects. About 4% or 5% of people with semaglutide had GI side effects and less than 1% of tirzepatide.

Elizabeth: I would point out that I think that this is all a process that’s underway and that we also have oral medicines that are on the horizon that are also really effective for weight loss and that activate these same receptors, and so I think that this is all transitional.

Rick: Right. We start with a medication we know is effective, and we test the next one is a little bit more effective, and we’ll continue to do that. I would be remiss if I didn’t mention, in addition to losing weight, these individuals had a reduction in their blood pressure, hemoglobin A1c, fasting serum glucose, and their lipid levels improved a little bit more in the tirzepatide than semaglutide [group].

Elizabeth: I would also point out, of course, that these medicines, if you have to pay for them out-of-pocket, are extremely expensive. Right now, [they] are not reimbursed for this indication of weight loss for most people in the absence of diabetes, so this exact patient population. Finally, just to echo our proclivity, prevention is worth a pound of cure. Catching people on the trajectory toward morbid obesity, I think, is the way to really interrupt this all before it becomes a big problem.

Rick: Elizabeth, you’re absolutely right.

Elizabeth: Let’s turn to JAMA, this very concerning rise in congenital syphilis.

This is a look again by the USPSTF at recommendations relative to screening women who are pregnant for syphilis. In all of our years of reporting, I don’t think I have ever seen them recommend an A recommendation, saying that we should absolutely be screening all women who are pregnant for congenital syphilis, and ideally early in pregnancy. And they reach that conclusion with high certainty.

They cite this very daunting statistic that there has been a 1src-fold increase in congenital syphilis from 334 cases in 2src12 to 3,882 cases in 2src23. There is a huge disproportion in who has this experience, with women of different ethnicities experiencing a good deal more congenital syphilis in their pregnancies than others, identifying these risk factors as poverty, neighborhood opportunities, incarceration rates, segregation, and ratio of men to women as things that help to drive this particular increase.

So they recommend screening. That involves a blood test that detects antibodies to the causative organism. There is a two-step process used to improve the diagnostic accuracy. This ideally takes place when they first present to care when they learn or suspect that they’re pregnant. National data from 2src22 found that only 5% of congenital syphilis cases occur in late pregnancy. The CDC recommends parenteral penicillin G as the only treatment with documented efficacy during pregnancy.

Rick: The other thing that I found absolutely remarkable was this is a reaffirmation. They became alarmed because of the marked increase — in fact, it’s the highest incidence of congenital syphilis in the last 3src years. The USPSTF really trying to grab our attention.

There are a group of high-risk women that could initially test negative and subsequently become positive. These are women who live in high-prevalence areas, have a history of HIV, incarceration, multiple sexual partners, they engage in sex in combination with drug use or commercial sex work, or experience homelessness, and in those women they’re recommending also tests in the third trimester and even at the time of delivery. We know that benzathine penicillin is effective in treating syphilis and preventing congenital syphilis.

Elizabeth: The editorialist mentions, of course, that one obstacle to treatment is the exorbitant cost of benzathine penicillin and notes that that was initially patented in 195src. So what is this cost barrier?

Rick: I read that as well. I was a little surprised because most women who are pregnant have some sort of coverage.

Elizabeth: Finally, the editorialist notes that in 2src23 there were almost 21src,srcsrcsrc syphilis cases reported in the U.S. This steady increase since 2src1src has been paralleled by a steady erosion of public health capacity, so this is also something that we need to pay attention to.

Rick: Right. Well, many obstetricians are aware of the recommendations. Individuals in primary care settings may not be. They need to be aware of these recommendations.

Elizabeth: Let’s turn to JAMA. Does it matter when you take your antihypertensive meds?

Rick: Most patients that have high blood pressure, or even a normal blood pressure, have what’s called a diurnal variation in their blood pressure measurements. They’re usually highest between 6:srcsrc and 1src:srcsrc in the morning. It goes down around noon. It goes up between 4:srcsrc and 6:srcsrc.

There were two early studies where they suggested if you took your blood pressure medicine at night it reduced cardiovascular events, as much as a 4src% or 6src% reduction if you took your blood pressure medicines at night.

Now, that was almost too good to be true, and there was another study that tried to replicate it and couldn’t. This is a really well-done study. It was done in Canada, five different provinces in the community setting. Over 3,3srcsrc patients who took a blood pressure medicine once a day. Half were randomized to take it at night, the other half were randomized to take it in the morning, and they were followed for 4.5 years.

There’s no difference in the outcomes. There was no difference with regard to safety outcomes — things like falls or fractures, or new glaucoma, or cognitive decline. They looked at a very small set of individuals, about 15src, where they monitored their blood pressure, and it looked like those that took their blood pressure medications at night had a slightly lower blood pressure both during the evening and early morning. That did not translate into improved outcomes at all. Whenever you can remember to take it, that’s the best time to take it.

Elizabeth: That seems like it should be a fairly easy barrier to overcome, send an electronic alarm or tie it to another behavior that you always do.

Rick: Elizabeth, that’s exactly right. Tie it to brushing your teeth. It’s tying it to that event that helps people to remember. Again, the most important thing is not when you take it, but that you do take it.

Elizabeth: Finally, then, turning to The BMJ and this is a look at something that’s near and dear to my heart, of course, since I spend so much time in ICUs in the chaplain role.

There is a pretty high rate of PTSD, post-traumatic stress disorder, in folks who have had a stay in an ICU and have survived their critical illness. And in this study they cite that it’s about 2src% of patients.

This study was looking at whether a brief intervention delivered by a primary care physician could help in this circumstance. The study was conducted in Germany. They had 319 adults who survived critical illness with symptoms of PTSD and they either got the intervention or the improved usual care from their primary care physician. The intervention group participants had three narrative exposure consultations with the general practitioner and eight scheduled contacts with the nurse.

Their primary outcome was self-reported PTSD symptoms using the Post-Traumatic Diagnostic Scale for DSM-5 at 6 months, and then they repeated it at 12 months. They also looked at secondary outcomes like depression, anxiety, patient activation, and health-related quality of life, and disability at the 6- and 12-month time periods.

What they showed was that the intervention showed a mean between-group difference in the score — the scale for PTSD — of 4.7 points. They were looking for a 6-point difference. They did show it was at 5.4 at the 12-month interval and patients in the intervention group did report greater improvements in depression, health-related quality of life, and disability.

This intervention is interesting because it required a pretty significant amount of training on the part of the primary care doc. In Germany, they already have to be qualified with an 8src-hour course in standard psychosomatic care. I’m not exactly sure what that all means, but they also had to learn how to deliver this intervention, which is basically storytelling to reconsolidate their autobiographical memory of what happened while they were in the ICU.

Another very interesting part of this study, I thought, was how they recruited these dyads. When they identified a patient who had PTSD secondary to an ICU stay, they reached out to their primary care doc — to that person’s primary care doc — and said, would you be willing to undertake this intervention? So to me, it sounds like it actually really could be helpful, although it didn’t reach their preconceived standard. It also sounds like it could be pretty intensive to implement.

Rick: Here’s a contrarian view. There’s a difference between it being statistically significant and clinically significant. Did the people feel a little bit better? They did — very little. In fact, it wasn’t even clinically beneficial.

The second thing is they called this a brief intervention. The physician had to visit with the patient for 45 minutes on three separate occasions, and I don’t know any physician that spends 45 minutes with a particular patient because you have so many other patients you’re seeing. Eight more visits by the nurse. There’s a lot of effort put into it with really, what I’m going to call, clinically insignificant benefit. I don’t think that we could translate this into practice in the U.S.

Elizabeth: Right. I do think it would be an uphill battle, although I applaud the effort to recognize this as a problem and to try to provide some kind of intervention that could be helpful. Maybe there is some kind of online exposure that would help.

Rick: Agreed. A very well done and very valuable study, just not the positive results that we hoped for.

Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I