Archive for month: November, 2024

“Metformin was linked to a notable reduction in asthma attacks, and the addition of GLP-1RAs, a newer class of drugs used to treat diabetes, produced a synergistic, additive effect,” the researchers wrote.

Asthma, a chronic respiratory condition characterized by inflammation and narrowing of the airways, has been linked to various factors, including genetic predisposition, environmental triggers, and comorbid conditions like obesity and diabetes. High body mass index (BMI) and type 2 diabetes are common in people with asthma and can increase the risk of asthma attacks. Experimental studies show that diabetes medications like metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs) may help reduce airway inflammation and other asthma symptoms. However, there is limited epidemiological evidence to support these findings.

To fill this knowledge gap, Bohee Lee, National Heart and Lung Institute, Imperial College London, London, England, and colleagues aimed to evaluate the relationship between metformin and additional anti-diabetic medications (such as GLP-1RAs, sulfonylureas, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, and insulin) and the occurrence of asthma attacks.

For this purpose, the researchers used data from the UK Clinical Practice Research Datalink (CPRD) Aurum, linked with hospital admissions and mortality data from 2004 to 2020. They applied a triangulation approach using two methods: a self-controlled case series (SCCS) and a metformin new user cohort with inverse probability of treatment weighting (IPTW).

The study focused on new metformin users with type 2 diabetes. The primary exposure was metformin, with secondary exposures being other antidiabetic medications. The primary outcome was the first asthma exacerbation during a 12-month follow-up, assessed using incidence rate ratios and hazard ratios.

Key Findings:

• The study included 4278 asthma patients (2617 women, 61.2%; mean age 52.9 years) for the SCCS analysis and 8424 patients (4690 women, 55.7%; unexposed mean age 61.6 years, exposed mean age 59.7 years) for the IPTW cohort.
• Metformin use was associated with fewer asthma attacks in both analyses (SCCS: IRR 0.68; IPTW: HR 0.76).
• Negative control analyses showed no significant bias.
• The association was not modified by hemoglobin A1c levels, BMI, blood eosinophil counts, or asthma severity.
• The only add-on antidiabetic medication with an additive effect was GLP-1RA (SCCS: IRR 0.60).

“The cohort study indicates that metformin use was linked to a reduced rate of asthma attacks, with additional reductions observed when combined with GLP-1RA. These effects appeared independent of glycemic control or weight loss and were consistent across various asthma phenotypes,” the researchers concluded.

Reference:

Lee B, Man KKC, Wong E, Tan T, Sheikh A, Bloom CI. Antidiabetic Medication and Asthma Attacks. JAMA Intern Med. Published online November 18, 2024. doi:10.1001/jamainternmed.2024.5982

Ablation, a procedure to treat abnormal electrical short circuits caused by a heart attack and is usually reserved for patients who do not improve with medication, may be a better first-line treatment for heart attack survivors experiencing dangerous rapid heartbeat episodes, according to late-breaking science presented today at the American Heart Association’s Scientific Sessions 2024.This study is simultaneously published in The New England Journal of Medicine.

Heart attacks create scar tissue in the heart muscle, which impedes the heart’s ability to function properly and may lead to other conditions, such as dangerous heart rhythms.

“The scarred heart tissue doesn’t contract and help with blood flow, however, sometimes the scar contains surviving bits of heart muscle that create abnormal electrical circuits in the heart, leading to dangerous rapid heart racing called ventricular tachycardia,” explained lead author John Sapp, M.D., a professor of medicine and assistant dean of clinical research at Dalhousie University, Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, Canada.

Ventricular tachycardia (VT), the most common cause of sudden cardiac death, is a fast heart rhythm that starts in the heart’s lower chambers (ventricles). This rapid heartbeat prevents the heart’s chambers from filling completely between contractions, which reduces blood flow to the rest of the body.

To reduce the risk of death from VT, the patient may receive an implantable cardioverter defibrillator (ICD), which will shock the heart back into a normal rhythm. The ICD can be lifesaving, but it does not prevent VT. “Even with an ICD, some patients still have recurrent attacks of ventricular tachycardia, which causes serious symptoms such as passing out, and the ICD shock itself can cause a very unpleasant feeling of being jolted or kicked in the chest,” Sapp said.

The usual first treatment to prevent dangerous episodes of ventricular tachycardia is anti-arrhythmia medications. However, these medications may have serious long-term side effects, such as worsening of the abnormal heart rhythm or potentially damaging other organs. When medication has been unsuccessful in reducing VT episodes, the second line of treatment has been ablation. This minimally invasive procedure uses radiofrequency energy to destroy the abnormal heart tissue causing the VT, while not damaging the rest of the heart.

“We have previously shown that when a medication is not preventing episodes of VT, ablation has led to better outcomes than increasing the medications. Now we know that ablation is a reasonable option for first-line treatment instead of starting with antiarrhythmic medication therapy,” Sapp said.

In the VANISH2 (Ventricular Tachycardia Antiarrhythmics or Ablation in Structural Health Disease 2) trial, 416 patients who developed recurrent ventricular tachycardia after surviving a heart attack were enrolled at 22 health centers in three countries. All participants had ICDs to shock the heart as needed. None of the participants had conditions that excluded them from receiving ablation or the antiarrhythmic medications used in the study, so treatment with medication or ablation was randomly determined. Patients chosen for medication received one of two antiarrhythmic medications: amiodarone or sotalol.

Participants were followed for at least two years after ablation or while taking the assigned medications (median of 4.3 years). Researchers tracked death, appropriate ICD shocks, three or more VT events within 24 hours, and sustained VT that was not treated by the ICD but treated urgently in a hospital.

The data analysis found:

People who received ablation were 25% less likely to die or experience VT requiring an ICD shock. This included having three or more VT episodes in a single day or VT episodes that were not detected by the ICD and were treated in a hospital.

“Although the study was not large enough to show a statistically definitive effect on all of the parameters that are important to patients and physicians, patients treated with ablation also had fewer ICD shocks for VT, fewer ICD treatments, episodes of three or more VT in a single day and fewer VT episodes not detected by their ICD,” Sapp said.

“For people who have survived a heart attack and developed VT, our findings show that performing a catheter ablation to directly treat the heart’s abnormal scar tissue causing the arrhythmia, rather than prescribing heart rhythm medications that can affect other organs as well as the heart, provides better overall outcomes,” he continued. “These results may change how heart attack survivors with ventricular tachycardia are treated.

“Currently, catheter ablation is often reserved as a last-resort therapy when antiarrhythmic medications fail or cannot be tolerated. Now we know that ablation is a reasonable option for first-line treatment. We hope that our data will be useful for clinicians and patients who are trying to decide the best option when they need treatment to suppress recurrent VT and prevent ICD shocks,” Sapp said.

Although the study could not confirm if ablation worked better than medication to reduce each outcome tracked, the researchers found that overall, the differences favored ablation. The study also did not determine which patients with particular characteristics would benefit more from one treatment or the other.

“In addition, these results cannot be generalized to patients who have heart muscle scarring caused by a disease other than a blocked coronary artery,” Sapp said. “We also note that, despite these treatments, the rate of VT episodes remained relatively high. We still need more research and innovation to develop better treatments for these patients.”

A Michigan man can blink, swallow, smile and breathe through his nose for the first time in a decade thanks to a face transplant performed at Mayo Clinic. This transformative and complex procedure underscores Mayo Clinic’s skilled multidisciplinary surgical team who provide hope to patients with complex medical needs.

Derek Pfaff’s life changed forever on March 5, 2014, when a tragic incident during his college years left his face severely damaged by a gunshot.

“I was under a lot of pressure at college. I don’t remember making the decision to take my own life. When I woke up in the hospital, I originally thought I had been in a car accident,” he says.

Despite undergoing 58 reconstructive facial surgeries in 10 years before going to Mayo Clinic in Rochester, he was still unable to eat solid food or speak casually with friends and family. Wearing glasses proved impossible without a nose. This transformational face transplant at Mayo Clinic means the now 30-year-old from Harbor Beach, Michigan, will once again be able to do all those things he has missed. He has also become a passionate advocate for suicide prevention and plans to share his story to encourage others who are struggling to get help.

“I lived for a reason. I want to help others,” Pfaff says. “I am so grateful to my donor, his family and my care team at Mayo Clinic for giving me this second chance.”

“Mayo Clinic Transplant Center is the largest integrated transplant center in the world. We were the first transplant center in the country to make face transplant part of its clinical practice. That has allowed us to focus exclusively on the needs of each individual patient,” says Hatem Amer, M.D., medical director of Mayo Clinic’s Reconstructive Transplant Program.

In the 19 years since the first face transplant was performed, more than 50 have been done around the world. Survival outcomes for these transplants are encouraging, according to a recent JAMA Surgery study. Mayo Clinic performed its first face transplant in 2016.

How the surgery was done

Mayo Clinic surgeons performed Pfaff’s face transplant in February 2024 in a procedure that lasted more than 50 hours and involved a medical team comprised of at least 80 healthcare professionals, including surgeons, anesthesiologists, nurses, technicians, assistants and other specialists.

This multidisciplinary team was led by Samir Mardini, M.D., a facial reconstructive and facial reanimation surgeon and surgical director of Mayo Clinic’s Reconstructive Transplant Program. Dr. Mardini estimates that 85% of Pfaff’s face, including the mandible and maxilla, was reconstructed and replaced with donor tissue.

Surgeons meticulously planned this complex operation over several months. To ensure precision and accuracy, a digital surgical plan was created relying on detailed scans of both the donor’s and recipient’s faces, allowing the team to perform the surgery digitally first. Facial nerve mapping also was performed of both the donor and recipient’s nerve system to understand the function of each nerve. While the digital aspect ensured preparation, customized 3D-printed cutting guides translated these plans into tangible tools to be used in the surgical suite.

The intricate transplant required replacing virtually everything below Pfaff’s eyebrows and part of his forehead, including his upper and lower eyelids and intraorbital fat, upper and lower jaws, teeth, nose, cheek structure, neck skin, hard palate and parts of his soft palate. Relying on the preoperative facial nerve mapping, one of the most critical aspects of the face transplant surgery was ensuring the donor and recipient’s delicate facial nerves — 18 branches between the two sides — were properly connected to restore function. A new microsurgery technique also was employed to transplant the donor’s tear drainage system, which allows Pfaff’s tears to drain normally into his new nose. Pfaff can now express happiness, sadness, joy and disappointment through his transplanted facial muscles and nerves.

“Most organ transplants are lifesaving. With facial transplantation, it’s a life-giving operation. You can live without it, but you are missing out on life,” Dr. Mardini says.

The medical team included specialists from Plastic and Reconstructive Surgery, Transplant, Nephrology, Neurology, Ophthalmology, Dermatology, Pathology, Radiology, Critical Care, Anesthesia, Psychiatry, Infectious Diseases, Histocompatibility, Pharmacy, Nursing, Social Work, Rehabilitation, and Speech and Language Pathology.

“This successful transplant would not have been possible without the donor and his family’s generous gift and the care team’s collaboration and dedication,” Dr. Mardini adds.

LifeSource, the federally designated organ procurement organization for the Upper Midwest, also played a pivotal role in the transplant, working closely with the family of the donor and Mayo Clinic care teams. Thanks to his face transplant, Pfaff says he is focused on making plans for his future.

“This surgery has transformed my life. I feel so much more confident. I am hoping to one day meet someone, settle down and have a family,” he says. “I’m also going to keep sharing my story with others to help as many people as I can.”