Cardio Complications of COVID; Gestational Diabetes on the Rise

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 a second booster for COVID-19, sociodemographics of drug overdose deaths, increasing gestational diabetes, and cardiometabolic impact of COVID-19 infection.

Program notes:

0:40 Fourth dose of COVID vaccine

1:42 Antibody titers before and after third and fourth dose

2:42 Nothing about how often vaccines needed

3:40 Cardiometabolic complications of COVID

4:40 Six fold increase in cardiovascular disease

5:40 Atrial arrhythmia in acute phase

5:55 Increases in gestational diabetes

6:55 Prepregnancy BMI

7:56 Need to understand better

8:40 Drug overdose sociodemographics

9:41 Black males over 65

10:53 Intentional and unintentional

11:58 End


Elizabeth: Do we know anything about timing of the second booster for COVID-19?

Rick: Cardiometabolic outcomes after COVID infection.

Elizabeth: A disturbing increase in gestational diabetes.

Rick: And the sociodemographics of drug overdose deaths.

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, if you don't mind, I think I'd like to turn first to this study that takes a look at timing of the fourth dose or the second booster shot for COVID-19. That's in JAMA Network Open. This is a study that kind of unsurprisingly, based on how much data we'vecovered from Israel, comes out of Israel. That, of course, speaks to the fact that they are able to gather a lot of data on their population.

They were looking at the response to the third and fourth vaccine doses among individuals 60 years and older. They did that by evaluating anti-spike immunoglobulin (IgG) antibody titers before and after each dose. This, of course, is a really important population who is more at risk for severe outcomes. Now that we are looking at this gigantic worldwide spike of our -- fifth variant now -- of Omicron, it's something that's of concern and everyone is wondering, "Gosh, should I go out and get a vaccine right now? Or should I wait until the fall when we here in the United States all start going inside?"

As I said, they took a look at what was your antibody titer before to after your third vaccine, and before to after the fourth. Their N was really small and this is one of my primary complaints about this particular study. They ended up with only 48 people in whom they were actually able to look at IgG data before and after the third and fourth doses.

Unsurprisingly, of course, what they find is that, sure enough, your antibody titer declines and then there is a spike after you receive the vaccination, and that is visible about 2 weeks post-vaccination. I'm not sure what new data this particular analysis sheds. What are your thoughts?

Rick: Elizabeth, I would agree with you. First of all, it's a small number of patients. Secondly, what they demonstrated is, even after the third and fourth dose, 2 weeks after you get those, there is a massive increase in antibodies and over the next 5 months it decreases substantially. It decreases about tenfold. That means the antibody response is fairly short-lived.

But it doesn't tell you anything about how often you need to get the vaccine because we know, for example, that even in individuals that have declining antibody, the vaccine may not prevent infection, but it prevents the severity of infection. It prevents ICU admissions, hospitalizations -- prevents deaths. That's really what we are most concerned about.

The other thing is antibodies are just one part of it. We have these memory B cells that can still be activated anytime and then we have T cells as well. Unfortunately, I don't think it gives us any insight into how we should time these.

Elizabeth: Of course, now we have a licensed vaccine that employs a totally different technology, which may also be worth considering for folks when it comes to the fall. Then finally, I would just note that with President Biden's positive COVID test and his use of Paxlovid, we also have other tools in the armamentarium.

Rick: Right. We are not going to outrun COVID infection. We have to find ways to live with it.

Elizabeth: Let's turn to PLOS Medicine and let's look at -- speaking of complications -- what about cardiometabolic complications?

Rick: We have reported before that acute COVID infections have been associated with a new onset of cardiovascular disease and diabetes. Are there longer-term effects as well? That's what these investigators tried to look at.

They looked at electronic records for over 1,300 family practices in the United Kingdom. They had a population of 13.4 million patients to draw upon. They were able to identify over 428,000 individuals that had COVID infection, and they compared them to the equal number of individuals that had not.

Does getting COVID increased your risk of cardiovascular disease and diabetes from 4 to 12 weeks, and from 12 weeks even up to a year? The diabetes diagnosis increased 81% in individuals that had acute COVID infection -- that is, within the first 4 weeks. That rate also remained elevated by 27% for the next 4 to 12 weeks.

When they looked at cardiovascular disease, acute COVID infection was associated with a 6-fold increase in cardiovascular disease, primarily because of a 11-fold increase in pulmonary embolism, a 6-fold increase in atrial arrhythmias, and a 5-fold increase in venous thrombosis. But the cardiovascular disease diagnosis declined from 4 to 12 weeks, and it was normal from 12 to 52 weeks.

Elizabeth: I think this is really showing us a lot of interesting stuff about acute illness, and I'm wondering if we looked at other acute illnesses if we would see a lot of the similar manifestations.

Rick: Yeah, and that's one takeaway message. The other is, in people that are recovering, can they consider measures to reduce their diabetes risk, for example, by eating a healthy diet and exercise? Would that lower the risk?

Elizabeth: One other thing I'd like to hear your comment on is previous data we have discussed relative to atrial fibrillation and its persistence after acute COVID infection.

Rick: Yep. This particular study didn't address that because I think that, again, the atrial arrhythmia risk occurs within the first 4 weeks. I think it's fairly acute. But again, during that time, these individuals have an increased risk of clots forming. These individuals clearly need to be anticoagulated in the first 4 weeks after they have had their COVID infection.

Elizabeth: Let's turn now to something that we have never discussed, the National Vital Statistics Report. They are taking a look at trends and characteristics in gestational diabetes from 2016 to 2020. We know, of course, that gestational diabetes is threatening not just for the mother, but also for the baby, and has long-term consequences.

The really bad news in this particular analysis is that there has been an increase of 30% since 2016 in the overall rate of gestational diabetes. They broke this down, of course, by different ethnicities and they found that this rate was highest for non-Hispanic Asian women, and lowest, interestingly, for non-Hispanic Black women. This is the first time, I think, that we have ever said that the Black population has had less of a problem with a deleterious health condition than everybody else.

The rate of gestational diabetes rose with increasing maternal age, unsurprisingly -- also unsurprisingly, pre-pregnancy BMI, and also whether there was more than one baby in there.

Then they also broke it down according to state. The rate was lowest in Mississippi, another place that we have seen a lot of really negative chronic health conditions at very high rates. That it was lowest in Mississippi, that's great -- then a high, unfortunately, of almost 13% in Alaska, again harkening to that non-Hispanic Asian population that they categorized in this analysis. It's something that we really need to start paying attention to.

Rick: Yep, gestational diabetes carries risk for both the mother and the fetus. Following this data, I think, is really important. But the next question is getting to the bottom, the source. Like, why is this?

They propose a potential hypothesis, decreased physical activity, experienced weight gain, and other lifestyle factors that are known to impact gestational diabetes. I'm a little surprised because you think in states in which those lifestyle factors are the worst, Mississippi being one, that's where the gestational diabetes rate will be the highest. I'm not sure that's the real explanation, but we certainly need to get to the bottom of it, so we can address this issue.

Elizabeth: They finger BMI, of course, as being a major factor and they say that increasing maternal BMI from 3.7%, this rate of gestational diabetes for underweight women, 4.6% for those who are normal, 7.6% those who are overweight, and almost 13% for those with frank obesity. I'm pretty persuaded by that and I agree with you: gosh, we know that those factors are really operational in Mississippi, so what are we looking at here?

Rick: You're right because that state has one of the highest incidences of obesity and you would consider that the highest rate of gestational diabetes as well. It makes one concerned that there may be underreporting in states like that. They need to do a little bit more digging.

Elizabeth, speaking about looking at underlying causes, I appreciate the fact that you chose this next study, which is in Morbidity and Mortality Weekly Report, which is a CDC publication, that looked at the sociodemographic and social determinants of drug overdose deaths in 25 states and the District of Columbia from 2019 to 2020. Drug overdose deaths increased approximately 30% over that 1-year period from 2019 to 2020 in the United States.

These authors looked at the demographic and social determinants of the health characteristics to see if they could identify affected populations that were disproportionately more likely to experience drug overdose. Here is what they discovered. From 2019 to 2020, in 25 states and the District of Columbia, the drug overdose deaths increased by 44% among Blacks and 39% among Native Alaskans or Native Indians, which was substantially more than [they] increased among whites.

If you looked in 2020 among Black males that were older than 65 years of age, their rate of drug overdose was approximately 7 times that of whites that were the same age. Individuals more likely to experience drug overdose were those that had a history of substance abuse, lower incidence of substance abuse treatment, and income inequality across different counties. These health disparities continue to worsen with regard to drug overdose deaths, particularly among Blacks and American Native Indians, and the social determinants of health such as income inequality exacerbate these inequities.

Elizabeth: One of my buddies here at Hopkins, Eric Strain, who is a psychiatrist and a substance use disorder expert, says and agrees with a lot of the experts on this that these are really deaths of despair -- that what we really need to do is figure out how we can help people render meaning in their lives, because that's the thing that really helps people choose survival, honestly.

Rick: Some of these are intentional, as you mentioned, deaths of despair. Unfortunately, many of those are unintentional. The increased use of fentanyl, putting fentanyl in either prescription drugs or nonprescription illicit drugs, has contributed substantially to the increased number of overdose deaths. Overdose not due to suicide, but because of unintentional deaths as well.

Elizabeth: Yeah, I think his point about despair is that that doesn't imply that it's suicide. It implies that drug use by itself as a means to escape one's circumstances is underpinning a lot of this use.

Rick: I am glad you mentioned that. I found it very surprising when you're talking about drug overdose deaths in people over the age of 65, that's not the group that you imagine using illicit drugs or being affected, and particularly the wide social disparity. To think that African American men have 6 times increased risk of death compared to the same age white counterparts is really distressing. I hope that information allows us to provide community messages that are unique and culturally sensitive to help these individuals to avoid these unnecessary drug overdose deaths.

Elizabeth: 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.

#Cardio #Complications #COVID #Gestational #Diabetes #Rise

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