The 2 Minute Medicine Podcast Episode 38

We begin with a discussion about our article of the week from JAMA, entitled “Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes”  In the second half of the episode, we begin with talking about a pioneering immunotherapy approach for brain cancer. Then we discuss the advantages of access to over-the-counter birth control. After that, we take a look at abortion ban rulings issued by the Florida Supreme Court. Finally, we go over cardiac pacemakers and how they have changed over time.

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Transcript

[Deepti] Welcome to the 2 Minute Medicine Podcast, summarizing the latest medical studies, curated and written by practicing physicians.

For our full suite of daily medical study summaries and updates written by practicing doctors, please visit our website at 2minutemedicine.com to start reading new daily content right now, for free. On this podcast, twice a month, we cover the latest in health care news and research evidence. We are your hosts Deepti and Andrew. On today’s episode, we’ll start off by discussing our two articles of the week. In the second half of the episode, we will look at health issues that have arisen in popular media. 

[Andrew] The article of the week comes from JAMA and is entitled “Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes”

T2D is a widespread and costly condition globally. Limited evidence suggests bariatric surgery may be superior to other treatments for type 2 diabetes, but it’s typically reserved for those with a body mass index (BMI) of 35 or higher, with few opting for surgery. Additionally, while some medications mimic the weight loss effects of surgery, they are expensive, lack long-term efficacy evidence, and necessitate ongoing use to sustain weight loss. Previous findings indicated that bariatric surgery remains superior in achieving and maintaining T2D remission, however this study provided extended follow-up data for 7 and 12 years after randomization.

In this study, the Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes (ARMMS-T2D) consortium analyzed data from four US single-center randomized trials to assess the long-term effectiveness, durability, and safety of bariatric surgery compared to medical and lifestyle treatment for type 2 diabetes, making it the largest and most extensive follow-up analysis to date.

This study is a pooled analysis from four US single-center randomized trials conducted between May 2007 and August 2013, with observational follow-up through July 2022. The study population included individuals with a diagnosis of T2D, BMI of 27 to 45,and age of 18 to 65 years. The primary outcome measured the difference in HbA1c percentage change between groups over 7 years, with additional data up to 12 years for those reaching that point before study closure. Secondary outcomes assessed changes in HbA1c levels over time, attainment of HbA1c less than 7.0%, and diabetes remission criteria.

Despite starting with higher initial values, individuals in the bariatric surgery group consistently maintained significantly lower HbA1c levels compared to those in the medical/lifestyle group throughout the study period (P < 0.001). By the 7-year mark, the mean HbA1c decreased from a baseline of 8.2% to 8.0% (difference, 0.2% [95% confidence interval (CI), −0.5% to 0.2%]) in the medical/lifestyle group, while in the bariatric surgery group, it decreased from 8.7% to 7.2% (difference, 1.6% [95% CI, −1.8% to −1.3%]). At year 7, diabetes remission rates were 6.2% in the medical/lifestyle group and 18.2% in the bariatric surgery group (odds ratio, 3.4 [95% CI, 1.3-9.2]; P = 0.02), and this disparity remained statistically significant at 12 years (P < 0.001).The rates of diabetes medication use were similar between the groups at baseline, and there were no significant changes over time in the medical/lifestyle group (P = 0.19 at year 7 and 0.12 at year 12); however, in contrast, medication usage significantly decreased from 97.6% at baseline to 38.0% at year 1 in the bariatric surgery group and remained significantly lower compared to baseline during follow-up (60.5% at year 7; P < 0.001). This study found that compared to medical and lifestyle intervention, bariatric surgery yielded superior glycemic control, along with reduced usage of diabetes medication and increased rates of diabetes remission. One limitation of the study was the discrepancies in the original trial protocols and the lack of consistent assessment for certain diabetes complications like retinopathy. This inconsistency could affect the reliability of the findings. In conclusion, the findings, in conjunction with existing evidence, substantiate the utilization of bariatric surgery as an effective therapeutic approach for managing T2D in individuals with obesity.

[Andrew] Now for The Scan.

The story: The Story:  Since June 20, 2023, Dr. Scolyer, an Australian pathologist, has been sharing his brain cancer journey with the public on Instagram. What has made his treatment path unique is that he is the patient zero in a pioneering immunotherapy approach to treating brain cancer. On March 19, 2024, Dr. Scolyer shared some fantastic news on his Insta account: His latest MRI brain scan showed no recurrence 10 months after his diagnosis. The median time to recurrence for his particular brain cancer, glioblastoma multiforme (GBM), is 6 to 9 months. 

You may be wondering, what is GBM and what kinds of treatment options are currently available. 

[Deepti] Great question! There are over 120 brain tumors, lesions and cysts which could be benign (non-cancerous) or malignant (cancerous). In the United States, brain and nervous system cancers are two of the most prevalent cancers among youth and young adults, accounting for 1 out of 100 cancer diagnoses. The movie “Suncoast” released in February 2024 is based on the movie director Laura Chinn’s life experience coping with her brother’s brain cancer. We see the brain cancer journey of a teenage patient who falls into a vegetative state and ultimately dies in a hospice. Globally, over 300,000 individuals are diagnosed per year. GBM is a fatal kind of brain cancer that is notorious for its aggressiveness. It is incurable and challenging to treat. Twelve to eighteen months is the usual survival period; just 25 percent of patients survive for more than a year, and only 5 percent survive for more than five years.  Temozolomide (TMZ), a chemotherapy approved by the FDA in 2005, is the only anticancer drug approved for first-line treatment of GBM. The standard of care for GBM involves maximal surgical resection, radiation, and adjuvant TMZ chemotherapy. Long-term adjuvant TMZ improves progression-free survival, however, the overall survival benefit of temozolomide is limited. Dr. Scolyer is the first patient to postpone his surgery to undergo immunotherapy before brain tumor removal. He is also the first to receive a personalized vaccine based on his tumor biomarkers, enhancing medication effectiveness in detecting malignancy. Considering the quick growth of most brain cancers, Dr. Scolyer’s experimental approach was a risky move, however, he is passionate about the power of research and how this experiment can contribute to developing new treatments for brain cancer. Next, a conversation about over the counter birth control

[Andrew] Barriers to birth control access have significant impacts on women’s lives as they increase the risk of unintended pregnancies, health, and financial-related complications. In the 2021 movie “Plan B” we follow the difficult journey of a teenage girl who tries to obtain Plan B in South Dakota. Her first stop is at a pharmacy where she is denied Plan B. Although legally, the emergency contraception Plan B and prescribed birth control drugs are not banned for under 18-year-old individuals, a study done in Los Angeles County has shown that nearly three-quarters of pharmacies enforce identification and age restrictions that are not mandated by law. 

A recent FDA decision may improve access to birth control. Starting in March 2024, birth control pills are available in some US stores without the need for a prescription! The medication known as Opill developed by Perrigo Company plc contains norgestrel, a type of progestin and is intended for regular use and not meant for emergency contraception. 

[Deepti] Considering that Opill only contains progestin, it is more time-sensitive than combination oral contraceptive pills which contain both estrogen and progestin. Over-the-counter birth control medications have been available in over 100 countries in the world including but not limited to Latin American and European countries. Non-prescription birth control drugs help increase women’s autonomy as they increase access to contraception options, especially for adolescents, undocumented immigrants and women in states that have banned abortion.  

Now, let’s discuss the latest news with respect to abortion access in Florida

In Florida, over 80,000 women received abortions in 2023 which shows an increasing trend compared to 2020. About 65% of this overall increase was attributed to individuals from out of state as Florida was the only state in the south region providing care after 12 weeks. Starting May 1st, this will not be the case anymore. On April 1st, the Florida Supreme Court upheld a 15-week ban that was already in place and permitted the implementation of a new, 6-week ban in 30 days. For anti-abortion activists such as Katie Daniel, the decision of the Supreme Court is a “victory for unborn children”. However, not everyone shares the same view. After Roe v. Wade was overturned in 2022, many celebrities such as Megan Markle, Michelle Obama, and Megan Fox used their voices to express their concerns and discuss the impact of this decision on women’s health and rights. Moreover, in a volunteer-driven effort, groups such as Las Libres and WeSaveUs are now serving many people who have difficulty accessing abortion within the traditional healthcare system. 

[Andrew] Thats right and despite these rulings, the future of abortion access in Florida is still to be decided as the state Supreme Court also approved a proposed abortion amendment for the 2024 ballot. This means that voters could reverse the abortion ban if they vote for the proposed amendment known as Amendment Four which will protect abortion up to about 24 weeks of pregnancy and uphold the right to an abortion under the Florida Constitution. Last not least lets take a closer look at cardiac pacemakers, the role they play and how they have changed over time. 

[Deepti] Arnold Schwarzenegger, the 76-year-old actor, has had multiple cardiac surgeries since the 1990s due to a congenital heart defect. In the past month of this year, he underwent pacemaker surgery, and on March 28, he shared a photo of himself with his pacemaker on Instagram. Despite this procedure, he reassured fans that he would be ready to film the Netflix series “FUBAR” season 2 in April.

A pacemaker is an electronic device used for treating arrhythmia, or irregular heartbeat. There has been a significant advancement in understanding arrhythmia and cardiac pacing technology since 1960, when the first American patient underwent successful pacemaker surgery. For example, the FDA approved the world’s first dual chamber and leadless pacemaker in 2023, and in February of 2024, US San Diego Health was the first to successfully implant this pacemaker in a patient in San Diego.

[Andrew] In the United States alone, about 3 million people live with pacemakers. While 70% of pacemaker wearers are at least 65 years old, people of any age may need pacemakers. For example, Julie Bowen, the now 54-year-old star of Modern Family TV series, has been wearing a pacemaker since her twenties. Pacemaker implantation is expected to significantly increase in the future due to an aging population and rising life expectancy.

We’d like to acknowledge the following members of our team for their contributions to this week’s episode

• Marzyeh Azimi
• Yasin Avci
• Yuchen Dai

Thank you for joining us today for this episode of the 2 Minute Medicine Podcast. New episodes come out every other week and all of our content has been curated and written by practicing physicians.