Dulaglutide, Weight Gain, and Smoking Cessation; New Year’s Eye Injuries

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 doxycycline and sexually transmitted infection (STI) prevention; artificial intelligence (AI) in medicine and risk of harm; dulaglutide (Trulicity), weight gain, and smoking cessation; and preventing eye harm from champagne corks.

Program notes:

0:50 Doxycycline and STI prevention

1:53 Chlamydia, gonorrhea, and syphilis

2:50 Seventy percent of women didn’t take it

3:52 Artificial intelligence and medical harms

4:52 Clinician made the decision, then AI came in

5:52 A lot of work to do to improve clinical decision-making

6:24 Dulaglutide, weight gain, and smoking cessation

7:24 No gender differences observed

8:24 Meant to help increase tobacco abstinence

9:03 Cheers not tears

10:07 Eye injuries are plentiful

11:36 End

Transcript:

Elizabeth: Can doxycycline be used to prevent STIs in women?

Rick: The risk of harm from using artificial intelligence in medicine.

Elizabeth: Dulaglutide to prevent weight gain when people quit smoking.

Rick: And for the New Year, cheers, not tears.

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: 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: All right. Before we get to the cheers, not tears — that will be our last one — why don’t we turn to the New England Journal of Medicine? This is a look at whether the antibiotic doxycycline can be used to prevent STIs (sexually transmitted infections) in what we’re going to call cisgender women, women who have men as their partners.

This was a study that was done in Kenya. However, I think it’s representative of conditions that are probably worldwide. What they did was they gave doxycycline post-exposure prophylaxis. They handed women who were already receiving pre-exposure prophylaxis against HIV doxycycline 200 mg to be taken within 72 hours after condomless sex. They compared that with standard care among a group of Kenyan women who were 18 to 30 years of age. They had 224 assigned to the doxycycline group and 225 to the standard care group.

Interestingly, they tested their hair to see how much of the doxycycline they were actually using. They were looking at the ability of doxycycline post-exposure prophylaxis to prevent chlamydia, gonorrhea, and syphilis. The bad news was that the incidence of these STIs was not significantly lower with the doxycycline post-exposure prophylaxis than with the standard care. Having said that, I would say that in fact when they looked at their hair samples, they found out that it wasn’t really being used very often either.

Rick: This ends up being a huge issue because these sexually transmitted infections are on the rise and it’s estimated there are going to be 374 million of these annually. Now, they have tested post-exposure doxycycline in other circumstances, particularly in cisgender men and in transgender women. In those two groups, the administration or the availability of doxycycline after sexual exposure actually decreased the risk of sexually transmitted infections, but not in this particular study, not with cisgender women. I think one of the major reasons is because 70% of the woman, even though they had the doxycycline, didn’t take it.

That was surprising because these women are already on HIV prophylaxis and so everybody thought, “Well, gosh, they are already taking medicines to prevent HIV. Certainly they would take their doxycycline,” but that appeared not to be the case.

Elizabeth: The editorialist notes that this burden of STI is highest actually for this group of women and it’s curious why they aren’t more compliant with using doxycycline under these circumstances. We’ve got to figure out why that’s the case and try to overcome that particular thing.

Rick: It’s interesting, Elizabeth, because they took their HIV prophylaxis because none of the women were diagnosed with HIV. Nevertheless, they didn’t take their doxycycline. Whether the education wasn’t good or whether the woman didn’t think that was going to be an issue, whatever the reason — and unfortunately, this study doesn’t tell us — it just tells us that post-exposure prophylaxis with doxycycline really wasn’t helpful in preventing sexually transmitted infections.

Elizabeth: Got to back to the drawing board here.

Rick: Let’s talk a little bit about artificial intelligence.

Elizabeth: And that’s in JAMA.

Rick: That’s in JAMA. We’re talking about using it to leverage complex information in a patient’s electronic record or looking at things such as imaging, documentation, diagnostic testing, and clinical symptoms to arrive at a diagnosis. This information, with the use of AI, supposedly can help the physician.

The unfortunate thing is the AI is no better than the information that’s put in. For most physicians, AI technology is kind of a big black box. We’re not sure really what goes in and quite frankly we haven’t figured out quite how to use it right now.

In this issue of JAMA, investigators evaluated the impact for different AI models on the clinician’s ability to diagnose some routine respiratory issues. They looked at different clinical vignettes that were supposed to direct the physician to decide did the person have chronic obstructive pulmonary disease, pneumonia, or did the person have heart failure. They had all the clinical information and they had the x-rays, and the clinician made the decision.

Then they incorporated artificial intelligence. What the AI did was it looked at that information and also the x-rays and it highlighted different areas in the x-ray that it was looking at to make that diagnosis. Then the physician could incorporate that information to see whether to increase their accuracy. Then, finally they took that same AI and they purposefully made some mistakes; they fed in bad information, so it couldn’t read the x-ray appropriately. They presented it to the physician, but they still showed where in the x-ray they were looking to say, “Well, gosh, maybe the physician sees that they can overcome it.”

Here is what they determined. When the physician did the work by themselves, their diagnostic accuracy was about 73%. When they added artificial intelligence, it increased the accuracy to only 76%. When they highlighted the x-ray, it went up to about 78%.

Now what about when they use the biased artificial intelligence? Well, the physician accuracy dropped to 62%. The physician believed it even though it was wrong and even when it pointed to the x-ray. This tells us we have a lot of work to do in terms of using AI to help us improve our clinical decision-making.

Elizabeth: I think this is extremely concerning because the energy behind full-scale adoption of AI in so many clinical venues is increasing so rapidly that getting our arms around what’s bad data is going to be hard to do.

Rick: You’re right. And Elizabeth, we think about the benefits of it, but if you have imperfect AI it can actually harm the patients.

Elizabeth: A lot of work to do and we need to stay aware in this arena I think.

Let’s turn to the BMJ. This is a look at gender differences in weight gain during attempted and successful smoking cessation with the use of the GLP-1 agonist dulaglutide. This is a secondary analysis of a randomized trial that already took place among 255 adults who smoked daily, 155 women and 100 men. Participants received weekly injections of dulaglutide or placebo in addition to their standardized smoking cessation care, which was varenicline [Chantix] 2 mg a day plus behavioral counseling over 12 weeks.

They wanted to see gender differences in weight gain in the group that took the dulaglutide because they say that women seem to historically have more difficulty quitting smoking than men. They seemed to also be more concerned with whether they are going to gain a lot of weight after they stopped smoking.

What they found was that there were no gender differences observed in the absolute or relative weight gain on either dulaglutide or the placebo. There was substantial weight gain — greater than 6% increase — in the placebo group that occurred almost five times more frequently in females than in males. That speaks to me about what’s the physiology that’s here. Females were less likely to have substantial weight gain when they were on the dulaglutide compared with the placebo. It seems to suggest that it might help in this particular arena with women who are concerned about the potential for weight gain.

Rick: Elizabeth, the real question is, does that translate into rates of abstinence? The thought process being some people are reluctant to stop smoking because they know that they’ll gain weight. The more weight they gain, the less likely they are to remain abstinent. This could be a particular issue in women that have a lower rate of abstinence than men. Adding this weight loss reduction medication was meant to help increase abstinence from tobacco, but in fact it didn’t. When we look at the weight-controlling-effective dulaglutide, those individuals that really didn’t have significant weight gain because of the use of medication, it didn’t increase the rate of abstinence. There doesn’t seem to be a relationship between weight gain and the rate of abstinence.

Elizabeth: How long do you have to keep on taking this stuff in order to maintain your weight? That’s something that’s not examined in this study.

Rick: Right. In fact, this is just looking at short-term abstinence rate. The patients in this study were just looked at for about 3 months. As we have reported earlier, when you start on these medications, unless you continue them, you’re more likely to gain weight when you stop them.

Elizabeth: Finally, let’s turn to champagne.

Rick: All right. I served this up as cheers, not tears, because many of us will be popping open a bottle of champagne when we ring in the New Year. That rapid release of carbon dioxide that uncorks a bottle of sparkling wine has a nice sound to it, but there is a dark side to uncorking these bubbly beverages. That’s what are known as cork eye injuries.

Elizabeth, I wasn’t aware until reading this that when you look at the pressure in a sparkling bottle of wine, it’s about three times that of a standard car tire and the potential to launch a cork up to 50 mph. A cork can travel from the bottle to your eye in less than 0.05 seconds, which means you don’t even have time to blink.

There are many reports of eye injuries related to opening up champagne bottle corks. Things like retinal detachment, perforation, bleeding in the eye, whether that’s in the iris or the anterior chamber, corneal injuries, trouble with the pupil, and also glaucoma.

Does that mean we shouldn’t be popping open champagne? No, but there are ways that one can do it that are safe. If you chill the bottle before you open it, it reduces the pressure and therefore the cork velocity decreases. Also, you shouldn’t shake the bottle. When you’re opening it, face the bottle away from you, and more importantly from others as well. Put it at about a 45-degree angle, pick off the wire cage because that can also be a projectile, put a towel over the top of the bottle, hold the cork firmly and gently twist it on a counteracting upward movement. If you have it faced away from you and others, you’ll have that nice pop, a little fizz, and be able to enjoy some bubbly as you bring in the New Year.

Elizabeth: That’s right. Happy New Year! This, of course, is in the annual Christmas edition of the BMJ. I guess what I would recommend is what about practice? Just drinking more sparkling wines, therefore getting really practiced at opening them without hurting anybody including yourself.

Rick: Elizabeth, I think what you’re advocating is don’t wait until the New Year, but 3 or 4 days before open up a bottle with some good friends, enjoy it so that on New Year’s Eve you’re well prepared to do it safely. I like that recommendation.

Elizabeth: On that note, a happy and healthy 2024 to everyone who listens. That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. In the New Year, y’all listen up and make healthy choices.

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