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Medication Risks, Food Policy, and Toronto's Heart Transplant Milestone · Morning Medical with Dr. Chow

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Welcome to another episode of Morning Medical with Dr.
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Chow.
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I'm your host, Dr.
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Chi-Ming Chow, and today we're diving into some important medical updates that you need to
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know.
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As always, our goal is to keep you informed about the latest in health and medical news
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from around the globe.
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Today, we're starting with a study that renews warnings about a particular combination of
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medications often prescribed in nursing homes.
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This study highlights the risks associated with using the painkiller tramadol in conjunction
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with certain types of antidepressants, specifically those that inhibit the enzyme
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CYP2D6.
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These findings are particularly relevant for elderly patients, who are often prescribed
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these medications to manage chronic pain and depressive disorders.
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The study, which involved over 70,000 nursing home residents, found that those who were
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prescribed tramadol alongside a CYP2D6-inhibiting antidepressant experienced a
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higher risk of seizures compared to those who were on a CYP2D6-neutral antidepressant.
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This increased seizure risk is significant, with a 9 percent higher risk observed in
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patients who added a CYP2D6-inhibiting antidepressant to their tramadol regimen.
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Conversely, patients who added tramadol to their existing regimen of a CYP2D6-inhibiting
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antidepressant also saw a 6 percent increase in seizure risk.
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The researchers advise that when the co-use of tramadol and antidepressants is clinically
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necessary, clinicians should opt for CYP2D6-neutral antidepressants to mitigate this
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risk.
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Particular attention should be paid to patients who are female, have moderate to severe
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cognitive impairment, or have a history of cardiovascular disease, as these factors were
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observed to further elevate seizure risk in the study.
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Despite previous safety warnings from the United States Food and Drug Administration
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about the risks of combining antidepressants and opioids like tramadol, this combination is
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still prevalent in nursing homes.
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The study's findings underscore the importance of cautious prescribing practices, especially
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given that tramadol can lead to seizures even within recommended dose ranges.
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This is due to the fact that CYP2D6-inhibiting antidepressants can reduce tramadol metabolism,
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increasing its concentration in the blood and thus enhancing the risk of seizures.
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It's worth noting that this study is the first to utilize a national Medicare nursing home
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sample to examine seizure risks associated with tramadol and antidepressant use.
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The findings are particularly pertinent to older adults, as both hepatic function and
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renal clearance decline with age, potentially exacerbating adverse effects when these drugs
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are used together.
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In conclusion, this study serves as a critical reminder for clinicians to carefully consider
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the types of antidepressants they prescribe alongside tramadol, especially in vulnerable
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populations like the elderly in nursing homes.
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By choosing CYP2D6-neutral antidepressants, the risk of seizures can potentially be reduced,
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improving patient safety and outcomes.
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California has made a groundbreaking move by becoming the first state in the United States
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to define and ban ultraprocessed foods from its public school meals.
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This historic legislation, signed into law as the "Real Food, Healthy Kids Act" by Governor
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Gavin Newsom, aims to reform the food supply for over one billion schoolchildren annually.
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This decisive action places California at the forefront of a growing movement to address the
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concerns around ultraprocessed foods, which are often packed with additives, sugars, salt, and
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unhealthy fats.
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The law not only defines what constitutes an ultraprocessed food, a task that many countries
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have yet to accomplish, but also mandates public health officials and scientists to
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identify the most harmful ultraprocessed foods.
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These foods, labeled as "ultraprocessed foods of concern," will be phased out from the school
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food supply.
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This initiative is a significant step forward compared to national efforts like the "Make
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American Healthy Again" movement, which has been criticized for lacking decisive action.
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Jesse Gabriel, the Democratic California Assemblymember who introduced the bill,
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emphasized California's proactive approach compared to the ongoing debates in Washington,
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D.C.
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He pointed out that while the federal government is still deliberating on defining
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ultraprocessed foods, California is already taking action to protect children's health.
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This sentiment was echoed by Bernadette Del Chiaro from the Environmental Working Group,
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who noted the strong opposition and lobbying efforts from industry groups but praised the
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broad bipartisan support the bill received.
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The "Real Food, Healthy Kids Act" sets specific guidelines for what qualifies as an
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ultraprocessed food, including those with nonnutritive sweeteners, high levels of
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saturated fat, sodium, added sugars, and various additives like emulsifiers and flavor
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enhancers.
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While not all ultraprocessed foods will be banned, those with the most harmful additives
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linked to health issues like food addiction, cancer, diabetes, and fatty liver disease will
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be targeted first.
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It's important to note that this transition won't happen overnight.
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The first regulation, requiring food vendors to report all ultraprocessed foods they supply, is
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due by February 2028.
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All ultraprocessed foods of concern must be removed from schools by July 2035.
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There are concerns about potential federal interference, but the strong bipartisan support
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in California suggests a robust commitment to public health and children's well-being.
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Today, we're exploring an intriguing discussion from the "Food Is Medicine" meeting, sponsored
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by Tufts University, where experts are pushing to expand the role of nutrition in medicine.
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The idea is that diet should be considered as crucial to patient treatment as medication,
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surgery, and other traditional interventions.
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Dr.
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Sean Hashmi, a nephrologist with the Southern California Permanente Medical Group, expressed
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a vision for 2030 where food becomes a vital sign, just like blood pressure or heart rate.
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Dr.
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Hashmi highlighted a simple yet powerful concept: prescribing food just like an
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angiotensin-converting enzyme inhibitor.
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He emphasized that improving diet is a key component in treating various diseases, but it
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should complement, not replace, medications.
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He likened doctors to carpenters, using the most effective tools available.
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For instance, in patients with congestive heart failure, dietary changes can enhance the
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effectiveness of medications like glucagon-like peptide-1 receptor agonists, improving outcomes
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such as ejection fraction by reducing weight.
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Dr.
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Alka Gupta, an internist and board member of the American College of Lifestyle Medicine,
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shared a compelling story about a 65-year-old patient with uncontrolled type 2 diabetes.
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Initially resistant to starting insulin, this patient embraced an intensive lifestyle
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modification approach, including a whole-food, plant-forward diet and daily exercise.
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Remarkably, within three months, his hemoglobin A1c dropped significantly, and five years
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later, his diabetes remains in remission.
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This story illustrates the profound impact that dietary changes can have on chronic conditions.
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Efforts to incorporate food as medicine are gaining momentum, with support from Congress
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and various organizations.
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Colin Schwartz from the American Heart Association's Health Care by Food initiative
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noted significant "food-is-medicine" wins in the fiscal year 2026 appropriations bill.
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This includes funding for food prescription pilots and continued support for collaborative
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efforts by the Department of Health and Human Services.
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The bipartisan bill reintroduced to provide medically tailored meals to Medicare patients
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represents another step forward in reducing rehospitalizations.
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Katie Garfield from the Center for Health Law and Policy Innovation at Harvard Law School
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highlighted the challenges in billing for food-is-medicine services.
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Currently, there are no standardized billing codes, but efforts like the Coding4Food project
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are working to create these codes.
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By doing so, they're also establishing consistent definitions and standards for these
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interventions to ensure quality across the country.
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It's clear that as we advance, integrating nutrition into medical practice will require
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innovation not only in treatment but in policy and infrastructure as well.
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Today, we're diving into a remarkable story from Toronto, where doctors have performed a
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groundbreaking heart transplant at the University Health Network.
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This isn't your typical heart transplant; it involves a heart that had stopped beating,
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marking a significant milestone in Canadian medical history.
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This innovative procedure, known as a donation after death by circulatory criteria, or DCC,
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heart transplant, was carried out at Toronto General Hospital in early September.
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Traditionally, heart donations come from donors who are brain dead, with a heart that continues
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to beat.
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However, this DCC process involves recovering the heart from a patient who has died but
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hasn't been declared brain dead by a neurologist.
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The heart experiences a brief period without oxygen, but thanks to advances in medical
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technology, it can now be successfully transplanted under carefully defined criteria.
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According to Dr.
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Seyed Alireza Rabi, a cardiac surgeon on the transplantation team, this process opens new
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doors for patients waiting for life-saving transplants.
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It's particularly significant for those with advanced heart failure, as many never make it
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to the waitlist, and others succumb to their disease while awaiting a donor organ.
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Heart transplants remain the only cure for advanced heart failure, making this advancement
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crucial.
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Data from the Canadian Institute for Health Information shows that at the end of 2024,
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there were 155 adults and 29 children in Canada waiting for heart transplants.
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The DCC procedure is expected to increase the heart donor pool by 30 percent, which is a
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substantial boost for those in need.
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Dr.
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Rabi explains that while the DCC procedure isn't entirely new—it's been performed in
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Australia since 2014, the United Kingdom since 2015, and the United States since 2019—the
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research and experience gathered in those countries helped prepare the Toronto team for
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this operation.
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The process involves two critical moments: the 'warm' period right after the donor has died
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and the heart is removed, and the 'cold' period when the heart is preserved and transported to
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the recipient.
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Dr.
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Thomas Forbes, the surgeon in chief at the University Health Network, describes this as a
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major advance in transplant surgery in Canada.
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He highlights the debilitating and often fatal nature of end-stage heart failure, where heart
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transplants are essential to increase life expectancy.
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This breakthrough provides hope for a productive and quality life for patients and
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their families.
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Ontario's Minister of Health, Sylvia Jones, congratulated the University Health Network
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team for this historic milestone in Canadian health care.
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She emphasized how innovation and collaboration are key to saving more lives, with the first
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DCC transplant in Canada setting a new standard for medical advancements.
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Our final story today takes us to New Brunswick, Canada, where the provincial
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government has just unveiled a comprehensive five-year health-care plan aimed at radically
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improving the province's health-care system.
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At the heart of this strategy is a commitment to ensuring every New Brunswicker has access to
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a family doctor.
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Health Minister John Dornan emphasized that this is his top priority, and a critical step
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towards maintaining the health and well-being of the province's residents.
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Minister Dornan announced the establishment of collaborative-care clinics as a cornerstone of
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this initiative.
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These clinics aim to provide timely access to a variety of health-care professionals, including
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doctors, nurse practitioners, nurses, and mental health specialists.
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As of now, six such clinics have been established, with plans to add at least four
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more by the end of the year.
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The ambitious goal is to have at least 30 collaborative-care clinics operational across
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New Brunswick by 2028.
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The urgency of this initiative is underscored by the fact that only 77 percent of New
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Brunswickers currently have a primary-care provider.
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The government aims to increase this to 79 percent by the end of this year and to 85
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percent by 2028.
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Minister Dornan, who is also a doctor and former CEO of the Horizon Health Network, has
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already received positive feedback from residents who are being matched with family
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doctors through the new clinics.
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He shared that many people, who have been on waiting lists for years, are now being attached
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to family doctors, and they're expressing gratitude for this progress.
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Premier Susan Holt elaborated on the broader goals of the five-year health-care plan, titled
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"Caring for New Brunswick." She emphasized its focus on ensuring that patients receive
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effective and timely care.
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The plan outlines six priority areas: primary care, workforce, seniors, urgent care, mental
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health and addictions, and connected services.
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These priorities are designed to ensure that residents receive the right care, in the right
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place, from the right person, at the right time.
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Addressing the needs of seniors is another top priority for Minister Dornan.
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The wait list for nursing home beds in New Brunswick currently exceeds 1,000 people, with
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many seniors occupying acute-care beds in hospitals when they could be in long-term care
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facilities.
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Dornan stressed that the goal is not just to move seniors out of hospitals, but to enhance
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community health support and provide better care tools and standards.
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Premier Holt highlighted ongoing efforts to support seniors living independently, such as
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the "Nursing Home Without Walls" initiative, which includes social visits and assistance
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with accessing government services.
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She expressed optimism that improvements in at-home and long-term care will lead to
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incremental enhancements in the health-care system for seniors.
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The sixth priority, connected care, is also pivotal.
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Only half of New Brunswick's clinicians currently use an electronic medical record
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system.
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The plan aims to address this by improving digital connectivity across health-care
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services, empowering patients with access to their health records through initiatives like
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MyHealthNB.
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Holt emphasized the importance of ensuring that all health-care experiences in New Brunswick
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are digitally connected, allowing for a comprehensive view of a patient's health by any
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health-care professional involved in their care.
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As we wrap up today's episode, it's clear that New Brunswick is taking bold steps towards
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transforming its health-care system.
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The focus on ensuring everyone has a family doctor and the establishment of
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collaborative-care clinics represent significant progress.
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By addressing the needs of seniors and improving connected care, the province is
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laying the groundwork for a more effective and accessible health-care system.
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Thank you for joining me today on Morning Medical with Dr.
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Chow.
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Stay healthy and informed, and I'll see you next time.