New Data: Acid Blockers NOT Associated with Risk of SARS-CoV-2, SARS-CoV-2 in the Pancreas, & Vaccine Passport

X Fan et al. Gastroenterol 2021; 160: 455-458. Full text link: Effect of Acid Suppressants on the Risk of COVID-19: A Propensity Score-Matched Study Using UK Biobank

Among 9469 included participants, 1516 (16%) were regular users of acid suppressants, and 7953 (84%) were not…propensity score matching (PSM) was applied to match users of acid suppressants and nonusers. 

Key findings:

  • The odds ratio (OR) of testing positive for COVID-19 associated with PPI or H2RA therapy in the PSM cohort was 1.083 (95% confidence interval [CI], 0.892–1.315) and 0.949 (95% CI, 0.650–1.387), respectively.
  • Omeprazole use alone was significantly related to an increased risk of SARS-CoV-2 infection from the subgroup analysis in patients with upper gastrointestinal diseases (OR, 1.353; 95% CI, 1.011–1.825)

My take: This study provides reassurance that acid blockers are unlikely to contribute to the risk of SARS-CoV-2 or to related complications.

Related blog post: PPIs Associated with Increased Risk of COVID-19

Other COVID-19 Information:

The Most Valuable Commodity: Attention

During the past week (as I write this), I came across two articles which focused on the subject of “attention.”

In the first, Toward a Medical “Ecology of Attention” (MJ Kissler et al. NEJM 2021; 384: 299-301), the authors assert that “in the clinical environment, the most important –and most limited–resource is attention.” They note that distraction contributes “to lapses in judgement, insensitivity to changing clinical conditions, and medication errors.” The article delves into modifications that can improve attention in clinical settings:

  • Prioritizing communications using triaging and batching
  • Designing physical spaces to improve concentration
  • Optimizing electronic health record to minimize attention spent maintaining the record outside vital patient care activities
  • Development measurement tools

The second article, “The Internet Rewired Our Brains. This Man Predicted It Would,” (title online is “I Talked to the Cassandra of the Internet Age”) assesses how the “the attention economy” and the internet are changing the country.

A few excerpts:

  • Most of this came to him in the mid-1980s, when Mr. Goldhaber, a former theoretical physicist, had a revelation. He was obsessed at the time with what he felt was an information glut — that there was simply more access to news, opinion and forms of entertainment than one could handle. His epiphany was this: One of the most finite resources in the world is human attention. To describe its scarcity, he latched onto what was then an obscure term, coined by a psychologist, Herbert A. Simon: “the attention economy“…
  • “Rational discussion of what people stand to gain or lose from policies will be drowned out by the loudest and most ridiculous.”
  • His biggest worry, though, is that we still mostly fail to acknowledge that we live in a roaring attention economy. In other words, we tend to ignore his favorite maxim, from the writer Howard Rheingold: “Attention is a limited resource, so pay attention to where you pay attention.”
  • Perhaps, just by acknowledging its presence [the attention economy], we can begin to direct it toward people, ideas and causes that are worthy of our precious resource.”

My take: I frequently relate a quote from Jim Gaffigan. He stated that his wife is great at multi-tasking but that he is trying just to task. I try to focus on what’s in front of me.

COVID Vaccine Myths and Facts from ACG

ACG: 1Fact/1Myth: Dispelling Misinformation on COVID-19 Vaccine

Some of the slides:

Full set of Slides: ACG_COVID_Vaccine Slide Set PDF

Related blog posts:

Why Every EHR User Needs a Physician Champion Colleague

NASPGHAN Webinar: (Link -requires registration to view): Changing the Dynamic: How to Enable EHRs to Work for You (if trouble with this link, go to https://learnonline.naspghan.org/webinar)

This webinar featured lectures by the following:

  • Steven Liu for Epic functionality (in the ~first 20 minutes)
  • John Pohl for Cerner functionality (in the ~second 20 minutes)
  • Jennifer Lee discussed patient portal, improving provider-patient communication, & protecting adolescent confidentiality-21st Century Cures Act
  • Jeannie Huang discussed the role of EHRs in value-based health care and clinical data collection.

Since our group mainly uses Epic, I will summarize some of the tips from Steven Liu, who also is our group’s Epic Physician Champion. Anyone who listened to the webinar will realize how there are so many tricks available. Some of the material from the talk is at the bottom in the form of screenshots; however, much of the information in the webinar is proprietary to EPIC and cannot be shared without permission.

Here are some of the key points:

  • Customize your templates for progress notes/H&Ps/other notes.
  • Scribes may relieve frustration and be a good investment
  • Use Smartphrases and Smartlinks
    • Smartphrases can be taken (or customized) from other users -can browse your superusers phrases by looking under Smartphrase manager
  • Smartforms can be very useful (eg. ImproveCareNow)
  • Using Dictionary, users can change autocorrect: example: if you type EoE, you could have it modified to Eosinophilic Esophagitis
  • Utilize/incorporate patient-entered questionnaires
  • Utilize customized filters (wrench icon) under the chart review tabs
  • Take advantage of the Chart Search function
    • can search “PPI” or “calprotectin” and this will identify if patient has used a PPI or had a calprotectin
    • can access this feature quickly with CTRL-spacebar
  • Shortcuts can save time -examples ALT-A and ALT-S
  • Take the time to build customized order panels, like “Celiac Annual Labs”
  • Health Maintenance Checklists can be incorporated but users may need their system to activate this feature
  • There is an Inbox Reminder function (to remind patient to get an appointment or test) or you can send a inbox message to yourself with a future date
  • For more sophisticated users: generating reports with Workbench
  • Epic has free classes (User Web -see slide below) available to help practitioners become more proficient (eg. Power User Course)

My take: Steven has helped everyone in our practice & listening to his talk makes me realize that I need to learn a good bit more and take some of his stuff. This EHR webinar provides a lot of tips to help good EHR users become better users. For those interested in research, understanding EHRs will be crucial going forward.

Related blog posts:

Dr. Steven Liu

AASLD COVID-19 Vaccine Recommendations (for patients with Liver Disease)

Link to 38 page guidance, last updated 2/2/21: AASLD EXPERT PANEL CONSENSUS STATEMENT:
VACCINES TO PREVENT COVID-19 INFECTION IN PATIENTS
WITH LIVER DISEASE

Key points:

  • “Due to their mechanism of action, both mRNA COVID-19 vaccines are recommended for all patients with CLD (compensated or decompensated) and immunosuppressed SOT recipients.”
  • “The AASLD recommends that providers advocate for prioritizing patients with compensated or decompensated cirrhosis or liver cancer, patients receiving immunosuppression such as SOT recipients, and living liver donors for COVID-19 vaccination based upon local health policies, protocols, and vaccine availability.”

COVID: Schools & Age-Related Morbidity and Mortality

JF Ludvigsson et al NEJM 2021; 384: 669-671. Full text: Open Schools, Covid-19, and Child and Teacher Morbidity in Sweden In this letter to the editor, the authors report on outcomes in Sweden, which kept schools open during the pandemic; time period: from March 1-June 30, 2020 (schools end around June 10th). Key findings:

  • Among 1-16 years of age (~1.95 million in total), 15 required ICU admission; there were no deaths in this age group
  • “Fewer than 10 pre-school teachers [1-6 years] and 20 schoolteachers received ICU care up to June 30, 2020.” Excluding health care workers, the occupational risk was similar to other occupations, with relative risk of 1.10 (0.49-2.49, 95% CI) and 0.43 (0.28-0.68, 95% CI) for preschool and school teachers respectively.

My take: This study suggests that school teachers are at similar risk for COVID-19 infection as other essential workers. In Sweden, during this timeframe, distancing but not masking was recommended. Thus, transmission rates could be lowered further.

Related article: SR Kadire et al. NEJM 2021; 384: DOI: 10.1056/NEJMclde2101987. Full text: Delayed Second Dose versus Standard Regimen for Covid-19 Vaccination This article provides rationale for both vaccine options.

Related blog posts:

Screening for Melanoma in At-Risk (Pediatric) Patients –Is This a Good Idea?

It would seem intuitive that screening for melanoma in at-risk pediatric patients would be worthwhile. And, this has been recommended in pediatric patients with inflammatory bowel disease who have received medications which increase the risk. However, a recent article (HG Welch et al. NEJM 2021; 384: 72-79. The Rapid Rise in Cutaneous Melanoma Diagnoses) provides a lot of reason to question this practice;. This article did not focus on pediatrics but its message about overdiagnosis of melanoma is applicable to this population as well.

Key points:

  • The increase in melanoma diagnosis (6-fold increase over 40 years) without a significant change in mortality (see Figure 4) indicates that the increase is primarily related to diagnostic scrutiny
  • This is driven by a fear of missing a diagnosis, medicolegal concerns and patient anxiety along with lower thresholds for referring to dermatology, lower thresholds for dermatologists to biopsy, and lower threshold by pathologists to diagnose melanoma
    • There are “no definitive diagnostic criteria for the pathological diagnosis of melanoma”
    • “The incidence of melanoma in situ is now 50 times as high as it was in 1975 (25 vs 0.5 per 100,000 population)…[yet there is a] lack of any appreciable effect in reducing the occurrence of invasive melanoma.”
  • Adverse consequences of unnecessary dermatology referrals: feeling vulnerable related to overdiagnosis of melanoma, increased costs, and difficulty obtaining life or health insurance
  • More “survivors” of melanoma overdiagnosis increase awareness of melanoma and can increase the cycle of overdiagnosis

My take: Routine visits to dermatology are difficult to justify in the absence of worrisome skin findings. “Although the conventional response has been to recommend regular skin checks, it is far more likely that more skin checks are the cause of the epidemic — not its solution.”

COVID-19 Vaccine in Israel & Effectiveness for Variants

From BBC (1/25/21): Moderna vaccine appears to work against variants

An excerpt:

“For the Moderna study, researchers looked at blood samples taken from eight people who had received the recommended two doses of the Moderna vaccine. The findings are yet to be peer reviewed, but suggest immunity from the vaccine recognises the new variants. Neutralising antibodies, made by the body’s immune system, stop the virus from entering cells.

Blood samples exposed to the new variants appeared to have sufficient antibodies to achieve this neutralising effect, although it was not as strong for the South Africa variant as for the UK one. Moderna says this could mean that protection against the South Africa variant might disappear more quickly.”

When We Can Stop Pre-Procedure Screening For COVID-19

Briefly noted: S Sultan, SM Siddique et al. Gastroenterol 2020; 159: 1935-1948. Full text: AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV-2 Testing and Endoscopy

Table 1 provides a summary of the recommendations and indicates a threshold for which routine pre-procedure testing may not be needed:

  • “For endoscopy centers where the prevalence of asymptomatic SARS-CoV-2 infection is low (<0.5%), the AGA suggests against implementing a pretesting strategy.”
  • Conditional recommendation, very low certainty evidence
  • Rationale: “In low-prevalence settings, a pretesting strategy may not be informative for triage due to the high number of false positives, thus PPE availability may drive decision-making.”

My take: Particularly after the rollout of vaccination to health care providers, routine testing for SARS-CoV-2 is not likely to be needed once the prevalence drops to low levels.

Related blog posts: