Summarizing the Plus and Minuses of Telemedicine

From The Doctor’s Company (an insurance company): Your Patient Is Logging on Now: The Risks and Benefits of Telehealth in the Future of Healthcare Thanks to John Pohl for sharing this link.

An excerpt:

Foreseeable Major Benefits

  • Increases access to care for most patients, including many patients in rural locations, patients who struggle to cover the peripheral costs of an in-person visit (transportation, childcare, time away from work, etc.), and patients with chronic conditions.
  • Enhances the ability to manage chronic conditions by making more frequent contact easier. This management is already supported by at-home devices that record blood pressure, blood sugar, and other essential data points.
  • Reduces infection risks, not just for COVID-19, but for post-op patients, patients who are immunosuppressed, etc.

Other benefits: Promotes patient satisfaction, and scheduling -fewer no shows

Foreseeable Major Risks

  • The remote exam’s inherent limitations mean physicians must know when to ask patients to come in to avoid missed diagnoses…[may be able to do] risk-stratifying patients with abdominal symptoms by, among other things, watching the patient jump up and down
  • Increases cyber liability, especially when providers are seeing patients from a variety of devices in a variety of locations.
  • Privacy issues come in high-tech forms: Is the video visit interface HIPAA compliant? And in low tech forms: Conversations may be interrupted by household members at either end.
  • Decreases access to care for some patients: … many communities do not have sufficient internet bandwidth; some patients are prevented by a language barrier or lack of technological savvy from accessing a telemedicine portal.
  • Reimbursement is uncertain: Pre-pandemic, “Low reimbursement for telehealth was viewed as a critical disincentive,” say the authors of an opinion piece in JAMA, because “Without payment, it would be difficult for clinicians to afford to provide the service, despite data from previous studies suggesting clinicians were broadly supportive about its use.”

Other drawbacks: Physician-patient relationship –glitches or delays in sound or video can impede the normal flow of conversation—a diagnostic risk, as well as a relational one.

This May Be a Good Time to Be Wearing Glasses

W Zeng et al. JAMA Ophthalmol. Published online September 16, 2020. doi:10.1001/jamaophthalmol.2020.3906. full text  Association of Daily Wear of Eyeglasses With Susceptibility to Coronavirus Disease 2019 Infection

Findings  In this cohort of 276 patients hospitalized with COVID-19 in Suizhou, China, the proportion of daily wearers of eyeglasses was lower than that of the local population (5.8% vs 31.5%).

Meaning  These findings suggest that daily wearers of eyeglasses may be less likely to be infected with COVID-19.



Flu Vaccine in Pregnant Women Did NOT Increase Risk of Autism

JV Ludvigsson et al. Annals of Internal Medicine 2020; Full Text: Maternal Influenza A(H1N1) Immunization During Pregnancy and Risk for Autism Spectrum Disorder in Offspring

  • In total, 39 726 infants were prenatally exposed to H1N1 vaccine (13 845 during the first trimester) and 29 293 infants were unexposed.
  • Mean follow-up was 6.7 years .
  • 394 (1.0%) vaccine-exposed and 330 (1.1%) unexposed children had a diagnosis of ASD.

My take (borrowed from authors): This large cohort study found no association between maternal H1N1 vaccination during pregnancy and risk for ASD in the offspring.

Put Your Own Oxygen Mask On First

D Atkins. Annals of Internal Medicine 2020; Put Your Own Oxygen Mask On First

Important commentary -here’s an excerpt:

My hope that his colleagues would honor his memory by spending time taking care of themselves. “Selflessness has its price. Skip was so ready to give someone the shirt off his back that he may not have realized when he was also cold. I hope each of you—especially those of you who are doctors and nurses and caregivers—will take time to be selfish when you need to be. Make a lunch date with your Skip to complain about your problems. Put your own oxygen mask on first.”

COVID-19 Toll on U.S. Children

From AAP News: AAP Report: 513,415 children diagnosed with COVID-19

  • The latest report shows a rate of 680 COVID-19 cases per 100,000 children.
  • Children make up 9.8% of the total cases and about 1.7% of all COVID-19 hospitalizations, up from 0.8% of hospitalizations in late May.
  • Roughly 1.9% of children diagnosed with COVID-19 have been hospitalized, according to data from the 23 states and New York City that are publicly reporting hospitalization data.
  • There also have been at least 103 pediatric deaths in 42 states and New York City, making up about 0.07% of all COVID-19 deaths. Roughly 0.02% of children who have contracted known cases of COVID-19 have died.
  • There have been 792 confirmed cases of multisystem inflammatory syndrome in children in 42 states, New York City and Washington, D.C., and 16 death

Briefly noted: COVID-19 Cardiac Toxicity, U.S. Pandemic Research, Air-Bus Transmission

VO Puntmann et al. JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557. Full text: Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19)

Conclusion:  In this study of a cohort of German patients recently recovered from COVID-19 infection, CMR revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), independent of preexisting conditions, severity and overall course of the acute illness, and time from the original diagnosis. These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19.

NY Times: E Emanuel et al.  Where Is America’s Groundbreaking Covid-19 Research? The U.S. could learn a lot from Britain.

Excerpt: “ Yet with over six million coronavirus cases and 183,000 deaths, the United States has produced little pathbreaking clinical research on treatments to reduce cases, hospitalizations and deaths. Even one of the most important U.S. studies to date, which showed that the antiviral drug remdesivir could reduce the time Covid-19 patients spent in the hospital to 11 days from about 15, had too few subjects to demonstrate a statistically significant reduction in mortality…[British] researchers found no benefits from the use of hydroxychloroquine in hospitalized Covid-19 patients, nor from the lopinavir-ritonavir drug combination. On the other hand, dexamethasone, an inexpensive steroid, was found to reduce mortality by up to one-third in hospitalized patients with severe respiratory complications.” 

“Unfortunately, unlike Britain, the United States has lacked a clear, unified message from government health care leaders, major insurance companies and hospital systems to put in place large, simple randomized trials that are considered the standard of care for Covid-19 treatment. We need to change that muddled approach now and reassert the nation’s clinical research excellence.

NY Times: Roni Rabin. How a Bus Ride Turned Into a Coronavirus Superspreader Event

An excerpt: “A passenger on one of the buses had recently dined with friends from Hubei. She apparently did not know she carried the coronavirus. Within days, 23 fellow passengers on her bus were also found to be infected.

It did not matter how far a passenger sat from the infected individual on the bus, according to a study published in JAMA Internal Medicine on Tuesday. Even passengers in the very last row of the bus, seven rows behind the infected woman, caught the virus…

The new study “adds strong epidemiological evidence that the virus is transmitted through the air, because if it were not, we would only see cases close to the index patient — but we see it spread throughout the bus,” said Linsey Marr…

[THIS]  took place on Jan. 19, when there were still no confirmed Covid-19 cases reported in Ningbo…The potential for airborne transmission in close confined spaces raises concern about the winter months, when people will be spending more time indoors, Dr. Marr said. Her advice: “Avoid crowded indoor spaces where people are not wearing masks and the ventilation is poor.”

Eric Topol to Stephen Hahn/FDA: “Tell the Truth or Resign”

An open letter from Eric Topol to Dr.Stephen Hahn details a number of glaring mistakes at the FDA which threaten its credibility and its mission.

Here’s the link: Dear Commissioner Hahn: Tell the Truth or Resign

The letter points to three high profile, politically-fraught decisions at the FDA:

  1. Authorization of hydroxychloroquine
    • “Immediately after President Trump widely and aggressively promoted hydroxychloroquine as a “miracle drug,” on March 30, 2020, you granted an Emergency Use Authorization (EUA) for this drug without any sufficient or meaningful supportive evidence”
  2. Authorization of convalescent plasma
    • “This is a major advance…[A]nd a 35% improvement in survival is a pretty substantial clinical benefit. What that means is — and if the data continue to pan out — [of] 100 people who are sick with COVID-19, 35 would have been saved because of the admission of plasma.” Every part of that statement is incorrect and a blatant misrepresentation of the data.
  3. Authorizaton of remdesevir
    • The third breach of evidence-based data was your EUA issued August 28, 2020 broadening the remdesivir approval to include any patient hospitalized with moderate COVID-19. There are insufficient data to support this approval, as it is based on small, open-label studies with subjective endpoints.

Dr. Topol worries that Dr. Hahn will further erode confidence in the FDA by approval of a SARS-CoV-2 vaccine prematurely.  “Any shortcuts will not only jeopardize the vaccine programs but betray the public trust, which is already fragile about vaccines, and has been made more so by your lack of autonomy from the Trump administration and its overt politicization of the FDA.”

For SARS-CoV-2–Is 2 Meters Enough?

NR Jones et al. BMJ 2020;370:m3223. Full Text: Two metres or one: what is the evidence for physical distancing in covid-19?

Key messages from article:

  • Current rules on safe physical distancing are based on outdated science
  • Distribution of viral particles is affected by numerous factors, including air flow
  • Evidence suggests SARS-CoV-2 may travel more than 2 m through activities such as coughing and shouting
  • Rules on distancing should reflect the multiple factors that affect risk, including ventilation, occupancy, and exposure time

Highlighted article from Eric Topol’s Twitter Feed

A more nuanced approach is recommended by authors -color-coded Figure 3 above –caption: “Risk of SARS-CoV-2 transmission from asymptomatic people in different settings and for different occupation times, venting, and crowding levels (ignoring variation in susceptibility and viral shedding rates). Face covering refers to those for the general population and not high grade respirators. The grades are indicative of qualitative relative risk and do not represent a quantitative measure. Other factors not presented in these tables may also need to be taken into account when considering transmission risk, including viral load of an infected person and people’s susceptibility to infection. Coughing or sneezing, even if these are due to irritation or allergies while asymptomatic, would exacerbate risk of exposure across an indoor space, regardless of ventilation.”