Category Archives: General Health

Use of Famotidine for COVID-19

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A recent study (DE Freedberg et al. Gastroenterol 2020; DOI:https://doi.org/10.1053/j.gastro.2020.05.053. Famotidine Use Is Associated With Improved Clinical Outcomes in Hospitalized COVID-19 Patients: A Propensity Score Matched Retrospective Cohort Study, highlighted on AGA blog, indicates that famotidine may improve outcomes in those with COVID-19.

Methods: Freedberg et al collected data from 1620 patients who tested positive for SARS-CoV-2 no more than 72 hours following admission; 84 of the patients (5.1%) had received famotidine (any dose, form of administration, or duration; median dose of 136 mg) within 24 hours of hospital admission.

Key finding: After the authors adjusted for baseline patient characteristics, use of famotidine was independently associated with risk for death or intubation (adjusted hazard ratio 0.42, 95% CI, 0.21–0.85). This did not change after propensity score matching to balance covariables (hazard ratio 0.43, 95% CI 0.21–0.88).

My take: While these results indicate that famotidine may improve outcomes with COVID-19, a randomized controlled trial is needed to confirm these findings (currently one is underway to determine whether famotidine can improve clinical outcomes in hospitalized patients with COVID-19 (NCT04370262)).

AGA Blog Summary: Use of Famotidine Associated With Improved Outcomes of Hospitalized COVID-19 Patients

Related blog posts:

NEJM: Competing Visions for U.S. Health Policy, Evolocumab for Pediatric Familial Hypercholesterolemia, and the Cervical Cancer Vaccine

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A recent commentary (M Fiedler. NEJM 2020; 383: 1197-99. Competing Visions for the Future of Health Policy) describes two competing approaches to U.S. healthcare policy.

  • The current administration has supported legislation which would repeal or sharply curtail many of the Affordable Care Act’s (ACA’s) coverage provisions and is “asking the U.S. Supreme Court to strike down the entire ACA.”  Their approach views “existing federal coverage programs, particularly those serving lower-income people, [as] too expansive.”
  • The main alternative approach aims for expanded insurance coverage and deep subsidies to cover low- and moderate-income individuals.
  • Areas of potential agreement include encouraging competition to lower costs as well as making prices more transparent to encourage patients to seek out lower-priced alternatives.

My take: Overall, I favor more expansive health care coverage.

RD Santos et al. NEJM 2020; 383: 1317-1327. Evolocumab in Pediatric Heterozygous Familial Hypercholesterolemia

Methods: In this 24-week, randomized, double-blind, placebo-controlled trial with pediatric patients (n=157) with heterozygous familial hypercholesterolemia, patients 10 to 17 years of age were treated with evolocumab.  All had been receiving lipid-lowering treatment before screening and had LDL cholesterol level of 130 mg/dL.

Key finding: At week 24, the mean percent change from baseline in LDL cholesterol level was −44.5% in the evolocumab group and −6.2% in the placebo group.

My take: Long-term data are needed.  However, in high risk patients who have not responded to other intensive treatment, evolocumab may be worthwhile.

J Lei et al. NEJM 2020; 383: 1340-1348. HPV Vaccination and the Risk of Invasive Cervical Cancer

Methods: We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017.

Key findings:

  • After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.

My take: HPV vaccine (aka ‘Cervical Cancer Vaccine’) may lower the risk of cancer by 88% in those vaccinated before the age of 17 years.

From The Onion

Missing Care Due to COVID-19

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When analyzing health care expenditures, it has been well-recognized that many patients/families cut back on both necessary and unnecessary care when faced with increased costs; that is, individuals are not very good at selecting care that is truly essential.  This is one reason why many health care policy advisors are opposed to  high copays and deductibles as a way of reducing health care costs.

I have seen the same type of problem amidst the pandemic.  Due to fears of contracting SARS-CoV-2 (rather than mainly cost), individuals/families are deferring routine medical care.  This is leading to delays in diagnosis of many serious illnesses and missing opportunities to prevent illnesses (eg. vaccines).  A recent study has shown some of the impact with regard to cancer that happened early in the pandemic (and may be ongoing).

HW Kaufman et al. JAMA Netw Open. 2020;3(8):e2017267. doi:10.1001/jamanetworkopen.2020.17267. Full text: Changes in the Number of US Patients With Newly Identified Cancer Before and During the Coronavirus Disease 2019 (COVID-19) Pandemic

Introduction/Background:  In this study, we analyzed weekly changes in the number of patients with newly identified cancer before and during the COVID-19 pandemic.

Methods: This cross-sectional study included patients across the United States who received testing for any cause by Quest Diagnostic; data was compared between baseline period (January 6, 2019, to February 29, 2020) and the COVID-19 period (March 1 to April 18, 2020). n=278 778 patients. Study evaluated  breast cancer,  colorectal cancer, lung cancer,  pancreatic cancer, gastric cancer, and esophageal cancer.

Key findings:

  • During the pandemic period, the weekly number fell 46.4% (from 4310 to 2310) for the 6 cancers combined, with significant declines in all cancer types, ranging from 24.7% for pancreatic cancer (from 271 to 204; P = .01) to 51.8% for breast cancer (from 2208 to 1064; P < .001)

The authors noted a similar problem has been reported with cardiovascular disease.  A study from 9 high-volume US cardiac catheterization laboratories found a 38% decrease in patients treated for ST-elevation myocardial infarction, considered a life-threatening condition.

My take: It is difficult to calculate the actual toll of this pandemic which includes a great deal of secondary problems: delays in diagnosis of life-threatening conditions, mental health/suicides, death from poverty, setbacks in the opioid crisis & overdose deaths, and enormous setbacks in global health projects.

Related blog posts:

Published IBD-COVID-19 Data from SECURE-IBD & Others

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When I received an email in EARLY MARCH of this year regarding SECURE-IBD, I thought the researchers were insightful and proactive.  Recently, the authors published their early findings: EJ Brenner, RC Ungaro et al. Gastroenterol 2020; 159: 481-491. Full Text PDF: Corticosteroids, But Not TNF Antagonists, Are Associated With Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results From an International Registry

“Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) is a large, international registry created to monitor outcomes of patients with IBD with confirmed COVID-19.”

Key findings:

  • 525 cases from 33 countries were reported (median age 43 years, 53% men)
  • Risk factors for severe COVID-19 among patients with IBD included increasing age (adjusted odds ratio [aOR], 1.04; 95% CI, 1.01–1.02), ≥2 comorbidities (aOR, 2.9; 95% CI, 1.1–7.8), systemic corticosteroids (aOR, 6.9; 95% CI, 2.3–20.5), and sulfasalazine or 5-aminosalicylate use (aOR, 3.1; 95% CI, 1.3–7.7).
  • Tumor necrosis factor antagonist treatment was not associated with severe COVID-19 (aOR, 0.9; 95% CI, 0.4–2.2)

Other COVID-19 articles from same journal:

My take: There is a tremendous amount of information regarding SARS-CoV-2 & COVID-19 with regard to the GI tract and liver disease.  For the most part, the data indicate that individuals need to continue to treat their underlying disease and that most therapies do not increase the risk of worsening infection; the biggest risk factors remain increasing age and common comorbidities (eg. obesity, hypertension, and diabetes).  The published studies also provide insight and recommendations for preventing SARS-CoV-2 for health care providers.

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Summarizing the Plus and Minuses of Telemedicine

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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

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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

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JV Ludvigsson et al. Annals of Internal Medicine 2020; https://doi.org/10.7326/M20-0167. 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

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D Atkins. Annals of Internal Medicine 2020; https://doi.org/10.7326/M20-6349. 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

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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