Missing Care Due to COVID-19

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

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.

Related blog posts:

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.”

What Our Office Is Recommending: School and Pediatric IBD Patients

We are getting a lot of calls from families trying to figure out what they should be doing for their children with inflammatory bowel disease in regards to school attendance.  Here is what our ICN team has developed:

School guidance during Covid pandemic:

With the flood of information in the lay and scientific media, GI Care for Kids wanted to assure that our patients and families who had children with inflammatory bowel disease (IBD), Crohn’s or ulcerative colitis, had some guidance in making important decisions about beginning the 2020-2021 school year.  Currently, research shows that just having IBD, DOES NOT put a person more at risk for acquiring (i.e. catching) coronavirus (COVID-19) infection.  In addition, research suggests that biologics (e.g. Remicade, Humira) DO NOT seem to increase the risk for more severe Covid related illnesses.

However, steroids, thiopurines (e.g. 6-MP; azathioprine, immuran) and prograf DO appear to have a larger effect on increasing risk for more severe coronavirus infection and COVID-19 disease.  Additional research is being carried out with oldest patients (e.g. > 65 years of age) who appear to be at increased risk for infection and COVID-related disease, and, other co-morbid conditions (e.g. obesity, diabetes, cardiovascular disease) being at highest risk for COVID-19 disease as well.

All patients should practice good hand hygiene, wear masks at all times outside of the house, and observe social distancing.  If your family does not feel that return to a traditional school building is in your child’s best interest, please let us know, and we will help make sure we support you from a medical standpoint. 

For further information on the status of coronavirus in people with IBD world-wide, young or old, please go to: www.covidibd.org.

Additional information about the status of COVID-19 can be found at the following websites:


Also, this:

Facebook link (1:22 min): This is what happens when a Special Effects guy stays at home with his son during lockdown


Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Is It Safe for Me to Go to Work?

Just for fun —YouTube (~3 minute video): The Swish Machine: 70 Step Basketball Trickshot (Rube Goldberg Machine)


Full text —MR Larochelle. DOI: 10.1056/NEJMp2013413. NEJM: Is It Safe for Me to Go to Work?

An excerpt:

I believe that a strategy to protect at-risk workers needs at least three components: a framework for counseling patients about the risks posed by continuing to work, urgent policy changes to ensure financial protections for people who are kept out of work, and a data-driven plan for safe reentry into the workforce…

The Occupational Safety and Health Administration has published guidance and proposed a scheme for classifying the risk of SARS-CoV-2 infection as high, medium, or low based on potential contact with persons who may or do have the virus (www.osha.gov/Publications/OSHA3990.pdf. opens in new tab). Low-, medium-, and high-risk categories of individual risk of death from Covid-19 are based on age and the presence of high-risk chronic conditions identified by the CDC…

As states move to reopen their economies, millions of nonessential employees will join essential employees in putting themselves at risk for contracting SARS-CoV-2 at work. Physicians should engage patients in individualized risk assessments. Our society has the moral imperative and means to provide vulnerable employees a financial safety net until we can better ensure their workplace safety.

Related blog post: @Atul_Gawande: How to Reopen

“Coronavirus Disease 2019 and the Pediatric Gastroenterologist”

Full Text: KF Murray, BD Gold, R Shamir et al. JPGN 2020; 70: 720-6. Coronavirus Disease 2019 and the Pediatric Gastroenterologist. This article includes CME availability too!

Some excerpts:

  • The latest global count updates can be found at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/.
  • SARS-CoV-2 is a positive-sense, single-stranded RNA virus belonging to the genus Betacoronavirus, and phylogenetically related (88%–89% similarity) to the two bat-derived SARS-like coronaviruses, bat-SL-CoVZC45 and bat-SL-CoVZXC21….
  • Routine gastroenterology practice poses increased risk of exposure and potential viral transmission during ambulatory interaction, especially during endoscopic procedures…
  • The use of telemedicine is now a critical tool for the pediatric gastroenterologists and their patients, whether in the academic setting or private practice…The recently published AAP guideline, entitled Telehealth Payer Policy in Response to COVID-19 (https://downloads.aap.org/DOPA/Telehealth_2_rev.pdf and https://www.aap.org/en-us/professional-resources/practice-transformation/telehealth/Pages/compendium.aspx), which outlines policy changes aiming to alleviate barriers to telehealth care, along with a webinar on telehealth and guidance on structuring your practice during the pandemic are tools that can be employed in both the academic and private practice pediatric gastroenterologist office to facilitate ongoing quality care of their patients

My take: This article provides a concise update and numerous resources.  As the information about the coronavirus is rapidly changing, the recommendations will continue to evolve.

Also, JPGN has a large number of articles available on its COVID-19 page: Link: COVID-19 page This page includes articles related to endoscopy, PPE, telemedicine, and central line infections.  Also, based on a personal communication, there will be a link to a recently published article soon on “Pediatric Crohn’s Disease and Multisystem Inflammatory Syndrome in Children (MIS-C) and COVID-19 Treated With Infliximab.”(Dolinger M T, Person H, Smith R, et al. Journal of Pediatric Gastroenterology & Nutrition 2020;  PMID: 32452979 DOI: 10.1097/MPG.0000000000002809)

“Channelopathy of the Pancreas Causes Chronic Pancreatitis” and SARS-CoV-2 in Sewage

Interesting article: Full Text: SARS-CoV-2 RNA concentrations in primary municipal sewage sludge as a leading indicator of COVID-19 outbreak dynamics 

___________________________________________________________________

M Sahin-Toth. Gastroenterology 2020; 158: 1538-40. Full Text Link: Channelopathy of the Pancreas Causes Chronic Pancreatitis

Excerpt from editorial:

In this issue of Gastroenterology, Masamune et al report a landmark discovery, the genetic association of functionally defective TRPV6 channel variants and chronic pancreatitis. The authors investigated the TRPV6 gene in Japanese and European patients with nonalcoholic chronic pancreatitis using targeted sequencing followed by functional analysis of the identified variants. In the Japanese discovery cohort, they found functionally defective variants in 4.3% of the patients and in 0.1% of the controls (odds ratio 48). In the European replication cohort, 2% of the patients carried a defective variant and none was found in controls.

Original research study: A Masamune et al. Gastroenterology 2020; 158: 1626-41. Full text: Variants That Affect Function of Calcium Channel TRPV6 Are Associated With Early-Onset Chronic Pancreatitis

An excerpt:

TRPV6 variants are globally associated with early-onset nonalcoholic CP. To our knowledge, TRPV6 is a novel pancreatitis-associated gene beyond the pancreatic digestive enzyme/enzyme inhibitor system, and it is the first gene that directly regulates Ca2+ homeostasis. Our findings open a completely new avenue by emphasizing the potential role of ductal cells and, especially, calcium channels in the pathophysiology of pancreatitis, which might lead to the development of personalized medicine targeting TRPV6 channel activity.

From editorial by Sahin-Toth

Visual abstract for research study by Masamne et al.