Lawmakers cleared the way for telemedicine, but seniors need access, training

Technology and lack of broadband are holding back some seniors. 

Monica Stynchula, a member of the Florida Telehealth Advisory Council and founder of ReunionCare, a digital platform for managing seniors’ care, said the biggest barrier to telemedicine is lack of universal broadband access.

The Trump administration has loosened restrictions on insurance coverage for telemedicine so doctors’ offices are able to bill for virtual appointments just as they do for office appointments. But some patient advocates worry that barriers still remain for seniors, one of the populations most vulnerable to COVID-19.

Telemedicine helps avoid possibly risky in-person visits, but access to the technology (including smartphones, Wi-Fi, and broadband), the ability to operate the technology, and cognitive or age-related impairment may affect the ability to take advantage of virtual visits.

While 96 percent of American adults use smartphones, almost half of Americans over the age of 65 still don’t have one, and nearly half lack broadband access, according to a Pew Research study conducted last year.

While there are seniors who function fully and are very interested in new technology and pride themselves on keeping up with millennials there are portions of the demographic with cognitive decline and/or physical limitations in assisted living or skilled nursing facilities. This population requires caregivers who also require training in telehealth and remote monitoring.

The entire health ecosystem needs the training to practice 21st Century medicine

“We’re seeing insurers clearing a lot of the barriers out of the way for this, but that last part, making sure that users are able to use the services, that may be the most time-consuming part of this,” said AARP Florida spokesman David Bruns.

Researchers share concerns about the ease of use of some apps.

“Now would be a time to think about how to create technologies that are universally accessible, regardless of age, regardless of socioeconomic status, racial or ethnic background, and also (to think) about those seniors or individuals where English is not their primary language,” said Uchechi Mitchell, an assistant professor at the University of Illinois at Chicago who focuses on racial and ethnic health disparities and aging.

In Florida, where almost 500,000 seniors had limited English proficiency as of 2018, this is even more of a concern.

Mercedes Carnethon, vice chair of the department of preventive medicine at Northwestern University’s medical school, said that without improvements to apps’ interfaces or access to devices such as iPads that enable video visits, patients may resort to phone appointments, but that means doctors lose the ability to check seniors’ energy levels, skin and eye brightness and mobility, for example.
“When we talk about frailty and looking at muscle function, you know, how many chair stands can you do? Well, suddenly, if you have an iPad, you could set that iPad down and you could watch on video, this older adult stand up and sit down unaided, repeatedly, and you could do some of these functional tests and witness them in real time,” she said. “You can’t do that on the phone.”

Carnethon added that telehealth may help to eliminate race-based disparities in health outcomes for seniors, such as diabetes, high blood pressure and COVID-19, by making it easier for doctors to monitor patients’ symptoms from home.

In practice, however, Florida-based doctors and patients have faced roadblocks in implementing the technology. Dr. Mark Moseley, chief clinical officer at USF Health in Tampa, said that while USF was able to set up a telehealth infrastructure within a week in March, it has conducted only about 60,000 telehealth appointments, out of the approximately 85,000 scheduled since then.

“What we learned pretty early on is that we had to call before their appointment,” he said. He said that staff would learn on these calls that some seniors lacked reliable internet access, devices or technical knowledge to set up a video appointment, so follow-up visits would be converted to phone calls.

The process requires an intermediary, someone on site who sets up the calls.
There are intermediaries that also fulfill this function, independently or part of a portal, health information exchange, such as Reunion Care. 

Lawmakers cleared the way for telemedicine, but seniors need access, training

First Person to Be Reinfected with COVID-19 Recorded in Hong Kong

Can I get Coronavirus more than once? That is a common question.  Yes.  This story from Hong Kong elaborates on your question.   

In many ways Coronavirus acts like most viruses. It's the mechanism of action however is quite different from an ordinary "respiratory virus'. It is not a true respiratory virus although it has been channeled into the 'influenza' family.

Like other viruses, it takes the immune system about 4 weeks to produce measurable antibodies, protective or not. During this incubation period, the immune system is triggered and specific T cells (specialized lymphocytes) are released from lymph nodes, spleen, and bone marrow.  T cells have a memory from previous foreign antibodies and the new agent is sensed. The immune factory begins to 'pump out" the correct T cells to attack foreign antibodies. In HIV the virus attacked the CD4 T-cells destroying it's the capability to multiply and produce anti-HIV antibodies.

It does not appear that Coronavirus attacks T-cells.

First proven case of reinfection

The World Health Organization (WHO) stated that there's no immediate need to jump to any conclusions on the basis of one patient, per the BBC's report.

Hong Kong scientists observing the patient in question have noted that the two strains of the virus are different.

The report on the matter, written by Hong Kong University scientists and shared on Twitter, explained how the man in his thirties spent 14 days in hospital when he was first diagnosed with COVID-19 where he recovered. Following this, during a screening at the airport, he tested positive once again for the virus, despite being asymptomatic. 

 













First Person to Be Reinfected with COVID-19 Recorded in Hong Kong

Stroking Out While Black—The Complex Role of Racism | Cerebrovascular Disease | JAMA Neurology | JAMA Network

America is in the midst of a racist revolution, specifically systemic racism built into the American way of life.

Physicians have been aware of this fact for over one hundred years.  People of color have been aware of and subject to the laws of systemic racism for centuries.

Just this week the JAMA Neurology published an academic article about "Stroking Out While Black-The Complex Role of Racism."

The killing of George Floyd, an unarmed 46-year-old Black man by a White police officer in Minneapolis, led to widespread protests against police brutality. Beginning with a focus on law enforcement reforms, the protests grew in diversity and objective, evolving into a broader call to end institutionalized racism. For the first time in history, a diverse, global coalition came together to protest injustice in the societal treatment of Black lives. Perhaps it was the collision of George Floyd’s horrific death with the disproportionate and egregiously high death rates and coronavirus disease 2019 infection rates within communities of color in the US that fueled this movement. Of note, precursors of change, such as the diversity, inclusion, and equity initiatives being spawned in all major sectors (economic, education, health), hold out hope for meaningful progress. This Viewpoint highlights the complex role of racism in stroke and suggests a framework for understanding its effects.

The same may be said for the systemic disparity in health care for people of color, African American, Latino, and Native Americans.  Each group has its own issues regarding health and wellness.

Native Americans in particular are isolated often in remote areas with a paucity of health institutions, although served by the Indian Health Service.  The incidence of infectious disease, chronic illness, especially diabetes, obesity, and hypertension is much higher than in white populations.

Levels of Racism Theoretical Framework

The Levels of Racism framework delineates 3 interacting levels of racism to guide the development of interventions aimed at reducing racial differences in health outcomes.1 These include institutionalized or structural racism, personally mediated racism, and internalized racism.1 Institutionalized racism occurs when access to goods, services, and opportunities is influenced by race.1 It is also referred to as structural racism owing to its codification in organizational practice and policy, to the extent that it becomes the normative behavior—a cultural disease—without the presence of a specific transgressor. Personally mediated racism is prejudice arising from conditioned assumptions about a person’s intentions and abilities, based on race, causing implicit and explicit bias.1 Internalized racism is a by-product of structural racism and personally mediated racism, reflecting the total capitulation of the individual’s self-worth and self-esteem. It occurs when people accept racist beliefs about their own abilities and human value.1

Social Determinants of Health

Social determinants of health are the conditions in which we are born, live, learn, work, and play and their impact on our health. Differences in social determinants are linked to wealth status and drive the powerful association between a person’s zip code and life expectancy. But these conditions, operating across the socioecological spectrum of human life, are not only influenced by socioeconomic status but also by levels of racism. They include upstream factors related to health outcomes, such as housing conditions, school quality, environmental conditions, employment opportunities, access to healthy foods, and access to quality health care, all of which may be influenced by racial inequities and moderate the downstream biological processes responsible for health outcomes.

Stroke Disparities

A 2003 Institute of Medicine report,2 entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” provided a compelling body of research highlighting health care injustices associated with greater mortality among Black patients. These included lower quality of health services and a lower likelihood to receive appropriate medical procedures among Black vs White US citizens.2 Poorer stroke outcomes for Black Americans compared with their White counterparts have persisted for more than 50 years. For example, Black individuals are twice as likely to die of stroke than White individuals, and this disparity is not entirely explained by differences in the prevalence of traditional risk factors (as defined by the Framingham Stroke Risk Function). Indeed, data from Reasons for Geographic and Racial Differences in Stroke (REGARDS) showed that only 40% of the Black-White incidence disparity is attributable to differences in the prevalence of traditional stroke risk factors and that the source of the outstanding 60% remains unclear.3 The REGARDS investigators suggest that this excess disparity may be driven by differences in risk factor control, the differential impact of risk factors by race and nontraditional risk factors, such as for physical inactivity, diet, and psychosocial factors, including depression and discrimination.3 Others have gone a step further by tracing stroke disparities to historical slavery, racism, and segregation.4 This active legacy of slavery manifests itself in the structural inequities of American society. They cause chronic repetitive, socially structured stressors shown to elicit physiological responses associated with cardiovascular disease and premature death. Indeed, a growing body of research regarding these physical consequences of social inequality referred to as the “weathering hypothesis,” shows that its physiological responses can be measured using markers of allostatic load.

Structural Racism and Stroke

Social determinants of health are riddled with race-based inequity due to the role of racial discrimination in resource allocation that have lingered since the US government’s redlining policies. These inequities are not only remnants of slavery and de jure segregation, but also related to the widespread de facto segregation in the US today. Evidence from US Census data suggests that, while the US has become more diverse, segregation has not appreciably improved since the era of Jim Crow. The separate social worlds between Black and White individuals are driven in part by income, preference, the absence of integrated experiences to help break the cycle of preference, and discriminatory practices, such as racial steering in which real estate brokers “steer” prospective homebuyers toward or away from certain neighborhoods based on their race. Consequently, Black individuals are concentrated in neighborhoods excluded from mainstream resources. It is why the variability of school quality across neighborhoods correlates with their racial composition. Such area deprivation, captured by economic, educational, and other environmental inequalities, is associated with worse mortality. Although beyond the purview of neurologists, these conditions may be drivers of stroke risk factors, such as smoking, obesity, hypertension, and type 2 diabetes.

Personally Mediated Racism and Stroke

This form of racism influences the decision-making of policymakers and members of governing bodies responsible for resource development and allocation, contributing to structural racism and its indirect effects on health. But personally mediated racism is also directly toxic to the health of those who experience it. It can be captured and quantified by validated scales, such as the Everyday Discrimination Scale,6 a measure of subjective experiences of discrimination. Examples of daily race-based indignities are itemized on this measure and range from microaggressions (eg, being treated as if you may be dishonest or as if people may be afraid of you, or receiving poorer service than others) to profiling and police brutality. While many of the experiences described in the measure appear minor, their sheer volume and chronicity have harmful consequences, including hypertension, higher levels of inflammation, and premature mortality.6 Moreover, even the recall of these experiences, a feature of rumination, produces adverse blood pressure responses comparable with those that occurred when the person was exposed.7

Internalized Racism and Stroke

Internalized racism and the resulting self-devaluation, self-rejection, engagement in risky health practices, and hopelessness1 has been linked to nontraditional stroke risk factors. These include depression, anxiety disorders, and several maladaptive behaviors in addition to cardiovascular disease.

The hydra-headed disadvantage of being deprived and a Black individual supports the need to include racism as a distinct construct of health disparities. Beyond social determinants of health, the insidious and paroxysmal health effects of racism directed at Black people, and which begins early in life, maybe underestimated, potentially explaining some of the excess Black-White stroke disparities observed. We call for increased funding and research that expands the use of an “equity lens” in the design and evaluation of stroke interventions and the role of racism in stroke outcomes. Promising areas of study include an examination of racism’s vascular effects on stroke risk and on differences in blood pressure control.

Stroking Out While Black—The Complex Role of Racism | Cerebrovascular Disease | JAMA Neurology | JAMA Network

Employers expect to boost virtual care offerings, survey finds | Healthcare Dive

Large employers expect to pay more than $15,500 per employee for health coverage next year, 5.3% higher than the $14,769 expected this year, according to an annual survey from nonprofit Business Group on Health. That's slightly up from the 5% increase employers estimated in each of the previous five years. 

Employers are increasingly welcoming virtual care options. About 80% of respondents said they believe telehealth will play a significant role in how care is delivered in the future, compared with 64% in 2019 and 52% in 2018. More than half said they will offer more virtual care to employees next year.

Employers also plan to expand access to virtual mental health and emotional well-being services. More than 90% said they will offer telemental health services, and 54% plan to lower or waive those costs in 2021.

Insight:

Six months into the pandemic, insurance companies are reporting record profits as Americans continue delaying routine in-person care. Many have turned to telehealth services or stopped receiving preventive and elective care altogether, making the exact cost employers will pay for workers' health coverage "a moving target" over the next few years, Ellen Kelsay, president, and CEO of the group said.

While the increased costs of treating pandemic patients, the. the pandemic caused patients to defer routine care, or even see their physician for possibly serious conditions, such as chest pain. After the acute wave of. coronavirus emergency visits, emergency rooms became empty. Patients are still wary of hospitals and doctors' offices.

Patient-provider encounter trends have stabilized, but remain significantly lower than before COVID-19

In-person doctor visits plummeted during the start of the COVID-19 crisis in the United States, but have rebounded to a rate somewhat below pre-pandemic levels, according to a new analysis issued by The Commonwealth Fund and conducted by researchers from Harvard Medical School, Harvard University and the life sciences firm Phreesia.

According to data compiled through Aug. 1, all physician visits were down 9% from pre-pandemic levels. That's significantly improved compared to data from late March when visits were down 58%. Although the rebound got major traction beginning in late April, it began plateauing in early June, when all visits were 13% lower than normal. As of early August, in-person visits were down 16% compared to pre-COVID levels. States that are currently coronavirus hot spots are seeing bigger declines than states where the case levels are lower.

Meanwhile, telemedicine encounters have settled in at rates much higher than pre-pandemic levels. However, they still make up just a fraction of patient-provider encounters for care. As of the start of this month, they comprised 7.8% of all such encounters. That's compared to a peak of 13.8% in the latter part of April. Prior to COVID-19, they were only 0.1% of all visits.

On another note:

The use of telehealth services has skyrocketed since the Trump administration broke down regulatory barriers to access early into the pandemic.

In the week ended March 7, only 11,000 elderly and disabled Americans in Medicare used telehealth. By the week ended April 25, that had snowballed to 1.7 million Medicare beneficiaries.

But providers who invested heavily in those services and the companies that furnish them are dependent on those regulations to make or break future use.

AHA said it was pleased with President Donald Trump's Aug. 3 executive order to improve telehealth access in rural communities through a new payment model for rural hospitals and accountable care organizations that will use upfront and capitated payments.

And while CMS' 2021 physician fee schedule draft also released earlier this month offers additional telehealth flexibilities, it's still not enough to ensure continued virtual care access, according to the hospital lobby.

CMS' proposal notably excluded payment for audio-only telehealth visits, which AHA strongly recommends it provide.

AHA also recommends allowing annual beneficiary consent to virtual treatment to be obtained at the same time, not necessarily before, services are provided. Hospitals should retain the ability to capture diagnoses impacting risk adjustment scores through telehealth visits too, according to AHA.

The 2021 PFS proposal does include the permanent addition of nine new telehealth codes, and 13 will be covered through the calendar year in which the public health emergency ends, to give physicians a chance to deliver services virtually before CMS decides whether to permanently allow them.

Other proposed changes from CMS include allowing Medicare providers to conduct evaluation and management home visits for established patients virtually, allow an emergency room E/M virtual visit for minor to moderately severe health issues and expand some telehealth services similar to those already covered by Medicare, like for group psychotherapy or care for patients with cognitive impairment.

The administration has viewed telehealth favorably, launching a pledge to "Embrace Technology to Advance America’s Health" on Wednesday in an effort to "reassure patients, providers, and payers that telehealth is here to stay and will be covered over the long term."

The pledge calls on commercial insurers to commit to expanding flexible and affordable telehealth options, and on providers to accelerate the adoption of telehealth services, though it's still unclear exactly how far CMS will go to help facilitate those expansions long-term.

Employers expect to boost virtual care offerings, survey finds | Healthcare Dive

US FDA announces emergency authorization for convalescent plasma to treat Covid-19

The FDA said more than 70,000 patients had been treated convalescent plasma, made using the blood of people who have recovered from coronavirus infections.  

On Sunday, a source who is close to the White House Coronavirus Task Force told CNN the FDA had reviewed additional data to inform its impending EUA decision. This official has not personally reviewed the data. They added the FDA is under no obligation to consult anyone outside the agency about its decision.  (they are the buck stops here agency for pharmaceuticals, and their protocols are rigid and sacrosanct) More about that later in one of my next blogs.

Researchers hope this old-fashioned treatment will work for coronavirus.  Convalescent plasma is taken from the blood of people who have recovered from Covid-19. At the end of March, the FDA set up a pathway for scientists to try convalescent plasma with patients and study its impact. It has already been used to treat more than 60,000 Covid-19 patients. However, like blood, convalescent plasma is in limited supply and must come from donors. And while there are promising signals from some studies, there is not yet randomized clinical trial data on convalescent plasma to treat Covid-19. Some of those trials are underway.

Impact of an EUA

The New York Times reported last week an FDA emergency use authorization for blood plasma to treat Covid-19 was on hold after NIH officials intervened. The hold came after a group of federal health officials -- including National Institutes of Health Director Dr. Francis Collins, National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci and Dr. H. Clifford Lane, NIAID deputy director -- stepped in to argue the emerging data on the treatment was too weak, the Times reported Wednesday, citing two senior administration sources.

n response to CNN, Dr. Anand Shah, FDA's deputy commissioner for medical and scientific affairs, said he couldn't comment but suggested the NIH was out of line.

"In general, NIH is not involved in the decision-making process at the FDA and does not have the entirety of confidential data the FDA uses to make these regulatory decisions," Shah said in a statement sent to CNN.

"We take seriously our mandate to follow the data and science on the review of medical products to prevent or treat COVID-19 based on the agency's established legal and regulatory standards," Shah added, saying the FDA appreciated the work of NIH and would collaborate with its sister agency.

A senior administration official told CNN's Jim Acosta on Sunday the expected emergency use authorization announcement is an important development.

Comment:  It is surprising. that FDA would make a decision without statistics from the CDC and Anthony Fauci M.D. who heads up the  Coronavirus task force. The reporting is most likely inaccurate.

Attacks on Public Health Officials During COVID-19 |

The unimaginable seems to be spreading almost as fast at Covid-19.  Public health officials have reported death threats to themselves and/or their families

(On June 24, 2020, California Governor Gavin Newsom remarked on a disturbing phenomenon: health officers are “getting attacked, getting death threats, they’re being demeaned and demoralized.”1 At least 27 health officers in 13 states (including Nichole Quick of Orange County in southern California, Ohio Health Director Amy Acton, and West Virginia Health Officer Cathy Slemp) have resigned or been fired since the start of the coronavirus disease 2019 (COVID-19) pandemic. Across the US, health officers have been subject to doxing (publishing private information to facilitate harassment), angry and armed protesters at their personal residences, vandalism, and harassing telephone calls and social media posts, some threatening bodily harm and necessitating private security details.1) 

The present harassment of health officials for proposing or taking steps to protect communities from COVID-19 is extraordinary in its scope and nature, use of social media, and danger to the ongoing pandemic response. It reflects a misunderstanding of the pandemic, biases in human risk perception, and a general decline in public civility. Some of these cases resist easy fixes, but elected officials and health officials can take certain actions to help address the problem.

Today’s increasingly routine harassment and threats against health officials have much in common with growing resistance to childhood vaccination. Since the 2015 measles outbreak that focused attention on vaccine policy, individuals opposed to vaccination mandates have attacked health officials and legislators online or in-person in Oregon, Washington, New York, New Jersey, and Colorado. For example, in 2019, protesters threw blood onto California legislators from the Senate gallery; State Senator Richard Pan received death threats and was physically assaulted. Some of the same groups, joined by other individuals frustrated with public health officials, are now actively resisting efforts to require masks, reinstitute business closures, and prepare for COVID-19 vaccination, jeopardizing the eventual acceptance of vaccines.2

What explains the unprecedented hostility to public health officials during COVID-19? Although acceptance of public health orders for COVID-19 is often framed as a “red vs blue” issue, even libertarians accept that liberty may be curtailed when its exercise harms others. However, people’s ability to perceive such harm can be undermined by decisional biases known to affect human thinking.3 Omission bias creates a preference for risks associated with doing nothing (ie, letting the virus spread) over those linked to affirmative acts, such as public health orders. Distance bias and optimism bias may be operating for those who believe COVID-19 will not seriously affect them or their loved ones. In an information space flooded with conflicting information, confirmation bias allows some people to dismiss evidence that does not comport with their preexisting beliefs.

Today I attended a meeting online with Sanjay Gupta MD (CNN correspondent) and Anthony Fauci M.D. a member of the Task Force Coordinators for the White House.  He mentioned that he hired security consultants to assure the safety of his family.  Fauci has been working 20 hour days for several months. He does not seem unusually stressed by events looking youthful and bright-eyed despite his birthdays.  He is three years older than I am and looks ten years younger. Sanjay Gupta asked how he does it.  Fauci replied it was due to the extensive every other night and weekend routines of internship and residency back in the day before regulations were put in place to prevent such "abuse" claimed by today's trainees.  Fauci seemed non-plussed about current events, perplexed about today's attitudes about government and scientists. Sanjay Gupta seemed worried and asked if he (Fauci) had a succession plan for his eventual exit from NIH, he went on to say as long as he was at the top of his game, there were no plans to exit the NIH, adding his wife would guide him when to pack it in.  

Fauci has no danger of being fired having been selected and appointed by a committee of peers at NIH and national scientific experts. Trump no longer asks Fauci nor Dr. Birx to appear with him to bolster his weak positions.

Despite the pandemic I know we would be much worse off had Fauci not been present. It is all relative, we have to work with what we have, and have no wishful thinking, we should have done this or that.   The present situation is like the perfect storm a collision of events that we must ride out to survive.  The present political division adds fuel to the storm.  The captain of the ship is indisposed, and the executive officers must take over.  We do have very competent experts in many departments, and loyalties to the captain aside intelligent people must ignore bad commands.  That is a major problem as well as conflicting orders from governors, mayors, and other local representatives. 

Fauci's plans include the rapid timely delivery of test logistics and vaccines. Although he indicated he hopes he will not be around for the next pandemic he assured us all that there would be another pandemic as sure as this one was predicted.  He emphasized the importance of lessons learned and investing in technology, and logistics to be ready for the next one.





Attacks on Public Health Officials During COVID-19 | Infectious Diseases | JAMA | JAMA Network

My Child has Acute Appendicitis. Should We Operate ?

This is a modern-day study relevant to many parents who bring their child to an emergency room. Almost every parent knows the signs and symptoms of acute appendicitis, right lower quadrant pain, nausea and vomiting, and fever.  

In the emergency department, the physicians formulate a quick differential diagnosis to determine the alternatives.  Some viral infections cause similar or even identical symptoms and signs.

The appendix is a normal part of the digestive tract located at the junction of the small intestine where it enters into the ascending colon. Along with symptoms of acute appendicitis, the signs of right lower quadrant point tenderness strengthen the possibility of acute appendicitis. Viral gastroenteritis is very common in children and can mimic appendicitis.

A ruptured appendix can lead to an abscess or diffuse peritonitis, which could lead to sepsis be a life-threatening complication. A one time this decision was critical when powerful antibiotics were not always readily available.  Complications and disability were much more common.

There have been articles contrasting the safety and efficacy of nonsurgical treatment from 2014. More recently in 2017 a study revealed some changes in outcomes. The 2017 group included over 1000 patients enrolled in a randomized group of patients assigned by the physicians doing the study.  Although making this study more accurate it created difficulties for parents to enroll their children.

How to find McBurney's Point

 Conclusions

Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was a substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not me

Limitations

This study has several limitations. First, the results of this study are only applicable to a limited percentage of children who present with acute appendicitis. Due to the inclusion-exclusion criteria, only 19.3% of patients with appendicitis treated at the participating sites qualified for this study. These criteria were intentionally selected based on the available data in the literature related to the safety and efficacy of nonoperative management for children and to ensure consensus across the participating institutions. Also, all the participating sites are tertiary children’s hospitals whose patient population may include a lower proportion of children meeting eligibility criteria. Second, the nonrandomized treatment allocation potentially allows for treatment selection bias, where treatment may be affected by participant characteristics, and those choosing nonoperative management differ, on average, from those choosing surgery. However, several steps to minimize this were taken including the use of a standardized enrollment script and decision aid, specific inclusion and exclusion criteria, standardized treatment protocols and algorithms, and obtaining agreement to participate from all participating surgeons prior to beginning the study. Furthermore, treatment decision-making in clinical practice is affected by the biases of patients, families, and surgeons, suggesting that a patient choice treatment allocation may be more reflective of current practice. Moreover, robust inferential methods to aid in accounting for treatment confounding bias were used. Third, the generalizability of the results may be limited by the substantial rates of incomplete follow-up.

ref:

Cash  CL, Frazee  RC, Abernathy  SW,  et al.  A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis.   J Am Coll Surg. 2012;215(1):101-105. doi:10.1016/j.jamcollsurg.2012.02.024PubMedGoogle Scholar

5.

Kocataş  A, Gönenç  M, Bozkurt  MA, Karabulut  M, Gemici  E, Alış  H.  Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis: a prospective randomized clinical trial.   Ulus Travma Acil Cerrahi Derg. 2013;19(3):200-204. doi:10.5505/tjtes.2013.58234PubMedGoogle Scholar

6.

Minneci  PC, Mahida  JB, Lodwick  DL,  et al.  Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis.   JAMA Surg. 2016;151(5):408-415. doi:10.1001/jamasurg.2015.4534

ArticlePubMedGoogle Scholar

7.

Salminen  P, Paajanen  H, Rautio  T,  et al.  Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial.   JAMA. 2015;313(23):2340-2348. doi:10.1001/jama.2015.6154

ArticlePubMedGoogle Scholar

8.

Fitzmaurice  GJ, McWilliams  B, Hurreiz  H, Epanomeritakis  E.  Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence.   Can J Surg. 2011;54(5):307-314. doi:10.1503/cjs.006610PubMedGoogle Scholar

Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis | Emergency Medicine | JAMA | JAMA Network

https://jamanetwork.com/journals/jama/fullarticle/2768929?guestAccessKey=3596f1a4-2e25-4247-a1f5-2fba7edb444e&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=081120

The Pandemic Could Be Worse in the Winter of 2020-21 - The Atlantic

       

Here in Southern California, we are experiencing a rather mild summer. We have had only one week of 100+ weather. Climate change does not necessarily mean warming. What we can expect is wider and more extreme changes in weather.

It is not too early to think about the coming fall and winter while hiking, camping, sailing, surfing, biking, or whatever your outdoor sport may be.  

It is not hard to distance and avoid closed spaces in spring, summer, and fall.  Covid-19 will necessitate some modifications in lifestyle.  Many Southern Californians categorize cold weather when the temperature gets below 60 degrees, and there is a mist or fog.  The lack of sunshine causes some Californians to shelter in place. (ie, inside)

Throughout the pandemic, one lodestar of public-health advice has come down to three words: Do things outside. For nearly five months now, the outdoors has served as a vital social release valve—a space where people can still eat, drink, relax, exercise, and worship together in relative safety.

Later this year, that precious space will become far less welcoming in much of the U.S. “What do you do when nobody wants to go to the beach on some cold November day?” Andrew Noymer, a public-health professor at UC Irvine, said to me. “People are going to want to go to bowling alleys and whatnot, and that’s a recipe for disaster, honestly—particularly if they don't want to wear masks.”

People will have to get used to wearing a mask. If you insist on going into closed spaces, wear a mask, and practice distancing. Take sanitizer with you, wash, wash,  wash, and don't be timid about cleaning your space. Think positive and use it as a fashion statement, with colors, artwork, and statements. Humorous captions bring smiles. Emoji may become the next think in masks.  LEDs and Gif's may be the next rage. Think positive, do not attach political ambition with your facial disguises.  We are in a divisive time in America.  Don't make it worse.  Your mask is not going to change an election.  In fact, by November the election will be over.

In recent interviews with Noymer and other experts, I caught glimpses of the winter to come, and what I saw was bleak, even compared with what Americans have already experienced. The winter will be worse—for the quality of daily life in America and, possibly, for the course of the pandemic itself.

“There really is no easy way to socialize during late fall [and] winter in large parts of the country if you're not doing it outside,”  

                

There are ways to extend the outdoor time by adopting cold-weather gear. People in Northern climates do it all the time. Wearing layered clothing, parkas and slacks designed for colder climates.  Minnesotan's go ice fishing, wearing ear protection and gloves make outdoor sports and activities doable. They do not give up outdoor athletics, adopting cross country skiing, outdoor skating. Ashish Jha, the director of the Harvard Global Health Institute, told me. “Could I have people over my house for two hours on a Sunday morning in December? Barring really good testing, probably not.”

That’s because the risk of spreading the coronavirus is heightened in enclosed spaces. Outdoors, there is enough air for the virus to be “rapidly diluted,” as well as the helpful “virus-killing action of sunlight,” explains Linsey Marr, an engineering professor at Virginia Tech. Indoors, she told me, “the virus can build up” and be more easily inhaled, and “if space is heated, it can lead to dry air,” which is more hospitable to the virus.

The experts I consulted were very concerned about the risks of indoor gatherings, but mentioned several measures that could make them safer if people decide to have them anyway: stay at least six feet apart, wear a mask, wipe down frequently touched surfaces, meet in a building with sufficient filters in its ventilation system, use a portable air purifier and a humidifier, and stay clear of crowded rooms. (If all of that sounds onerous, it’s because spending time indoors with people you don’t live with is really risky—and better avoided if you can help it.)

Experts have emphasized sanitizing, distancing, and avoiding indoor crowds.  However, they have not addressed other aspects of prevention.  Early prevention emphasized the prevention of infection by masking.

Nothing much was said about aerosolizing the virus.  Improving ventilation is a means of dilution, and HEPA filtering can reduce viral exposure.  Opening a window or increasing room airflow

There is a big dispute in the scientific community, however, about both the size and the behavior of these particles, and the resolution of that question would change many recommendations about staying safe. Many scientists believe that the virus is emitted from our mouths also in much smaller particles, which are infectious but also tiny enough that they can remain suspended in the air, float around, be pushed by air currents, and accumulate in enclosed spaces—because of their small size, they are not as subject to gravity’s downward pull. Don Milton, a medical doctor and an environmental-health professor at the University of Maryland compares larger droplets “to the spray from a Windex dispenser” and the smaller, airborne particles (aerosols) “to the mist from an ultrasonic humidifier.” Clearly, it’s enough to merely step back—distance—to avoid the former, but distancing alone would not be enough to avoid breathing in the latter.

The disagreement got heated enough that earlier this month, hundreds of scientists around the world signed a letter, pleading with the WHO to acknowledge these smaller particles as an extra mode of transmission and to update its guidelines accordingly. Some experts I spoke with told me that they had been trying to convince the WHO to take the possibility of airborne transmission since March and that the open letter was borne out of frustration about lack of progress. Signatories who study aerosols—the smaller, floating particles—including professor Linsey Marr of Virginia Tech and Jimenez, told me that they don’t disagree with the idea that transmission at close range represents the most risk, as per the WHO and CDC guidelines. But they disagree that the dominance of close-contact transmission implies that ballistic trajectories or larger respiratory droplets are the overwhelming modes of transmission. In their view, even some portion of that close-contact transmission is likely due to aerosols, and many experts told me that they think even particles bigger than the WHO’s definition of respiratory droplets (larger than 5-10 microns in diameter) can float for a bit. In response, the WHO published a scientific brief on July 9 acknowledging the possibility of airborne transmission but still concluding that COVID-19 is “primarily transmitted” between people through respiratory droplets and touching and that the  question needs “further study.”

Anyone wanting to learn more about airborne disease must read the article in the Atlantic Magazine

Now is the time to give individual thought to the coming winter season.  Remember winter clothing goes on the shelves in August and September.  Preparation may give you a more enjoyable winter.

The Pandemic Could Be Worse in the Winter of 2020-21 - The Atlantic

Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial | JAMA | JAMA Network

Key Points

During the early days of the Coronavirus pandemic from January 2020 through March 2020, there was confusion, misinformation and disinformation coming from the media, China, CDC, and the White House.  There were only two credible sources for information Dr. Anthony Fauci and Dr. Deborah Birx. Numerous polls indicated trust in Fauci and Birx.  The White House frequently gave contradictory statements during live broadcasts.

One study has appeared regarding a potential treatment for acute disease

What is the effect of convalescent plasma therapy added to standard treatment, compared with standard treatment alone, on clinical outcomes in patients with severe or life-threatening coronavirus disease 2019 (COVID-19)?

This randomized clinical trial that included 103 patients and was terminated early, the hazard ratio for time to clinical improvement within 28 days in the convalescent plasma group vs the standard treatment group was 1.40 and was not statistically significant.

Meaning  Among patients with severe or life-threatening COVID-19, convalescent plasma therapy added to standard treatment did not significantly improve the time to clinical improvement within 28 days, although the trial was terminated early and may have been underpowered to detect a clinically important difference.

Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial | JAMA | JAMA Network

References

1.

Wang  D, Hu  B, Hu  C,  et al.  Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.   JAMA. 2020;323(11):1061-1069. doi:10.1001/jama.2020.1585

ArticlePubMedGoogle ScholarCrossref

2.

Wu  Z, McGoogan  JM.  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648

ArticlePubMedGoogle ScholarCrossref

3.

Garraud  O, Heshmati  F, Pozzetto  B,  et al.  Plasma therapy against infectious pathogens, as of yesterday, today and tomorrow.   Transfus Clin Biol. 2016;23(1):39-44. doi:10.1016/j.tracli.2015.12.003PubMedGoogle ScholarCrossref

4.

Cheng  Y, Wong  R, Soo  YO,  et al.  Use of convalescent plasma therapy in SARS patients in Hong Kong.   Eur J Clin Microbiol Infect Dis. 2005;24(1):44-46. doi:10.1007/s10096-004-1271-9PubMedGoogle ScholarCrossref

5.

Yeh  KM, Chiueh  TS, Siu  LK,  et al.  Experience of using convalescent plasma for severe acute respiratory syndrome among healthcare workers in a Taiwan hospital.   J Antimicrob Chemother. 2005;56(5):919-922. doi:10.1093/jac/dki346PubMedGoogle ScholarCrossref

6.

Arabi  YM, Hajeer  AH, Luke  T,  et al.  Feasibility of using convalescent plasma immunotherapy for MERS-CoV infection, Saudi Arabia.   Emerg Infect Dis. 2016;22(9):1554-1561. doi:10.3201/eid2209.151164PubMedGoogle ScholarCrossref

7.

Kraft  CS, Hewlett  AL, Koepsell  S,  et al; Nebraska Biocontainment Unit and the Emory Serious Communicable Diseases Unit.  The use of TKM-100802 and convalescent plasma in 2 patients with Ebola virus disease in the United States.   Clin Infect Dis. 2015;61(4):496-502. doi:10.1093/cid/civ334PubMedGoogle ScholarCrossref

8.

Shen  C, Wang  Z, Zhao  F,  et al.  Treatment of 5 critically ill patients with COVID-19 with convalescent plasma.   JAMA. 2020;323(16):1582-1589. doi:10.1001/jama.2020.4783

ArticlePubMedGoogle ScholarCrossref

9.

Duan  K, Liu  B, Li  C,  et al.  Effectiveness of convalescent plasma therapy in severe COVID-19 patients.   Proc Natl Acad Sci U S A. 2020;117(17):9490-9496. doi:10.1073/pnas.2004168117PubMedGoogle ScholarCrossref

10.

Recommendations for Investigational COVID-19 Convalescent Plasma. US FDA. Published May 1, 2020. Accessed May 26, 2020. https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/recommendations-investigational-covid-19-convalescent-plasma

11.

Position Paper on Use of Convalescent Plasma, Serum or Immune Globulin Concentrates as an Element in Response to an Emerging Virus. In: Network WBR, ed. 2017. Accessed April 18, 2020. https://www.who.int/bloodproducts/brn/en/

12.

National Health Commission of the People’s Republic of China. Covid-19 treatment plan (trial version 6). Accessed April 20, 2020. http://www.nhc.gov.cn/yzygj/s7653p/202002/8334a8326dd94d329df351d7da8aefc2/files/b218cfeb1bc54639af227f922bf6b817

13.

Wang  Y, Zhang  D, Du  G,  et al.  Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial.   Lancet. 2020;395(10236):1569-1578. doi:10.1016/S0140-6736(20)31022-9PubMedGoogle ScholarCrossref

14.

Kleinbaum  DG. Evaluating the proportional hazards assumption. In:  Survival Analysis. Statistics in the Health Sciences. Springer; 1996:183-184.

15.

Daily update on covid-19. National Health Commission of the People’s Republic of China. Accessed May 24, 2020. http://www.nhc.gov.cn/xcs/yqtb/202003/f01fc26a8a7b48debe194bd1277fdba3.shtml

16.

Annual SHOT (Serious Hazards of Transfusion) Report 2018. Published July 2019. Accessed May 25, 2020. https://www.shotuk.org/

17.

Beigel  JH, Aga  E, Elie-Turenne  MC,  et al; IRC005 Study Team.  Anti-influenza immune plasma for the treatment of patients with severe influenza A: a randomised, double-blind, phase 3 trial.   Lancet Respir Med. 2019;7(11):941-950. doi:10.1016/S2213-2600(19)30199-7PubMedGoogle ScholarCrossref

18.

Soo  YO, Cheng  Y, Wong  R,  et al.  Retrospective comparison of convalescent plasma with continuing high-dose methylprednisolone treatment in SARS patients.   Clin Microbiol Infect. 2004;10(7):676-678. doi:10.1111/j.1469-0691.2004.00956.xPubMedGoogle ScholarCrossref

Trump signs order expanding use of virtual doctors

Trump signs order expanding use of virtual doctors

© Doug Mills

Physicians and patients sigh a breath of relief.  Telehealth, something pressed into service due to the Coronavirus pandemic has become a way of affording relief and more health care accessibility to more patients will become a standard of care

President Trump on Monday signed an executive order seeking to expand the use of virtual doctor visits, as his administration looks to highlight achievements in health care. 

The administration waived certain regulatory barriers to video and phone calls with doctors, known as telehealth when the coronavirus pandemic struck and many people were stuck at home. Now, the administration is looking to make some of those changes permanent, arguing the moves will provide another option for patients to talk to their doctors. 

The order calls on the secretary of Health and Human Services to issue rules within 60 days making some of the changes permanent. 

“Today I’m taking action to make sure telehealth is here to stay,” Trump said during a White House news briefing. 

It is unclear when any of the changes proposed by these orders will actually take effect, though, given that there are still regulatory processes that take time to play out.  There are regulations still in existence for payers to reimburse for telehealth charges after the pandemic ends. These include restrictions in urban areas, telehealth limited to established patients in a doctor's panel, and other limitations.

“In an earlier age, doctors commonly made house calls,” Centers for Medicare and Medicaid Service Administrator Seema Verma said in a statement. “Given how effectively and efficiently the healthcare system has adapted to the advent of telehealth, it’s become increasingly clear that it is poised to resurrect that tradition in modern form. Thanks to President Trump, the telehealth genie is not going back into the bottle.”

The order also calls on HHS to propose a new model that can be tested for how Medicare will pay for some health services in rural areas, with the goal of improving care in rural areas. 

Telehealth Services: What Medicare Covers

Tags:  CMS CENTERS FOR MEDICARE AND MEDICAID SERVICES DONALD TRUMP TELEHEALTH CORONAVIRUS COVID-19

https://tinyurl.com/y5rfymgq

Body mass index (BMI) is a miscalculation

 

Most of us recognize BMI as a calculation for body mass index.  Physicians like the term since it gives them a number indicating obesity.

However, BMI has ignored the weight of evolution and elementary physics according to Alan Finkel (Alan Finkel is an electrical engineer, neuroscientist, and Chief Scientist of Australia.).

It naturally got me wondering: how scientific is the BMI?

It may be a 188-year-old staple of health statistics, but modern health professionals have documented many flaws. For starters, the BMI doesn’t distinguish whether body weight comes from fat or muscle, so Michelin Man and the Terminator might have the same BMI despite their very obvious differences in fat and muscle distribution. Neither does it factor in other key health criteria such as age, gender, or body type. For instance, people who deposit fat around their waists are at a higher risk of disease than people who deposit it on their hips and thighs.

My concern, however, is that the BMI ignores elementary physics.

The problem traces back to Lambert Adolphe Jacques Quetelet, the Belgian statistician who invented the BMI in 1830. Quetelet failed to consider the mathematics of scaling. He defined the BMI as weight divided by height squared. Note, however, that weight is proportional to volume, which is proportional to height cubed. The upshot of this is that all other things being equal, BMI varies directly with height, which it clearly should not.

For instance, observe the formula

Perhaps the fault goes back to Jonathan Swift’s wildly popular 1726 tale of Gulliver’s Travels. Swift’s giant Brobdingnagians and tiny Lilliputians could not actually exist. 

For example, consider a giant twice as tall as myself but with exactly my shape and looks. If the giant was standing on a beach with no other objects in sight, a far-off observer could not tell that he was not me. Because his mass would be proportional to my height cubed, my double-height doppelganger would weigh eight times more than me. However, the cross-sectional area of his legs would be proportional to my height squared, so they would be only four times stronger. Those poor bones! They would be over-stressed by carrying eight times the weight. My giant double would collapse under his own weight. Now create a version of me half my height. He would weigh one-eighth of what I weigh, but his leg bones and muscles would be twice as strong as they needed to be. 

Nature understands this, which is why elephants look like elephants and ants like ants. The BMI formula does not share this insight. It can make tall people appear overweight when they are not. Compared with a 152 cm (five foot) individual with a ‘normal’ BMI of 22, an identically proportioned 183 cm (six foot) person would have a BMI of 26.5 – overweight.

Based on BMI ranges, most Australians are too plump: 28% are classified as obese, 35% overweight, 35% normal and a mere 2% underweight. No doubt this skewing towards being overweight reflects a genuine health problem. But it might be affected by the increase in the average height of the population since 1830. 

Fortunately for Quetelet, there were few Terminators back then to question his BMI. And fortunately for Jonathan Swift his satire was not questioned by an incurable engineer who would have pointed out that the Brobdingnagian giants, at 12 times the height of Gulliver, would have weighed more than 100 tonnes, with a BMI in the hundreds.

I don’t suggest changing the way the BMI is calculated, despite its flaws, because we would not want to throw out the past 188 years of BMI records (noting that in most cases the raw data – height and weight – will not have been kept). Instead, we could adjust the standard BMI numerical ranges for underweight, normal weight, overweight and obese based on height, and perhaps even gender and body shape.

Body mass index miscalculation - Cosmos Magazine