Telemedicine Visits: Are They Right For You During and Beyond COVID-19?

The skeptical cardiologist, like most physicians in America began converting scheduled in-person office visits to “telemedicine” visits in late March when it became clear that  COVID-19 was spreading rapidly.

It made no sense at that time to bring patients into our office for regular visits who were vulnerable and high risk, exposing them to physicians and staff who might have asymptomatic COVID-19 and vice versa.

Telemedicine made a lot of sense. As eloquently expressed by Dr. Russel Libby:

With the evolving COVID-19 pandemic and its impact on access to medical care, there is no better time to help physicians navigate and implement telemedicine into their practices and enhance their ability to care for patients. Through telemedicine, we can triage patients and help avoid unnecessary visits to health care settings, thereby reducing exposure to the COVID-19 virus and helping to keep our front lines safe, ensuring they have the resources needed to take on this immense challenge. The tools and guidelines being created now are already helping many to use telemedicine and will continue to help define its role at this moment, and shape the future of physician practice.” 

I wrote a post on March 20 (but didn’t publish it for some reason) explaining this change to patients:

Because the virus can be spread from infected individuals before they have symptoms there is a risk that patients can be infected anytime they are out in public.
Infected patients can visit the doctor’s office without any symptoms and transmit the virus to health care workers and other patients.
The perfectly healthy person sitting near you  in the doctor’s waiting room could be infected.This means you should reserve  seeing in person a doctor for when it is absolutely necessary that you be examined.

Due to the above concerns, beginning yesterday I personally began contacting all patients on my office schedule for the day.  After having a conversation with them, if  they were doing well and could delay their visit, the appointment was canceled. I encourage all physicians and patients to do everything they can to minimize unnecessary health care visits. Stop elective surgeries and screening procedures. Stop routine check-up visits.


The Rise of Telemedicine

Fortunately, due to COVID-19 CMS changed its coverage policies for telemedicine and has been reimbursing visits done utilizing video connections as if these were office visits.

For those individuals who do not have the ability to connect via video means (including Face time, WebEx, Zoom,and  Doximity) we have been utilizing telephone only visits. CMS has also ramped up reimbursement for these interactions.

In addition, I can see new patients as a telemedicine visit since CMS announced waivers on old restrictions.

CMS also announced that “the requirement for physicians to hold a license in the state in which services are rendered is waived.”

This means (as best I can determine) that if you live anywhere in the United States,  you can make a new telemedicine appointment with the skeptical cardiologist for a consultation about your cardiac condition.

Yes, now instead of emailing me at dr_pearson@icloud.com to answer your questions you can get a full consultation from the comforts of your own home.

Rules, coding, and reimbursement for billing are in flux right now but I have found CodingIntel.com to be a reliable source and this summary PDF from Woodcock and Associates to be unusually clear:

I’ve been trying to get my employers to utilize telehealth services for several years unsuccessfully. I think they make good sense for many patient situations, especially when combined with the kinds of remote patient monitoring (like Kardia Pro) have implemented with my patients.

Hopefully, now that telehealth has been expanded it will become the norm after COVID-19.

 


Telemedicine Visits Work For Many Patients

It’s been two months since we began utilizing telemedicine visit  and we have successfully flattened the curve of the epidemic.

For the most part I think the telemedicine visits have been successful in allowing me to check on the status of my patients and manage their cardiac conditions. We are typically able to get the patient to record a home blood pressure and heart rate. Many of my patients have home ECG devices (mostly Kardia) which allow us to monitor their cardiac rhythm

The video allows a rudimentary physical exam. I can tell how the patient is breathing, speaking, and answering questions. I can see any gross abnormalities of their head, neck, ears, and eyes.

One significant limitation is that  I cannot listen to their heart and lungs. In cases where patients are having difficulties that would best be assessed by a full physical exam or by an ECG  we have brought them into the office.


Reopening

On May 18 St. Louis City and County officials announced the reopening of certain businesses. Of note, hospitals and doctor’s offices weren’t mentioned in these announcements.

The CMS document on “Opening Up America Again” states:

Therefore, if states or regions have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, then they may proceed to Phase I. The Guidelines for Opening Up America Again can be found at the following link: https://www.whitehouse.gov/openingamerica/#criteria

Maximum use of all telehealth modalities is strongly encouraged.

In conversations with patients these last 2 months I have found that they have almost without exception been sheltering at home and practicing social distancing and have been very happy to conduct the visits using telemedicine.

Of course, some have elected to reschedule follow-up visits to a future time with the hope that COVID-19 will be less of an issue and these are the patients I’m not having conversations with.

In the next few weeks I will be personally contacting patients on my schedule and assessing their need and desire for an in-person office visit.

The guidance I have from CMS and from the leadership of my medical group is to continue primarily favoring telemedicine visits. However, if my patient has a strong preference for an in-person office visit or if I perceive that a physical examination, vital sign check, or ECG is essential for their proper care we will keep the in-person office visit.

I’d appreciate hearing all reader’s and patient’s thoughts on this topic so feel free to leave comments or email me at dr_pearson@icloud.com.

Virtually Yours,

-ACP

Feature Image

LDN 1471: A Windblown Star Cavity
Image Credit: Hubble, NASA, ESA; Processing & License: Judy Schmidt

Let’s Celebrate Bob Moog’s Birthday Today: Be Creative!

Robert Moog , engineer and pioneer of electronic music synthesis, was born 86 years ago on this date.

The skeptical cardiologist first revealed his love of electronic music and Bob’s Moog synthesizers in a post about the annual Moogfest music festival (sadly not held this year due to Covid-19.)

In college I became obsessed with Moog synthesizers and this obsession has only increased with age.  I was inspired by Wendy Carlos’ Switched on Bach which features her renditions of Bach pieces performed on an early modular Moog synthesizer. The glory of Bach transmuted by otherworldly Moog voices was mesmerizing.

I and my college roommate,  APOD-to-be Jerry Bonnell , purchased components from PAIA electronics, and with the assistance of electrical engineer and pi-plate-to-be Jerry Wasinger  built our  own modular synthesizer.  After my post on the delights of Asheville and the Moog Factory Museum piece was published several readers contacted me and have turned me on to other synthesizer performance pioneers including Gershon Kingsley (who has subsequently died-see obituary at end of post.)

Around the time of the 20014 Moogfest I missed due to THE FLU I acquired a small Sub Phatty Moog.

I used it in a song I created based on Phillip K. Dick’s novel Radio Free Albemuth  as the sound of the superintelligent, extraterrestrial, but less than omnipotent being (or network) named VALIS:

Valis/Sub Phatty goes wild delivering its rebellious message for the last 50 seconds and then fizzzles out.

Subsequently, I’ve acquired a duophonic (Bob Moog Tribute Edition!) Sub 37 Moog. The built-in arpeggiator/sequencer on the Sub 37 allows for some really creative rhythmic and patterned music creation. You gotta love all those flashing lights and delightful knobs just begging to be twirled!

An Email from the folks at Moog Music suggests

More Ways to Celebrate Bob

  1. Create your own music with the free Minimoog Model D iOS app.
  2. Share a memory or musical creation online using #CelebrateBob.
  3. Try your hand at this interactive Google Doodle, originally shared by Google on Bob’s birthday in 2012.
  4. Watch Hans Fjellestad’s Moog documentary.
  5. Listen to this episode of The Music History Project’s podcast.
  6. Learn more about electronic music pioneers and Moog Music’s history.
  7. Encourage creativity all around you!

So here’s to my hero, Bob Moog!

Paraphonically Yours,

-ACP

N.B. Bonnell is one-half of the astronomy picture of the day and today’s picture is cool

Ghost Fungus to Magellanic Cloud
Image Credit & Copyright: Gill Fry

N.B.2 From the NYTimes obituary:

Gershon Kingsley, a composer who brought electronic sounds into popular music and wrote the enduring instrumental hit “Pop Corn,” died on Dec. 10 at his home in Manhattan. He was 97. His daughter Alisse Kingsley announced the death. Mr. Kingsley was an early convert to the Moog synthesizer in the 1960s. He used it to create music for commercials and to orchestrate perky melodies — most notably “Pop Corn,” an instrumental originally released on Mr. Kingsley’s 1969 album “Music to Moog By.” It became a best seller and was remade (usually renamed “Popcorn”) in hundreds of versions: by Herb Alpert & the Tijuana Brass, Aphex Twin and the Muppets, among others. A 1972 version of “Popcorn” by Hot Butter made the song an international hit, and a 2005 remake for the animated character Crazy Frog became a major hit in Europe.

Source: Gershon Kingsley, Master of Electronic Sounds, Dies at 97 – The New York Times

 

Asthma, Inhaled Steroids and Covid-19

If you, like the skeptical cardiologist, suffer from asthma you may be wondering if you are at a higher risk of contracting Covid-19 or developing more severe respiratory complications from the disease once infected.

There are 25 million asthma sufferers in the United States, about 8% of the population and many of us are using as primary treatment a combination of inhaled beta-agonists (for immediate relief) and inhaled corticosteroids (ICS) (for long-term conditioning of the lung).

How are these treatments influencing our risks during the Covid-19 pandemic?

A commentary published online in Lancet Respiratory medicine suggested that there is a lower prevalence of asthma in patients with Covid-19. However, the sum of evidence from this commentary and elsewhere is insufficient to say asthma is protective.

When there is an absence of evidence, as we saw with hypertension as a risk factor and hydroxychloroquine as a treatment, the tendency of journalists is to obtain a quote from a physician who has treated patients with Covid-19 to buttress a particular argument. Quotes which say something like “we don’t know” or “there is not enough evidence right now” are highly unlikely to be published whereas anecdotal speculation is always intriguing (but often misleading.). The New York Times published this quote on the topic:

“We’re not seeing a lot of patients with asthma,” said Dr. Bushra Mina, a pulmonary and critical care physician at Lenox Hill Hospital in New York City, which has treated more than 800 Covid cases. The more common risk factors, he added, are “morbid obesity, diabetes and chronic heart disease.”

A major problem in sorting out asthma as an independent risk factor is that many papers are lumping all “chronic respiratory diseases” together which puts asthma in a bucket with chronic obstructive pulmonary disease (COPD) and interstitial lung disease like pulmonary fibrosis. There are striking differences in the demographics and prognosis of these diseases. For example, patients with COPD are older and much more likely to have smoked cigarettes, two factors clearly associated with Covid-19 risk.

In addition, asthma in older adults is highly associated with obesity, a well-recognized independent risk factor Covid-19 complications.

Among adults aged 60 and over, there was a significant trend of increasing asthma prevalence with weight status: 7.0% among normal weight adults; 9.1% among overweight adults; 11.6% among adults with obesity.

In addition, almost no data is available on asthma stratified by severity and treatment. The severe asthma patient who requires oral corticosteroids is markedly different from the mild asthmatic whose only treatment is intermittent inhaled beta-agonists.

These data, like the data on hypertension, should be taken with a grain of salt, but at a minimum, we can say there is no signal that asthma by itself increases the risk of Covid-19 infection.

Inhaled Corticosteroids and Covid-19

The authors* of the commentary in Lancet which implied asthma (and chronic respiratory disease) was protective against Covid-19 infection also concluded that

“the possibility that inhaled corticosteroids might prevent (at least partly) the development of symptomatic infection or severe presentation of COVID-19 cannot be ignored”

They cited some very preliminary data to support this contention:

in in-vitro models, inhaled corticosteroids alone or in combination with bronchodilators have been shown to suppress coronavirus replication and cytokine production. Low- quality evidence also exists from a case series in Japan, in which improvement was seen in three patients with COVID-19 requiring oxygen, but not ventilatory support,

Personally, I have always worried that my use of ICS put me at a higher risk of respiratory infections because corticosteroids are potent immunosuppressives, potentially lowering my immune response to bacterial, viral, or fungal infections. This 2019 meta-analysis in Infection found a 24% higher rate of upper respiratory tract infection in patients using ICS.

Due to these concerns, when the pandemic began I purposely cut back on my Advair usage. Fortunately, my asthma has been very mild since I started taking Dupixent for eczema 3 years ago. Since then, Dupixent has been approved for treatment of asthma. (By the way, although dupilumab is a targeted biologic therapy that inhibits signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13), two key proteins that may play a central role in type 2 inflammation that underlies atopic dermatitis and several other allergic diseases we have no idea if it increases or decreases Covid-19 risks or complications.)

Does ICS usage increase or lower our risk of Covid-19 outcomes?

This figure from a review of the topic shows where in the process ICS could influence Covid-19, either increasing or decreasing risk of 1) initial infection 2) progression to pneumonia or 3) progression to ARDS and death once pneumonia is established.

F1.medium.gif

There are theoretical arguments to suggest the use of ICS could either improve or worsen all 3 stages.

The review of 59 publications on Covid-19 concluded:

Following examination of the full texts including translations of those in Chinese, no publications were identified as having data on prior ICS use in patients with SARS, MERS or COVID-19 infection. No data were available for either a qualitative or narrative answer to the review question.

The bottom line right now is that we don’t know if ICS use is an important risk factor in Covid-19 outcomes.

Should ICS Stay or Go

The recommendations of the CDC, and all pulmonary/asthma societies at this point is to stick to your current asthma action plan. If that includes taking an ICS, keep on taking it at current levels.

In fact, the AAAAI  and other major asthma or pulmonary organization emphasize that patients should remain on their current medications because experiencing an exacerbation event and the need for hospitalization, in those who become poorly controlled, could actually increase patient exposure and the risk of infection.

I’ve gone back to taking my ICS at pre-pandemic levels and I don’t consider that my asthma puts me at any higher risk during the pandemic.

Skeptically Yours,

-ACP

N.B. Common inhaled corticosteroids include:

  • Beclomethasone (QvarTM)
  • Budesonide (Pulmicort FlexhalerTM)
  • Ciclesonide (AlvescoTM)
  • Flunisolide (AerospanTM)
  • Fluticasone (Flovent Diskus TM, Flovent HFATM, Arnuity ElliptaTM)
  • Mometasone (AsmanexTM)

ICS are commonly combined with long-acting beta agonists.  The “purple circle” Advair is one such combination.

N.B. The authors of the Lancet commentary seem to have heavy ties to companies that stand to profit from sales of ICS

DMGH has received personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Pfizer, and Sanofi, and non-financial support from Boehringer Ingelheim and Novartis, outside of the submitted work. RF has received grants from GlaxoSmithKline and Menarini, outside of the submitted work. AA has received grants from AstraZeneca, GlaxoSmithKline, and Menarini, and personal fees from AstraZeneca, Chiesi, GlaxoSmithKline, and Menarini, outside of the submitted work. OS and JRB declare no competing interests

Here are the references they cited suggested ICS might be beneficial against coronavirus.

  1. Yamaya M, Nishimura H, Deng X, et al. Inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells. Respir Investig 2020; published online Feb 21. DOI:10.1016/j.resinv.2019.12.005.
  2. Matsuyama S, Kawase M, Nao N, et al. The inhaled corticosteroid ciclesonide blocks coronavirus RNA replication by targeting viral NSP15. bioRxiv 2020; published online March 12. DOI:10.1101/2020.03.11.987016 (preprint).
  3. Iwabuchi K, Yoshie K, Kurakami Y, Takahashi K, Kato Y. Morishima T. COVID-19. Three cases improved with inhaled ciclesonide in the early to middle stages of pneumonia. 2020. http://www.kansensho.or.jp/uploads/ files/topics/2019ncov/covid19_casereport_200310.pdf (accessed March 27, 2020; in Japanese).

 

Does Hypertension Put You at a Higher Risk for Infection or Death From Covid-19?

Early news reports of fatalities in China from coronavirus strongly implied that hypertension was an independent risk factor for severe disease and death.

Bloomberg and many other seemingly reliable news sources relied on one Chinese doctor’s anecdotal statements along with a Lancet article to make this claim:

“A top Chinese intensive care doctor told Bloomberg that of 170 patients who died in January in Wuhan, nearly half had hypertension, and anecdotally he said that he and other doctors have noticed hypertension is prevalent in those who die.”

However the actual Lancet report on 191 patients published March 11, 2020 , entitled Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study did not find hypertension or heart disease to be an independent risk factor for severe respiratory disease or death.

Of the 191 patients, 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients).

Although patients with hypertension were more likely to die than those without hypertension this does not prove hypertension is an independent risk factor

Age was by far the most significant risk  factor and the older patients also had more hypertension. When all variables were factored into an analysis, hypertension and heart disease were not significantly related to death:

Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission

Heart disease and hypertension were not significant factors after accounting for age.

Nephrology Journal Club (NephJC) has an excellent discussion (frequently updated and well-reference)  on this topic here. After looking at all current publications in this area they agree with me that the current data do not support the idea that hypertension is an independent risk factor for either getting SARS-CoV2 or having a more serious illness from it.

Among the patients with COVID-19, it seems the prevalence of prior h/o HT is higher in those who develop severe disease than those who do not. Same applies for development of ARDS or death – but mostly in unadjusted analysis. See table below for more. The last two rows are the best quality data so far, and suggest the association between COVID-19 severity and hypertension is attenuated after adjustment.

updated HT table.JPG

Sources: Guan et al, NEJM; Huang et al, Lancet; Wang et al, JAMA; Zhang et al, Allergy; Zhou et al, Lancet; Wu et al, JAMA IM; Italian report (PDF); Chen et al, BMJ; Shi et al, JAMA Cardiol; McMichael et al, NEJM; Guo et al, JAMA Cardiol; Bean et al, MedRxiv 2020; Petrilli et al, MedRXiv 2020

As can be seen, most of the studies except the last two, did not adjust for age. Even age-stratified association of hypertension would have been a more useful way to see these data to understand this issue a bit better. We hope more data in coming days will clarify this relationship. Unlike what we stated earlier, the Zhou et al study did not adjust for hypertension.

Source: AHA website , using NHANES data

Source: AHA website, using NHANES data

As can be seen above, hypertension in the general population closely associates with increasing age, hence any association with hypertension may merely represent confounding due to age, and should be interpreted after careful analysis.

The Question Is Definitively Answered

The speed at which data and studies are being published on Covid-19 is so rapid that a study has been published since I began writing this post which I feel definitively answers my title question.
Using observational data on 8910 hospitalized patients in 169 hospitals in Asia, Europe, and North America, investigators examined cardiovascular factors that were associated with in-hospital death.
Surprisingly, in this database, although the average age of the 515 nonsurvivors was 56 years versus 49 years for the 8195 survivors, there was no difference in the prevalence of hypertension. In fact survivors had a slightly higher prevalence of hypertension (26.4% versus 25.2%) despite being younger than the nonsurvivors.
A multivariable logistic-regression model identified age>65 years, coronary artery disease, heart failure, arrhythmia, COPD and current smoking as independently associated with in-hospital death.
nejmoa2007621_f1
Hypertension was not independently associated with in-hospital death.
Interestingly, patients receiving ACE inhibitors and statins were substantially less likely to die.
In Summary
  1. Hypertension does not put you at a higher risk of serious illness or death due to Covid-19.
  2. As discussed in previous posts (see here and here), there is no reason to stop taking your ACE inhibitor or angiotensin receptor blocker (ARB) blood pressure medication during this pandemic. (Also don’t start demanding you be put on an ACE inhibitor-the protective association seen in one study does not prove causality, we need randomized trials to show drugs safety and effectiveness!)
  3. Be very skeptical of early anecdotal reports and small trials rushed to publication (especially “preprints” which have not been peer-reviewed) during Covid-19. The poorly substantiated claims that hypertension was a major risk factor for death and that ACE inhibitors increased patient’s risk during Covid-19 have proven false. As better data emerges regarding hydroxychloroquine, despite enthusiastic anecdotal reports from some physicians, this drug has not been proven safe and/or effective for Covid-19 treatment.

Skeptically Yours,

-ACP

 

Forest Park And The Greatest Urban Bike Ride Are Open During Covid-19

The skeptical cardiologist has been planning a post on “The Greatest Urban Bike Ride” since last summer. The GUBR (pronounced goober) as I whimsically term it begins near Mooney Park near my house in University City, travels along the quiet, tree-lined Ivy League avenues of University Park (the largest private subdivision in the state of Missouri) and through a secret passageway near tiny (and now closed) Lewis Park (which features a fish on a bicycle sculpture in its pond).

Lewis Park. Can you spot the fish on a bicycle? The secret passageway is not in this shot

Upon emerging from the secret passageway one beholds University Heights which is on the National Register of Historic Places.

In 1902, Edgar Gardner Lewis, the enigmatic publisher and founder of University City purchased  85 acres just northwest of the construction site in Forest Park for the Louisiana Purchase Exhibition, aka the 1904 St. Louis World’s Fair and created a planned community-an exclusive “Residence Park.”

Meandering down the winding streets of University Heights on a bike is a great way to appreciate the variety of architecture, cool street signs and unique land-hugging design of the lots and streets.

Eventually, the GUBR leaves University Heights and after crossing Delmar Boulevard (using a roundabout!) at the entrance to the legendary Delmar Loop (“The Delmar Loop is a buzzing entertainment and dining hub with an eclectic mix of noodle bars, BBQ restaurants, Korean and Mexican eateries, cocktail lounges and pubs lining Delmar Boulevard. Well-known locals with stars on the St. Louis Walk of Fame include Maya Angelou and Betty Grable, as well as Chuck Berry, whose statue is nearby. Music venues like the Pageant and Delmar Hall stage rock, roots and indie gigs”) it traverses more beautiful city streets in Ames Place.

The GUBR now enters the pseudo-Ivy League campus of Washington University after crossing over Forest Park Blvd using a newly built combined Pedway/Bikeway.

Three of my children attended Washington University so I feel like I’ve contributed personally to the majority of the buildings there. After many ill-fated rides across the campus (I have discovered that riding a bike on stairs yields poor outcomes) I discovered a short and simple route (using ramps!) which takes me to Forsyth Blvd a few blocks from Forest Park.

Forest Park Is Open

Forest Park is the sparkling gem at the center of the GUBR and miraculously it is still open. Whereas St. Louis County has closed all of its parks, from massive Queeny and Greensfelder to tiny Lewis Park of fish-on-bicycle fame, the city of St. Louis (which is not within St. Louis County strangely enough) has left open its parks.

City mayor Lydia Krewson was quoted as saying:

“People need to be able to take a walk, They need it for their physical well-being, but they also need it for their mental well-being.”

I whole-heartedly agree and an open Forest Park has done wonders for my psyche.

Krewson has made some modifications to enhance social distancing in the parks which make sense:

“We have closed down playgrounds because it’s really not safe having your kids on that playground equipment,” Krewson said. “We’ve closed down court sports like tennis, and basketball, and pickleball, and handball.”

Krewson also shut down one-third of the streets in city parks to create more space for walking and biking while abiding by social distancing boundaries.

“We’ve closed some of the streets in our big parks,” Krewson said. “We want those streets to be available for walkers. So that if you’re walking, it’s very easy for you to stay six feet apart if you’re walking down a street that’s closed.”

Once I reach Forest Park I ride the bike trails around the periphery, often stopping at a bench (I’ve labeled position #4 on the map below) positioned between bucolic Jefferson “Lake” and the towers of the Barnes-Jewish medical complex.

forest park
Trail begins at #1 and continues around the periphery of the park in front of The Missouri History Museum (2), the Fish Hatchery (3), Jefferson “lake” (4), the planetarium and T. Rex statue (5) before heading west and staying close to I-64. After passing the St. Louis Zoo you head north and speed downhill down Skinker Avenue back to Forsyth.

The round trip from home and back, including the circuit around Forest Park , is about 11 miles which takes me about an hour.

I could go on for hours about the wonders of the GUBR, Forest Park and the great outdoors but the weather is perfect today and I can feel the great T Rex sculpture in Forest Park calling me.

I will be practicing social distancing and If it seems I’m too close to you I will pull my hammer-head shark bandana over my nose and mouth.

The skeptical cardiologist near bucolic Jefferson “Lake” wearing his neck thing which was purchased at the Charles Darwin Research Station in the Galapagos Islands

If you are wondering why I’m not wearing a bike helmet please read this before yelling at me.

Awomanneedsamalikeafishneedsabicyclely Yours,

-ACP

N.B. Here’s more detail on Edgar Lewis and University Heights

Lewis envisioned the remaining acreage as becoming the first subdivision, University Heights No.1, in “A City Beautiful.”  In 1903, Lewis employed an expert to survey the property to provide him with full measurements, elevations, and topographical features.  He then used this survey to construct a wax model of the landscape and to lay out the curving maze of streets we know today.  Using little tubes, he checked the dimensions for sewers and created mini-rainfalls with a sprinkler system to check drainage.  The streets were laid out so as to hug the contours of the undulating landscape.

The subdivision would be a planned community– an exclusive “Residence Park.”  The lots were drawn in several sizes, with the larger lots at the top of the hillside, near his new headquarters.  In addition, to maintain a standard of design and structural integrity, a certain minimum sum was required to erect a home on each lot size.  The more expensive homes were to be located on the crown of the slope, while less expensive and smaller ones were allowed downhill.  The range of lot sizes allowed for the great diversity of architectural styles of the homes in University Heights, while the varying shapes of the lots, a result of the winding streets, also influenced the type of home that could be erected to fit the space.  Only Dartmouth and Princeton offer relatively straight views down the street.  The winding inner streets, which sometimes confuse even long-time residents as well as visitors, offer ever-changing vistas that contribute greatly to the character of the neighborhood.

Hydroxychloroquine Cardiotoxicity: A Rare But Potentially Deadly Adverse Effect

The antimalarial drug hydroxychloroquine (HCQ) has been promoted by President Trump as a game-changing treatment for coronavirus infection. Of the drug, Trump declared “What do you have to lose? Take it! Try it if you’d like.”

As with any drug treatment one should consider the risks and the benefits of HCQ before “trying.” For expert virologists and infectious disease doctors, HCQ has not been proven to be beneficial in the treatment of coronavirus infection despite a glimmer of hope from early, small, poorly controlled trials from China and France.

The Chinese and French papers which reported on the use of HCQ with or without azithromycin in patients with coronavirus did not clearly show a clinical benefit. The most recent information suggests no benefits and potential harms to HCQ use.

With benefit unproven, we must be particularly cognizant of the adverse effects of any proposed or experimental treatment, and both HCQ and azithromycin (AZ) have well documented potentially lethal cardiac adverse effects.

I wrote about the risk of QT prolongation and sudden death with azithromycin here

A patient of mine with known left bundle branch block and cardiomyopathy recently contacted me because he had been prescribed HCQ for a rheumatologic disease. To determine if he should take this drug I reviewed the literature on HCQ cardiotoxicity.

Hydroxychloroquine Cardiotoxicity

HCQ is primarily utilized now for the treatment of rheumatologic disorders, most commonly systemic lupus erythematosus ( SLE.)

A recent review of  HCQ use in SLE concluded

HCQ may reduce the risk of flares, allow the reduction of the dosage of steroids, reduce organ damage, and prevent the thrombotic effects of anti-phospholipid antibodies. The drug is generally safe and may be prescribed to pregnant women. However, some cautions are needed to prevent retinopathy, a rare but serious complication of the prolonged use of HCQ

The Johns Hopkins Lupus Center section devoted to “Treating Lupus with Anti-Malarial Drugs” mentions a dozen side effects but does not mention cardiotoxicity.

However, the scientific literature contains numerous case reports of patients with SLE who developed either severe heart failure or conduction abnormalities (sometimes both) with strong evidence that HCQ was responsible.

Joyce, et al, (Hydroxychloroquine cardiotoxicity presenting as a rapidly evolving biventricular cardiomyopathy: key diagnostic features and literature reviewdescribed a case of HCQ cardiotoxicity in 2013 and reviewed the literature on the topic. They emphasized typical findings on cardiac biopsy and concluded:

“although rare, hydroxychloroquine cardiotoxicity can be fatal, particularly if irreversible histopathological changes have occurred prior to drug discontinuation. Given this, regular screening with 12-lead electrocardiography and transthoracic echocardiography to detect conduction system disease and/or biventricular morphological or functional changes should be considered in hydroxychloroquine-treated patients”

The most recent review of HCQ was published in 2018 and identified 127 patients from case reports or case series with cardiac complications from HCQ or chloroquine.

Two-thirds of these patients were female and the majority were treated with chloroquine (58%.)

Patients had been on drug treatment from 3 days to 35 years (median 7 years.)

The median cumulative dose was 1.235 grams for HCQ.

Conduction disorders were the most common adverse cardiac effect noted with 85% of patients

Other non-specific adverse cardiac events included ventricular hypertrophy (22%), hypokinesia (9.4%), heart failure (26.8%), pulmonary arterial hypertension (3.9%), and valvular dysfunction (7.1%).

For 78 patients reported to have been withdrawn from treatment, some recovered normal heart function (44.9%), while for others progression was unfavorable, resulting in irreversible damage (12.9%) or death (30.8%)

To summarize:

  1. HCQ and chloroquine have associated and well-documented, albeit rare cases of potentially lethal cardiotoxicity.
  2. The benefit of these drugs in the treatment of coronavirus infection is currently unproven.
  3. Data from high-quality randomized trials of HCQ treatment in patients with coronavirus is needed before we can assess whether the drug benefits outweigh its risk in COVID-19 patients.

Much has been written in the cardiology literature recently about QT prolongation with HCQ and ECG monitoring and I will publish a separate post on that topic shortly.

Skeptically Yours,

-ACP

A Reliable Source for Reliable Sources During Covid-19

It is a daunting task tracking down reliable information during Covid-19. Misinformation tends to spread like …the coronavirus. The Baker institute Blog is providing excellent succinct summaries of reliable information and sources as the pandemic evolves.

The post below  originally appeared on the Baker Institute Blog April 20, 2020  and was  coauthored by Vivian Ho, Ph.D. (@healthecontx), James A. Baker III Institute Chair in Health Economics, Kirstin Matthews, Ph.D. (@stpolicy), Baker Institute  Fellow in Science and Technology Policy and Heidi Russell, M.D., Ph.D., Associate Professor, Department of Pediatrics, Baylor College of Medicine and Associate Director, Center for Medical Ethics and Health Policy, Baylor College of Medicine.


Having finished our fifth week in isolation, we are encouraged that the nation may have passed its peak date for the number of new cases and new deaths. We update you on efforts to identify treatments for the coronavirus, as well as policymakers’ discussions on when to reopen the economy, what that might look like, and where government funding should be directed. Previous issues are posted here.

Epidemiology and Treatment

Health experts warn us not to expect a single peak day in terms of new cases, deaths, or otherwise. Daily reports of new cases and deaths can fluctuate depending upon the availability of tests and delays in reporting. The New York Times’ juxtaposes a bar graph of the number of new cases by day with a line calculating the 7-day average of these numbers, indicating that the number of new cases has fallen to less than 30,000 per day. The 7-day average of new deaths also has begun to fall, to roughly 2,000 per day.

On Friday Worldometers estimated that 58,000 people in the U.S. have recovered from the coronavirus. Mark Lipsitch, an epidemiologist at Harvard University, provides a compelling case that most individuals who contracted the virus will have an immune response, some better than others. He suggests that the immune response will offer some protection over the medium term — at least a year — and then its effectiveness might decline. This view that contracting the virus yields only temporary immunity, is shared by other experts. Thus, treatments and a vaccine for COVID-19 are crucial in ultimately conquering this pandemic.

To date, researchers and drug companies have launched over 100 human experiments to identify treatments for the coronavirus. However, an article in the Washington Post warns that the lack of coordination across investigations could generate numerous small-scale trials with conflicting answers. For example, there are more than two dozen separate U.S. trials listed for the anti-malarial drug hydroxychloroquine. Some use the drug as a preventive, others as a treatment; some in combination with other drugs, and some with no comparison group. Information from multiple investigations is often better, but coordination across these studies could have yielded larger sample sizes and cleaner study designs, so that results could be used to prioritize treatments. Francis Collins, director of the National Institutes of Health has been working behind the scenes to launch an unprecedented public-private partnership to achieve better coordination.

In the scientific journal Immunity, researchers review the COVID-19/SARS-CoV-2 vaccine development and its challenges  In addition, the WHO cataloged a long list of potential candidates, and an article from “The Scientist” describes frontrunners that hoped to be tested this year, providing details on each vaccine’s approach to target the virus as well as preliminary evidence. Meanwhile, fake news regarding causes of and treatment for coronavirus are circulating through social media. The World Health Organization (WHO) has posted a series mythbuster infographics to dispel rumors such as one that 5G mobile networks spread COVID-19.

Policy Response

Public health experts continue to emphasize that passing the peak number of cases or deaths does not mean that the pandemic is over, and that we will need to maintain social distancing in one form or the other for months to come. More than a dozen states have extended stay-home orders past the White House deadline of April 30th. In the meantime, governors on the east and west coasts were reported last Monday to have formed pacts to decide when they would reopen their economies. Governors of Midwest states followed suit soon afterwards. These pacts will draw on facts and science to create plans to re-open each state in a way that limits new outbreaks of coronavirus. Among the steps are contact tracing, treatment and social distancing measures.

For example, last week we highlighted the recommendation for A National COVID-19 Surveillance System which included capacity to conduct 750,000 coronavirus tests per week. Unfortunately, most parts of the country report test supply shortages that remain “crippling.” Experts emphasize the need for contact tracers, to identify those who could have contracted the virus by coming into contact with someone who has tested positive for the virus. Policy makers are acting on that recommendation, with the C.D.C. planning to hire hundreds of contacts tracers and, it is in discussions to divert 25,000 Census Bureau workers to do contact tracing in the coming weeks and months. Experts suggest that employers can do their part to reduce the spread of coronavirus by offering screening at their place of business. Employers can help workers to safely self-isolate at home and work with local health authorities to improve contact tracing.

As TIME magazine stated, “Public health experts have savaged President Donald Trump’s decision to cut U.S. funding to the WHO.” Critics include U.N. Secretary General António Guterres and the editor-in-chief of the Lancet medical journal, who called the decision “a crime against humanity.” The administration is reportedly withholding funds, because the WHO failed to adequately investigate early information about the virus’s ability to spread between humans and for not criticizing China for its lack of transparency over the virus. This view is echoed in an article in The Atlantic, which points to structural problems at the WHO that make the organization vulnerable to misinformation and political influence, in this case by China. Nevertheless, the U.S. pays for about 22% of the WHO’s budget. Cutting funding for international public health initiatives in the midst of a crisis could have dire consequences for Americans in the future.

Health and Human Services is distributing the first $30 billion in emergency grants to hospitals and doctors from the CARES Act according to their historical share of revenue from the Medicare program for seniors — not according to their coronavirus burden. States lightly hit by the coronavirus, such as Minnesota, are getting more than $300,000 per COVID-19 case, while New York is receiving $12,000 per case. The HHS decision raises the prospects that hospitals in hard-hit areas will be weighing their financial health more heavily than patient well-being for each additional COVID-19 case that comes through their doors.

On the Medical Frontlines

Evidence of strain on the healthcare workforce continues to mount.  The Centers for Disease Control (CDC) published a report estimating at least 9,282 United States health care workers have been sickened by COVID-19, and at least 27 died.  This is likely an underestimate because of how local or state authorities report cases. The CDC concluded that approximately half of these providers were exposed in their workplace.  The worse outcomes were in the over 65 workforce, although death and critical illness occurred at all ages. The first installment of a bi-weekly survey of medical staff across the country was performed by MedPage Today.  The responses suggest that regional variation in the share of the healthcare workforce that is temporarily out, critically ill or dead because of COVID-19 lies between 1% and 20%.  The proportions are much higher in concentrated areas like New York.  For an in-depth account of healthcare workers who died from COVID-19, we applaud the stories found in Lost on the Frontline.

Healthcare workers are particularly at risk when performing nasal swabbing to test for the coronavirus, which requires the provider to stand directly in front of the person being tested. The swabbing generates a natural reflex to cough or sneeze, sending droplets into the air. To that end the first COVID-19 test of saliva was approved by the FDA this week.  This new test will allow patients to spit into a vial and hand it back to the health care worker. The test is not yet available in most health care organizations, and questions remain about its accuracy. But as these hurdles are overcome, this safer, simpler testing would also circumvent the shortage of nasal swabs that is hindering test availability across the country.

In the coming we week, hopefully new cases of the coronavirus and daily death toll continue to decline. We are most concerned about the continuing short supply of coronavirus tests. We hope that federal, state, and local governments aggressively pursue efforts to hire and train contact tracers throughout the country. Debate has begun on what role smartphone apps by Apple and Google could play in contact tracing, and we will follow that discussion closely. We also look forward to reviewing state governors’ developing plans to reopen their economies.


Still socially distanced but ever skeptically Yours,

-ACP

Aaron Carroll Answers Forty Coronavirus Questions In Twenty-Two Minutes

In these times of great uncertainty, the public has lots of questions about the coronavirus. Finding good answers can be exhausting.

Aaron Carroll, at The Incidental Economist, is providing lots of high quality, easily digestible answers to his followers through a series of videos he has created.

I’ve been following his writing for some time and enthusiastically reviewed his book about diet and diets, The Bad Food Bible, in 2018:

I recently discovered a food/diet/nutrition book which with I almost completely agree. The author is Aaron Carroll,  a pediatrician, blogger on health care research (The incidental Economist) and a Professor of Pediatrics and Associate Dean for Research Mentoring at Indiana University School of Medicine.

He writes a regular column for the New York Times and covers various topics in health care. His articles are interesting,  very well written and researched and he often challenges accepted dogma.

Like the skeptical cardiologist, he approaches his topics from an unbiased perspective and utilizes a good understanding of the scientific technique along with a research background to bring fresh perspective to health-related topics.

Yesterday, he posted an updated video addressing 40 COVID-19 questions which may answer one of your many questions. Total duration is around 20 minutes.

More COVID-19 Questions & Answers

Skeptically Yours,

-ACP

Should You Be Wearing a Mask in Public During Covid-19?

President Trump announced yesterday that the CDC is advising “the use of nonmedical cloth face covering as a voluntary health measure.”

The CDC website today states:

CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission.

CDC also advises the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others.  Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.

For a detailed and well-referenced article on the argument for wearing a mask in public I recommend this article ( Should You Wear a Mask in Public for Coronavirus? — Diet Doctor). 

Yes. Research shows that any barrier — tea towel, pillow case, vacuum cleaner bag — provides some protection and is better than nothing. The layer of fabric, or even paper, across the nose and mouth creates an obstacle to respiratory droplets, helping reduce the viral load that you either exhale upon someone else or they exhale upon you.

The article features this powerful graphic:

In addition to persuasive arguments for everyone wearing a mask in public, the article gives good information on mask creation and handling.

The CDC website  gives very detailed instructions on how to create the facial barrier at home and how to clean and disinfect them.

You can create one by sewing or non sewing methods. Helpful graphics are included:

You can also use a coffee filter and bandana to create a mask

 

Turbulent Gas Clouds

 

I became a believer in universal masking during Covid-19 after reading an article entitled “Turbulent Gas Clouds and Respiratory Pathogen Emissions Potential Implications for Reducing Transmission of COVID-19″ published March 26 in JAMA insights.

Figure 1 from that paper below shows a sneeze cloud projecting up to 8 meters.

The author notes

Recent work has demonstrated that exhalations, sneezes, and coughs not only consist of mucosalivary droplets following short-range semiballistic emission trajectories but, importantly, are primarily made of a multiphase turbulent gas (a puff) cloud that entrains ambient air and traps and carries within it clusters of droplets with a continuum of droplet sizes

Owing to the forward momentum of the cloud, pathogen-bearing droplets are propelled much farther than if they were emitted in isolation without a turbulent puff cloud trapping and carrying them forward. Given various combinations of an individual patient’s physiology and environmental conditions, such as humidity and temperature, the gas cloud and its payload of pathogen-bearing droplets of all sizes can travel 23 to 27 feet (7-8 m).

I’ve included additional comments from this paper at the end of this post for those with strong stomachs.

Universal Masking In Hospitals/Clinics

An opinion piece   published April 1 in  NEJM is less enthusiastic about the benefits of universal public masking

We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to Covid-19 as face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.

However, these authors feel that universal masking in hospitals may be beneficial for two reasons:

The first is during the care of a patient with unrecognized Covid-19. A mask alone in this setting will reduce risk only slightly, however, since it does not provide protection from droplets that may enter the eyes or from fomites on the patient or in the environment that providers may pick up on their hands and carry to their mucous membranes (particularly given the concern that mask wearers may have an increased tendency to touch their faces).

More compelling is the possibility that wearing a mask may reduce the likelihood of transmission from asymptomatic and minimally symptomatic health care workers with Covid-19 to other providers and patients. This concern increases as Covid-19 becomes more widespread in the community. We face a constant risk that a health care worker with early infection may bring the virus into our facilities and transmit it to others. Transmission from people with asymptomatic infection has been well documented, although it is unclear to what extent such transmission contributes to the overall spread of infection

Personally, I am convinced of the benefits of mask wearing and I will be wearing one when I go to my office.

Skeptically Yours,

-ACP

N.B. More about turbulent gas clouds.

Importantly, the range of all droplets, large and small, is extended through their interaction with and trapping within the turbulent gas cloud, compared with the commonly accepted dichotomized droplet model that does not account for the possibility of a hot and moist gas cloud. Moreover, throughout the trajectory, droplets of all sizes settle out or evaporate at rates that depend not only on their size, but also on the degree of turbulence and speed of the gas cloud, coupled with the properties of the ambient environment (temperature, humidity, and airflow).

Droplets that settle along the trajectory can contaminate surfaces, while the rest remain trapped and clustered in the moving cloud. Eventually the cloud and its droplet payload lose momentum and coherence, and the remaining droplets within the cloud evaporate, producing residues or droplet nuclei that may stay suspended in the air for hours, following airflow patterns imposed by ventilation or climate-control systems

An Update On ACE2, RAAS and Covid-19: Still No Reason To Stop Or Change Your Blood Pressure Medication

Previously, I wrote a detailed post on concerns that have been raised about certain blood pressure medications potentially  increasing the risk of contracting SARS-CoV-2 or increasing the likelihood of death and serious disease related to the virus.

Millions of patients worldwide with heart failure and hypertension are taking drugs that inhibit pathways in the renal angiotensin aldosterone system termed angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs.)

Lisinopril and ramipril are common ACE inhibitors whereas valsartan, losartan, and irbesartan are common ARBs.

Speculation that these drugs might be contributing to mortality associated with COVID-19 was initiated by a “Rapid Response” published online March 3 by the British Medical Journal in response to an editorial on “preventing a COVID-19 pandemic.” and “Correspondence” to the Lancet published March 7.

Since then I’ve been following this topic closely but nothing has emerged from any new data or new expert analysis to suggest that patients should stop taking ACE inhibitors or ARBs.

Yesterday, an excellent summary of the topic from some of the world’s leading authorities was published in the New England Journal of Medicine entitled “Renin–Angiotensin–Aldosterone System Inhibitors in Patients with Covid-19″

It begins with this wonderful sentence: “The renin–angiotensin–aldosterone system (RAAS) is an elegant cascade of vasoactive peptides that orchestrate key processes in human physiology.”

The authors outline in detail the possible interactions between ACE2 receptors and SARS CoV-2.

For those not interested in the scientific details in the paper, the Cliff’s Notes version of this article is below. Basically, we have insufficient data to know if patients taking RAAS inhibitors are at higher or lower risk for serious SARS-CoV-2 infection.


KEY POINTS RELATED TO THE INTERPLAY BETWEEN COVID-19 AND THE RENIN–ANGIOTENSIN–ALDOSTERONE SYSTEM

  • • ACE2, an enzyme that physiologically counters RAAS activation, is the functional receptor to SARS-CoV-2, the virus responsible for the Covid-19 pandemic
  • • Select preclinical studies have suggested that RAAS inhibitors may increase ACE2 expression, raising concerns regarding their safety in patients with Covid-19
  • • Insufficient data are available to determine whether these observations readily translate to humans, and no studies have evaluated the effects of RAAS inhibitors in Covid-19
  • • Clinical trials are under way to test the safety and efficacy of RAAS modulators, including recombinant human ACE2 and the ARB losartan in Covid-19
  • • Abrupt withdrawal of RAAS inhibitors in high-risk patients, including those who have heart failure or have had myocardial infarction, may result in clinical instability and adverse health outcomes
  • • Until further data are available, we think that RAAS inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with Covid-19

So my recommendations (and more importantly the recommendations of every major society or organization which has weighted in on this topic) to patients remain the same: don’t stop your ACE inhibitor or ARB due to concerns about coronavirus.

Skeptically Yours,

-ACP

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

%d bloggers like this: