In this audio interview conducted on June 3, 2020, the editors discuss two new studies: one comparing test swabs collected by health care workers with swabs collected by the patients themselves and one assessing hydroxychloroquine treatment in people who had been exposed to Covid-19 but weren’t yet ill.
The continuing spread of SARS-CoV-2 remains a Public Health Emergency of International Concern. What physicians need to know about transmission, diagnosis, and treatment of Covid-19 is the subject of ongoing updates from infectious disease experts at the Journal.
Eric Rubin is the Editor-in-Chief of the Journal. Lindsey Baden is a Deputy Editor of the Journal. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal.
Interview with Dr. Nicole Lurie on rapid vaccine development, including new tools to facilitate vaccine testing and manufacturing and persistent challenges.
The need to rapidly develop a vaccine against SARS-CoV-2 comes at a time of explosion in basic scientific understanding, including in areas such as genomics and structural biology, that is supporting a new era in vaccine development. Over the past decade, the scientific community and the vaccine industry have been asked to respond urgently to epidemics of H1N1 influenza, Ebola, Zika, and now SARS-CoV-2. An H1N1 influenza vaccine was developed relatively rapidly, largely because influenza-vaccine technology was well developed and key regulators had previously decided that vaccines made using egg- and cell-based platforms could be licensed under the rules used for a strain change. Although a monovalent H1N1 vaccine was not available before the pandemic peaked in the Northern Hemisphere, it was available soon afterward as a stand-alone vaccine and was ultimately incorporated into commercially available seasonal influenza vaccines.
Nicole Lurie is a strategic advisor to the CEO of the Coalition for Epidemic Preparedness Innovations. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal.
Featuring articles on deaths due to e-cigarette– or vaping-associated lung injury, apixaban for venous thromboembolism in cancer, the management of coronary disease in patients with advanced kidney disease, health-status outcomes in the ISCHEMIA-CKD trial, and ten weeks to crush the curve.
Additionally, renin–angiotensin–aldosterone system inhibitors in patients with Covid-19, and teasing the immune system to repair the heart; a review article on the care of patients with diabetic retinopathy; a case report of a man with high blood pressure, renal insufficiency, and hematuria; and Perspective articles on clinical and social risk adjustment, on prediction models, and on medical care during the pandemic.
Cardiovascular consults are way down. Is the threat of COVID-19 infection scaring people away from ED’s?
We caught up with Dr. Comilla Sasson, the American Heart Association’s VP for science and innovation. She’s an emergency physician who teaches at the University of Colorado. She’d traveled to New York City to “help with the response,” and she talked with us from a field hospital that had been set up on a tennis court in Central Park.
She had lots to say about what’s driving patients away from emergency departments these days and what’s likely to happen in medicine (hello, telemedicine!) once the pandemic abates.
Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection.
Osteoarthritis of the knee is a leading cause of disability.1 Current management is typically limited to the treatment of symptoms until late stages of arthritis lead to knee replacement.2 Intraarticular glucocorticoid injections are commonly used as a primary treatment for osteoarthritis of the knee,3 but there are conflicting reports regarding the extent and duration of the relief of symptoms with this therapy.4-6 Complications from these injections occur infrequently but include joint infection,7 accelerated degradation of articular cartilage,8 and subchondral insufficiency fractures.9
The physical therapy intervention, which is described in the protocol,26 included instructions and images for exercises, joint mobilizations, and the clinical reasoning underlying the priorities, dosing, and progression of treatment. During a typical clinical session, the physical therapist would implement hands-on, manual techniques immediately before the patient performed reinforcing exercises to help the patient perform the movements with little or no pain. For example, if a patient could not fully extend or flex the knee, or those movements were painful, the physical therapist would use a hands-on, passive mobilizing technique to repeatedly move the knee to reduce stiffness while altering the mechanics of the technique to avoid pain. The patient would then perform repeated active knee movements in the same direction.
NEJM talks with Dr. Julian Flores, who works in a Broward County, Florida, emergency room.
When he was interviewed, the count of Covid-19 cases stood at 412, less than 12 hours later, the new number was 505. He’s expecting the wave to hit hard there. Broward is home to Fort Lauderdale (think spring break) and Pompano Beach (think aging retirees). Couple those demographics with a lack of easy testing for the virus, and you’ve got a worrisome situation.
Though U.S. legislation targeting the problem of surprise medical bills advanced out of key congressional committees in 2019 with support from leaders in both parties, Congress ultimately failed to pass a law to end such bills.
Erin Fuse Brown is an associate professor of law at Georgia State University. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal.
From a New England Journal of Medicine article (March 11, 2020):
A central strategy for health care surge control is “forward triage” — the sorting of patients before they arrive in the emergency department (ED). Direct-to-consumer (or on-demand) telemedicine, a 21st-century approach to forward triage that allows patients to be efficiently screened, is both patient-centered and conducive to self-quarantine, and it protects patients, clinicians, and the community from exposure.
It can allow physicians and patients to communicate 24/7, using smartphones or webcam-enabled computers. Respiratory symptoms — which may be early signs of Covid-19 — are among the conditions most commonly evaluated with this approach. Health care providers can easily obtain detailed travel and exposure histories. Automated screening algorithms can be built into the intake process, and local epidemiologic information can be used to standardize screening and practice patterns across providers.
More than 50 U.S. health systems already have such programs. Jefferson Health, Mount Sinai, Kaiser Permanente, Cleveland Clinic, and Providence, for example, all leverage telehealth technology to allow clinicians to see patients who are at home. Systems lacking such programs can outsource similar services to physicians and support staff provided by Teladoc Health or American Well. At present, the major barrier to large-scale telemedical screening for SARS-CoV-2, the novel coronavirus causing Covid-19, is coordination of testing. As the availability of testing sites expands, local systems that can test appropriate patients while minimizing exposure — using dedicated office space, tents, or in-car testing — will need to be developed and integrated into telemedicine workflows.
From the New England Journal of Medicine (February 13, 2020):
In our opinion, the current recommendation to greatly increase consumption of dairy foods to 3 or more servings per day does not appear to be justified…When consumption of milk is low, the two nutrients of primary concern, calcium and vitamin D (which is of particular concern at higher latitudes), be obtained from other foods or supplements without the potential negative consequences of dairy foods.
For calcium, alternative dietary sources include kale, broccoli, tofu, nuts, beans, and fortified orange juice for vitamin D, supplements can provide adequate intake at far lower cost than fortified milk. Pending additional research, guidelines for milk and equivalent dairy foods ideally should designate an acceptable intake (such as 0 to 2 servings per day for adults), deemphasize reduced-fat milk as preferable to whole milk, and discourage consumption of sugar-sweetened dairy foods in populations with high rates of overweight and obesity.
For adults, the overall evidence does not support high dairy consumption for reduction of fractures, which has been a primary justification for current U.S. recommendations. Moreover, total dairy consumption has not been clearly related to weight control or to risks of diabetes and cardiovascular disease. High consumption of dairy foods is likely to increase the risks of prostate cancer and possibly endometrial cancer but reduce the risk of colorectal cancer.
Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so.
Evidence is accumulating that eating in a 6-hour period and fasting for 18 hours can trigger a metabolic switch from glucose-based to ketone-based energy, with increased stress resistance, increased longevity, and a decreased incidence of diseases, including cancer and obesity.