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.
Featuring articles on lung-cancer screening in the NELSON trial, ribociclib and fulvestrant in metastatic breast cancer, vitamin D in pregnancy and asthma, treatment thresholds for neonatal hypoglycemia, and CAR-NK cells in anti-CD19 lymphoid tumors; a review article on placebo and nocebo effects; a Clinical Problem-Solving describing a rapid change in pressure; and Perspective articles on altruism in Extremis, on abuses of FDA regulatory procedures, and on joining forces against delirium.
Listen to a chat with Julia Adler-Milstein, the author of an editorial that comments on a recent Annals of Internal Medicine study detailing the amount of time clinicians typically spend hunched over their EHRs during a patient visit.
Why aren’t you able to navigate your electronic health record (EHR) as easily as you can find a recipe on, say, Google?
And, what about those requirements for documenting everything?