Telemedicine: Disruptive & Sustaining Innovation

“…telemedicine can improve through both sustaining innovation (incremental improvement upon what we are already doing for patients) and through disruptive innovation (simpler solutions for patients with simpler needs and/or patients we are not currently serving).”

Telemedicine as a Sustaining Innovation

Most telemedicine in its current form is a sustaining innovation. There has been incremental improvement in telecommunication technologies from the traditional phone to current videoconferencing software integrated with electronic medical records, development of secure platforms for short messaging service (SMS) between patients and providers, and introduction of connected devices that can monitor and transmit patients’ health data to their providers.

Disruptive Telemedicine

Beyond improving the way care is already delivered, telemedicine may also serve as a vehicle for disruption in overlooked health care markets, particularly low-end or new-market segments. Many customers are currently overserved by traditional care delivery in the form of regular visits (in-person or virtual) with a physician, which are structured to provide more than what they need and less of what they want.

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Coronary artery bypass graft (CABG) was supported as superior to fractional flow reserve (FFR)–guided percutaneous coronary intervention (PCI) for three-vessel coronary artery disease (CAD). PCI failed to meet noninferiority criteria at 1-year follow-up in a study comparing outcomes between FFR-guided PCI using contemporary stents and CABG. This adds to existing evidence showing superior outcomes with CABG in patients with the most-complex CAD.

The sodium–glucose transporter-2 (SGLT-2) inhibitor empagliflozin was found to be beneficial in heart failure with preserved ejection fraction. Empagliflozin is the first medication shown to improve outcomes in this population. It’s unknown if this is a class effect of all SGLT-2 inhibitors, but this could be a game changer.

Poor-quality carbohydrates were linked to cardiovascular mortality, around the world. Consumption of higher-glycemic-index carbohydrates was associated with higher rates of cardiovascular disease and mortality in countries all around the world. These data are particularly important because lower-income countries often have diets high in refined carbohydrates, which may worsen cardiovascular disparities.

New guidelines for managing valvular heart disease were released. These new guidelines add or elevate several recommendations for transcatheter therapy, and they lower thresholds for intervention in some conditions.

The editors of Circulation: Cardiovascular Quality and Outcomes addressed racial-ethnic disparities. The editors affirmed that structural racism is a public health crisis and that the scientific publishing community can play a role in addressing it.

Tricuspid annuloplasty for moderate regurgitation during mitral-valve surgery was of unclear benefit. Annuloplasty was associated with less progression of moderate tricuspid regurgitation but more pacemakers at 2 years. Unfortunately, this mixed outcome does not clearly inform the decision on performing annuloplasty at the time of surgery, and longer-term follow-up is needed.

Immediate angiography was not beneficial in out-of-hospital cardiac arrest without ST elevation. Patients with out-of-hospital cardiac arrest who did not have ST elevation on their initial ECG did not benefit from immediate angiography. Although a potential coronary culprit was identified in about 40% of patients, neurologic injury was by far the most frequent cause of death, negating any benefit from coronary revascularization.

Many statin side effects are related to the “nocebo” effect. A creative study enrolled 60 people with statin intolerance and gave them 12 randomly ordered 1-month treatment periods: 4 periods of no medication, 4 of placebo, and 4 of statin. Symptom intensity did not differ between placebo and statin periods and, interestingly, some even had more symptoms on placebo. This demonstrates that some cases of “statin intolerance” may be related to the “nocebo” effect.

Shorter duration of dual antiplatelet therapy following PCI/stent placement was found to be acceptable in patients with high bleeding risk. A large, randomized trial found that 1 month of dual antiplatelet therapy provided similar clinical outcomes and a lower bleeding risk than 3-to-6-month regimens for this challenging patient subset.

De-escalation” of dual antiplatelet therapy for patients undergoing PCI for acute myocardial infarction (MI). This industry-funded study evaluated patients who had received 1 month of aspirin plus ticagrelor after acute MI and stent placement and “de-escalated” half to aspirin plus clopidogrel. At 1 year, there was significantly less bleeding in the de-escalation group and a nonsignificant trend toward fewer ischemic events as well.

Oral Health: Brushing, Flossing & Mouthwash

#1. If your gums are bleeding, you’re brushing too hard.

True, sometimes. Bleeding gums are usually a sign of gum disease, but over-vigorous brushing can cause gums to bleed as well. Pregnancy, poorly fitting dentures, and some medications, such as anti-clotting drugs, also can contribute to bleeding gums. However, if you’re brushing correctly (see the next question for tips!), healthy gums generally will not bleed.

#2. It doesn’t matter how I brush, as long as I brush for two minutes.

False. One of the better ways is to move your toothbrush in a circle. This is called the Modified Bass Technique. This circular motion picks up the plaque on your teeth and sweeps it out. The other ways of brushing only move the plaque and push it against other surfaces. To use the Modified Bass Technique, hold your brush at a 45-degree angle to the gum line. Let the bristles reach just beneath the gum line.

Regardless of the technique you use, it’s also possible to brush too hard. This can damage your gums and wear away tooth enamel. Gentle pressure is all that’s needed to remove debris and plaque.

Two minutes of brushing is ideal, though. If it helps, set a timer. Use a fluoride toothpaste, and floss at least once a day. Brushing and flossing before bed is especially important in order to remove food particles from your mouth before you sleep.

#3. There’s no single “right way” to floss.

False. For effective flossing, wrap the floss around the middle finger of each hand, leaving a section in the middle that’s several inches long. Use your thumbs and index fingers to hold that section. Gently work the floss into the space between two teeth and press it against one of the teeth cre­ating a C-shape, sliding it up and down a few times. Then press against the other tooth, repeat, and move to the next space. These motions scrub away the plaque. Make sure to move gently around the gums to avoid placing damaging pressure on them.

Floss holders, floss tape, and different types of floss offer something for every mouth.

#4. Electric toothbrushes are often more effective than manual ones.

True. Research has found that electric toothbrushes are better at removing plaque and reducing the risk of gingivitis. Proper use of a manual toothbrush should be as effective as an electric toothbrush, but most people don’t remove enough plaque with a manual toothbrush; they don’t brush long enough or use correct brushing techniques.

A research review by Cochrane, an independent review organization, found a “moderate benefit” for using an electric toothbrush over a manual one. And an 11-year study published in 2019 found that people who used electric toothbrushes had lower rates of tooth loss, as well as healthier gums and less plaque, compared with people using manual toothbrushes.

#5.  Mouthwash can be used instead of brushing and flossing.

False. The American Dental Association (ADA) says: “Using a mouthwash does not take the place of optimal brushing and flossing.” This doesn’t mean that mouthwash is useless, however. It can fight bad breath, and the ADA notes that some mouthwashes help reduce the risk of gum disease and tooth decay, but only if used as part of a daily oral hygiene routine.

Over-the-counter mouthwashes may be targeted toward prevent­ing decay (fluoride rinses), bad breath, mouth sores, or gum disease. Prescription mouthwashes can help treat gum disease, dry mouth, mouth sores, or dry socket. Most mouthwashes prescribed for gum disease con­tain chlorhexidine, which is also in some over-the-counter mouthwashes in lower concentrations. Talk with your dentist to decide which mouthwash is best for you.

Brain Health: Endurance Exercise Raises Cognition


Cancer is a huge problem, since it is actually a collection of a lot of different diseases in different places, resulting from mutation of the genes and invasiveness as the common characteristic. All cancers are different.

Carcinoid tumor is a good illustration. These are so called neutoendocrine tumors. They are slow growing, and are usually not detected until they are quite advanced. They can be located in different organs such as the gastrointestinal tract and the lung.

In their vicinity they produce symptoms characteristic of the area; trouble swallowing, nausea, vomiting, constipation and abdominal pain for gastrointestinal carcinoid, and cough, wheezing, shortness of breath and chest pain for those located in the lung.

Many advanced cancers can produce weight loss, muscle pain and fatigue In addition to symptoms characteristic of their location. The special characteristic of carcinoid tumors is that they may secrete substances that produce diverse symptoms such as  flushing of the skin, sudden diarrhea and vomiting and, strangest of all, heart valve leakages.

Diagnosis of carcinoid tumors is often made by checking for serotonin or chromogranin-A in the blood, and 5-Hydroxy indolacetic acid ( 5-HIAA) in the urine, and locating the tumor with Imaging such as CT and MRI.

It is usually treated best for surgery, but cell surface somatostatin can be targeted for hormone therapy, and targeted radiotherapy with PRRT. It is very much to the advantage of the patient if she has a tumor with specific hormone or other marker that can be targeted for treatment, such as a breast cancer with estrogen receptors that can be targeted by tamoxifen.

Please check the accompanying mayo clinic article for more information.

—Dr. C.

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