Stephen Hahn, U.S. Food and Drug Administration Commissioner, Sigal Atzmon, founder and chief executive officer of Medix Global, and Roche CEO Severin Schwan, on the pandemic, Covid-19 vaccines and the new mutation.
Anthony S. Fauci, MD returns to JAMA’s Q&A series to discuss the latest developments in the COVID-19 pandemic, including the continued importance of nonpharmaceutical interventions (masking, handwashing, physical distancing) for managing rising case numbers in the US and globally.
Recorded October 28, 2020.
Topics discussed in this interview: 0:00 Introduction 0:20 NAM Presidential Citation for Exemplary Leadership 1:19 COVID-19 numbers and excess deaths 4:05 National masking mandate 5:55 How to get people to accept masking 7:07 Herd Immunity and the Great Barrington Declaration 9:51 The holidays and airplane travel 13:44 Therapies update 17:54 Vaccines update 20:08 Vaccine distribution 22:00 Vaccine safety 24:42 How Australia has dealt with COVID-19 spikes 27:00 Acknowledgements and baseball
Comprehensive care in patients with diabetes and CKD
Management of CKD in diabetes can be challenging and complex, and a multidisciplinary team should be involved (doctors, nurses, dietitians, educators, etc). Patient participation is important for self-management and to participate in shared decision-making regarding the management plan. (Practice point).
We recommend that treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and that these medications be titrated to the highest approved dose that is tolerated (1B).
Lifestyle interventions in patients with diabetes and CKD
We suggest maintaining a protein intake of 0.8 g protein/kg)/d for those with diabetes and CKD not treated with dialysis (2C).
On the amount of proteins recommended in these guidelines, they suggest (‘recommend’ becomes a ‘suggest’ at this level of evidence) a very precise intake of 0.8g/kg/d in patients with diabetes and CKD. Lower dietary protein intake has been hypothesized but never proven to reduce glomerular hyperfiltration and slow progression of CKD, however in patients with diabetes, limiting protein intake below 0.8g/kg/d can be translated into a decreased caloric content, significant weight loss and quality of life. Malnutrition from protein and calorie deficit is possible.
We recommend that patients with diabetes and CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (1D).
Colonic diverticulosis refers to herniation of the mucosa and submucosa through the muscular layer of the colonic wall and may be the result of colonic smooth muscle over-activity. Diverticular disease may be defined as any clinical state caused by symptoms pertaining to colonic diverticula and includes a wide-ranging spectrum from asymptomatic to severe and complicated disease.
Mohamed Thaha, Senior Lecturer & Lead Consultant in Colorectal Surgery, National Bowel Research Centre, Barts and The London School of Medicine and Dentistry, tells us more.
The US Surgeon General’s office has released a report emphasizing the importance of making hypertension control a national public health priority. Vice Admiral Jerome Adams, MD, MPH, the 20th US Surgeon General, discusses the report’s background and recommendations.
Recorded October 7, 2020.
Chest pain is a common chief complaint. It may be caused by either benign or life-threatening aetiologies and is usually divided into cardiac and non-cardiac causes. James E. Brown, Professor and Chair, Wright State University Boonshoft School of Medicine, Kettering, Ohio, gives us an overview of assessing chest pain in the emergency setting.
Dr. James E Brown of the Wright State school Of medicine in Kettering Ohio gave a very interesting discussion of chest pain.
One interesting takeaway is the value of a very experienced clinician dealing with large volumes of emergency room patients. This would make telemedicine with an emergency room hub in a teaching center a very attractive platform.
The consultant doctor in the center has the advantage of his vast experience in rapidly narrowing down the heterogeneous list of different diagnoses that must be considered- the “differential diagnosis”.
Dr. Brown mentioned the “gestalt”, the incorporation of subjective features such as facial and voice cues which add to the objective parameters in patient evaluation. This of course would be amenable to telemedicine although other old-time clinical information like the changes in breath sounds would be more favorable to conventional in-person evaluation.
Ultrasound would More easily be done locally as well.
An interesting take away from this discussion is the value of The patient’s history and past laboratory data, so undervalued by rushed modern doctors. For instance, Electronic medical records (EMR) could provide past history or a previous electrocardiogram for comparison.
Dr. Brown favors the division of chest pain causes into cardiac and non-cardiac. It is easy to develop tunnel vision and look at the patient only as a possible coronary thrombosis. In fact it is better to Rapidly consider the non-cardiac causes that would demand immediate attention while waiting for the results of the Troponin-T test.
For instance pulmonary embolism, aortic dissection, tension pneumothorax, cardiac Tamponade should be considered.
These considerations should be running through the head of the clinician as the IV, EKG, and pulse oximetry are being set up.
In addition to the Troponin-T, bedside ultrasound, and Higher “slice count” CAT machines, and higher “Tesla” MRIs are becoming available major centers which could support small emergency rooms.
If there is One place where “the Flow” would be Appropriate it would be in the mind of the emergency room doctor evaluating acute chest pain.
I have a hard time imagining artificial intelligence endangering her job.
Diagnostics World (June 30, 2020): The shift from face-to-face patient visits to remote medical appointments is a worldwide phenomenon, but most especially in the U.S., finds a recent global survey conducted by the doctors-only social networking platform Sermo. Unsurprisingly, Zoom tops the list of most-mentioned technologies. About one-fifth of surveyed doctors say they expect to be using telehealth tools “significantly” more post-pandemic than before COVID-19 upended business as usual.
On a Friday afternoon last summer, a patient, “Barb,” texted me: “Call me. I can’t breathe.” As a heart failure nurse serving rural patients, getting messages like Barb’s launches my adrenaline. I called her immediately.
A month earlier, I’d trained Barb to send daily vital signs via my clinic’s digital portal—blood pressure, weight, heart rate, and oxygen saturation.
Barb was suffering from a congestive heart failure exacerbation: her lungs were filling with fluid. If we didn’t remove it, she’d need to be hospitalized or worse.
Once I was sure she wasn’t in emergency distress, I called the clinic’s cardiologist for instructions. Then I phoned Barb’s pharmacy and ordered a new diuretic to add to her regimen—a water pill so powerful in its fluid off-loading effect that I’ve nicknamed it the Bellagio. Within two hours, Barb had taken the pill and begun to urinate out the fluid flooding her lungs. By the next morning, she was breathing comfortably.
Without access to a telehealth program, Barb would probably have gone to the emergency room, then to the intensive care unit for expensive intravenous medications.