Telemedicine: A Lifeline for Rural Residents

It looked like a bad case of shingles. At least that’s what the doctor working at a hospital in rural Virginia thought when he examined a patient who had come in. Still, he wanted to be sure. So he arranged to consult with a dermatologist.

But the specialist was not just down the hall, or even in an office across town. He was hundreds of miles away at the University of Virginia. The consultation would occur over the Internet, with the dermatologist doing a virtual examination of the woman’s damaged skin.

It turned out it wasn’t shingles. The doctor on the other end of the video connection recognized the condition as something much more serious — a flesh-eating strep infection. Immediate, aggressive treatment with surgery and antibiotics was necessary and the woman recovered.

That’s a dramatic example, but one that reflects a trend that’s beginning to transform rural health care in America: the use of telemedicine to compensate for the dwindling supply of doctors in rural communities.

Examining and diagnosing patients remotely is a long, long way from the iconic, hands-on country doctor. But it appears to be the future model for treating those living where stoplights — and specialists — are few and far between. And it is especially needed for rural older adults whose transportation options may already be limited by their inability to drive and lack of public transit.

Dietary supplement may help older adults to keep warm

Do your elderly parents keep the house at 80 degrees? This might help....

Older adults are known to be more sensitive to the cold, and new research has found that a nutritional supplement called L-carnitine might one day be used as a way to jump-start the body's central heating.

As we age, our ability to keep warm as temperatures drop is compromised, leaving older individuals at risk of hyperthermia.

Recently, a study using aging mice - conducted at the University of Utah Health in Salt Lake City - investigated whether or not there was something that could be done to reduce this risk. Led by senior author Claudio Villanueva, Ph.D., an assistant professor of biochemistry, the team focused particularly on fats.

White fat accumulates when we take on too many calories, which puts us at risk of metabolic disease. Brown fat, however, is different; it is rich in mitochondria, and, as temperatures turn frosty, brown fat is activated to generate heat.

In human adults, there is little brown fat to be found. However, in newborns and other animals that need to brave the cold (such as mice), it is much more abundant.

If L-carnitine - a readily available and cost-effective supplement - could be useful for helping older adults to stave off hyperthermia, this would be a considerable breakthrough. Of course, there will need to be further testing.

The fact that humans have considerably less brown fat than mice is likely to be an important factor. However, it is not just older adults that might benefit from this new line of inquiry.

"This work is putting a new face on an old character," says Dr. Simcox. "We're changing how we think about cold-induced thermogenesis."

Recently, there has been a lot of interest in brown fat and how it could potentially be used to combat obesity. Because it burns calories, it is thought that it might be able to burn excess fat.

As Prof. Villanueva explains, "The idea is to increase fuel utilization to drive the energy-demanding process of adapting to the cold. If we can find a way to tell the body to expend more energy than it is taking in, the calories lost can lead to weight loss."

Another Thing Disappearing From Rural America: Maternal Care

Maternity care is disappearing from America’s rural counties, and for the 28 million women of reproductive age living in those areas, pregnancy and childbirth are becoming more complicated — and more dangerous. That’s the upshot of a new report from the Rural Health Research Center at the University of Minnesota that examined obstetric services in the nation’s 1,984 rural counties over a 10-year period. In 2004, 45 percent of rural counties had no hospitals with obstetric services; by 2014, that figure had jumped to 54 percent. The decline was greatest in heavily black counties and in states with the strictest eligibility rules for Medicaid.

The decrease in services has enormous implications for women and families, says Katy B. Kozhimannil, an associate professor in health policy who directs the Minnesota center’s research efforts. Rural areas have higher rates of chronic conditions that make pregnancy more challenging, higher rates of childbirth-related hemorrhages — and higher rates of maternal and infant deaths. And because rural counties tend to be poorer, any efforts to revamp or slash Medicaid could hit rural mothers especially hard. We spoke with Kozhimannil about the new study and the implications for maternal care. (The conversation has been edited and condensed.)

Triple Threat: New Pneumonia Is Drug-Resistant, Deadly And Contagious

Still in China and should be amenable to a vaccine; for those of us who have to worry about our lungs....

In the past few years, there have been so many "superbugs" appearing in hospitals around the world that we here at Goats and Soda haven't had the time or resources to report on all of them.

But a new type of pneumonia emerging in China seems so important that we dropped what we were doing to write about it.

Doctors in Hangzhou in southeastern China have detected a a type of pneumonia that is both highly drug-resistant and very deadly. It also spreads easily.

The bacterium — a type of Klebsiella pneumoniae — killed five people in an intensive care unit in Hangzhou in 2016, researchers reported Tuesday in the journal Lancet Infectious Diseases.

"This fatal outbreak happened in a brand new hospital with very good hygiene," says microbiologist Sheng Chen, who co-led the study at the Hong Kong Polytechnic University. "Drug-resistant strains shouldn't have appeared so quickly."

The microbe can fight off all drugs available in China, Chen says. "We don't have anything in China to stop it," he says. "There is a drug available in the U.S. that should be effective against it, but we haven't tested it yet."

In the outbreak, the five patients who died were all older than 53. They were all on ventilators after undergoing major surgeries. And they died from severe lung failure, multiorgan failure or septic shock, the researchers found.

When Chen and his team sequenced the microbes found in the infections, they were shocked at what they saw. These bacteria aren't like other multidrug-resistant pneumonia reported before. They are a fusion of two dangerous forms.

How Well Do Health Trackers Really Work for Managing Chronic Conditions?

Physicians call it the 5,000-hour problem. If you have a common chronic condition such as cardiovascular disease or diabetes, the expert in charge of your health for almost all of your 5,000 waking hours annually is—you. And, frankly, you won’t always make the best choices.

“The behavior changes that are necessary to address chronic disease are much more in your hands than in the doctor’s,” points out Stacey Chang, executive director of the Design Institute for Health at Dell Medical School in Austin, Texas. “To cede that control to the doctor sometimes is actually counterproductive.”

With that in mind, a rapidly evolving set of new digital health tools is angling to help patients engage better with their own care. Wearable health monitors already on the market help to track heart rate, footsteps, or blood glucose levels; sophisticated home health sensors can report on weight and blood pressure; and phone apps can present key feedback and maybe even offer personalized advice.

The only problem: It has thus far proved very difficult to know what really works.

Many early attempts to truly test the efficacy of such digital technologies have shown them to be a flop in clinical trials—in large part because participants drop out. An analysis of five health apps built with Apple iPhone software, for example, found that only about one-eighth of participants, or less, were still hanging in after 10 weeks. Another recent study out of Singapore found that about 200 people outfitted with fitness trackers showed no better health outcomes than a similar control group after a year. And when Cedars-Sinai Medical Center in Los Angeles invited about 66,000 patients registered on its portal to share data from their fitness trackers, less than 1 percent did so, according to a paper published last year in the journal PLOS One, part of the open-access Public Library of Science.

In chronic disease, people lack instant gratification for, say, dropping that slice of pizza and eating their damn broccoli. Individual patients need to find personally meaningful ways to motivate themselves, like picturing themselves playing actively with their grandchildren, Chang said. A trained human health coach can help them build this motivational framework, but it remains a real challenge for a mobile app.

Research in behavioral economics can help to optimize more concrete healthy-habit incentives offered by employers or health plans, Volpp said. A clinical studypublished last year in the Annals of Internal Medicine, for example, either paid participants $1.40 for each day they took 7,000 steps, or gave them a virtual bank account holding 30 days’ worth of those payments—or $42—and then subtracted $1.40 for each day they didn’t walk 7,000 steps. The second method worked appreciably better.

“If you build it,” quipped Brennan Spiegel, an internal-medicine physician and head of the Cedars-Sinai Center for Outcomes Research and Education, “they will not come.”

Five ways to cope with migraine

What, then, are the options of prevention and treatment available to people who face migraines? Here is a list of the five most cited approaches.

1. Prescription and over-the-counter drugs

A range of over-the-counter (OTC) and prescription drugs are used to manage migraines. These include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). These are common OTC drugs and include aspirin (acetylsalicylic acid), ibuprofen, diclofenac, and naproxen. They are by far the most widely used type of medication in the case of migraines, partly because they are readily available and inexpensive, but also because they are effective in both mild and moderate attacks.
  • Triptans. These are serotonin receptor agonists, which, as their name suggests, selectively activate serotonin receptors. Low levels of serotonin are sometimes believed to be one of the causes behind migraine attacks. Triptans are occasionally prescribed to regulate that imbalance, but they are not effective in all cases.
  • Ergotamine. This is a chemical that can provide immediate pain relief. The drug is usually prescribed only to people who experience migraines infrequently, or whose attacks go on for a long time. Ergotamine is a vasoconstrictor, meaning that it causes blood vessels to become narrower. As such, it can have unpleasant cardiovascular side effects, so it is not recommended to people who experience migraines often.
  • Antiemetics. Since severe nausea and vomiting affect most people who experience migraines, antiemetic agents, or drugs that counter the sensation of nausea, are often prescribed.
  • Specialists advise that medication taken to relieve migraine "should be taken as early as possible after the onset of [an attack]" to maximize effectiveness.

The simple change stopping so many elderly people falling in Hampshire care home

Elderly people living in a Hampshire care home are less likely to stumble or fall thanks to a remarkably simple scheme that encourages older people to drink more.

Nurses working in West Hampshire CCG area introduced the idea, which uses red coloured glasses to prompt residents to drink water regularly.

Dehydration among older people can lead to a deterioration in mental state, and increase the risk of dizziness and fainting. Staying well hydrated can, on the other hand, help prevent falls as well as reduce urinary infection and improve concentration, memory and reaction time.

Equitable Relief Opportunity for Marketplace Enrollees Who Need Medicare Expires on September 30

The deadline for equitable relief is fast approaching and, because the best way to apply is through an inperson visit to a Social Security office, your clients should not wait until the last minute. 

What’s the issue: Many people who had Marketplace coverage and then qualified for Medicare made a costly mistake. They kept their Marketplace coverage and did not enroll in Medicare because they mistakenly believed that their Marketplace subsidies would continue. As a result they now face Medicare Part B late enrollment penalties and, for many, gaps in coverage. CMS has launched an initiative to provide these individuals with equitable relief including a Special Enrollment Period to sign up for Part B and, importantly, relief from Part B late enrollment penalties. 

The deadline for applications is September 30, 2017 

Please share this opportunity broadly! 

Who should apply: People who became eligible for Medicare on or after March 1, 2013, but did not enroll in Part B during their Initial enrollment period and, instead, stayed in a Marketplace plan. They must qualify for premium-free Part A. 

If they currently are not enrolled in Part B, they can get a Special Enrollment Period and relief from late Part B late enrollment penalties They can also ask for up to two months retroactive enrollment, but would have to pay premiums for those months. 

If they already enrolled in Part B but have late enrollment penalties, they can still apply for relief from the penalties. It does not matter whether they had qualified for Marketplace subsidies (advance premium tax credits, or ATPC). All can apply for relief.

Prolonged sitting and frailty a deadly combination

The Physical Activity Guidelines for Americans state that adults aged 18 to 64 and those aged 65 and older should aim to get at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity every week.

For adults who are unable to meet these guidelines, it is recommended that "they should be as physically active as their abilities and conditions allow."

According to statistics from the 2016 National Health Interview Survey, just 44.9 percent of older adults aged 65 to 74 met the physical activity guidelines last year.

What is more, previous research has shown that older adults spend more than 9 hours of their day sitting down.

The harms of sedentary behavior have been well documented. A study reported by Medical News Today last year, for example, suggested that sitting for more than 3 hours daily is responsible for more than 430,000 deaths across 54 countries every year.

The study included the data of 3,141 adults aged 50 and older who participated in the 2003-2004 and 2005-2006 United States National Health and Nutrition Examination Survey.

As part of the survey, subjects were required to wear activity trackers during waking hours, and the researchers used these data to calculate how much time each adult spent sedentary.

The team also used a 46-item index to assess the frailty of each subject. Frailty is generally defined as an aging-related process characterized by weakness, unintended weight loss, slowness, and fatigue.

Participants were followed up until 2011, or until their date of death.

Among adults who scored highly on the frailty index and did not meet the physical activity guidelines, the researchers found that prolonged sitting was associated with an increased risk of death. This was not the case for adults with low frailty who met exercise guidelines.

"Thus, among people who are inactive and vulnerable or frail, sitting time increases mortality risk, but among those who are non-frail or active, sitting time does not affect the risk of mortality," say the researchers.