In-person clinic visits are being replaced with virtual visits at a rapid pace

From the NEJM:

What if health care were designed so that in-person visits were the second, third, or even last option for meeting routine patient needs, rather than the first?

At Kaiser Permanente, 52% of 100 million patient encounters each year are now “virtual visits”. It spends 25% of its annual $3.8 billion budget on information technology.

"Payment models are an obvious barrier to deemphasizing in-person visits, but every provider’s business success depends on market share. The best way to win market share is to design and deliver better care, then modify the payment system to support it. Moreover, payment systems are already evolving to support nonvisit care. For example, use of bundled payment programs and accountable care organizations — which reward nontraditional care delivery models that reduce spending and meet patients’ needs — is growing."

Patients are increasingly asking, “Isn’t there a way to do this without my having to drive to your office?”

References:

In-Person Health Care as Option B — NEJM http://bit.ly/2ASHHTZ
NEJM Interview — In-Person Health Care as Option B http://bit.ly/2D8we8w
5% of patients account for 50% of healthcare costs http://bit.ly/2CVtvLR

Smartphone and Social Media Use in Lectures Makes Your Learn Less

Several studies have shown that problematic smartphone use (PSU) is related to detrimental outcomes, such as:

- worse psychological well-being
- higher cognitive distraction
- poorer academic outcomes

Problematic smartphone use (PSU) is strongly related to social media use.

The study participants were 415 Estonian university students aged 19-46 years (79% females).

Problematic smartphone use (PSU) and the frequency of social media use in lectures were negatively correlated with a deep approach to learning (defined as learning for understanding) and positively correlated with a surface approach to learning (defined as superficial learning).

Mediation analysis showed that social media use in lectures completely mediates the relationship between PSU and approaches to learning. These results indicate that the frequency of social media use in lectures might explain the relationships between poorer academic outcomes and PSU.

References:

Problematic Smartphone Use, Deep and Surface Approaches to Learning, and Social Media Use in Lectures. Int J Environ Res Public Health. 2018 Jan 8;15(1). pii: E92. doi: 10.3390/ijerph15010092.
https://www.ncbi.nlm.nih.gov/pubmed/29316697?dopt=Abstract

How to treat dry eyes

How common are dye eyes?

The prevalence of dry eyes has been estimated to be 5-30% percent in persons aged 50 years and older, 7% of US adult population has been diagnosed with dry eye disease. The prevalence increases with age (2.7% in those 18 to 34 years old vs. 19% in those aged 75 years and older). Prevalence is higher in women than men (9% versus 4%).

What are the risk factors for dry eye disease?

- Advanced age
- Female gender
- Hormonal changes (primarily due to decreased androgens)
- Systemic diseases (eg, diabetes mellitus, Parkinson disease)
- Contact lens wear
- Systemic medications (antihistamines, anticholinergics, estrogens, isotretinoin, selective serotonin receptor antagonists, amiodarone, nicotinic acid)
- Ocular medications (especially those containing preservatives)
- Nutritional deficiencies (eg, vitamin A deficiency)
- Decreased corneal sensation, for example, after Laser-assisted in situ keratomileusis (LASIK)
- Ophthalmic surgery (especially corneal refractive surgery)
- Low humidity environments
- Sjögren's syndrome

What are the treatments for dry eyes?

Tear conservation

The use of medications that may worsen symptoms of dryness should be avoided.

Moisture-conserving eyewear

Physical barriers, such as large-frame glasses to minimize tear evaporation, can be helpful. Moisture-conserving eyewear can be employed to conserve the tear film. These may be most helpful in particular situations, such as when traveling into dry and/or windy environments such as airplanes or long air-conditioned car rides, during which humidity is low; and while exercising, especially jogging or biking, during which increased air movement on the ocular surface and decreased blink rate are encountered.

Examples of moisture-conserving eyewear include:

- Side shields, which can be fitted to glasses, reducing the evaporation rate of normal or artificial tears
- Wraparound sunglasses, which are more socially acceptable to many patients than are side shields or goggles
- Ski or swim goggles, which also reduce evaporation

Environmental management

Artificial tears should be used regularly to help prevent complications and to increase comfort before entry into dry environments.

The following environments may be problematic:

- Dry or windy outdoor environments
- Dry indoor environments
- Areas with polluted air and other irritants, including the presence of smokers
- Hospital operating and recovery rooms

Computer use is associated with a decreased blink rate, and extended computer use can be especially problematic and may worsen dry eye. Frequent, short breaks and additional longer breaks may be beneficial.

The use of humidifiers is helpful in bedrooms and other rooms in which the patient spends a lot of time. Here is the best seller from Amazon:



Warm compresses

How to use warm compresses:

- boil water and leave it to cool to a warm temperature
- soak a clean flannel or eye pad in the warm water and gently place this over the eyes for around 10 minutes
- reheat the compress periodically by soaking it in warm water, ensuring the flannel doesn't become cold
- You can also buy a special microwaveable compress for your eyes to use instead of a flannel

The regular use of warm compresses over the eyes can also provide symptomatic relief by improving meibomian gland secretions. Thermalon is one such product:



Eyelid massage

From NIH (http://bit.ly/2libUXE): Gently massage your closed eyes by rolling your little finger in a circular motion. Take a cotton wool bud and, with your eyes shut, gently roll it downwards on the upper eyelid towards the lashes and edges of the eyelids – this helps to push the melted oil out of the glands, although you won't see anything come out. Repeat this process along the whole width of the upper and lower eyelids

This process may cause your eyes to become slightly irritated at first, a bit like getting soap in your eyes, but this is normal and should get better with time.

Diet

There's some evidence to suggest a diet high in omega-3 fats can help improve dry eye syndrome. The best sources of omega-3s are oily fish, such as:

- mackerel
- salmon
- sardines
- herring
- fresh or frozen tuna – not canned, as the canning process sometimes removes the beneficial oils

Aim to eat at least two portions of fish a week, one of which should be oily fish. You can also get omega-3s from various nuts and seeds, vegetable oils, soy and soy products, and green leafy vegetables. Omega-7, or sea buckthorn oil, has also been found to be helpful.

Artificial tears

Artificial tears generally include 3 agents:

- cellulose to maintain viscosity
- a spreading agent such as polyethylene glycol or polyvinyl alcohol to prevent evaporation
- a preservative to prevent contamination

Different forms of artificial tears

"Artificial tears" come in liquid, gel, and ointment forms. Preservative-free forms of these supplements are often recommended as some individuals with dry eye will have inflammatory reactions to the preservatives. These are often single-use formulations.

Laser-assisted in situ keratomileusis (LASIK) is a refractive procedure that causes dry eyes, in part due to decreased postoperative corneal sensation.

How often to use artificial tears?

A reasonable starting dose for artificial tear administration is one drop in each eye, four times per day. Patients often begin to notice improvement within a few days of initiating treatment but may take up to three to four weeks to note a significant change in their symptoms.

If individuals remain symptomatic, the frequency of artificial tear use can be increased to the level of symptoms, even as frequently as every hour. If used more often than four to six times per day, it is recommended that a preservative-free formulation be used to minimize the potential for toxicity.

Higher-viscosity artificial tear gels and ointments are also commercially available and can be used if patients feel that the eye drops are not providing enough symptomatic relief. Patients should be warned that the gels, and especially ointments, can blur vision temporarily and are often best used at bedtime.

How long to use artificial tears?

Unless there is a specific inciting factor that can be eliminated, dry eyes are most often a chronic condition and require chronic treatment. Patients should be advised that they will need to use artificial tears for relief of dry eye symptoms indefinitely.

Topical cyclosporine

Topical cyclosporine is an immunosuppressive agent that has been found to be relatively safe.

It is important to note that not all patients respond to cyclosporine.

A 0.05% emulsion of cyclosporin is available for treatment of dry eye disease. It may take up to six weeks or longer to achieve noticeable improvement of dryness. In some patients, cyclosporine can result in long-term resolution of dry eye symptoms.

An important limiting factor of cyclosporine use is high cost.

As patients may have other concurrent problems such as infection leading to eye irritation, they should have a complete ophthalmological examination prior to receiving cyclosporine.

Topical lifitegrast

A topical eye drop formulation, lifitegrast 5.0%, an integrin antagonist, was approved by the FDA in 2016. The ophthalmic solution is used twice a day and has known side effects of eye irritation or discomfort and an associated bad taste in approximately 25% of patients.

Adjunctive treatments by eye specialists

- Topical sodium hyaluronate

- Low dose topical glucocorticoids (CS) - only on a short-term basis. CS can have significant side effects with continued use, including cataracts and glaucoma.

- Autologous serum tears – The serum of a patient's blood can be formulated into eye drops.

- Tear stimulation – Systemic pilocarpine (a cholinergic agonist) has been found to improve dry eye symptoms in patients with Sjögren's syndrome but is associated with systemic side effects.

- Topical omega-3 fatty acids

- Oral antioxidants

- Vitamin A – Systemic vitamin A deficiency is associated with severe ocular surface dryness with keratinization of the conjunctiva (Bitot spots) and night blindness. Topical vitamin A eye drops can improve dry eye symptoms.

- Punctal occlusion – Either temporary or permanent occlusion of the openings of the tear drainage system.

- Scleral contact lenses – large-diameter contact lenses can be used to help retain a tear reservoir over the ocular surface. These types of contact lenses require a specialized fitting by an experienced contact lens practitioner.

- Acupuncture

- Surgery – Eyelid abnormalities should be surgically corrected to realign and maintain normal lid architecture.

- Investigational – Diquafosol and rebamipide eye drops

References:

Dry eyes - UpToDate http://bit.ly/2BSmKdc
Treatment of dry eye in Sjögren's syndrome: General principles and initial therapy - UpToDate http://bit.ly/2lkfyA4
Treatment of moderate to severe dry eye in Sjögren's syndrome - UpToDate http://bit.ly/2lisWoe
NIH Self-help http://bit.ly/2libUXE
Using warm compresses to treat meibomian gland disease http://bit.ly/2litJ8G
Simple Solutions for Dry Eye http://bit.ly/2lqQV3S

Major Success for Gene Therapy for Factor IX Deficiency: near elimination of bleeding and factor use

Hemophilia B Gene Therapy with a High-Specific-Activity Factor IX Variant: the researchers infused a single-stranded adeno-associated viral (AAV) vector consisting of a bioengineered capsid, liver-specific promoter and factor IX Padua (factor IX–R338L) transgene in 10 men with hemophilia B who had factor IX coagulant activity of 2% or less of the normal value.

They found sustained therapeutic expression of factor IX coagulant activity after gene transfer in the 10 participants with hemophilia who received the same vector dose. Transgene-derived factor IX coagulant activity enabled the termination of baseline prophylaxis and the near elimination of bleeding and factor use.

More info here: http://www.nejm.org/doi/full/10.1056/NEJMoa1708538

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