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Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000668432.62986.75
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COVID-19 PANDEMIC

Summer heat may not affect transmission

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Weather variables are known to influence the transmission of some respiratory infections, such as seasonal influenza. Will COVID-19 respond similarly? To investigate whether warmer temperatures and UV light from the sun are likely to inhibit the spread of COVID-19, researchers conducted a study based on meteorologic data and the cumulative number of confirmed COVID-19 cases from 224 Chinese cities with no less than 10 cases as of March 9, and calculated the basic reproduction number (R0) of COVID-19 for 62 cities with more than 50 cases as of February 10, 2020. R0 is the expected number of secondary cases generated by an initial infectious individual in a completely susceptible population.

The results showed that the cumulative incidence rate and R0 of COVID-19 were not significantly affected by ambient temperature. Noting that other emerging diseases such as Ebola and pandemic strains of influenza have occurred in unpredictable patterns, the researchers concluded that “our study does not support the hypothesis that high temperature and UV radiation can reduce the transmission of COVID-19. It might be premature to count on warmer weather to control COVID-19.”

Source: Yao Y, Pan J, Liu Z, et al. No association of COVID-19 transmission with temperature or UV radiation in Chinese cities. Eur Respir J. 2020;55(5).

DIABETES CARE

Safety guidelines during the pandemic

People with diabetes who contract COVID-19 are known to be at risk for a more severe course of infection. To help keep these patients safe, the JDRF/Beyond Type 1 Alliance has collected best practices recommended by 50 global organizations focused on both type 1 and type 2 diabetes. Besides reinforcing guidelines for anyone in the general public, such as maintaining personal hygiene and social distancing, these best practices also provide recommendations specific to those with diabetes; for example:

  • Test blood glucose levels more often than usual, because the body may react differently under these new circumstances.
  • Learn how to check for ketones and check ketone levels regularly, regardless of blood glucose levels.
  • Keep enough supplies on hand, including ketone strips and glucagon for severe hypoglycemia treatment.
  • Maintain a routine of healthy eating and exercise.
  • Look for support from the diabetes community via online and digital resources.

The guidelines are available in both English and Spanish and can be accessed at https://coronavirusdiabetes.org.

Source: JDFR/Beyond Type 1 Alliance. Coronavirus + diabetes. https://coronavirusdiabetes.org.

GASTRIC BALLOON DEVICES

FDA warns about risk of acute pancreatitis

The FDA has issued an update on the risks of hyperinflation, acute pancreatitis, and deaths associated with two liquid-filled intragastric balloon systems used for weight loss in adult patients with obesity. Hyperinflation, which involves the spontaneous filling of intragastric balloons with additional air or liquid while inside a patient's stomach, typically requires early device removal. Acute pancreatitis may result when pressure from the hyperinflated balloon and distended stomach causes direct or indirect injury to pancreatic structures.

The Orbera and ReShape intragastric balloon systems were approved by the FDA in 2015. Based on subsequent postmarketing studies and adverse event reporting on these devices, the FDA recommends:

  • educating patients about the signs and symptoms of potentially life-threatening complications associated with liquid-filled intragastric balloon devices and teaching them when to seek medical attention.
  • monitoring patients closely throughout treatment with these devices for potentially fatal complications, including acute pancreatitis and spontaneous hyperinflation.

To date, the FDA has received no reports of hyperinflation, acute pancreatitis, or death in the US associated with a gas-filled intragastric balloon system approved in 2016. Report any adverse events related to intragastric balloon systems through the MedWatch voluntary reporting system. Access an online form at www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home.

Source: US Food and Drug Administration. Update: potential risks with liquid-filled intragastric balloons—letter to health care providers. News release. April 27, 2020.

POISON CONTROL

Chemical exposures rise during pandemic

Probably reflecting increased efforts by consumers to disinfect surfaces during the pandemic, the CDC reports that from January to March 2020, more chemical exposures were reported to the National Poison Data System than in the corresponding months of 2019 and 2018. Poison centers received 45,550 exposure calls related to cleaners and disinfectants from January through March 2020, representing increases of 20.4% and 16.4% from the same 3-month periods in 2019 and 2018, respectively.

The number of calls to poison centers increased sharply at the beginning of March 2020 for both cleaners and disinfectants. From 2019 to 2020, bleaches amounted for the largest percentage of the increase among all cleaner categories (62%); nonalcohol disinfectants and hand sanitizers accounted for the largest percentage of increase among disinfectants (about 37% for each). An increase in calls was found across all age groups, but calls involving children age 5 and younger “consistently represented a large percentage of total calls in the 3-month study period for each year,” the author writes. Among all exposure routes, inhalation represented the largest percentage increase from 2019 to 2020.

The authors concluded that “although a causal association cannot be demonstrated, the timing of these reported exposures corresponded to increased media coverage of the COVID-19 pandemic, reports of consumer shortages of cleaning and disinfection products, and the beginning of some local and state stay-at-home orders.” Teach patients to read labels carefully, use products only as directed, and keep all toxic substances and medications out of children's reach.

Source: Chang A, Schnall AH, Law R, et al. Cleaning and disinfectant chemical exposures and temporal associations with COVID-19—National Poison Data System, United States, January 1, 2020-March 31, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(16):496-498.

SELF-INJURIOUS BEHAVIORS

FDA bans electrical stimulus devices

Effective in April, the FDA finalized a ban on electrical stimulus devices (ESDs) for managing self-injurious behavior (SIB) or aggressive behavior (AB). Characterized as aversive conditioning devices, ESDs are used to apply an electric shock to a person's skin to discourage these behaviors, which may include head-banging, hand-biting, excessive scratching, picking the skin, and repeated physical assaults. The FDA has concluded that ESDs are associated with many potentially serious physical and psychological harms such as pain, burns, tissue damage, depression, anxiety, worsening of underlying symptoms, and posttraumatic stress disorder. In addition, research “has not established a durable long-term conditioning effect or an overall-favorable benefit-risk profile for the devices,” according to the FDA. The FDA also notes that individuals with intellectual or developmental disabilities display SIBs and ABs in disproportionate numbers and may have difficulty communicating their pain or treatment choices. Intended to protect this vulnerable population, the ban applies to both new ESDs and those already in use.

Source: US Food and Drug Administration/Health and Human Services. Banned devices; electrical stimulation devices for self-injurious or aggressive behavior. Federal Register. March 6, 2020. www.federalregister.gov.

RHEUMATOID ARTHRITIS

Educate patients about CVD risk

Although patients with rheumatoid arthritis (RA) have a higher incidence of cardiovascular disease (CVD) compared with similar people without RA, they may not be well informed about the risk. A telephone study of 185 patients with RA revealed that nearly half (47%) were unaware that RA put them at greater risk for CVD. Only 25% reported receiving counseling on CVD risk from a rheumatologist or other physician. The study authors write that patient counseling “is an unmet need in clinical practice, which may be overcome by multimodal approaches such as developing websites, organizing symposiums, and involving health care providers at various levels.”

Source: Banerjee S, George MD, Singh S, et al. Patient perception of cardiovascular risk in rheumatoid arthritis. ACR Open Rheumatol. [e-pub April 20, 2020]

PEDIATRICS

Screen time for toddlers linked to ASD symptoms

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Evidence is growing that parent-child interactions and time viewing digital media affect child development, but little research has been performed on this issue with regard to symptoms of autism spectrum disorder (ASD). In a recent cohort study, researchers investigated the possible link between ASD and ASD-like symptoms with several experiential factors, including screen media exposure in children age 2 and younger. A total of 2,152 children were enrolled at birth from October 1, 2010, to October 31, 2012. Caregivers reported whether the child viewed TV and/or videos at age 12 months, hours of viewing at 18 months, time spent by the caregiver reading to the child at 12 months, and frequency of playing with the child at 12 months. Prematurity, maternal age at birth, child gender, household income, race/ethnicity, and caregiver English-language status were taken into account. Main outcomes and measures were significant association of exposures with ASD risk as assessed by the Modified Checklist for Autism in Toddlers (M-CHAT) and/or ASD-like symptoms assessed by revised M-CHAT total score in multiple regression models.

The researchers found “greater screen exposure and less caregiver-child play early in life to be associated with later ASD-like symptoms. Further research is needed to evaluate experiential factors for potential risk or protective effects in ASD.”

Source: Heffler KF, Sienko DM, Subedi K, McCann KA, Bennett DS. Association of early-life social and digital media experiences with development of autism spectrum disorder-like symptoms. JAMA Pediatr. [e-pub April 20, 2020]

In July, celebrate

E-CIGARETTES

Vascular damage rivals that of cigarette smoking

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Although many people believe that vaping e-cigarettes is safer than smoking combustible cigarettes, new research adds to the evidence that vaping takes a similar toll on the cardiovascular system. Researchers studied over 400 men and women (ages 21 to 45) who had not been diagnosed with heart disease or heart disease risk factors. Participants included 94 nonsmokers, 285 cigarette smokers, 36 e-cigarette users, and 52 dual users who used both combustible cigarettes and e-cigarettes. All e-cigarette users were former smokers of combustible cigarettes, and dual users had been using e-cigarettes for at least 3 months.

The investigators performed noninvasive vascular function testing on participants and analyzed measures of arterial stiffness: carotid-femoral pulse wave velocity, augmentation index, carotid-radial pulse wave velocity, and central BP. They found that former smokers who switched to e-cigarettes and dual users had an augmentation index similar to that of traditional cigarette users, meaning that arterial stiffness in these groups was comparable. In addition, they found that endothelial cells lining cardiac vessels appeared to be equally damaged in people using e-cigarettes, combustible cigarettes, or both.

Sources: Fetterman JL, Keith RJ, Palmisano JN, et al. Alterations in vascular function associated with the use of combustible and electronic cigarettes. J Am Heart Assoc. 2020;9(9):e014570. American Heart Association. E-cigarette users experience vascular damage similar to that of smokers of combustible cigarettes. News release. April 29, 2020.

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