Health Topics – Johns Hopkins Medicine Podcasts

Anchor lead: Barriers to universal access to telestroke services need political will to overcome, Elizabeth Tracey reports

With Zoom and other technologies employed nationally, why can’t some people who have strokes receive expert opinions on treatment and management via telestroke? A recent study clearly demonstrated improvement of outcomes when the technique is employed. Mona Bahouth, a telestroke expert at Johns Hopkins, describes the barriers.

Bahouth: This is not a new thing. Telestroke has been going for two decades now. We’ve had a lot of limitations and those limitations have really been policy, insurance and licensure limitations, meaning that you have a lot of restrictions for treating patients across state lines, if the patient’s insurance doesn’t count, so much of the onus has really fallen on to the individual hospitals to pay for this technique so I would say that it would expand greatly if we could eliminate some of those barriers like insurance barriers, licensure barriers, and that to me requires a big commitment from the community, and policy changes together.  :31

So vote for expansion of telehealth services, Bahouth says. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: What are the barriers to allowing everyone to access an expert when they have a stroke? Elizabeth Tracey reports

When someone has a stroke due to a clot, access to stroke experts via telemedicine, known as ‘telestroke’ was associated with decreased death and disability, a recent study showed. Mona Bahouth, a telestroke expert at Johns Hopkins, says there are barriers to universal access.

Bahouth: It sounds like a very easy proposition I mean we all have FaceTime or a way to get an audiovisual these days with our loved ones but its actually quite a proposition. You have to have a lot of capability at the center itself to use the technology in the midst of an emergent situation. You have to have a team of stroke experts who are on the ready 24/7 to answer those stroke calls and conduct the telemedicine visit with the patient. Not every hospital can have the financial support to do that especially if they have a lower census of stroke patients.  :28

Bahouth says that when people have a choice, choosing a center with first of all the ability to handle comprehensive stroke treatment and management is best. Failing that, employ all options to obtain expert opinions. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Does having cancer make people more susceptible to Covid? Elizabeth Tracey reports

Some people with cancer are more likely to become infected with Sars-CoV2 and develop Covid-19 than people who don’t have cancer, a very large analysis reveals. William Nelson, director of the Kimmel Cancer Center at Johns Hopkins, describes the data.

Nelson: There were 2.5 million cancer cases diagnosed within the past year in this group. Among them there were 16, 570 patients diagnosed with Covid-19. Twelve hundred of them had a cancer diagnosis. Overall the increased chance to get Covid-19 among cancer patients was seven fold. Seven times the number of the chance to get Covid-19 among the cancer patients. The strongest effect was for leukemia, non-Hodgkin’s lymphoma and lung cancer.  :31

Nelson says the increased susceptibility among those with these specific cancers makes sense since they are involved with the immune response and respiration, and points to the need for increased vigilance in these populations. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: What are the benefits of CT screening for smokers? Elizabeth Tracey reports

Those who’ve smoked a pack of cigarettes a day for 20 years or more should have low dose CT scans to screen them for lung cancer, the United States Preventive Services Task Force recommends. William Nelson, director of the Kimmel Cancer Center at Johns Hopkins, says they also assess the impact of screening on lung cancer.

Nelson: The benefits of screening they actually can estimate for you. There’s a 20 to 25% decrease in cancer deaths among people who get screened. The harms potentially of screening is that you see false positives, you see something on the scan that isn’t cancer that leads you to do something, in somewhere on the order of 25 to 30% of the first CT scan that you get, invasive procedures in about 1.7% of everyone who gets screened, so that’s the tradeoff. The US Preventive Services Task Force believes that that tradeoff is worth it and it’s worth it to extend this benefit to people who haven’t smoked quite as much.  :31

Nelson notes that such CT scanning is quick and widely available, so those with a smoking history that meets or exceeds the standard should definitely be screened. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: New lung cancer screening guidelines for those who’ve smoked are here, Elizabeth Tracey reports

People with a 20 pack year history of cigarette smoking should have low dose CT scans to screen them for lung cancer, a federal task force has recommended. William Nelson, director of the Kimmel Cancer Center at Johns Hopkins, says there are important implications to these expanded guidelines.

Nelson: One of the things is they’ve modeled through what that would mean and here’s the most important thing: by doing so you probably screen or make eligible for screening probably double the number of people we screen now and included among that is a greater fraction of African Americans. African Americans, individuals do different things but as a group they typically smoke a little bit less in terms of cigarettes than Caucasians but they still have lung cancer risk so now you use a screening tool to better aid African Americans.  :30

Nelson notes that even though such recommendations have been in place for heavy smokers for several years now, only about 15% of those eligible chose screening. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Treatment options for stroke are expanding, Elizabeth Tracey reports

If you experience a stroke that’s the result of a blot clot, treatment options may be employed for longer than ever before. Victor Urrutia, an expert in the use of telemedicine to evaluate stroke, says that’s one reason to get an expert opinion using this technology.

Urrutia: The window for TPA has expanded to 4 and a half hours. However for thrombectomy, which is available to patients that have large artery occlusion, so the big vessels in the brain, it’s standard for patients selected with advanced imaging, up to 24 hours. A significant number of the primary stroke centers have acquired the capacity to do advanced imaging. They can help with the selection of those patients and a faster transfer to those hospitals where they perform the procedure. Telemedicine can definitely help with this.  :33

Telestroke is becoming more available, Urrutia says. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: Why are there differences among stroke treatments around the US? Elizabeth Tracey reports

If you’re experiencing symptoms of a stroke, evaluation and treatment can vary quite a bit around the country, with a new study on the benefits of telemedicine in stroke evaluation perhaps helping to even the field. Victor Urrutia, a telestroke expert at Johns Hopkins, explains.

Urrutia: The stroke system in the US is organized broadly in several tiers. So there’s stroke ready hospitals, where they have prepared themselves to evaluate and treat, start for example the TPA, the thrombolytic agent then transfer the patient out to another center to continue the management of that patient. There’s the primary stroke centers, where they are equipped to treat the patient with the antithrombolytic, and keep the patient and continue the rest of the management.    :29

Urrutia says that with telestroke evaluation, people can feel confident that they will get expert evaluation and management even in more isolated areas although that may involve transfer to another facility. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: People experiencing a stroke can still get best management via telemedicine, Elizabeth Tracey reports

Stroke is a medical emergency, because early intervention with either clot-busting medicines or surgical removal of the clot, called thrombectomy, results in greater preservation of function. Now a new study shows that telestroke, where an expert is called in via telemedicine, enables centers without stroke experts to help their patients best. Victor Urrutia, a telestroke expert at Johns Hopkins, comments.

Urritia: This paper refers to the acute stroke evaluation. So the initial evaluation of a patient suspected of having a stroke, that occurs usually in the emergency department but can also in the hospital. The encounter is typically to determine if clinically this seems to be a stroke and whether they are a candidate for either thrombolytic therapy so the clot-busting medication, or mechanical thrombectomy, so in this setting would be a transfer for that.  :28

Urrutia notes that people can feel confident in the telestroke approach to achieve best outcomes. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: A year of experience has led to greater knowledge in managing Covid-19 infection, Elizabeth Tracey reports

Reflecting on the past year of treating people with Covid-19 infection, Brian Garibaldi, a critical care medicine expert at Johns Hopkins, says there are lessons learned.

Garibaldi: If you go on oxygen you’re going to get remdesivir. And you’re probably going to get dexamethasone. They’ll be a subset of patients who get tocilizumab, and they’ll be selected patients who get full dose anticoagulation. It’s hard to know what has really driven some of the decreases we’ve seen in mortality. Some of it’s going to be therapeutics I do think they have a role to play. A lot of it is we’ve become accustomed to working in these environments. One of the big factors I think underlies some of the ebbs and flows we’ve seen in mortality is simply the number of people who get hospitalized.  :29

Garibaldi says there is still a need to develop effective medications to treat Covid-19, and there are a number of trials ongoing looking at both repurposing existing medicines as well as developing and testing novel therapeutics. He notes that a need for updated vaccines appears likely. At Johns Hopkins, I’m Elizabeth Tracey.

Anchor lead: What are the ramifications of delaying second doses of Covid-19 vaccine? Elizabeth Tracey reports

Vaccinate as many people as possible or follow protocols for those vaccines that require two doses? Lots of attention is being paid to this issue as vaccine supplies remain tight, even with the Johnson and Johnson vaccine entering the fray. Brian Garibaldi, a critical care medicine expert at Johns Hopkins, says what’s needed is data.

Garibaldi: It’s very likely that delaying that second dose will still have that booster response from the immune system and get pretty high levels of efficacy. But it’s really going to be hard to compare that to the initial trials because there are now different variants that are circulating and so you’re not going to know is it because there are different variants that the efficacy is a little bit less or is it because of that delay. The other issue if you’ve had Covid already and recovered and you get your first dose of the vaccine it looks like those patients have as high antibody levels as people who never had Covid but got their second shot.  :30

Garibaldi says getting vaccinated with whatever vaccine is available to you is your best strategy. At Johns Hopkins, I’m Elizabeth Tracey.