Cecilia Pessoa Gingerich

Telehealth is a growing avenue for providing health care, and is used in specialties from 

. A cross-sectional study of the accessibility of 

 clinics and teledermatological programs to American Indians in rural areas found that there were significant barriers to brick-and-mortar dermatology services and that telehealth programs are lacking but could be an avenue toward reducing disparities in access to dermatological care.

Investigators found that the mean driving distance between a rural Indian Health Service (IHS) or tribal health care facility and the nearest dermatology clinic was 68 miles. A majority (62%, n = 21) of these facilities did not have a dermatology clinic within a 35-mile driving distance and 32% (n = 11) were over 90 miles from a dermatology clinic.

Additionally, of the 25 dermatology clinics that responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance.

Study authors led by Anna Morenz, BA, Harvard Medical School, noted that the burden of the distance of dermatology clinics hides many costs including the time spent driving, the time away from work or caregiving, and the costs of owning a vehicle and paying for gas. Furthermore, roads in rural areas may not always be passable. For those without access to a vehicle, public transportation is limited or unavailable in rural areas.

“Given the geographic barriers, telehealth innovations are an appealing intervention,” wrote Morenz et al. However, in surveying telehealth programs offering dermatology services, they found that 14 (29%) of the 49 surveyed programs were no longer active. Additionally, just 9% (n = 27) of the 303 rural IHS or tribal health care facilities were served by a teledermatological service.

An accompanying editorial by Lucinda Kohn, MD, MHS, Department of Dermatology, University of California, San Francisco and Camille Introcaso, MD, Pennsylvania Center for Dermatology, outlined the historical injustices with ongoing consequences that have shaped American Indian and Alaskan Native communities and their health care systems.

Kohn and Introcaso wrote that in order to provide effective and sustainable care for American Indians and Alaskan Natives in rural areas, providers must understand the historical context, the complex federal and tribal policies, and fully respect tribal sovereignty.

Morenz et al acknowledged the complex historical and current factors affecting access to dermatology care for these populations, pointing out that while the study focused on geographic and insurance limitations, there are also potential language barriers and mistrust of the health care system due to a history of unethical research and practice.

“Without complete appreciation for this cultural context, teledermatology is an incomplete solution for dermatology inequity seen in American Indian and Alaskan Native communities,” wrote Kohn and Introcaso.

Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities

,” and editorial, “A Cultural Context for Providing Dermatologic Care to American Indian and Alaskan Native Communities Through Telehealth,” were published in 

Articles

Both brick-and-mortar dermatology clinics as well as telehealth programs are limited and restricted by barriers to access.

Dermatology Care Limited in Rural American Indian Communities

 The US Food and Drug Administration (FDA) has approved a new cochlear implant—the Cochlear Nucleus Profile Plus Series. The new implant was designed to be safe for MRI scans and implant users will not need to remove the internal magnet or use a head wrap for 1.5 and 3.0 Tesla (T) MRI scans.

"For more than 2 decades, Cochlear has been pleased to provide Nucleus Cochlear Implant recipients with access to MRIs," said Tony Manna, President, Cochlear Americas. "Now with the approval of the Nucleus Profile Plus Implant, we are able to provide our cochlear implant recipients MRI access without the need to remove the internal magnet or needing a head wrap at 1.5 and 3.0 T, improving the experience for both healthcare professionals and their patients."

The FDA also approved an integrated connectivity feature for the Nucleus 7 Sound Processor which allows users to directly connect with and stream audio from compatible Android phones.

"When a person chooses a cochlear implant, it begins a partnership between them and the cochlear implant company for the rest of their life. As the most chosen cochlear implant manufacturer with recipients all around the world, we at Cochlear understand our responsibility to innovate reliable implants and upgradeable sound processors that meet the needs of our customers today and in the future," said Patricia Trautwein, AuD, Vice President, Marketing and Product Management, Cochlear Americas.

The company announced that the Nucleus Profile Plus Series Cochlear Implant will become available this month, and the new features for the Nucleus 7 Sound Processor will become commercially available in the US and Canada this fall.

The new approval allows for easier access to MRIs and direct audio streaming from Android devices.

FDA Approves MRI-friendly Cochlear Implant

Results of a prospective cohort study of parous women found that 77% of the excess cardiovascular disease risk for women with a history of hypertensive disorders of pregnancy (HDP) is due to blood pressure and body mass index.

“Blood pressure plays a substantial role in driving the excess cardiovascular risk in women who experienced preeclampsia and an even larger role in women who experienced gestational hypertension,” wrote the study authors led by Eirin Beate Haug, PhD, K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.

The authors noted that several previous studies have established that women with a history of HDP have about double the risk of cardiovascular disease (CVD) as women with normotensive pregnancies. However, they added that identifying which factors this excess risk is associated with is important for developing preventive measures.

This study examined the risk factors of body mass index (BMI), blood pressure (BP), glucose levels, and lipid levels in 23,885 women participating in the HUNT study. Authors linked data from the HUNT study, the Medical Birth Registry of Norway, the Norwegian Cause of Death Registry, and validated cardiovascular events from the local hospitals.

For this study, women with HDP were those who had ever experienced preeclampsia or gestational 

 at ≥40 years of age. Among participants, 2119 (9%) had a history of HDP, 1391 experienced preeclampsia at least once, and 728 experienced only gestational hypertension.

During the median follow-up period of 18 years, 1688 participants experienced at least 1 CV event and 1565 (92.7%) had a validated CV event. Of the 1688 participants, 553 had a myocardial infarction, 233 had heart failure, and 878 had a cerebrovascular event. The authors adjusted hazard ratios for age, maternal birth year, highest educational level, ever daily smoking, parity before age 40 years, and family history of coronary heart disease in sibling or parents.

Women between 40 and 70 years of age with a history of HDP had a higher risk of experiencing any CV event (HR, 1.57; 95% CI, 1.32-1.86; 

 <.001) than participants without any history of HDP. For the same comparison, women with previous preeclampsia (HR, 1.66; 95% CI, 1.34-2.06; 

 <.001) and women with previous gestational hypertension (HR, 1.43; 95% CI, 1.09-1.88; 

For women over the age of 70 years, however, the association was reversed but not statistically significant—those with a history of HDP had a lower risk of CV event (HR, 0.60; 95% CI, 0.34- 1.04; 

 = .07) than women with only normotensive pregnancies. This apparent reversal may be the result of survivor bias, according to the investigators.

For participants 40 to 70 years of age, 41% of the association between HDP and cardiovascular disease was associated with BMI (HR 1.19; 95% CI, 1.07-1.33; 

 =.001). Systolic BP was associated with 60% (HR 1.30; 95% CI, 1.16-1.47) and diastolic BP with 73% (HR 1.38; 95% CI, 1.23-1.55) of the association between HDP and CVD (

When investigators analyzed BMI and blood pressure jointly, they found that BMI and systolic BP were associated with 67% of the HDP and CVD association while BMI and diastolic BP were associated with 79% (

“The association of conventional risk factors, in particular blood pressure and BMI, with the development of CVD in women with history HDP indicate that preventive efforts aimed at decreasing the levels of these risk factors could reduce cardiovascular risk in women with history of HDP,” wrote Haug et al.

Association of Conventional Cardiovascular Risk Factors With Cardiovascular Disease After Hypertensive Disorders of Pregnancy

Up to 77% of the increased CVD risk associated with preeclampsia and gestational hypertension is associated with conventional risk factors like BMI and blood pressure.

Much Pregnancy-related CVD Risk Associated with BMI, BP

The preliminary results of a new study show that 49% nurses at an academic medical center averaged less than 7 hours of sleep per night and many experience symptoms of disordered sleep.

For comparison, authors noted that nationally, 28% of adults average under 7 hours of sleep per night.

“We were surprised by the number of nurses potentially suffering from common sleep disorders, most notably, chronic insomnia and shift work disorder,” said lead author Francis Christian, MD, a second-year fellow at the University of Oklahoma Health Sciences Center in Oklahoma City.

The findings were presented as a poster on Monday at SLEEP 2019, the 33rd annual meeting of the Associated Professional Sleep Societies LLC (APSS) and will be presented orally on Wednesday at the conference.

“Nurses are at increased risk for circadian rhythm sleep-wake disorders such as shift work disorder,” said Christian. “Recognition needs to take place so that we can screen appropriately and make scheduling modifications to help alleviate the burden of shift work disorder among nurses.”

The cross-sectional study was completed online by nurses over 18 years of age at a tertiary care medical center. Data on demographics, sleep schedule, medications used to sleep or stay awake, and history of obstructive sleep apnea, restless leg syndrome, insomnia, and shift work disorder were collected. Additionally, each respondent completed the STOP-BANG questionnaire and Epworth sleepiness scale (ESS), which authors used to assess sleep disorder symptoms. The study included 1165 nurses at University of Oklahoma Health Sciences Center in Oklahoma City.

The average sleep time reported by nurses was 6.6 hours per night compared to an average of 6.8 hours nationally. Regarding medications, 26% of nurses used medicine to assist with sleeping and 13% used medicine to stay awake.

Both symptoms of chronic insomnia and shift work disorder were identified in 31% of surveyed nurses, each. Additionally, 14% had restless leg syndrome, 4.5% had excessive daytime sleepiness, and 18.5% were at moderate to severe risk for obstructive sleep apnea.

“A focus on self-awareness and interventions is warranted to mitigate against the detrimental effects of sleep disorders, ensuring proper safety and performance for nurses at work,” the authors concluded.

Sleep Health of Nursing Staff in an Academic Medical Center: Results of a Survey Study

,” was presented at SLEEP 2019 in San Antonio, Texas, and published in 

A survey of nurses at an academic medical center found that 49% averaged less than 7 hours of sleep per night, compared to the national figure of 28%.