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Telehealth might be best as a supplement to office visits, not a replacement

The findings suggest that while patients 70 and older may well be capable of navigating the technical aspects of virtual doctor visits and are interested in communicating online with health-care professionals, their opinions on the effectiveness of the care they receive varied widely.

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Photo by Samantha Borges from Unsplash.com

With the pandemic, there has been a rise in the use of virtual appointments for patients seeking health care. A new study by Tufts researchers, however, suggests that for many older and chronically ill patients, telehealth appointments may be most effective when they augment in-person health-care visits rather than fully replace them.

The findings suggest that while patients 70 and older may well be capable of navigating the technical aspects of virtual doctor visits and are interested in communicating online with health-care professionals, their opinions on the effectiveness of the care they receive varied widely.

The study, which focused on older patients with serious and chronic kidney disease, found that not all patients were satisfied with telehealth. People of color, including patients who identified as Black, Native American, or Hispanic, or required additional accessibility features such as interpreters, were largely dissatisfied with telehealth.

Patients of color disproportionately suffer from chronic kidney disease and may more often contend with challenges associated with at-home care, such as inadequate space for home-dialysis and limited broadband access to support video-telehealth visits, said Keren Ladin, associate professor of occupational therapy and community health, who led the study.

Owing to historical and experienced discrimination, “we found that patients of color were less comfortable with telehealth and had more concerns about the quality of the care and being deprived of care in a telehealth setting than white patients did,” said Ladin.

Ladin said she was surprised by these findings, given that the study, which was recently published in JAMA Network Open, was conducted during the height of the COVID-19 pandemic.

“I thought people of color who were at higher risk would prefer to stay out of the health system for longer, but that was not what we found,” she said. Black patients also reported that telehealth appointments prevented them from connecting meaningfully with their doctors, contributing to feelings of mistrust.

“It was really striking,” said Ladin. “One woman told us, ‘I need to see the physician’s eyes to know that they were understanding me,’ underscoring that the persistent impacts of structural racism on health-care experiences of patients of color.”

The patients did appreciate that telehealth facilitated the ability of care partners such as family members to join them for appointments, something that has been limited during the pandemic. Beyond the comfort of accompanying patients, care partner participation can help improve treatment and adherence and patient education for older patients managing complex, chronic illnesses such as kidney disease, Ladin said.

Downsides from the Clinical Perspective

For clinicians, the low regard for telehealth appointments was more pronounced. A majority of the physicians interviewed remotely from Boston, Chicago, Portland (Maine), and San Diego equated telehealth with lower-quality care.

They could not, for example, conduct physical examinations and lab tests virtually, nor could they naturally build and maintain a personal rapport with chronic-disease patients. Patients, too, were worried about this.

“We heard loud and clear from clinicians that they felt that the human aspects of their job that they love so much—the communication with patients and those relationships—were fraught and damaged by this flat interaction style,” Ladin said. She conceded that although clinicians were generally dissatisfied with telehealth in its current form, most agreed that it did provide critical insight into a patient’s home, which was previously unavailable.

“Up until now, the patient’s home environment was really a black box,” Ladin said, “Whatever the patient said when they came into the office was accepted as truth.” During video visits, however, doctors are able to see patient’s homes, the exact medications they are taking, and interact directly with care partners. “That was a positive feature of these types of visits—more holistic care.”

To address the range of obstacles perceived by both patients and clinicians in the study, the researchers recommend doctors share detailed post-visit summaries with patients and care partners, leave time during virtual visits for patients to absorb difficult news, and inquire specifically after patients’ emotions in the absence of nonverbal cues. Structural inequalities require a longer-term but equally important investment beyond simple communication strategies.

“I wish I could say we are doing it perfectly in person, and that telehealth is the only challenge we’re facing,” said Ladin. “We’re not. We need to work on this both in person and for telehealth.”

She stressed the importance of increasing the availability of interpreters during virtual visits and a more diverse workforce throughout the medical training pipeline, including nurses and physician assistants.

“The type of community-building and relationship repair that need to happen in health care will go a long way in improving this aspect,” said Ladin. “Diversifying the health-care workforce is crucial.”

Many telehealth services will stay covered by Medicare through 2023, under current law. After that, the future of remote health care for older Americans remains uncertain. Much of it will depend on whether perceptions among these patients, and in particular those with chronic illness, are positive. For Ladin, the benefits are as clear as the drawbacks.

“At its best, maybe we are getting back to a more patient-centered approach,” she said. “But I would be cautious to use it as a replacement device. For older, complex patients, we want to strive for a balance between seeing somebody in person in the clinic most times and then occasionally seeing them onscreen.”

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Eating late increases hunger, decreases calories burned, and changes fat tissue

Eating later had profound effects on hunger and appetite-regulating hormones leptin and ghrelin, which influence our drive to eat. Specifically, levels of the hormone leptin, which signals satiety, were decreased across the 24 hours in the late eating condition compared to the early eating conditions.

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Obesity afflicts approximately 42 percent of the adult population and contributes to the onset of chronic diseases, including diabetes, cancer, and other conditions. While popular healthy diet mantras advise against midnight snacking, few studies have comprehensively investigated the simultaneous effects of late eating on the three main players in body weight regulation and thus obesity risk: regulation of calorie intake, the number of calories you burn, and molecular changes in fat tissue. A new study by investigators from Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system, found that when we eat significantly impacts our energy expenditure, appetite, and molecular pathways in adipose tissue. Their results are published in Cell Metabolism.

“We wanted to test the mechanisms that may explain why late eating increases obesity risk,” explained senior author Frank A. J. L. Scheer, PhD, Director of the Medical Chronobiology Program in the Brigham’s Division of Sleep and Circadian Disorders. “Previous research by us and others had shown that late eating is associated with increased obesity risk, increased body fat, and impaired weight loss success. We wanted to understand why.”

“In this study, we asked, ‘Does the time that we eat matter when everything else is kept consistent?’” said first author Nina Vujović, PhD, a researcher in the Medical Chronobiology Program in the Brigham’s Division of Sleep and Circadian Disorders. “And we found that eating four hours later makes a significant difference for our hunger levels, the way we burn calories after we eat, and the way we store fat.”

Vujović, Scheer and their team studied 16 patients with a body mass index (BMI) in the overweight or obese range. Each participant completed two laboratory protocols: one with a strictly scheduled early meal schedule, and the other with the exact same meals, each scheduled about four hours later in the day. In the last two to three weeks before starting each of the in-laboratory protocols, participants maintained fixed sleep and wake schedules, and in the final three days before entering the laboratory, they strictly followed identical diets and meal schedules at home.

In the lab, participants regularly documented their hunger and appetite, provided frequent small blood samples throughout the day, and had their body temperature and energy expenditure measured. To measure how eating time affected molecular pathways involved in adipogenesis, or how the body stores fat, investigators collected biopsies of adipose tissue from a subset of participants during laboratory testing in both the early and late eating protocols, to enable comparison of gene expression patterns/levels between these two eating conditions.

Results revealed that eating later had profound effects on hunger and appetite-regulating hormones leptin and ghrelin, which influence our drive to eat. Specifically, levels of the hormone leptin, which signals satiety, were decreased across the 24 hours in the late eating condition compared to the early eating conditions. When participants ate later, they also burned calories at a slower rate and exhibited adipose tissue gene expression towards increased adipogenesis and decreased lipolysis, which promote fat growth. Notably, these findings convey converging physiological and molecular mechanisms underlying the correlation between late eating and increased obesity risk.

Vujović explains that these findings are not only consistent with a large body of research suggesting that eating later may increase one’s likelihood of developing obesity, but they shed new light on how this might occur. By using a randomized crossover study, and tightly controlling for behavioral and environmental factors such as physical activity, posture, sleep, and light exposure, investigators were able to detect changes the different control systems involved in energy balance, a marker of how our bodies use the food we consume.

In future studies, Scheer’s team aims to recruit more women to increase the generalizability of their findings to a broader population. While this study cohort included only five female participants, the study was set up to control for menstrual phase, reducing confounding but making recruiting women more difficult. Going forward, Scheer and Vujović are also interested in better understanding the effects of the relationship between meal time and bedtime on energy balance.

“This study shows the impact of late versus early eating. Here, we isolated these effects by controlling for confounding variables like caloric intake, physical activity, sleep, and light exposure, but in real life, many of these factors may themselves be influenced by meal timing,” said Scheer. “In larger scale studies, where tight control of all these factors is not feasible, we must at least consider how other behavioral and environmental variables alter these biological pathways underlying obesity risk. ”

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DKSH, LEO Pharma partner to deliver products, solutions to people with skin conditions, thrombosis

DKSH Business Unit Healthcare, a leading partner for healthcare companies seeking to grow their business in Asia and beyond, has partnered with LEO Pharma to bring high-quality therapeutic products for dermatology and thrombosis to patients across Asia.

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DKSH Business Unit Healthcare, a leading partner for healthcare companies seeking to grow their business in Asia and beyond, has partnered with LEO Pharma to bring high-quality therapeutic products for dermatology and thrombosis to patients across Asia.

Partnering in Hong Kong, Malaysia, Singapore, Taiwan, Thailand, Vietnam, and the Philippines, the two companies seek to solidify brand presence, grow market share, and ultimately improve patient health outcomes in the region. Skin diseases can cause serious physical and social discomfort for millions of patients around the world whereas thrombosis can affect anyone regardless of their age, race, gender, and ethnicity.

DKSH will support LEO Pharma by building dedicated sales and marketing teams on the ground in Asia and managing logistics and product distribution in these markets. The firm’s experienced teams and broad distribution network will ensure LEO Pharma products reach modern trade, traditional trade, hospitals, clinics, and other medical channels, as well as patients in need across the region.

LEO Pharma is a global company dedicated to advancing the standard of care for the benefit of people with skin conditions, their families and society. With decades of research and development to advance the science of dermatology, LEO Pharma now offers a wide range of innovative treatments and therapies for all skin disease severities as well as thrombosis.

Khalid Aouidat, Vice President, responsible for commercial activities in Southeast Asia at LEO Pharma commented: “At LEO Pharma, we are dedicated to changing the standards of care for people with skin diseases by bringing new innovative treatments forward and making them easily accessible. Supporting this ambition, we are delighted to be partnering with DKSH. Their experience and strong regional footprint in Asia, as well as their marketing and sales expertise will help to further strengthen LEO Pharma’s brand and its continued growth.”

Bijay Singh, Head of Business Unit Healthcare at DKSH, said: “We are committed to enriching people’s lives and improving healthcare for all. The partnership with LEO Pharma strengthens our ambition to become the preferred partner for clients to help patients in Asia to have better access to high-quality and innovative products and solutions. While we drive their growth across the region, LEO Pharma can focus on researching and developing products and solutions for people with skin conditions.”

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Epson partners with WWF, launches mangrove restoration project in Palawan

Epson, which has previously supported the development of WWF-Philippines’ virtual museum Museo Kalikasan, is now supporting the Mangrove Restoration Project in the municipalities of Balabac and Bataraza, Southern Palawan.

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Epson Philippines’ partnership with the World Wide Fund for Nature (WWF) Philippines for marine ecosystem restoration has officially kickstarted with a ceremonial launch in Balabac, Palawan. Supported by project stakeholders such as the European Union delegation to the Philippines and local government officials, the project launch highlights the importance of rehabilitating mangrove sites, recognizing their critical role in marine biodiversity and protecting coasts from erosion and storm surges.

Epson, which has previously supported the development of WWF-Philippines’ virtual museum Museo Kalikasan, is now supporting the Mangrove Restoration Project in the municipalities of Balabac and Bataraza, Southern Palawan. As part of the wider European Union-funded Ocean Governance Project—an initiative focused on strengthening habitat resilience through restoration in the Sulu Sulawesi Seascape that covers the Philippines, Indonesia, Malaysia—the joint mission in Palawan aims to boost local capacity in taking care of the mangroves, as well as address other critical issues such as plastic waste management. With Epson as a key partner, the Mangrove Restoration Project was able to expand beyond Balabac and into the neighboring municipality of Bataraza. In addition, the growing relationship between Epson Philippines and WWF-Philippines only further drives Epson Philippines’ commitment to support sustainable innovations and initiatives to solve the world’s greatest challenges.

“Corporations have a shared responsibility in sustainable development,” said Eduardo Bonoan, Epson Philippines’ General Manager for Marketing Division, who shared his remarks virtually during the project launch. “As Epson continues its commitment to sustainable innovation and environmental responsibility, we believe in forming critical partnerships with organizations that are aligned with our values—such as WWF-Philippines.”

To further the goals of the Mangrove Restoration Project, WWF-Philippines will continue to work with local government and key stakeholders such as Epson Philippines to establish a ‘Community Learning and Innovation Hub’ that aims to bridge knowledge gaps and strengthen coastal communities’ experience in resource management, thereby helping to build local capacity.

“It is important that we continue to protect and manage Balabac’s valued mangrove forests to boost our efforts in keeping a healthy environment and supporting local livelihoods,” said Balabac Mayor Shuiab J. Astami, who officially launched the project in Balabac Island.

“We are excited to be part of this multi-stakeholder effort that will restore critical mangroves in Balabac, Palawan and improve the way their coastal resources are managed for the long haul. We strongly hope that this project will succeed and serve as an example for many other communities,” said Executive Director of WWF-Philippines, Katherine Custodio.

Moving forward, Epson aims to continue setting a more sustainable example for corporations across the region.

“Working alongside governments, local champions and conservation organizations, we are proud to be part of this public-private partnership that is aligned with our renewed Epson 25 Corporate Vision—which aims to enrich communities and help realize a sustainable society,” concludes Bonoan. ”We hope that this opens up a path for more sustainable partnerships in the future.”

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