The Technology Review Site for Primary Care Providers
Advances in technology have improved healthcare providers' ability to rapidly diagnose patients at the point of care, screen for common conditions, and provide a variety of effective treatment options. Providers need to be aware of what innovations are available - or will become available in the near future. It is the purpose of Medgizmos to educate and inform healthcare providers regarding the latest and greatest technologies.
ScopeAround Wifi Otoscope, new inexpensive digital otoscope!
I’ve long been a fan of Masimo pulse oximeters for use in pediatric patients. They produce sturdy devices ideal for the medical office that integrates their proprietary signal extraction technology (SET. SET provides accurate readings in moving patients and uncooperative patients as often are the children and infants in my practice. I’ve previous reviewed the Masimo Rad-G pulse oximeter and well and the MightySat. Both have colorful screens, easy to navigate interfaces, reasonable pricetags and display oximetry readings, heart rate, perfusion index, and respiratory rate derived from the plethysmographic waveform.
You may encounter patients whom you suspect have a sleep disorder. Many are reluctant to visit sleep specialist who may order home or sleep center sleep studies. It may be prudent to recommend the $80 Masimo Sleep Device. As presented in the video one fastens the Masimo Sleep device to the wrist, attaches the sensor to a fingertip, and connects the app via Bluetooth to the Masimo Sleep Application. One initiates a sleep session which continuous monitors, oxygen saturation, heart rate, breathing rate, and respiratory rate. Once a session has ended the user is presented with a comprehensive report with the above data and lists major and minor sleep events. This information can be shared with a provider and a referral placed to a sleep center if indicated. Great device and so easy to use.
Amblyopia is one of the most common visual problems of childhood, occurring in as many as 1% to 4% of children.1 It is defined as poor vision caused by abnormal development of visual areas of the brain; if undetected and untreated it can lead to permanent vision impairment.
Unfortunately, less than 40% of children are screened for this condition.2 Causes of amblyopia include strabismus (misalignment of eyes), anisometropia (inequality of vision of both eyes because of refractive errors or astigmatism), cataracts, ptosis, or other factors. Because children do not complain of problems with visual acuity, and affected eyes often appear normal, amblyopia can easily go undetected unless a child has vision screening done routinely at health maintenance examinations.
Vision screening in children aged younger than 3 years in a medical office can be challenging because few children this age can be screened with a vision chart. From age 3 to 5 years, screening is possible with Snellen charts, Tumbling E charts, or picture tests such as Allen Visual Acuity Cards, but this is time consuming and can lead to inconsistent or erroneous results. According to the 2016 guidelines Screening instruments detect amblyopia, high refractive error, and strabismus. I recommend that Instrument-based screening should be performed at age two and repeated at each annual preventive medicine encounter through 7 years of age.
Amblyopia remains treatable until age 7, with rapid decline of effective treatment after this time. The goal of vision screening in infants and young children, therefore, must be the early detection of high severity (magnitude) amblyopia risk factors (ARFs), including moderate or severe astigmatism, anisometropic myopia, high hyperopia, severe strabismus, and opacities in the visual axis, including retinoblastoma or other ocular entities that cause opacities that interfere with transmission of light to and from the retina.
Plusoptix has offers the S16 photoscreener for practices who do not need a portable device. The S16 features a terrific interface that is displayed on a monitor attached to the device. The results can be printed via a network printer and the system keeps track of previous screens. Plusoptix also provides the free plusoptiXconnect software for practices to store, review, print results.
It is vitally important that providers have unobscured view of the tympanic membrane in order to diagnose Otitis Media, Serous Otitis Media, or Otitis Externa. Additionally, impacted cerumen may be uncomfortable for patients, and in some situations may reduce hearing acuity. So, it has become routine practice for physicians to remove cerumen during an office visit.
Many of us have developed our favorite techniques for removing cerumen. In the video above I share mine. Basic principles include using a ceruminolytic to soften wax. My preferred agent is sodium docusate liquid. ($12 or so for a big bottle on Amazon) I saturate cotton balls with the liquid and put them in the ears for 15 minutes. By using cotton balls, one can soften the cerumen in both ears at the same time. One then can use a syringe or an ear wash system such as the Elephant Ear Washer System ($26 on Amazon) that uses soft plastic catheters ($16 for a bag of 20). The catheter is pushed gently through the wax before irrigation begins, so the cerumen is push out of the canal and not toward the tympanic membrane. Often the cerumen is extruded as a solid plug.
The irrigation solution is room temperature water mixed 4 to 1 with hydrogen peroxide. I use an ear basin to catch cerumen and place chucks on the patient’s shoulder to prevent accidents.
Contraindications to irrigation include the presence or history of a perforated tympanic membrane (or ear tubes), previous pain on irrigation, previous surgery to the middle ear , or the presence of a discharge.
If you use a curette exercise caution. I prefer the EasiEar curettes which are metal, but flexible. These cost $69 for 25 from splashcap.com
I’ve been doing Telehealth visits for many years, mostly for following patients who I treat for attention deficit hyperactivity disorder and/or anxiety or depression. The quality of the visit on several factors, including bandwidth, quality of microphone and webcam at both ends of the virtual visit. As a pediatrician, particularly for my younger patients, I find I can improve patient and parent engagement by using backgrounds with my zoom calls. This can be videos showing me on a warm beach with the waves rolling in, or backgrounds with patient pleasing designs and colors. While Zoom virtual visits can be used without a “green screen”, background images or videos can be distorted unless you use one.
A very affordable and versatile 56-inch circular green screen is the Webaround which can be purchased on Amazon.com, for $50 or less. As described in the video the Webaround is attached to a chair with Velcro straps and positioned appropriately in the room used for virtual visits. In my experience it is a complicated process to re-fold the Webaround so it can be placed back in its transport bag, so I just leave it attached to a chair in a room in my office I use for Telehealth visits.
Please let me know if you have any advice that improves the quality of the virtual visits you conduct with patients.
Early physicians recognized that illness often was associated with fever, but it took centuries for scientists to develop the means to measure body temperature. Although Galileo in 1592 was the first to fashion a crude thermometer, it was another Italian scientist, Santorio Santorio, who was the first to take oral temperatures in 1625. His thermoscope, as it was called, was large and cumbersome, and took hours to perform a single measurement.
It was not until the mid-1800s that the German physician Carl Wunderlich developed a foot-long thermometer that could take clinical temperatures. In 1868, he published his data of more than 1 million axillary readings from more than 25,000 patients. He determined that there was a diurnal variation in daily body temperatures ranging from 97.3°F in the morning to 99.5°F in the evening. He also originated the standard of 98.6°F as “normal body temperature” that we use today. His readings took 20 minutes to perform, and for anyone but the most patient of physicians, this was not a practical device.
When I opened my first practice in 1986, I was intrigued by an advertisement in Contemporary Pediatrics that caught my attention, and days later I was the proud owner of a FirstTemp tympanic thermometer. The manufacturer (Intelligent Medical Systems; Carlsbad, California) promised the device’s measurements were as accurate as oral and rectal temperatures taken with glass thermometers. I was initially skeptical of this high-tech thermometer, but within weeks it proved to be a very popular device among staff, providers, and patients. The reason it was successful was that it required little patient cooperation and took temperatures in seconds, and it produced measurements comparable to those obtained with our digital oral and rectal thermometers.
Before the Haemophilus influenzae type b vaccine first became available in 1985 and the first pediatric conjugate pneumococcal vaccine became available in 2000, pediatricians routinely encountered severe illnesses in patients that included meningitis, septic arthritis, osteomyelitis, and sepsis. These were so common that blood cultures and spinal taps were routine office procedures. Before the introduction of the H influenzae and pneumococcal vaccines, 3% of young febrile children without a focus of infection had positive blood cultures for H influenzae, Streptococcus pneumoniae, or Neisseria meningitides. Six percent of those patients positive for pneumococcus also were discovered to have meningitis, while up to 20% of positive blood cultures for H influenzae were associated with meningitis. Today, the incidence of occult bacteremia is 0.5%, and we rarely perform blood cultures or spinal taps in the workup of infections, except in febrile young infants. The key point is that, just 2 decades ago, parents and pediatricians were alerted to the possibility of severe pediatric illness by the presence of fever, and they were comforted by its absence. Today, documentation of a fever alerts physicians regarding the cause of the associated symptoms. In most situations, there is an infectious cause with rheumatologic illnesses, malignancy-related fevers, and period fevers being much less common.
Ron Benincasa and Gary O’Hara invented the first infrared ear thermometer, the FirstTemp mentioned above, which was introduced to medical practices in 1984. Because of its speed, it became extremely popular and eventually sold about 80,000 units. It was replaced by a more streamlined unit called the Genius and the company was eventually sold to Sherwood Medical (Now Covidien) in 1993. You can still purchase the Genius 3 online for $379 dollars.
Ron and Gary reinvented infrared thermometry about a decade ago, forming a company called Thermomedics, producing first accurate non-contact clinical forehead thermometer called the Caregiver PRO-TF300-CS. Ron estimates the company has sold more than 80,000 units and studies have demonstrated that the thermometer is extremely accurate. It takes temperatures in 2 seconds and two AA batteries can provide up to 15000 measurements. In my own experience it produces temperature measurements comparable to that produced Exergen’s TAT-5000 contact thermometer, while costing substantially less.
Forehead temperatures have been taken by concerned mothers since the dawn of time, and Francesco Pompei, the founder and chief executive officer of Exergen, suspected that the superficial branch of the temporal artery was an ideal site for reliable and reproducible temperature measurement. Exergen introduced its clinical temporal artery thermometer, the TAT-5000, in 2000. Now nearly years later, the company has sold millions of devices and the thermometer is being used by over half of pediatric practices in the United States.
The device measures the patient’s core body temperature, which is about 1°F or 0.5°C higher than oral readings. The TAT-5000 thermometer uses dual scanners, one that measures ambient environmental temperature and another that gauges the arterial temperature of the patient’s skin. The thermometer records over 1000 readings per second, producing an audible click as the device registers a higher reading. After taking 3000 readings, an internal “heat balance” algorithm determines the arterial temperature, which is displayed on the unit’s LED screen. Best of all, although the thermometer lists for over $400, Exergen frequently puts the device on sale for $200. One reason the device is so popular in the medical community is that it carries a lifetime warranty.
Parents also can purchase a home forehead thermometer manufactured by Exergen for less than $30. This is the Exergen consumer TAT-2000C. It uses the same technology as the TAT-5000, but it can store up to 8 temperatures, has an illuminated screen, and can be silenced so it doesn’t wake a child. The device has a warranty of 1 year.