Good morning! Postcall here, ready to brighten your gloomy November morning like a spelunker's headlamp!

Speaking of much-maligned darkness — did you know the lack of sunlight can make time warp? That’s what French geologist Michel Siffre discovered after isolating himself in a cave for two months. By the end, he’d settled into a 24.5-hr circadian rhythm. Also, he was certain his colleagues were wrong — that only one month had passed. You’d think he’d be all, Let’s not do the time warp again 👄 — but 10 years later, he holed himself up for another experiment… this time, for 6 months. One must suffer to be… scientific? 🔬 😫

Now on to this week’s stories!

• The Tea on Virtual Care 🍵🫖

• 🫀 Does Semaglutide Reduce CV Outcomes? 

• Apixaban in Stroke Prevention for Subclinical AFib

• Stages of Heart Attack According to CCS-AMI ⏭️ 

• Postcall Classics: Bites, picks, crossword 🧩, oh my!

Driving these numbers: A small boost in energy stocks hasn’t quite made up for TSX losses this year. If you have exposure to the S&P, you’re doing a bit better (up 15.5% YTD on AI tech and interest-rate optimism).

The Tea on Virtual Care 🍵🫖

Sometimes a bite isn’t enough — you need a whole meal 🤷. Last week, we served a quick bite on CMAJ’s ER study. This week: a dive into the world of virtual clinics. 

What happened: A CMAJ study spilled tea on Ontario’s virtual care clinics during COVID-19. Initially aimed at reducing in-person visits, these clinics only translated to a modest 3-4% dip in low-acuity emergency visits. Of virtual care users, 12.5% hit the ED within three days, and 21.5% within 30 days. Users tended towards middle-aged, female, well-educated, and urban with a higher socioeconomic status — highlighting potential disparities in awareness and access.

The Ontario Ministry of Health threw $4 million into the program. Now, CMAJ’s results question whether those “millions of dollars could have been better spent.” 

Why it’s interesting: Lead author Dr. Lauren Lapointe-Shaw has hunches behind these ER stats. Patients often use virtual walk-in clinics for issues that can’t be examined virtually. Patients might also feel less sure about meeting virtual doctors without a physical exam, and they’re more likely to swing by the ER for a second opinion🩺.

But that doesn't mean virtual care lacks its place in health care. During the pandemic, video or phone appointments became a convenient way to access help and get prescription refills. With a nationwide shortage of healthcare workers, Canadian provinces leaned on virtual care to ease the pressure. Two months into the pandemic, Justin Trudeau announced a $240.5 million investment in expanding virtual and mental public health care for Canadians. Private virtual care companies like Maple and Telus Health exploded faster than microwaved pizza pops🤯.

While Ontario and Manitoba cut funding for services without in-person doctor visits, western provinces recognized the importance of virtual care for isolated rural areas and those with mobility issues. And now, NL is set to announce a new virtual care plan. But that comes with its own problems. Doctors worry that relying more on private companies could pull workers away from traditional practice. Dr. Gerard Farrell questions if this signals a split between public and private health care, and what the cost implications might be.

Bottom line: Virtual healthcare opens many doors, but Dr. Rose Zacharias warns against replacing in-person visits, emphasizing the importance of patient-doctor relationships. Maybe CMAJ’s study played a role in the Ontario government cutting fees for physicians at virtual walk-in clinics in December. KixCare, once fully covered by the public system, switched to a private model, where families pay $29/month to connect with practitioners.

Aviva Lowe, a pediatrician at KixCare, highlights how these new rules create two patient classes: those with a primary-care doctor, who can use virtual options; and those without, who are stranded. 

Private virtual-healthcare companies aren't genies, but they're an efficient way for Canadians to access medical care. In the words of journalist Christina Frangou, “As long as governments continue to downplay the value of virtual health care, they leave it open for private pay.”💰

Things your attending might pimp you on 🙋🏽‍♀️👨‍⚕️ 

1. Does semaglutide reduce CV outcomes? 

Results from the SELECT trial show that weekly injection with Semaglutide in patients with pre-existing cardiovascular disease and obesity/elevated BMI (but without diabetes !!) resulted in reduced death from cardiovascular causes, nonfatal MI, or nonfatal stroke outcomes at a mean follow-up of almost 40 months. Meanwhile, the FDA has just approved tirzepatide (Zepbound), a dual GLP-1/GIP agonist, for obesity/elevated BMI.

2. Is apixaban indicated in stroke prevention in subclinical afib?

Another positive trial from NEJM has dropped this week. The ATRESIA trial, which compared apixaban vs. aspirin for patients with short-duration subclinical afib, showed that apixaban resulted in a lower risk of stroke or systemic embolism at the cost of a higher risk of bleeding. The trial suggests that perhaps we should be putting patients with subclinical AF on anticoagulation.

3. What are the new breast cancer screening guidelines in Ontario?

Ontario recently lowered the age for screening mammograms from 50 to 40, following a similar move in the US. Starting in fall of 2024, Ontario women, non-binary, trans and two-spirit people with breast tissue between the ages of 40 and 74 can self-refer for a mammogram every two years. 

4. What are the 4 stages of a heart attack?

The Canadian Cardiovascular Society has just released brand new classification for heart attacks known as CCS-AMI. Check out the 4 stages here. The international classification is expected to better predict a patient’s risk of developing heart failure, arrhythmia, and death.

🍔 Quick Bites

1: 🎾 Canada's women are Billie Jean King Cup champions for the first time. On Sunday, the women’s tennis premiere team tournament was led by Leylah Fernandez's straight-sets victory in Seville, Spain. "It feels amazing and I'm extremely proud that I was able to get to represent Canada on the biggest stage," Fernandez said in an on-court interview. Canadian tennis is on a roll, since the men’s team took the Davis Cup last November.

2: 🧠 Back in May this year, Neuralink (another Elon company) received approval to begin human trials for brain chips from the US FDA, for people with quadriplegia or amyotrophic lateral sclerosis. Now, thousands of people have signed up to potentially get an implant. Here’s how it attaches to the brain.

3: 💼 Hiring soon? In the near future, it’ll be mandatory for Ontario employers to disclose wages or a salary range on job postings. The proposal is part of new legislation meant to increase transparency for job seekers and reduce systemic discrimination. BC announced earlier this year that it’s doing the same (while also prohibiting employers from asking job seekers for their pay history).

4: 💰️ Doug Ford’s government is paying for-profit clinics more than hospitals for OHIP-covered surgeries ($4037 vs $1692 for a knee surgery, for example), CBC Investigates piece highlights. The government has pitched expanding the volume and scope of surgeries performed outside of hospitals as a cost-efficient way to get more surgeries done and reduce wait times. However, healthcare experts believe outsourcing to privately run, for-profit clinics would merely shift resources away from Ontario's hospitals and boost clinic owners' revenues without actually shortening wait lists.

Postcall Picks ✅ 

🛫 Travel: Would you pay to go on vacation without your smartphone? A company is betting you’ll want the opportunity to ditch your device and enjoy a more immersive experience.

🥧 Eat: Here’s 50 recipes to get you in that baking mood.

👀 Watch: a 45-minute-long orca attack sink yet another yacht off Morocco.

🕹️ Game ⛳️

Welcome to a special edition of our weekly crossword! 🔢 Every medical answer has a number, or numeral prefix in it.

First question: What’s the term for too little fluid around the fetus?

Did you beat last week’s fastest time, 1:30? (Second fastest time: 1:45!)

Liked the puzzle? Share the link! 😄

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