Urgent Virtual Eye Assessments During the COVID-19 Pandemic.

Purpose: We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system implemented in response to COVID-19. Patients and Methods: We conducted a retrospective cross-sectional study using a consecutive sample of all virtual assessments conducted from March 24 to June 7, 2020 at a single ophthalmology center in Toronto, ON, Canada. Visual acuity and smartphone photographs were uploaded to an electronic assessment website. All patients were virtually triaged to an email or phone consult. Patient outcomes and satisfaction were assessed with a quality assurance survey. Primary outcome measures were the incidence of unplanned additional in-person visits and changes in treatment. Results: We performed 1535 virtual assessments. Of the triage pathways, 15% received an email consult only and 85% received a phone consult. Subsequently, 15% required an in-person assessment, 3% were referred elsewhere, and 0.1% were sent to the emergency. Presentations were most commonly cornea (52%) and retina (25%). They were non-urgent in 68% of cases and no pharmacologic treatment was required for 49%. Of 397 patients that responded out of 653 patients surveyed, 4% had an unplanned additional visit to the emergency, after which two patients underwent urgent retinal surgery and one patient underwent urgent glaucoma surgery. Two patients (0.5%) had a minor change in treatment. Conclusion: As routine regular in-person visits were not possible during the COVID-19 lockdown, virtual eye assessments provided an opportunity to triage patients. Virtual assessments have the potential to reduce in-person visits, but caution must be exercised to not miss vision-threatening conditions.

Addressing Behavioral Health of the Diverse Older Adults in the Various Health Care Setting during COVID pandemia

During COVID-19 pandemia being in a “golden age” group, having chronic health conditions make people more susceptible to the virus. The need to socially distance creates the sense of isolation, affects older adults routines, mass transportation, and some “non-essential” social services. Those factors in addition to the uncertainty and fear COVID-19 creates, and the potential for older adults to be more vulnerable to the virus and higher mortality rates among older adults may exacerbate depression and anxiety for which effective and safe treatment interventions are required. Virtual partial hospitalization program offers affordable and convenient opportunity to address mental health needs of older adults. There were a number of challenges with transitioning to and utilizing a telehealth platform for psychiatric evaluation in the long term care setting during the COVID 19 pandemic. First, staffing of facilities was stretched during the pandemic, making facilitation of Tele visits difficult. Without staff present through the entire visit to sort out technical difficulties, repeat questions and instructions for patients with hearing difficulties, and help patients complete questionnaires, evaluation was significantly limited. Additionally, the restrictions in place to mitigate viral transmission to residents and staff played unique roles in the psychiatric population. Isolation, lack of intellectual stimulation though group activities/dining, and halted family visits contributed to depression, anxiety, and agitation. Compounded with limited access to staff for therapy and medical management, we certainly observed a decline in motivation and functioning in our patients. In sum, while telehealth was successfully used in many settings during the COVID 19 pandemic, unique challenges in the geriatric psychiatry population residing in long term care facilities made implementation difficult. Lack of in-person visits and staffing shortages may have also contributed to escalation of psychiatric symptoms. Offering tele-psychiatry to diverse VA older adult patient population appears to be a valuable option although especially in the rural areas may present some challenges including irregularities of the internet connection, limited equipment availability as well as limited proficiency of the patient's utilization of the various telehealth platforms. However with appropriate training and equipment supplies those challenges can be resolved.

Vulnerable Elders, Social Determinants and COVID-19: A perfect storm

The COVID-19 pandemic has brought to an even more glaring spotlight the impact of social determinants of health on the medical and psychiatric morbidity and mortality outcomes from the infection in individuals both in the US and globally. Social determinants of health (SDOH) impact health outcomes for both medical and psychiatric disorders (Compton and Shim 2015). . In this session, we will begin with a vignette presented by Dr. Ahmed that illustrates this phenomenon. Dr. Trinh will then facilitate group discussions of the case. We will transition to an overview of SDOH led by Emily Tan, in which she will discuss how social determinants implicated in poor medical and mental health outcomes include being part of a disadvantaged minority or immigrant group or other marginalized population, experiencing systemic and structural racism, poverty, living environment (including crowding, pollution, and climate change), and having limited access to healthcare. Dr. Trinh will then present on the ways SDOH can increase the likelihood of numerous mental health concerns, including dementia, depression, suicide, anxiety disorders, and substance use disorder– all of which themselves have been identified as risk factors in contracting and experiencing poorer outcomes from COVID-19 infection. Dr. Nix will discuss how the intersectionality of older age, SDOH, and COVID-19 has led to a perfect storm of widespread devastation from the COVID-19 pandemic, impacting medical comorbidity and mortality. Three groups in particular have disproportionately suffered this health burden: (1) ethnic/racial minorities;(2) the socio-economically disadvantaged;and (3) the elderly, especially those living in residential care homes and nursing homes (Ali, Asaria, and Stranges, 2020). We will wrap up the session with a presentation from Dr. Ahmed on lessons learned from the pandemic and future directions, with a focus on how we can support elders and those affected by SDOH.

Pandemics: Historical Perspective and Vulnerabilities Among Minority Elderly

While infectious organisms surround us, critical circumstances need to occur for a pandemic to develop, such as that of the novel coronavirus disease 2019 (COVID-19), declared by the World Health Organization in March 2020. Prior pandemics had many feautres in common with COVID-19. Pandemics can expose weaknesses in public health response systems, as well as vulnerabilities in the populations who are most susceptible to adverse outcomes, and can lead to scapegoating of specific groups and attempts to conceal the disease. COVID-19 has disproportionately impacted the mental and physical health of minority seniors, and caused significant economic hardships. Long-standing social determinants of mental and physical health have led to health disparities highlighted by COVID-19, and demonstrate the complex intersection of health, medical comorbidities, and barriers to access to culturally competent physical and mental healthcare. The pandemic has caused significant mental health problems even among those who were spared the infection, primarily manifested as social isolation, depression, anxiety and opioid use disorders. Public health measures, including screening, vaccinations, and access to quality healthcare can all mitigate adverse outcomes. Similarly, best practices that include collaborations between social service agencies and faith-based groups are effective strategies to bring these mitigating strategies nearer to the minority seniors who are most in need. Addressing vaccine hesitancy is a critical component of ending this pandemic. Future research should bring together practitioners, public health agencies, and community-based organizations for the collaborative design and implementation of effective, culturally competent interventions to address the medical, psychosocial, and behavioral health needs of ethnic/racial minority older adult communities in the face of COVID-19 and other chronic health conditions. Using the Social Determinants Of Health framework as a guide, clinicians and researchers can work to address structural and systemic racism and poverty and create targeted interventions to COVID-19 and to prevent future pandemics.

Coronaviruses and COVID-19 - complications and lessons learned for the future. (Special Issue: Coronaviruses and COVID-19- Past, Present, and Future.)

Despite the earlier two Coronavirus outbreaks, this appearance of the third Coronavirus outbreak has brought several complications and now emerged as a human-health related pandemic issue. The wide geographical spread and transmissibility of newly emerged novel-Coronavirus (2019-nCoV) and severity of coronavirus disease 2019 (COVID-19) raised serious concerns about the future trajectory of the 2019-nCoV/COVID-19 outbreak. Herein, we have briefly covered some important aspects of the 2019-nCoV/COVID-19 outbreak to highlight the need to learn lessons for a safer future. First, an epidemiological comparison of respiratory viral infections with particular reference to 2019-nCoV is given with relevant examples. Following that, considering the earlier two Coronavirus outbreaks, the emergence of another new 2019-nCoV is given. Finally, the lesson learned, so far, and key concerns for pandemic impact assessment at large and COVID-19, in particular, are discussed for future considerations.

Enhanced neutrophil extracellular trap formation in COVID-19 is inhibited by the PKC inhibitor ruboxistaurin. (preprint)

Neutrophil extracellular traps (NETs) are web-like DNA and protein lattices which are expelled by neutrophils to trap and kill pathogens, but which cause significant damage to the host tissue. NETs have emerged as critical mediators of lung damage, inflammation and thrombosis in COVID-19 and other diseases, but there are no therapeutics to prevent or reduce NETs that are available to patients. Here, we show that neutrophils isolated from hospitalised patients with COVID-19 produce significantly more NETs in response to LPS compared to cells from healthy control subjects. A subset of patients were captured at follow-up clinics (3-4 month post-infection) and while LPS-induced NET formation is significantly lower at this time point, it remains elevated compared to healthy controls. LPS- and PMA-induced NETs were significantly inhibited by the protein kinase C (PKC) inhibitor ruboxistaurin. Ruboxistaurin-mediated inhibition of NETs in healthy neutrophils reduces NET-induced epithelial cell death. Our findings suggest ruboxistaurin could reduce proinflammatory and tissue-damaging consequences of neutrophils during disease, and since it has completed phase III trials for other indications without safety concerns, it is a promising and novel therapeutic strategy for COVID-19.

Effectiveness of a 3D-printed mask fitter in an Ophthalmology setting during COVID-19.

OBJECTIVE: To assess the effectiveness of a 3D-printed custom mask fitter in lieu of N95 respirators among ophthalmologists and other eye care professionals who may not be prioritized to receive N95 respirators amidst the coronavirus disease 2019 pandemic. METHODS: This was a proof-of-concept study from a tertiary eye care center in Oakville, Canada. All participants underwent the N95 Qualitative Fit Test with a custom mask fitter secured over an American Society for Testing and Materials Level 3 face mask. Participants answered a 10-point Likert scale questionnaire on comfort, ease of use, and feasibility of the custom mask fitter, as well as comfort of a regular face mask. RESULTS: Twenty participants were recruited. Of the 20 recruited, 18 (90%) successfully passed the fit test. The median scores for comfort, ease of use, and everyday feasibility for the custom mask fitter were 3.5, 4.5, and 3, respectively, whereas the median score for comfort of a regular face mask was 8.5. CONCLUSION: A reusable, low-cost, 3D-printed custom mask fitter is a potential effective alternative to an N95 respirator among eye care professionals but may require improvement in its design and comfort. This is especially relevant in the context of a limited supply of N95 respirators amidst a global pandemic.

Novel Case Report: A Previously Reported, but Pathophysiologically Unexplained, Association Between Collagenous Colitis and Protein-Losing Enteropathy May Be Explained by an Undetected Link with Collagenous Duodenitis.

Collagenous colitis (CC) is associated with non-bloody, watery diarrhea, which is pathophysiologically reasonable because normal colonic absorption (or excretion) of water and electrolytes can be blocked by the abnormally thick collagen layer in CC. However, CC has also been associated with six previous cases of protein-losing enteropathy (PLE), with no pathophysiologic explanation. The colon does not normally absorb (or excrete) amino acids/proteins, which is primarily the function of the small bowel. Collagenous duodenitis (CD) has not been associated with PLE. This work reports a novel case of CD (and CC) associated with PLE; a pathophysiologically reasonable mechanism for CD causing PLE (by the thick collagen layer of CD blocking normal intestinal amino acid absorption); and a novel association of PLE with severe COVID-19 infection (attributed to relative immunosuppression from hypoproteinemia, hypoalbuminemia, hypogammaglobulinemia, and malnutrition from PLE).