Cerebral Venous Thromboses in a Patient With No Reported Risk Factors: A Case Report.

Stroke is a neurologic condition caused either by brain ischemia or brain hemorrhage, where most cases are a result of ischemic brain injury. Stroke more commonly affects the arterial blood supply of the brain, but in rare cases, it is evoked by the occlusion of the venous sinuses that drain blood from the brain. This phenomenon is known as cerebral venous sinus thrombosis (CVST), also referred to as cerebral sinovenous thrombosis. The pathogenesis of CVST is not completely understood, although common risk factors associated with the condition include obesity, hypercoagulable states, oral contraceptive use, intracranial infections, trauma, and, more recently, coronavirus disease 2019 (COVID-19). Immediate medical intervention is required because CVST can result in increased intracranial pressure and diffuse cerebral edema, which can bring about fatal complications that can lead to early death. However, CVST is challenging to diagnose, as its clinical presentation is highly variable. It can range from headaches to signs of elevated intracranial pressure, including nausea, vomiting, and vision problems. In this case report, the patient is a 25-year-old previously healthy African American female who presented with a weeklong headache and acute onset of delirium an hour prior to arrival at the hospital. The patient had prior emergency department (ED) visits from different facilities where head imaging was performed and showed negative results allowing her to return home. The patient was then brought by a friend to our ED due to altered mental status and agitation. Initial computed tomography of the head did not reveal acute abnormalities; however, magnetic resonance angiography and magnetic resonance venography revealed evidence of venous sinus thrombosis and lack of flow requiring urgent attention. The patient was then referred to endovascular neurology, but despite medical intervention, the patient's medical status deteriorated, and she was declared brain dead. Although rare, this case report emphasizes the atypical presentation and the severity of CVST where a young individual with no significant past medical history presented with neurological symptoms that rapidly progressed to complications that caused her early death.

What Is the Future of Primary Mental Health Care?: A Post COVID-19 Service Evaluation

Aims During the COVID-19 pandemic, many service lines needed to be transformed to enable more telemedicine and virtual consultations. This enabled seamless care across many service boundaries as all services adapted to operate virtually. During COVID-19, the mental health of many patients deteriorated. With easing of restrictions, we wanted the patient voice to be heard and to ensure our service was patient-centred. We undertook a service evaluation to understand our patients preferences. Our cross-sectional study evaluated patient preferences for their care which we felt was important as earlier during pandemic, patients did not have the choice to choose between virtual vs face-to-face consultations. We felt this was important to our patients so they could exercise choice of consultation and this would enable the patient voice to be heard. Methods 591 patients across three practices in primary care were identified from the Serious Mental Illness (SMI) and on the depression register. They were asked about their preference of care: telemedicine vs face-to-face consultations. Using a simple questionnaire, in order to record their preference on the patient screen. Of these a total of 495 patients (83%) participated in the study. Results Of the 495 respondents, 308 (52%) declined virtual telemedicine consultations and 175 (29%) patients were content with virtual consultations. Of the 175 patients who wanted telemedicine were 20 to 40 years of age. Reasons given included convenience (allows family and work commitment) and overall time management (reluctancy to travel). The 308 patients (52%) wanted face-to-face consultations because they wanted human contact, validation of their mental health problems, reassurance and were uncomfortable about discussions on the phone. They also had poor mobility especially the elderly who chose traditional models of care. Conclusion As services are restored to the new norm of patient care, patient choice should remain paramount if services are to remain patient centric. During the COVID-19 pandemic, many services transformed to virtual consultation of necessity without recognising the impact on patients themselves. Patients with serious mental health and depression are inherently vulnerable and our evaluation goes to show that despite the popularity of telemedicine. Patient choice should enable patients to access face-to-face care for greater patient satisfaction.

Metabolic Effects of Antidepressants;Is It Time to Change the Conversation?

AimsThe incidence of depression has risen both nationally and internationally. The mainstay of management remains referral to IAPT and treatment with SSRI and SNRIs and the rates of prescribing are rising exponentially. During the COVID-19 pandemic, more people faced mental health challenges. In the last ten years, the incidence of SSRI prescribing rose from 6.8% to 100%. A known side effect of antidepressant medication is weight gain, dyslipidemia, increasing risk of impaired fasting glycaemia and diabetes. Our study was conducted to assess the actual risk incurred in our population from the point of starting therapy till date.MethodsPatients were identified from the GP clinical system (SystmOne) to identify those with a current prescription of antidepressants and antipsychotics. A retrospective analysis of 591 patients' case records was undertaken. Body weight, BMI, fasting glucose, HbA1c, fasting lipids and Q risk were analysed at the time of prescription initiation, post treatment and any rise in cardiovascular risk over a period of years. The data were analysed to see the trajectory of deterioration in metabolic risk. All patients were assessed to ensure they had been signposted and referred to weight management services.ResultsThe data show a positive correlation between the onset of antidepressant and antipsychotic prescribing, worsening of BMI, increase of cardiovascular and metabolic risk. The data show an exponential rise in BMI and metabolic risk (cardiovascular Q risk, dyslipidemia, imparied fasting glycaemia, diabetes and ischaemic heart disease) for patients taking SSRI and SNRI within 12 months. This effect continues for the length of the prescribing interval. We also found that with the rise of BMI dose, escalation was common due to reduced effectiveness. The average rise in cardiovascular Q risk average was 14.05% over three years. Patients need careful counselling at the outset and need regular reassessment of metabolic risks at each medication review. Informed consent must be obtained - risks of SSRI, SNRI and antipsychotic risk should be stated.ConclusionA known iatrogenic risk of antidepressant medication is weight gain, dyslipidemia, increasing risk of impaired fasting glycaemia and diabetes. Careful counselling and metabolic risk assessment is required when initiating these medications. Throughout the length of prescribing patients need re-assessment of their cardiovascular and diabetes risk with timely referral to weight management services to counterbalance metabolic risks.

Systemic and mucosal IgA responses are variably induced in response to SARS-CoV-2 mRNA vaccination and are associated with protection against subsequent infection.

Although SARS-CoV-2 infects the upper respiratory tract, we know little about the amount, type, and kinetics of antibodies (Ab) generated in the oral cavity in response to COVID-19 vaccination. We collected serum and saliva samples from participants receiving two doses of mRNA COVID-19 vaccines and measured the level of anti-SARS-CoV-2 Ab. We detected anti-Spike and anti-Receptor Binding Domain (RBD) IgG and IgA, as well as anti-Spike/RBD associated secretory component in the saliva of most participants after dose 1. Administration of a second dose of mRNA boosted the IgG but not the IgA response, with only 30% of participants remaining positive for IgA at this timepoint. At 6 months post-dose 2, these participants exhibited diminished anti-Spike/RBD IgG levels, although secretory component-associated anti-Spike Ab were more stable. Examining two prospective cohorts we found that participants who experienced breakthrough infections with SARS-CoV-2 variants had lower levels of vaccine-induced serum anti-Spike/RBD IgA at 2-4 weeks post-dose 2 compared to participants who did not experience an infection, whereas IgG levels were comparable between groups. These data suggest that COVID-19 vaccines that elicit a durable IgA response may have utility in preventing infection. Our study finds that a local secretory component-associated IgA response is induced by COVID-19 mRNA vaccination that persists in some, but not all participants. The serum and saliva IgA response modestly correlate at 2-4 weeks post-dose 2. Of note, levels of anti-Spike serum IgA (but not IgG) at this timepoint are lower in participants who subsequently become infected with SARS-CoV-2. As new surges of SARS-CoV-2 variants arise, developing COVID-19 booster shots that provoke high levels of IgA has the potential to reduce person-to-person transmission.

An Australian hospital pharmacy department’s pandemic response plan to coronavirus disease of 2019

Abstract Aim This paper provides the main accomplishments of the Royal North Shore Hospital (RNSH) Pharmacy Department?s COVID-19 Pandemic Response Plan and key recommendations for other departments developing a remote model of care. Methods The overall objective was to preserve the active workforce by minimising staff-to-staff and staff-to-patient contact. The response plan involved splitting the department into teams, implementing a remote ward-based clinical pharmacy service, staff upskilling and optimising the physical environment. Results In April 2020, 1240 clinical tasks were completed remotely compared with 1254 tasks completed on site. In May 2020, 1700 tasks were completed offsite, compared with 1544 tasks onsite. The percentage of pharmacists rating themselves 5 out of 5 (very confident) in communicating over the phone increased from 34.8% prior to remote service delivery, to 60% after completion of the service. Counselling patients over the phone increased from 17.4% to 40% while providing remote clinical service increased from 26.1% to 80%. Discussion The paper provides key recommendations for other sites wanting to implement a remote model of care. There are details of recommendations for communication, adequate skill mix, upskilling, education, training, staff resilience, role expansion and administration. Conclusion The formation of a team hospital pharmacy department COVID-19 Pandemic Response Plan has provided assurance that a complete pharmacy service could continue in the event of reduced staffing. Intense, thoughtful, collaborative work was required in a short period of time to design an appropriate physical environment, create a remote working model of care, and to train and educate members of staff.

Cerebrovascular Accident and SARS-CoV-19 (COVID-19): A Systematic Review.

BACKGROUND: While the most common neurologic symptoms reported in patients affected by SARS-CoV-2 are headache, dizziness, myalgia, mental fog, and anosmia, there is a growing basis of published peer-reviewed cases reporting stroke in the setting of SARS-CoV-2 infection. The peer-reviewed literature suggests an increased risk of cerebrovascular accident (CVA) in the setting of COVID-19 infection. METHODS: We searched 3 databases (PubMed, MEDLINE, and CINAHL) with search terms COVID-19, novel coronavirus, stroke, and cerebrovascular accident. Case series and case studies presenting patients positive for both COVID-19 and CVA published from January 1 through September 1, 2020, were included. Data collection and analysis was completed and risk of bias assessed. RESULTS: The search identified 28 studies across 7 counties comprising 73 patients. Amongst patients hospitalized for COVID-19 infection and CVA, the average age was 60; the most common preexisting conditions were hypertension and diabetes mellitus, and those without preexisting conditions were significantly younger with an average age of 47. Amongst hospitalized patients with COVID-19 and CVA, there was a bimodal association with COVID-19 infection severity with majority of patients classified with mild or critical COVID-19 infection. DISCUSSION: The data suggest SARS-CoV-2 is a risk factor for developing stroke, particularly in patients with hypertension and diabetes. Furthermore, the younger average age of stroke in patients with SARS-CoV-2, particularly those patients with zero identifiable preexisting conditions, creates high suspicion that SARS-CoV-2 is an independent risk factor for development of stroke; however, this cannot yet be proven without comparable control population. The data suggest the risk of developing CVA in the setting of COVID-19 infection is not dependent upon severity of illness. Continued studies must be done to understand the epidemiologic factors of COVID-19 infection and stroke and the pathophysiology of the COVID-associated hypercoagulable state.

Peginterferon lambda for the treatment of outpatients with COVID-19: a phase 2, placebo-controlled randomised trial.

BACKGROUND: To date, only monoclonal antibodies have been shown to be effective for outpatients with COVID-19. Interferon lambda-1 is a type III interferon involved in innate antiviral responses with activity against respiratory pathogens. We aimed to investigate the safety and efficacy of peginterferon lambda in the treatment of outpatients with mild-to-moderate COVID-19. METHODS: In this double-blind, placebo-controlled trial, outpatients with laboratory-confirmed COVID-19 were randomly assigned to a single subcutaneous injection of peginterferon lambda 180 µg or placebo within 7 days of symptom onset or first positive swab if asymptomatic. Participants were randomly assigned (1:1) using a computer-generated randomisation list created with a randomisation schedule in blocks of four. At the time of administration, study nurses received a sealed opaque envelope with the treatment allocation number. The primary endpoint was the proportion of patients who were negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA on day 7 after the injection, analysed by a χ2 test following an intention-to-treat principle. Prespecified analysis of the primary endpoint, adjusted for baseline viral load, using bivariate logistic regression was done. The trial is now complete. This trial is registered with ClinicalTrials.gov, NCT04354259. FINDINGS: Between May 18, and Sept 4, 2020, we recruited 30 patients per group. The decline in SARS-CoV-2 RNA was greater in those treated with peginterferon lambda than placebo from day 3 onwards, with a difference of 2·42 log copies per mL at day 7 (p=0·0041). By day 7, 24 (80%) participants in the peginterferon lambda group had an undetectable viral load, compared with 19 (63%) in the placebo group (p=0·15). After controlling for baseline viral load, patients in the peginterferon lambda group were more likely to have undetectable virus by day 7 than were those in the placebo group (odds ratio [OR] 4·12 [95% CI 1·15-16·73; p=0·029). Of those with baseline viral load above 106 copies per mL, 15 (79%) of 19 patients in the peginterferon lambda group had undetectable virus on day 7, compared with six (38%) of 16 in the placebo group (OR 6·25 [95% CI 1·49-31·06]; p=0·012). Peginterferon lambda was well tolerated, and adverse events were similar between groups with mild and transient aminotransferase, concentration increases more frequently observed in the peginterferon lambda group. Two individuals met the threshold of grade 3 increase, one in each group, and no other grade 3 or 4 laboratory adverse events were reported. INTERPRETATION: Peginterferon lambda accelerated viral decline in outpatients with COVID-19, increasing the proportion of patients with viral clearance by day 7, particularly in those with high baseline viral load. Peginterferon lambda has potential to prevent clinical deterioration and shorten duration of viral shedding. FUNDING: The Toronto COVID-19 Action Initiative, University of Toronto, and the Ontario First COVID-19 Rapid Research Fund, Toronto General & Western Hospital Foundation.

POGIL Instruction Implemented as a Remote Learning Tool

This study seeks to effectively administer the teaching pedagogy Process Oriented Guided Inquiry Learning (POGIL) in biochemistry courses during a remote learning circumstance to encourage students to establish a solid foundation of knowledge that will support them through their further academic endeavors. Amidst the recent COVID-19 pandemic, many learning institutions have faced an unprecedented transition to remote learning environments. This has created a communication barrier that has challenged collaboration, critical thinking, and demonstration of understanding. Hence, we aimed to equip students with active learning tools to enrich the newfound virtual classroom by encouraging group discussion and ensuring deep learning of introductory biochemistry principles. Along with pre-recorded lectures, we utilized online ZOOM break-out rooms and POGIL style worksheets implemented by a group of upper-class former students of the course. In addition to POGIL, we incorporated collaborative discussion questions that aimed to challenge students to apply concepts they were taught in lectures and worksheets to real-world models. The effectiveness of the active learning tools as complements to the remote learning environment was determined through the analysis of voluntary surveys, conducted at the midpoint and final of each semester.