Lowering the transmission and spread of human coronavirus.

The emergence of the severe acute respiratory syndrome coronavirus 2 pandemic has created an unprecedented healthcare, social, and economic disaster. Wearing of masks and social distancing can significantly decrease transmission and spread, however, due to circumstances such as medical or dental intervention and personal choice these practices have not been universally adopted. Additional strategies are required to lessen transmission. Nasal rinses and mouthwashes, which directly impact the major sites of reception and transmission of human coronaviruses (HCoV), may provide an additional level of protection against the virus. Common over-the-counter nasal rinses and mouthwashes/gargles were tested for their ability to inactivate high concentrations of HCoV using contact times of 30 s, 1 min, and 2 min. Reductions in titers were measured by using the tissue culture infectious dose 50 (TCID50 ) assay. A 1% baby shampoo nasal rinse solution inactivated HCoV greater than 99.9% with a 2-min contact time. Several over-the-counter mouthwash/gargle products including Listerine and Listerine-like products were highly effective at inactivating infectious virus with greater than 99.9% even with a 30-s contact time. In the current manuscript we have demonstrated that several commonly available healthcare products have significant virucidal properties with respect to HCoV.

Comparison of Factors Identified by Patients and Physicians Associated with Hospital Readmission (COMPARE2).

OBJECTIVE: Factors contributing to hospital readmission have rarely been sought from the patient perspective. Furthermore, it is unclear how patients and physicians compare in identifying factors contributing to readmission. The objective of the study was to identify and compare factors contributing to hospital readmission identified by patients and physicians by surveying participants upon hospital readmission to a teaching medicine service. METHODS: Patients 18 years and older who were discharged and readmitted to the same service within 30 days and the physicians caring for these patients were surveyed to identify factors contributing to readmission. Secondary outcomes included comparing responses between groups and determining level of agreement. Patients could be surveyed multiple times on subsequent readmissions; physicians could be surveyed for multiple patients. RESULTS: A total of 131 patients and 37 physicians were consented. The mean patient age was 60.1 years (standard deviation 16.8 years) and 55.6% were female; 56.4% were white, and 42.1% were black/African American. In total, 179 patient surveys identified "multiple medical problems" (48.6%), "trouble completing daily activities" (45.8%), and "discharged too soon" (43.6%) most frequently as contributing factors; 231 physician surveys identified "multiple medical problems" (45.0%) and "medical condition too difficult to care for at home" (35.6%) most frequently as contributing factors. Paired survey results were available for 135 readmissions and showed fair agreement for only 1 factor but no agreement for 5 factors. CONCLUSIONS: Patients identified previously unknown factors contributing to readmission. Little agreement existed between patients and physicians. Additional research is needed to determine how best to address patient-identified factors contributing to readmission.

Are Patients Frequently Readmitted to the Hospital Different from the Other Admitted Patients?

INTRODUCTION: Although the characteristics of readmitted patients associated with a family medicine inpatient service have been reported, differing characteristics between groups of patients based on readmission rates have not been studied. The aim of this project was to examine patients with differing rates of readmission. METHODS: Patients admitted to a family medicine inpatient service were classified into 1 of 3 groups based on the number of admission and readmissions in a given year. Demographic data and other characteristics of these patients were collected and used in analysis. Descriptive statistics were used to characterize the 3 groups of admissions. Differences in characteristics of groups were compared using Wilcoxon rank sum test for continuous variables and χ2 test or Fisher exact test for categoric variables. Multivariate logistic regressions were used for predicting high-frequency readmission. RESULTS: Patients in the high-frequency readmission group more commonly had a psychiatric, substance abuse, and chronic pain diagnosis. The primary discharge diagnoses among the 3 groups were similar. Age-group, Charlson severity index, Morse Fall Scale medication list, and problem list were significant for predicting high frequency of readmission. Annually, patients in the high-frequency readmission group had about an 80% turnover rate. CONCLUSIONS: Although this study examined patient care data from only one large academic health center hospital, the results found that patients who experience 3 or more readmissions in a calendar are associated with specific characteristics. In addition, the list of specific individual patients considered to be high utilizers for hospital readmissions was dynamic and significantly changed during 3 consecutive years.

Parent attitudes toward resident involvement in their child's strabismus surgery.

PURPOSE: To explore patterns in parents' understanding and preferences related to ophthalmology resident participation in their child's strabismus surgery. METHODS: Over a 4-week period, a survey was distributed at a suburban, academic eye center to English-speaking parents of children with strabismus who have not previously undergone, or were not being scheduled for, strabismus surgery. RESULTS: All of the 64 eligible parents participated in the survey. For a resident to assist or perform the surgery, 80% and 97% of parents, respectively, indicated it was important or extremely important to be asked permission beforehand; 69% indicated the attending surgeon should ask permission for the resident to perform the surgery, whereas only 11% believed a standard written consent was sufficient. Of the 64 respondents, 77% indicated that they would agree to a resident assisting with their child's operation; 36% would agree to a resident performing the surgery. CONCLUSIONS: Nearly all parents in our study indicated that they would want to be informed of resident involvement by the attending surgeon. The vast majority would consent to having an ophthalmology resident assist in their child's strabismus surgery, and more than one-third would consent to having the resident perform their child's strabismus surgery. Obtaining informed consent prior to resident involvement increases transparency and highlights the importance of ophthalmology residency education.

Impaired Retinal Vasoreactivity: An Early Marker of Stroke Risk in Diabetes.

Diabetes is a common cause of small vessel disease leading to stroke and vascular dementia. While the function and structure of large cerebral vessels can be easily studied, the brain's microvasculature remains difficult to assess. Previous studies have demonstrated that structural changes in the retinal vessel architecture predict stroke risk, but these changes occur at late disease stages. Our goal was to examine whether retinal vascular status can predict cerebral small vessel dysfunction during early stages of diabetes. Retinal vasoreactivity and cerebral vascular function were measured in 78 subjects (19 healthy controls, 22 subjects with prediabetes, and 37 with type-2 diabetes) using a new noninvasive retinal imaging device (Dynamic Vessel Analyzer) and transcranial Doppler studies, respectively. Cerebral blood vessel responsiveness worsened with disease progression of diabetes. Similarly, retinal vascular reactivity was significantly attenuated in subjects with prediabetes and diabetes compared to healthy controls. Subjects with prediabetes and diabetes with impaired cerebral vasoreactivity showed mainly attenuation of the retinal venous flicker response. This is the first study to explore the relationship between retinal and cerebral vascular function in diabetes. Impairment of venous retinal responsiveness may be one of the earliest markers of vascular dysfunction in diabetes possibly indicating subsequent risk of stroke and vascular dementia.

Fundamentals of Fluorescein Angiography.

In order to provide safe patient care during fluorescein angiography, it is critical that ophthalmic team members understand the use of fluorescein for diagnosing eye-related diseases and conditions, including appropriate doses for adult and pediatric patients. Awareness of side effects, adverse reactions, and complications of the contrast agent allow the ophthalmic health-care team to anticipate, respond quickly, and support the patient during and following the angiographic procedure using fluorescein.

Exercise in Pregnancy: A Clinical Review.

CONTEXT: Health professionals who care for pregnant women should discuss potential health benefits and harms of exercise. Although most pregnant women do not meet minimal exercise recommendations, there are a growing number of physically active women who wish to continue training throughout pregnancy. EVIDENCE ACQUISITION: A search of the Web of Science database of articles and reviews available in English through 2014. The search terms exercise pregnancy, strenuous exercise pregnancy, and vigorous exercise pregnancy were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: With proper attention to risk stratification and surveillance, exercise is safe for the mother and fetus. Benefits of exercise in pregnancy include reduction in Cesarean section rates, appropriate maternal and fetal weight gain, and managing gestational diabetes. Exercise as a means of preventing gestational diabetes, preeclampsia, or perinatal depression cannot be reliably supported. Overall, the current evidence suffers from a lack of rigorous study design and compliance with physical activity interventions. CONCLUSION: Research thus far has been unable to consistently demonstrate proposed benefits of exercise in pregnancy, such as preventing gestational diabetes, preeclampsia, or perinatal depression. However, moderate- and high-intensity exercise in normal pregnancies is safe for the developing fetus and clearly has several important benefits. Thus, exercise should be encouraged according to the woman's preconception physical activity level.

Impaired coronary and retinal vasomotor function to hyperoxia in Individuals with Type 2 diabetes.

PURPOSE: Adults with diabetes are at a high risk of developing coronary heart disease. The purpose of this study was to assess coronary artery vascular function non-invasively in individuals with and without Type 2 diabetes and to compare these coronary responses to another microvascular bed (i.e. retina). We hypothesized that individuals with diabetes would have impaired coronary reactivity and that these impairments would be associated with impairments in retinal reactivity. METHODS: Coronary blood velocity (Transthoracic Doppler Echocardiography) and retinal diameters (Dynamic Vessel Analyzer) were measured continuously during five minutes of breathing 100% oxygen (i.e. hyperoxia) in 15 persons with Type 2 diabetes and 15 age-matched control subjects. Using fundus photographs, retinal vascular calibers were also measured (central retinal arteriole and venule equivalents). RESULTS: Individuals with diabetes compared to controls had impaired coronary (-2.34±16.64% vs. -14.27±10.58%, P=0.03) and retinal (arteriole: -0.04±3.34% vs. -3.65±5.07%, P=0.03; venule: -1.65±3.68% vs. -5.23±5.47%, P=0.05) vasoconstrictor responses to hyperoxia, and smaller central arteriole-venule equivalent ratios (0.83±0.07 vs. 0.90±0.07, P=0.014). Coronary reactivity was associated with central retinal arteriole equivalents (r=-0.516, P=0.005) and retinal venular reactivity (r=0.387, P=0.034). CONCLUSION: Diabetes impairs coronary and retinal microvascular function to hyperoxia. Impaired vasoconstrictor responses may be part of a systemic diabetic vasculopathy, which may contribute to adverse cardiovascular events in individuals with diabetes.

Effect of doxycycline vs placebo on retinal function and diabetic retinopathy progression in mild to moderate nonproliferative diabetic retinopathy: a randomized proof-of-concept clinical trial.

IMPORTANCE: Microglia have been associated with inflammatory changes underlying diabetic retinopathy. OBJECTIVE: To investigate whether low-dose oral doxycycline monohydrate, a drug capable of inhibiting microglial activation, can improve or slow the deterioration of retinal function and whether it can induce regression or slow progression of diabetic retinopathy in patients with mild to moderate nonproliferative diabetic retinopathy (NPDR). DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-masked, 24-month proof-of-concept clinical trial. We randomized 33 patients (from the Penn State Hershey Eye Center) with at least 1 eye with mild to moderate NPDR (Early Treatment Diabetic Retinopathy Study level 20-43) to doxycycline monohydrate, 50 mg/d, or daily placebo for 24 months. MAIN OUTCOMES AND MEASURES: Mean change at 24 months compared with baseline in the foveal sensitivity of matrix frequency-doubling perimetry in each treatment group. We also compared the 2 groups with respect to change from baseline to 24 months in functional variables (Humphrey photopic visual field testing using the Swedish interactive thresholding algorithm 24-2 strategy, contrast sensitivity, dark adaptation, visual acuity, and quality of life) and anatomical variables (diabetic retinopathy severity level, area of retinal thickening, central subfield thickness on optical coherence tomography, and macular volume on optical coherence tomography). RESULTS: From baseline to month 24, no significant difference was detected between groups with respect to all visual function and anatomical outcomes assessed. CONCLUSIONS AND RELEVANCE: Although a link between low-dose oral anti-inflammatory agents and subclinical improvement in inner retinal function has been suggested in patients with severe NPDR or non-high-risk proliferative diabetic retinopathy, the same association was not found in the present study of patients with mild to moderate NPDR. The different findings in the 2 patient populations may relate to a differential effect of doxycycline on different stages of diabetic retinal dysfunction, or the sample size of the present study may be too small to detect a treatment effect of doxycycline in patients with mild to moderate NPDR. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00917553.

Twelve-month natural history of dark adaptation in patients with AMD.

PURPOSE: A sensitive endpoint is required for clinical trials evaluating preventative therapies for early age-related macular degeneration (AMD). Dark adaptation (DA) is a sensitive marker of AMD and has been proposed as a potential endpoint. This study evaluated whether significant changes in DA speed could be detected in participants with early to intermediate AMD at 12 months following baseline DA measurement. METHODS: Dark adaptation, visual acuity (VA), and fundus photography were obtained at baseline and at 6 and 12 months in 26 subjects with AMD and in 6 subjects with normal retinal health. Disease severity was assessed by the Nine-Step Age-Related Eye Disease Study AMD severity scale. RESULTS: At 12 months, significant progression of DA impairment occurred in 5 of 26 (19%) participants with AMD. None of the participants with AMD exhibited a significant worsening of fundus grade or decrease of acuity related to disease progression. The normal group exhibited stable DA and VA during the observation period. CONCLUSIONS: Significant worsening of DA was observed in 19% of subjects with AMD in 12 months of observation, despite stable VA and fundus appearance. This study suggests that DA may be a suitable functional endpoint for early clinical studies evaluating novel treatments for early to intermediate AMD.

Effect of doxycycline vs placebo on retinal function and diabetic retinopathy progression in patients with severe nonproliferative or non-high-risk proliferative diabetic retinopathy: a randomized clinical trial.

IMPORTANCE: Inflammation may contribute to the pathogenesis of diabetic retinopathy (DR). OBJECTIVES: To investigate, in a proof-of-concept clinical trial, whether low-dose oral doxycycline monohydrate can (1) slow the deterioration of, or improve, retinal function or (2) induce regression or slow the progression of DR in patients with severe nonproliferative DR (NPDR) or non-high-risk proliferative (PDR), and to determine the potential usefulness of visual function end points to expedite the feasibility of conducting proof-of-concept clinical trials in patients with DR. DESIGN, SETTING, AND PARTICIPANTS: We conducted a randomized, double-masked, 24-month proof-of-concept clinical trial. Thirty patients (from hospital-based retina practices) with 1 or more eyes with severe NPDR or PDR less than Early Treatment Diabetic Retinopathy Study-defined high-risk PDR. INTERVENTIONS: Patients were randomized to receive 50 mg of doxycycline monohydrate or placebo daily for 24 months. MAIN OUTCOMES AND MEASURES: Change at 24 months compared with baseline in functional factors (frequency doubling perimetry [FDP], Humphrey photopic Swedish Interactive Thresholding Algorithm 24-2 testing, contrast sensitivity, dark adaptation, visual acuity, and quality of life) and anatomic factors (Early Treatment Diabetic Retinopathy Study DR severity level, area of retinal thickening, central macular thickness, macular volume, and retinal vessel diameters). RESULTS: From baseline to month 24, mean FDP foveal sensitivity decreased in the placebo group (-1.9 dB) and increased in the doxycycline group (+1.8 dB) (P = .02). A higher mean FDP foveal sensitivity in the doxycycline group compared with the placebo group was detected at 6 months (P = .04), and this significant difference persisted at 12 and 24 months. A difference between the groups was not detected with respect to the other visual function outcomes and all anatomic outcomes assessed. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first observation suggesting a link between a low-dose oral anti-inflammatory agent and subclinical improvement in inner retinal function. Oral doxycycline may be a promising therapeutic strategy targeting the inflammatory component of DR. Furthermore, study results suggest that FDP, which primarily measures inner retinal function, is responsive to intervention and may be a useful clinical trial end point for proof-of-concept studies in patients with DR. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00511875.

Diagnostic sensitivity and specificity of dark adaptometry for detection of age-related macular degeneration.

PURPOSE: Difficulty with night vision is a common complaint of patients with age-related macular degeneration (AMD). Consistent with this complaint, dark adaptation (DA) is substantially impaired in these patients. Because of the severity of the deficit, measurement of DA has been suggested as a means for the diagnosis of AMD. Previous methods for measurement of DA were time intensive (>30 minutes), which made them unsuitable for clinical use. This study evaluated a rapid DA test (≤ 6.5 minutes) for the detection of AMD. METHODS: Dark adaptation was measured by using the AdaptDx dark adaptometer in two groups: subjects with normal retinal health and subjects with AMD. Subjects were assigned to their group by clinical examination and grading of fundus photographs. Subjects were classified as having DA consistent with normal retinal health (rod intercept ≤ 6.5 minutes) or having dark adaptation consistent with AMD (rod intercept > 6.5 minutes). RESULTS: The eligible sample for analysis included 21 normal adults and 127 AMD patients. The rapid test was found to have a diagnostic sensitivity of 90.6% (P < 0.001) and specificity of 90.5% (P < 0.027). Thus, abnormal DA was detected in 115 of 127 AMD patients, and normal DA was found in 19 of 21 normal adults. CONCLUSIONS: The high diagnostic sensitivity and specificity compared favorably to long-duration research methods for the measurement of DA, and slit lamp biomicroscopy performed by a retina specialist. These results suggest that a rapid DA test is useful for the detection of AMD.