Telemedicine Use by Older Adults in a COVID-19 Epicenter.

BACKGROUND: In early 2020, New York City was the epicenter of the Coronavirus disease 2019 (COVID-19) pandemic in the United States. Older adults were at especially high risk. Telemedicine (TM) was used to shift care from overburdened emergency departments (EDs) to provide health care to a community in lockdown. TM options presented unique challenges to our diverse older adult population, including visual, hearing, cognitive, and language limitations. OBJECTIVE: Our objective was to evaluate the use of TM during the peak of the pandemic in New York City. METHODS: We conducted a retrospective chart review of patients 65 years and older evaluated remotely via TM during our pandemic surge. Chart extraction was performed by six emergency physicians. Outcomes included demographics, technical limitations, rates of ED referral, and 30-day mortality. RESULTS: During the study period, a total of 140 encounters were reviewed. The mean age was 73 years. Overall, 20% of patients in the cohort were emergently referred to the ED. Use of TM by this age cohort increased 20-fold as compared with a similar time frame pre-pandemic. ED referral was highest in those over 75 (45.9% > 75 years). Forty-three percent used family to assist. Thirty-day mortality was 7%. CONCLUSION: TM use by older adults grew substantially at our institution during our initial COVID-19 surge. The same-day emergent referral rate and mortality rate reflect the high acuity represented in this cohort and points to the need for telehealth providers that are trained in triage and emergency medicine with a knowledge of local resource availability.

Virtual powers of observation: A telemedicine approach for the suspected COVID-19 patient.

STUDY OBJECTIVES: Prior to COVID-19, telemedicine and its applications to the emergency department (ED) had made significant inroads toward remote evaluation and care. During the local peak of the COVID-19 pandemic in New York City (NYC), there was a dramatic increase in telemedicine based patient encounters for suspected COVID-19 symptoms. In response, pathways were developed to promote a standardized telemedicine approach to remote evaluation and assessment of suspected COVID-19 patients. METHODS: A pathway was developed and implemented at two academic EDs in NYC, which collectively had approximately 8,300 telemedicine visits for suspected COVID-19 from March 2020 to June 2020. A protocol was developed by an expert consensus panel of four board-certified emergency physicians and two pediatric emergency physicians, all with telemedicine training/administrative roles. RESULTS: The pathway was initiated for any telehealth patient with suspected COVID-19 symptoms (cough, fever, shortness of breath, and bodyaches). A standardized history solicited known or suspected risk factors for worse prognosis, including age > 50, cardiovascular or lung disease, obesity, immunosuppression, and living alone, as well as a focused assessment of symptom severity and exercise tolerance. An exam at rest included visual counting of breaths along with instruction on palpation of radial pulse. Saturation was included if pulse oximetry was available. If exam at rest was reassuring, providers were instructed to repeat the respiratory assessment on exertion by having the patient walk in place briskly for 1 minute. Patients with severe illness defined by resting or exertional respiratory rate greater than 30 and/or oxygen saturation less than 90 percent were instructed to go to the ED. Patients with moderate illness defined by exertional metrics of respiratory rate less than 22, oxygen saturation greater than 94 percent, and heart rate less than 125 were discharged from the virtual urgent care visit with a repeat telehealth follow-up call at either 12 or 24 hours depending on the number of risk factors. Patients without risk factors and with reassuring respiratory assessment were discharged from the telemedicine encounter with reassurance and standard discharge precautions for escalation of care. CONCLUSION: Designing and disseminating a standardized pathway helped to provide a framework to approach patients suspected of COVID-19 over telemedicine. Future work focusing on patient outcome data will help guide and refine any standardized telehealth approach to the COVID-19-suspected patient.

Role of a ubiquitously expressed receptor in the vertebrate olfactory system.

Odorant cues are recognized by receptors expressed on olfactory sensory neurons, the primary sensory neurons of the olfactory epithelium. Odorant receptors typically obey the "one receptor, one neuron" rule, in which the receptive field of the olfactory neuron is determined by the singular odorant receptor that it expresses. Odor-evoked receptor activity across the population of olfactory neurons is then interpreted by the brain to identify the molecular nature of the odorant stimulus. In the present study, we characterized the properties of a C family G-protein-coupled receptor that, unlike most other odorant receptors, is expressed in a large population of microvillous sensory neurons in the zebrafish olfactory epithelium and the mouse vomeronasal organ. We found that this receptor, OlfCc1 in zebrafish and its murine ortholog Vmn2r1, is a calcium-dependent, low-sensitivity receptor specific for the hydrophobic amino acids isoleucine, leucine, and valine. Loss-of-function experiments in zebrafish embryos demonstrate that OlfCc1 is required for olfactory responses to a diverse mixture of polar, nonpolar, acidic, and basic amino acids. OlfCc1 was also found to promote localization of other OlfC receptor family members to the plasma membrane in heterologous cells. Together, these results suggest that the broadly expressed OlfCc1 is required for amino acid detection by the olfactory system and suggest that it plays a role in the function and/or intracellular trafficking of other olfactory and vomeronasal receptors with which it is coexpressed.

Physical and mental health of rural southern Indian women living with AIDS.

The purpose of this descriptive study is to highlight the physical and mental health symptoms of 68 rural women living with AIDS (WLA) in India, their compliance to antiretroviral therapy (ART) medication, and barriers to accessing health care within the past 6 months. Physical and mental health status was obtained by self-report, administered by questionnaire and physician-determined clinical assessment, as well as selected objective parameters. Findings revealed that while rural WLA had been on antiretroviral therapy for just under 2 years, they self-reported a high prevalence of physical symptoms, and more than half reported high levels of depressive symptoms and major barriers to accessing health care. CD4 levels, body weight, and basal metabolic rate were also low. While the rural and urban WLA faced similar health care challenges, the demographic characteristics of the rural women may make them more vulnerable, as they are less adherent to ART and slimmer than their urban counterparts.

Alcohol consumption patterns and sexual risk behavior among female sex workers in two South Indian communities.

BACKGROUND: HIV transmission in India is primarily heterosexual and there is a concentrated HIV epidemic among female sex workers (FSWs). Earlier reports demonstrate that many FSWs consume alcohol regularly before sexual encounters. This qualitative study is part of a larger quantitative study designed to assess alcohol consumption patterns among female sex workers and their association with sexual risk taking. Here we investigate the environmental influence, reasons for and consequences of consuming alcohol in the FSW population. METHODS: Trained staff from two Non-Governmental Organizations in Andhra Pradesh and Kerala conducted semi-structured interviews with 63 FSWs in Chirala, Andhra Pradesh (n = 35) and Calicut, Kerala (n = 28) following extensive formative research, including social mapping and key informant interviews, to assess drinking patterns and sexual risk behaviors. RESULTS: FSWs reported consuming alcohol in multiple contexts: sexual, social, mental health and self-medication. Alcohol consumption during sexual encounters with clients was usually forced, but some women drank voluntarily. Social drinking took place in public locations such as bars and in private locations including deserted buildings, roads and inside autorickshaws (motorcycle taxis). Consequences of alcohol consumption included failure to use condoms and to collect payments from clients, violence, legal problems, gastrointestinal side effects, economic loss and interference with family responsibilities. CONCLUSION: FSWs consume alcohol in multilevel contexts. Alcohol consumption during transactional sex is often forced and can lead to failure to use condoms. Social drinkers consume alcohol with other trusted FSWs for entertainment and to help cope with psychosocial stressors. There are multiple reasons for and consequences of alcohol consumption in this population and future interventions should target each specific aspect of alcohol use.

Correlates of depression among rural women living with AIDS in Southern India.

Although depression may be commonly experienced by persons living with AIDS, it may be challenging for health care providers to identify persons who are suffering from depression symptoms, particularly if they are living in the more isolated rural areas of India. The purpose of this study is to assess correlates of depression among women living with AIDS in rural Andhra Pradesh, India. A total of 68 rural women living with AIDS (WLA) completed baseline data and were assessed by means of structured instruments. Regression modeling revealed that disclosure avoidance and making at least six health care visits in the last six months were all associated with depression. Further, living with a spouse was associated with lower depressive symptom scores. Stigma was not found to be associated with depression. Understanding correlates of depression can lead the way toward designing culturally-tailored interventions that can mitigate disclosure avoidance and improve the health of women. A more comprehensive health focus may be needed to empower the women to seek quality care for both physical health, as well as mental health, symptomatology.

Challenges experienced by rural women in India living with AIDS and implications for the delivery of HIV/AIDS care.

Researchers explored the barriers to AIDS care for rural women living with AIDS, and they investigated alternative delivery models to increase the women's adherence to antiretroviral therapy (ART). Community-based participatory research focus groups were conducted by the researchers with a convenience sample of 39 women living with AIDS from a primary health center (PHC) near Chennai, India, and with nurses, physicians, and Accredited Social Health Activists (Ashas), who are lay health care workers. The most prevalent barriers expressed by the women were sickness-related, psychological, financial issues with childcare, and distance, or transportation to the site. Women living with AIDS reviewed Ashas favorably.

Perceptions of Women Living with AIDS in Rural India Related to the Engagement of HIV-Trained Accredited Social Health Activists for Care and Support.

A community-based participatory research study was conducted using focus groups with 39 women living with AIDS (WLA) in the rural setting of Andhra Pradesh, India. In addition, three nurses, two physicians, and five reproductive health accredited social health activists (ASHAs) took part in focus groups. The WLA offered insight into the benefits of HIV-trained ASHAs including emotional support, assistance with travel to health care providers and antiretroviral therapy medication adherence. Health care providers also identified benefits of using HIV-trained ASHAs and suggested modalities for how to train these individuals. These findings will contribute to the design of a future program of care involving HIV-trained ASHAs.