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Study finds novel mechanism that may confer protection against glaucoma

A team of researchers from LSU Health New Orleans Neuroscience Center of Excellence and the University of Copenhagen provides the first evidence that patients with ocular hypertension may exhibit superior antioxidant protection that promotes resistance to the elevated intraocular pressure associated with glaucoma. Their findings are published online in the Journal of Clinical Medicine, available here.

In general, glaucoma patients are vulnerable to increased intraocular pressure. However, a particular group of patients has no glaucomatous neurodegeneration despite high intraocular pressure—patients with ocular hypertension.

The paper reports the discovery of a new mechanism to explain why patients with ocular hypertension do not have glaucoma. This is the first study evaluating oxidative stress and antioxidative agents in patients with normal-tension glaucoma and ocular hypertension during oxygen stress.

According to the American Academy of Ophthalmology, ocular hypertension is when the pressure inside the eye (intraocular pressure or IOP) is higher than normal.

The authors found that patients with ocular hypertension have increased antioxidant capacity and higher levels of anti-inflammatory, omega-3 derived chemical messengers involved in sustaining cell function in their plasma compared to patients with normal-tension glaucoma and age-matched controls. The abundance of these omega-3 fatty acid chemical messengers provides antioxidant defense, and as a consequence, potential resistance to elevated intraocular pressure and glaucomatous neurodegeneration by eliminating increases in systemic oxidative stress.

"The study opens avenues of therapeutic exploration highlighting the significance of the omega-3 fatty acid chemical messengers' antioxidant capacity as a potential diagnostic biomarker and as a novel treatment to prevent glaucomatous neurodegeneration," notes Dr. Nicolas G. Bazan, Boyd Professor, Ernest C. and Ivette C. Villere Chair of Retinal Degeneration, and Director of the Neuroscience Center of Excellence at LSU Health New Orleans School of Medicine.

Glaucoma is the most common cause of irreversible blindness. The sight-threatening disease is defined by a progressive loss of the innermost retinal neurons with corresponding visual field losses. Despite current treatments to lower the intraocular pressure, 15% of glaucoma patients go blind, and as many as 42% will lose sight in one eye.

The study is a result of a collaboration between Dr. Bazan and Professor in Translational Eye Research, Chief Physician, and Glaucoma Specialist at the Copenhagen University Hospital, Dr. Miriam Kolko. Their collaboration began many years ago when, as a medical student from Denmark, Dr. Kolko worked with Bazan at LSU Health New Orleans.

"I began developing my interests in neuroprotection and ophthalmology working under Nicolas Bazan, who mentored, motivated and guided me, as a medical school student from Denmark supported by a Fulbright Scholarship (1994-1996), and from 2000-2003," says Dr. Kolko." I was lucky to work with and be inspired by Dr. Nicolas Bazan. Later, he also became my Ph.D. thesis director."

"Professor Kolko is a brilliant and innovative clinician-scientist who bridges a clinical career treating patients with glaucoma medically and surgically with basic and translational research to understand the pathophysiology behind it," concludes Bazan. "We are so proud that this international superstar's roots are here at LSU Health New Orleans."

Source: https://medicalxpress.com/news/2020-09-mechanism-confer-glaucoma.html

COVID-19 Pandemic Leads to Decrease in Emergency Department Wait Times

Prior to the COVID-19 pandemic, EDs around the country were under strain. Seven million people waited more than 2 hours for care in 2017, with many waiting much longer than that. Emergency departments are routinely crowded, and the majority of hospitals report boarding patients in the ED while they wait for available treatment beds in a different part of the hospital.

Long wait times are not just inconvenient. When emergency care is delayed, there can be serious health consequences. There are numerous reports of patients dying while they wait for emergency care because they did not get treatment in time. Crowded EDs are also connected to increased stress on staff, poor adherence to protocols, and clinical errors. So, it may seem like decreasing wait times during the pandemic would be a good thing. But that is not the whole story.

Where Did All the Patients Go?

During the month of April, ED visits across the country declined a staggering 42% from the same time in 2019. These declines were most profound in areas heavily affected by COVID-19. The decrease of patients may be due to multiple reasons. First, it may be a sign of effective strategies to streamline the health system in response to the pandemic. Second, some emergencies, such as injuries, may simply decrease as people stay at home more.

Unfortunately, ED visits for actual medical emergencies are declining as well. Independent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, emergency calls for cardiac arrests increased dramatically in March and many patients were declared dead at the scene. This suggests that people are waiting too long to seek care for true medical emergencies—a potentially lethal decision.

Fear of SARS-CoV-2 infection seems to be affecting the demand for emergency care. Many patients perceive a trip to the ED as a trip to a COVID-19 hotbed. A recent study on patients’ perceptions about EDs during the pandemic found that hospitals were seen as infection reservoirs and that patients were unaware of the steps that hospitals had taken to protect uninfected patients from COVID-19.

Striking the Right Balance in ED Demand

As fear over the COVID-19 pandemic decreases, ED wait times might increase again, perhaps becoming longer than ever. Delayed care and undermanaged chronic conditions as a result of the pandemic might trigger emergencies and lead to increased need for ED services.

The current, temporary decrease in ED wait times is an opportunity to optimize ED workflows to keep wait times manageable. There are 2 bottlenecks in EDs that drive up wait times—inputs and outputs—and there are also solutions deployed during the pandemic that should be maintained to keep wait times manageable in the future.

A significant part of why EDs are seeing decreased wait times during this pandemic appears to result from decreased demand. Some of this decrease may stem from effective ways to keep nonemergent patients away from the ED during the pandemic. Before COVID-19, many EDs already had fast-track clinics to divert nonemergent patients to a lower level of care. COVID-19 may have simply increased the importance of these clinics to keep EDs functional.

In addition, the increase in telehealth may be changing the way community-based health centers and independent practitioners deliver care. As COVID-19 spread, health systems implemented telehealth solutions to avoid in-person care. Many nonemergent patients are referred to the ED by outpatient clinics, often due to a lack of same-day appointments. Stay-at-home orders and expanded telehealth capability may be refocusing community-based clinicians to treat patients at home rather than referring them to an ED. Telehealth may be increasing the capacity of community-based clinics to provide timely care, which is linked to the number of nonurgent visits that EDs are used to seeing.

Thus, maintaining solutions such as fast-track clinics and telehealth might continue to divert nonemergent patients from EDs and help maintain the delicate balance between supply and demand for ED care. Even more important than input in achieving the delicate balance between supply and demand is output, which is an ED’s ability to discharge a patient, and the most commonly identified cause of ED crowding. Medical floor bed availability, psychiatric and substance treatment bed availability, or homeless shelter admitting schedules can all affect when an ED can safely discharge someone. When safe discharge options are not available, EDs have little choice but to keep patients in the ED.

The American College of Emergency Physicians has identified this as the major driver of ED crowding. When a bed is occupied by someone waiting to leave, new patients see longer wait times.

The surge in patients during the COVID-19 pandemic was met with increased planning in bed availability and organization. Active bed management is an important way to reduce ED wait times. Another potentially powerful tool is reverse triage, a system of ranking patients by risk for adverse events at the end of ED care and discharging those at low risk. Reverse triage can rapidly reduce bed occupancy and ED wait times but must be implemented with care to protect patient safety. Hospitals that successfully implemented these strategies to increase capacity for COVID-19 should maintain them even when the pandemic abates.

Emergency departments operate within the delicate balance of supply and demand. Decreased demand for ED services during the COVID-19 pandemic reflects both fear and avoidance. Patients who are experiencing an emergency should not be afraid to seek treatment, nor should the negative effects of crowded EDs be the norm. The COVID-19 pandemic may be the right time to reinvent emergency care delivery by keeping wait times manageable while treating patients with emergencies.

Article Information

Alex Woodruff, MPH^1,²; Austin B. Frakt, PhD^1,²

Corresponding Author: Austin Frakt, PhD, Partnered Evidence-Based Policy Resource Center, VA Boston Health Care System, 150 S Huntington Ave (152 H), Jamaica Plain, MA 02130 (This email address is being protected from spambots. You need JavaScript enabled to view it.).

Conflict of Interest Disclosures: Dr Woodruff reported receiving grants from the Laura and John Arnold Foundation. Dr Frakt reported receiving grants from the Laura and John Arnold Foundation.

Source: https://jamanetwork.com/channels/health-forum/fullarticle/2770930

Who should get the COVID-19 vaccine first?

Coronavirus vaccine concept (stock image).

Credit: © Dmytro S / stock.adobe.com

When effective COVID-19 vaccines are developed, their supply will inevitably be scarce. The World Health Organization (WHO), global leaders, and vaccine producers are already facing the question of how to appropriately allocate them across countries. And while there is vocal commitment to "fair and equitable" distribution, what exactly does "fair and equitable" look like in practice?

Now, nineteen global health experts from around the world have proposed a new, three-phase plan for vaccine distribution -- called the Fair Priority Model -- which aims to reduce premature deaths and other irreversible health consequences from COVID-19. Published this week in Science, the paper was led by Ezekiel J. Emanuel, MD, PhD, vice provost for Global Initiatives and chair of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania.

Though little progress has been made to describe a single, global distribution framework for COVID-19 vaccines, two main proposals have emerged: Some experts have argued that health care workers and high-risk populations, such as people over 65, should be immunized first. The WHO, on the other hand, suggests countries receive doses proportional to their populations.

From an ethical perspective, both of these strategies are "seriously flawed," according to Emanuel and his collaborators.

"The idea of distributing vaccines by population appears to be an equitable strategy," Emanuel said. "But the fact is that normally, we distribute things based on how severe there is suffering in a given place, and, in this case, we argue that the primary measure of suffering ought to be the number of premature deaths that a vaccine would prevent."

In their proposal, the authors point to three fundamental values that must be considered when distributing a COVID-19 vaccine among countries: Benefiting people and limiting harm, prioritizing the disadvantaged, and giving equal moral concern for all individuals. The Fair Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, such as health care system strain and stress, as well as economic destruction.

Of all of these dimensions, preventing death -- especially premature death -- is particularly urgent, the authors argue, which is the focus of Phase 1 of the Fair Priority Model. Premature deaths from COVID-19 are determined in each country by calculating "standard expected years of life lost," a commonly-used global health metric. In Phase 2, the authors propose two metrics that capture overall economic improvement and the extent to which people would be spared from poverty. And in Phase 3, countries with higher transmission rates are initially prioritized, but all countries should eventually receive sufficient vaccines to halt transmission -- which is projected to require that 60 to 70 percent of the population be immune.

The WHO plan, by contrast, begins with 3 percent of each country's population receiving vaccines and continues with population-proportional allocation until every country has vaccinated 20 percent of its citizens. Emanuel and his co-authors argue that, while that plan may be politically tenable, it "mistakenly assumes that equality requires treating differently-situated countries identically, rather than equitably responding to their different needs." In reality, equally populous countries are facing dramatically different levels of death and economic devastation from the pandemic, they say.

The authors also object to a plan that would prioritize countries according to the number of front-line health care workers, the proportion of the population over 65, and the number of people with comorbidities within each country. They say that preferentially immunizing health care workers -- who already have access to personal protective equipment (PPE) and other advanced infectious disease prevention methods -- likely would not substantially reduce harm in higher-income countries. Similarly, focusing on vaccinating countries with older populations would not necessarily reduce the spread of the virus or minimize death. Moreover, low- and middle-income countries have fewer older residents and health care workers per capita than higher-income countries.

"What you end up doing is giving a lot of vaccine to rich countries, which doesn't seem like the goal of fair and equitable distribution," Emanuel said. The authors conclude that the Fair Priority Model is the best embodiment of the ethical values of limiting harms, benefiting the disadvantaged, and recognizing equal concern for all people.

"It will be up to political leaders, the WHO, and manufacturers to implement this model," Emanuel said. "Decision-makers are looking for a framework to ensure that everyone throughout the world can be vaccinated so that we can stop the spread of this virus."

Other institutions involved in work include the University of Denver, Princeton University, University of Arizona, University of Oxford, University of Melbourne, University of Toronto, University of Groningen, University of Manitoba, Jobs Creation Commission of Ethiopia, Facultad Latinoamerica de Ciencias Sociales (FLACSO) in Argentina, University of Bergen, Norwegian Institute of Public Health, National University of Singapore, Washington University in St. Louis, and Georgetown University.

Story Source:

Materials provided by University of Pennsylvania School of Medicine. Note: Content may be edited for style and length.

Journal Reference:

Ezekiel J. Emanuel, Govind Persad, Adam Kern, Allen Buchanan, Cécile Fabre, Daniel Halliday, Joseph Heath, Lisa Herzog, R.J. Leland, Ephrem T. Lemango, Florencia Luna, Matthew S. McCoy, Ole F. Norheim, Trygve Ottersen, G. Owen Schaefer, Kok-Chor Tan, Christopher Heath Wellman, Jonathan Wolff, Henry S. Richardson. An ethical framework for global vaccine allocation. Science, Sept. 3, 2020; DOI: 10.1126/science.abe2803

Source: https://www.sciencedaily.com/releases/2020/09/200903145011.htm

A new approach to understanding the biology of wound healing

Our bodies frequently heal wounds, like a cut or a scrape, on their own. However patients with diabetes, vascular disease, and skin disorders, sometimes have difficulty healing. This can lead to chronic wounds, which can severely impact quality of life. The management of chronic wounds is a major cost to healthcare systems, with the U.S alone spending an estimated 10-20 billion dollars per year. Still, we know very little about why some wounds become chronic, making it hard to develop effective therapeutics to promote healing. New research from Jefferson describes a novel way to sample the cells found at wounds -- using discarded wound dressings. This non-invasive approach opens a window into the cellular composition of wounds, and an opportunity to identify characteristics of wounds likely to heal versus those that become chronic, as well as inform the development of targeted therapies.

The study was published in Scientific Reports on September 15th.

"Studying wound healing in humans is very challenging, and we know very little about the process in humans," says Andrew South, PhD, Associate Professor in the Department of Dermatology and Cutaneous Biology and one of the lead authors of the study. "What we do know is from animal studies, and animal skin and the way it heals is very different from human skin."

Dr. South and his lab study a group of inherited skin diseases called epidermolysis bullosa (EB), where wound healing is severely impaired. Patients, often from birth, suffer from blisters and lesions that are slow to heal, and some become chronic. In a subset of patients, chronic wounds are at high risk of developing into aggressive skin cancer. At this time, it is very difficult to predict which wounds in a given patient will heal, and which won't. Being able to sample the wounds is a key to understanding the mechanisms behind healing.

"Performing a biopsy to sample the cells in the wound would help us understand the differences between these wounds," says Dr. South "But biopsy in these patients is extremely painful and could delay healing of the wound even further. On the other hand, collecting these bandages that are just going to be thrown away, it poses no harm to the patient, and can be applied to a variety of conditions where wounds don't heal properly."

The researchers, which included collaborators in Chile and Austria, collected and analyzed 133 discarded wound dressings from 51 EB patients. Both acute and chronic wounds were sampled, with acute defined as present for 21 days or less, and chronic as present for more than 3 months.

"Previous studies had used wound dressings or bandages to collect fluid and look at what proteins are in there," says Dr. South. "But no one has actually looked at what cells are present. Applying the techniques our lab frequently uses, we were able to isolate viable or living cells from the dressings."

The researchers recovered a large number of cells from the dressings, often in excess of a 100 million. The larger the wound, and the more time a dressing was on a wound, the more number of cells were recovered.

The researchers then characterized the cells to see what type of cells are present at the wound. They detected a variety of immune cells including lymphocytes, granulocytes or neutrophils, and monocytes or macrophages. When comparing dressings from acute and chronic wounds, they found a significantly higher number of neutrophils at chronic wound sites. Neutrophils are the first line of defense in our immune system, and when a wound starts to form, they're the first ones to arrive at the scene.

"Previous findings from animal studies and protein analysis of human wound dressings had supported the idea that when neutrophils hang around longer than they should, that stalls the healing process and can lead to chronicity," says Dr. South. "Our findings support that theory more definitively, by showing that chronic wounds are characterized by higher levels of neutrophils."

These findings give more insight into wound healing, and could help develop therapies that promote the process; for instance, those that neutralize excess neutrophils, or recruit macrophages, the immune cells that begin the next stage in healing after neutrophils.

The researchers now plan to expand on their technique, by further analyzing the individual cells collected from the wound dressings, and the genetic material inside them. "Currently we're working with colleagues in Santiago, Chile on collecting dressings from EB patients over a period of time," says Dr. South. "This allows us to follow patients longitudinally, and observe a wound and how its cellular composition changes as it heals or doesn't heal."

The team hopes that this will reveal genetic markers that can predict healing or chronicity.

"This method of sampling could be an alternative to bothersome swabs or blood draws, which are especially hard to do in newborns," says Dr. South. "Since we know EB can present at birth, this technique could give us really early insight into the how severe the disease might be."

While the current study focuses on EB, Dr. South and his colleagues hope that this technique can be applied to a variety of other conditions, such as diabetic foot ulcers and vascular leg ulcers.

"The field of wound healing has been crying out for a better understanding of what drives a chronic wound," says Dr. South. "This technique could be transformative, and eventually help patients live more comfortable and healthy lives."

Story Source:

Materials provided by Thomas Jefferson University. Original written by Karuna Meda. Note: Content may be edited for style and length.

Journal Reference:

Ignacia Fuentes, Christina Guttmann-Gruber, Birgit Tockner, Anja Diem, Alfred Klausegger, Glenda Cofré-Araneda, Olga Figuera, Yessia Hidalgo, Pilar Morandé, Francis Palisson, Boris Rebolledo-Jaramillo, María Joao Yubero, Raymond J. Cho, Heather I. Rishel, M. Peter Marinkovich, Joyce M. C. Teng, Timothy G. Webster, Marco Prisco, Luis H. Eraso, Josefina Piñon Hofbauer, Andrew P. South. Cells from discarded dressings differentiate chronic from acute wounds in patients with Epidermolysis Bullosa. Scientific Reports, 2020; 10 (1) DOI: 10.1038/s41598-020-71794-1

Source: https://www.sciencedaily.com/releases/2020/09/200915152443.htm

DOH and WHO Promote holistic mental health wellness in light of World Suicide Prevention Day

Mental health hotlines bolstered amidst a surge of calls during COVID-19 pandemic

The Department of Health (DOH), in partnership with the World Health Organization (WHO), is jointly raising awareness on the importance of public mental health, especially amidst the COVID-19 pandemic.

Though the Philippines has consistently ranked in the Top 5 of a global optimism index, the National Center for Mental Health (NCMH) has revealed a significant increase in monthly hotline calls regarding depression, with numbers rising from 80 calls pre-lockdown to nearly 400.

Globally, the most vulnerable population is those aged 15-29. Mental health-related deaths are also the second leading cause of fatalities in this age group. These numbers illustrate the need for more conversations and programs that will break the stigma around mental health. Most times, Filipinos do not feel comfortable sharing their mental health challenges for fear of alienation or prejudice.

“The importance of mental health initiatives is just as crucial as those for the COVID-19 pandemic,” said Health Secretary Francisco T. Duque. “Now more than ever, we need to promote holistic health, where we are caring for the body, the mind, and even the spirit.”

The DOH has launched a multi-sectoral approach for mental health with programs and interventions across a variety of settings (e.g. workplaces, schools, communities) aimed at high-risk groups. The commemoration of World Suicide Prevention Day also calls attention to the plight of those who are undergoing severe forms of depression.

Another project is the development of a multi-sectoral National Suicide Prevention Strategy, which includes psychosocial services such as the NCMH’s Crisis Hotline “Kamusta Ka?, Tara Usap Tayo”, launched on 2 May 2019. The hotline is available 24/7 for prompt psychological first aid. The UP Diliman Psychosocial Services (UPD PsychServ) has also provided free counseling via telephone for front liners. RA 11036 or the (“Mental Health Act”) mandates the provision of comprehensive suicide prevention services encompassing crisis intervention, and a response strategy on a nationwide scale.

“I know how difficult it has been for Filipinos enduring the setbacks brought about by the COVID-19 pandemic and of the quarantine to prevent further transmission of COVID-19. Many people haven’t been able to work or have lost their jobs, some may have had difficulty going back to their home provinces or are impacted by the loss of loved ones or are separated from loved ones. This continues to be an especially stressful time. Someone in your community, workplace, family, or circle of friends, or even you may be feeling hopeless, isolated, and feeling they have no reason to live.” said WHO Representative in the Philippines, Dr. Rabindra Abeyasinghe. “We are not facing this alone. With compassion and understanding for others, we can recognize the signs and educate ourselves on how to access help. We all have a critical role in preventing suicide by socially connecting with affected people and connecting people to mental health services or medical care”.

It might help to:

Let them know that you care about them and that they are not alone, empathize with them. You could say something like, “I can’t imagine how painful this is for you, but I would like to try to understand,”
Be non-judgmental. Don’t criticize or blame them.
Show that you are listening by repeating the information they have shared with you. This can also make sure that you have understood them properly.
Ask about their reasons for living and dying and listen to their answers. Try to explore their reasons for living in more detail.
Ask if they have felt like this before. If so, ask how their feelings changed last time,
Reassure them they will not feel this way forever.
Encourage them to focus on getting through the day rather than focusing on the future.
Volunteer to assist them in finding professional help. If need be, offer to keep them company during their session with a licensed therapist.
Follow up on any commitments that you agree to.
Make sure someone is with them if they are in immediate danger,
If you’re unsure about how to help, reach out to medical professionals for guidance.

Remember that you don’t need to find an answer, or even to completely understand why they feel the way they do. Listening to what they have to say will at least let them know you care.

DOH, together with WHO Philippines, calls for every Filipino to be more involved in the discussion around mental health. If you or someone you know may be experiencing feelings of sadness, don’t hesitate to talk about it. The first step to healing begins at home in an environment that encourages open conversation and seeking advice from medical professionals.

“The last six months have been difficult for many of us. As we transition into the new normal, let us enter it with an attitude of supportiveness and compassion. We need to be champions for positive change and total well-being.” Duque added.

24/7 NCMH Crisis Hotline 1553, 0917 899 8727(USAP), and/or 7-989-8727 (USAP)

https://www.who.int/health-topics/suicide

https://www.who.int/news-room/feature-stories/mental-well-being-resources-for-the-public

Source: https://www.who.int/philippines/news/detail/10-09-2020-doh-and-who-promote-holistic-mental-health-wellness-in-light-of-world-suicide-prevention-day