Culture

BOSTON - New research from Boston Medical Center finds that the COVID-19 emergency systemic changes made to decrease in-person visits during the pandemic have led to a decrease in hospital-wide Hepatitis C (HCV) testing by 50 percent, and a reduction in new HCV diagnoses by more than 60 percent. Published in the Journal of Primary Care and Community Health, this new research highlights the impact that the COVID-19 pandemic is having on hospital-wide and ambulatory HCV testing, and the ramifications of this decrease in identification of the virus.

The study findings demonstrate a greater impact in primary care clinics where there was a 72 percent decrease in testing and 63 percent decrease in new diagnoses. This is where telemedicine was incorporated into the clinical workflows, showing standard preventive care, including HCV testing, was not routinely performed throughout the pandemic, and telemedicine acting as a barrier to HCV care. The findings that testing for and diagnoses of HCV were decreased during the COVID-19 surge is alarming, due to the effect that undetected disease can have on those who are unknowingly infected. From the public health perspective, HCV is a transmissible infection that can propagate throughout a population if not detected and treated.

"The large decrease in HCV screening demonstrates the tradeoffs that occurred between maintaining safety and delivering preventive care services as a result of the health system responses during this pandemic," says Heather Sperring, MS, a data quality specialist in the Center for Infectious Diseases and Public Health Programs at Boston Medical Center and corresponding author on this study. "Nontraditional methods of preventive healthcare delivery need to be used in order to prevent the detrimental long-term effects of these gaps in patient care. This includes proactive efforts aimed at increasing preventive care and screening, and interventions that reduce health risks, decrease avoidable emergency room visits, and minimize the time necessary for patients to be in the hospital."

The data for this analysis was collected prospectively from December 1, 2019 to June 30, 2020. Using descriptive statistics, the analysis was completed by comparing unique patient tests for 3.5-month periods before and after March 16, 2020, analyzing total tests and total new HCV RNA positive results before and after, and mean daily tests. Effective March 16, 2020, BMC implemented the utilization of telemedicine for outpatient clinics wherever possible; preventive care, including phlebotomy for HCV screening, was not performed during this time. HCV test results for patients were collected each day and comparisons were made for all testing across the hospital, as well as exclusively for the primary care sites that have been the most heavily affected by the introduction of telemedicine. Since 2016, BMC has been utilizing an HCV screening program to better identify and treat patients with HCV.

"The healthcare impacts of COVID-19 are more widespread than the effects of the disease itself. The pandemic has had substantial implications for our patients, and not just those who contracted COVID-19," says Elissa Schechter-Perkins, MD, MPH, an emergency medicine physician at Boston Medical Center, an associate professor of emergency medicine at Boston University School of Medicine and co-author on this study. "Hepatitis C virus is likely just one example of many chronic diseases whose cascade of care was affected by COVID-19."

As an urban safety-net hospital, the patient population at BMC has four times more cases of HCV than the national average and are consistently screened for HCV in the emergency department and other clinics throughout the hospital, per current CDC recommendations. Other public health initiatives need to be monitored in the context of telemedicine workflows in order to improve access to HCV testing, and for healthcare professionals to continue to monitor HCV screening trends.

First came their pioneering research a few years ago linking burnout and depression. Now City College of New York psychologist Irvin Sam Schonfeld and his University of Neuchâtel collaborator Renzo Bianchi present the Occupational Depression Inventory [ODI], a measure designed to quantify the severity of work-attributed depressive symptoms and establish provisional diagnoses of job-ascribed depression.

Touted by the duo as the first such measure of its kind, the ODI comprises nine symptom items and a subsidiary question assessing turnover intention. A total of 2254 employed individuals in the United States, New Zealand and France participated in the study.

"We examined the psychometric and structural properties of the ODI as well as the nomological network of work-attributed depressive symptoms," said Schonfeld, describing the methodology.

They adopted an approach centered on exploratory structural equation modeling (ESEM) bifactor analysis and developed a diagnostic algorithm for identifying likely cases of job-ascribed depression. Work-attributed depressive symptoms correlated in the expected direction with other variables of interest?e.g., job satisfaction, general health status?and were markedly associated with turnover intention. Of the 2254 participants, 7.6% (n = 172) met the criteria for a provisional diagnosis of job-ascribed depression.

According to Schonfeld, their study suggests that the ODI constitutes a sound measure of work-attributed depressive symptoms. "It may help occupational health researchers and practitioners identify, track and treat job-ascribed depression more effectively," he said, adding: "ODI-based research may contribute to informing occupational health policies and regulations in the future."

Schonfeld said unlike other researchers who charge researchers to use instruments they develop; he and Bianchi would make the ODI available to colleagues worldwide at no cost. Entitled "The Occupational Depression Inventory: A new tool for clinicians and epidemiologists," their study appears in the Journal of
Psychosomatic Research.

LA JOLLA--Researchers at La Jolla Institute for Immunology (LJI) have found that people with sepsis have never-before-seen particles in their blood. The scientists are the first to show that these particles, called elongated neutrophil-derived structures (ENDS), break off of immune cells and change their shape as they course through the body.

"We actually found a new particle in the human body that had never been described before," explains LJI Instructor Alex Marki, M.D., who served as first author of the study. "That's not something that happens every day."

The research, published December 4, 2020 in the Journal of Experimental Medicine shows the importance of understanding how immune cells change over the course of a disease.

"ENDS are not normal--they are not detectable in healthy people or mice," says LJI Professor Klaus Ley, M.D., who served as senior author of the study. "But ENDS are very high in sepsis, and I would not be surprised if they were high in other inflammatory diseases."

The beginning of the ENDS

The discovery of ENDS started with an odd observation.

Marki was studying neutrophils, a kind of immune cell that moves through the bloodstream and slips into tissues to fight infections. At the time, he was studying living mice to confirm the presence of tubes called tethers. These tethers are attached to neutrophils as they roll on the blood vessel wall.

During these experiments Marki noticed long, thin objects of neutrophil origin sticking to the vessel wall. Since no such structure was described in the scientific literature, the team had to come up with a name for them. The initial lab slang name "sausages" was eventually replaced by the elongated neutrophil-derived structures or ENDS.

Desperate for learning more about these new objects, the LJI team developed a series of new techniques to study how ENDS form and degrade--and to detect them in human and mouse blood plasma.

Thanks to sophisticated imaging techniques, the LJI team figured out that tethers become ENDS. As the neutrophils flop and roll along, their tethers get longer and longer. Eventually the tethers become too thin--just 150 nanometers (around 1/500th the width of a human hair). Then they break in the middle. Part of the tether stays with the neutrophil, but the broken fragment flies away in the bloodstream, off to form an ENDS.

The researchers showed that these ENDS curl against the vessel wall until they get a rounded shape. It's likely that the ENDS stay intact for a while, but not for long. Without any life-sustaining organelles inside, the ENDS begin to die. In fact, the researchers found that the ENDS secrete tell-tale signaling molecules that promote inflammation.

Compared with healthy subjects, the researchers showed that ENDS are around 100-fold more detectable in septic patients.

What this means for sepsis

Sepsis can occur when the immune system overreacts to an infection by flooding the body with dangerous chemicals. Instead of just fighting the infection, these chemicals trigger organ damage as they course through the bloodstream. The mortality rate for septic "shock" is 30 percent.

"Once you're in the hospital, sepsis is the most common cause of death," Ley says.

Ley and Marki are still not sure why ENDS form in patients with sepsis. To learn more, Marki hopes to collect more patient samples to track ENDS formation and frequency over time. "I'd like to study blood from several time points from each patient--to see the dynamics of how ENDS change," he says.

Ley says it is theoretically possible that ENDS could one day serve as a biomarker for early sepsis detection, but it is currently impossible to detect them in a clinical setting. "Right now, the assay is not practical because it takes specialized instrumentation," says Ley.

Rather than serving as a diagnostic, Ley thinks studying ENDS could reveal secrets to how the immune system evolved. He's curious to learn how the process to form ENDS evolved--and why.

"Neutrophils are very soft cells that can deform to reach almost any place in the body," says Ley. "So one hypothesis I have is that ENDS might be the price you pay for having such a soft cell--that if you pull too hard, it falls apart."

Boston, Mass. - Since the novel coronavirus emerged at the end of last year, scientists around the world -- including Beth Israel Deaconess Medical Center (BIDMC) immunologist Dan Barouch, MD, PhD -- have been developing vaccines to protect against COVID-19 and to put an end to the global pandemic. As of November 2020, three pharmaceutical companies released early data showing high rates of protection in Phase 3 human trials for their vaccines, but questions remain about how the body develops and maintains immunity after vaccination or infection.

In a new paper in the journal Nature, Barouch, Director of BIDMC's Center for Virology and Vaccine Research, and colleagues shed light on the role of antibodies and immune cells in protection against SARS-CoV-2, the virus that causes COVID-19, in rhesus macaques. "In this study, we define the role of antibodies versus T cells in protection against COVID-19 in monkeys. We report that a relatively low antibody titer (the concentration of antibodies in the blood) is needed for protection," said Barouch. "Such knowledge will be important in the development of next generation vaccines, antibody-based therapeutics, and public health strategies for COVID-19."

Building on previous findings that SARS-CoV-2 infection protects rhesus monkeys from re-exposure, Barouch and colleagues purified and collected antibodies from animals that had recovered from infection. They administered the antibodies at various concentrations to 12 uninfected macaques and observed that protection against SARS-CoV-2 challenge was dose dependent. Animals that received higher amounts of antibodies were protected more completely, while animals that received lower amounts of antibodies were protected less well. Similarly, when the researchers administered various concentrations of the purified antibodies to 6 macaques with active SARS-CoV-2 infection, those given higher doses demonstrated more rapid viral control.

In a second set of experiments, Barouch and colleagues evaluated the role of specific immune cells -- CD8+ T cells -- in contributing to protection against the virus by removing these cells from animals that had recovered from SARS-CoV-2 infection. Removal of these immune cells left the animals vulnerable to infection after re-exposure to SARS-CoV-2.

"Our data define the role of antibodies and T cells in protection against COVID-19 in monkeys. Antibodies alone can protect, including at relatively low levels, but T cells are also helpful if antibody levels are insufficient," said Barouch, who is also Professor of Medicine at Harvard Medical School, and a member of the Ragon Institute of MGH, MIT, and Harvard. "Such correlates of protection are important given the recent successful vaccine results from human trials, and the likelihood that these and other vaccines will become widely available in the spring; as a result future vaccines may need to be licensed based on immune correlates rather than clinical efficacy."

HOUSTON - (Dec. 4, 2020) - In his first year of graduate school, Rice University biochemist Zachary Wright discovered something hidden inside a common piece of cellular machinery that's essential for all higher order life from yeast to humans.

What Wright saw in 2015 -- subcompartments inside organelles called peroxisomes -- is described in a study published today in Nature Communications.

"This is, without a doubt, the most unexpected thing our lab has ever discovered," said study co-author Bonnie Bartel, Wright's Ph.D. advisor and a member of the National Academy of Sciences. "This requires us to rethink everything we thought we knew about peroxisomes."

Peroxisomes are compartments where cells turn fatty molecules into energy and useful materials, like the myelin sheaths that protect nerve cells. In humans, peroxisome dysfunction has been linked to severe metabolic disorders, and peroxisomes may have wider significance for neurodegeneration, obesity, cancer and age-related disorders.

Much is still unknown about peroxisomes, but their basic structure -- a granular matrix surrounded by a sacklike membrane -- wasn't in question in 2015. Bartel said that's one reason Wright's discovery was surprising.

"We're geneticists, so we're used to unexpected things. But usually they don't come in Technicolor," she said, referring to another surprising thing about Wright's find: beautiful color images that show both the walls of the peroxisome subcompartments and their interiors. The images were possible because of bright fluorescent reporters, glowing protein tags that Wright employed for the experiments. Biochemists modify the genes of model organisms -- Bartel's lab uses Arabidopsis plants -- to tag them with fluorescent proteins in a controlled way that can reveal clues about the function and dysfunction of specific genes, including some that cause diseases in people, animals and plants.

Wright, now a postdoctoral research associate in Bartel's lab, was testing a new reporter in 2015 when he spotted the peroxisome subcompartments.

"I never thought Zach did anything wrong, but I didn't think it was real," Bartel said. She thought the images must be the result of some sort of artifact, a feature that didn't really exist inside the cell but was instead created by the experiment.

"If this was really happening, somebody would have already noticed it," she recalled thinking.

"Basically, from that point on, I was trying to understand them," Wright said. He checked his instruments, replicated his experiments and found no evidence of an artifact. He gathered more evidence of the mysterious subcompartments, and eventually wound up at Fondren Library, combing through old studies.

"I revisited the really old literature about peroxisomes from the '60s, and saw that they had observed similar things and just didn't understand them," he said. "And that idea was just lost."

There were a number of references to these inner compartments in studies from the '60s and early '70s. In each case, the investigators were focused on something else and mentioned the observation in passing. And all the observations were made with transmission electron microscopes, which fell out of favor when confocal microscopy became widely available in the 1980s.

"It's just much easier than electron microscopy," Bartel said. "The whole field started doing confocal microscopy. And in the early days of confocal microscopy, the proteins just weren't that bright."

Wright was also using confocal microscopy in 2015, but with brighter reporters that made it easier to resolve small features. Another key: He was looking at peroxisomes from Arabidopsis seedlings.

"One reason this was forgotten is because peroxisomes in yeast and mammalian cells are smaller than the resolution of light," Wright said. "With fluorescence microscopy, you could only ever see a dot. That's just the limit that light can do."

The peroxisomes he was viewing were up to 100 times larger. Scientists aren't certain why peroxisomes get so large in Arabidopsis seedlings, but they do know that germinating Arabidopsis seeds get all of their energy from stored fat, until the seedling leaves can start producing energy from photosynthesis. During germination, they are sustained by countless tiny droplets of oil, and their peroxisomes must work overtime to process the oil. When they do, they grow several times larger than normal.

"Bright fluorescent proteins, in combination with much bigger peroxisomes in Arabidopsis, made it extremely apparent, and much easier, to see this," Wright said.

But peroxisomes are also highly conserved, from plants to yeast to humans, and Bartel said there are hints that these structures may be general features of peroxisomes.

"Peroxisomes are a basic organelle that has been with eukaryotes for a very long time, and there have been observations across eukaryotes, often in particular mutants, where the peroxisomes are either bigger or less packed with proteins, and thus easier to visualize," she said. But people didn't necessarily pay attention to those observations because the enlarged peroxisomes resulted from known mutations.

The researchers aren't sure what purpose is served by the subcompartments, but Wright has a hypothesis.

"When you're talking about things like beta-oxidation, or metabolism of fats, you get to the point that the molecules don't want to be in water anymore," Wright said. "When you think of a traditional kind of biochemical reaction, we just have a substrate floating around in the water environment of a cell -- the lumen -- and interacting with enzymes; that doesn't work so well if you've got something that doesn't want to hang around in the water."

"So, if you're using these membranes to solubilize the water-insoluble metabolites, and allow better access to lumenal enzymes, it may represent a general strategy to more efficiently deal with that kind of metabolism," he said.

Bartel said the discovery also provides a new context for understanding peroxisomal disorders.

"This work could give us a way to understand some of the symptoms, and potentially to investigate the biochemistry that's causing them," she said.

Organic-inorganic hybrid lead iodide perovskites are universally recognized as very promising photovoltaic (PV) materials. While outstanding PV performance is continuously reported, manipulating these hybrid perovskites for extraordinary optoelectronic properties with a greater intrinsic structural stability becomes a growing attention. The soft nature of organic-inorganic halide perovskites renders their lattice particularly tunable to external stimuli such as pressure, undoubtedly offering an effective way to modify their structure for extraordinary optoelectronic properties. However, these soft materials meanwhile feature a general characteristic that even a very mild pressure will lead to detrimental lattice distortion and weaken the critical light-matter interaction, thereby triggering the performance degradation.

Herein, an international research team led by scientists from Center for high pressure science and technology advanced research (HPSTAR) reported a comprehensive high-pressure isotope research on hybrid perovskites. To their surprise, it is observed that the pressure-driven lattice disorder can be significantly suppressed via hydrogen isotope effect, which is crucial for better optical and mechanical properties previously unattainable. By in situ neutron/synchrotron-based analysis and optical characterizations, a remarkable photoluminescence (PL) enhancement by threefold is convinced in deuterated CD3ND3PbI3, which also shows much greater structural robustness with retainable PL after high peak-pressure compression-decompression cycle.

The researchers also proposed an atomic level understanding of the strong correlation among the organic sublattice and lead iodide octahedral framework and structural photonics, where the less dynamic CD3ND3+ cations are vital to maintain the long-range crystalline order through steric and Coulombic interactions. In addition, the result of device-related investigations shows CD3ND3PbI3-based solar cell has comparable photovoltaic performance as CH3NH3PbI3-based device but exhibits considerably slower degradation behavior, thus representing a paradigm by suggesting isotope-functionalized perovskite materials for better materials-by-design and more stable photovoltaic application.

AMHERST, MASS. - If you find yourself in a car with someone outside your household during the COVID-19 pandemic, your instinct may be to roll down your window, whether you're the driver or a back-seat passenger. But a University of Massachusetts Amherst physicist has shown in a new study that opening the car window closest to you isn't always the best option to protect yourself from coronavirus or any airborne infection.

In a paper published Dec. 4 in the journal Science Advances, researchers have revealed certain surprising ways in which the airflow patterns within a car's interior could either heighten or suppress the risk of airborne infection during everyday commutes.

"One might imagine that people instinctively open windows right beside them while riding with a co-passenger during the pandemic. That may not be optimal - though it's better than opening no window," says lead author Varghese Mathai, an assistant professor of physics at UMass Amherst.

He explains, "We designed this research with ride-sharing in mind, from a traditional taxi or Uber and Lyft to noncommercial commutes, assuming a driver and one passenger, seated in the back on the passenger side to provide the best possible spacing between the occupants."

Briefly, the research suggests that opening the windows farthest from the driver and the back-seat passenger might offer some benefits. The findings may provide COVID-19 risk reduction measures for the hundreds of millions of people driving in passenger cars or taking a taxi worldwide.

The most and least risky scenarios for airborne pathogen transmission in a car are understood by scientists: Opening all the windows, along with bringing in fresh air through the vents, is thought to create the best in-cabin environment to reduce the risk of transmission by increasing ventilation. Keeping all the windows up and using only the recirculating air mode is likely the riskiest option.

Realizing the impracticalities of keeping all car windows open in winter or rainy weather, Mathai wanted to examine what happens to aerosolized particles exhaled by occupants inside the car's cabin under various configurations of open and closed windows. "These tiny, potentially pathogenic particles remain in the air for long durations without settling down, so if they are not flushed out of the cabin, they can build up over time posing an increased risk of infection," he explains.

Generally, the air flowing around a car creates a lower pressure on the front windows as compared to the back windows, Mathai says. "We had this idea that if you open the rear and front windows on opposite sides, then you might create an air current from the rear to the front of the cabin, and crossing through the middle."

The study was conducted with colleagues Asimanshu Das, Jeffrey Bailey and Kenneth Breuer at Brown University, where Mathai worked previously and started the study. The researchers hypothesized that if all windows can't be left open, opening the front window on the right side and the rear window on the left side might best protect the driver and passenger from the hundreds of aerosol particles released in every human breath.

"To our surprise, the simulations showed an air current that acts like a barrier between the driver and the passenger," says Mathai, who likened this phenomenon to the air curtain created by a draft blown down vertically at some supermarket entrances, which prevents outdoor air from mixing with indoor air, even if the entrance door is open.

"While these measures are no substitute for wearing a face mask while inside a car, they can help reduce the pathogen load inside the very confined space of a car cabin," he points out.

Like many other researchers during the pandemic, Mathai -- an experimental physicist -- decided to shift his focus toward computer simulations while working from home. He later backed up his findings using smoke visualization and field tests that identified low-speed and high-speed zones inside the car.

The research describes the driver-to-passenger and passenger-to-driver transmission for different ventilation options, and used passive scalar transport as a proxy for infectious particles. Heat maps illustrate the scalar concentration fields originating from either the driver or passenger.

The researchers used a simplified, time-averaged model for the turbulent air flow, and study implications are limited to airborne mode of transmission, the authors stress. The computer model was based roughly on the exterior of a Toyota Prius driven at around 50 mph and the field tests of smoke and flow wand were recorded in the cabin of a Kia Optima.

An analysis of lung tissues from patients with different types of pulmonary fibrosis - including cases triggered by COVID-19 - has revealed a promising molecular target to ameliorate the chronic and irreversible disease. Experiments in mouse models of lung fibrosis showed that administering blockers of an epigenetic regulator called MBD2 via intratracheal inhalation protected the mice against fibrotic lung injury, highlighting a potential viable therapy. A poor understanding of what causes pulmonary fibrosis has greatly hindered the development of treatments, and to this day, no effective therapy is available other than lung transplantation. To tackle this limitation, Yi Wang and colleagues studied lung samples from patients with pulmonary fibrosis triggered by one of three causes: SARS-CoV-2 infection, systemic sclerosis-associated interstitial lung disease, or an unknown factor. The researchers also studied mouse models of pulmonary fibrosis, which they induced in the animals by administering the compound bleomycin. All cases of pulmonary fibrosis, they found, were characterized by overexpression of MBD2. This activity localized in areas occupied by macrophages - known contributors to the development of pulmonary fibrosis. To investigate this further, the scientists depleted the Mbd2 gene in macrophages of mice, which protected the animals against pulmonary fibrosis, characterized by markedly reduced macrophage accumulation in the lung following administration of bleomycin. As well, direct administration of liposomes - established carriers of inhaled drugs - loaded with Mbd2 silencer RNA into the trachea of mice protected them from lung injuries and fibrosis. Since MBD2 itself does not affect the essential epigenetic process of DNA methylation, inhibiting the molecule could prove to be a safe way to treat pulmonary fibrosis. However, future studies will first need to assess the impact of altered MBD2 expression in other types of cells relevant to pulmonary fibrosis, the authors say.

A new series of computational fluid dynamics simulations suggests that, for two people who must travel together in the same passenger car, the safest way to prevent possible transmission of COVID-19 in such a risky, enclosed environment is to do so with all four windows down and the passenger seated as far as possible from the driver, in the rear seat on the opposite side. Varghese Mathai and colleagues found that this modeled configuration created two distinct flows of air in the car's cabin, separated along the midline of the car and moving - perhaps counterintuitively - from the rear towards the front of the car, due to exterior pressure differentials dictated by the car's aerodynamics. This separated airflow configuration was the most effective at reducing the transmission of simulated infectious droplets from either driver to passenger, or vice versa. However, recognizing that such a breezy configuration may be less desirable for many travelers, the researchers also tested the opposite scenario - all four windows up - as well as four other scenarios with either one or two windows closed. The fully enclosed scenario, which relied only on simulated, non-recirculated airflow from the car's air conditioning system, was the riskiest of all six simulated scenarios, conferring the highest risk of droplet transmission. Traveling with three open windows fared better than only two open windows, but the researchers found that choosing which window to close may in fact matter a great deal. In scenarios that simulated either an infected driver or an infected passenger, closing only the window closest to the non-infected person conferred the greatest protection, second only to the scenario with all four windows open. Mathai et al. note that their simulations, based on an idealized model sedan patterned after the body shape of a Toyota Prius, may not accurately reflect airflow dynamics in other vehicles such as trucks, minivans, and cars with an open sunroof. They also note that their models may also miss some other nuances of airflow and particle residence times that may result from, for example, strong crosswinds or otherwise exceptionally windy conditions. All the same, the authors conclude that "these results will have a strong bearing on infection mitigation measures for the hundreds of millions of people driving in passenger cars and taxis worldwide, and potentially yield to safer and lower-risk approaches to personal transportation."

When the COVID-19 lockdowns began in mid-March 2020, hospitals and clinics faced a new challenge: How could they continue to provide care to those who could not leave their homes?

The answer lay in virtual visits -- doctor visits that take place over the phone or through videoconferencing -- but for many healthcare providers, these virtual visits were a new frontier.

University of Chicago Medicine, like many hospital systems across the country, quickly built a telehealth infrastructure to support these visits. From mid-March to the end of May, the system provided nearly 50,000 virtual visits to patients.

A new study published December 4, 2020, in the journal JMIR Medical Informatics examines the increase in these visits, and recommends adopting policies that encourage virtual visits going forward.

"Oftentimes, virtual visits are just as good as in-person visits, and we found that telephone visits are particularly important going forward if we are going to keep providing service to communities that do not have access to the technology needed for video visits," said Craig Umscheid, MD, Vice President of Healthcare Delivery Science and Chief Quality and Innovation Officer at the University of Chicago Medicine and co-author of the study.

When the University of Chicago Medical Center and its five practice sites began giving patients the option of rescheduling their appointment or switching to a virtual visit, either via videoconferencing or over the phone, it entered a new era of widespread telehealth.

Though technology has existed to make virtual visits possible, the Centers for Medicare and Medicaid Services (CMS) and commercial insurance providers generally did not cover those visits. That changed during the COVID-19 public health emergency, when CMS expanded coverage to include virtual visits. Many commercial insurance companies followed suit.

To understand the effects of these visits, a UChicago research team, including senior author Sachin Shah, MD, Associate Chief Medical Information Officer for UChicago Medicine, set out to analyze the data to find out who was using the virtual visit option during the first 11 weeks of the stay-at-home order.

In that timeframe, 60 percent of UChicago Medicine visits were virtual. Of those, 60 percent were by video and 40 percent were by phone.

But use of virtual visits was not equal across demographics. Virtual visits were more likely among patients with Medicare. Those less likely to use virtual visits included men, the very young and very old, and patients with Medicaid.

The research team also studied the demographics of video visit use versus telephone visit use. Telephone visits were more likely to be used by older patients, Black patients, and patients with Medicare and Medicaid (as opposed to commercial) insurance.

In fact, Black patients were half as likely as white patients to use video for their virtual visits. Though video visits generally provide a higher quality experience, many patients do not have access to a computer or the internet, or do not have the digital literacy to download and use a mobile application.

After analyzing the data, the researchers made five recommendations for virtual visits going forward, including creating a reimbursement parity between video and telephone visits. Right now, physicians who conduct a video visit are reimbursed for all time spent on patient care for that visit, including time spent on documentation. For telephone visits, they can only bill for time spent in direct communication with a patient.

Many are worried that once the pandemic is over, insurers will stop covering virtual visits or will only cover video visits. "Our research shows that if telephone visits aren't covered going forward, many patients will not have the same access to healthcare," Shah said. "There is widespread agreement among patients and providers that virtual visits shouldn't go away. But we need to make sure that policymakers understand how different types of virtual visits benefit different populations."

The researchers recommend developing legislation that makes virtual visit reimbursement permanent. But because virtual visits aren't appropriate for every visit, they recommend that guidance be developed to distinguish which visits are best suited for the virtual environment.

They also recommend that the usability of video visits be improved, and they advocate for universal broadband access to close the digital divide among populations. "A lot of software isn't as easy to navigate as you might think," Shah said. "We should incentivize companies to make it more usable for providers and patients."

The researchers hope to continue to study virtual visits, since it will continue to be a significant part of healthcare delivery in the future.

"There has been a lot of excitement around the pivot to virtual visits, because it allows us to broaden our reach to communities that don't normally leverage the services of UChicago Medicine," Umscheid said. "This is opening a completely new frontier around patient engagement and accessibility and ultimately the quality of care we deliver."

While multiple research studies show that Black and Hispanic patients are more likely to test positive for COVID-19, a team of investigators at NYU Langone Health has found that once hospitalized, Black patients (after controlling for other serious health conditions and neighborhood income) were less likely to have severe illness, die, or be discharged to hospice compared to White patients.

The study -- recently published online in JAMA Network Open - is, according to its authors, one of the first to examine the impact of comorbid conditions and neighborhood socioeconomic status (SES) on outcomes for Black, Hispanic and Asian patients hospitalized for COVID-19. Findings indicate that Black and Hispanic populations are not inherently more susceptible to poor COVID-19 outcomes compared to other groups, and that once hospitalized, their outcomes are equal to or better than their White counterparts.

"We know that Black and Hispanic populations account for a disproportionate share of COVID-19-related deaths relative to their population size in New York and major cities across the country," says Gbenga Ogedegbe, MD, MPH, Dr. Adolph and Margaret Berger Professor of Medicine and Population Health at NYU Langone Health, and the study's lead author. "We were, however, surprised to find that Black and Hispanic patients were no more likely to be hospitalized across NYU Langone than White patients, which means we need to look at other structural factors at play that are negatively affecting outcomes in these communities. These factors include poor housing conditions, unequal access to health care, differential employment opportunities, and poverty--and they must be addressed," says Ogedegbe, who is also director of NYU Langone's Institute for Excellence in Health Equity.

How the Study Was Conducted

The team of investigators obtained all data from NYU Langone Health's electronic health record (EHR) of 9,722 patients tested for COVID-19 at the health system's 260 outpatient office sites and four acute care hospitals in Manhattan, Brooklyn, and Long Island between March 1, 2020 and April 8, 2020, and followed them through May 13, 2020. The patients' race and ethnicity data was self-reported.

For every patient who tested positive for COVID-19 , the researchers compiled race/ethnicity data, patient characteristics such as body mass index (BMI), age and sex, and neighborhood socioeconomic (SES) data contained in a weighted index of seven indicators (including median household income, level of education and housing value, among others).

Study Findings

Among the 4,843 patients who tested positive for COVID-19, 39 percent were White, 15.7 percent were Black, 25.9 percent were Hispanic, 7 percent were Asian, and 7.4 percent were multiracial/other; 2,623 patients were hospitalized.

Of 2,623 patients hospitalized, 39.9 percent were White, 14.3 percent were Black, 27.3 percent were Hispanic, 6.9 percent were Asian, and 7.9 percent were multiracial/other. Hospitalized patients were older and had higher comorbidity than patients who tested positive but were not hospitalized. 70.8 percent were discharged, 36.3 percent experienced critical illness, 24.7 percent died or were discharged to hospice, and 4.5 percent remained hospitalized as of May 13, 2020.

Black and Hispanic patients had a lower risk of critical illness and were less likely to die or be discharged to hospice compared to White patients. After adjusting for age, sex, insurance status and comorbidity, Black patients continued to have lower risk of death compared to White patients, while Hispanics and Asian patients had similar rates to White patients.

After adjusting for all the above factors, Asian patients had higher odds of being hospitalized than White patients even though they were less likely to test positive for COVID-19.

"Our findings provide more evidence that the social determinants of health play a critical role in determining patient outcomes, particularly for Black patients, before they ever get to the hospital," said Joseph Ravenell, MD, associate professor in the Department of Population Health and associate dean for Diversity Affairs and Inclusion at NYU Langone.

"However, we do see a bit of a paradox," said Ravenell. "In keeping with other research, we've found that once Black patients with COVID-19 make it to the hospital-- despite coming from lower-income neighborhoods--their odds of dying are similar to or lower than White patients. Meanwhile, we also know that Black and Hispanic people are disproportionately contracting and dying of COVID-19 across the country."

According to Ogedegbe and Ravenell, Black populations are more likely to be uninsured and underinsured than White populations and thus more likely to die at home as opposed to in hospital due to poorer access to care. Another predictor of poor outcomes for patients hospitalized with COVID-19 is male sex. In this particular study cohort, 62 percent of Black hospitalized patients were female, which could explain their relatively better outcomes. The study population may also not be representative of the overall New York City population, they said.

Study senior author Leora Horwitz, MD, associate professor in the Departments of Population Health and Medicine and director of the Center for Healthcare Innovation and Delivery Science at NYU Langone, says that future studies need to better examine the direct impact of structural inequities on racial and ethnic disparities in COVID-19 related hospitalization, morbidity, and mortality.

Los Robles Health System is leading the way in neurovascular clinical trials enrolling the first patient in the nation in STEM, the Squid trial for the treatment of chronic subdural hematoma (cSDH). Chronic subdural hematoma is a disease that presents as a collection of blood that positions itself between the surface of the brain and the outermost layer of the brain covering, called the dura. cSDH is a debilitating, causing many neurologist deficits and often requiring invasive surgery to open the skull. The patient population most commonly affected by cSDH are older adults, who are more likely to experience bleeding and rebleeding in the small vessels of the brain due to atrophy.

"This is a landmark trial that can change the management of chronic subdural hematomas completely," says Dr. Asif Taqi, principal investigator for the trial and medical director of Neurosciences at Los Robles Health System. "Recent medical literature suggests there is a benefit in the liquid embolization of the middle meningeal artery to prevent future reaccumulation of blood and help reduce the present SDH."

The STEM trial is a prospective, multicenter and randomized controlled trial at 25 different sites across the US, which aims to assess the safety and effectiveness of the Squid embolic agent. Leading this national trial, Los Robles enrolled the first ever patient in United States into this trial. "We are very excited to be leading this exciting research study that will potentially change the management of this disease in our community," says Dr. Taqi.

"Los Robles is thrilled to have the first patient enrolled in the STEM trial in the nation," says Chief Medical Officer, Dr. Gabriella Sherman. "We know that the results of STEM are crucial as they will add to our overall knowledge of chronic subdural hematomas a common and disabling disease in the senior population." The trial has the potential to determine whether treatment of cSDH with the Squid liquid embolic system is safe and effective. In addition, the trial will allow for a better understanding into the disease's natural progression and the safety and efficacy of current treatment strategies.

December 4, 2020 -- Unless we take urgent action to tackle climate change, we can expect an ever-hotter world that threatens global health, disrupts lives and livelihoods and overwhelms healthcare systems, according to The Lancet's Global Countdown on Health and Climate Change, a comprehensive global analysis tracking the impact of climate change on human health across 41 key indicators.

Experts from institutions across the globe who work at the nexus of climate change and health contributed to the published findings, including faculty from Columbia University Mailman School of Public Health. While the report presents the most worrying outlook to date as key trends worsen, the collaborators also find that with urgent climate action and a holistic response to the converging crises, the lives of millions can be improved and saved.

The 41 indicators are organized across five categories: 1) climate change impacts, exposures and vulnerabilities; 2) adaptation planning and resilience for health; 3) mitigation actions and health co-benefits; 4) economics and finance; and 5) public and political engagement.

Jeffrey Shaman, PhD, professor of environmental health sciences, director of the climate and health program and vice chairman of Columbia's Climate School, was a report contributor and reviewer. Lewis Ziska, PhD, associate professor of environmental health sciences, contributed to the chapter on food insecurity following extreme climate events where he also addressed structural and social determinants of food insecurity. "An important aspect of public health involves ensuring food security following a climate change induced extreme event. Here we look for common occurrences, problems and potential solutions that can be used as recommendations to ensure that no one goes hungry following a hurricane, flood or intense windstorm. But more needs to be done," noted Ziska.

According to Kim Knowlton, DrPH, assistant professor of environmental health sciences at Columbia Mailman and senior scientist, Natural Resources Defense Council, "This year's Lancet Countdown is the latest warning that the U.S. is going in the wrong direction on climate change and health. But it's not too late to change course. The incoming Biden/Harris administration should seize this opportunity to embrace the knowledge, expertise, and passion of the American public health and healthcare community. Together, we can build back a healthier, more equitable, and climate-resilient nation."

"Whether it's the spread of viruses and infectious diseases, heat exposure, or wildfires, the 2020 Lancet Countdown on Health and Climate Change U.S. Policy Brief shows how climate change makes communities and health care systems more vulnerable. The Brief lays out how climate action across sectors will lead to major environmental and public health gains," said Brittany Shea, Project Director, Global Consortium on Climate & Health Education, Columbia University Mailman School of Public Health.

Astronomers have caught a rare glimpse of a rapidly fading shroud of gas around an aging star. Archival data from the NASA/ESA Hubble Space Telescope reveal that the nebula Hen 3-1357, nicknamed the Stingray nebula, has faded precipitously over just the past two decades. Witnessing such a swift rate of change in a planetary nebula is exceedingly without precedent, researchers say.

Even though the Universe is constantly changing, most processes are too slow to be observed within a human lifespan. However, the Stingray Nebula is now offering scientists a special opportunity to observe a system's evolution in real time.

Images captured by Hubble in 2016, when compared to Hubble images taken in 1996, show a nebula that has drastically dimmed in brightness and changed shape. Bright blue shells of gas near the centre of the nebula have all but disappeared, and the wavy edges that earned this nebula its aquatic-themed name are virtually gone. The young nebula no longer pops against the black velvet background of the distant Universe.

Researchers discovered unprecedented changes in the light emitted by glowing gas -- nitrogen, hydrogen and oxygen -- that is being blasted off by the dying star at the centre of the nebula. The oxygen emission, in particular, dropped in brightness by a factor of nearly 1000.

"In most studies, the nebula usually gets bigger," said Bruce Balick of the University of Washington, USA, who led the new research. "Here, it's fundamentally changing its shape and getting fainter, and doing so on an unprecedented timescale."

"Because of Hubble's optical stability, we are very, very confident that this nebula is changing in brightness," said team member Martin Guerrero of the Instituto de Astrofísica de Andalucía in Granada, Spain. "That easy to see since, unlike the nebula, all of the other stars in the Hubble image - including a distant companion star - stayed constant in brightness."

The researchers note that while speculating on causes for this surprising finding, it's important to explore the properties of the dying star at the centre of the Stingray nebula, which influences the structure and brightness of the nebula.

A 2016 study by Nicole Reindl of the University of Leicester, UK, and a team of international researchers, also using Hubble data, noted that the star at the centre of the Stingray nebula, SAO 244567, is special in its own right.

Observations from 1971 to 2002 showed the temperature of the star skyrocketing to almost ten times hotter than the surface of our Sun. Reindl speculates the temperature jump was caused by a brief flash of helium fusion that occurred outside the core of the central star. After that the star began to cool again, returning to its previous stage of stellar evolution.

The team studying the rapid fading of the Stingray nebula can only speculate at this time what's in store for the future of this young nebula.

URBANA, Ill. - An aging U.S. population is rapidly increasing the demand for nursing care. The number of U.S. citizens aged 65 and over is expected to almost double from 43.1 million in 2012 to 87.5 million by 2050, while the workforce is shrinking. The COVID-19 pandemic has further exacerbated the need for health care professionals.

One strategy to meet rising health care needs is to hire foreign nurses to fill the gaps. The availability of immigrant visas for nurses has fluctuated considerably over the years with different policy approaches. Opponents of immigration have asserted that the influx of foreign nurses has resulted in unemployment and lower wages for domestic nurses. However, a new study from the University of Illinois found no such displacement effects.

"Our findings show relying on foreign-educated registered nurses to balance demand and supply in the U.S. healthcare workforce does not hurt the employment of U.S.-educated nurses," says Hyeran Chung, a doctoral student in the Department of Agricultural and Consumer Economics (ACE) at U of I and the lead author on the paper.

Chung and co-author Mary Arends-Kuenning, associate professor in ACE, analyzed data from the U.S. Census and the American Community Survey from 1980-2015. Their research measures the inflow of foreign-educated registered nurses per 1,000 people in commuting zones across the U.S.

Some studies have found foreign nurses displaced U.S. nurses, but Arends-Kuenning and Chung questioned those findings and wanted to do a deeper dive into the complex factors that influence the nursing labor market.

Their research differs in important ways from previous studies by other scientists. One major difference is their definition of foreign nurses as those who are foreign-educated rather than foreign-born.

"It really matters whether you're looking at nurses who were born in the United States versus nurses who were trained here. We believe the real issue is the foreign-educated nurses; it's bringing nurses from abroad to work in hospitals," Arends-Kuenning explains. "The difference between our results and those of previous studies is primarily driven by the use of foreign-educated instead of foreign-born nurses."

A foreign-born nurse could have come to the U.S. as a child and obtained their education in this country, she notes. To adjust for this, the researchers assumed that a foreign-born registered nurse was educated in the U.S. if the nurse was younger than 25 when first arriving to live in the U.S.

Another distinct feature is that the research covers a large geographical area, including every commuting zone in the U.S. where registered nurses are employed.

"Many previous studies have used metropolitan statistical areas, which does make sense because many of the immigrant nurses settle down in bigger cities. But we wanted to include rural America, where the health care issues often have been severe," Chung says.

To further amplify the validity of their results, the researchers used several multiple variable techniques in their analyses, allowing them to capture separately the short- and long-term effects of foreign-educated nurses on the labor outcomes of native nurses. This also helped them take into account possible unobserved characteristics that might be affecting both immigration and other general hiring.

The researchers found no significant effect of foreign-educated nurses on the employment of native nurses in either the short or the long term. They found marginally significant displacement effects on the youngest native nurses in the long run, whereas highly educated natives were positively affected by the foreign-educated nurses in the short run.

They suggest these positive effects may be due to the higher skill level of immigrant nurses. To obtain a work visa, a foreign nurse must have at least a bachelor's degree and two years of work experience. Arends-Kuenning says, "Hospitals might find that foreign-educated nurses are more productive when they work with highly educated native nurses, so they hire accordingly."

The researchers found that ten countries account for the majority of immigrant nurses. The largest group is from the Philippines, followed by India and Canada. The foreign nurses are more likely to be older and male. They are also more likely to earn more than their domestic counterparts, possibly because of their higher education level.

Overall, the study found no displacement effects of bringing in foreign-educated nurses. Hiring foreign-educated nurses does not lower U.S.-educated nurses' wages, either. Those findings have policy implications, Chung says.

"With an aging population and increasing health care needs, hiring foreign nurses might be a viable way to meet the high demand for nursing care," she concludes.