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- Page navigation anchor for RE: Can the Ophthalmologist contribute to the point-of-care testing for COVID-19?RE: Can the Ophthalmologist contribute to the point-of-care testing for COVID-19?
Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic due to infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).1 Considering presence of the virus in body fluids of patients, a potential risk of tear and conjunctival transmission of exists.2 However the transmission route of this virus remains unclear yet believed through aerosols.2 As-on-date, we have a limited understanding of the ocular complications of SARS-CoV-2 infection. The point worth writing this letter was to understand whether subjecting the conjunctival and tear secretions using disposable sampling swabs to laboratory testing by the Ophthalmologist be helpful? Anecdotal reports have given a pointer that SARS-CoV-2 may exist in samples in novel coronavirus pneumonia patients with conjunctivitis.2,3 Research in Singapore also revealed positive test results in three out of 34 highly suspected COVID-19 cases.4 An isolated report from a case in China suggested that viral loads in conjunctival specimens and the potential for transmission gradually decrease over time.5The standard conjunctival swab technique is used to collect the samples by wiping the conjunctiva of the lower eyelid fornix of the patient's eyes without anesthesia. The transfer and storage of these samples in virus transport media is as per routine COVID-19 testing protocol.1In many centers testing for the usual adenoviral conjunctivitis using real transcriptase polymerase chain reaction (RT-PCR) techniqu...
Show MoreCompeting Interests: None declared.References
- Andreas Laupacis. Working together to contain and manage COVID-19. CMAJ 2020;192:E340-E341.
- 2. Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol. 2020 Feb 26; doi: 10.1002/jmv.25725. Epub ahead of print. PMID: 32100876.
- 3. Colavita F, Lapa D, Carletti F, Lalle E, Bordi L, Marsella P, et al. SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection. Ann Intern Med. 2020 Apr 17;M20-1176. doi: 10.7326/M20-1176.
- 4. Loon S-C, Teoh SCB, Oon LLE, Se-Thoe S-Y, Ling A-E, Leo Y-S, et al. The severe acute respiratory syndrome coronavirus in tears. Br J Ophthalmol. 2004 Jul;88(7):861–3.
- 5. Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020 Mar 31;e201291. doi:10.1001/jamaophthalmol.2020.1291
- Page navigation anchor for RE: Priorities for Protective Masks Among Healthcare Workers and PublicRE: Priorities for Protective Masks Among Healthcare Workers and Public
Letter to the Editor,
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Respiratory virus acquisition depends on many factors. Masks prevent aerosolized acquisition, but efficacy depends on particulate efficiency and fit. Experimentally, N95 masks are more effective than surgical masks for excluding particulates.(1) Surgical masks are superior to cloth masks.(2) Uncertain over COVID-19, N95 masks with other protective gear is recommended for high-risk settings.
As healthcare availability becomes compromised due to consumption, rationing or acquisition from non-suppliers needs promotion. Who truly needs N95 masks prioritized? Views of community use illustrate considerable gain for having the public understand mask benefits.
For influenza acquisition among healthcare workers, there was dubious benefit for N95 protection versus routine masks.(3) Despite controversy, it is likely that public use of N95 in most circumstances outside of acute care would be excessive.(4) Support for the aforementioned has also drawn support from systematic review.(5) N95 was popularized for influenza preparations. Past experience was considerable for efficient use of medical surgical masks in many contexts (e.g., preventing airborne chicken pox, tuberculosis, and respiratory viruses in acute care). In publicly applying that experience, it would be evident that there is considerable over-use in circumstances where risks are minimal.
It would be useful to coach the populace for risk and mask suitability. This would not p...Competing Interests: None declared.References
- 1. Lindsley WG, King WP, Thewlis JS, et al. Dispersion and exposure to a cough-generated aerosol in a simulated medical examination room. J Occup Environ Hyg 2012;9(12):681-90.
- 2. Shakya KM, Noyes A, Kallin R, Peltier RE. Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure. J Expo Sci Environ Epidemiol 2017;27(3):352-7.
- 3. Radonovich LJ Jr, Simberkoff MS, Bessesen MT, et al. N95 respirtors vs medical masks for preventing influenza among health care personnel: a randomized clinical trial. JAMA 2019;322(9):824-33.
- 4. McDiarmid M, Harrison R, Nicas M. N95 respirators vs medical masks in outpatient settings. JAMA 2019;323(8):789.
- 5. Long Y, Hu T, Liu L, et al. Effectiveness of N95 respirators versus surgical masks against influenza: a systematic review and meta-analysis. J Evid Based Med 2020 Mar 13. doi: 10.1111/jebm.12381
- Page navigation anchor for RE:Supporting Autism Spectrum Disorder in the face of the COVID-19 pandemicRE:Supporting Autism Spectrum Disorder in the face of the COVID-19 pandemic
The call for innovative approaches and the need to ensure continuity of care for those with chronic health issues during the pandemic cannot be overemphasized.[1] A specific response to address the mental distress of children who are quarantined is needed.[2] There needs to be greater emphasis on designing diverse, socio-culturally appropriate programs to address and provide mental health and psychosocial supports to mitigate the effects of prolonged isolation in children. Children and youth diagnosed with Autism Spectrum Disorder (ASD) are vulnerable to the effects of prolonged isolation or quarantine and may have difficulty adapting to this new norm, especially as inflexibility and insistence on sameness are hallmark characteristic of this disorder. [3] Consequences of a pandemic and measures put in place to decrease transmission of COVID-19 has the potential to adversely affect children/ youth diagnosed with ASD and their families including siblings. Parental anxiety around job loss, economic uncertainty, lack of access to health care facilities/ treatment centres, extension of waitlist for early intervention programs may cripple a caregiver’s/ parent’s ability to cope with the COVID-19 pandemic.
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Integration of varied levels of intervention co-created within a child-family specific pandemic response program is needed.[4] Such programs may not require new initiatives and funding; the current pandemic instead challenges health care providers/ institutions to re-...Competing Interests: None declared.References
- Andreas Laupacis. Working together to contain and manage COVID-19. CMAJ 2020;192:E340-E341.
- Liu, J.J., et al., Mental health considerations for children quarantined because of COVID-19. Lancet Child Adolesc Health, 2020.
- American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force., Diagnostic and statistical manual of mental disorders : DSM-5. 5th ed. 2013, Arlington, Va.: American Psychiatric Association. 947 p.
- Campbell, V.A., et al., Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health, 2009. 99 Suppl 2: p. S294-300.
- Page navigation anchor for Chaos, complexity and systems thinking to contain and manage COVID-19Chaos, complexity and systems thinking to contain and manage COVID-19
Andreas Laupacis’ CMAJ Editorial calls for us to work together to contain and manage COVID-19, describing unprecedented measures needed and hardships to come (1).
Complexity, considered the science for a complex world, and the science for the 21st century, now being used widely across many disciplines can help with this (2).
Selected references: “Tsunami Chaos Global Heart” book (2), “Simply Complexity” book (3), interactive website “What is Complexity Science,” and PDF booklet “Complexity Explained” (4), Stopping the Corona Virus Pandemic - New England Complex Systems Institute website.
Chaos science describes unpredictable effect of small changes, uncertainty and transitions. Complexity is the science of the many dynamic social, biologic, behavioral, political and other nonlinear interactions with often unexpected outcomes, and complex systems, with many interdependent and interrelated parts, follow the rules of complexity (2-5).
It is the basis of network medicine, network science and the spread of viruses, described as complex adaptive systems, with a systems approach to preventing and responding to COVID-19 proposed (5). It is also a science of management and change amidst uncertainty, as in this pandemic (2-5).
The physician ethic of caring for humanity will see us through this, with sharing and caring like the global heart after the tsunami of 2004, described in...
Show MoreCompeting Interests: None declared.References
- 1. Andreas Laupacis. Working together to contain and manage COVID-19. CMAJ 2020;192:E340-E341.
- 2 Rambihar VS, Rambihar SP, Rambihar VS Jr. Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world. 2005. Vashna Publications. Toronto, Canada. http://femmefractal.com/FinalwebTsunamiBK12207.pdf (accessed April 1, 20
- 3 Johnson N. Simply Complexity: a clear guide to complexity theory. 2007. Oneworld Publications. London.
- 4 M. De Domenico, D. Brockmann, C. Camargo, 2019 Complexity Explained. https://complexityexplained.github.io/ComplexityExplained.pdf (accessed April 1, 2020)
- 5 Bradley DT, Mansouri MA, Kee F, et al. A Systems approach to preventing and responding to COVID-19. EClinical Medicine 2020, https://doi.org/10.1016/j.eclinm.2020.100325 (accessed April 4, 2020)
- Page navigation anchor for Certain social distancing measures are counterintuitiveCertain social distancing measures are counterintuitive
I want to congratulate the federal and provincial governments for reinforcement of social distancing,[1] such as fining the violators,[2] which is probably an effective strategy to reduce the transmission of COVID-19. Nevertheless, I cannot help but notice the double-standard the governments have on the public versus large companies. For instance, several domestic and international flights in Canada have been cancelled due to significant reduction of passengers.[3] That could be a cost-saving move by these flight companies.[4] That result in several passengers being crowded into a few aircrafts that defeat the purpose of social distancing. Ironically, when these flight companies are elaborating how they bring Canadians home amid this global pandemic,[5] they are actually increasing the risk of COVID-19 transmission by cancellation of their flights. Perhaps, these flight companies should also be fined each time they fail to provide a passenger a 2-meter social distance space in aircraft.
I also heard of medical schools prohibiting their students, who were in their out-of-province electives, to return home by flights. I wonder whether the risk of COVID-19 transmission is even worse when these students carpool and interact with various strangers in gas stations and hotels. I understand we currently have only limited evidence-based measures to halt COVID-19 transmission. However, if we logically think about it, these aforementioned strategies are somewhat counterintuiti...
Show MoreCompeting Interests: I have been paid for working in primary and secondary care settings, but not for writing this letter.References
- 1. Andreas Laupacis. Working together to contain and manage COVID-19. CMAJ 2020;192:E340-E341.
- 2. Bains, C. Fine Canadians for ignoring COVID-19 orders or face consequences: doctor. https://nationalpost.com/pmn/news-pmn/canada-news-pmn/fine-canadians-for-ignoring-covid-19-orders-or-face-consequences-doctor (accessed Apr 2, 2020).
- 3. Marchitelli, R. Why many passengers grounded by COVID-19 aren't getting refunds for cancelled flights. https://www.cbc.ca/news/business/passengers-grounded-covid-19-air-canada-westjet-sunwing-1.5510105 (accessed Mar 26, 2020).
- 4. The Canadian Press Air Canada to lay off 16,500 employees amid pandemic-related flight cancellations. https://www.cbc.ca/news/business/air-canada-layoffs-1.5515197 (accessed Mar 30, 2020).
- 5. Markusoff, J.; Friscolanti, M. Inside the frantic, gruelling, all-hands-on-deck effort to bring Canadians home. https://www.macleans.ca/news/canada/inside-the-frantic-gruelling-all-hands-on-deck-effort-to-bring-canadians-home/ (accessed Apr 3, 2020).
- Page navigation anchor for RE: Residents during the pandemicRE: Residents during the pandemic
Resident physicians carry a significant clinical burden in the context of 60-120 hrs/wk of service. At the best of times, this carries risk for burnout. I speak as a resident concerned for other residents during the pandemic.
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We are nearing redeployment to COVID-19 related services. The residents in certain programs (internal medicine, anesthesia, emergency medicine) are experiencing increasingly high service demands, along with exposure to COVID-19 patients.
We must allow for adequate backup for on-call residents and rest residents when possible. Too heavy a workload may result in errors. Errors in particular with donning and doffing PPE could be disastrous. Minimization of the individual role in favor of spread of work will reduce risk. We must avoid the peak of burnout and anxiety that causes the resident to question their own decision making. Good work is ongoing regarding patient flow1-3.
In addition, mobilization of latent workforce such as outpatient residents (ie. Family Medicine), those on research, and residents less in demand during the pandemic may be needed. Assistance with the increasing load on the busiest services (ie. CTU, emergency, ICU) will help to relieve the residents on those services. As colleagues, ensuring a safe burden for fellow residents should be a priority.
Some good examples at my center include roving teams (which my service uses) where small teams manage the service for a week and then are rested for 1-2 weeks. CTU...Competing Interests: None declared.References
- Andreas Laupacis. Working together to contain and manage COVID-19. CMAJ 2020;192:E340-E341.
- Lin M, Beliavsky A, Katz K, et al. What can early Canadian experience screening for COVID-19 teach us about how to prepare for a pandemic? [published online ahead of print, 2020 Mar 6]. CMAJ. 2020;
- Glauser W. Proposed protocol to keep COVID-19 out of hospitals. CMAJ. 2020;192(10):E264–E265.
- Glauser W. Uncalm before the storm. Mar 27, 2020. CMAJ
- Page navigation anchor for RE: COVID-19 Response and Chronic Disease ManagementRE: COVID-19 Response and Chronic Disease Management
We thank Dr. Laupacis for his solemn yet hopeful editorial on COVID-19.[1] While the focus on acute care and public health services is justified, we posit that chronic disease management must continue during this pandemic.[2]
Social distancing decelerates viral transmission, but could have substantial adverse impacts on older Canadians living with frailty and multimorbidity.[3] Many healthcare providers prioritise “urgent” conditions, downsizing access to “non-urgent” frail older persons. Social distancing is likely to affect both formal and informal care, lead to loneliness, depression, anxiety, accelerated functional and cognitive decline, and falls and fractures.[4] A distressed caregiver can quickly become overburdened if supports are reduced, with respite being sought in the emergency department. Those with chronic cardiac or lung disease may see mild symptoms worsen to the point of requiring hospitalization.[4] Vulnerable older adults who are discharged from home and community services may fall victim to exacerbation of conditions that had previously been stable with appropriate community supports. If hospitalized, these persons will be further isolated and face a greater risk for delirium and functional decline, leading to increased length of stay and need for home care, rehabilitation, or institutionalization upon discharge.[5]
Thus, outbreak measures may in fact lead to greater burden on hospitals.
Geriatric assessment can prevent acute care u...
Show MoreCompeting Interests: All authors are members of interRAI, a not-for-profit international scientific organization. They are writing on behalf of interRAI. - Page navigation anchor for RE: COVID-19RE: COVID-19
One of the arguments in favour of the strict measures against COVID-19 [1-3] is the supposed efficiency of restrictions in China and some neighbouring countries. However, the optimistic forecasts like “COVID-19 in China may end soon” [2] appear questionable. The strict measures have a rebound effect. Hardly anybody would like to go into quarantine – either alone nor with their housemates. SARS-CoV-2 infection is externally hardly distinguishable from a common cold apart from severe cases mainly in aged persons. Of note, the mean age of patients with COVID-19 who died in Italy was 81 years while more than two-thirds had diabetes, cardiovascular diseases or cancer, or were former smokers [2]. It can be reasonably assumed that, in view of the strict measures, increasing numbers of people in China and elsewhere would hide respiratory diseases. The symptoms can be conveniently hidden behind a facemask.
Influenza spreads around the world in yearly outbreaks, resulting in millions cases of severe illness. Presumably, seasonal flu kills 250-500 thousand people yearly. Influenza pandemics resulted in millions of deaths [4-6]. The effectiveness of travel restrictions, quarantines, contact tracing etc. appears questionable because SARS-CoV-2 is already spreading worldwide like influenza did repeatedly in the past. In particular, the spread around the world is putting into question the utility of travel bans [7]. Historical data over recent centuries suggest no change in the sp...
Show MoreCompeting Interests: None declared.