A virtual COVID-19 ophthalmology rotation

The coronavirus (COVID-19) pandemic temporarily suspended medical student involvement in clinical rotations, resulting in the need to develop virtual clinical experiences. The cancellation of clinical ophthalmology electives and away rotations reduces opportunities for exposure to the field, to network with faculty, conduct research, and prepare for residency applications. We review the literature and discuss the impact and consequences of COVID-19 on undergraduate medical education with an emphasis on ophthalmic undergraduate medical education. We also discuss innovative learning modalities used from medical schools around the world during the COVID-19 pandemic such as virtual didactics, online cases, and telehealth. Finally, we describe a novel, virtual neuro-ophthalmology elective created to educate medical students on neuro-ophthalmology foundational principles, provide research and presentation opportunities, and build relationships with faculty members. These innovative approaches represent a step forward in further improving medical education in ophthalmology during COVID-19 pandemic and beyond.     

The effect of emergency department crowding on the management of pain in older adults with hip fracture

OBJECTIVES: To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults. DESIGN: Retrospective review of ED records from a prospective cohort study. SETTING: Urban, academically affiliated, tertiary medical center. PARTICIPANTS: One hundred fifty-eight patients, aged 50 and older, evaluated and hospitalized from the ED with hip fracture. MEASUREMENTS: Patient-related risk factors: age, sex, nursing home residence, ED triage status, dementia, Acute Physiology in Age and Chronic Health Evaluation II physiological score, and RAND comorbidity score. ED crowding risk factors: ED census and mean length of stay. Outcomes: documentation of pain assessment, time to pain assessment, time to pain treatment, patients reporting pain receiving analgesia, and meperidine use. RESULTS: Mean age was 83 (range 52-101), 81.0% of patients complained of pain, mean time to pain assessment was 40 minutes (range 0-600), time to treatment was 141 minutes (range 10-525), and mean delay to treatment was 122 minutes (range 0-526). Of those with pain, 35.9% received no analgesia, 7.0% received nonopioids, and 57.0% received opioids. Of those receiving opioids, 32.8% received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment (P = .05) and longer times to pain assessment (P = .01). CONCLUSION: Older adults with hip fracture are at risk for underassessment of pain, considerable delays in analgesic administration after pain is identified, and treatment with inappropriate analgesics (e.g., meperidine) in the ED. Higher levels of ED census are significantly associated with poorer pain management.     

Immunoglobulin A antibodies against ricin A and B subunits protect epithelial cells from ricin intoxication

Epithelial cells of the respiratory and gastrointestinal tracts are extremely vulnerable to the cytotoxic effects of ricin, a Shiga-like toxin with ribosome-inactivating properties. While mucosal immunity to ricin correlates with secretory immunoglobulin A (IgA) antibody levels in vivo, the potential of IgA to protect epithelial cells from ricin in vitro has not been examined due to the unavailability of well-defined antitoxin IgA antibodies. Here we report the characterization of four monoclonal IgA antibodies (IgA MAbs) produced from the Peyer's patches and mesenteric lymph nodes of BALB/c mice immunized intragastrically with ricin toxoid. Two IgA MAbs (33G2 and 35H6) were active against ricin's lectin subunit (RTB), and two (23D7 and 25A4) reacted with the toxin's enzymatic subunit (RTA). All four IgA MAbs neutralized ricin in a Vero cell cytotoxicity assay, blocked toxin-induced interleukin-8 release by the human monocyte/macrophage cell line 28SC, and protected polarized epithelial cell monolayers from ricin-mediated protein synthesis inhibition. 33G2 and 35H6 reduced ricin binding to the luminal surfaces of human intestinal epithelial cells to undetectable levels in tissue section overlay assays, whereas 23D7 had no effect on toxin attachment. 23D7 and 25A4 did, however, reduce ricin transcytosis across MDCK II cell monolayers, possibly by interfering with intracellular toxin transport. We conclude that IgA antibodies against RTA and RTB can protect mucosal epithelial cells from ricin intoxication.