Healthcare is in a state of flux. As extraordinary measures are taken to stem the spread of the coronavirus, regular medical care—from routine checkups and screenings to in-office treatments and procedures—has been subject to significant disruptions and challenges. Social distancing requirements of the 

 pandemic have created new limitations on in-person physician visits. 

Office closures and safety concerns have resulted in the delay or cancelation of medical appointments for some patients. Compounding matters is the dynamic and uncertain nature of the pandemic. The issues that patients and physicians are confronting today have evolved since the COVID-19 shutdowns began in March—and further change is undoubtedly on the horizon.

 patients and their eye care professionals, the pandemic has led to an array of stressors, given the progressive but indolent nature of a disease that can lead to blindness and requires close ongoing monitoring and treatment. The current health environment is particularly worrisome for elderly patients because they are most at risk for vision loss from glaucoma and are also among the highest risk groups for COVID-19 mortality.

To better understand the concerns and experiences of glaucoma patients during the pandemic, the Glaucoma Research Foundation (GRF) commissioned an online survey in May 2020. The aim was to gain valuable, real-time patient input that can help eye care professionals better address patients’ emotional needs as they adapt to the new, and continually changing, care requirements of COVID-19. 

The GRF survey, which was supported by Aerie Pharmaceuticals, assessed patients’ confidence in their disease management during the pandemic; specific disease management concerns; patients’ experience with telemedicine; and patients’ comfort in returning to eye professionals’ offices. The survey drew a national response, with 1051 adult glaucoma patients from 49 states participating in the questionnaire.

The survey findings bring to light several key considerations for ophthalmology practices evolving glaucoma care in the COVID-19 environment.

Notably, the survey found that more than half of respondents (53%) had to delay and/or cancel an eye care appointment during the first months of the pandemic. These disruptions seem to have significantly impacted patients’ confidence in their disease management, with approximately one-third (36%) of glaucoma patients surveyed saying they were not confident that their disease was well-managed. Those who had the lowest confidence levels in their glaucoma management were 30% more likely to have had an eye care appointment delayed or canceled.

This feedback highlights the central role of communication in enhancing glaucoma care and the importance of nurturing the physician-patient relationship during the pandemic. With physician offices open again, personal and direct doctor-patient communication is paramount to helping patients understand their unique level of risk and rebuild confidence in their disease management. 

Without scaring patients, it’s important that they understand the consequences of delaying an office visit and the real risk it may have for further, even permanent, vision loss.

At my practice in San Francisco, we went through every patient record that had an appointment during the early phase of the pandemic and conducted a risk assessment. We then communicated with each patient to make them aware of their particular situation and the risk of not coming in to be evaluated when our office reopened.

The first step was to speak with our staff about our responsibility to be safe, not just in the office, but also outside of work, with specifics about how to minimize risk. I sought their input and we developed together an action plan with new office protocols.

We also invested in an expansion of our office team. With this increased staff, we are able to directly answer more patient calls and engage in longer, in-depth conversations. In addition, we have placed a greeter at our main entrance who screens patients, which includes basic health questions, a temperature check, and a check for an appropriate mask. 

After completing these safety protocols, the greeter asks patients to use hand sanitizer prior to entering the clinic. These new measures have played a valuable role in boosting our patients’ confidence in their disease management during the pandemic.

The “COVID-19 Office” and Telemedicine

The survey also reveals that glaucoma patients place high value on being able to see their physician in person. Six in 10 (63%) respondents said they are comfortable returning to their eye doctors’ offices as long as social distancing measures, such as face masks and less crowded waiting rooms, are implemented. This preference for in-person physician visits, coupled with technology challenges, make patients largely uninterested in telemedicine. A vast majority (87%) of glaucoma patients surveyed said they would rather wait six weeks for an in-person office visit than have a telemedicine visit in two weeks.

While telemedicine has been a valuable tool in other medical specialties during the pandemic, it has significant limitations for standard diagnostic procedures in glaucoma care. Since intraocular pressure (IOP) checks, visual field evaluation, and other tests cannot be easily conducted virtually, practitioners may lose considerable clinical information by trying to manage glaucoma via telemedicine.

During these unprecedented times, the safety and well-being of patients is the principal concern of all eye care professionals. It is also important to consider the needs of your staff as well. At my center, we have modified several standard procedures that not only have enhanced patient safety during COVID-19 but have also made us operate more efficiently and safely as an eye care practice. 

I have found that when members of my office team feel safe at work, their calmness and confidence extend to the patient-provider relationship, helping patients feel more comfortable about the visit. By fostering a caring and professional approach to glaucoma care in the midst of uncertainty, we can all navigate the COVID-19 pandemic while continuing to protect the vision of our patients.

Andrew Iwach, MD, is Executive Director of the Glaucoma Center of San Francisco, Associate Clinical Professor of Ophthalmology at the University of California, San Francisco, and a faculty instructor at the California Pacific Medical Center Department of Ophthalmology. 

The article reflects the views of the author, not necessarily those of the publication.

A new survey assessed patients’ confidence in their disease management during the pandemic, specific disease management concerns, and experiences with telemedicine.

Managing Glaucoma During COVID-19: Patients Point the Way to Improved Care

Andrew Iwach, MD

Dr. Andrew Concoff brings tremendous range and unique experience to envisioning the future practice of musculoskeletal medicine. After completing fellowships in rheumatology and sports medicine and a Career Development Award from the National Institutes of Health to study exercise for osteoarthritis, Dr. Concoff has developed novel, hybrid approaches to treating musculoskeletal disorders over the course of over 20 years in private practice. He is also a nationally recognized expert in the diagnostic and procedural musculoskeletal ultrasound in rheumatology and sports medicine. For twelve years, Dr. Concoff supervised a renowned wellness center where he developed evidence-driven physical therapy protocols and holistic care paradigms incorporating mind-body approaches, acupuncture, massage therapy, Pilates, yoga and nutritional interventions.

Dr. Concoff is focused on advancing value in the practice of musculoskeletal medicine as Chief Value Medical Officer for United Rheumatology. He has created innovative programs, supported by economic modeling, to evolve specific aspects of clinical care toward better outcomes and lower costs. His programs span the range of musculoskeletal medicine from shoulder and low back pain to osteoarthritis of the knee, as well as a variety of autoimmune diseases.

“The Sports Rheum I” is an introduction to the clinical interface between rheumatology and sports medicine. Several examples are provided to illustrate the rich opportunities provided by this approach. A general description of the pathophysiology of joint damage in osteoarthritis forms the basis for the complementarity of exercise and pharmacologic intervention in osteoarthritis. Two clinical cases are provided to demonstrate the challenges of diagnosing athletes that present with rheumatic disease. An initial introduction to the application of advanced physical therapy techniques to improve strength without antagonizing affected arthritic joints is also provided. Finally, a description of the application of complementary medicine approaches to musculoskeletal disorders is presented.

Each of these examples will be explored in greater depth in subsequent episodes of The Sports Rheum as a part of The Concoff Method from The Rheum Additional series will explore the challenges of practicing medicine during the COVID-19 pandemic, The COVID Rheum, and efforts to evolve musculoskeletal medicine toward better outcomes and lower costs, The Value Rheum.

In today's issue of Rheumatology Network, we introduce The Concoff Method, a new column by Andrew Concoff, M.D., a rheumatologist who serves as executive vice president and chief value medical officer of United Rheumatology. Over the course of the next year, Dr. Concoff will publish columns that address sports medicine, value in rheumatology and managing a medical practice in the era of COVID-19. In this inaugural issue of the column, he covers the interface between sports medicine and rheumatology. 

Introducing the Concoff Method:  The Interface Between Sports Medicine and Rheumatology

Andrew L. Concoff, MD, FACR, CAQSM

Christopher Parker, DO

Dr. Karp is the 84th president of the American College of Rheumatology. He is chief of the Rheumatic Diseases Division at UT Southwestern Medical Center, Dallas, a role he has held for the past 18 years.

For the past 15 years, Dr. Karp’s research has focused on systemic lupus erythe­matosus, including the of use of genomics and proteomics to help understand disease progression. He joined the ACR during his fellowship and has been involved as a volunteer for the past 17 years, serving in various committee roles, leading the Rheumatology Research Foundation and serving on the ACR Board of Directors’ Executive Committee.

David R. Karp, MD, PhD

Aggressive fluid resuscitation has long been the cornerstone of treatment for 

While initial observational studies suggesting hypovolemia is associated with pancreatic necrosis fueled this practice, subsequent work has signaled that increased volume resuscitation may not improve outcomes. 

Randomized controlled trials comparing different volumes of fluid resuscitation, though, have had heterogeneous results and were limited by their small sample sizes and inclusion criteria.

E. de-Madaria et al. conducted an open-label, parallel-group, multicenter randomized controlled trial comparing moderate versus aggressive fluid resuscitation in patients with acute pancreatitis of multiple disease severities.

Adult patients with a diagnosis of acute pancreatitis according to the Revised Atlanta Classification who presented to the emergency department within 24 hours of pain onset were recruited from 18 centers. 

Patients meeting criteria for moderately severe or severe disease at baseline were excluded. Enrolled patients were randomly assigned to either receive aggressive or moderate fluid resuscitation per the trial protocol (Figure 1). 

Randomization was stratified according to trial center, systemic inflammatory response syndrome (SIRS), and hypovolemia. 

Enrolled patients underwent an initial physical assessment at 3 hours and then both biochemical and physical assessments at periodic intervals up to 72 hours, with adjustment of volume resuscitation based on the protocol and presence of hypovolemia, normovolemia, or hypervolemia. 

Oral feeding was initiated at 12 hours if abdominal pain was significantly improved. The sample size included all patients who underwent randomization and the data were analyzed according to an intention-to-treat principle.

A total of 249 patients were enrolled in the study and randomly assigned to the aggressive resuscitation group (n = 122) or the moderate resuscitation group (n = 127). Patients in the aggressive resuscitation group received a median of 7.8 L (interquartile range [IQR], 6.5 - 9.8) of fluid while patients in the moderate fluid resuscitation group received a median of 5.5 liters (IQR, 4.0 - 6.8). 

There was no significant difference between the aggressive and moderate fluid resuscitation groups in the primary outcome of rates of development of moderately severe (22.1%) or severe acute pancreatitis (17.3%; adjusted relative risk [aRR], 1.30; 95% confidence interval [CI], 0.78 - 2.18; 

However, aggressive fluid resuscitation was associated with a significantly higher incidence of fluid overload (20.5% vs 6.3%; aRR, 2.85; 95% CI, 1.36 - 5.94) with 1 patient in the aggressive fluid group requiring orotracheal intubation, and 6 patients classified as having moderate-to-severe fluid overload.

While not statistically significant, there was also a notable trend toward worse symptom intensity, longer hospital stay duration, and increased incidence of necrotizing pancreatitis among patients in the aggressive fluid resuscitation group. 

These safety results were reviewed by the data and safety monitoring board who halted the trial early due to the worse safety outcomes in the aggressive resuscitation group that were not balanced by improved outcomes. Subgroup analysis to assess the effect of baseline hypovolemia and SIRs did not find any major differences compared to the main analysis. 

While patients with acute pancreatitis have traditionally been treated with early aggressive fluid resuscitation, E. de-Madaria et al. demonstrated that this practice does not significantly improve the prevention of moderately severe or severe acute pancreatitis. Furthermore, when accounting for the risk of volume overload, these data lend support towards a more conservative fluid resuscitation approach.

This study is limited by its early termination and is thus underpowered to definitively evaluated efficacy.

While the study’s fluid resuscitation protocol is one method for managing patients with acute pancreatitis, there remains debate over the best practice for managing these patients during the first 24 hours. Still, this trial is the best evidence to date supporting the practice for less aggressive fluid resuscitation in patients with acute pancreatitis.

1. de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884

A recent randomized controlled trial showed the limitations of either option, despite being a cornerstone of care.

Does Aggressive or Moderate Fluid Resuscitation Better Treat Acute Pancreatitis?

Hassieb Din, MD

But maybe we could finish up this discussion. And Dr Seminerio, you could start us off. Maybe a piece of advice or one take home message from the discussion today and we could go around.

: The take home is that there is a lot that's coming and that it is going to be very, very important for us to have discussions with our patients, come up with a plan together, and just be very cognizant that that plan may need some adjustments. If we put that out there that it's not a failure if we have to make an adjustment or one treatment doesn't work but that we're on top of it as quickly as possible. That is the best thing we can do for our patients is to show that we're never going to give up on them.

I'd say a couple of things, one listen to your patient. Obviously, the shared decision, set the goals with the patient. And then number 2, like we've talked about is if you know that Crohn's disease, 80% of Crohn's disease, from the start will require an advanced therapy. Starting that earlier, Jen said that several times, but also then, even within that group, what are the ones with the highest risk factors? Fistula and deep ulcers, multiple segments involved versus which are the ones that are moderate to severe single segments. I know we have great options for both.

: Not much more to add other than we are not exactly at precision medicine and practice of precision medicine in IBD but we are certainly getting there. And again, identifying- initiate early appropriate therapy and recognize that we could still practice individualized care.

: I would echo everyone's comments here. But the key takeaway I would say is start our patients early. Don't delay their care. We can limit all the complications and poor outcomes if you start that patient early. Then personalize it based on all their risk, their severity, comorbidities. Choose appropriately. And then once you have done that, follow them closely over time. This is not a disease that ends after one year. This is a chronic lifetime disease. You cannot go wrong by starting early, choosing a therapy that you think may be the best for that patient. It may or may not work but if it doesn't then you know that you're following them closely and then follow them throughout their time. And of course, you can adjust how frequently you follow them once you get them into complete remission.

I agree. And just one last thing to add is personalizing the target. We've been hearing about treat to target so much. But the target for each patient is different. And as we started the discussion, it's different for each patient. Starting early and personalizing that target. But I want to thank everyone for this rich and informative discussion and thank you for watching this 

® Peer Exchange. If you enjoy the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

Experts in gastroenterology share advice for the treatment of patients of Crohn’s disease.

Take-Home Messages for the Management of Crohn’s Disease

Jennifer Seminerio, MD

 Anita, let’s follow that train of thought. [Let’s say] a patient is doing well on 1 therapy and then starts to have worsening symptoms. If they’re worsening symptoms, how do you approach that patient?

 First, we need to emphasize the importance of symptoms and objective data to determine whether there’s active ongoing inflammation. This is very important because we know, especially for Crohn disease, it doesn’t necessarily correlate. First, whatever medication we initiate, we want it to be effective for our patients, and that’s what they want. Once they start it, what’s important is proactive disease monitoring—not drug-level therapy—to make sure that whatever you’ve initiated is effective for them in terms of symptoms and based on objective data. My approach is if the patient is able to be monitored, get some biomarkers, fecal calprotectin, and CRP, and determine if their symptoms are also associated with the objective information. If they’re not responding to therapy, perhaps we have to optimize their treatment regimen. Before I make any immediate changes, as a rule of thumb, we need to evaluate symptoms clinically but also look for objective evaluations.

 This was a nice way to start, a nice overview on how we approach our patients. Obviously, our therapies need to work. Safety is tied to efficacy and shared decision-making.

Experts discuss how to care for Inflammatory Bowel Disease (IBD) patients who are not responding to treatment. 

Managing Care for IBD Patients Not Responding to Treatment

Maia Kayal, MD

COVID-19 has obviously presented significant challenges in our clinical work, particularly in the evaluation, diagnosis, and treatment of patients with ADHD [attention-deficit/hyperactivity disorder] of all ages. What we’ve all done, of course, is acclimate to this, largely through the use of telemedicine, telepsychiatry for a lot of our patients. Although more recently, I’ve gone back to more of a hybrid model where I am seeing some patients live and some via telepsychiatry. 

There are significant challenges. Some of those challenges include the fact that it’s a little more difficult to do an evaluation and to collect all the nonverbal information that you might get from being in the room with a person. Part of the problem is you may be seeing only a portion of the patient’s body. You may not be seeing the lower half of the body if you’re on a virtual call. You might not see some of the fidgeting or hyperactivity, for instance.

Also, what I find is patients either do really well with virtual telepsychiatry or don’t. They have trouble focusing. They get distracted. It’s really important to try to individualize care for our patients. Some people try to do in-person meetings. Ideally, this may be helpful for the initial evaluation so we can collect as much information as possible. When you’re dealing with children, you’d like to have collateral information, so you’d like to have parents and caregivers involved. That can be a little harder too, although it can be done virtually.

As far as prescribing medications, that can present a challenge. Although now, states are going to e-prescribing. In Florida, we now have to e-prescribe all controlled substances. That makes it easier, not having to handwrite a prescription and somehow get it to the patient in a COVID-19 environment.

The other thing I find is that sometimes children do a little better in this virtual environment, but many with ADHD struggle more. There’s a lot more stress and difficulty in school. Obviously, there’s more isolation, so fewer social relationships, fewer extracurricular activities, and maybe less access to exercise, which has been shown to be very beneficial for ADHD. These are some of the challenges that we’re trying to negotiate in the era of COVID-19.

Tele-prescribing of stimulants presents some unique challenges in the era of COVID-19. Part of the challenge is making sure you can e-prescribe appropriately. Most of us have figured out how to do that. Also, you want to make sure the pharmacy is available and shows up on your e-prescribing software. It is required, when we prescribe stimulants, that we monitor certain things. This can be more challenging in this environment, particularly when assessing vital signs, height, and weight. Blood pressure, heart rate, height, and weight can be a challenge in the virtual environment. This is when I may sometimes have the patient come to the office, just for the vital signs and height and weight checks. Or the patient can get 1 of the home monitoring devices, which you can get at many pharmacies. These devices can monitor blood pressure and heart rate. Your patients can check those periodically and report the results to you. Or you can certainly have them email that to you or communicate electronically.

As far as monitoring for abuse and possibility of diversion, this is something we also need to keep our eyes on. We can do this in various ways, including by checking prescribing databases, which can certainly be done online.

As far as monitoring for other issues and problems, such as the emergence of psychotic or manic symptoms or the possibility of vasoconstriction or cardiovascular issues, this is where taking a very careful history and evaluation and trying to look at the patient and evaluate them as best you can on camera really seems to help.

It’s important to understand that when evaluating and treating ADHD, comorbidity is the rule. Three-quarters of patients with ADHD will have a least 1 other comorbid condition. This is important because sometimes our core treatments for ADHD can help alleviate these other conditions. For instance, secondary anxiety or secondary depression. Sometimes, however, we do have to institute specific treatment in addition to the ADHD treatment to address a comorbid condition.

Rakesh Jain, MD, MPH: When parents and their children first come to see me for an evaluation for ADHD, there’s often a lot of confusion. We have a lot of myths in our heads. “Is this bad parenting?” “Was this just because one of us got divorced?” Is it because I had too many Diet Cokes when I was pregnant?” 

My first job is to offer parents and children a combination of sympathy and encouragement. I offer sympathy for the suffering they have gone through and encouragement that, if we do the right thing, we can make a pretty significant difference in all the challenges your child is having and you’re having as parents and caregivers. I have found that injection of enthusiasm, support, and knowledge to be as useful as anything I do.

The second step is really a pretty quick but accurate increase in knowledge base about the disease. Most people are quite surprised to know that it is a neurobiologically active condition. It is an inherited condition. It is a brain-based condition. Even though behavior is what they might see, the child is not being a “bad” child. 

Finally, we need to give an explanation of why interventions work or why a combination of nonpharmacological and pharmacological interventions is best explained in the context of neurobiology. 

When I offer that whole package of information, from sympathy to increasing their enthusiasm and encouragement to disease-state knowledge and then finally medication and nonmedication knowledge, you can see the parents and the child breathe a sigh of relief. “I’ve got a direction. There’s something I can do. I feel empowered.” That is precious. As a clinician, once I see that, I know I have established a solid therapeutic relationship that will lead to good outcomes.

Optimizing care and managing challenges for patients with ADHD during the COVID-19 pandemic and advice for clinicians educating patients and families on disease management. 

Optimizing Care for ADHD During COVID-19 

Rakesh Jain, MD, MPH, Texas Tech University School of Medicine

 I’d love for you to share with the viewers what strategies you have implemented based on your experiences to educate patients about their journey. Because that’s so important, as John has said, about making this a patient-centered diagnosis. What’s a day in the life of Dr Maron and Dr Ommen in how you approach these issues?

 I’ll go first. Like I’m sure Steve does, we spend a lot of time with patients when they come and do our own education with them, along with our health care team and nurse practitioners to educate patients about the disease. We spend a lot of time on education, reassurance, putting these issues that we’ve talked about in perspective, and doing a lot of shared decision-making, going through treatment options. At the end of the day, we try to deliver the message that hypertrophic cardiomyopathy [HCM] is a highly treatable disease. It’s going to probably be more so in the future, but even today it’s very treatable and a disease that’s compatible with normal life expectancy and good quality of life for the vast majority of patients. That’s the messaging that we give to patients the best that we can.

 I’d echo the same thing. Patients come to us after having done their own education attempts on the internet, freaked out with wide eyes because they’ve read all the dramatic stories that are available, and we have to remind them that people who have normal lives don’t usually blog about it.

I’d like to reiterate the same words about HCM in the modern era. We’ve gone from an era where it was 100% fatal in 1958 when Donald Teare described it to a 6% annual mortality in the 1980s to an annual mortality that’s the same as the general population. It’s a highly treatable disease for most patients. There are patients in whom there are issues. This discussion wasn’t about sudden cardiac arrest, which would be another 2 hours. Then there are quality-of-life issues that some patients have. But it’s a highly treatable disease and we’re getting more tools in our toolbox for the future, which is exciting.

 That’s super. Javed, any final thoughts you want to share?

 My final thought is that we have these therapies and we want to do anything and everything that we can for the patients to not unnecessarily suffer. The question is how do we educate the clinical community at large to refer the patients to the appropriate centers and to diagnose and screen these patients? While the specialists are very interested in and have a lot of these tools, more mass education about this disease would also be needed.

 From an administrator’s point of view, let me ask you to put that hat on for a second. When you’re looking at making recommendations for clinicians who are interested in getting involved in this, what things would you say are needed in terms of understanding things like catheter-based approaches, surgical approaches, and volume, which you talked a bit about? What do you think about setting certain expectations?

 You can modify behavior quite a lot by creating appropriate incentive structures in terms of education, screening, and quality metrics. You can also set up tools. We live in this digital age and everybody is on an electronic health record. A lot of the education and best practice advisories can be had for our patients in this era. Education and reminder systems are easier in the current day and age.

 Super. John, I’m going to turn to you last. You always keep the patient in the center. I’m curious to hear your final thoughts.

 First, I’m humbled by the expertise at this panel and not being an HCM expert. I feel a tremendous need to think about the infrastructure for elevating the quality of care throughout the nation. What does that entail? Does it entail thinking about algorithms, building shared decision-making tools, integrating routine assessments of health status with the KCCQ [Kansas City Cardiomyopathy Questionnaire], and coming up with very practical management strategies so that you don’t have to be in Boston or Rochester, Minnesota, to get high-quality care?

 Or Kansas City. That’s what I’m left with. It’s a complicated disease, but it’s an exciting disease. As more treatment options become available, there’s a greater call for thinking about the infrastructure of delivering high-quality patient-centered care. That’s what I’d like to see us move toward so that we can all benefit from the advances being made.

 Super. That’s a great way to conclude. I want to thank all of you for this rich and informative discussion. I want to thank you, our viewers, for watching this 

. If you enjoyed the content, please subscribe for our e-newsletters to receive upcoming 

 and other great content right in your inbox. I’m Jim Januzzi from the Massachusetts General Hospital. Thanks very much for joining.

Expert cardiologists share strategies for educating patients on the treatment and management of hypertrophic cardiomyopathy. 

Authors