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It’s interesting because what we are seeing more and more with COVID is that being outside is one of the safest places to be—much safer than being inside with a lot of people. -Eugenia South, MD, MSHP, assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania

, South said it has been interesting to hear more people talking about spending more time outside and the positive effects it has had on their mental health, stress, and anxiety levels. It is extremely vital for us as a country right now to have a safe place to be outside.

Even for South, she can feel increased levels of stress or anxiety on days she is unable to spend a lot of time outside.

With the benefits of nature, especially now, it is necessary to realize not everyone has a suitable green space outside. There is a need for more green spaces, and health systems can and should invest in local green space in their community.

“It’s important to partner with the community, including Community Development Organizations who are on the ground and thinking about development in their neighbors and other community leaders to figure out what they want, where they want it, and what that looks like,” South said.

Greening, however, could look like gentrification, she added. And in communities undergoing such transformation, it might not be best to add the spaces to those areas, even though it should not be thought of as a tool for gentrification. Instead, there should be a focus on underserved populations and those who are far from gentrification who have worse health outcomes could benefit most from greening.

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Being outside is safer than being inside with a lot of people.


Eugenia South, MD, MSHP: COVID-19 and Nature

 reaching the US, emergent medicines and equipment were quickly lacking. As much stress was put on social distancing parameters and protocol to expedite promising agents against the virus, there was an even greater call for often relied-upon resources.

Take, for example, blood. By March 17, the American Red Cross announced a severe blood shortage due to mass cancellation of donor drives. The situation highlighted a significant issue now unique to the COVID-19 pandemic: the virus affected non-patients as severely as it does infected persons.

Blood transfusions, a routinely critical facet of 

 care, were at risk of lacking their most precious commodity.

One way to combat the matter was emphasizing use of therapies that reduced the need for transfusions. Newest sickle cell disease therapy voxelotor (Oxbryta) fit that bill.

In the next segment of an interview with 

, Richard Drachtman, MD, clinical section chief of Pediatric Hematology/Oncology at Rutgers Medicine, discussed how the recently-approved agent came into benefit for prescribing early into the pandemic.

It’s already often the mindset of a hematologist to over-value donor blood. Once COVID-19 began to limit its availability further—especially in hard-hit areas including Drachtman’s New Brunswick, NJ—it became a responsibility to reduce the need for patient transfusions.

“Use of voxelotor has allowed me to do that,” Drachtman said. “In this time, it’s like ‘The Omega Man’ practicing medicine, driving to work in an empty town. It really has helped quite a bit.”

In Drachtman’s practice, patient volume has recently begun to increase. But transfusion need has remained low due to agents including voxelotor.

“It gives you one more option of being able to avoid transfusions in this one population of patients,” he said.

The pandemic has burdened blood drives nationally. A new sickle cell drug keeps patients from needing as many transfusions.

How Voxelotor Benefits the Blood Shortage

The ability to communicate with family members and other loved ones can be extremely difficult for patients suffering from a 

While in-person training for both the patient and communication partner has shown benefits in the past, with the advent of new technology, telehealth might be another option.

A team, led by Rachael Rietdijk, BAppSc, Faculty of Health Sciences, The University of Sydney,investigated the efficacy of telehealth-based and in-person social communication skills training for individuals with moderate-to-severe traumatic brain injuries based on outcomes reported by the survivor and a close communication partner.

The standard program often involves 35 hours of intervention consisting of a combination of group sessions and dyad sessions that are attended by both the injured patient and their communication partner. However, telehealth could allow a more expansive therapy service be reducing some of the time constraints linked to in-person training.

The partially randomized controlled trial contained a telehealth intervention group using a program called TBIconneCT, an in-person intervention group that uses the TBI Express therapy program, and a historical control arm.

The investigators examined 51 adults at least 6 months following a moderate or severe traumatic brain injury. Each patient had exhibited some communication skills deficits. The investigators also utilized communication partners, including family members, friends, and paid care of the injured individual.

The investigators sought main measures of La Trobe Communication Questionnaire total score, as well as the number of items with perceived positive change.

The researchers found trained participants had significantly more items with perceived positive change than the historical controls did. There was also a medium effect size in the sample observed for improvements in total score reported by trained communication partners following treatment.

Comparisons between telehealth and in-person groups showed medium to large effect sizes in the sample. This favored the telehealth group on certain La Trobe Communication Questionnaire variables.

“Whether delivered via telehealth or in-person, social communication skills training led to perceived positive change in communication skills,” the authors wrote. “It was unexpected that outcomes for the telehealth group were better than for the in-person group on some variables.”

Providing communication partners with skills can help enable those suffering from traumatic brain injuries to have effective conversations and create a more positive daily communication environment.

This training involves focusing on addressing negative patterns that communication partners may use in conversations with patients with TBI, including failing to follow up on the person's contributions, not giving enough information to support the person's comprehension, using questions designed to test the person's memory rather than asking for meaningful information, and querying the person's accuracy.

Training can facilitate collaborative interactions between the person with TBI and communication partners.

A Clinical Trial Investigating Telehealth and In-Person Social Communication Skills Training for People With Traumatic Brain Injury: Participant-Reported Communication Outcomes

The Journal of Head Trauma Rehabilitation

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A telehealth group showed better outcomes than an in-person training group for some variables of communication skills for individuals who suffered a traumatic brain injury.

Telehealth Helps Traumatic Brain Injury Patients Recover Communication Skills

As nature becomes more seriously looked at as a social determinant of health and a factor that could positively impact a patient’s over well-being, the provider must know their role in how the process can be most beneficial.

While community workers can offer nature counseling and help assess whether particular neighborhoods have enough safe space and green areas, the involvement of the provider varies from practice to practice.

“At the very least, I think talking about nature as a brief part of the interaction with physicians and patients—just like talking about exercise, just like talking about smoking cessation—is important for setting the baseline and expectation that this is something important,” Eugenia South, MD, MSHP, an assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania, said in a recent interview with 

After that, patients can spend more time with someone like a community health worker. During any given well visit, it is important where this should be covered.

 has been leading the way in thinking about nature and its health benefits. South would like to see it talked about more in adults.

 it’s the most important place to start,” she said.

There are room in other specialties like 

Pediatrics is leading the way in prescribing nature.

Eugenia South, MD, MSHP: Nature and the Role of the Provider

When coronavirus disease 2019 (COVID-19) cases began to substantially rise in March, experts from virtually medical specialty began scrambling for data on how the virus might impact different internal systems.

 symptoms linked to infections, but in an interview with 

, Miguel Regueiro, MD, chair of the Department of Gastroenterology, Hepatology, and Nutrition at the Cleveland Clinic, explained how those symptoms are much more prevalent than originally thought.

HCPLive: What have we ultimately learned since we last spoke in early March in terms of the gastroenterological symptoms of COVID-19?

Obviously we keep learning every month, where something new comes. What we've learned in general is that the percentage of patients who have gastrointestinal symptoms is nearly two-thirds, much, much higher than we originally thought.

Now, we also have learned that there's still about 20% that will present only with GI symptoms. And interestingly, there have been some reports that some of these patients with only GI symptoms, really that's their main presentation. Meaning they don't go on to have those respiratory symptoms, they're more diarrhea, loss of taste and smell.

HCPLive: Do the gastrointestinal issues that present without the respiratory issues get as severe as some of the other manifestations of the virus?

The numbers are still small, but what we're actually seeing as some of these patients may not get the respiratory failure, but may get very bad fatigue, very bad flu-like symptoms. And yeah, it can be pretty severe, not ICU, but still some pretty significant symptoms.

HCPLive: I think it’s safe to say we don’t know a lot about this virus and why it impacts different people differently. Would figuring out what exactly triggers the disease differently in different people be the major breakthrough we need?

Absolutely 100%. Things that have been looked at is male versus female, different ethnicities, different blood types. The problem is that it is vague enough that we don't know enough to lead us down that precision path.

If we had the precision medicine and the predictors of COVID-19 that says one person goes down the path of being really sick and needing to go to ICU and being on a ventilator, then maybe we started antiviral therapy a lot earlier. Is the other path of GI leading to a set of different symptoms that we learn that maybe they respond to different therapy?

HCPLive: There have been recent reports of permanent lung damage seen for COVID-19 patients. Are we seeing anything concerning regarding some permanent gastrointestinal symptoms?

So, they're worried about inflammation that leads to scarring in the lungs, and that's permanent. In the GI tract, the things that we’re wondering could be permanently changes is the microbiome. The bacteria makeup in the gut, is it somehow shifting people and that’s why they’re getting more diarrhea or bloating or cramps or pain.

The other thing is that there's clearly evidence of what we call ischemic colitis. So, the blood vessels in the GI tract get inflamed and there’s poor blood flow to the colon, the gastrointestinal tract. Those people are they set up for other problems down the line?

So, whether it be some type of colitis or some inflammatory condition, are they going to have more diarrhea, pain? Absolutely likely.

HCPLive: Have we had any success testing the IBD drugs for efficacy against COVID-19?

We're still learning about it. Those drugs for IBD like low-dose steroids, dexamethasone, the anti-TNF agent tofacitinib. That's all being discussed and researched.

Those are treating more of what we call the cytokine storm. The immune system's reaction to the virus that these drugs actually tamp down to improve inflammation. Those are in the discovery phase, so I don’t think we have enough information that we can say conclusively.

HCPLive: Have we learned whether IBD patients are more susceptible to some of the more severe outcomes?

We’ve learned a lot more and the fortunate answer is they don’t seem to have a worse course. This SECURE-IBD registry is a worldwide registry of patients that we entered that have known Crohn’s or ulcerative colitis and then they get COVID-19.

We have good and expanding data on that and so far it seems that the incidence and prevalence of somebody getting COVID-19 doesn’t seem any different whether you’re on IBD medications or immunosuppression compared to someone who’s not.

Our IBD patients had a slightly lower prevalence. Our IBD patients are more careful anyway. They practice more careful hygiene, social distancing to some degree, kind of very cautious in what they do.

Nearly two-thirds of COVID-19 patients have gastrointestinal symptoms.

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