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COVID-19 registry tracks pregnant women, newborns
A multidisciplinary team of researchers has created a national registry to study how COVID-19 affects pregnant women and their newborns.
“Pregnant women are generally considered healthy, but they are also a vulnerable group, and we currently have no data on COVID-19 in pregnancy,” coprincipal investigator Yalda Afshar, MD, PhD, an ob.gyn. at UCLA Health in Los Angeles, said in an interview.
“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” Dr. Afshar, a fellow with UCLA Biodesign, stated in a news release.
The Pregnancy Coronavirus Outcomes Registry is enrolling pregnant women and those who have been pregnant or post partum within the past 6 weeks and who have either received a confirmed diagnosis of COVID-19 or are being evaluated for COVID-19.
Women are being recruited through their health care provider. A study coordinator contacts the participants by telephone. Women can also join the registry on their own without a referral by visiting the registry website.
The registry collects data on COVID-19 symptoms, clinical course, pregnancy, and neonatal outcomes and follows women from enrollment through the second and third trimesters and the postpartum period. The goal is to follow the mothers and babies for up to 1 year.
Hundreds of women already enrolled
Dr. Afshar noted that these kinds of registries often take months to design and to receive funding, but with COVID-19, “there was no time for that. We had to get it up and running ASAP.”
She said the team has been “blown away” by how quickly people have come forward to join the registry. Within 2 weeks of going live, the registry had enrolled more than 400 participants from across the United States. “At this rate, I think we will easily get 1,000 participants in a month or so,” Dr. Afshar said.
“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” Johnese Spisso, CEO of UCLA Health, said in the news release.
Dr. Afshar noted that, although the impact of COVID-19 on pregnancy remains unknown, history suggests the disease will make some pregnancies and deliveries more challenging. “We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women.”
Dr. Afshar is overseeing the study with colleagues at the University of California, Los Angeles, and the University of California, San Francisco, where the registry data will be coordinated.
“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero and during the postpartum period, such as in breast milk,” UCSF’s Stephanie Gaw, MD, PhD, who is leading the biospecimen core of the study, said in the release.
Health care providers interested in more information about the registry may send an email to [email protected]. A YouTube video on the registry is also available.
Dr. Afshar disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
A multidisciplinary team of researchers has created a national registry to study how COVID-19 affects pregnant women and their newborns.
“Pregnant women are generally considered healthy, but they are also a vulnerable group, and we currently have no data on COVID-19 in pregnancy,” coprincipal investigator Yalda Afshar, MD, PhD, an ob.gyn. at UCLA Health in Los Angeles, said in an interview.
“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” Dr. Afshar, a fellow with UCLA Biodesign, stated in a news release.
The Pregnancy Coronavirus Outcomes Registry is enrolling pregnant women and those who have been pregnant or post partum within the past 6 weeks and who have either received a confirmed diagnosis of COVID-19 or are being evaluated for COVID-19.
Women are being recruited through their health care provider. A study coordinator contacts the participants by telephone. Women can also join the registry on their own without a referral by visiting the registry website.
The registry collects data on COVID-19 symptoms, clinical course, pregnancy, and neonatal outcomes and follows women from enrollment through the second and third trimesters and the postpartum period. The goal is to follow the mothers and babies for up to 1 year.
Hundreds of women already enrolled
Dr. Afshar noted that these kinds of registries often take months to design and to receive funding, but with COVID-19, “there was no time for that. We had to get it up and running ASAP.”
She said the team has been “blown away” by how quickly people have come forward to join the registry. Within 2 weeks of going live, the registry had enrolled more than 400 participants from across the United States. “At this rate, I think we will easily get 1,000 participants in a month or so,” Dr. Afshar said.
“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” Johnese Spisso, CEO of UCLA Health, said in the news release.
Dr. Afshar noted that, although the impact of COVID-19 on pregnancy remains unknown, history suggests the disease will make some pregnancies and deliveries more challenging. “We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women.”
Dr. Afshar is overseeing the study with colleagues at the University of California, Los Angeles, and the University of California, San Francisco, where the registry data will be coordinated.
“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero and during the postpartum period, such as in breast milk,” UCSF’s Stephanie Gaw, MD, PhD, who is leading the biospecimen core of the study, said in the release.
Health care providers interested in more information about the registry may send an email to [email protected]. A YouTube video on the registry is also available.
Dr. Afshar disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
A multidisciplinary team of researchers has created a national registry to study how COVID-19 affects pregnant women and their newborns.
“Pregnant women are generally considered healthy, but they are also a vulnerable group, and we currently have no data on COVID-19 in pregnancy,” coprincipal investigator Yalda Afshar, MD, PhD, an ob.gyn. at UCLA Health in Los Angeles, said in an interview.
“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” Dr. Afshar, a fellow with UCLA Biodesign, stated in a news release.
The Pregnancy Coronavirus Outcomes Registry is enrolling pregnant women and those who have been pregnant or post partum within the past 6 weeks and who have either received a confirmed diagnosis of COVID-19 or are being evaluated for COVID-19.
Women are being recruited through their health care provider. A study coordinator contacts the participants by telephone. Women can also join the registry on their own without a referral by visiting the registry website.
The registry collects data on COVID-19 symptoms, clinical course, pregnancy, and neonatal outcomes and follows women from enrollment through the second and third trimesters and the postpartum period. The goal is to follow the mothers and babies for up to 1 year.
Hundreds of women already enrolled
Dr. Afshar noted that these kinds of registries often take months to design and to receive funding, but with COVID-19, “there was no time for that. We had to get it up and running ASAP.”
She said the team has been “blown away” by how quickly people have come forward to join the registry. Within 2 weeks of going live, the registry had enrolled more than 400 participants from across the United States. “At this rate, I think we will easily get 1,000 participants in a month or so,” Dr. Afshar said.
“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” Johnese Spisso, CEO of UCLA Health, said in the news release.
Dr. Afshar noted that, although the impact of COVID-19 on pregnancy remains unknown, history suggests the disease will make some pregnancies and deliveries more challenging. “We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women.”
Dr. Afshar is overseeing the study with colleagues at the University of California, Los Angeles, and the University of California, San Francisco, where the registry data will be coordinated.
“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero and during the postpartum period, such as in breast milk,” UCSF’s Stephanie Gaw, MD, PhD, who is leading the biospecimen core of the study, said in the release.
Health care providers interested in more information about the registry may send an email to [email protected]. A YouTube video on the registry is also available.
Dr. Afshar disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
COVID-19: Telemedicine boosting access but is not a panacea
The recent surge in telemedicine services fueled by the COVID-19 pandemic has improved access to psychiatry care and may have set the stage for even more dramatic forays into virtual care in the future. However, not all patients want video visits, and it is not clear that the way telepsychiatry is practiced right now will be the best model for clinical practice once the crisis abates, speakers said at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
The COVID-19 pandemic has effectively “democratized” telepsychiatry, a mode of health care delivery that previously was thought of as “overly complex” and limited to a few specialists, said Avrim Fishkind, MD, CEO/consultant in emergency psychiatry and psychiatric emergency services design at Empathic Soul Health in Houston.
“In a blink of an eye, every psychiatrist and every mental health professional now can see themselves – and many have been forced into – becoming telepsychiatrists,” Dr. Fishkind said in a presentation at the meeting.
“Access to you is fantastic ... and your no-show rates decrease dramatically when people have flexibility to talk to you when they want to schedule and where they want to schedule.”
On the other hand, telepsychiatry should not be viewed as a panacea, cautioned Patrice A. Harris, MD, a child and adolescent psychiatrist and current president of the American Medical Association. The AMA has advocated for the more flexible federal regulations and payment policies that have helped boost telemedicine adoption during the crisis.
“Not every regulation that was relaxed, and not everything we are doing now in the midst of this pandemic, should be continued,” Dr. Harris said in a question-and-answer session earlier in the conference.
“I don’t want us all to say, ‘Wow, we had this experience, and it worked,’ and then continue to do it in the exact same way,” she added. “I know that we, the APA, and AMA, will be there to have a thoughtful, science-based, data-driven conversation about the next move regarding telemedicine and telehealth after we get through this pandemic.”
Telepsychiatry has nevertheless proven very versatile and applicable to a broad swath of patients during the COVID-19 pandemic, according to Dr. Fishkind. “I start from the position that I can see every patient this way, and I have to find a reason why I can’t,” said Dr. Fishkind, who also is lead telepsychiatrist at the Harris Center in Houston and a past president of the American Association for Emergency Psychiatry.
Telemedicine services can be as good as office visits, if not better, he told attendees at the virtual meeting. For example, a virtual visit can obviate the need for an in-person evaluation of a child with autism for whom an in-person visit would be challenging for the patient and parent alike.
However, Dr. Fishkind acknowledged that telepsychiatry is not for everyone: “I don’t want to say it’s heaven on earth. There are some patients who do refuse to be seen this way.”
What happens next in telepsychiatry is anyone’s guess, though Dr. Fishkind said he envisions an online “wheel of access” model of psychiatric services delivery.
In this portal-style model, the psychiatric patient might log in, answer a few automated questions, and then, based on their responses, they would be routed to a social worker or nurse navigator at the center of that services wheel.
In turn, the navigator might route the patient to one of the services on the spokes of the wheel, such as a psychiatrist consult, video-based or online cognitive-behavioral therapy, peer forums, group therapy, a pharmacist, or to other clinicians and interventions.
“Patients would have instant access to all of the things that we always want them to have access to – but now, by using virtual technologies, they could actually get them,” said Dr. Fishkind.
Dr. Fishkind reported no financial conflicts.
SOURCE: Fishkind A. APA 2020, Abstract.
The recent surge in telemedicine services fueled by the COVID-19 pandemic has improved access to psychiatry care and may have set the stage for even more dramatic forays into virtual care in the future. However, not all patients want video visits, and it is not clear that the way telepsychiatry is practiced right now will be the best model for clinical practice once the crisis abates, speakers said at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
The COVID-19 pandemic has effectively “democratized” telepsychiatry, a mode of health care delivery that previously was thought of as “overly complex” and limited to a few specialists, said Avrim Fishkind, MD, CEO/consultant in emergency psychiatry and psychiatric emergency services design at Empathic Soul Health in Houston.
“In a blink of an eye, every psychiatrist and every mental health professional now can see themselves – and many have been forced into – becoming telepsychiatrists,” Dr. Fishkind said in a presentation at the meeting.
“Access to you is fantastic ... and your no-show rates decrease dramatically when people have flexibility to talk to you when they want to schedule and where they want to schedule.”
On the other hand, telepsychiatry should not be viewed as a panacea, cautioned Patrice A. Harris, MD, a child and adolescent psychiatrist and current president of the American Medical Association. The AMA has advocated for the more flexible federal regulations and payment policies that have helped boost telemedicine adoption during the crisis.
“Not every regulation that was relaxed, and not everything we are doing now in the midst of this pandemic, should be continued,” Dr. Harris said in a question-and-answer session earlier in the conference.
“I don’t want us all to say, ‘Wow, we had this experience, and it worked,’ and then continue to do it in the exact same way,” she added. “I know that we, the APA, and AMA, will be there to have a thoughtful, science-based, data-driven conversation about the next move regarding telemedicine and telehealth after we get through this pandemic.”
Telepsychiatry has nevertheless proven very versatile and applicable to a broad swath of patients during the COVID-19 pandemic, according to Dr. Fishkind. “I start from the position that I can see every patient this way, and I have to find a reason why I can’t,” said Dr. Fishkind, who also is lead telepsychiatrist at the Harris Center in Houston and a past president of the American Association for Emergency Psychiatry.
Telemedicine services can be as good as office visits, if not better, he told attendees at the virtual meeting. For example, a virtual visit can obviate the need for an in-person evaluation of a child with autism for whom an in-person visit would be challenging for the patient and parent alike.
However, Dr. Fishkind acknowledged that telepsychiatry is not for everyone: “I don’t want to say it’s heaven on earth. There are some patients who do refuse to be seen this way.”
What happens next in telepsychiatry is anyone’s guess, though Dr. Fishkind said he envisions an online “wheel of access” model of psychiatric services delivery.
In this portal-style model, the psychiatric patient might log in, answer a few automated questions, and then, based on their responses, they would be routed to a social worker or nurse navigator at the center of that services wheel.
In turn, the navigator might route the patient to one of the services on the spokes of the wheel, such as a psychiatrist consult, video-based or online cognitive-behavioral therapy, peer forums, group therapy, a pharmacist, or to other clinicians and interventions.
“Patients would have instant access to all of the things that we always want them to have access to – but now, by using virtual technologies, they could actually get them,” said Dr. Fishkind.
Dr. Fishkind reported no financial conflicts.
SOURCE: Fishkind A. APA 2020, Abstract.
The recent surge in telemedicine services fueled by the COVID-19 pandemic has improved access to psychiatry care and may have set the stage for even more dramatic forays into virtual care in the future. However, not all patients want video visits, and it is not clear that the way telepsychiatry is practiced right now will be the best model for clinical practice once the crisis abates, speakers said at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
The COVID-19 pandemic has effectively “democratized” telepsychiatry, a mode of health care delivery that previously was thought of as “overly complex” and limited to a few specialists, said Avrim Fishkind, MD, CEO/consultant in emergency psychiatry and psychiatric emergency services design at Empathic Soul Health in Houston.
“In a blink of an eye, every psychiatrist and every mental health professional now can see themselves – and many have been forced into – becoming telepsychiatrists,” Dr. Fishkind said in a presentation at the meeting.
“Access to you is fantastic ... and your no-show rates decrease dramatically when people have flexibility to talk to you when they want to schedule and where they want to schedule.”
On the other hand, telepsychiatry should not be viewed as a panacea, cautioned Patrice A. Harris, MD, a child and adolescent psychiatrist and current president of the American Medical Association. The AMA has advocated for the more flexible federal regulations and payment policies that have helped boost telemedicine adoption during the crisis.
“Not every regulation that was relaxed, and not everything we are doing now in the midst of this pandemic, should be continued,” Dr. Harris said in a question-and-answer session earlier in the conference.
“I don’t want us all to say, ‘Wow, we had this experience, and it worked,’ and then continue to do it in the exact same way,” she added. “I know that we, the APA, and AMA, will be there to have a thoughtful, science-based, data-driven conversation about the next move regarding telemedicine and telehealth after we get through this pandemic.”
Telepsychiatry has nevertheless proven very versatile and applicable to a broad swath of patients during the COVID-19 pandemic, according to Dr. Fishkind. “I start from the position that I can see every patient this way, and I have to find a reason why I can’t,” said Dr. Fishkind, who also is lead telepsychiatrist at the Harris Center in Houston and a past president of the American Association for Emergency Psychiatry.
Telemedicine services can be as good as office visits, if not better, he told attendees at the virtual meeting. For example, a virtual visit can obviate the need for an in-person evaluation of a child with autism for whom an in-person visit would be challenging for the patient and parent alike.
However, Dr. Fishkind acknowledged that telepsychiatry is not for everyone: “I don’t want to say it’s heaven on earth. There are some patients who do refuse to be seen this way.”
What happens next in telepsychiatry is anyone’s guess, though Dr. Fishkind said he envisions an online “wheel of access” model of psychiatric services delivery.
In this portal-style model, the psychiatric patient might log in, answer a few automated questions, and then, based on their responses, they would be routed to a social worker or nurse navigator at the center of that services wheel.
In turn, the navigator might route the patient to one of the services on the spokes of the wheel, such as a psychiatrist consult, video-based or online cognitive-behavioral therapy, peer forums, group therapy, a pharmacist, or to other clinicians and interventions.
“Patients would have instant access to all of the things that we always want them to have access to – but now, by using virtual technologies, they could actually get them,” said Dr. Fishkind.
Dr. Fishkind reported no financial conflicts.
SOURCE: Fishkind A. APA 2020, Abstract.
FROM APA 2020
COVID-19 linked to large vessel stroke in young adults
In a rapid communication to be published online April 29 in the New England Journal of Medicine, investigators led by Thomas Oxley, MD, PhD, of the department of neurosurgery at Mount Sinai Health System, reported five cases of large vessel stroke over a 2-week period in COVID-19 patients under age 50 years. This represents a sevenfold increase in what would normally be expected.
The five cases had either no, or mild, COVID-19 symptoms.
“It’s been surprising to learn that the virus appears to cause disease through a process of blood clotting,” Dr. Oxley said in an interview.
The message for neurologists and other physicians is “we’re learning that this can disproportionally affect large vessels more than small vessels in terms of presentation of stroke,” he said.
Inflammation in the blood vessel walls may be driving thrombosis formation, Dr. Oxley added. This report joins other research pointing to this emerging phenomenon.
Recently, investigators in the Netherlands found a “remarkably high” 31% rate of thrombotic complications among 184 critical care patients with COVID-19 pneumonia.
Dr. Oxley and colleagues also suggested that, since the onset of the pandemic, fewer patients may be calling emergency services when they experience signs of a stroke. The physicians noted that two of the five cases in the report delayed calling an ambulance.
“I understand why people do not want to leave the household. I think people are more willing to ignore other [non–COVID-19] symptoms in this environment,” he said.
As previously reported, physicians in hospitals across the United States and elsewhere have reported a significant drop in stroke patients since the COVID-19 pandemic took hold, which suggests that patients may indeed be foregoing emergency care.
The observations from Dr. Oxley and colleagues call for greater awareness of the association between COVID-19 and large vessel strokes in this age group, they add.
One patient in the case series died, one remains hospitalized, two are undergoing rehabilitation, and one was discharged home as of April 24.
Dr. Oxley and colleagues dedicated their report to “our inspiring colleague Gary Sclar, MD, a stroke physician who succumbed to COVID-19 while caring for his patients.”
Dr. Oxley has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
In a rapid communication to be published online April 29 in the New England Journal of Medicine, investigators led by Thomas Oxley, MD, PhD, of the department of neurosurgery at Mount Sinai Health System, reported five cases of large vessel stroke over a 2-week period in COVID-19 patients under age 50 years. This represents a sevenfold increase in what would normally be expected.
The five cases had either no, or mild, COVID-19 symptoms.
“It’s been surprising to learn that the virus appears to cause disease through a process of blood clotting,” Dr. Oxley said in an interview.
The message for neurologists and other physicians is “we’re learning that this can disproportionally affect large vessels more than small vessels in terms of presentation of stroke,” he said.
Inflammation in the blood vessel walls may be driving thrombosis formation, Dr. Oxley added. This report joins other research pointing to this emerging phenomenon.
Recently, investigators in the Netherlands found a “remarkably high” 31% rate of thrombotic complications among 184 critical care patients with COVID-19 pneumonia.
Dr. Oxley and colleagues also suggested that, since the onset of the pandemic, fewer patients may be calling emergency services when they experience signs of a stroke. The physicians noted that two of the five cases in the report delayed calling an ambulance.
“I understand why people do not want to leave the household. I think people are more willing to ignore other [non–COVID-19] symptoms in this environment,” he said.
As previously reported, physicians in hospitals across the United States and elsewhere have reported a significant drop in stroke patients since the COVID-19 pandemic took hold, which suggests that patients may indeed be foregoing emergency care.
The observations from Dr. Oxley and colleagues call for greater awareness of the association between COVID-19 and large vessel strokes in this age group, they add.
One patient in the case series died, one remains hospitalized, two are undergoing rehabilitation, and one was discharged home as of April 24.
Dr. Oxley and colleagues dedicated their report to “our inspiring colleague Gary Sclar, MD, a stroke physician who succumbed to COVID-19 while caring for his patients.”
Dr. Oxley has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
In a rapid communication to be published online April 29 in the New England Journal of Medicine, investigators led by Thomas Oxley, MD, PhD, of the department of neurosurgery at Mount Sinai Health System, reported five cases of large vessel stroke over a 2-week period in COVID-19 patients under age 50 years. This represents a sevenfold increase in what would normally be expected.
The five cases had either no, or mild, COVID-19 symptoms.
“It’s been surprising to learn that the virus appears to cause disease through a process of blood clotting,” Dr. Oxley said in an interview.
The message for neurologists and other physicians is “we’re learning that this can disproportionally affect large vessels more than small vessels in terms of presentation of stroke,” he said.
Inflammation in the blood vessel walls may be driving thrombosis formation, Dr. Oxley added. This report joins other research pointing to this emerging phenomenon.
Recently, investigators in the Netherlands found a “remarkably high” 31% rate of thrombotic complications among 184 critical care patients with COVID-19 pneumonia.
Dr. Oxley and colleagues also suggested that, since the onset of the pandemic, fewer patients may be calling emergency services when they experience signs of a stroke. The physicians noted that two of the five cases in the report delayed calling an ambulance.
“I understand why people do not want to leave the household. I think people are more willing to ignore other [non–COVID-19] symptoms in this environment,” he said.
As previously reported, physicians in hospitals across the United States and elsewhere have reported a significant drop in stroke patients since the COVID-19 pandemic took hold, which suggests that patients may indeed be foregoing emergency care.
The observations from Dr. Oxley and colleagues call for greater awareness of the association between COVID-19 and large vessel strokes in this age group, they add.
One patient in the case series died, one remains hospitalized, two are undergoing rehabilitation, and one was discharged home as of April 24.
Dr. Oxley and colleagues dedicated their report to “our inspiring colleague Gary Sclar, MD, a stroke physician who succumbed to COVID-19 while caring for his patients.”
Dr. Oxley has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
COVID-19: Psychiatrists ‘more than a match’ for crisis moment
Tackling the COVID-19 crisis will require psychiatrists to muster the courage to lead, establish trust, and ultimately provide psychiatric care with competence, honesty, and compassion, said Patrice A. Harris, MD, an Atlanta-based psychiatrist who is president of the American Medical Association.
Leaders in psychiatry are uniquely positioned to combat a wave of disease misinformation, address inequities in care, and meet the logistical challenges of safely meeting patient needs as the outbreak continues, Dr. Harris said at the American Psychiatric Association annual meeting, which was held as a virtual live event.
“I believe you, we, are more than a match for this moment – a moment that requires our leadership and requires us to hold other leaders accountable as we fight this pandemic,” she said in remarks to online attendees.
Using trust to fight myths
Misinformation about COVID-19 has been “spreading rapidly, even intentionally, due to fear or political agendas,” said Dr. Harris, who became the 174th president of the AMA in June 2019.
Others believe the coronavirus crisis is a new way to force vaccinations on people who don’t want them, added Dr. Harris.
Myths, rumors, and conspiracy theories lead to “more illness and death,” she said, at a time when most Americans say they’ve lost trust in the federal government and even in other American citizens.
“Fortunately, people still trust us – their doctors,” she added. “We fight for science, we call out quackery and snake oil when we see it, [and] we are willing to counter the propaganda of the antiscience voice.”
Physicians are ranked among the most trusted professions because they are committed to seeing, acknowledging, and sharing patients’ human experience, “and of course, I believe we do that as psychiatrists more than most,” Dr. Harris said.
Fighting COVID-19 at the AMA level
During the pandemic, the AMA has advocated for adequate testing and supplies, adequate insurance coverage, and changes to current procedural technology (CPT) codes to streamline novel coronavirus testing. The AMA has also developed a free COVID-19 resource center on the JAMA Network website, Dr. Harris said, as well as guidance on protecting medical students responding to the pandemic.
The safety of health care clinicians remains a central issue for the AMA at a time when masks and other personal protective equipment (PPE) remain in short supply.
In a recent letter to Vice President Mike Pence, who is leading the White House’s coronavirus task force, AMA Executive Vice President and CEO James L. Madara, MD, urged the Trump administration to undertake a Manhattan Project–like effort to expand capacity for needed supplies.
“We will continue to call on the White House, and APA has as well, to make sure these needs are met,” Dr. Harris said.
COVID-19 and inequities in care
Because the pandemic has had dramatic effects on African American communities across the United States, AMA Chief Health Equity Officer Aletha Maybank, MD, has made recent media appearances to highlight care inequities and what can be done about them.
Meanwhile, the AMA and other physician associations have urged the Trump Administration to collect, analyze, and make available COVID-19 data by race and ethnicity: “We can’t fix a problem until we identify a problem,” Dr. Harris said in her address to the APA.
Relying on science
In a virtual address hosted by the National Press Club earlier in April, Dr. Harris made an appeal for “relying on the science and evidence” to inform COVID-19–related decisions.
Elected officials need to “affirm science, evidence, and fact in their words and actions,” while media need to be vigilant in citing credible sources and challenging those who “chose to trade in misinformation,” she said in that address.
Speaking at the APA virtual meeting, Dr. Harris spoke of an “assault on science for several years” that inspired the National Press Club address. “We wanted to remind the public of its responsibility to focus on science and the evidence, for us to turn the tide against COVID-19,” she explained.
Physician care and self-care
While the AMA urges social distancing, Dr. Harris used the term “physical distancing” in her APA address. Physical distancing emphasizes the need for stay-at-home and shelter-in-place restrictions, while recognizing the need for maintaining meaningful social interactions, she explained.
Social media use represents one “opportunity” to bridge that gap when physical proximity is not an option, she added.
Dr. Harris also stressed the need for physicians to “take time out and practice self-care” to ensure that they are recharged and able to provide optimal patient care.
“We need to be there for others, but we have to put our own masks on first,” she said.
Dr. Harris reported no financial relationships with commercial interests.
SOURCE: Harris PA. APA 2020 Virtual Meeting.
Tackling the COVID-19 crisis will require psychiatrists to muster the courage to lead, establish trust, and ultimately provide psychiatric care with competence, honesty, and compassion, said Patrice A. Harris, MD, an Atlanta-based psychiatrist who is president of the American Medical Association.
Leaders in psychiatry are uniquely positioned to combat a wave of disease misinformation, address inequities in care, and meet the logistical challenges of safely meeting patient needs as the outbreak continues, Dr. Harris said at the American Psychiatric Association annual meeting, which was held as a virtual live event.
“I believe you, we, are more than a match for this moment – a moment that requires our leadership and requires us to hold other leaders accountable as we fight this pandemic,” she said in remarks to online attendees.
Using trust to fight myths
Misinformation about COVID-19 has been “spreading rapidly, even intentionally, due to fear or political agendas,” said Dr. Harris, who became the 174th president of the AMA in June 2019.
Others believe the coronavirus crisis is a new way to force vaccinations on people who don’t want them, added Dr. Harris.
Myths, rumors, and conspiracy theories lead to “more illness and death,” she said, at a time when most Americans say they’ve lost trust in the federal government and even in other American citizens.
“Fortunately, people still trust us – their doctors,” she added. “We fight for science, we call out quackery and snake oil when we see it, [and] we are willing to counter the propaganda of the antiscience voice.”
Physicians are ranked among the most trusted professions because they are committed to seeing, acknowledging, and sharing patients’ human experience, “and of course, I believe we do that as psychiatrists more than most,” Dr. Harris said.
Fighting COVID-19 at the AMA level
During the pandemic, the AMA has advocated for adequate testing and supplies, adequate insurance coverage, and changes to current procedural technology (CPT) codes to streamline novel coronavirus testing. The AMA has also developed a free COVID-19 resource center on the JAMA Network website, Dr. Harris said, as well as guidance on protecting medical students responding to the pandemic.
The safety of health care clinicians remains a central issue for the AMA at a time when masks and other personal protective equipment (PPE) remain in short supply.
In a recent letter to Vice President Mike Pence, who is leading the White House’s coronavirus task force, AMA Executive Vice President and CEO James L. Madara, MD, urged the Trump administration to undertake a Manhattan Project–like effort to expand capacity for needed supplies.
“We will continue to call on the White House, and APA has as well, to make sure these needs are met,” Dr. Harris said.
COVID-19 and inequities in care
Because the pandemic has had dramatic effects on African American communities across the United States, AMA Chief Health Equity Officer Aletha Maybank, MD, has made recent media appearances to highlight care inequities and what can be done about them.
Meanwhile, the AMA and other physician associations have urged the Trump Administration to collect, analyze, and make available COVID-19 data by race and ethnicity: “We can’t fix a problem until we identify a problem,” Dr. Harris said in her address to the APA.
Relying on science
In a virtual address hosted by the National Press Club earlier in April, Dr. Harris made an appeal for “relying on the science and evidence” to inform COVID-19–related decisions.
Elected officials need to “affirm science, evidence, and fact in their words and actions,” while media need to be vigilant in citing credible sources and challenging those who “chose to trade in misinformation,” she said in that address.
Speaking at the APA virtual meeting, Dr. Harris spoke of an “assault on science for several years” that inspired the National Press Club address. “We wanted to remind the public of its responsibility to focus on science and the evidence, for us to turn the tide against COVID-19,” she explained.
Physician care and self-care
While the AMA urges social distancing, Dr. Harris used the term “physical distancing” in her APA address. Physical distancing emphasizes the need for stay-at-home and shelter-in-place restrictions, while recognizing the need for maintaining meaningful social interactions, she explained.
Social media use represents one “opportunity” to bridge that gap when physical proximity is not an option, she added.
Dr. Harris also stressed the need for physicians to “take time out and practice self-care” to ensure that they are recharged and able to provide optimal patient care.
“We need to be there for others, but we have to put our own masks on first,” she said.
Dr. Harris reported no financial relationships with commercial interests.
SOURCE: Harris PA. APA 2020 Virtual Meeting.
Tackling the COVID-19 crisis will require psychiatrists to muster the courage to lead, establish trust, and ultimately provide psychiatric care with competence, honesty, and compassion, said Patrice A. Harris, MD, an Atlanta-based psychiatrist who is president of the American Medical Association.
Leaders in psychiatry are uniquely positioned to combat a wave of disease misinformation, address inequities in care, and meet the logistical challenges of safely meeting patient needs as the outbreak continues, Dr. Harris said at the American Psychiatric Association annual meeting, which was held as a virtual live event.
“I believe you, we, are more than a match for this moment – a moment that requires our leadership and requires us to hold other leaders accountable as we fight this pandemic,” she said in remarks to online attendees.
Using trust to fight myths
Misinformation about COVID-19 has been “spreading rapidly, even intentionally, due to fear or political agendas,” said Dr. Harris, who became the 174th president of the AMA in June 2019.
Others believe the coronavirus crisis is a new way to force vaccinations on people who don’t want them, added Dr. Harris.
Myths, rumors, and conspiracy theories lead to “more illness and death,” she said, at a time when most Americans say they’ve lost trust in the federal government and even in other American citizens.
“Fortunately, people still trust us – their doctors,” she added. “We fight for science, we call out quackery and snake oil when we see it, [and] we are willing to counter the propaganda of the antiscience voice.”
Physicians are ranked among the most trusted professions because they are committed to seeing, acknowledging, and sharing patients’ human experience, “and of course, I believe we do that as psychiatrists more than most,” Dr. Harris said.
Fighting COVID-19 at the AMA level
During the pandemic, the AMA has advocated for adequate testing and supplies, adequate insurance coverage, and changes to current procedural technology (CPT) codes to streamline novel coronavirus testing. The AMA has also developed a free COVID-19 resource center on the JAMA Network website, Dr. Harris said, as well as guidance on protecting medical students responding to the pandemic.
The safety of health care clinicians remains a central issue for the AMA at a time when masks and other personal protective equipment (PPE) remain in short supply.
In a recent letter to Vice President Mike Pence, who is leading the White House’s coronavirus task force, AMA Executive Vice President and CEO James L. Madara, MD, urged the Trump administration to undertake a Manhattan Project–like effort to expand capacity for needed supplies.
“We will continue to call on the White House, and APA has as well, to make sure these needs are met,” Dr. Harris said.
COVID-19 and inequities in care
Because the pandemic has had dramatic effects on African American communities across the United States, AMA Chief Health Equity Officer Aletha Maybank, MD, has made recent media appearances to highlight care inequities and what can be done about them.
Meanwhile, the AMA and other physician associations have urged the Trump Administration to collect, analyze, and make available COVID-19 data by race and ethnicity: “We can’t fix a problem until we identify a problem,” Dr. Harris said in her address to the APA.
Relying on science
In a virtual address hosted by the National Press Club earlier in April, Dr. Harris made an appeal for “relying on the science and evidence” to inform COVID-19–related decisions.
Elected officials need to “affirm science, evidence, and fact in their words and actions,” while media need to be vigilant in citing credible sources and challenging those who “chose to trade in misinformation,” she said in that address.
Speaking at the APA virtual meeting, Dr. Harris spoke of an “assault on science for several years” that inspired the National Press Club address. “We wanted to remind the public of its responsibility to focus on science and the evidence, for us to turn the tide against COVID-19,” she explained.
Physician care and self-care
While the AMA urges social distancing, Dr. Harris used the term “physical distancing” in her APA address. Physical distancing emphasizes the need for stay-at-home and shelter-in-place restrictions, while recognizing the need for maintaining meaningful social interactions, she explained.
Social media use represents one “opportunity” to bridge that gap when physical proximity is not an option, she added.
Dr. Harris also stressed the need for physicians to “take time out and practice self-care” to ensure that they are recharged and able to provide optimal patient care.
“We need to be there for others, but we have to put our own masks on first,” she said.
Dr. Harris reported no financial relationships with commercial interests.
SOURCE: Harris PA. APA 2020 Virtual Meeting.
FROM APA 2020
COVID-19 decimates outpatient visits
There has been a massive decline in outpatient office visits as patients have stayed home – likely deferring needed care – because of COVID-19, new research shows.
The number of visits to ambulatory practices dropped by a whopping 60% in mid-March, and continues to be down by at least 50% since early February, according to new data compiled and analyzed by Harvard University and Phreesia, a health care technology company.
Phreesia – which helps medical practices with patient registration, insurance verification, and payments – has data on 50,000 providers in all 50 states; in a typical year, Phreesia tracks 50 million outpatient visits.
The report was published online April 23 by the Commonwealth Fund.
The company captured data on visits from February 1 through April 16. The decline was greatest in New England and the Mid-Atlantic states, where, at the steepest end of the decline in late March, visits were down 66%.
They have rebounded slightly since then but are still down 64%. Practices in the mountain states had the smallest decline, but visits were down by 45% as of April 16.
Many practices have attempted to reach out to patients through telemedicine. As of April 16, about 30% of all visits tracked by Phreesia were provided via telemedicine – by phone or through video. That’s a monumental increase from mid-February, when zero visits were conducted virtually.
However, the Harvard researchers found that telemedicine visits barely made up for the huge decline in office visits.
Decline by specialty
Not surprisingly, declining visits have been steeper in procedure-oriented specialties.
Overall visits – including telemedicine – to ophthalmologists and otolaryngologists had declined by 79% and 75%, respectively, as of the week of April 5. Dermatology saw a 73% decline. Surgery, pulmonology, urology, orthopedics, cardiology, and gastroenterology all experienced declines ranging from 61% to 66%.
Primary care offices, oncology, endocrinology, and obstetrics/gynecology all fared slightly better, with visits down by half. Behavioral health experienced the lowest rate of decline (30%).
School-aged children were skipping care most often. The study showed a 71% drop in visits in 7- to 17-year-olds, and a 59% decline in visits by neonates, infants, and toddlers (up to age 6). Overall, pediatric practices experienced a 62% drop-off in visits.
Nearly two-thirds of Americans over age 65 also stayed away from their doctors. Only half of those aged 18 to 64 reduced their physician visits.
This article first appeared on Medscape.com.
There has been a massive decline in outpatient office visits as patients have stayed home – likely deferring needed care – because of COVID-19, new research shows.
The number of visits to ambulatory practices dropped by a whopping 60% in mid-March, and continues to be down by at least 50% since early February, according to new data compiled and analyzed by Harvard University and Phreesia, a health care technology company.
Phreesia – which helps medical practices with patient registration, insurance verification, and payments – has data on 50,000 providers in all 50 states; in a typical year, Phreesia tracks 50 million outpatient visits.
The report was published online April 23 by the Commonwealth Fund.
The company captured data on visits from February 1 through April 16. The decline was greatest in New England and the Mid-Atlantic states, where, at the steepest end of the decline in late March, visits were down 66%.
They have rebounded slightly since then but are still down 64%. Practices in the mountain states had the smallest decline, but visits were down by 45% as of April 16.
Many practices have attempted to reach out to patients through telemedicine. As of April 16, about 30% of all visits tracked by Phreesia were provided via telemedicine – by phone or through video. That’s a monumental increase from mid-February, when zero visits were conducted virtually.
However, the Harvard researchers found that telemedicine visits barely made up for the huge decline in office visits.
Decline by specialty
Not surprisingly, declining visits have been steeper in procedure-oriented specialties.
Overall visits – including telemedicine – to ophthalmologists and otolaryngologists had declined by 79% and 75%, respectively, as of the week of April 5. Dermatology saw a 73% decline. Surgery, pulmonology, urology, orthopedics, cardiology, and gastroenterology all experienced declines ranging from 61% to 66%.
Primary care offices, oncology, endocrinology, and obstetrics/gynecology all fared slightly better, with visits down by half. Behavioral health experienced the lowest rate of decline (30%).
School-aged children were skipping care most often. The study showed a 71% drop in visits in 7- to 17-year-olds, and a 59% decline in visits by neonates, infants, and toddlers (up to age 6). Overall, pediatric practices experienced a 62% drop-off in visits.
Nearly two-thirds of Americans over age 65 also stayed away from their doctors. Only half of those aged 18 to 64 reduced their physician visits.
This article first appeared on Medscape.com.
There has been a massive decline in outpatient office visits as patients have stayed home – likely deferring needed care – because of COVID-19, new research shows.
The number of visits to ambulatory practices dropped by a whopping 60% in mid-March, and continues to be down by at least 50% since early February, according to new data compiled and analyzed by Harvard University and Phreesia, a health care technology company.
Phreesia – which helps medical practices with patient registration, insurance verification, and payments – has data on 50,000 providers in all 50 states; in a typical year, Phreesia tracks 50 million outpatient visits.
The report was published online April 23 by the Commonwealth Fund.
The company captured data on visits from February 1 through April 16. The decline was greatest in New England and the Mid-Atlantic states, where, at the steepest end of the decline in late March, visits were down 66%.
They have rebounded slightly since then but are still down 64%. Practices in the mountain states had the smallest decline, but visits were down by 45% as of April 16.
Many practices have attempted to reach out to patients through telemedicine. As of April 16, about 30% of all visits tracked by Phreesia were provided via telemedicine – by phone or through video. That’s a monumental increase from mid-February, when zero visits were conducted virtually.
However, the Harvard researchers found that telemedicine visits barely made up for the huge decline in office visits.
Decline by specialty
Not surprisingly, declining visits have been steeper in procedure-oriented specialties.
Overall visits – including telemedicine – to ophthalmologists and otolaryngologists had declined by 79% and 75%, respectively, as of the week of April 5. Dermatology saw a 73% decline. Surgery, pulmonology, urology, orthopedics, cardiology, and gastroenterology all experienced declines ranging from 61% to 66%.
Primary care offices, oncology, endocrinology, and obstetrics/gynecology all fared slightly better, with visits down by half. Behavioral health experienced the lowest rate of decline (30%).
School-aged children were skipping care most often. The study showed a 71% drop in visits in 7- to 17-year-olds, and a 59% decline in visits by neonates, infants, and toddlers (up to age 6). Overall, pediatric practices experienced a 62% drop-off in visits.
Nearly two-thirds of Americans over age 65 also stayed away from their doctors. Only half of those aged 18 to 64 reduced their physician visits.
This article first appeared on Medscape.com.
COVID-19: Loss and grief without an expiration date
We are all experiencing collective loss and grief because of COVID-19, but that doesn’t mean that we are experiencing the same loss or grieving the same way.
Losses can be unique to individuals, such as the death of a loved one or divorce from a spouse. They can also be more universal, such as the tragedy of Sept. 11, 2001. However, both of these types of losses are generally associated with a distinct event that has a known beginning and endpoint. What makes the losses related to the coronavirus so different is that there is not a known expiration date. This lack of certainty about when the losses caused by the pandemic will end makes it difficult to process and mourn appropriately.
The multitude of potential losses includes, of course, the death of thousands of people. Many of us have personally lost loved ones or know people who have had loss because of COVID-19-related illnesses. There have also been numerous illnesses caused by delayed medical care tied to fears of going to a hospital during the pandemic. Unfortunately, there is an anticipatory loss because of the invariable diseases that will be diagnosed because of the halt of routine and preventive medical care during this current restricted phase of social distancing.
There are also losses that are not related to health. These more intangible losses may include the loss of employment and stable income; loss of our children’s completion of their academic year; loss of socialization; loss of travel and visits to friends and family; loss of normal childbirth where a pregnant mother is accompanied by her partner; loss of visiting sick relatives and newborns; loss of dating, weddings, graduations, and milestone birthday celebrations; loss of visits to nursing homes of your loved ones; loss of the needed services and support to help with your young child’s disabilities; and loss of intimacy, connection and touch.
Such losses may seem inconsequential, compared with the death of an acquaintance or loved one. But we do not know the back story behind these other losses. For example, could a family member who is unable to meet the newest addition to the family have a terminal disease and his or her own expiration date? Could the lack of dating exacerbate a new divorcée’s feeling of loneliness and despair?
When we know the details associated with the individual’s loss due to COVID-19, we can understand and better empathize. Continued collective loss without an expiration date will lead to collective grief without an endpoint.
Stages of grief
The five distinct stages of grief experienced after a loss were initially developed by psychiatrist Elisabeth Kübler-Ross, in her 1969 book “On Death and Dying” and again explored in her book “On Grief and Grieving” in 2005. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The grief process is unique to each individual and not necessarily a predictable process, with some moving through the stages at a slower pace while others can get stuck in one or more of the stages. This non-linear pattern of grief is evident in our grief response to the COVID-19 pandemic.
Some of us had experiences of denial back in early March, when initial thoughts crept up, such as “this can’t be as bad as what the medical officials are proposing” and “how is this any different from the flu?” Denial is used as a protective defense against feeling an abundance of emotions all at once, while allowing us time to adjust to the new situation.
Most of us have also had experiences with anger directed at our leaders for not adequately preparing us and intense rage at health care administrators for lack of proper protective gear for our first-line health care workers.
Bargaining tactics were noticeable with common thoughts such as “if we stay home and risk the demise of our economy, we will have the chance to protect our most vulnerable populations and therefore save lives.” Unfortunately, many of us have also experienced thoughts of despair and depression. Feelings of hopelessness and helplessness set in with many parents, who, overnight, were given dual roles as a parent and teacher. Many parents are attempting to simultaneously juggle a full-time workload.
Some of us already have begun to move to the last stage of grief, which is acceptance. Although most of us will experience all five of the stages of grief, we are not necessarily in the same stage at the same time. This can lead to contentious conversations among colleagues, friends, and family members. We might not necessarily be in the same mourning stage as our spouse, child, mother, father, sister, brother, aunt, uncle, cousins, or friend. The differences in how we mourn can result in your spouse remaining in the denial phase of grief and refusing to wear a mask to the grocery store. At the same time, you may have already entered the bargaining phase and are willing to forgo the niceties of grocery shopping to protect and promote the common good.
With loss inevitably comes change
This difference in these stages of loss can affect how we all return to a new sense of routine when we begin to reopen our communities.
Unfortunately, we will not have defined guidelines or cookbook steps and rules to abide by. The one thing we will have is our ability to accept each other’s differences, especially when it comes to grief.
Remember, we all will grieve in our way, and this isn’t a race to the finish line. What we do know is that none of us are coming out of this unscathed. This global loss will forever change us. Our new standard will take time for acclimation, but we will get there. With loss inevitably comes change, and this experience will allow us to redefine who we are and what we choose to prioritize and focus on post pandemic. There will be a post-pandemic period, whether it is 6 months, 1 year, or 2 years from now; we will eventually start to shake hands again, even hug and kiss hello. What we need to make sure of is that we don’t forget this time. Whatever meaning you find, and change for the better, will hopefully transcend to your post-pandemic life.
Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.
We are all experiencing collective loss and grief because of COVID-19, but that doesn’t mean that we are experiencing the same loss or grieving the same way.
Losses can be unique to individuals, such as the death of a loved one or divorce from a spouse. They can also be more universal, such as the tragedy of Sept. 11, 2001. However, both of these types of losses are generally associated with a distinct event that has a known beginning and endpoint. What makes the losses related to the coronavirus so different is that there is not a known expiration date. This lack of certainty about when the losses caused by the pandemic will end makes it difficult to process and mourn appropriately.
The multitude of potential losses includes, of course, the death of thousands of people. Many of us have personally lost loved ones or know people who have had loss because of COVID-19-related illnesses. There have also been numerous illnesses caused by delayed medical care tied to fears of going to a hospital during the pandemic. Unfortunately, there is an anticipatory loss because of the invariable diseases that will be diagnosed because of the halt of routine and preventive medical care during this current restricted phase of social distancing.
There are also losses that are not related to health. These more intangible losses may include the loss of employment and stable income; loss of our children’s completion of their academic year; loss of socialization; loss of travel and visits to friends and family; loss of normal childbirth where a pregnant mother is accompanied by her partner; loss of visiting sick relatives and newborns; loss of dating, weddings, graduations, and milestone birthday celebrations; loss of visits to nursing homes of your loved ones; loss of the needed services and support to help with your young child’s disabilities; and loss of intimacy, connection and touch.
Such losses may seem inconsequential, compared with the death of an acquaintance or loved one. But we do not know the back story behind these other losses. For example, could a family member who is unable to meet the newest addition to the family have a terminal disease and his or her own expiration date? Could the lack of dating exacerbate a new divorcée’s feeling of loneliness and despair?
When we know the details associated with the individual’s loss due to COVID-19, we can understand and better empathize. Continued collective loss without an expiration date will lead to collective grief without an endpoint.
Stages of grief
The five distinct stages of grief experienced after a loss were initially developed by psychiatrist Elisabeth Kübler-Ross, in her 1969 book “On Death and Dying” and again explored in her book “On Grief and Grieving” in 2005. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The grief process is unique to each individual and not necessarily a predictable process, with some moving through the stages at a slower pace while others can get stuck in one or more of the stages. This non-linear pattern of grief is evident in our grief response to the COVID-19 pandemic.
Some of us had experiences of denial back in early March, when initial thoughts crept up, such as “this can’t be as bad as what the medical officials are proposing” and “how is this any different from the flu?” Denial is used as a protective defense against feeling an abundance of emotions all at once, while allowing us time to adjust to the new situation.
Most of us have also had experiences with anger directed at our leaders for not adequately preparing us and intense rage at health care administrators for lack of proper protective gear for our first-line health care workers.
Bargaining tactics were noticeable with common thoughts such as “if we stay home and risk the demise of our economy, we will have the chance to protect our most vulnerable populations and therefore save lives.” Unfortunately, many of us have also experienced thoughts of despair and depression. Feelings of hopelessness and helplessness set in with many parents, who, overnight, were given dual roles as a parent and teacher. Many parents are attempting to simultaneously juggle a full-time workload.
Some of us already have begun to move to the last stage of grief, which is acceptance. Although most of us will experience all five of the stages of grief, we are not necessarily in the same stage at the same time. This can lead to contentious conversations among colleagues, friends, and family members. We might not necessarily be in the same mourning stage as our spouse, child, mother, father, sister, brother, aunt, uncle, cousins, or friend. The differences in how we mourn can result in your spouse remaining in the denial phase of grief and refusing to wear a mask to the grocery store. At the same time, you may have already entered the bargaining phase and are willing to forgo the niceties of grocery shopping to protect and promote the common good.
With loss inevitably comes change
This difference in these stages of loss can affect how we all return to a new sense of routine when we begin to reopen our communities.
Unfortunately, we will not have defined guidelines or cookbook steps and rules to abide by. The one thing we will have is our ability to accept each other’s differences, especially when it comes to grief.
Remember, we all will grieve in our way, and this isn’t a race to the finish line. What we do know is that none of us are coming out of this unscathed. This global loss will forever change us. Our new standard will take time for acclimation, but we will get there. With loss inevitably comes change, and this experience will allow us to redefine who we are and what we choose to prioritize and focus on post pandemic. There will be a post-pandemic period, whether it is 6 months, 1 year, or 2 years from now; we will eventually start to shake hands again, even hug and kiss hello. What we need to make sure of is that we don’t forget this time. Whatever meaning you find, and change for the better, will hopefully transcend to your post-pandemic life.
Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.
We are all experiencing collective loss and grief because of COVID-19, but that doesn’t mean that we are experiencing the same loss or grieving the same way.
Losses can be unique to individuals, such as the death of a loved one or divorce from a spouse. They can also be more universal, such as the tragedy of Sept. 11, 2001. However, both of these types of losses are generally associated with a distinct event that has a known beginning and endpoint. What makes the losses related to the coronavirus so different is that there is not a known expiration date. This lack of certainty about when the losses caused by the pandemic will end makes it difficult to process and mourn appropriately.
The multitude of potential losses includes, of course, the death of thousands of people. Many of us have personally lost loved ones or know people who have had loss because of COVID-19-related illnesses. There have also been numerous illnesses caused by delayed medical care tied to fears of going to a hospital during the pandemic. Unfortunately, there is an anticipatory loss because of the invariable diseases that will be diagnosed because of the halt of routine and preventive medical care during this current restricted phase of social distancing.
There are also losses that are not related to health. These more intangible losses may include the loss of employment and stable income; loss of our children’s completion of their academic year; loss of socialization; loss of travel and visits to friends and family; loss of normal childbirth where a pregnant mother is accompanied by her partner; loss of visiting sick relatives and newborns; loss of dating, weddings, graduations, and milestone birthday celebrations; loss of visits to nursing homes of your loved ones; loss of the needed services and support to help with your young child’s disabilities; and loss of intimacy, connection and touch.
Such losses may seem inconsequential, compared with the death of an acquaintance or loved one. But we do not know the back story behind these other losses. For example, could a family member who is unable to meet the newest addition to the family have a terminal disease and his or her own expiration date? Could the lack of dating exacerbate a new divorcée’s feeling of loneliness and despair?
When we know the details associated with the individual’s loss due to COVID-19, we can understand and better empathize. Continued collective loss without an expiration date will lead to collective grief without an endpoint.
Stages of grief
The five distinct stages of grief experienced after a loss were initially developed by psychiatrist Elisabeth Kübler-Ross, in her 1969 book “On Death and Dying” and again explored in her book “On Grief and Grieving” in 2005. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The grief process is unique to each individual and not necessarily a predictable process, with some moving through the stages at a slower pace while others can get stuck in one or more of the stages. This non-linear pattern of grief is evident in our grief response to the COVID-19 pandemic.
Some of us had experiences of denial back in early March, when initial thoughts crept up, such as “this can’t be as bad as what the medical officials are proposing” and “how is this any different from the flu?” Denial is used as a protective defense against feeling an abundance of emotions all at once, while allowing us time to adjust to the new situation.
Most of us have also had experiences with anger directed at our leaders for not adequately preparing us and intense rage at health care administrators for lack of proper protective gear for our first-line health care workers.
Bargaining tactics were noticeable with common thoughts such as “if we stay home and risk the demise of our economy, we will have the chance to protect our most vulnerable populations and therefore save lives.” Unfortunately, many of us have also experienced thoughts of despair and depression. Feelings of hopelessness and helplessness set in with many parents, who, overnight, were given dual roles as a parent and teacher. Many parents are attempting to simultaneously juggle a full-time workload.
Some of us already have begun to move to the last stage of grief, which is acceptance. Although most of us will experience all five of the stages of grief, we are not necessarily in the same stage at the same time. This can lead to contentious conversations among colleagues, friends, and family members. We might not necessarily be in the same mourning stage as our spouse, child, mother, father, sister, brother, aunt, uncle, cousins, or friend. The differences in how we mourn can result in your spouse remaining in the denial phase of grief and refusing to wear a mask to the grocery store. At the same time, you may have already entered the bargaining phase and are willing to forgo the niceties of grocery shopping to protect and promote the common good.
With loss inevitably comes change
This difference in these stages of loss can affect how we all return to a new sense of routine when we begin to reopen our communities.
Unfortunately, we will not have defined guidelines or cookbook steps and rules to abide by. The one thing we will have is our ability to accept each other’s differences, especially when it comes to grief.
Remember, we all will grieve in our way, and this isn’t a race to the finish line. What we do know is that none of us are coming out of this unscathed. This global loss will forever change us. Our new standard will take time for acclimation, but we will get there. With loss inevitably comes change, and this experience will allow us to redefine who we are and what we choose to prioritize and focus on post pandemic. There will be a post-pandemic period, whether it is 6 months, 1 year, or 2 years from now; we will eventually start to shake hands again, even hug and kiss hello. What we need to make sure of is that we don’t forget this time. Whatever meaning you find, and change for the better, will hopefully transcend to your post-pandemic life.
Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.
COVID-19: Frequently asked clinical questions
Question
How should patients on immunosuppressive therapy be advised during the COVID-19 pandemic?
Answer
In general, those patients who have not tested positive, have not been exposed, and are asymptomatic should continue their medications as prescribed.
The American College of Rheumatology issued a statement on April 14, recommending that stable patients continue their medications. Those with known exposure but without confirmed infection may continue hydroxychloroquine, sulfasalazine, and NSAIDs.
Immunosuppressants, non–IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test or after two weeks without symptoms. In patients with confirmed positive COVID-19 infection, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test or after two weeks without symptoms. In patients with confirmed positive COVID-19 infection, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily. Anti-malarial therapies (hydroxycholoroquine and chloroquine) may be continued and IL-6 inhibitors may be continued in select circumstances.1
The American Academy of Dermatology recommends that the discussion of continuation of biologics be based on a case-by-case basis, citing insufficient evidence to recommend against discontinuation at this time in those patients who have not tested positive. In patients who have tested positive for COVID-19 it is recommended that biologic therapy be suspended until symptoms have resolved.2
Question
Should I continue preventive services during peak COVID-19?
Answer
The Centers for Disease Control and Prevention recommends delaying all elective ambulatory provider visits. In general, preventative services, such as adult immunizations, lipid screening, and cancer screenings, should be delayed. Additionally, the CDC recommends reaching out to patients who are at high risk for complications from respiratory diseases to ensure medication adherence and provide resources if these patients become ill. Facilities can reduce transmission of COVID-19 by triaging and assessing patients through virtual visits through phone calls, video conferences, text-monitoring systems, and other telemedicine tools. Physicians should try to provide routine and chronic care through virtual visits when possible over in-person visits.3
Question
Should I continue to vaccinate my pediatric population during peak COVID-19?
Answer
Practices that schedule separate well visits and sick visits in different sessions or locations can continue to provide well child visits. A practice could, for example, schedule well visits in the morning and sick visits in the afternoon if a single facility is used. These practices should prioritize newborn care and vaccinations of children, especially for those under the age of 24 months.4
Question
Can physicians use telehealth (phone only or audiovisual) to conduct visits with Medicare patients even if they are new patients?
Answer
Effective March 1 through the duration of the pandemic, Medicare will pay physicians for telehealth services at the same rate as an in-office visit. On March 30th, the Centers for Medicare & Medcaid Services announced new policies for physicians and hospitals during the COVID-19 pandemic. These guidelines were updated on April 9.
Audio-only visits are now permitted and the limit on the number of these kinds of visits allowed per month has been waived. Controlled substances can be prescribed via telehealth; however, complying with each state’s individual laws is still required.
Use of any two-way, audiovisual device is permitted. The level of service billed for visits with both audio and visual components is the same as an in-office visit. Telemedicine can be used for both new and existing patients.5
A list of services that may be rendered via telehealth are available on the CMS website.6
It will be important to regularly check the references given, as information on some of these topics is updated frequently.
Dr. Chuong is a second-year resident in the family medicine residency, Dr. Flanagan is a third-year resident, and Dr. Matthews is an intern, all at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
References
1. ACR issues COVID-19 treatment guidance for rheumatic disease patients.
2. American Academy of Dermatology: Guidance on the use of biologic agents during COVID-19 outbreak.
3. Centers for Disease Control and Prevention. Actions to take in response to community transmission of COVID-19.
4. Centers for Disease Control and Prevention. Maintaining childhood immunizations during COVID19 pandemic.
5. Centers for Medicare & Medcaid Services. COVID-19 frequently asked questions (FAQs) on Medicare Fee-for-Service (FFS) billing.
6. Centers for Medicare & Medcaid Services. List of telehealth services.
Question
How should patients on immunosuppressive therapy be advised during the COVID-19 pandemic?
Answer
In general, those patients who have not tested positive, have not been exposed, and are asymptomatic should continue their medications as prescribed.
The American College of Rheumatology issued a statement on April 14, recommending that stable patients continue their medications. Those with known exposure but without confirmed infection may continue hydroxychloroquine, sulfasalazine, and NSAIDs.
Immunosuppressants, non–IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test or after two weeks without symptoms. In patients with confirmed positive COVID-19 infection, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test or after two weeks without symptoms. In patients with confirmed positive COVID-19 infection, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily. Anti-malarial therapies (hydroxycholoroquine and chloroquine) may be continued and IL-6 inhibitors may be continued in select circumstances.1
The American Academy of Dermatology recommends that the discussion of continuation of biologics be based on a case-by-case basis, citing insufficient evidence to recommend against discontinuation at this time in those patients who have not tested positive. In patients who have tested positive for COVID-19 it is recommended that biologic therapy be suspended until symptoms have resolved.2
Question
Should I continue preventive services during peak COVID-19?
Answer
The Centers for Disease Control and Prevention recommends delaying all elective ambulatory provider visits. In general, preventative services, such as adult immunizations, lipid screening, and cancer screenings, should be delayed. Additionally, the CDC recommends reaching out to patients who are at high risk for complications from respiratory diseases to ensure medication adherence and provide resources if these patients become ill. Facilities can reduce transmission of COVID-19 by triaging and assessing patients through virtual visits through phone calls, video conferences, text-monitoring systems, and other telemedicine tools. Physicians should try to provide routine and chronic care through virtual visits when possible over in-person visits.3
Question
Should I continue to vaccinate my pediatric population during peak COVID-19?
Answer
Practices that schedule separate well visits and sick visits in different sessions or locations can continue to provide well child visits. A practice could, for example, schedule well visits in the morning and sick visits in the afternoon if a single facility is used. These practices should prioritize newborn care and vaccinations of children, especially for those under the age of 24 months.4
Question
Can physicians use telehealth (phone only or audiovisual) to conduct visits with Medicare patients even if they are new patients?
Answer
Effective March 1 through the duration of the pandemic, Medicare will pay physicians for telehealth services at the same rate as an in-office visit. On March 30th, the Centers for Medicare & Medcaid Services announced new policies for physicians and hospitals during the COVID-19 pandemic. These guidelines were updated on April 9.
Audio-only visits are now permitted and the limit on the number of these kinds of visits allowed per month has been waived. Controlled substances can be prescribed via telehealth; however, complying with each state’s individual laws is still required.
Use of any two-way, audiovisual device is permitted. The level of service billed for visits with both audio and visual components is the same as an in-office visit. Telemedicine can be used for both new and existing patients.5
A list of services that may be rendered via telehealth are available on the CMS website.6
It will be important to regularly check the references given, as information on some of these topics is updated frequently.
Dr. Chuong is a second-year resident in the family medicine residency, Dr. Flanagan is a third-year resident, and Dr. Matthews is an intern, all at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
References
1. ACR issues COVID-19 treatment guidance for rheumatic disease patients.
2. American Academy of Dermatology: Guidance on the use of biologic agents during COVID-19 outbreak.
3. Centers for Disease Control and Prevention. Actions to take in response to community transmission of COVID-19.
4. Centers for Disease Control and Prevention. Maintaining childhood immunizations during COVID19 pandemic.
5. Centers for Medicare & Medcaid Services. COVID-19 frequently asked questions (FAQs) on Medicare Fee-for-Service (FFS) billing.
6. Centers for Medicare & Medcaid Services. List of telehealth services.
Question
How should patients on immunosuppressive therapy be advised during the COVID-19 pandemic?
Answer
In general, those patients who have not tested positive, have not been exposed, and are asymptomatic should continue their medications as prescribed.
The American College of Rheumatology issued a statement on April 14, recommending that stable patients continue their medications. Those with known exposure but without confirmed infection may continue hydroxychloroquine, sulfasalazine, and NSAIDs.
Immunosuppressants, non–IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test or after two weeks without symptoms. In patients with confirmed positive COVID-19 infection, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test or after two weeks without symptoms. In patients with confirmed positive COVID-19 infection, sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily. Anti-malarial therapies (hydroxycholoroquine and chloroquine) may be continued and IL-6 inhibitors may be continued in select circumstances.1
The American Academy of Dermatology recommends that the discussion of continuation of biologics be based on a case-by-case basis, citing insufficient evidence to recommend against discontinuation at this time in those patients who have not tested positive. In patients who have tested positive for COVID-19 it is recommended that biologic therapy be suspended until symptoms have resolved.2
Question
Should I continue preventive services during peak COVID-19?
Answer
The Centers for Disease Control and Prevention recommends delaying all elective ambulatory provider visits. In general, preventative services, such as adult immunizations, lipid screening, and cancer screenings, should be delayed. Additionally, the CDC recommends reaching out to patients who are at high risk for complications from respiratory diseases to ensure medication adherence and provide resources if these patients become ill. Facilities can reduce transmission of COVID-19 by triaging and assessing patients through virtual visits through phone calls, video conferences, text-monitoring systems, and other telemedicine tools. Physicians should try to provide routine and chronic care through virtual visits when possible over in-person visits.3
Question
Should I continue to vaccinate my pediatric population during peak COVID-19?
Answer
Practices that schedule separate well visits and sick visits in different sessions or locations can continue to provide well child visits. A practice could, for example, schedule well visits in the morning and sick visits in the afternoon if a single facility is used. These practices should prioritize newborn care and vaccinations of children, especially for those under the age of 24 months.4
Question
Can physicians use telehealth (phone only or audiovisual) to conduct visits with Medicare patients even if they are new patients?
Answer
Effective March 1 through the duration of the pandemic, Medicare will pay physicians for telehealth services at the same rate as an in-office visit. On March 30th, the Centers for Medicare & Medcaid Services announced new policies for physicians and hospitals during the COVID-19 pandemic. These guidelines were updated on April 9.
Audio-only visits are now permitted and the limit on the number of these kinds of visits allowed per month has been waived. Controlled substances can be prescribed via telehealth; however, complying with each state’s individual laws is still required.
Use of any two-way, audiovisual device is permitted. The level of service billed for visits with both audio and visual components is the same as an in-office visit. Telemedicine can be used for both new and existing patients.5
A list of services that may be rendered via telehealth are available on the CMS website.6
It will be important to regularly check the references given, as information on some of these topics is updated frequently.
Dr. Chuong is a second-year resident in the family medicine residency, Dr. Flanagan is a third-year resident, and Dr. Matthews is an intern, all at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
References
1. ACR issues COVID-19 treatment guidance for rheumatic disease patients.
2. American Academy of Dermatology: Guidance on the use of biologic agents during COVID-19 outbreak.
3. Centers for Disease Control and Prevention. Actions to take in response to community transmission of COVID-19.
4. Centers for Disease Control and Prevention. Maintaining childhood immunizations during COVID19 pandemic.
5. Centers for Medicare & Medcaid Services. COVID-19 frequently asked questions (FAQs) on Medicare Fee-for-Service (FFS) billing.
6. Centers for Medicare & Medcaid Services. List of telehealth services.
FDA reiterates hydroxychloroquine limitations for COVID-19
The U.S. Food and Drug Administration reinforced its March guidance on when it’s permissible to use hydroxychloroquine and chloroquine to treat COVID-19 patients and on the multiple risks these drugs pose in a Safety Communication on April 24.
The new communication reiterated the agency’s position from the Emergency Use Authorization (EUA) it granted on March 28 to allow hydroxychloroquine and chloroquine treatment of COVID-19 patients only when they are hospitalized and participation in a clinical trial is “not available,” or “not feasible.” The April 24 update to the EUA noted that “the FDA is aware of reports of serious heart rhythm problems in patients with COVID-19 treated with hydroxychloroquine or chloroquine, often in combination with azithromycin and other QT-prolonging medicines. We are also aware of increased use of these medicines through outpatient prescriptions.”
In addition to reiterating the prior limitations on permissible patients for these treatment the agency also said in the new communication that “close supervision is strongly recommended, “ specifying that “we recommend initial evaluation and monitoring when using hydroxychloroquine or chloroquine under the EUA or in clinical trials that investigate these medicines for the treatment or prevention of COVID-19. Monitoring may include baseline ECG, electrolytes, renal function, and hepatic tests.” The communication also highlighted several potential serious adverse effects from hydroxychloroquine or chloroquine that include QT prolongation with increased risk in patients with renal insufficiency or failure, increased insulin levels and insulin action causing increased risk of severe hypoglycemia, hemolysis in selected patients, and interaction with other medicines that cause QT prolongation.
“If a healthcare professional is considering use of hydroxychloroquine or chloroquine to treat or prevent COVID-19, FDA recommends checking www.clinicaltrials.gov for a suitable clinical trial and consider enrolling the patient,” the statement added.
The FDA’s Safety Communication came a day after the European Medicines Agency issued a similar reminder about the risk for serious adverse effects from treatment with hydroxychloroquine and chloroquine, the need for adverse effect monitoring, and the unproven status of purported benefits from these agents.
The statement came after ongoing promotion by the Trump administration of hydroxychloroquine, in particular, for COVID-19 despite a lack of evidence.
The FDA’s communication cited recent case reports sent to the FDA, as well as published findings, and reports to the National Poison Data System that have described serious, heart-related adverse events and death in COVID-19 patients who received hydroxychloroquine and chloroquine, alone or in combination with azithromycin or another QT-prolonging drug. One recent, notable but not peer-reviewed report on 368 patients treated at any of several U.S. VA medical centers showed no apparent benefit to hospitalized COVID-19 patients treated with hydroxychloroquine and a signal for increased mortality among certain patients on this drug (medRxiv. 2020 Apr 23; doi: 10.1101/2020.04.16.20065920). Several cardiology societies have also highlighted the cardiac considerations for using these drugs in patients with COVID-19, including a summary coauthored by the presidents of the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society (Circulation. 2020 Apr 8. doi: 10.1161/CIRCULATIONAHA.120.047521), and in guidance from the European Society of Cardiology.
The U.S. Food and Drug Administration reinforced its March guidance on when it’s permissible to use hydroxychloroquine and chloroquine to treat COVID-19 patients and on the multiple risks these drugs pose in a Safety Communication on April 24.
The new communication reiterated the agency’s position from the Emergency Use Authorization (EUA) it granted on March 28 to allow hydroxychloroquine and chloroquine treatment of COVID-19 patients only when they are hospitalized and participation in a clinical trial is “not available,” or “not feasible.” The April 24 update to the EUA noted that “the FDA is aware of reports of serious heart rhythm problems in patients with COVID-19 treated with hydroxychloroquine or chloroquine, often in combination with azithromycin and other QT-prolonging medicines. We are also aware of increased use of these medicines through outpatient prescriptions.”
In addition to reiterating the prior limitations on permissible patients for these treatment the agency also said in the new communication that “close supervision is strongly recommended, “ specifying that “we recommend initial evaluation and monitoring when using hydroxychloroquine or chloroquine under the EUA or in clinical trials that investigate these medicines for the treatment or prevention of COVID-19. Monitoring may include baseline ECG, electrolytes, renal function, and hepatic tests.” The communication also highlighted several potential serious adverse effects from hydroxychloroquine or chloroquine that include QT prolongation with increased risk in patients with renal insufficiency or failure, increased insulin levels and insulin action causing increased risk of severe hypoglycemia, hemolysis in selected patients, and interaction with other medicines that cause QT prolongation.
“If a healthcare professional is considering use of hydroxychloroquine or chloroquine to treat or prevent COVID-19, FDA recommends checking www.clinicaltrials.gov for a suitable clinical trial and consider enrolling the patient,” the statement added.
The FDA’s Safety Communication came a day after the European Medicines Agency issued a similar reminder about the risk for serious adverse effects from treatment with hydroxychloroquine and chloroquine, the need for adverse effect monitoring, and the unproven status of purported benefits from these agents.
The statement came after ongoing promotion by the Trump administration of hydroxychloroquine, in particular, for COVID-19 despite a lack of evidence.
The FDA’s communication cited recent case reports sent to the FDA, as well as published findings, and reports to the National Poison Data System that have described serious, heart-related adverse events and death in COVID-19 patients who received hydroxychloroquine and chloroquine, alone or in combination with azithromycin or another QT-prolonging drug. One recent, notable but not peer-reviewed report on 368 patients treated at any of several U.S. VA medical centers showed no apparent benefit to hospitalized COVID-19 patients treated with hydroxychloroquine and a signal for increased mortality among certain patients on this drug (medRxiv. 2020 Apr 23; doi: 10.1101/2020.04.16.20065920). Several cardiology societies have also highlighted the cardiac considerations for using these drugs in patients with COVID-19, including a summary coauthored by the presidents of the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society (Circulation. 2020 Apr 8. doi: 10.1161/CIRCULATIONAHA.120.047521), and in guidance from the European Society of Cardiology.
The U.S. Food and Drug Administration reinforced its March guidance on when it’s permissible to use hydroxychloroquine and chloroquine to treat COVID-19 patients and on the multiple risks these drugs pose in a Safety Communication on April 24.
The new communication reiterated the agency’s position from the Emergency Use Authorization (EUA) it granted on March 28 to allow hydroxychloroquine and chloroquine treatment of COVID-19 patients only when they are hospitalized and participation in a clinical trial is “not available,” or “not feasible.” The April 24 update to the EUA noted that “the FDA is aware of reports of serious heart rhythm problems in patients with COVID-19 treated with hydroxychloroquine or chloroquine, often in combination with azithromycin and other QT-prolonging medicines. We are also aware of increased use of these medicines through outpatient prescriptions.”
In addition to reiterating the prior limitations on permissible patients for these treatment the agency also said in the new communication that “close supervision is strongly recommended, “ specifying that “we recommend initial evaluation and monitoring when using hydroxychloroquine or chloroquine under the EUA or in clinical trials that investigate these medicines for the treatment or prevention of COVID-19. Monitoring may include baseline ECG, electrolytes, renal function, and hepatic tests.” The communication also highlighted several potential serious adverse effects from hydroxychloroquine or chloroquine that include QT prolongation with increased risk in patients with renal insufficiency or failure, increased insulin levels and insulin action causing increased risk of severe hypoglycemia, hemolysis in selected patients, and interaction with other medicines that cause QT prolongation.
“If a healthcare professional is considering use of hydroxychloroquine or chloroquine to treat or prevent COVID-19, FDA recommends checking www.clinicaltrials.gov for a suitable clinical trial and consider enrolling the patient,” the statement added.
The FDA’s Safety Communication came a day after the European Medicines Agency issued a similar reminder about the risk for serious adverse effects from treatment with hydroxychloroquine and chloroquine, the need for adverse effect monitoring, and the unproven status of purported benefits from these agents.
The statement came after ongoing promotion by the Trump administration of hydroxychloroquine, in particular, for COVID-19 despite a lack of evidence.
The FDA’s communication cited recent case reports sent to the FDA, as well as published findings, and reports to the National Poison Data System that have described serious, heart-related adverse events and death in COVID-19 patients who received hydroxychloroquine and chloroquine, alone or in combination with azithromycin or another QT-prolonging drug. One recent, notable but not peer-reviewed report on 368 patients treated at any of several U.S. VA medical centers showed no apparent benefit to hospitalized COVID-19 patients treated with hydroxychloroquine and a signal for increased mortality among certain patients on this drug (medRxiv. 2020 Apr 23; doi: 10.1101/2020.04.16.20065920). Several cardiology societies have also highlighted the cardiac considerations for using these drugs in patients with COVID-19, including a summary coauthored by the presidents of the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society (Circulation. 2020 Apr 8. doi: 10.1161/CIRCULATIONAHA.120.047521), and in guidance from the European Society of Cardiology.
FROM THE FDA
COVID-19: Experts call for ‘urgent’ global action to prevent suicide
A global group of suicide experts is urging governments around the world to take action to prevent a possible jump in suicide rates because of the ongoing COVID-19 pandemic.
In a commentary published online April 21 in Lancet Psychiatry, members of the International COVID-19 Suicide Prevention Research Collaboration warned that suicide rates are likely to rise as the pandemic spreads and its ensuing long-term effects on the general population, economy, and vulnerable groups emerge.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices,” the experts wrote.
The COVID-19 collaboration was started by David Gunnell, MBChB, PhD, University of Bristol, England, and includes 42 members with suicide expertise from around the world.
“We’re an ad hoc grouping of international suicide prevention researchers, research leaders, and members of larger international suicide prevention organizations. We include specialists in public health, psychiatry, psychology, and other clinical disciplines,” Dr. Gunnell said in an interview.
“Through this comment piece we hope to share our ideas and experiences about best practice, and ask others working in the field of suicide prevention at a regional, national, and international level to share our intervention and surveillance/data collection recommendations with relevant policy makers,” he added.
Lessons from the past
During times of crisis, people with existing mental health disorders may suffer worsening symptoms, whereas others may develop new mental health problems, especially depression, anxiety, and posttraumatic stress disorder (PTSD), the group notes.
There is some evidence that suicide increased in the United States during the Spanish flu pandemic of 1918 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) outbreak.
An increase in suicide related to COVID-19 is not inevitable provided preventive action is prompt, the group notes.
In their article, the group offered several potential public health responses to mitigate suicide risk associated with the COVID-19 pandemic.
These include:
- Clear care pathways for those who are suicidal.
- Remote or digital assessments for patients currently under the care of a mental health professional.
- Staff training to support new ways of working.
- Increased support for mental health helplines.
- Providing easily accessible grief counseling for those who have lost a loved one to the virus.
- Financial safety nets and labor market programs.
- Dissemination of evidence-based online interventions.
Public health responses must also ensure that those facing domestic violence have access to support and a place to go during times of crisis, they suggested.
“These are unprecedented times. The pandemic will cause distress and leave many vulnerable. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention,” the group wrote.
Dr. Gunnell said it’s hard to predict what impact the pandemic will have on suicide rates, “but given the range of concerns, it is important to be prepared and take steps to mitigate risk as much as possible.”
Concerning spike in gun sales
Eric Fleegler, MD, MPH, and colleagues from Boston Children’s Hospital and Harvard Medical School, Boston, agreed.
“The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months,” they wrote in a commentary published online April 22 in Annals of Internal Medicine.
Dr. Fleegler and colleagues are particularly concerned about a potential increase in gun-related suicides, as gun sales in the United States have “skyrocketed” during the COVID-19 pandemic.
In March, more than 2.5 million firearms were sold, including 1.5 million handguns. That’s an 85% increase in gun sales compared with March 2019 and the highest firearm sales ever recorded in the United States, they reported.
In addition, research has shown that individuals who buy handguns have a 22-fold higher rate of firearm-related suicide within the first year vs. those who don’t purchase a handgun.
“In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide. These are not the best of times,” the authors wrote.
Dr. Fleegler and colleagues said From 2006 to 2018, firearm-related suicide rates increased by more than 25%, according to the National Center for Injury Prevention and Control. In 2018 alone, there were 24,432 firearm-related suicides in the United States.
“The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic,” they concluded.
This research had no specific funding. Dr. Gunnell and Dr. Fleegler disclosed no relevant financial relationships .
A version of this article originally appeared on Medscape.com.
A global group of suicide experts is urging governments around the world to take action to prevent a possible jump in suicide rates because of the ongoing COVID-19 pandemic.
In a commentary published online April 21 in Lancet Psychiatry, members of the International COVID-19 Suicide Prevention Research Collaboration warned that suicide rates are likely to rise as the pandemic spreads and its ensuing long-term effects on the general population, economy, and vulnerable groups emerge.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices,” the experts wrote.
The COVID-19 collaboration was started by David Gunnell, MBChB, PhD, University of Bristol, England, and includes 42 members with suicide expertise from around the world.
“We’re an ad hoc grouping of international suicide prevention researchers, research leaders, and members of larger international suicide prevention organizations. We include specialists in public health, psychiatry, psychology, and other clinical disciplines,” Dr. Gunnell said in an interview.
“Through this comment piece we hope to share our ideas and experiences about best practice, and ask others working in the field of suicide prevention at a regional, national, and international level to share our intervention and surveillance/data collection recommendations with relevant policy makers,” he added.
Lessons from the past
During times of crisis, people with existing mental health disorders may suffer worsening symptoms, whereas others may develop new mental health problems, especially depression, anxiety, and posttraumatic stress disorder (PTSD), the group notes.
There is some evidence that suicide increased in the United States during the Spanish flu pandemic of 1918 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) outbreak.
An increase in suicide related to COVID-19 is not inevitable provided preventive action is prompt, the group notes.
In their article, the group offered several potential public health responses to mitigate suicide risk associated with the COVID-19 pandemic.
These include:
- Clear care pathways for those who are suicidal.
- Remote or digital assessments for patients currently under the care of a mental health professional.
- Staff training to support new ways of working.
- Increased support for mental health helplines.
- Providing easily accessible grief counseling for those who have lost a loved one to the virus.
- Financial safety nets and labor market programs.
- Dissemination of evidence-based online interventions.
Public health responses must also ensure that those facing domestic violence have access to support and a place to go during times of crisis, they suggested.
“These are unprecedented times. The pandemic will cause distress and leave many vulnerable. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention,” the group wrote.
Dr. Gunnell said it’s hard to predict what impact the pandemic will have on suicide rates, “but given the range of concerns, it is important to be prepared and take steps to mitigate risk as much as possible.”
Concerning spike in gun sales
Eric Fleegler, MD, MPH, and colleagues from Boston Children’s Hospital and Harvard Medical School, Boston, agreed.
“The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months,” they wrote in a commentary published online April 22 in Annals of Internal Medicine.
Dr. Fleegler and colleagues are particularly concerned about a potential increase in gun-related suicides, as gun sales in the United States have “skyrocketed” during the COVID-19 pandemic.
In March, more than 2.5 million firearms were sold, including 1.5 million handguns. That’s an 85% increase in gun sales compared with March 2019 and the highest firearm sales ever recorded in the United States, they reported.
In addition, research has shown that individuals who buy handguns have a 22-fold higher rate of firearm-related suicide within the first year vs. those who don’t purchase a handgun.
“In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide. These are not the best of times,” the authors wrote.
Dr. Fleegler and colleagues said From 2006 to 2018, firearm-related suicide rates increased by more than 25%, according to the National Center for Injury Prevention and Control. In 2018 alone, there were 24,432 firearm-related suicides in the United States.
“The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic,” they concluded.
This research had no specific funding. Dr. Gunnell and Dr. Fleegler disclosed no relevant financial relationships .
A version of this article originally appeared on Medscape.com.
A global group of suicide experts is urging governments around the world to take action to prevent a possible jump in suicide rates because of the ongoing COVID-19 pandemic.
In a commentary published online April 21 in Lancet Psychiatry, members of the International COVID-19 Suicide Prevention Research Collaboration warned that suicide rates are likely to rise as the pandemic spreads and its ensuing long-term effects on the general population, economy, and vulnerable groups emerge.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices,” the experts wrote.
The COVID-19 collaboration was started by David Gunnell, MBChB, PhD, University of Bristol, England, and includes 42 members with suicide expertise from around the world.
“We’re an ad hoc grouping of international suicide prevention researchers, research leaders, and members of larger international suicide prevention organizations. We include specialists in public health, psychiatry, psychology, and other clinical disciplines,” Dr. Gunnell said in an interview.
“Through this comment piece we hope to share our ideas and experiences about best practice, and ask others working in the field of suicide prevention at a regional, national, and international level to share our intervention and surveillance/data collection recommendations with relevant policy makers,” he added.
Lessons from the past
During times of crisis, people with existing mental health disorders may suffer worsening symptoms, whereas others may develop new mental health problems, especially depression, anxiety, and posttraumatic stress disorder (PTSD), the group notes.
There is some evidence that suicide increased in the United States during the Spanish flu pandemic of 1918 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) outbreak.
An increase in suicide related to COVID-19 is not inevitable provided preventive action is prompt, the group notes.
In their article, the group offered several potential public health responses to mitigate suicide risk associated with the COVID-19 pandemic.
These include:
- Clear care pathways for those who are suicidal.
- Remote or digital assessments for patients currently under the care of a mental health professional.
- Staff training to support new ways of working.
- Increased support for mental health helplines.
- Providing easily accessible grief counseling for those who have lost a loved one to the virus.
- Financial safety nets and labor market programs.
- Dissemination of evidence-based online interventions.
Public health responses must also ensure that those facing domestic violence have access to support and a place to go during times of crisis, they suggested.
“These are unprecedented times. The pandemic will cause distress and leave many vulnerable. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention,” the group wrote.
Dr. Gunnell said it’s hard to predict what impact the pandemic will have on suicide rates, “but given the range of concerns, it is important to be prepared and take steps to mitigate risk as much as possible.”
Concerning spike in gun sales
Eric Fleegler, MD, MPH, and colleagues from Boston Children’s Hospital and Harvard Medical School, Boston, agreed.
“The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months,” they wrote in a commentary published online April 22 in Annals of Internal Medicine.
Dr. Fleegler and colleagues are particularly concerned about a potential increase in gun-related suicides, as gun sales in the United States have “skyrocketed” during the COVID-19 pandemic.
In March, more than 2.5 million firearms were sold, including 1.5 million handguns. That’s an 85% increase in gun sales compared with March 2019 and the highest firearm sales ever recorded in the United States, they reported.
In addition, research has shown that individuals who buy handguns have a 22-fold higher rate of firearm-related suicide within the first year vs. those who don’t purchase a handgun.
“In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide. These are not the best of times,” the authors wrote.
Dr. Fleegler and colleagues said From 2006 to 2018, firearm-related suicide rates increased by more than 25%, according to the National Center for Injury Prevention and Control. In 2018 alone, there were 24,432 firearm-related suicides in the United States.
“The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic,” they concluded.
This research had no specific funding. Dr. Gunnell and Dr. Fleegler disclosed no relevant financial relationships .
A version of this article originally appeared on Medscape.com.
What will pediatrics look like in 2022?
In 1966 I was struggling with the decision of whether to become an art historian or go to medical school. I decided corporate ladder climbs and tenure chases were not for me. I wanted to be my own boss. I reckoned that medicine would offer me rock-solid job security and a comfortable income that I could adjust to my needs simply by working harder. In my Norman Rockwell–influenced view of the world, there would always be sick children. There would never be a quiet week or even a day when I would have to worry about not having an income.
So it was an idyllic existence for decades, tarnished only slightly when corporate entities began gobbling up owner-operator practices. But I never envisioned a pandemic that would turn the world – including its pediatricians – upside down. For the last several weeks as I pedal past my old office, I am dumbstruck by the empty parking lot. For the present I appear to be buffered by my retirement, but know that many of you are under serious financial pressure as a result of the pandemic.
We are all yearning to return to business as usual, but we know that it isn’t going to happen because everything has changed. The usual has yet to be defined. When you finally reopen your offices, you will be walking into a strange and eerie new normal. Initially you may struggle to make it feel like nothing has changed, but very quickly the full force of the postpandemic tsunami will hit us all broadside. In 2 years, the ship may still be rocking but what will clinical pediatrics look like in the late spring of 2022?
Will the patient mix have shifted even more toward behavioral and mental health complaints as a ripple effect of the pandemic’s emotional turmoil? Will your waiting room have become a maze of plexiglass barriers to separate the sick from the well? Has the hospital invested hundreds of thousands of dollars in a ventilation system in hopes of minimizing contagion in your exam rooms? Maybe you will have instituted an appointment schedule with sick visits in the morning and well checks in the afternoon. Or you may no longer have a waiting room because patients are queuing in their cars in the parking lot. Your support staff may be rollerskating around like carhops at a drive-in recording histories and taking vital signs.
Telemedicine will hopefully have gone mainstream with more robust guidelines for billing and quality control. Medical schools may be devoting more attention to teaching student how to assess remotely. Parents may now be equipped with a tool kit of remote sensors so that you can assess their child’s tympanic membranes, pulse rate, oxygen saturation, and blood pressure on your office computer screen.
Will the EHR finally have begun to emerge from its awkward and at times painful adolescence into an easily accessible and transportable nationwide data bank that includes immunization records for all ages? Patients may have been asked or ordered to allow their cell phones to be used as tracking devices for serious communicable diseases. How many vaccine-resistant people will have responded to the pandemic by deciding that immunizations are worth the minimal risks? I fear not many.
How many of your colleagues will have left pediatrics and heeded the call for more epidemiologists? Will you be required to take a CME course in ventilation management? The good news may be that to keep the pediatric workforce robust the government has decided to forgive your student loans.
None of these changes may have come to pass because we have notoriously short memories. But I am sure that we will all still bear the deep scars of this world changing event.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
In 1966 I was struggling with the decision of whether to become an art historian or go to medical school. I decided corporate ladder climbs and tenure chases were not for me. I wanted to be my own boss. I reckoned that medicine would offer me rock-solid job security and a comfortable income that I could adjust to my needs simply by working harder. In my Norman Rockwell–influenced view of the world, there would always be sick children. There would never be a quiet week or even a day when I would have to worry about not having an income.
So it was an idyllic existence for decades, tarnished only slightly when corporate entities began gobbling up owner-operator practices. But I never envisioned a pandemic that would turn the world – including its pediatricians – upside down. For the last several weeks as I pedal past my old office, I am dumbstruck by the empty parking lot. For the present I appear to be buffered by my retirement, but know that many of you are under serious financial pressure as a result of the pandemic.
We are all yearning to return to business as usual, but we know that it isn’t going to happen because everything has changed. The usual has yet to be defined. When you finally reopen your offices, you will be walking into a strange and eerie new normal. Initially you may struggle to make it feel like nothing has changed, but very quickly the full force of the postpandemic tsunami will hit us all broadside. In 2 years, the ship may still be rocking but what will clinical pediatrics look like in the late spring of 2022?
Will the patient mix have shifted even more toward behavioral and mental health complaints as a ripple effect of the pandemic’s emotional turmoil? Will your waiting room have become a maze of plexiglass barriers to separate the sick from the well? Has the hospital invested hundreds of thousands of dollars in a ventilation system in hopes of minimizing contagion in your exam rooms? Maybe you will have instituted an appointment schedule with sick visits in the morning and well checks in the afternoon. Or you may no longer have a waiting room because patients are queuing in their cars in the parking lot. Your support staff may be rollerskating around like carhops at a drive-in recording histories and taking vital signs.
Telemedicine will hopefully have gone mainstream with more robust guidelines for billing and quality control. Medical schools may be devoting more attention to teaching student how to assess remotely. Parents may now be equipped with a tool kit of remote sensors so that you can assess their child’s tympanic membranes, pulse rate, oxygen saturation, and blood pressure on your office computer screen.
Will the EHR finally have begun to emerge from its awkward and at times painful adolescence into an easily accessible and transportable nationwide data bank that includes immunization records for all ages? Patients may have been asked or ordered to allow their cell phones to be used as tracking devices for serious communicable diseases. How many vaccine-resistant people will have responded to the pandemic by deciding that immunizations are worth the minimal risks? I fear not many.
How many of your colleagues will have left pediatrics and heeded the call for more epidemiologists? Will you be required to take a CME course in ventilation management? The good news may be that to keep the pediatric workforce robust the government has decided to forgive your student loans.
None of these changes may have come to pass because we have notoriously short memories. But I am sure that we will all still bear the deep scars of this world changing event.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
In 1966 I was struggling with the decision of whether to become an art historian or go to medical school. I decided corporate ladder climbs and tenure chases were not for me. I wanted to be my own boss. I reckoned that medicine would offer me rock-solid job security and a comfortable income that I could adjust to my needs simply by working harder. In my Norman Rockwell–influenced view of the world, there would always be sick children. There would never be a quiet week or even a day when I would have to worry about not having an income.
So it was an idyllic existence for decades, tarnished only slightly when corporate entities began gobbling up owner-operator practices. But I never envisioned a pandemic that would turn the world – including its pediatricians – upside down. For the last several weeks as I pedal past my old office, I am dumbstruck by the empty parking lot. For the present I appear to be buffered by my retirement, but know that many of you are under serious financial pressure as a result of the pandemic.
We are all yearning to return to business as usual, but we know that it isn’t going to happen because everything has changed. The usual has yet to be defined. When you finally reopen your offices, you will be walking into a strange and eerie new normal. Initially you may struggle to make it feel like nothing has changed, but very quickly the full force of the postpandemic tsunami will hit us all broadside. In 2 years, the ship may still be rocking but what will clinical pediatrics look like in the late spring of 2022?
Will the patient mix have shifted even more toward behavioral and mental health complaints as a ripple effect of the pandemic’s emotional turmoil? Will your waiting room have become a maze of plexiglass barriers to separate the sick from the well? Has the hospital invested hundreds of thousands of dollars in a ventilation system in hopes of minimizing contagion in your exam rooms? Maybe you will have instituted an appointment schedule with sick visits in the morning and well checks in the afternoon. Or you may no longer have a waiting room because patients are queuing in their cars in the parking lot. Your support staff may be rollerskating around like carhops at a drive-in recording histories and taking vital signs.
Telemedicine will hopefully have gone mainstream with more robust guidelines for billing and quality control. Medical schools may be devoting more attention to teaching student how to assess remotely. Parents may now be equipped with a tool kit of remote sensors so that you can assess their child’s tympanic membranes, pulse rate, oxygen saturation, and blood pressure on your office computer screen.
Will the EHR finally have begun to emerge from its awkward and at times painful adolescence into an easily accessible and transportable nationwide data bank that includes immunization records for all ages? Patients may have been asked or ordered to allow their cell phones to be used as tracking devices for serious communicable diseases. How many vaccine-resistant people will have responded to the pandemic by deciding that immunizations are worth the minimal risks? I fear not many.
How many of your colleagues will have left pediatrics and heeded the call for more epidemiologists? Will you be required to take a CME course in ventilation management? The good news may be that to keep the pediatric workforce robust the government has decided to forgive your student loans.
None of these changes may have come to pass because we have notoriously short memories. But I am sure that we will all still bear the deep scars of this world changing event.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].