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After navigating a pandemic that turned the world – including the world of hospital medicine – upside down for so long, the very idea of returning to a “normal” career and way of life can seem strange.

Vineet Arora, MD, MAPP, MHM, assistant dean for scholarship and discovery and associate chief medical officer for clinical learning environment at the University of Chicago, offered guidance to hospitalists on the transition from pandemic life to postpandemic life on May 5 at SHM Converge, the annual conference of the Society of Hospital Medicine.

The pandemic, Dr. Arora said, showed how important it is to develop trust. When resources were scarce as dire COVID-19 cases flooded hospitals, a culture of trust was essential to getting through the crisis.

“My team expects me to speak up on their behalf – it’s how we do things. It’s so germane to safety,” Dr. Arora said. “This is what you’re looking for in your organization – a place of psychological safety and trust.”

Surveys show that patients do trust their physicians, and healthcare providers “got a big bump” in trust during the pandemic, she said, which offers a unique opportunity.

“Doctors are trusted messengers for the COVID vaccine,” she said. “It really does matter.” But clinicians should also advocate for social justice, she said. “We must speak up even louder to fight everyday racism.”

As hospitalists move into the postpandemic medical world, Dr. Arora encouraged them to “get rid of delusions of grandeur,” expecting incredible accomplishments around every corner.

“Amazing things do happen, but oftentimes they happen because we sustain the things we start,” Dr. Arora said. For instance, physicians should consider small changes in workflow, but then sustain those changes. Maintaining pushes for change is not necessarily the norm, she said, adding that all hospitalists are probably familiar with quality improvement projects that generate only 3 months of data, because of lost focus.

Hospitalists should also “seek out information brokers” in the postpandemic medical world, or those interacting with a variety of groups who are often good sources of ideas. Hospitalists, she said, are “natural information brokers,” communicating routinely with a wide variety of specialists and healthcare professionals.

“You’ve got to know what’s important to your organization and to your patients and to everybody else,” Dr. Arora said.

She suggested that hospitalists find “zero-gravity thinkers,” and even to be this type of thinker themselves – one who stays open to new ideas and has diverse interests and experiences.

It is easy to settle into the same ways we’ve always done things, Dr. Arora said.

“The truth is there are ways that it can be better,” she said. “But we sometimes have to seek out new ideas and maintain an open mind – and sometimes we need someone to do it for us.”

Often, those closest to us are the least valuable in this regard, she said, referring to them as “innovation killers.”

“They’re not going to give you the next breakthrough idea,” she said. “You have to get outside of your network to understand where the good ideas are coming from.”

With the trauma that hospitalists have experienced for more than a year, well-being might never have been a more vital topic than it is now, Dr. Arora said.

“We’re done with online wellness modules,” she said. “Fix the system and not the person because we all know the system is not working for us. As hospitalists, we actually are experts at fixing systems.”

Dr. Arora said that one way to think of how to improve hospitalist well-being is by emphasizing “the Four Ts” – teamwork (such as the use of scribes and good communication), time (consider new work schedule models), transitions (refining workflows) and tech (technology that works for clinicians rather than creating a burden).

As hospitalists attempt to move ahead in their post–COVID-19 careers, the key is finding new challenges and never stopping the learning process, Dr. Arora said. Referring to a concept described by career coach May Busch, she said physicians can consider successful careers as a “series of S curves” – at the beginning, there is a lot of work without much advancement, followed by a rapid rise, and then arrival at the destination, which brings you to a new plateau higher up the ladder. At the higher plateau, hospitalists should “jump to a new S curve,” learning a new skill and embarking on a new endeavor, which will lift them even higher.

“Success,” Dr. Arora said, “is defined by continuous growth and learning.”

Dr. Arora reported having no financial disclosures.

After navigating a pandemic that turned the world – including the world of hospital medicine – upside down for so long, the very idea of returning to a “normal” career and way of life can seem strange.

Vineet Arora, MD, MAPP, MHM, assistant dean for scholarship and discovery and associate chief medical officer for clinical learning environment at the University of Chicago, offered guidance to hospitalists on the transition from pandemic life to postpandemic life on May 5 at SHM Converge, the annual conference of the Society of Hospital Medicine.

The pandemic, Dr. Arora said, showed how important it is to develop trust. When resources were scarce as dire COVID-19 cases flooded hospitals, a culture of trust was essential to getting through the crisis.

“My team expects me to speak up on their behalf – it’s how we do things. It’s so germane to safety,” Dr. Arora said. “This is what you’re looking for in your organization – a place of psychological safety and trust.”

Surveys show that patients do trust their physicians, and healthcare providers “got a big bump” in trust during the pandemic, she said, which offers a unique opportunity.

“Doctors are trusted messengers for the COVID vaccine,” she said. “It really does matter.” But clinicians should also advocate for social justice, she said. “We must speak up even louder to fight everyday racism.”

As hospitalists move into the postpandemic medical world, Dr. Arora encouraged them to “get rid of delusions of grandeur,” expecting incredible accomplishments around every corner.

“Amazing things do happen, but oftentimes they happen because we sustain the things we start,” Dr. Arora said. For instance, physicians should consider small changes in workflow, but then sustain those changes. Maintaining pushes for change is not necessarily the norm, she said, adding that all hospitalists are probably familiar with quality improvement projects that generate only 3 months of data, because of lost focus.

Hospitalists should also “seek out information brokers” in the postpandemic medical world, or those interacting with a variety of groups who are often good sources of ideas. Hospitalists, she said, are “natural information brokers,” communicating routinely with a wide variety of specialists and healthcare professionals.

“You’ve got to know what’s important to your organization and to your patients and to everybody else,” Dr. Arora said.

She suggested that hospitalists find “zero-gravity thinkers,” and even to be this type of thinker themselves – one who stays open to new ideas and has diverse interests and experiences.

It is easy to settle into the same ways we’ve always done things, Dr. Arora said.

“The truth is there are ways that it can be better,” she said. “But we sometimes have to seek out new ideas and maintain an open mind – and sometimes we need someone to do it for us.”

Often, those closest to us are the least valuable in this regard, she said, referring to them as “innovation killers.”

“They’re not going to give you the next breakthrough idea,” she said. “You have to get outside of your network to understand where the good ideas are coming from.”

With the trauma that hospitalists have experienced for more than a year, well-being might never have been a more vital topic than it is now, Dr. Arora said.

“We’re done with online wellness modules,” she said. “Fix the system and not the person because we all know the system is not working for us. As hospitalists, we actually are experts at fixing systems.”

Dr. Arora said that one way to think of how to improve hospitalist well-being is by emphasizing “the Four Ts” – teamwork (such as the use of scribes and good communication), time (consider new work schedule models), transitions (refining workflows) and tech (technology that works for clinicians rather than creating a burden).

As hospitalists attempt to move ahead in their post–COVID-19 careers, the key is finding new challenges and never stopping the learning process, Dr. Arora said. Referring to a concept described by career coach May Busch, she said physicians can consider successful careers as a “series of S curves” – at the beginning, there is a lot of work without much advancement, followed by a rapid rise, and then arrival at the destination, which brings you to a new plateau higher up the ladder. At the higher plateau, hospitalists should “jump to a new S curve,” learning a new skill and embarking on a new endeavor, which will lift them even higher.

“Success,” Dr. Arora said, “is defined by continuous growth and learning.”

Dr. Arora reported having no financial disclosures.

After navigating a pandemic that turned the world – including the world of hospital medicine – upside down for so long, the very idea of returning to a “normal” career and way of life can seem strange.

Vineet Arora, MD, MAPP, MHM, assistant dean for scholarship and discovery and associate chief medical officer for clinical learning environment at the University of Chicago, offered guidance to hospitalists on the transition from pandemic life to postpandemic life on May 5 at SHM Converge, the annual conference of the Society of Hospital Medicine.

The pandemic, Dr. Arora said, showed how important it is to develop trust. When resources were scarce as dire COVID-19 cases flooded hospitals, a culture of trust was essential to getting through the crisis.

“My team expects me to speak up on their behalf – it’s how we do things. It’s so germane to safety,” Dr. Arora said. “This is what you’re looking for in your organization – a place of psychological safety and trust.”

Surveys show that patients do trust their physicians, and healthcare providers “got a big bump” in trust during the pandemic, she said, which offers a unique opportunity.

“Doctors are trusted messengers for the COVID vaccine,” she said. “It really does matter.” But clinicians should also advocate for social justice, she said. “We must speak up even louder to fight everyday racism.”

As hospitalists move into the postpandemic medical world, Dr. Arora encouraged them to “get rid of delusions of grandeur,” expecting incredible accomplishments around every corner.

“Amazing things do happen, but oftentimes they happen because we sustain the things we start,” Dr. Arora said. For instance, physicians should consider small changes in workflow, but then sustain those changes. Maintaining pushes for change is not necessarily the norm, she said, adding that all hospitalists are probably familiar with quality improvement projects that generate only 3 months of data, because of lost focus.

Hospitalists should also “seek out information brokers” in the postpandemic medical world, or those interacting with a variety of groups who are often good sources of ideas. Hospitalists, she said, are “natural information brokers,” communicating routinely with a wide variety of specialists and healthcare professionals.

“You’ve got to know what’s important to your organization and to your patients and to everybody else,” Dr. Arora said.

She suggested that hospitalists find “zero-gravity thinkers,” and even to be this type of thinker themselves – one who stays open to new ideas and has diverse interests and experiences.

It is easy to settle into the same ways we’ve always done things, Dr. Arora said.

“The truth is there are ways that it can be better,” she said. “But we sometimes have to seek out new ideas and maintain an open mind – and sometimes we need someone to do it for us.”

Often, those closest to us are the least valuable in this regard, she said, referring to them as “innovation killers.”

“They’re not going to give you the next breakthrough idea,” she said. “You have to get outside of your network to understand where the good ideas are coming from.”

With the trauma that hospitalists have experienced for more than a year, well-being might never have been a more vital topic than it is now, Dr. Arora said.

“We’re done with online wellness modules,” she said. “Fix the system and not the person because we all know the system is not working for us. As hospitalists, we actually are experts at fixing systems.”

Dr. Arora said that one way to think of how to improve hospitalist well-being is by emphasizing “the Four Ts” – teamwork (such as the use of scribes and good communication), time (consider new work schedule models), transitions (refining workflows) and tech (technology that works for clinicians rather than creating a burden).

As hospitalists attempt to move ahead in their post–COVID-19 careers, the key is finding new challenges and never stopping the learning process, Dr. Arora said. Referring to a concept described by career coach May Busch, she said physicians can consider successful careers as a “series of S curves” – at the beginning, there is a lot of work without much advancement, followed by a rapid rise, and then arrival at the destination, which brings you to a new plateau higher up the ladder. At the higher plateau, hospitalists should “jump to a new S curve,” learning a new skill and embarking on a new endeavor, which will lift them even higher.

“Success,” Dr. Arora said, “is defined by continuous growth and learning.”

Dr. Arora reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

Whether they realize it or not, hospitalists treating patients during the COVID-19 pandemic have been in a combat-like situation, with challenges and stresses similar to those faced by soldiers in a war zone.

And now, as the pandemic shows signs of subsiding, they’re about to emerge from this fight, which poses a whole new set of challenges, according a retired U.S. Army general who spoke May 4 at SHM Converge, the annual conference of the Society of Hospital Medicine.

Lt. Gen. (Ret.) Mark Hertling, DBA, said during his keynote speech that clinicians and soldiers – the only two professions that routinely have to navigate through life and death situations – must lead during all phases of combat.

“This is a period where you’re going to experience some things that you may or may not be ready for,” he said. “These are the same kind of issues soldiers face when redeploying from a combat zone.”

To help draw the comparison between hospitalists during the COVID-19 era and troops during a war, Lt. Gen. Hertling showed a photo of a U.S. paratrooper who’d just dropped into northern Iraq, carrying a backpack engorged with gear. He was on one knee with his face downcast as he seemed to be taking a moment to reflect on the enormity, complexity, and danger of the crisis into which he was about to plunge. He was, Lt. Gen. Hertling said, likely pondering the mission, his family he left behind, and concerns about making mistakes in front of his comrades.

Then he showed a picture of a health care worker in a hospital corridor slumped on the floor with his or her back against the wall, knees up, and hands loosely clasped, looking exhausted and dazed. Health care workers also have carried a load that has seemed unbearable.

“You can certainly see that they are experiencing an emotional trauma at the very start of the pandemic,” he said. “The things you have carried over the last year-plus as the pandemic has raged will be with you in good and sometimes bad ways, and you need to address those things.”

Lt. Gen. Hertling described several issues – mirroring those seen in combat – that clinicians will take away from the COVID-19 experience and must grapple with as the closing chapters of the pandemic play out:
 

A sense of teamwork in a crisis

While it’s not unusual, he said, for physicians not to get along well with administrators, and for nurses sometimes not to trust doctors, the COVID-19 crisis created a sense of effective teamwork.

“They have built trust because they see a common mission and a common requirement,” he said.
 

A sense of loss

“You have lost patients, you probably have lost comrades, and some of you are having this associated survivor’s guilt – why did you survive and so many of your patients, perhaps a lot of your friends, did not?”

At memorial services for fallen soldiers, Lt. Gen. Hertling would bring a laminated card with the soldier’s picture and put it in a box with the words “Make It Matter” on it.

“That was our code for ensuring that every one of these individual soldiers who sacrificed their lives for the organization, we would carry on their legacy and make their sacrifice matter,” he said. “That’s one of the few ways you can overcome survivor’s guilt.”
 

Sense of accomplishment

Lt. Gen. Hertling said hospitalists, pushed to the extreme, were able to do things they never thought they were capable of.

“You have to relish in that, and you have to write those things down so you can go back and think about the things you did in a crisis environment to help,” he said.

In the post-pandemic era, health care workers should reflect on what they have seen, learned, and experienced, to help set a new standard and to establish ways to eliminate “bureaucratic morasses,” which seemed more possible than ever because the urgency of the moment demanded it.

Lt. Gen. Hertling also said hospitalists should take time to make a plan to handle personal, professional, team, and organizational requirements. For instance, health care workers should get a physical to take stock of how their bodies reacted to the stress of the pandemic. He said they should also recognize the difference between posttraumatic stress, which is to be expected, and posttraumatic stress disorder (PTSD), which is less common.

“It’s only at the extreme that it becomes a dysfunction and you have to address it with the help of others,” he said. Hospitalists should examine the state of their emotional and spiritual relationships – with family and friends as well as with God or other figures important to them spiritually.

Professionally, hospitalists should review professional accomplishments and shortcomings and make changes based on those assessments, he said. It’s also a good time to assess leadership issues – recall who the contributors were and who could have done more. Hospitalists should also consider contributing post-pandemic articles to the Journal of Hospital Medicine, he said.

Lt. Gen. Hertling concluded by suggesting that hospitalists seek feedback on themselves and their own leadership qualities, from their team members.

“Really press the issue,” he said, “and get a good critique on how you can improve personally and professionally in terms of your leadership approach.”

Whether they realize it or not, hospitalists treating patients during the COVID-19 pandemic have been in a combat-like situation, with challenges and stresses similar to those faced by soldiers in a war zone.

And now, as the pandemic shows signs of subsiding, they’re about to emerge from this fight, which poses a whole new set of challenges, according a retired U.S. Army general who spoke May 4 at SHM Converge, the annual conference of the Society of Hospital Medicine.

Lt. Gen. (Ret.) Mark Hertling, DBA, said during his keynote speech that clinicians and soldiers – the only two professions that routinely have to navigate through life and death situations – must lead during all phases of combat.

“This is a period where you’re going to experience some things that you may or may not be ready for,” he said. “These are the same kind of issues soldiers face when redeploying from a combat zone.”

To help draw the comparison between hospitalists during the COVID-19 era and troops during a war, Lt. Gen. Hertling showed a photo of a U.S. paratrooper who’d just dropped into northern Iraq, carrying a backpack engorged with gear. He was on one knee with his face downcast as he seemed to be taking a moment to reflect on the enormity, complexity, and danger of the crisis into which he was about to plunge. He was, Lt. Gen. Hertling said, likely pondering the mission, his family he left behind, and concerns about making mistakes in front of his comrades.

Then he showed a picture of a health care worker in a hospital corridor slumped on the floor with his or her back against the wall, knees up, and hands loosely clasped, looking exhausted and dazed. Health care workers also have carried a load that has seemed unbearable.

“You can certainly see that they are experiencing an emotional trauma at the very start of the pandemic,” he said. “The things you have carried over the last year-plus as the pandemic has raged will be with you in good and sometimes bad ways, and you need to address those things.”

Lt. Gen. Hertling described several issues – mirroring those seen in combat – that clinicians will take away from the COVID-19 experience and must grapple with as the closing chapters of the pandemic play out:
 

A sense of teamwork in a crisis

While it’s not unusual, he said, for physicians not to get along well with administrators, and for nurses sometimes not to trust doctors, the COVID-19 crisis created a sense of effective teamwork.

“They have built trust because they see a common mission and a common requirement,” he said.
 

A sense of loss

“You have lost patients, you probably have lost comrades, and some of you are having this associated survivor’s guilt – why did you survive and so many of your patients, perhaps a lot of your friends, did not?”

At memorial services for fallen soldiers, Lt. Gen. Hertling would bring a laminated card with the soldier’s picture and put it in a box with the words “Make It Matter” on it.

“That was our code for ensuring that every one of these individual soldiers who sacrificed their lives for the organization, we would carry on their legacy and make their sacrifice matter,” he said. “That’s one of the few ways you can overcome survivor’s guilt.”
 

Sense of accomplishment

Lt. Gen. Hertling said hospitalists, pushed to the extreme, were able to do things they never thought they were capable of.

“You have to relish in that, and you have to write those things down so you can go back and think about the things you did in a crisis environment to help,” he said.

In the post-pandemic era, health care workers should reflect on what they have seen, learned, and experienced, to help set a new standard and to establish ways to eliminate “bureaucratic morasses,” which seemed more possible than ever because the urgency of the moment demanded it.

Lt. Gen. Hertling also said hospitalists should take time to make a plan to handle personal, professional, team, and organizational requirements. For instance, health care workers should get a physical to take stock of how their bodies reacted to the stress of the pandemic. He said they should also recognize the difference between posttraumatic stress, which is to be expected, and posttraumatic stress disorder (PTSD), which is less common.

“It’s only at the extreme that it becomes a dysfunction and you have to address it with the help of others,” he said. Hospitalists should examine the state of their emotional and spiritual relationships – with family and friends as well as with God or other figures important to them spiritually.

Professionally, hospitalists should review professional accomplishments and shortcomings and make changes based on those assessments, he said. It’s also a good time to assess leadership issues – recall who the contributors were and who could have done more. Hospitalists should also consider contributing post-pandemic articles to the Journal of Hospital Medicine, he said.

Lt. Gen. Hertling concluded by suggesting that hospitalists seek feedback on themselves and their own leadership qualities, from their team members.

“Really press the issue,” he said, “and get a good critique on how you can improve personally and professionally in terms of your leadership approach.”

Whether they realize it or not, hospitalists treating patients during the COVID-19 pandemic have been in a combat-like situation, with challenges and stresses similar to those faced by soldiers in a war zone.

And now, as the pandemic shows signs of subsiding, they’re about to emerge from this fight, which poses a whole new set of challenges, according a retired U.S. Army general who spoke May 4 at SHM Converge, the annual conference of the Society of Hospital Medicine.

Lt. Gen. (Ret.) Mark Hertling, DBA, said during his keynote speech that clinicians and soldiers – the only two professions that routinely have to navigate through life and death situations – must lead during all phases of combat.

“This is a period where you’re going to experience some things that you may or may not be ready for,” he said. “These are the same kind of issues soldiers face when redeploying from a combat zone.”

To help draw the comparison between hospitalists during the COVID-19 era and troops during a war, Lt. Gen. Hertling showed a photo of a U.S. paratrooper who’d just dropped into northern Iraq, carrying a backpack engorged with gear. He was on one knee with his face downcast as he seemed to be taking a moment to reflect on the enormity, complexity, and danger of the crisis into which he was about to plunge. He was, Lt. Gen. Hertling said, likely pondering the mission, his family he left behind, and concerns about making mistakes in front of his comrades.

Then he showed a picture of a health care worker in a hospital corridor slumped on the floor with his or her back against the wall, knees up, and hands loosely clasped, looking exhausted and dazed. Health care workers also have carried a load that has seemed unbearable.

“You can certainly see that they are experiencing an emotional trauma at the very start of the pandemic,” he said. “The things you have carried over the last year-plus as the pandemic has raged will be with you in good and sometimes bad ways, and you need to address those things.”

Lt. Gen. Hertling described several issues – mirroring those seen in combat – that clinicians will take away from the COVID-19 experience and must grapple with as the closing chapters of the pandemic play out:
 

A sense of teamwork in a crisis

While it’s not unusual, he said, for physicians not to get along well with administrators, and for nurses sometimes not to trust doctors, the COVID-19 crisis created a sense of effective teamwork.

“They have built trust because they see a common mission and a common requirement,” he said.
 

A sense of loss

“You have lost patients, you probably have lost comrades, and some of you are having this associated survivor’s guilt – why did you survive and so many of your patients, perhaps a lot of your friends, did not?”

At memorial services for fallen soldiers, Lt. Gen. Hertling would bring a laminated card with the soldier’s picture and put it in a box with the words “Make It Matter” on it.

“That was our code for ensuring that every one of these individual soldiers who sacrificed their lives for the organization, we would carry on their legacy and make their sacrifice matter,” he said. “That’s one of the few ways you can overcome survivor’s guilt.”
 

Sense of accomplishment

Lt. Gen. Hertling said hospitalists, pushed to the extreme, were able to do things they never thought they were capable of.

“You have to relish in that, and you have to write those things down so you can go back and think about the things you did in a crisis environment to help,” he said.

In the post-pandemic era, health care workers should reflect on what they have seen, learned, and experienced, to help set a new standard and to establish ways to eliminate “bureaucratic morasses,” which seemed more possible than ever because the urgency of the moment demanded it.

Lt. Gen. Hertling also said hospitalists should take time to make a plan to handle personal, professional, team, and organizational requirements. For instance, health care workers should get a physical to take stock of how their bodies reacted to the stress of the pandemic. He said they should also recognize the difference between posttraumatic stress, which is to be expected, and posttraumatic stress disorder (PTSD), which is less common.

“It’s only at the extreme that it becomes a dysfunction and you have to address it with the help of others,” he said. Hospitalists should examine the state of their emotional and spiritual relationships – with family and friends as well as with God or other figures important to them spiritually.

Professionally, hospitalists should review professional accomplishments and shortcomings and make changes based on those assessments, he said. It’s also a good time to assess leadership issues – recall who the contributors were and who could have done more. Hospitalists should also consider contributing post-pandemic articles to the Journal of Hospital Medicine, he said.

Lt. Gen. Hertling concluded by suggesting that hospitalists seek feedback on themselves and their own leadership qualities, from their team members.

“Really press the issue,” he said, “and get a good critique on how you can improve personally and professionally in terms of your leadership approach.”

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

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New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

Moral distress can result when health professionals like doctors and nurses feel prevented from doing what they know is right and ethically correct – reflecting the values of their profession and their own sense of professional integrity – because of unmanageable caseload demands, lack of resources, coverage limitations, or institutional policies.

Hospitalists are not exempt from moral distress, which is associated with soul-searching, burnout, and even PTSD. It is also associated with a higher likelihood for professionals to report an intention to leave their jobs. But the COVID-19 pandemic has superimposed a whole new layer of challenges, constraints, and frustrations, creating a potent mix of trauma and exhaustion, cumulative unease, depleted job satisfaction, and difficult ethical choices.

These challenges include seeing so many patients die and working with short supplies of personal protective equipment (PPE) – with resulting fears that they could catch the virus or pass it on to others, including loved ones. Also, not having enough ventilators or even beds for patients in hospitals hit hard by COVID surges raises fears that decisions for rationing medical care might become necessary.

In a commentary published in the Journal of General Internal Medicine in October 2019 – shortly before the COVID pandemic burst onto the scene – hospitalist and medical sociologist Elizabeth Dzeng, MD, PhD, MPH, and hospital medicine pioneer Robert Wachter, MD, MHM, both from the University of California, San Francisco, described “moral distress and professional ethical dissonance as root causes of burnout.”¹ They characterized moral distress by its emotional exhaustion, depersonalization, reduced sense of accomplishment, and moral apathy, and they called for renewed attention to social and ethical dimensions of practice and threats to physician professionalism.

Prevailing explanations for documented high rates of burnout in doctors have tended to focus on work hours and struggles with electronic medical records and the like, Dr. Dzeng and Dr. Wachter wrote. “We see evidence of an insidious moral distress resulting from physicians’ inability to act in accord with their individual and professional ethical values due to institutional and social constraints.”

COVID has intensified these issues surrounding moral distress. “In a short period of time it created more situations that raise issues of moral distress than I have seen since the early days of HIV,” Dr. Wachter said. “Those of us who work in hospitals often find ourselves in complex circumstances with limited resources. What was so striking about COVID was finding ourselves caring for large volumes of patients who had a condition that was new to us.”

And the fact that constraints imposed by COVID, such as having to don unwieldy PPE and not allowing families to be present with hospitalized loved ones, are explainable and rational only helps a little with the clinician’s distress.

People talk about the need for doctors to be more resilient, Dr. Dzeng added, but that’s too narrow of an approach to these very real challenges. There are huge issues of workforce retention and costs, major mental health issues, suicide – and implications for patient care, because burned-out doctors can be bad doctors.
 

What is moral distress?

Moral distress is a term from the nursing ethics literature, attributed to philosopher Andrew Jameton in 1984.² Contributors to moral distress imposed by COVID include having to make difficult medical decisions under stressful circumstances – especially early on, when effective treatment options were few. Doctors felt the demands of the pandemic were putting care quality and patient safety at risk. Poor working conditions overall, being pushed to work beyond their normal physical limits for days at a time, and feelings of not being valued added to this stress. But some say the pandemic has only highlighted and amplified existing inequities and disparities in the health care system.

Experts say moral distress is about feeling powerless, especially in a system driven by market values, and feeling let down by a society that has put them in harm’s way. They work all day under physically and emotionally exhausting conditions and then go home to hear specious conspiracy theories about the pandemic and see other people unwilling to wear masks.

Moral distress is complicated, said Lucia Wocial, PhD, RN, a nurse ethicist and cochair of the ethics consultation subcommittee at Indiana University Health in Indianapolis. “If you say you have moral distress, my first response is: tell me more. It helps to peel back the layers of this complexity. Emotion is only part of moral distress. It’s about the professional’s sense of responsibility and obligation – and the inability to honor that.”

Dr. Wocial, whose research specialty is moral distress, is corresponding author of a study published in the Journal of General Internal Medicine in February 2020, which identified moral distress in 4 out of 10 surveyed physicians who cared for older hospitalized adults and found themselves needing to work with their surrogate decision-makers.³ “We know physician moral distress is higher when people haven’t had the chance to hold conversations about their end-of-life care preferences,” she said, such as whether to continue life support.

“We have also learned that communication is key to diminishing physician moral distress. Our responsibility as clinicians is to guide patients and families through these decisions. If the family feels a high level of support from me, then my moral distress is lower,” she added. “If you think about how COVID has evolved, at first people were dying so quickly. Some patients were going to the ICU on ventilators without ever having a goals-of-care conversation.”

COVID has shifted the usual standard of care in U.S. hospitals in the face of patient surges. “How can you feel okay in accepting a level of care that in the prepandemic world would not have been acceptable?” Dr. Wocial posed. “What if you know the standard of care has shifted, of necessity, but you haven’t had time to prepare for it and nobody’s talking about what that means? Who is going to help you accept that good enough under these circumstances is enough – at least for today?”
 

What to call it

Michael J. Asken, PhD, director of provider well-being at UPMC Pinnacle Harrisburg (Pa.), has questioned in print the use of the military and wartime term “moral injury” when applied to a variety of less serious physician stressors.⁴ More recently, however, he observed, “The pandemic has muted or erased many of the distinctions between medical care and military conflict. ... The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care.”⁵

In a recent interview with the Hospitalist, he said: “While I initially resisted using the term moral injury, especially pre-COVID, because it was not equivalent to the moral injury created by war, I have relented a bit.” The volume of deaths and the apparent dangers to providers themselves reflect some of the critical aspects of war, and repetitive, intense, and/or incessant ethical challenges may have longer term negative psychological or emotional effects.

“Feeling emotional pain in situations of multiple deaths is to be expected and, perhaps, should even be welcomed as a sign of retained humanity and a buffer against burnout and cynicism in these times of unabating stress,” Dr. Asken said. “This is only true, however, if the emotional impact is tolerable and not experienced in repetitive extremes.”

Courtesy Avera Health

“These things are real,” said Clarissa Barnes, MD, a physician adviser, hospitalist at Avera McKennan Hospital in Sioux Falls, S.D., and former medical director of Avera’s LIGHT Program, a wellness-oriented service for clinicians. Dr. Barnes herself caught the virus on the job but has since recovered.

“Physicians don’t see their work as an occupation. It’s their core identity: I am a doctor; I practice medicine. If things are being done in ways I don’t think are right, that’s fundamentally a breach,” she said. “As internists, we have an opportunity to forestall death whenever we can and, if not, promote a peaceful death. That’s what made me choose this specialty. I think there’s value in allowing a person to end well. But when that doesn’t happen because of social or administrative reasons, that’s hard.”
 

Where is the leadership?

“A lot of moral injury comes down to the individual health system and its leaders. Some have done well; others you hear saying things that make you question whether these are the people you want leading the organization. Hospitalists need to have a clear value framework and an idea of how to negotiate things when decisions don’t match that framework,” Dr. Barnes said.

“Sometimes administrators have additional information that they’re not sharing,” she added. “They’re caught between a rock and a hard place regarding the decisions they have to make, but they need to be more transparent and not hold things so close to their vest while thinking they are helping clinicians [by doing so]. Physicians need to understand why they are being asked to do things counter to what they believe is appropriate.”

David Oliver, MD, a geriatrics and internal medicine consultant at Royal Berkshire Hospital in Reading, England, also practices as a hospital physician, a role similar to the hospitalist in the United States. “In any system, in any environment, the job of being a doctor, nurse, or other health professional carries a lot of responsibility. That is a timeless, inherent stress of medical practice. With COVID, we’ve seen a lot of emotional burdens – a whole separate set of problems outside of your control, where you are responsible for care but don’t have accountability,” he said.

“People like me, hospital doctors, are used to chronic workforce issues in the National Health Service. But we didn’t sign up to come and get COVID and be hospitalized ourselves.” More than 850 frontline health care providers in the U.K. have so far died from the virus, Dr. Oliver said. “I saw five patients die in 90 minutes one day in April. That’s above and beyond normal human capacity.”

In England specifically, he said, it has exposed underlying structural issues and serious workforce gaps, unfilled vacancies, and a much lower number of ICU beds per 100,000 population than the United States or Europe. And there is consistent pressure to send patients home in order to empty beds for new patients.

But a range of supportive services is offered in U.K. hospitals, such as making senior clinicians available to speak to frontline clinicians, providing mentorship and a sounding board. The Point of Care Foundation has helped to disseminate the practice of Schwartz Rounds, a group reflective practice forum for health care teams developed by the Schwartz Center for Compassionate Healthcare in Boston.

“We don’t need this clap-for-the-NHS heroes stuff,” Dr. Oliver said. “We need an adequate workforce and [better] working conditions. What happened on the front lines of the pandemic was heroic – all done by local clinical teams. But where was the government – the centralized NHS? A lot of frontline clinicians aren’t feeling valued, supported, or listened to.”
 

What can be done?

What are some things that hospitalists can do, individually and collectively, to try to prevent moral distress from turning into full-scale burnout? Dr. Wocial emphasized the importance of unit-based ethics conversations. “At IU Health we have someone who is available to sit down with frontline clinicians and help unpack what they are experiencing,” she said. Clinicians need to be able to process this terrible experience in order to sort out the feelings of sadness from questions of whether they are doing something wrong.

Hospital chaplains are exquisitely skilled at supporting people and debriefing hospital teams, Dr. Wocial added. Palliative care professionals are also skilled at facilitating goals of care conversations with patients and families and can support hospitalists through coaching and joint family meetings.

“It’s about raising your sense of agency in your job – what in your practice you can control. People need to be able to talk frankly about it. Some managers say to clinicians: ‘Just buck up,’ while others are doing a fabulous job of offering support to their staff,” Dr. Wocial said. Hospitalists have to be willing to say when they’ve had too much. “You may not get help when you first ask for it. Be persistent. Asking for help doesn’t make you weak.”

Most doctors have their own strategies for managing stress on the job, Dr. Wachter noted. “What makes it a little easier is not having to do it alone. Many find solace in community, but community has been constrained by this pandemic. You can’t just go out for a beer after work anymore. So what are other ways to let off steam?”

The people leading hospitalist programs need to work harder at creating community and empathy when the tools allowing people to get together are somewhat limited. “Everybody is tired of Zoom,” he said. “One thing I learned as a manager was to just send messages to people acknowledging that I know this is hard. Try to think from the lens of other people and what they would find useful.”

The pandemic has been terribly unpredictable, Dr. Wachter added, but it won’t go on forever. For some doctors, yoga or mindfulness meditation may be very comforting. “For me, that’s not what I do. Golf or a good Seinfeld episode works for me.”

SHM’s Wellbeing Taskforce has created a “Hospital Medicine COVID Check-in Guide for Self & Peers” to promote both sharing and support for one another. It can be found at SHM’s Wellbeing webpage [www.hospitalmedicine.org/practice-management/wellbeing/]. The Taskforce believes that sharing common stressors as hospitalists can be healing, said its chair, Sarah Richards, MD, assistant professor of medicine at the University of Nebraska, Omaha. “This is especially true in situations where we feel we can’t provide the type of care we know our patients deserve.”
 

Respect, advocacy, self-care

Dr. Asken encouraged clinicians to focus on the efforts they are making on the job, not just the outcomes. “If someone has done their absolute best in a given circumstance, satisfaction and solace needs to be taken from that,” he said.

“Ongoing support group meetings, which we have called frontline support groups, should occur on a regular basis. Designated for physicians on the medical floors and in critical care units who are directly involved with COVID patients, these provide a brief respite but also engagement, sharing, and strengthening of mutual support.”

A lot of these issues have a fundamental thread, which comes down to respect, Dr. Barnes said. “Hospitalists need to hear their hospital administrators say: ‘I hear what you’re saying [about a problem]. Let’s think together about how to solve it.’ We need to work on being clear, and we need to speak up for what’s right. If you aren’t comfortable doing things you are being asked to do in the hospital, maybe you’re not working in the right place.”

Some efforts in the area of wellness and self-care really are helpful, Dr. Barnes said. “But you can’t exercise you way through a health system that doesn’t respect you. You need to get out of the mindset that you have no ability to make things different. We are not powerless as doctors. We can do a lot, actually. Physicians need to take ownership. If you are a hospitalist and you’re not part of any local or state or national organization that advocates for physicians, you should be.”
 

References

1. Dzeng L and Wachter RM. Ethics in conflict: Moral distress as a root cause of burnout. J Gen Intern Med. 2020 Feb;35(2):409-11. doi: 10.1007/s11606-019-05505-6.

2. Jameton A, Nursing Practice: The ethical issues. Prentice Hall Series in the Philosophy of Medicine. 1984, Englewood Cliffs, N.J.: Prentice Hall.

3. Wocial LD et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med. 2020 May;35(5):1405-12. doi: 10.1007/s11606-020-05652-1.

4. Asken MJ. It’s not moral injury: It’s burnout (or something else). Medical Economics; June 7, 2019.

5. Asken MJ. Now it is moral injury: The COVID-19 pandemic and moral distress. Medical Economics; April 29, 2020.

Moral distress can result when health professionals like doctors and nurses feel prevented from doing what they know is right and ethically correct – reflecting the values of their profession and their own sense of professional integrity – because of unmanageable caseload demands, lack of resources, coverage limitations, or institutional policies.

Hospitalists are not exempt from moral distress, which is associated with soul-searching, burnout, and even PTSD. It is also associated with a higher likelihood for professionals to report an intention to leave their jobs. But the COVID-19 pandemic has superimposed a whole new layer of challenges, constraints, and frustrations, creating a potent mix of trauma and exhaustion, cumulative unease, depleted job satisfaction, and difficult ethical choices.

These challenges include seeing so many patients die and working with short supplies of personal protective equipment (PPE) – with resulting fears that they could catch the virus or pass it on to others, including loved ones. Also, not having enough ventilators or even beds for patients in hospitals hit hard by COVID surges raises fears that decisions for rationing medical care might become necessary.

In a commentary published in the Journal of General Internal Medicine in October 2019 – shortly before the COVID pandemic burst onto the scene – hospitalist and medical sociologist Elizabeth Dzeng, MD, PhD, MPH, and hospital medicine pioneer Robert Wachter, MD, MHM, both from the University of California, San Francisco, described “moral distress and professional ethical dissonance as root causes of burnout.”¹ They characterized moral distress by its emotional exhaustion, depersonalization, reduced sense of accomplishment, and moral apathy, and they called for renewed attention to social and ethical dimensions of practice and threats to physician professionalism.

Prevailing explanations for documented high rates of burnout in doctors have tended to focus on work hours and struggles with electronic medical records and the like, Dr. Dzeng and Dr. Wachter wrote. “We see evidence of an insidious moral distress resulting from physicians’ inability to act in accord with their individual and professional ethical values due to institutional and social constraints.”

COVID has intensified these issues surrounding moral distress. “In a short period of time it created more situations that raise issues of moral distress than I have seen since the early days of HIV,” Dr. Wachter said. “Those of us who work in hospitals often find ourselves in complex circumstances with limited resources. What was so striking about COVID was finding ourselves caring for large volumes of patients who had a condition that was new to us.”

And the fact that constraints imposed by COVID, such as having to don unwieldy PPE and not allowing families to be present with hospitalized loved ones, are explainable and rational only helps a little with the clinician’s distress.

People talk about the need for doctors to be more resilient, Dr. Dzeng added, but that’s too narrow of an approach to these very real challenges. There are huge issues of workforce retention and costs, major mental health issues, suicide – and implications for patient care, because burned-out doctors can be bad doctors.
 

What is moral distress?

Moral distress is a term from the nursing ethics literature, attributed to philosopher Andrew Jameton in 1984.² Contributors to moral distress imposed by COVID include having to make difficult medical decisions under stressful circumstances – especially early on, when effective treatment options were few. Doctors felt the demands of the pandemic were putting care quality and patient safety at risk. Poor working conditions overall, being pushed to work beyond their normal physical limits for days at a time, and feelings of not being valued added to this stress. But some say the pandemic has only highlighted and amplified existing inequities and disparities in the health care system.

Experts say moral distress is about feeling powerless, especially in a system driven by market values, and feeling let down by a society that has put them in harm’s way. They work all day under physically and emotionally exhausting conditions and then go home to hear specious conspiracy theories about the pandemic and see other people unwilling to wear masks.

Moral distress is complicated, said Lucia Wocial, PhD, RN, a nurse ethicist and cochair of the ethics consultation subcommittee at Indiana University Health in Indianapolis. “If you say you have moral distress, my first response is: tell me more. It helps to peel back the layers of this complexity. Emotion is only part of moral distress. It’s about the professional’s sense of responsibility and obligation – and the inability to honor that.”

Dr. Wocial, whose research specialty is moral distress, is corresponding author of a study published in the Journal of General Internal Medicine in February 2020, which identified moral distress in 4 out of 10 surveyed physicians who cared for older hospitalized adults and found themselves needing to work with their surrogate decision-makers.³ “We know physician moral distress is higher when people haven’t had the chance to hold conversations about their end-of-life care preferences,” she said, such as whether to continue life support.

“We have also learned that communication is key to diminishing physician moral distress. Our responsibility as clinicians is to guide patients and families through these decisions. If the family feels a high level of support from me, then my moral distress is lower,” she added. “If you think about how COVID has evolved, at first people were dying so quickly. Some patients were going to the ICU on ventilators without ever having a goals-of-care conversation.”

COVID has shifted the usual standard of care in U.S. hospitals in the face of patient surges. “How can you feel okay in accepting a level of care that in the prepandemic world would not have been acceptable?” Dr. Wocial posed. “What if you know the standard of care has shifted, of necessity, but you haven’t had time to prepare for it and nobody’s talking about what that means? Who is going to help you accept that good enough under these circumstances is enough – at least for today?”
 

What to call it

Michael J. Asken, PhD, director of provider well-being at UPMC Pinnacle Harrisburg (Pa.), has questioned in print the use of the military and wartime term “moral injury” when applied to a variety of less serious physician stressors.⁴ More recently, however, he observed, “The pandemic has muted or erased many of the distinctions between medical care and military conflict. ... The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care.”⁵

In a recent interview with the Hospitalist, he said: “While I initially resisted using the term moral injury, especially pre-COVID, because it was not equivalent to the moral injury created by war, I have relented a bit.” The volume of deaths and the apparent dangers to providers themselves reflect some of the critical aspects of war, and repetitive, intense, and/or incessant ethical challenges may have longer term negative psychological or emotional effects.

“Feeling emotional pain in situations of multiple deaths is to be expected and, perhaps, should even be welcomed as a sign of retained humanity and a buffer against burnout and cynicism in these times of unabating stress,” Dr. Asken said. “This is only true, however, if the emotional impact is tolerable and not experienced in repetitive extremes.”

Courtesy Avera Health

“These things are real,” said Clarissa Barnes, MD, a physician adviser, hospitalist at Avera McKennan Hospital in Sioux Falls, S.D., and former medical director of Avera’s LIGHT Program, a wellness-oriented service for clinicians. Dr. Barnes herself caught the virus on the job but has since recovered.

“Physicians don’t see their work as an occupation. It’s their core identity: I am a doctor; I practice medicine. If things are being done in ways I don’t think are right, that’s fundamentally a breach,” she said. “As internists, we have an opportunity to forestall death whenever we can and, if not, promote a peaceful death. That’s what made me choose this specialty. I think there’s value in allowing a person to end well. But when that doesn’t happen because of social or administrative reasons, that’s hard.”
 

Where is the leadership?

“A lot of moral injury comes down to the individual health system and its leaders. Some have done well; others you hear saying things that make you question whether these are the people you want leading the organization. Hospitalists need to have a clear value framework and an idea of how to negotiate things when decisions don’t match that framework,” Dr. Barnes said.

“Sometimes administrators have additional information that they’re not sharing,” she added. “They’re caught between a rock and a hard place regarding the decisions they have to make, but they need to be more transparent and not hold things so close to their vest while thinking they are helping clinicians [by doing so]. Physicians need to understand why they are being asked to do things counter to what they believe is appropriate.”

David Oliver, MD, a geriatrics and internal medicine consultant at Royal Berkshire Hospital in Reading, England, also practices as a hospital physician, a role similar to the hospitalist in the United States. “In any system, in any environment, the job of being a doctor, nurse, or other health professional carries a lot of responsibility. That is a timeless, inherent stress of medical practice. With COVID, we’ve seen a lot of emotional burdens – a whole separate set of problems outside of your control, where you are responsible for care but don’t have accountability,” he said.

“People like me, hospital doctors, are used to chronic workforce issues in the National Health Service. But we didn’t sign up to come and get COVID and be hospitalized ourselves.” More than 850 frontline health care providers in the U.K. have so far died from the virus, Dr. Oliver said. “I saw five patients die in 90 minutes one day in April. That’s above and beyond normal human capacity.”

In England specifically, he said, it has exposed underlying structural issues and serious workforce gaps, unfilled vacancies, and a much lower number of ICU beds per 100,000 population than the United States or Europe. And there is consistent pressure to send patients home in order to empty beds for new patients.

But a range of supportive services is offered in U.K. hospitals, such as making senior clinicians available to speak to frontline clinicians, providing mentorship and a sounding board. The Point of Care Foundation has helped to disseminate the practice of Schwartz Rounds, a group reflective practice forum for health care teams developed by the Schwartz Center for Compassionate Healthcare in Boston.

“We don’t need this clap-for-the-NHS heroes stuff,” Dr. Oliver said. “We need an adequate workforce and [better] working conditions. What happened on the front lines of the pandemic was heroic – all done by local clinical teams. But where was the government – the centralized NHS? A lot of frontline clinicians aren’t feeling valued, supported, or listened to.”
 

What can be done?

What are some things that hospitalists can do, individually and collectively, to try to prevent moral distress from turning into full-scale burnout? Dr. Wocial emphasized the importance of unit-based ethics conversations. “At IU Health we have someone who is available to sit down with frontline clinicians and help unpack what they are experiencing,” she said. Clinicians need to be able to process this terrible experience in order to sort out the feelings of sadness from questions of whether they are doing something wrong.

Hospital chaplains are exquisitely skilled at supporting people and debriefing hospital teams, Dr. Wocial added. Palliative care professionals are also skilled at facilitating goals of care conversations with patients and families and can support hospitalists through coaching and joint family meetings.

“It’s about raising your sense of agency in your job – what in your practice you can control. People need to be able to talk frankly about it. Some managers say to clinicians: ‘Just buck up,’ while others are doing a fabulous job of offering support to their staff,” Dr. Wocial said. Hospitalists have to be willing to say when they’ve had too much. “You may not get help when you first ask for it. Be persistent. Asking for help doesn’t make you weak.”

Most doctors have their own strategies for managing stress on the job, Dr. Wachter noted. “What makes it a little easier is not having to do it alone. Many find solace in community, but community has been constrained by this pandemic. You can’t just go out for a beer after work anymore. So what are other ways to let off steam?”

The people leading hospitalist programs need to work harder at creating community and empathy when the tools allowing people to get together are somewhat limited. “Everybody is tired of Zoom,” he said. “One thing I learned as a manager was to just send messages to people acknowledging that I know this is hard. Try to think from the lens of other people and what they would find useful.”

The pandemic has been terribly unpredictable, Dr. Wachter added, but it won’t go on forever. For some doctors, yoga or mindfulness meditation may be very comforting. “For me, that’s not what I do. Golf or a good Seinfeld episode works for me.”

SHM’s Wellbeing Taskforce has created a “Hospital Medicine COVID Check-in Guide for Self & Peers” to promote both sharing and support for one another. It can be found at SHM’s Wellbeing webpage [www.hospitalmedicine.org/practice-management/wellbeing/]. The Taskforce believes that sharing common stressors as hospitalists can be healing, said its chair, Sarah Richards, MD, assistant professor of medicine at the University of Nebraska, Omaha. “This is especially true in situations where we feel we can’t provide the type of care we know our patients deserve.”
 

Respect, advocacy, self-care

Dr. Asken encouraged clinicians to focus on the efforts they are making on the job, not just the outcomes. “If someone has done their absolute best in a given circumstance, satisfaction and solace needs to be taken from that,” he said.

“Ongoing support group meetings, which we have called frontline support groups, should occur on a regular basis. Designated for physicians on the medical floors and in critical care units who are directly involved with COVID patients, these provide a brief respite but also engagement, sharing, and strengthening of mutual support.”

A lot of these issues have a fundamental thread, which comes down to respect, Dr. Barnes said. “Hospitalists need to hear their hospital administrators say: ‘I hear what you’re saying [about a problem]. Let’s think together about how to solve it.’ We need to work on being clear, and we need to speak up for what’s right. If you aren’t comfortable doing things you are being asked to do in the hospital, maybe you’re not working in the right place.”

Some efforts in the area of wellness and self-care really are helpful, Dr. Barnes said. “But you can’t exercise you way through a health system that doesn’t respect you. You need to get out of the mindset that you have no ability to make things different. We are not powerless as doctors. We can do a lot, actually. Physicians need to take ownership. If you are a hospitalist and you’re not part of any local or state or national organization that advocates for physicians, you should be.”
 

References

1. Dzeng L and Wachter RM. Ethics in conflict: Moral distress as a root cause of burnout. J Gen Intern Med. 2020 Feb;35(2):409-11. doi: 10.1007/s11606-019-05505-6.

2. Jameton A, Nursing Practice: The ethical issues. Prentice Hall Series in the Philosophy of Medicine. 1984, Englewood Cliffs, N.J.: Prentice Hall.

3. Wocial LD et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med. 2020 May;35(5):1405-12. doi: 10.1007/s11606-020-05652-1.

4. Asken MJ. It’s not moral injury: It’s burnout (or something else). Medical Economics; June 7, 2019.

5. Asken MJ. Now it is moral injury: The COVID-19 pandemic and moral distress. Medical Economics; April 29, 2020.

Moral distress can result when health professionals like doctors and nurses feel prevented from doing what they know is right and ethically correct – reflecting the values of their profession and their own sense of professional integrity – because of unmanageable caseload demands, lack of resources, coverage limitations, or institutional policies.

Hospitalists are not exempt from moral distress, which is associated with soul-searching, burnout, and even PTSD. It is also associated with a higher likelihood for professionals to report an intention to leave their jobs. But the COVID-19 pandemic has superimposed a whole new layer of challenges, constraints, and frustrations, creating a potent mix of trauma and exhaustion, cumulative unease, depleted job satisfaction, and difficult ethical choices.

These challenges include seeing so many patients die and working with short supplies of personal protective equipment (PPE) – with resulting fears that they could catch the virus or pass it on to others, including loved ones. Also, not having enough ventilators or even beds for patients in hospitals hit hard by COVID surges raises fears that decisions for rationing medical care might become necessary.

In a commentary published in the Journal of General Internal Medicine in October 2019 – shortly before the COVID pandemic burst onto the scene – hospitalist and medical sociologist Elizabeth Dzeng, MD, PhD, MPH, and hospital medicine pioneer Robert Wachter, MD, MHM, both from the University of California, San Francisco, described “moral distress and professional ethical dissonance as root causes of burnout.”¹ They characterized moral distress by its emotional exhaustion, depersonalization, reduced sense of accomplishment, and moral apathy, and they called for renewed attention to social and ethical dimensions of practice and threats to physician professionalism.

Prevailing explanations for documented high rates of burnout in doctors have tended to focus on work hours and struggles with electronic medical records and the like, Dr. Dzeng and Dr. Wachter wrote. “We see evidence of an insidious moral distress resulting from physicians’ inability to act in accord with their individual and professional ethical values due to institutional and social constraints.”

COVID has intensified these issues surrounding moral distress. “In a short period of time it created more situations that raise issues of moral distress than I have seen since the early days of HIV,” Dr. Wachter said. “Those of us who work in hospitals often find ourselves in complex circumstances with limited resources. What was so striking about COVID was finding ourselves caring for large volumes of patients who had a condition that was new to us.”

And the fact that constraints imposed by COVID, such as having to don unwieldy PPE and not allowing families to be present with hospitalized loved ones, are explainable and rational only helps a little with the clinician’s distress.

People talk about the need for doctors to be more resilient, Dr. Dzeng added, but that’s too narrow of an approach to these very real challenges. There are huge issues of workforce retention and costs, major mental health issues, suicide – and implications for patient care, because burned-out doctors can be bad doctors.
 

What is moral distress?

Moral distress is a term from the nursing ethics literature, attributed to philosopher Andrew Jameton in 1984.² Contributors to moral distress imposed by COVID include having to make difficult medical decisions under stressful circumstances – especially early on, when effective treatment options were few. Doctors felt the demands of the pandemic were putting care quality and patient safety at risk. Poor working conditions overall, being pushed to work beyond their normal physical limits for days at a time, and feelings of not being valued added to this stress. But some say the pandemic has only highlighted and amplified existing inequities and disparities in the health care system.

Experts say moral distress is about feeling powerless, especially in a system driven by market values, and feeling let down by a society that has put them in harm’s way. They work all day under physically and emotionally exhausting conditions and then go home to hear specious conspiracy theories about the pandemic and see other people unwilling to wear masks.

Moral distress is complicated, said Lucia Wocial, PhD, RN, a nurse ethicist and cochair of the ethics consultation subcommittee at Indiana University Health in Indianapolis. “If you say you have moral distress, my first response is: tell me more. It helps to peel back the layers of this complexity. Emotion is only part of moral distress. It’s about the professional’s sense of responsibility and obligation – and the inability to honor that.”

Dr. Wocial, whose research specialty is moral distress, is corresponding author of a study published in the Journal of General Internal Medicine in February 2020, which identified moral distress in 4 out of 10 surveyed physicians who cared for older hospitalized adults and found themselves needing to work with their surrogate decision-makers.³ “We know physician moral distress is higher when people haven’t had the chance to hold conversations about their end-of-life care preferences,” she said, such as whether to continue life support.

“We have also learned that communication is key to diminishing physician moral distress. Our responsibility as clinicians is to guide patients and families through these decisions. If the family feels a high level of support from me, then my moral distress is lower,” she added. “If you think about how COVID has evolved, at first people were dying so quickly. Some patients were going to the ICU on ventilators without ever having a goals-of-care conversation.”

COVID has shifted the usual standard of care in U.S. hospitals in the face of patient surges. “How can you feel okay in accepting a level of care that in the prepandemic world would not have been acceptable?” Dr. Wocial posed. “What if you know the standard of care has shifted, of necessity, but you haven’t had time to prepare for it and nobody’s talking about what that means? Who is going to help you accept that good enough under these circumstances is enough – at least for today?”
 

What to call it

Michael J. Asken, PhD, director of provider well-being at UPMC Pinnacle Harrisburg (Pa.), has questioned in print the use of the military and wartime term “moral injury” when applied to a variety of less serious physician stressors.⁴ More recently, however, he observed, “The pandemic has muted or erased many of the distinctions between medical care and military conflict. ... The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care.”⁵

In a recent interview with the Hospitalist, he said: “While I initially resisted using the term moral injury, especially pre-COVID, because it was not equivalent to the moral injury created by war, I have relented a bit.” The volume of deaths and the apparent dangers to providers themselves reflect some of the critical aspects of war, and repetitive, intense, and/or incessant ethical challenges may have longer term negative psychological or emotional effects.

“Feeling emotional pain in situations of multiple deaths is to be expected and, perhaps, should even be welcomed as a sign of retained humanity and a buffer against burnout and cynicism in these times of unabating stress,” Dr. Asken said. “This is only true, however, if the emotional impact is tolerable and not experienced in repetitive extremes.”

Courtesy Avera Health

“These things are real,” said Clarissa Barnes, MD, a physician adviser, hospitalist at Avera McKennan Hospital in Sioux Falls, S.D., and former medical director of Avera’s LIGHT Program, a wellness-oriented service for clinicians. Dr. Barnes herself caught the virus on the job but has since recovered.

“Physicians don’t see their work as an occupation. It’s their core identity: I am a doctor; I practice medicine. If things are being done in ways I don’t think are right, that’s fundamentally a breach,” she said. “As internists, we have an opportunity to forestall death whenever we can and, if not, promote a peaceful death. That’s what made me choose this specialty. I think there’s value in allowing a person to end well. But when that doesn’t happen because of social or administrative reasons, that’s hard.”
 

Where is the leadership?

“A lot of moral injury comes down to the individual health system and its leaders. Some have done well; others you hear saying things that make you question whether these are the people you want leading the organization. Hospitalists need to have a clear value framework and an idea of how to negotiate things when decisions don’t match that framework,” Dr. Barnes said.

“Sometimes administrators have additional information that they’re not sharing,” she added. “They’re caught between a rock and a hard place regarding the decisions they have to make, but they need to be more transparent and not hold things so close to their vest while thinking they are helping clinicians [by doing so]. Physicians need to understand why they are being asked to do things counter to what they believe is appropriate.”

David Oliver, MD, a geriatrics and internal medicine consultant at Royal Berkshire Hospital in Reading, England, also practices as a hospital physician, a role similar to the hospitalist in the United States. “In any system, in any environment, the job of being a doctor, nurse, or other health professional carries a lot of responsibility. That is a timeless, inherent stress of medical practice. With COVID, we’ve seen a lot of emotional burdens – a whole separate set of problems outside of your control, where you are responsible for care but don’t have accountability,” he said.

“People like me, hospital doctors, are used to chronic workforce issues in the National Health Service. But we didn’t sign up to come and get COVID and be hospitalized ourselves.” More than 850 frontline health care providers in the U.K. have so far died from the virus, Dr. Oliver said. “I saw five patients die in 90 minutes one day in April. That’s above and beyond normal human capacity.”

In England specifically, he said, it has exposed underlying structural issues and serious workforce gaps, unfilled vacancies, and a much lower number of ICU beds per 100,000 population than the United States or Europe. And there is consistent pressure to send patients home in order to empty beds for new patients.

But a range of supportive services is offered in U.K. hospitals, such as making senior clinicians available to speak to frontline clinicians, providing mentorship and a sounding board. The Point of Care Foundation has helped to disseminate the practice of Schwartz Rounds, a group reflective practice forum for health care teams developed by the Schwartz Center for Compassionate Healthcare in Boston.

“We don’t need this clap-for-the-NHS heroes stuff,” Dr. Oliver said. “We need an adequate workforce and [better] working conditions. What happened on the front lines of the pandemic was heroic – all done by local clinical teams. But where was the government – the centralized NHS? A lot of frontline clinicians aren’t feeling valued, supported, or listened to.”
 

What can be done?

What are some things that hospitalists can do, individually and collectively, to try to prevent moral distress from turning into full-scale burnout? Dr. Wocial emphasized the importance of unit-based ethics conversations. “At IU Health we have someone who is available to sit down with frontline clinicians and help unpack what they are experiencing,” she said. Clinicians need to be able to process this terrible experience in order to sort out the feelings of sadness from questions of whether they are doing something wrong.

Hospital chaplains are exquisitely skilled at supporting people and debriefing hospital teams, Dr. Wocial added. Palliative care professionals are also skilled at facilitating goals of care conversations with patients and families and can support hospitalists through coaching and joint family meetings.

“It’s about raising your sense of agency in your job – what in your practice you can control. People need to be able to talk frankly about it. Some managers say to clinicians: ‘Just buck up,’ while others are doing a fabulous job of offering support to their staff,” Dr. Wocial said. Hospitalists have to be willing to say when they’ve had too much. “You may not get help when you first ask for it. Be persistent. Asking for help doesn’t make you weak.”

Most doctors have their own strategies for managing stress on the job, Dr. Wachter noted. “What makes it a little easier is not having to do it alone. Many find solace in community, but community has been constrained by this pandemic. You can’t just go out for a beer after work anymore. So what are other ways to let off steam?”

The people leading hospitalist programs need to work harder at creating community and empathy when the tools allowing people to get together are somewhat limited. “Everybody is tired of Zoom,” he said. “One thing I learned as a manager was to just send messages to people acknowledging that I know this is hard. Try to think from the lens of other people and what they would find useful.”

The pandemic has been terribly unpredictable, Dr. Wachter added, but it won’t go on forever. For some doctors, yoga or mindfulness meditation may be very comforting. “For me, that’s not what I do. Golf or a good Seinfeld episode works for me.”

SHM’s Wellbeing Taskforce has created a “Hospital Medicine COVID Check-in Guide for Self & Peers” to promote both sharing and support for one another. It can be found at SHM’s Wellbeing webpage [www.hospitalmedicine.org/practice-management/wellbeing/]. The Taskforce believes that sharing common stressors as hospitalists can be healing, said its chair, Sarah Richards, MD, assistant professor of medicine at the University of Nebraska, Omaha. “This is especially true in situations where we feel we can’t provide the type of care we know our patients deserve.”
 

Respect, advocacy, self-care

Dr. Asken encouraged clinicians to focus on the efforts they are making on the job, not just the outcomes. “If someone has done their absolute best in a given circumstance, satisfaction and solace needs to be taken from that,” he said.

“Ongoing support group meetings, which we have called frontline support groups, should occur on a regular basis. Designated for physicians on the medical floors and in critical care units who are directly involved with COVID patients, these provide a brief respite but also engagement, sharing, and strengthening of mutual support.”

A lot of these issues have a fundamental thread, which comes down to respect, Dr. Barnes said. “Hospitalists need to hear their hospital administrators say: ‘I hear what you’re saying [about a problem]. Let’s think together about how to solve it.’ We need to work on being clear, and we need to speak up for what’s right. If you aren’t comfortable doing things you are being asked to do in the hospital, maybe you’re not working in the right place.”

Some efforts in the area of wellness and self-care really are helpful, Dr. Barnes said. “But you can’t exercise you way through a health system that doesn’t respect you. You need to get out of the mindset that you have no ability to make things different. We are not powerless as doctors. We can do a lot, actually. Physicians need to take ownership. If you are a hospitalist and you’re not part of any local or state or national organization that advocates for physicians, you should be.”
 

References

1. Dzeng L and Wachter RM. Ethics in conflict: Moral distress as a root cause of burnout. J Gen Intern Med. 2020 Feb;35(2):409-11. doi: 10.1007/s11606-019-05505-6.

2. Jameton A, Nursing Practice: The ethical issues. Prentice Hall Series in the Philosophy of Medicine. 1984, Englewood Cliffs, N.J.: Prentice Hall.

3. Wocial LD et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med. 2020 May;35(5):1405-12. doi: 10.1007/s11606-020-05652-1.

4. Asken MJ. It’s not moral injury: It’s burnout (or something else). Medical Economics; June 7, 2019.

5. Asken MJ. Now it is moral injury: The COVID-19 pandemic and moral distress. Medical Economics; April 29, 2020.

The majority of children with type 1 diabetes who tested positive for SARS-CoV-2 were cared for at home and did well, according to the first report of outcomes of pediatric patients with type 1 diabetes and COVID-19 from the United States.

Most children who were hospitalized had diabetic ketoacidosis (DKA) and high hemoglobin A1c levels, the new report from the T1D Exchange Quality Improvement Collaborative indicates. Fewer than 2% required respiratory support, and no deaths were recorded.

The greatest risk for adverse COVID-19 outcomes was among children with A1c levels >9%. In addition, children of certain ethnic minority groups and those with public health insurance were more likely to be hospitalized.

The study, conducted by G. Todd Alonso, MD, of the University of Colorado, Barbara Davis Center, Aurora, and colleagues, was published online April 14 in the Journal of Diabetes..

“As early reports identified diabetes as a risk factor for increased morbidity and mortality with COVID-19, the findings from this surveillance study should provide measured reassurance for families of children with type 1 diabetes as well as pediatric endocrinologists and their care teams,” say Dr. Alonso and colleagues.
 

Disproportionate rate of hospitalization, DKA among Black patients

Initiated in April 2020, the T1D Exchange Quality Improvement Collaborative comprises 56 diabetes centers, of which 52 submitted a total of 266 cases involving patients younger than 19 years who had type 1 diabetes and who tested positive for SARS-CoV-2 infection. Those with new-onset type 1 diabetes were excluded from this analysis and were reported separately. The data were collected between April 9, 2020, and Jan. 15, 2021.

Of the 266 patients, 23% (61) were hospitalized, and 205 were not. There were no differences by age, gender, or diabetes duration.

However, those hospitalized were more likely to be Black (34% vs. 13% among White patients; P < .001) and to have public health insurance (64% vs. 41%; P < .001). They also had higher A1c levels than patients who were not hospitalized (11% vs. 8.2%; P < .001), and fewer used insulin pumps (26% vs. 54%; P < .001) and continuous glucose monitors (39% vs. 75%; P < .001).

Those hospitalized were also more likely to have hyperglycemia (48% vs. 28%; P = .007), nausea (33% vs. 6%; P < .001), and vomiting (49% vs. 3%; P < .001). Rates of dry cough, excess fatigue, and body aches/headaches did not differ between those hospitalized and those who remained at home.

The most common adverse outcome was DKA, which occurred in 72% (44) of those hospitalized.

The most recent A1c level was less than 9% in 82% of those hospitalized vs. 31% of those who weren’t (P < .001) and in 38 of the 44 (86%) who had DKA.

“Our data reveal a disproportionate rate of hospitalization and DKA among racial and ethnic minority groups, children who were publicly insured, and those with higher A1c. It is essential to find pathways for the most vulnerable patients to have adequate, equitable access to medical care via in person and telehealth services, to obtain and successfully use diabetes technology, and to optimize sick day management,” say Dr. Alonso and colleagues.

One child, a 15-year-old White boy, underwent intubation and was placed on a ventilator. His most recent A1c was 8.9%. Another child, a 13-year-old boy whose most recent A1c level was 11.1%, developed multisystem inflammatory syndrome of childhood.

The registry remains open.

The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received partial financial support for this study from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. None of the sponsors were involved in initiating, designing, or preparing the manuscript for this study.

A version of this article first appeared on Medscape.com.

The majority of children with type 1 diabetes who tested positive for SARS-CoV-2 were cared for at home and did well, according to the first report of outcomes of pediatric patients with type 1 diabetes and COVID-19 from the United States.

Most children who were hospitalized had diabetic ketoacidosis (DKA) and high hemoglobin A1c levels, the new report from the T1D Exchange Quality Improvement Collaborative indicates. Fewer than 2% required respiratory support, and no deaths were recorded.

The greatest risk for adverse COVID-19 outcomes was among children with A1c levels >9%. In addition, children of certain ethnic minority groups and those with public health insurance were more likely to be hospitalized.

The study, conducted by G. Todd Alonso, MD, of the University of Colorado, Barbara Davis Center, Aurora, and colleagues, was published online April 14 in the Journal of Diabetes..

“As early reports identified diabetes as a risk factor for increased morbidity and mortality with COVID-19, the findings from this surveillance study should provide measured reassurance for families of children with type 1 diabetes as well as pediatric endocrinologists and their care teams,” say Dr. Alonso and colleagues.
 

Disproportionate rate of hospitalization, DKA among Black patients

Initiated in April 2020, the T1D Exchange Quality Improvement Collaborative comprises 56 diabetes centers, of which 52 submitted a total of 266 cases involving patients younger than 19 years who had type 1 diabetes and who tested positive for SARS-CoV-2 infection. Those with new-onset type 1 diabetes were excluded from this analysis and were reported separately. The data were collected between April 9, 2020, and Jan. 15, 2021.

Of the 266 patients, 23% (61) were hospitalized, and 205 were not. There were no differences by age, gender, or diabetes duration.

However, those hospitalized were more likely to be Black (34% vs. 13% among White patients; P < .001) and to have public health insurance (64% vs. 41%; P < .001). They also had higher A1c levels than patients who were not hospitalized (11% vs. 8.2%; P < .001), and fewer used insulin pumps (26% vs. 54%; P < .001) and continuous glucose monitors (39% vs. 75%; P < .001).

Those hospitalized were also more likely to have hyperglycemia (48% vs. 28%; P = .007), nausea (33% vs. 6%; P < .001), and vomiting (49% vs. 3%; P < .001). Rates of dry cough, excess fatigue, and body aches/headaches did not differ between those hospitalized and those who remained at home.

The most common adverse outcome was DKA, which occurred in 72% (44) of those hospitalized.

The most recent A1c level was less than 9% in 82% of those hospitalized vs. 31% of those who weren’t (P < .001) and in 38 of the 44 (86%) who had DKA.

“Our data reveal a disproportionate rate of hospitalization and DKA among racial and ethnic minority groups, children who were publicly insured, and those with higher A1c. It is essential to find pathways for the most vulnerable patients to have adequate, equitable access to medical care via in person and telehealth services, to obtain and successfully use diabetes technology, and to optimize sick day management,” say Dr. Alonso and colleagues.

One child, a 15-year-old White boy, underwent intubation and was placed on a ventilator. His most recent A1c was 8.9%. Another child, a 13-year-old boy whose most recent A1c level was 11.1%, developed multisystem inflammatory syndrome of childhood.

The registry remains open.

The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received partial financial support for this study from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. None of the sponsors were involved in initiating, designing, or preparing the manuscript for this study.

A version of this article first appeared on Medscape.com.

The majority of children with type 1 diabetes who tested positive for SARS-CoV-2 were cared for at home and did well, according to the first report of outcomes of pediatric patients with type 1 diabetes and COVID-19 from the United States.

Most children who were hospitalized had diabetic ketoacidosis (DKA) and high hemoglobin A1c levels, the new report from the T1D Exchange Quality Improvement Collaborative indicates. Fewer than 2% required respiratory support, and no deaths were recorded.

The greatest risk for adverse COVID-19 outcomes was among children with A1c levels >9%. In addition, children of certain ethnic minority groups and those with public health insurance were more likely to be hospitalized.

The study, conducted by G. Todd Alonso, MD, of the University of Colorado, Barbara Davis Center, Aurora, and colleagues, was published online April 14 in the Journal of Diabetes..

“As early reports identified diabetes as a risk factor for increased morbidity and mortality with COVID-19, the findings from this surveillance study should provide measured reassurance for families of children with type 1 diabetes as well as pediatric endocrinologists and their care teams,” say Dr. Alonso and colleagues.
 

Disproportionate rate of hospitalization, DKA among Black patients

Initiated in April 2020, the T1D Exchange Quality Improvement Collaborative comprises 56 diabetes centers, of which 52 submitted a total of 266 cases involving patients younger than 19 years who had type 1 diabetes and who tested positive for SARS-CoV-2 infection. Those with new-onset type 1 diabetes were excluded from this analysis and were reported separately. The data were collected between April 9, 2020, and Jan. 15, 2021.

Of the 266 patients, 23% (61) were hospitalized, and 205 were not. There were no differences by age, gender, or diabetes duration.

However, those hospitalized were more likely to be Black (34% vs. 13% among White patients; P < .001) and to have public health insurance (64% vs. 41%; P < .001). They also had higher A1c levels than patients who were not hospitalized (11% vs. 8.2%; P < .001), and fewer used insulin pumps (26% vs. 54%; P < .001) and continuous glucose monitors (39% vs. 75%; P < .001).

Those hospitalized were also more likely to have hyperglycemia (48% vs. 28%; P = .007), nausea (33% vs. 6%; P < .001), and vomiting (49% vs. 3%; P < .001). Rates of dry cough, excess fatigue, and body aches/headaches did not differ between those hospitalized and those who remained at home.

The most common adverse outcome was DKA, which occurred in 72% (44) of those hospitalized.

The most recent A1c level was less than 9% in 82% of those hospitalized vs. 31% of those who weren’t (P < .001) and in 38 of the 44 (86%) who had DKA.

“Our data reveal a disproportionate rate of hospitalization and DKA among racial and ethnic minority groups, children who were publicly insured, and those with higher A1c. It is essential to find pathways for the most vulnerable patients to have adequate, equitable access to medical care via in person and telehealth services, to obtain and successfully use diabetes technology, and to optimize sick day management,” say Dr. Alonso and colleagues.

One child, a 15-year-old White boy, underwent intubation and was placed on a ventilator. His most recent A1c was 8.9%. Another child, a 13-year-old boy whose most recent A1c level was 11.1%, developed multisystem inflammatory syndrome of childhood.

The registry remains open.

The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received partial financial support for this study from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. None of the sponsors were involved in initiating, designing, or preparing the manuscript for this study.

A version of this article first appeared on Medscape.com.

Background: Treatment goals of heart failure include improvement in quality of life, prevention of hospitalization, and decreases in mortality. Loop diuretics can improve these goals. Furosemide (Lasix) is the most widely used diuretic in heart failure patients. Torsemide (Demadex) has a better pharmacokinetic and pharmacodynamic profile than does furosemide, with greater bioavailability, a longer half-life, and higher potency. In addition, there is a suggestion that torsemide has a vasodilatory effect and a possible antialdosterone effect that may contribute to its efficacy. However, it is not known if that better profile leads to differences or improvements in primary treatment goals.

Dr. Tsien is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Treatment goals of heart failure include improvement in quality of life, prevention of hospitalization, and decreases in mortality. Loop diuretics can improve these goals. Furosemide (Lasix) is the most widely used diuretic in heart failure patients. Torsemide (Demadex) has a better pharmacokinetic and pharmacodynamic profile than does furosemide, with greater bioavailability, a longer half-life, and higher potency. In addition, there is a suggestion that torsemide has a vasodilatory effect and a possible antialdosterone effect that may contribute to its efficacy. However, it is not known if that better profile leads to differences or improvements in primary treatment goals.

Dr. Tsien is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Treatment goals of heart failure include improvement in quality of life, prevention of hospitalization, and decreases in mortality. Loop diuretics can improve these goals. Furosemide (Lasix) is the most widely used diuretic in heart failure patients. Torsemide (Demadex) has a better pharmacokinetic and pharmacodynamic profile than does furosemide, with greater bioavailability, a longer half-life, and higher potency. In addition, there is a suggestion that torsemide has a vasodilatory effect and a possible antialdosterone effect that may contribute to its efficacy. However, it is not known if that better profile leads to differences or improvements in primary treatment goals.

Dr. Tsien is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.