Infectious Diseases

This month, I would like to touch on a few COVID-19 topics that have received much publicity, with some messages about them having been confusing.

Let’s start with a case:

A 37-year-old woman is seen in clinic for a 5-day history of cough, fever, chest tightness, and onset of dyspnea on the day of her office visit.

An exam reveals her blood pressure is 100/60 mm Hg, her pulse is 100 beats per minute, her temperature is 38.7° C, her oxygen saturation is 93%, and her respiratory rate is 20 breaths per minute.

Auscultation of the chest revealed bilateral wheezing and rhonchi. A nasopharyngeal swab is sent for COVID-19 and is negative; she also tests negative for influenza.

Her hemoglobin level is 13 g/dL, hematocrit was 39%, platelet count was 155,000 per mcL of blood, and D-dimer level was 8.4 mcg/mL (normal is less than 0.4 mcg/mL.) Her white blood cell count was 6,000 per mcL of blood (neutrophils, 4,900; lymphocytes, 800; basophils, 200). Her chest x-ray showed bilateral lower lobe infiltrates.
 

What do you recommend?

A. Begin azithromycin plus ceftriaxone

B. Begin azithromycin

C. Begin oseltamivir

D. Obtain chest CT

E. Repeat COVID-19 test

With the massive amount of information coming out every day on COVID-19, it is hard to keep up with all of it, and sort out accurate, reviewed studies. We are in a position where we need to take in what we can and assess the best data available.

In the case above, I think choices D or E would make sense. This patient very likely has COVID-19 based on clinical symptoms and lab parameters. The negative COVID-19 test gives us pause, but several studies show that false negative tests are not uncommon.

Long et al. reported on 36 patients who had received both chest CT and real-time reverse transcription polymerase chain reaction (rRT-PCR) for COVID-19.¹ All were eventually diagnosed with COVID-19 pneumonia. The CT scan had a very high sensitivity (35/36) of 97.2%, whereas the rRT-PCR had a lower sensitivity (30/36) of 83%. All six of the patients with a negative COVID-19 test initially were positive on repeat testing (three on the second test, three on the third test).

There are concerns about what the sensitivity of the rRT-PCR tests being run in the United States are. At this point, I think that, when the pretest probability of COVID-19 infection is very high based on local epidemiology and clinical symptoms, a negative COVID rRT-PCR does not eliminate the diagnosis. In many cases, COVID-19 may still be the most likely diagnosis.

Early in the pandemic, the symptoms that were emphasized were fever, cough, and dyspnea. Those were all crucial symptoms for a disease that causes pneumonia. GI symptoms were initially deemphasized. In an early study released from Wuhan, China, only about 5% of COVID-19 patients had nausea or diarrhea.² In a study of 305 patients focused on gastrointestinal symptoms, half of the patients had diarrhea, half had anorexia and 30% had nausea.³ In a small series of nine patients who presented with only GI symptoms, four of these patients never developed fever or pulmonary symptoms.³

On March 14, the French health minister, Olivier Véran, tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone ...) could be an aggravating factor for the infection. If you have a fever, take paracetamol.” This was picked up by many news services, and soon became standard recommendations, despite no data.

There is reason for concern for NSAIDs, as regular NSAID use has been tied to more complications in patients with respiratory tract infections.⁴ I have never been a proponent of regular NSAID use in patients who are infected, because the likelihood of toxicity is elevated in patients who are volume depleted or under physiologic stress. But at this time, there is no evidence on problems with episodic NSAID use in patients with COVID-19.

Another widely disseminated decree was that patients with COVID-19 should not use ACE inhibitors and angiotensin II receptor blockers (ARBs). COVID-19 binds to their target cells through ACE2, which is expressed by epithelial cells of the lung, intestine and kidney. Patients who are treated with ACE inhibitors and ARBs have been shown to have more ACE2 expression.

In a letter to the editor by Fang et al. published in Lancet Respiratory Medicine, the authors raised the question of whether patients might be better served to be switched from ACE inhibitors and ARBs to calcium-channel blockers for the treatment of hypertension.⁵ A small study by Meng et al. looked at outcomes of patients on these drugs who had COVID-19 infection.⁶ They looked at 417 patients admitted to a hospital in China with COVID-19 infection. A total of 42 patients were on medications for hypertension. Group 1 were patients on ACE inhibitors/ARBs (17 patients) and group 2 were patients on other antihypertensives (25 patients). During hospitalization 12 patients (48%) in group 2 were categorized as having severe disease and 1 patient died. In group 1 (the ACE inhibitor/ARB–treated patients) only four (23%) were categorized as having severe disease, and no patients in this group died.

Vaduganathan et al. published a special report in the New England Journal of Medicine strongly arguing the point that “[u]ntil further data are available, we think that [renin-angiotensin-aldosterone system] inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19”.⁷ This position is supported by the American Heart Association, the American College of Cardiology, the American College of Physicians, and 11 other medical organizations.
 

Take-home messages

• Testing isn’t perfect – if you have strong suspicion for COVID-19 disease, retest.
• GI symptoms appear to be common, and rarely may be the only symptoms initially.
• NSAIDs are always risky in really sick patients, but data specific to COVID-19 is lacking.
• ACE inhibitors/ARBs should not be avoided in patients with COVID-19.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact Dr. Paauw at [email protected].

References

1. Long C et al. Diagnosis of the Coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.

2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.

3. Tian Y et al. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;00:1–9.

4. Voiriot G et al. Risks related to the use of nonsteroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients. J Clin Med. 2019;8:E786.

5. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 Mar 11. doi:10.1016/S2213-2600(20)30116-8.

6. Meng J et al. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect. 2020 Dec;9(1):757-60.

7. Vaduganathan M et al. Renin-angiotensin-aldosterone system inhibitors in patients with COVID-19. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMsr2005760.

This month, I would like to touch on a few COVID-19 topics that have received much publicity, with some messages about them having been confusing.

Let’s start with a case:

A 37-year-old woman is seen in clinic for a 5-day history of cough, fever, chest tightness, and onset of dyspnea on the day of her office visit.

An exam reveals her blood pressure is 100/60 mm Hg, her pulse is 100 beats per minute, her temperature is 38.7° C, her oxygen saturation is 93%, and her respiratory rate is 20 breaths per minute.

Auscultation of the chest revealed bilateral wheezing and rhonchi. A nasopharyngeal swab is sent for COVID-19 and is negative; she also tests negative for influenza.

Her hemoglobin level is 13 g/dL, hematocrit was 39%, platelet count was 155,000 per mcL of blood, and D-dimer level was 8.4 mcg/mL (normal is less than 0.4 mcg/mL.) Her white blood cell count was 6,000 per mcL of blood (neutrophils, 4,900; lymphocytes, 800; basophils, 200). Her chest x-ray showed bilateral lower lobe infiltrates.
 

What do you recommend?

A. Begin azithromycin plus ceftriaxone

B. Begin azithromycin

C. Begin oseltamivir

D. Obtain chest CT

E. Repeat COVID-19 test

With the massive amount of information coming out every day on COVID-19, it is hard to keep up with all of it, and sort out accurate, reviewed studies. We are in a position where we need to take in what we can and assess the best data available.

In the case above, I think choices D or E would make sense. This patient very likely has COVID-19 based on clinical symptoms and lab parameters. The negative COVID-19 test gives us pause, but several studies show that false negative tests are not uncommon.

Long et al. reported on 36 patients who had received both chest CT and real-time reverse transcription polymerase chain reaction (rRT-PCR) for COVID-19.¹ All were eventually diagnosed with COVID-19 pneumonia. The CT scan had a very high sensitivity (35/36) of 97.2%, whereas the rRT-PCR had a lower sensitivity (30/36) of 83%. All six of the patients with a negative COVID-19 test initially were positive on repeat testing (three on the second test, three on the third test).

There are concerns about what the sensitivity of the rRT-PCR tests being run in the United States are. At this point, I think that, when the pretest probability of COVID-19 infection is very high based on local epidemiology and clinical symptoms, a negative COVID rRT-PCR does not eliminate the diagnosis. In many cases, COVID-19 may still be the most likely diagnosis.

Early in the pandemic, the symptoms that were emphasized were fever, cough, and dyspnea. Those were all crucial symptoms for a disease that causes pneumonia. GI symptoms were initially deemphasized. In an early study released from Wuhan, China, only about 5% of COVID-19 patients had nausea or diarrhea.² In a study of 305 patients focused on gastrointestinal symptoms, half of the patients had diarrhea, half had anorexia and 30% had nausea.³ In a small series of nine patients who presented with only GI symptoms, four of these patients never developed fever or pulmonary symptoms.³

On March 14, the French health minister, Olivier Véran, tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone ...) could be an aggravating factor for the infection. If you have a fever, take paracetamol.” This was picked up by many news services, and soon became standard recommendations, despite no data.

There is reason for concern for NSAIDs, as regular NSAID use has been tied to more complications in patients with respiratory tract infections.⁴ I have never been a proponent of regular NSAID use in patients who are infected, because the likelihood of toxicity is elevated in patients who are volume depleted or under physiologic stress. But at this time, there is no evidence on problems with episodic NSAID use in patients with COVID-19.

Another widely disseminated decree was that patients with COVID-19 should not use ACE inhibitors and angiotensin II receptor blockers (ARBs). COVID-19 binds to their target cells through ACE2, which is expressed by epithelial cells of the lung, intestine and kidney. Patients who are treated with ACE inhibitors and ARBs have been shown to have more ACE2 expression.

In a letter to the editor by Fang et al. published in Lancet Respiratory Medicine, the authors raised the question of whether patients might be better served to be switched from ACE inhibitors and ARBs to calcium-channel blockers for the treatment of hypertension.⁵ A small study by Meng et al. looked at outcomes of patients on these drugs who had COVID-19 infection.⁶ They looked at 417 patients admitted to a hospital in China with COVID-19 infection. A total of 42 patients were on medications for hypertension. Group 1 were patients on ACE inhibitors/ARBs (17 patients) and group 2 were patients on other antihypertensives (25 patients). During hospitalization 12 patients (48%) in group 2 were categorized as having severe disease and 1 patient died. In group 1 (the ACE inhibitor/ARB–treated patients) only four (23%) were categorized as having severe disease, and no patients in this group died.

Vaduganathan et al. published a special report in the New England Journal of Medicine strongly arguing the point that “[u]ntil further data are available, we think that [renin-angiotensin-aldosterone system] inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19”.⁷ This position is supported by the American Heart Association, the American College of Cardiology, the American College of Physicians, and 11 other medical organizations.
 

Take-home messages

• Testing isn’t perfect – if you have strong suspicion for COVID-19 disease, retest.
• GI symptoms appear to be common, and rarely may be the only symptoms initially.
• NSAIDs are always risky in really sick patients, but data specific to COVID-19 is lacking.
• ACE inhibitors/ARBs should not be avoided in patients with COVID-19.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact Dr. Paauw at [email protected].

References

1. Long C et al. Diagnosis of the Coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.

2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.

3. Tian Y et al. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;00:1–9.

4. Voiriot G et al. Risks related to the use of nonsteroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients. J Clin Med. 2019;8:E786.

5. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 Mar 11. doi:10.1016/S2213-2600(20)30116-8.

6. Meng J et al. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect. 2020 Dec;9(1):757-60.

7. Vaduganathan M et al. Renin-angiotensin-aldosterone system inhibitors in patients with COVID-19. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMsr2005760.

This month, I would like to touch on a few COVID-19 topics that have received much publicity, with some messages about them having been confusing.

Let’s start with a case:

A 37-year-old woman is seen in clinic for a 5-day history of cough, fever, chest tightness, and onset of dyspnea on the day of her office visit.

An exam reveals her blood pressure is 100/60 mm Hg, her pulse is 100 beats per minute, her temperature is 38.7° C, her oxygen saturation is 93%, and her respiratory rate is 20 breaths per minute.

Auscultation of the chest revealed bilateral wheezing and rhonchi. A nasopharyngeal swab is sent for COVID-19 and is negative; she also tests negative for influenza.

Her hemoglobin level is 13 g/dL, hematocrit was 39%, platelet count was 155,000 per mcL of blood, and D-dimer level was 8.4 mcg/mL (normal is less than 0.4 mcg/mL.) Her white blood cell count was 6,000 per mcL of blood (neutrophils, 4,900; lymphocytes, 800; basophils, 200). Her chest x-ray showed bilateral lower lobe infiltrates.
 

What do you recommend?

A. Begin azithromycin plus ceftriaxone

B. Begin azithromycin

C. Begin oseltamivir

D. Obtain chest CT

E. Repeat COVID-19 test

With the massive amount of information coming out every day on COVID-19, it is hard to keep up with all of it, and sort out accurate, reviewed studies. We are in a position where we need to take in what we can and assess the best data available.

In the case above, I think choices D or E would make sense. This patient very likely has COVID-19 based on clinical symptoms and lab parameters. The negative COVID-19 test gives us pause, but several studies show that false negative tests are not uncommon.

Long et al. reported on 36 patients who had received both chest CT and real-time reverse transcription polymerase chain reaction (rRT-PCR) for COVID-19.¹ All were eventually diagnosed with COVID-19 pneumonia. The CT scan had a very high sensitivity (35/36) of 97.2%, whereas the rRT-PCR had a lower sensitivity (30/36) of 83%. All six of the patients with a negative COVID-19 test initially were positive on repeat testing (three on the second test, three on the third test).

There are concerns about what the sensitivity of the rRT-PCR tests being run in the United States are. At this point, I think that, when the pretest probability of COVID-19 infection is very high based on local epidemiology and clinical symptoms, a negative COVID rRT-PCR does not eliminate the diagnosis. In many cases, COVID-19 may still be the most likely diagnosis.

Early in the pandemic, the symptoms that were emphasized were fever, cough, and dyspnea. Those were all crucial symptoms for a disease that causes pneumonia. GI symptoms were initially deemphasized. In an early study released from Wuhan, China, only about 5% of COVID-19 patients had nausea or diarrhea.² In a study of 305 patients focused on gastrointestinal symptoms, half of the patients had diarrhea, half had anorexia and 30% had nausea.³ In a small series of nine patients who presented with only GI symptoms, four of these patients never developed fever or pulmonary symptoms.³

On March 14, the French health minister, Olivier Véran, tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone ...) could be an aggravating factor for the infection. If you have a fever, take paracetamol.” This was picked up by many news services, and soon became standard recommendations, despite no data.

There is reason for concern for NSAIDs, as regular NSAID use has been tied to more complications in patients with respiratory tract infections.⁴ I have never been a proponent of regular NSAID use in patients who are infected, because the likelihood of toxicity is elevated in patients who are volume depleted or under physiologic stress. But at this time, there is no evidence on problems with episodic NSAID use in patients with COVID-19.

Another widely disseminated decree was that patients with COVID-19 should not use ACE inhibitors and angiotensin II receptor blockers (ARBs). COVID-19 binds to their target cells through ACE2, which is expressed by epithelial cells of the lung, intestine and kidney. Patients who are treated with ACE inhibitors and ARBs have been shown to have more ACE2 expression.

In a letter to the editor by Fang et al. published in Lancet Respiratory Medicine, the authors raised the question of whether patients might be better served to be switched from ACE inhibitors and ARBs to calcium-channel blockers for the treatment of hypertension.⁵ A small study by Meng et al. looked at outcomes of patients on these drugs who had COVID-19 infection.⁶ They looked at 417 patients admitted to a hospital in China with COVID-19 infection. A total of 42 patients were on medications for hypertension. Group 1 were patients on ACE inhibitors/ARBs (17 patients) and group 2 were patients on other antihypertensives (25 patients). During hospitalization 12 patients (48%) in group 2 were categorized as having severe disease and 1 patient died. In group 1 (the ACE inhibitor/ARB–treated patients) only four (23%) were categorized as having severe disease, and no patients in this group died.

Vaduganathan et al. published a special report in the New England Journal of Medicine strongly arguing the point that “[u]ntil further data are available, we think that [renin-angiotensin-aldosterone system] inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19”.⁷ This position is supported by the American Heart Association, the American College of Cardiology, the American College of Physicians, and 11 other medical organizations.
 

Take-home messages

• Testing isn’t perfect – if you have strong suspicion for COVID-19 disease, retest.
• GI symptoms appear to be common, and rarely may be the only symptoms initially.
• NSAIDs are always risky in really sick patients, but data specific to COVID-19 is lacking.
• ACE inhibitors/ARBs should not be avoided in patients with COVID-19.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact Dr. Paauw at [email protected].

References

1. Long C et al. Diagnosis of the Coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.

2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.

3. Tian Y et al. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;00:1–9.

4. Voiriot G et al. Risks related to the use of nonsteroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients. J Clin Med. 2019;8:E786.

5. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 Mar 11. doi:10.1016/S2213-2600(20)30116-8.

6. Meng J et al. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect. 2020 Dec;9(1):757-60.

7. Vaduganathan M et al. Renin-angiotensin-aldosterone system inhibitors in patients with COVID-19. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMsr2005760.

Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.

In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.

“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.

“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
 

Anxiety, depression, child abuse

The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.

As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.

The authors suggest that three steps, taken now, can help prepare for the coming mental health problems and associated problems that will result from the pandemic.

The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.

To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.

Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.

“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.

Need for creative thinking

The authors noted the second “critical” step is to have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse.

“Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home,” they wrote.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they noted.

Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.

“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.”
 

Invaluable advice

Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”

Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”

Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article

Dr. Galea and Dr. Sederer have reported no relevant financial relationships.

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

Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.

In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.

“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.

“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
 

Anxiety, depression, child abuse

The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.

As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.

The authors suggest that three steps, taken now, can help prepare for the coming mental health problems and associated problems that will result from the pandemic.

The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.

To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.

Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.

“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.

Need for creative thinking

The authors noted the second “critical” step is to have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse.

“Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home,” they wrote.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they noted.

Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.

“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.”
 

Invaluable advice

Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”

Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”

Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article

Dr. Galea and Dr. Sederer have reported no relevant financial relationships.

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

Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.

In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.

“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.

“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
 

Anxiety, depression, child abuse

The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.

As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.

The authors suggest that three steps, taken now, can help prepare for the coming mental health problems and associated problems that will result from the pandemic.

The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.

To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.

Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.

“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.

Need for creative thinking

The authors noted the second “critical” step is to have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse.

“Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home,” they wrote.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they noted.

Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.

“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.”
 

Invaluable advice

Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”

Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”

Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article

Dr. Galea and Dr. Sederer have reported no relevant financial relationships.

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

Jails provide ideal conditions for the spread of COVID-19, as made clear by the distressing stories coming out of New York City. Beyond the very substantial risks posed by the virus itself, practitioners tasked with attending to the large proportion of inmates with mental illness now face additional challenges.

Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Elizabeth Ford, MD, former chief of psychiatry for NYC Health + Hospitals/Correctional Health Services and current chief medical officer for the Center for Alternative Sentencing and Employment Services (CASES), a community organization focused on the needs of people touched by the criminal justice system, to find out how COVID-19 may be reshaping the mental health care of incarcerated patients. As noted by Ford, who authored the 2017 memoir Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward, the unique vulnerabilities of this population were evident well before the coronavirus pandemic’s arrival on our shores.
 

What are the unique health and mental health challenges that can arise in correctional facilities during crises like this, in particular, infectious crises? Or are we still learning this as COVID-19 spreads?

I think it’s important to say that they are still learning it, and I don’t want to speak for them. I left Correctional Health Services on Feb. 14, and we weren’t aware of [all the risks posed by COVID-19] at that point.

I worked in the jail proper for five and a half years. Prior to that I spent a decade at Bellevue Hospital, where I took care of the same patients, who were still incarcerated but also hospitalized. In those years, the closest I ever came to managing something like this was Superstorm Sandy, which obviously had much different health implications.

All of the things that the community is struggling with in terms of the virus also apply in jails and prisons: identifying people who are sick, keeping healthy people from getting sick, preventing sick people from getting worse, separating populations, treatment options, testing options, making sure people follow the appropriate hygiene recommendations. It’s just amplified immensely because these are closed systems that tend to be poorly sanitized, crowded, and frequently forgotten or minimized in public health and political conversations.

A really important distinction is that individuals who are incarcerated do not have control over their behavior in the way that they would in the outside world. They may want to wash their hands frequently and to stay six feet away from everybody, but they can’t because the environment doesn’t allow for that. I know that everyone – correctional officers, health staff, incarcerated individuals, the city – is trying to figure out how to do those things in the jail. The primary challenge is that you don’t have the ability to do the things that you know are right to prevent the spread of the infection.
 

I know you can’t speak to what’s going on at specific jails at the moment, but what sort of psychiatric measures would a jail system put forth in a time like this?

It’s a good question, because like everybody, they’re having to balance the safety of the staff and the patients. Mental health interventions are mostly in person and very time intensive, and social distancing guidelines don’t allow for that now.

I expect that the jails are trying to stratify patients based on severity, both physical and psychological, although increasingly it’s likely harder to separate those who are sick from those who aren’t. In areas where patients are sick, I think the mental health staff are likely doing as much intervention as they can safely, including remote work like telehealth. Telehealth actually got its start in prisons, because they couldn’t get enough providers to come in and do the work in person.
 

I’ve read a lot of the criticism around this, specifically at Rikers Island, where inmates are still closely seated at dining tables, with no possibility of social distancing. [Editor’s note: At the time of this writing, Rikers Island experienced its first inmate death due to COVID-19.] But I see the other side of it. What are jails supposed to do when limited to such a confined space?

That’s correct. I think it is hard for someone who has not lived or worked intensely in these settings to understand how difficult it can be to implement even the most basic hygiene precautions. There are all sorts of efforts happening to create more space, to reduce admissions coming into the jail, to try to expedite discharges out, to offer a lot more sanitation options. I think they may have opened up a jail that was empty to allow for more space.
 

In a recent Medscape commentary, Jeffrey Lieberman, MD, from Columbia University detailed how a crisis like this may affect those in different tiers of mental illness. Interestingly, there are data showing that those with serious mental illness – schizophrenia, severe mania – often aren’t panicked by disasters. I assume that a sizable percentage of the jail population has severe mental illness, so I was curious about what your experience is, about how they may handle it psychologically.

The rate of serious mental illness in jail is roughly 16% or so, which is three or four times higher than the general population.

Although I don’t know if these kinds of crises differentially affect people with serious mental illness, I do believe very strongly that situations like this, for those who are and who are not incarcerated, can exacerbate or cause symptoms like anxiety, depression, and elevated levels of fear – fear about the unknown, fear of illness or death, fear of isolation.

For people who are incarcerated and who understandably may struggle with trusting the system that is supposed to be keeping them safe, I am concerned that this kind of situation will make that lack of trust worse. I worry that when they get out of jail they will be less inclined to seek help. I imagine that the staff in the jails are doing as much as they can to support the patients, but the staff are also likely experiencing some version of the abandonment and frustration that the patients may feel.

I’ve also seen – not in a crisis of this magnitude but in other crisis situations – that a community really develops among everybody in incarcerated settings. A shared crisis forces everybody to work together in ways that they may not have before. That includes more tolerance for behaviors, more understanding of differences, including mental illness and developmental delay. More compassion.
 

Do you mean between prisoners and staff? Among everybody?

Everybody. In all of the different relationships you can imagine.
 

That speaks to the vulnerability and good nature in all of us. It’s encouraging.

It is, although it’s devastating to me that it happens because they collectively feel so neglected and forgotten. Shared trauma can bind people together very closely.
 

What psychiatric conditions did you typically see in New York City jails?

For the many people with serious mental illness, it’s generally schizophrenia-spectrum illnesses and bipolar disorder – really severe illnesses that do not do well in confinement settings. There’s a lot of anxiety and depression, some that rises to the level of serious illness. There is near universal substance use among the population.

There is also almost universal trauma exposure, whether early-childhood experiences or the ongoing trauma of incarceration. Not everyone has PTSD, but almost everyone behaves in a traumatized way. As you know, in the United States, incarceration is very racially and socioeconomically biased; the trauma of poverty can be incredibly harsh.

What I didn’t see were lots of people with antisocial personality disorder or diagnoses of malingering. That may surprise people. There’s an idea that everybody in jail is a liar and lacks empathy. I didn’t experience that. People in jail are doing whatever they can to survive.
 

What treatments are offered to these patients?

In New York City, all of the typical treatments that you would imagine for people with serious mental illness are offered in the jails: individual and group psychotherapy, medication management, substance use treatment, social work services, even creative art therapy. Many other jails are not able to do even a fraction of that.

In many jails there also has to be a lot of supportive therapy. This involves trying to help people get through a very anxiety-provoking and difficult time, when they frequently don’t know when they are going to be able to leave. I felt the same way as many of the correction officers – that the best thing for these patients is to be out of the jail, to be out of that toxic environment.
 

We have heard for years that the jail system and prison system is the new psych ward. Can you speak to how this occurred and the influence of deinstitutionalization?

When deinstitutionalization happened, there were not enough community agencies available that were equipped to take care of patients who were previously in hospitals. But I think a larger contributor to the overpopulation of people with mental illness in jails and prisons was the war on drugs. It disproportionately affected people who were poor, of color, and who had mental illness. Mental illness and substance use frequently occur together.

At the same time as deinstitutionalization and the war on drugs, there was also a tightening up of the laws relating to admission to psychiatric hospitals. The civil rights movement helped define the requirements that someone had to be dangerous and mentally ill in order to get admitted against their will. While this was an important protection against more indiscriminate admissions of the past, it made it harder to get into hospitals; the state hospitals were closed but the hospitals that were open were now harder to get into.
 

You mentioned that prisoners are undergoing trauma every day. Is this inherent to punitive confinement, or is it something that can be improved upon in the United States?

It’s important that you said “in the United States” as part of that question. Our approach to incarceration in the U.S. is heavily punishment based.
 

Compared to somewhere like Scandinavia, where inmates and prisoners are given a lot more support?

Or England or Canada. The challenge with comparing the United States to Scandinavia is that we are socioeconomically, demographically, and politically so different. But yes, my understanding about the Scandinavian systems are that they have a much more rehabilitative approach to incarceration. Until the U.S. can reframe the goals of incarceration to focus on helping individuals behave in a socially acceptable way, rather than destroy their sense of self-worth, we will continue to see the impact of trauma on generations of lives.

Now, that doesn’t mean that every jail and prison in this country is abusive. But taking away autonomy and freedom, applying inconsistent rules, using solitary confinement, and getting limited to no access to people you love all really destroy a person’s ability to behave in a way that society has deemed acceptable.
 

Assuming that mental health professionals such as yourself have a more compassionate understanding of what’s going on psychologically with the inmates, are you often at odds with law enforcement in the philosophy behind incarceration?

That’s an interesting question. When I moved from the hospital to the jail, I thought that I would run into a lot of resistance from the correction officer staff. I just thought, we’re coming at this from a totally different perspective: I’m trying to help these people and see if there’s a way to safely get them out, and you guys want to punish them.

It turns out that I was very misguided in that view, because it seemed to me that everybody wanted to do what was right for the patient. My perspective about what’s right involved respectful care, building self-esteem, treating illness. The correction officer’s perspective seemed to be keeping them safe, making sure that they can get through the system as quickly as possible, not having them get into fights. Our perspectives may have been different, but the goals were the same. I want all that stuff that the officers want as well.

It’s important to remember that the people who work inside jails and prisons are usually not the ones who are making the policies about who goes in. I haven’t had a lot of exposure working directly with many policymakers. I imagine that my opinions might differ from theirs in some regards.
 

For those working in the U.S. psychiatric healthcare system, what do you want them to know about mental health care in the correctional setting?

Patients in correctional settings are mostly the same patients seen in the public mental health system setting. The vast majority of people who spend time in jail or prison return to the community. But there’s a difference in how patients are perceived by many mental health professionals, including psychiatrists, depending on whether they have criminal justice experience or not.

I would encourage everybody to try to keep an open mind and remember that these patients are cycling through a very difficult system, for many reasons that are at least rooted in community trauma and poverty, and that it doesn’t change the nature of who they are. It doesn’t change that they’re still human beings and they still deserve care and support and treatment.

In this country, patients with mental illness and incarceration histories are so vulnerable and are often black, brown, and poor. It’s an incredible and disturbing representation of American society. But I feel like you can help a lot by getting involved in the frequently dysfunctional criminal justice system. Psychiatrists and other providers have an opportunity to fix things from the inside out.
 

What’s your new role at CASES?

I’m the chief medical officer at CASES [Center for Alternative Sentencing and Employment Services]. It’s a large community organization that provides mental health treatment, case management, employment and education services, alternatives to incarceration, and general support for people who have experienced criminal justice involvement. CASES began operating in the 1960s, and around 2000 it began developing programs specifically addressing the connection between serious mental illness and criminal justice system involvement. For example, we take care of the patients who are coming out of the jails or prisons, or managing patients that the courts have said should go to treatment instead of incarceration.

I took the job because as conditions for individuals with serious mental illness started to improve in the jails, I started to hear more frequently from patients that they were getting better treatment in the jail than out in the community. That did not sit well with me and seemed to be almost the opposite of how it should be.

I also have never been an outpatient public psychiatrist. Most of the patients I treat live most of their lives outside of a jail or a hospital. It felt really important for me to understand the lives of these patients and to see if all of the resistance that I’ve heard from community psychiatrists about taking care of people who have been in jail is really true or not.

It was a logical transition for me. I’m following the patients and basically deinstitutionalizing [them] myself.

This article was first published on Medscape.com.

Jails provide ideal conditions for the spread of COVID-19, as made clear by the distressing stories coming out of New York City. Beyond the very substantial risks posed by the virus itself, practitioners tasked with attending to the large proportion of inmates with mental illness now face additional challenges.

Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Elizabeth Ford, MD, former chief of psychiatry for NYC Health + Hospitals/Correctional Health Services and current chief medical officer for the Center for Alternative Sentencing and Employment Services (CASES), a community organization focused on the needs of people touched by the criminal justice system, to find out how COVID-19 may be reshaping the mental health care of incarcerated patients. As noted by Ford, who authored the 2017 memoir Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward, the unique vulnerabilities of this population were evident well before the coronavirus pandemic’s arrival on our shores.
 

What are the unique health and mental health challenges that can arise in correctional facilities during crises like this, in particular, infectious crises? Or are we still learning this as COVID-19 spreads?

I think it’s important to say that they are still learning it, and I don’t want to speak for them. I left Correctional Health Services on Feb. 14, and we weren’t aware of [all the risks posed by COVID-19] at that point.

I worked in the jail proper for five and a half years. Prior to that I spent a decade at Bellevue Hospital, where I took care of the same patients, who were still incarcerated but also hospitalized. In those years, the closest I ever came to managing something like this was Superstorm Sandy, which obviously had much different health implications.

All of the things that the community is struggling with in terms of the virus also apply in jails and prisons: identifying people who are sick, keeping healthy people from getting sick, preventing sick people from getting worse, separating populations, treatment options, testing options, making sure people follow the appropriate hygiene recommendations. It’s just amplified immensely because these are closed systems that tend to be poorly sanitized, crowded, and frequently forgotten or minimized in public health and political conversations.

A really important distinction is that individuals who are incarcerated do not have control over their behavior in the way that they would in the outside world. They may want to wash their hands frequently and to stay six feet away from everybody, but they can’t because the environment doesn’t allow for that. I know that everyone – correctional officers, health staff, incarcerated individuals, the city – is trying to figure out how to do those things in the jail. The primary challenge is that you don’t have the ability to do the things that you know are right to prevent the spread of the infection.
 

I know you can’t speak to what’s going on at specific jails at the moment, but what sort of psychiatric measures would a jail system put forth in a time like this?

It’s a good question, because like everybody, they’re having to balance the safety of the staff and the patients. Mental health interventions are mostly in person and very time intensive, and social distancing guidelines don’t allow for that now.

I expect that the jails are trying to stratify patients based on severity, both physical and psychological, although increasingly it’s likely harder to separate those who are sick from those who aren’t. In areas where patients are sick, I think the mental health staff are likely doing as much intervention as they can safely, including remote work like telehealth. Telehealth actually got its start in prisons, because they couldn’t get enough providers to come in and do the work in person.
 

I’ve read a lot of the criticism around this, specifically at Rikers Island, where inmates are still closely seated at dining tables, with no possibility of social distancing. [Editor’s note: At the time of this writing, Rikers Island experienced its first inmate death due to COVID-19.] But I see the other side of it. What are jails supposed to do when limited to such a confined space?

That’s correct. I think it is hard for someone who has not lived or worked intensely in these settings to understand how difficult it can be to implement even the most basic hygiene precautions. There are all sorts of efforts happening to create more space, to reduce admissions coming into the jail, to try to expedite discharges out, to offer a lot more sanitation options. I think they may have opened up a jail that was empty to allow for more space.
 

In a recent Medscape commentary, Jeffrey Lieberman, MD, from Columbia University detailed how a crisis like this may affect those in different tiers of mental illness. Interestingly, there are data showing that those with serious mental illness – schizophrenia, severe mania – often aren’t panicked by disasters. I assume that a sizable percentage of the jail population has severe mental illness, so I was curious about what your experience is, about how they may handle it psychologically.

The rate of serious mental illness in jail is roughly 16% or so, which is three or four times higher than the general population.

Although I don’t know if these kinds of crises differentially affect people with serious mental illness, I do believe very strongly that situations like this, for those who are and who are not incarcerated, can exacerbate or cause symptoms like anxiety, depression, and elevated levels of fear – fear about the unknown, fear of illness or death, fear of isolation.

For people who are incarcerated and who understandably may struggle with trusting the system that is supposed to be keeping them safe, I am concerned that this kind of situation will make that lack of trust worse. I worry that when they get out of jail they will be less inclined to seek help. I imagine that the staff in the jails are doing as much as they can to support the patients, but the staff are also likely experiencing some version of the abandonment and frustration that the patients may feel.

I’ve also seen – not in a crisis of this magnitude but in other crisis situations – that a community really develops among everybody in incarcerated settings. A shared crisis forces everybody to work together in ways that they may not have before. That includes more tolerance for behaviors, more understanding of differences, including mental illness and developmental delay. More compassion.
 

Do you mean between prisoners and staff? Among everybody?

Everybody. In all of the different relationships you can imagine.
 

That speaks to the vulnerability and good nature in all of us. It’s encouraging.

It is, although it’s devastating to me that it happens because they collectively feel so neglected and forgotten. Shared trauma can bind people together very closely.
 

What psychiatric conditions did you typically see in New York City jails?

For the many people with serious mental illness, it’s generally schizophrenia-spectrum illnesses and bipolar disorder – really severe illnesses that do not do well in confinement settings. There’s a lot of anxiety and depression, some that rises to the level of serious illness. There is near universal substance use among the population.

There is also almost universal trauma exposure, whether early-childhood experiences or the ongoing trauma of incarceration. Not everyone has PTSD, but almost everyone behaves in a traumatized way. As you know, in the United States, incarceration is very racially and socioeconomically biased; the trauma of poverty can be incredibly harsh.

What I didn’t see were lots of people with antisocial personality disorder or diagnoses of malingering. That may surprise people. There’s an idea that everybody in jail is a liar and lacks empathy. I didn’t experience that. People in jail are doing whatever they can to survive.
 

What treatments are offered to these patients?

In New York City, all of the typical treatments that you would imagine for people with serious mental illness are offered in the jails: individual and group psychotherapy, medication management, substance use treatment, social work services, even creative art therapy. Many other jails are not able to do even a fraction of that.

In many jails there also has to be a lot of supportive therapy. This involves trying to help people get through a very anxiety-provoking and difficult time, when they frequently don’t know when they are going to be able to leave. I felt the same way as many of the correction officers – that the best thing for these patients is to be out of the jail, to be out of that toxic environment.
 

We have heard for years that the jail system and prison system is the new psych ward. Can you speak to how this occurred and the influence of deinstitutionalization?

When deinstitutionalization happened, there were not enough community agencies available that were equipped to take care of patients who were previously in hospitals. But I think a larger contributor to the overpopulation of people with mental illness in jails and prisons was the war on drugs. It disproportionately affected people who were poor, of color, and who had mental illness. Mental illness and substance use frequently occur together.

At the same time as deinstitutionalization and the war on drugs, there was also a tightening up of the laws relating to admission to psychiatric hospitals. The civil rights movement helped define the requirements that someone had to be dangerous and mentally ill in order to get admitted against their will. While this was an important protection against more indiscriminate admissions of the past, it made it harder to get into hospitals; the state hospitals were closed but the hospitals that were open were now harder to get into.
 

You mentioned that prisoners are undergoing trauma every day. Is this inherent to punitive confinement, or is it something that can be improved upon in the United States?

It’s important that you said “in the United States” as part of that question. Our approach to incarceration in the U.S. is heavily punishment based.
 

Compared to somewhere like Scandinavia, where inmates and prisoners are given a lot more support?

Or England or Canada. The challenge with comparing the United States to Scandinavia is that we are socioeconomically, demographically, and politically so different. But yes, my understanding about the Scandinavian systems are that they have a much more rehabilitative approach to incarceration. Until the U.S. can reframe the goals of incarceration to focus on helping individuals behave in a socially acceptable way, rather than destroy their sense of self-worth, we will continue to see the impact of trauma on generations of lives.

Now, that doesn’t mean that every jail and prison in this country is abusive. But taking away autonomy and freedom, applying inconsistent rules, using solitary confinement, and getting limited to no access to people you love all really destroy a person’s ability to behave in a way that society has deemed acceptable.
 

Assuming that mental health professionals such as yourself have a more compassionate understanding of what’s going on psychologically with the inmates, are you often at odds with law enforcement in the philosophy behind incarceration?

That’s an interesting question. When I moved from the hospital to the jail, I thought that I would run into a lot of resistance from the correction officer staff. I just thought, we’re coming at this from a totally different perspective: I’m trying to help these people and see if there’s a way to safely get them out, and you guys want to punish them.

It turns out that I was very misguided in that view, because it seemed to me that everybody wanted to do what was right for the patient. My perspective about what’s right involved respectful care, building self-esteem, treating illness. The correction officer’s perspective seemed to be keeping them safe, making sure that they can get through the system as quickly as possible, not having them get into fights. Our perspectives may have been different, but the goals were the same. I want all that stuff that the officers want as well.

It’s important to remember that the people who work inside jails and prisons are usually not the ones who are making the policies about who goes in. I haven’t had a lot of exposure working directly with many policymakers. I imagine that my opinions might differ from theirs in some regards.
 

For those working in the U.S. psychiatric healthcare system, what do you want them to know about mental health care in the correctional setting?

Patients in correctional settings are mostly the same patients seen in the public mental health system setting. The vast majority of people who spend time in jail or prison return to the community. But there’s a difference in how patients are perceived by many mental health professionals, including psychiatrists, depending on whether they have criminal justice experience or not.

I would encourage everybody to try to keep an open mind and remember that these patients are cycling through a very difficult system, for many reasons that are at least rooted in community trauma and poverty, and that it doesn’t change the nature of who they are. It doesn’t change that they’re still human beings and they still deserve care and support and treatment.

In this country, patients with mental illness and incarceration histories are so vulnerable and are often black, brown, and poor. It’s an incredible and disturbing representation of American society. But I feel like you can help a lot by getting involved in the frequently dysfunctional criminal justice system. Psychiatrists and other providers have an opportunity to fix things from the inside out.
 

What’s your new role at CASES?

I’m the chief medical officer at CASES [Center for Alternative Sentencing and Employment Services]. It’s a large community organization that provides mental health treatment, case management, employment and education services, alternatives to incarceration, and general support for people who have experienced criminal justice involvement. CASES began operating in the 1960s, and around 2000 it began developing programs specifically addressing the connection between serious mental illness and criminal justice system involvement. For example, we take care of the patients who are coming out of the jails or prisons, or managing patients that the courts have said should go to treatment instead of incarceration.

I took the job because as conditions for individuals with serious mental illness started to improve in the jails, I started to hear more frequently from patients that they were getting better treatment in the jail than out in the community. That did not sit well with me and seemed to be almost the opposite of how it should be.

I also have never been an outpatient public psychiatrist. Most of the patients I treat live most of their lives outside of a jail or a hospital. It felt really important for me to understand the lives of these patients and to see if all of the resistance that I’ve heard from community psychiatrists about taking care of people who have been in jail is really true or not.

It was a logical transition for me. I’m following the patients and basically deinstitutionalizing [them] myself.

This article was first published on Medscape.com.

Jails provide ideal conditions for the spread of COVID-19, as made clear by the distressing stories coming out of New York City. Beyond the very substantial risks posed by the virus itself, practitioners tasked with attending to the large proportion of inmates with mental illness now face additional challenges.

Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Elizabeth Ford, MD, former chief of psychiatry for NYC Health + Hospitals/Correctional Health Services and current chief medical officer for the Center for Alternative Sentencing and Employment Services (CASES), a community organization focused on the needs of people touched by the criminal justice system, to find out how COVID-19 may be reshaping the mental health care of incarcerated patients. As noted by Ford, who authored the 2017 memoir Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward, the unique vulnerabilities of this population were evident well before the coronavirus pandemic’s arrival on our shores.
 

What are the unique health and mental health challenges that can arise in correctional facilities during crises like this, in particular, infectious crises? Or are we still learning this as COVID-19 spreads?

I think it’s important to say that they are still learning it, and I don’t want to speak for them. I left Correctional Health Services on Feb. 14, and we weren’t aware of [all the risks posed by COVID-19] at that point.

I worked in the jail proper for five and a half years. Prior to that I spent a decade at Bellevue Hospital, where I took care of the same patients, who were still incarcerated but also hospitalized. In those years, the closest I ever came to managing something like this was Superstorm Sandy, which obviously had much different health implications.

All of the things that the community is struggling with in terms of the virus also apply in jails and prisons: identifying people who are sick, keeping healthy people from getting sick, preventing sick people from getting worse, separating populations, treatment options, testing options, making sure people follow the appropriate hygiene recommendations. It’s just amplified immensely because these are closed systems that tend to be poorly sanitized, crowded, and frequently forgotten or minimized in public health and political conversations.

A really important distinction is that individuals who are incarcerated do not have control over their behavior in the way that they would in the outside world. They may want to wash their hands frequently and to stay six feet away from everybody, but they can’t because the environment doesn’t allow for that. I know that everyone – correctional officers, health staff, incarcerated individuals, the city – is trying to figure out how to do those things in the jail. The primary challenge is that you don’t have the ability to do the things that you know are right to prevent the spread of the infection.
 

I know you can’t speak to what’s going on at specific jails at the moment, but what sort of psychiatric measures would a jail system put forth in a time like this?

It’s a good question, because like everybody, they’re having to balance the safety of the staff and the patients. Mental health interventions are mostly in person and very time intensive, and social distancing guidelines don’t allow for that now.

I expect that the jails are trying to stratify patients based on severity, both physical and psychological, although increasingly it’s likely harder to separate those who are sick from those who aren’t. In areas where patients are sick, I think the mental health staff are likely doing as much intervention as they can safely, including remote work like telehealth. Telehealth actually got its start in prisons, because they couldn’t get enough providers to come in and do the work in person.
 

I’ve read a lot of the criticism around this, specifically at Rikers Island, where inmates are still closely seated at dining tables, with no possibility of social distancing. [Editor’s note: At the time of this writing, Rikers Island experienced its first inmate death due to COVID-19.] But I see the other side of it. What are jails supposed to do when limited to such a confined space?

That’s correct. I think it is hard for someone who has not lived or worked intensely in these settings to understand how difficult it can be to implement even the most basic hygiene precautions. There are all sorts of efforts happening to create more space, to reduce admissions coming into the jail, to try to expedite discharges out, to offer a lot more sanitation options. I think they may have opened up a jail that was empty to allow for more space.
 

In a recent Medscape commentary, Jeffrey Lieberman, MD, from Columbia University detailed how a crisis like this may affect those in different tiers of mental illness. Interestingly, there are data showing that those with serious mental illness – schizophrenia, severe mania – often aren’t panicked by disasters. I assume that a sizable percentage of the jail population has severe mental illness, so I was curious about what your experience is, about how they may handle it psychologically.

The rate of serious mental illness in jail is roughly 16% or so, which is three or four times higher than the general population.

Although I don’t know if these kinds of crises differentially affect people with serious mental illness, I do believe very strongly that situations like this, for those who are and who are not incarcerated, can exacerbate or cause symptoms like anxiety, depression, and elevated levels of fear – fear about the unknown, fear of illness or death, fear of isolation.

For people who are incarcerated and who understandably may struggle with trusting the system that is supposed to be keeping them safe, I am concerned that this kind of situation will make that lack of trust worse. I worry that when they get out of jail they will be less inclined to seek help. I imagine that the staff in the jails are doing as much as they can to support the patients, but the staff are also likely experiencing some version of the abandonment and frustration that the patients may feel.

I’ve also seen – not in a crisis of this magnitude but in other crisis situations – that a community really develops among everybody in incarcerated settings. A shared crisis forces everybody to work together in ways that they may not have before. That includes more tolerance for behaviors, more understanding of differences, including mental illness and developmental delay. More compassion.
 

Do you mean between prisoners and staff? Among everybody?

Everybody. In all of the different relationships you can imagine.
 

That speaks to the vulnerability and good nature in all of us. It’s encouraging.

It is, although it’s devastating to me that it happens because they collectively feel so neglected and forgotten. Shared trauma can bind people together very closely.
 

What psychiatric conditions did you typically see in New York City jails?

For the many people with serious mental illness, it’s generally schizophrenia-spectrum illnesses and bipolar disorder – really severe illnesses that do not do well in confinement settings. There’s a lot of anxiety and depression, some that rises to the level of serious illness. There is near universal substance use among the population.

There is also almost universal trauma exposure, whether early-childhood experiences or the ongoing trauma of incarceration. Not everyone has PTSD, but almost everyone behaves in a traumatized way. As you know, in the United States, incarceration is very racially and socioeconomically biased; the trauma of poverty can be incredibly harsh.

What I didn’t see were lots of people with antisocial personality disorder or diagnoses of malingering. That may surprise people. There’s an idea that everybody in jail is a liar and lacks empathy. I didn’t experience that. People in jail are doing whatever they can to survive.
 

What treatments are offered to these patients?

In New York City, all of the typical treatments that you would imagine for people with serious mental illness are offered in the jails: individual and group psychotherapy, medication management, substance use treatment, social work services, even creative art therapy. Many other jails are not able to do even a fraction of that.

In many jails there also has to be a lot of supportive therapy. This involves trying to help people get through a very anxiety-provoking and difficult time, when they frequently don’t know when they are going to be able to leave. I felt the same way as many of the correction officers – that the best thing for these patients is to be out of the jail, to be out of that toxic environment.
 

We have heard for years that the jail system and prison system is the new psych ward. Can you speak to how this occurred and the influence of deinstitutionalization?

When deinstitutionalization happened, there were not enough community agencies available that were equipped to take care of patients who were previously in hospitals. But I think a larger contributor to the overpopulation of people with mental illness in jails and prisons was the war on drugs. It disproportionately affected people who were poor, of color, and who had mental illness. Mental illness and substance use frequently occur together.

At the same time as deinstitutionalization and the war on drugs, there was also a tightening up of the laws relating to admission to psychiatric hospitals. The civil rights movement helped define the requirements that someone had to be dangerous and mentally ill in order to get admitted against their will. While this was an important protection against more indiscriminate admissions of the past, it made it harder to get into hospitals; the state hospitals were closed but the hospitals that were open were now harder to get into.
 

You mentioned that prisoners are undergoing trauma every day. Is this inherent to punitive confinement, or is it something that can be improved upon in the United States?

It’s important that you said “in the United States” as part of that question. Our approach to incarceration in the U.S. is heavily punishment based.
 

Compared to somewhere like Scandinavia, where inmates and prisoners are given a lot more support?

Or England or Canada. The challenge with comparing the United States to Scandinavia is that we are socioeconomically, demographically, and politically so different. But yes, my understanding about the Scandinavian systems are that they have a much more rehabilitative approach to incarceration. Until the U.S. can reframe the goals of incarceration to focus on helping individuals behave in a socially acceptable way, rather than destroy their sense of self-worth, we will continue to see the impact of trauma on generations of lives.

Now, that doesn’t mean that every jail and prison in this country is abusive. But taking away autonomy and freedom, applying inconsistent rules, using solitary confinement, and getting limited to no access to people you love all really destroy a person’s ability to behave in a way that society has deemed acceptable.
 

Assuming that mental health professionals such as yourself have a more compassionate understanding of what’s going on psychologically with the inmates, are you often at odds with law enforcement in the philosophy behind incarceration?

That’s an interesting question. When I moved from the hospital to the jail, I thought that I would run into a lot of resistance from the correction officer staff. I just thought, we’re coming at this from a totally different perspective: I’m trying to help these people and see if there’s a way to safely get them out, and you guys want to punish them.

It turns out that I was very misguided in that view, because it seemed to me that everybody wanted to do what was right for the patient. My perspective about what’s right involved respectful care, building self-esteem, treating illness. The correction officer’s perspective seemed to be keeping them safe, making sure that they can get through the system as quickly as possible, not having them get into fights. Our perspectives may have been different, but the goals were the same. I want all that stuff that the officers want as well.

It’s important to remember that the people who work inside jails and prisons are usually not the ones who are making the policies about who goes in. I haven’t had a lot of exposure working directly with many policymakers. I imagine that my opinions might differ from theirs in some regards.
 

For those working in the U.S. psychiatric healthcare system, what do you want them to know about mental health care in the correctional setting?

Patients in correctional settings are mostly the same patients seen in the public mental health system setting. The vast majority of people who spend time in jail or prison return to the community. But there’s a difference in how patients are perceived by many mental health professionals, including psychiatrists, depending on whether they have criminal justice experience or not.

I would encourage everybody to try to keep an open mind and remember that these patients are cycling through a very difficult system, for many reasons that are at least rooted in community trauma and poverty, and that it doesn’t change the nature of who they are. It doesn’t change that they’re still human beings and they still deserve care and support and treatment.

In this country, patients with mental illness and incarceration histories are so vulnerable and are often black, brown, and poor. It’s an incredible and disturbing representation of American society. But I feel like you can help a lot by getting involved in the frequently dysfunctional criminal justice system. Psychiatrists and other providers have an opportunity to fix things from the inside out.
 

What’s your new role at CASES?

I’m the chief medical officer at CASES [Center for Alternative Sentencing and Employment Services]. It’s a large community organization that provides mental health treatment, case management, employment and education services, alternatives to incarceration, and general support for people who have experienced criminal justice involvement. CASES began operating in the 1960s, and around 2000 it began developing programs specifically addressing the connection between serious mental illness and criminal justice system involvement. For example, we take care of the patients who are coming out of the jails or prisons, or managing patients that the courts have said should go to treatment instead of incarceration.

I took the job because as conditions for individuals with serious mental illness started to improve in the jails, I started to hear more frequently from patients that they were getting better treatment in the jail than out in the community. That did not sit well with me and seemed to be almost the opposite of how it should be.

I also have never been an outpatient public psychiatrist. Most of the patients I treat live most of their lives outside of a jail or a hospital. It felt really important for me to understand the lives of these patients and to see if all of the resistance that I’ve heard from community psychiatrists about taking care of people who have been in jail is really true or not.

It was a logical transition for me. I’m following the patients and basically deinstitutionalizing [them] myself.

This article was first published on Medscape.com.

Tuberculosis symptoms as defined by the World Health Organization were effective in identifying patients with TB for the purposes of same-day antiretroviral therapy (ART) initiation in patients diagnosed with HIV, according to a pooled study of patients in two clinical trials. Guidelines suggest that patients with one or more TB symptoms be investigated for active TB before initiation of ART.

xrender/Thinkstock

However, more than 80% of patients with TB symptoms did not have the disease and faced a delay of ART initiation, despite the many benefits of same-day ART initiation, according to the study presented online at the Conference on Retroviruses & Opportunistic Infections. This year CROI organizers chose to hold a virtual meeting because of concerns about the spread of COVID-19.

In her presentation, Alana T. Brennan, PhD, of the Boston University School of Public Health discussed the pooled results of 834 patients in the SLATE (Simple Algorithm for Treatment Eligibility) I and SLATE II trials. These two trials, conducted in South Africa and Kenya, respectively, assessed two variations of a simplified algorithm for eligibility for same-day ART initiation.

A total of 834 patients at baseline reported any self-described symptoms of TB using the WHO four-symptom TB screen (cough, fever, weight loss, night sweats). Those patients with any TB symptoms were assessed by sputum samples. The outcomes were prevalence of TB symptoms, TB diagnosis, and treatment.

Among the 834 patients, 493 (60%) reported no symptoms; 215 (26%) reported one to two symptoms, and 120 (14%) reported three to four symptoms. Only 66% of the patients with one to two symptoms were tested for TB; 78% of the patients with three to four symptoms were tested. Of these, only 1% of the patients with one to two symptoms tested positive for TB, and only 2% of the patients with three to four symptoms tested positive, according to Dr. Brennan.

“More than 80% of patients with TB symptoms did not have TB, but faced delay in ART initiation. No same-day [ART] initiators reported adverse events, so we hope that there would be some reconsideration of the requirement of TB testing prior to ART initiation due to any symptom of TB. … A potential consideration of the severity of the symptoms a patient has is necessary,” Dr. Brennan concluded.

Dr. Brennan reported that there were no disclosures.

[email protected]

SOURCE: Brennan AT et al. CROI 2020, Abstract 720.

Tuberculosis symptoms as defined by the World Health Organization were effective in identifying patients with TB for the purposes of same-day antiretroviral therapy (ART) initiation in patients diagnosed with HIV, according to a pooled study of patients in two clinical trials. Guidelines suggest that patients with one or more TB symptoms be investigated for active TB before initiation of ART.

xrender/Thinkstock

However, more than 80% of patients with TB symptoms did not have the disease and faced a delay of ART initiation, despite the many benefits of same-day ART initiation, according to the study presented online at the Conference on Retroviruses & Opportunistic Infections. This year CROI organizers chose to hold a virtual meeting because of concerns about the spread of COVID-19.

In her presentation, Alana T. Brennan, PhD, of the Boston University School of Public Health discussed the pooled results of 834 patients in the SLATE (Simple Algorithm for Treatment Eligibility) I and SLATE II trials. These two trials, conducted in South Africa and Kenya, respectively, assessed two variations of a simplified algorithm for eligibility for same-day ART initiation.

A total of 834 patients at baseline reported any self-described symptoms of TB using the WHO four-symptom TB screen (cough, fever, weight loss, night sweats). Those patients with any TB symptoms were assessed by sputum samples. The outcomes were prevalence of TB symptoms, TB diagnosis, and treatment.

Among the 834 patients, 493 (60%) reported no symptoms; 215 (26%) reported one to two symptoms, and 120 (14%) reported three to four symptoms. Only 66% of the patients with one to two symptoms were tested for TB; 78% of the patients with three to four symptoms were tested. Of these, only 1% of the patients with one to two symptoms tested positive for TB, and only 2% of the patients with three to four symptoms tested positive, according to Dr. Brennan.

“More than 80% of patients with TB symptoms did not have TB, but faced delay in ART initiation. No same-day [ART] initiators reported adverse events, so we hope that there would be some reconsideration of the requirement of TB testing prior to ART initiation due to any symptom of TB. … A potential consideration of the severity of the symptoms a patient has is necessary,” Dr. Brennan concluded.

Dr. Brennan reported that there were no disclosures.

[email protected]

SOURCE: Brennan AT et al. CROI 2020, Abstract 720.

Tuberculosis symptoms as defined by the World Health Organization were effective in identifying patients with TB for the purposes of same-day antiretroviral therapy (ART) initiation in patients diagnosed with HIV, according to a pooled study of patients in two clinical trials. Guidelines suggest that patients with one or more TB symptoms be investigated for active TB before initiation of ART.

xrender/Thinkstock

However, more than 80% of patients with TB symptoms did not have the disease and faced a delay of ART initiation, despite the many benefits of same-day ART initiation, according to the study presented online at the Conference on Retroviruses & Opportunistic Infections. This year CROI organizers chose to hold a virtual meeting because of concerns about the spread of COVID-19.

In her presentation, Alana T. Brennan, PhD, of the Boston University School of Public Health discussed the pooled results of 834 patients in the SLATE (Simple Algorithm for Treatment Eligibility) I and SLATE II trials. These two trials, conducted in South Africa and Kenya, respectively, assessed two variations of a simplified algorithm for eligibility for same-day ART initiation.

A total of 834 patients at baseline reported any self-described symptoms of TB using the WHO four-symptom TB screen (cough, fever, weight loss, night sweats). Those patients with any TB symptoms were assessed by sputum samples. The outcomes were prevalence of TB symptoms, TB diagnosis, and treatment.

Among the 834 patients, 493 (60%) reported no symptoms; 215 (26%) reported one to two symptoms, and 120 (14%) reported three to four symptoms. Only 66% of the patients with one to two symptoms were tested for TB; 78% of the patients with three to four symptoms were tested. Of these, only 1% of the patients with one to two symptoms tested positive for TB, and only 2% of the patients with three to four symptoms tested positive, according to Dr. Brennan.

“More than 80% of patients with TB symptoms did not have TB, but faced delay in ART initiation. No same-day [ART] initiators reported adverse events, so we hope that there would be some reconsideration of the requirement of TB testing prior to ART initiation due to any symptom of TB. … A potential consideration of the severity of the symptoms a patient has is necessary,” Dr. Brennan concluded.

Dr. Brennan reported that there were no disclosures.

[email protected]

SOURCE: Brennan AT et al. CROI 2020, Abstract 720.

Women with HIV had more bone mobilization during lactation, and attenuated skeletal recovery after lactation, compared with HIV-negative women, according to research presented during the Conference on Retroviruses & Opportunistic Infections, which was presented online this year. CROI organizers chose to hold a virtual meeting because of concerns about the spread of COVID-19.

The study “demonstrated that there were reductions as expected in BMD during breastfeeding, and there was recovery at the end of breastfeeding, which was higher among women who were not HIV-infected compared to HIV-infected women,” said Mary Glenn Fowler, MD, speaking in a video presentation during the virtual conference. The differences between women who had HIV and the HIV-negative reference group were statistically significant (P = .003 for lumbar spine and P less than .001 for whole-body aBMD).

“We also saw that for whole-body BMD, there was recovery at the end of breastfeeding for women who were not HIV infected, but a dampened response of recovery for BMD for HIV-infected women,” she went on, adding: “These findings held after adjustment for parity, age, body mass, breastfeeding practices, duration of breastfeeding, use of [injectable medroxyprogesterone acetate], and resumption of menses.”

Dr. Fowler presented the study’s results on behalf of lead author Florence Nabwire, PhD, an investigator scientist in the nutrition and bone health group of the United Kingdom’s Medical Research Council (Cambridge).

Although it’s known that antiretroviral therapy (ART) is associated with bone loss, Dr. Fowler explained that there are only limited data in HIV-positive women who are lactating. It’s important to see what happens during lactation for this group of women because of the potential sequelae later in life of insufficient recovery from the physiological bone mobilization that occurs during lactation. The study looked at changes in areal bone mineral density (aBMD) both during and after lactation for women with HIV living in Uganda who were taking Option B+ ART, a regimen that includes tenofovir, 3TC, and efavirenz. These women were compared with a reference group of HIV-negative women.

In all, 95 women with HIV and 96 HIV negative women were recruited into the study during pregnancy. Participants were followed postpartum at weeks 2, 14, and 26, and at a final visit that occurred 14 weeks after lactation stopped.

In addition to lumbar spine, total hip, and femoral neck aBMD measurements, the investigators also obtained whole body-less-head reading.

For total hip and femoral neck aBMD, the nadir of density was seen at 26 postpartum, when a drop of about 6% was seen from baseline readings. By the final post-lactation visit, women without HIV had recovered to their baseline; for women with HIV, some recovery also occurred, but the effect was dampened, with a persistent bone density deficit of about 3% from baseline. The differences between HIV-positive and HIV-negative women in these measurements were also statistically significant, at P less than .001 for total hip aBMD differences and P = .0008 for femoral neck differences. Again, correction for multiple confounders didn’t attenuate the results, said Dr. Fowler.

“In conclusion, these data showed accentuated mobilization of hip and whole body aBMD during lactation,” said Dr. Fowler, who also noted “slower skeletal recovery post lactation for HIV-infected women.” Clinical implications of these findings aren’t currently known, she said. Further ongoing studies are aiming to tease out both mechanisms and longer-term consequences for the bone health of HIV-infected women and their children, who may also see differences in bone mineral accretion and growth.

Session moderator Risa Hoffman, MD, in introductory remarks, set the findings in some context. “As we know, HIV-positive adults have low bone mineral density, and this appears to be a result of interactions of HIV, traditional risk factors for loss of bone density, and antiretroviral therapy,” said Dr. Hoffman, director of the global health program at the University of California, Los Angeles. She added that previous work had shown that “middle-aged HIV-positive women have higher 10-year fracture incidence compared to their HIV-negative counterparts.” The current study, she said, “has both short- and long-term implications for women as they go through multiple pregnancies and multiple periods of breastfeeding.”

The study was funded by the United Kingdom’s Medical Research Council and Department for International Development as well as the Alborada Trust and the Gates Cambridge Scholarship. The authors reported no conflicts of interest.

[email protected]

SOURCE: Nabwire F et al. CROI 2020, Abstract 768.

Women with HIV had more bone mobilization during lactation, and attenuated skeletal recovery after lactation, compared with HIV-negative women, according to research presented during the Conference on Retroviruses & Opportunistic Infections, which was presented online this year. CROI organizers chose to hold a virtual meeting because of concerns about the spread of COVID-19.

The study “demonstrated that there were reductions as expected in BMD during breastfeeding, and there was recovery at the end of breastfeeding, which was higher among women who were not HIV-infected compared to HIV-infected women,” said Mary Glenn Fowler, MD, speaking in a video presentation during the virtual conference. The differences between women who had HIV and the HIV-negative reference group were statistically significant (P = .003 for lumbar spine and P less than .001 for whole-body aBMD).

“We also saw that for whole-body BMD, there was recovery at the end of breastfeeding for women who were not HIV infected, but a dampened response of recovery for BMD for HIV-infected women,” she went on, adding: “These findings held after adjustment for parity, age, body mass, breastfeeding practices, duration of breastfeeding, use of [injectable medroxyprogesterone acetate], and resumption of menses.”

Dr. Fowler presented the study’s results on behalf of lead author Florence Nabwire, PhD, an investigator scientist in the nutrition and bone health group of the United Kingdom’s Medical Research Council (Cambridge).

Although it’s known that antiretroviral therapy (ART) is associated with bone loss, Dr. Fowler explained that there are only limited data in HIV-positive women who are lactating. It’s important to see what happens during lactation for this group of women because of the potential sequelae later in life of insufficient recovery from the physiological bone mobilization that occurs during lactation. The study looked at changes in areal bone mineral density (aBMD) both during and after lactation for women with HIV living in Uganda who were taking Option B+ ART, a regimen that includes tenofovir, 3TC, and efavirenz. These women were compared with a reference group of HIV-negative women.

In all, 95 women with HIV and 96 HIV negative women were recruited into the study during pregnancy. Participants were followed postpartum at weeks 2, 14, and 26, and at a final visit that occurred 14 weeks after lactation stopped.

In addition to lumbar spine, total hip, and femoral neck aBMD measurements, the investigators also obtained whole body-less-head reading.

For total hip and femoral neck aBMD, the nadir of density was seen at 26 postpartum, when a drop of about 6% was seen from baseline readings. By the final post-lactation visit, women without HIV had recovered to their baseline; for women with HIV, some recovery also occurred, but the effect was dampened, with a persistent bone density deficit of about 3% from baseline. The differences between HIV-positive and HIV-negative women in these measurements were also statistically significant, at P less than .001 for total hip aBMD differences and P = .0008 for femoral neck differences. Again, correction for multiple confounders didn’t attenuate the results, said Dr. Fowler.

“In conclusion, these data showed accentuated mobilization of hip and whole body aBMD during lactation,” said Dr. Fowler, who also noted “slower skeletal recovery post lactation for HIV-infected women.” Clinical implications of these findings aren’t currently known, she said. Further ongoing studies are aiming to tease out both mechanisms and longer-term consequences for the bone health of HIV-infected women and their children, who may also see differences in bone mineral accretion and growth.

Session moderator Risa Hoffman, MD, in introductory remarks, set the findings in some context. “As we know, HIV-positive adults have low bone mineral density, and this appears to be a result of interactions of HIV, traditional risk factors for loss of bone density, and antiretroviral therapy,” said Dr. Hoffman, director of the global health program at the University of California, Los Angeles. She added that previous work had shown that “middle-aged HIV-positive women have higher 10-year fracture incidence compared to their HIV-negative counterparts.” The current study, she said, “has both short- and long-term implications for women as they go through multiple pregnancies and multiple periods of breastfeeding.”

The study was funded by the United Kingdom’s Medical Research Council and Department for International Development as well as the Alborada Trust and the Gates Cambridge Scholarship. The authors reported no conflicts of interest.

[email protected]

SOURCE: Nabwire F et al. CROI 2020, Abstract 768.

Women with HIV had more bone mobilization during lactation, and attenuated skeletal recovery after lactation, compared with HIV-negative women, according to research presented during the Conference on Retroviruses & Opportunistic Infections, which was presented online this year. CROI organizers chose to hold a virtual meeting because of concerns about the spread of COVID-19.

The study “demonstrated that there were reductions as expected in BMD during breastfeeding, and there was recovery at the end of breastfeeding, which was higher among women who were not HIV-infected compared to HIV-infected women,” said Mary Glenn Fowler, MD, speaking in a video presentation during the virtual conference. The differences between women who had HIV and the HIV-negative reference group were statistically significant (P = .003 for lumbar spine and P less than .001 for whole-body aBMD).

“We also saw that for whole-body BMD, there was recovery at the end of breastfeeding for women who were not HIV infected, but a dampened response of recovery for BMD for HIV-infected women,” she went on, adding: “These findings held after adjustment for parity, age, body mass, breastfeeding practices, duration of breastfeeding, use of [injectable medroxyprogesterone acetate], and resumption of menses.”

Dr. Fowler presented the study’s results on behalf of lead author Florence Nabwire, PhD, an investigator scientist in the nutrition and bone health group of the United Kingdom’s Medical Research Council (Cambridge).

Although it’s known that antiretroviral therapy (ART) is associated with bone loss, Dr. Fowler explained that there are only limited data in HIV-positive women who are lactating. It’s important to see what happens during lactation for this group of women because of the potential sequelae later in life of insufficient recovery from the physiological bone mobilization that occurs during lactation. The study looked at changes in areal bone mineral density (aBMD) both during and after lactation for women with HIV living in Uganda who were taking Option B+ ART, a regimen that includes tenofovir, 3TC, and efavirenz. These women were compared with a reference group of HIV-negative women.

In all, 95 women with HIV and 96 HIV negative women were recruited into the study during pregnancy. Participants were followed postpartum at weeks 2, 14, and 26, and at a final visit that occurred 14 weeks after lactation stopped.

In addition to lumbar spine, total hip, and femoral neck aBMD measurements, the investigators also obtained whole body-less-head reading.

For total hip and femoral neck aBMD, the nadir of density was seen at 26 postpartum, when a drop of about 6% was seen from baseline readings. By the final post-lactation visit, women without HIV had recovered to their baseline; for women with HIV, some recovery also occurred, but the effect was dampened, with a persistent bone density deficit of about 3% from baseline. The differences between HIV-positive and HIV-negative women in these measurements were also statistically significant, at P less than .001 for total hip aBMD differences and P = .0008 for femoral neck differences. Again, correction for multiple confounders didn’t attenuate the results, said Dr. Fowler.

“In conclusion, these data showed accentuated mobilization of hip and whole body aBMD during lactation,” said Dr. Fowler, who also noted “slower skeletal recovery post lactation for HIV-infected women.” Clinical implications of these findings aren’t currently known, she said. Further ongoing studies are aiming to tease out both mechanisms and longer-term consequences for the bone health of HIV-infected women and their children, who may also see differences in bone mineral accretion and growth.

Session moderator Risa Hoffman, MD, in introductory remarks, set the findings in some context. “As we know, HIV-positive adults have low bone mineral density, and this appears to be a result of interactions of HIV, traditional risk factors for loss of bone density, and antiretroviral therapy,” said Dr. Hoffman, director of the global health program at the University of California, Los Angeles. She added that previous work had shown that “middle-aged HIV-positive women have higher 10-year fracture incidence compared to their HIV-negative counterparts.” The current study, she said, “has both short- and long-term implications for women as they go through multiple pregnancies and multiple periods of breastfeeding.”

The study was funded by the United Kingdom’s Medical Research Council and Department for International Development as well as the Alborada Trust and the Gates Cambridge Scholarship. The authors reported no conflicts of interest.

[email protected]

SOURCE: Nabwire F et al. CROI 2020, Abstract 768.

As of April 9, at least 27 health care personnel had died from COVID-19 infection in the United States, according to the Centers for Disease Control and Prevention.

That number, however, is probably an underestimation because health care personnel (HCP) status was available for just over 49,000 of the 315,000 COVID-19 cases reported to the CDC as of April 9. Of the cases with known HCP status, 9,282 (19%) were health care personnel, Matthew J. Stuckey, PhD, and the CDC’s COVID-19 Response Team said.

“The number of cases in HCP reported here must be considered a lower bound because additional cases likely have gone unidentified or unreported,” they said.

The median age of the nearly 9,300 HCP with COVID-19 was 42 years, and the majority (55%) were aged 16-44 years; another 21% were 45-54, 18% were 55-64, and 6% were age 65 and over. The oldest group, however, represented 10 of the 27 known HCP deaths, the investigators reported in the Morbidity and Mortality Weekly Report.

The majority of infected HCP (55%) reported exposure to a COVID-19 patient in the health care setting, but “there were also known exposures in households and in the community, highlighting the potential for exposure in multiple settings, especially as community transmission increases,” the response team said.

Since “contact tracing after recognized occupational exposures likely will fail to identify many HCP at risk for developing COVID-19,” other measures will probably be needed to “reduce the risk for infected HCP transmitting the virus to colleagues and patients,” they added.

HCP with COVID-19 were less likely to be hospitalized (8%-10%) than the overall population (21%-31%), which “might reflect the younger median age … of HCP patients, compared with that of reported COVID-19 patients overall, as well as prioritization of HCP for testing, which might identify less-severe illness,” the investigators suggested.

The prevalence of underlying conditions in HCP patients, 38%, was the same as all patients with COVID-19, and 92% of the HCP patients presented with fever, cough, or shortness of breath. Two-thirds of all HCP reported muscle aches, and 65% reported headache, the CDC response team noted.

“It is critical to make every effort to ensure the health and safety of this essential national workforce of approximately 18 million HCP, both at work and in the community,” they wrote.

[email protected]

SOURCE: Stuckey MJ et al. MMWR. Apr 14;69(early release):1-5.

As of April 9, at least 27 health care personnel had died from COVID-19 infection in the United States, according to the Centers for Disease Control and Prevention.

That number, however, is probably an underestimation because health care personnel (HCP) status was available for just over 49,000 of the 315,000 COVID-19 cases reported to the CDC as of April 9. Of the cases with known HCP status, 9,282 (19%) were health care personnel, Matthew J. Stuckey, PhD, and the CDC’s COVID-19 Response Team said.

“The number of cases in HCP reported here must be considered a lower bound because additional cases likely have gone unidentified or unreported,” they said.

The median age of the nearly 9,300 HCP with COVID-19 was 42 years, and the majority (55%) were aged 16-44 years; another 21% were 45-54, 18% were 55-64, and 6% were age 65 and over. The oldest group, however, represented 10 of the 27 known HCP deaths, the investigators reported in the Morbidity and Mortality Weekly Report.

The majority of infected HCP (55%) reported exposure to a COVID-19 patient in the health care setting, but “there were also known exposures in households and in the community, highlighting the potential for exposure in multiple settings, especially as community transmission increases,” the response team said.

Since “contact tracing after recognized occupational exposures likely will fail to identify many HCP at risk for developing COVID-19,” other measures will probably be needed to “reduce the risk for infected HCP transmitting the virus to colleagues and patients,” they added.

HCP with COVID-19 were less likely to be hospitalized (8%-10%) than the overall population (21%-31%), which “might reflect the younger median age … of HCP patients, compared with that of reported COVID-19 patients overall, as well as prioritization of HCP for testing, which might identify less-severe illness,” the investigators suggested.

The prevalence of underlying conditions in HCP patients, 38%, was the same as all patients with COVID-19, and 92% of the HCP patients presented with fever, cough, or shortness of breath. Two-thirds of all HCP reported muscle aches, and 65% reported headache, the CDC response team noted.

“It is critical to make every effort to ensure the health and safety of this essential national workforce of approximately 18 million HCP, both at work and in the community,” they wrote.

[email protected]

SOURCE: Stuckey MJ et al. MMWR. Apr 14;69(early release):1-5.

As of April 9, at least 27 health care personnel had died from COVID-19 infection in the United States, according to the Centers for Disease Control and Prevention.

That number, however, is probably an underestimation because health care personnel (HCP) status was available for just over 49,000 of the 315,000 COVID-19 cases reported to the CDC as of April 9. Of the cases with known HCP status, 9,282 (19%) were health care personnel, Matthew J. Stuckey, PhD, and the CDC’s COVID-19 Response Team said.

“The number of cases in HCP reported here must be considered a lower bound because additional cases likely have gone unidentified or unreported,” they said.

The median age of the nearly 9,300 HCP with COVID-19 was 42 years, and the majority (55%) were aged 16-44 years; another 21% were 45-54, 18% were 55-64, and 6% were age 65 and over. The oldest group, however, represented 10 of the 27 known HCP deaths, the investigators reported in the Morbidity and Mortality Weekly Report.

The majority of infected HCP (55%) reported exposure to a COVID-19 patient in the health care setting, but “there were also known exposures in households and in the community, highlighting the potential for exposure in multiple settings, especially as community transmission increases,” the response team said.

Since “contact tracing after recognized occupational exposures likely will fail to identify many HCP at risk for developing COVID-19,” other measures will probably be needed to “reduce the risk for infected HCP transmitting the virus to colleagues and patients,” they added.

HCP with COVID-19 were less likely to be hospitalized (8%-10%) than the overall population (21%-31%), which “might reflect the younger median age … of HCP patients, compared with that of reported COVID-19 patients overall, as well as prioritization of HCP for testing, which might identify less-severe illness,” the investigators suggested.

The prevalence of underlying conditions in HCP patients, 38%, was the same as all patients with COVID-19, and 92% of the HCP patients presented with fever, cough, or shortness of breath. Two-thirds of all HCP reported muscle aches, and 65% reported headache, the CDC response team noted.

“It is critical to make every effort to ensure the health and safety of this essential national workforce of approximately 18 million HCP, both at work and in the community,” they wrote.

[email protected]

SOURCE: Stuckey MJ et al. MMWR. Apr 14;69(early release):1-5.

“Uncertainty creates weakness. Uncertainty makes one tentative, if not fearful, and tentative steps, even when in the right direction, may not overcome significant obstacles.”¹

Recently, I spent my vacation time quarantined reading “The Great Influenza,” which recounts the history of the 1918 pandemic. Despite over a century of scientific and medical progress, the parallels to our current situation are indisputable. Just as in 1918, we are limiting social gatherings, quarantining, wearing face masks, and living with the fear and anxiety of keeping ourselves and our families safe. In 1918, use of aspirin, quinine, and digitalis therapies in a desperate search for relief despite limited evidence mirror the current use of hydroxychloroquine, azithromycin, and lopinavir/ritonavir. While there are many similarities between the two situations, in this pandemic our channels for dissemination of scientific literature are better developed, and online networks are enabling physicians across the globe to communicate their experience and findings in near real time.

During this time of uncertainty, our understanding of COVID-19 evolves daily. Without the advantage of robust randomized, controlled trials and large-scale studies to guide us, we are forced to rely on pattern recognition for surveillance and anecdotal or limited case-based accounts to guide clinical care. Fortunately, free open-access medical education (FOAM) and social networks offer a significant advantage in our ability to collect and disseminate information.
 

Free open access medical education

The concept of FOAM started in 2012 with the intent of creating a collaborative and constantly evolving community to provide open-access medical education. It encompasses multiple platforms – blogs, podcasts, videos, and social media – and features content experts from across the globe. Since its inception, FOAM has grown in popularity and use, especially within emergency medicine and critical care communities, as an adjunct for asynchronous learning.^2,3

In a time where knowledge of COVID-19 is dynamically changing, traditional sources like textbooks, journals, and organizational guidelines often lag behind real-time clinical experience and needs. Additionally, many clinicians are now being tasked with taking care of patient populations and a new critical illness profile with which they are not comfortable. It is challenging to find a well-curated and updated repository of information to answer questions surrounding pathophysiology, critical care, ventilator management, caring for adult patients, and personal protective equipment (PPE). During this rapidly evolving reality, FOAM is becoming the ideal modality for timely and efficient sharing of reviews of current literature, expert discussions, and clinical practice guidelines.

A few self-directed hours on EMCrit’s Internet Book of Critical Care’s COVID-19 chapter reveals a bastion of content regarding diagnosis, pathophysiology, transmission, therapies, and ventilator strategies.⁴ It includes references to major journals and recommendations from international societies. Websites like EMCrit and REBEL EM are updated daily with podcasts, videos, and blog posts surrounding the latest highly debated topics in COVID-19 management.⁵ Podcasts like EM:RAP and Peds RAP have made COVID segments discussing important topics like pharmacotherapy, telemedicine, and pregnancy available for free.^6,7 Many networks, institutions, and individual physicians have created and posted videos online on critical care topics and refreshers.
 

Social networks

Online social networks composed of international physicians within Facebook and LinkedIn serve as miniature publishing houses. First-hand accounts of patient presentations and patient care act as case reports. As similar accounts accumulate, they become case series. Patterns emerge and new hypotheses are generated, debated, and critiqued through this informal peer review. Personal accounts of frustration with lack of PPE, fear of exposing loved ones, distress at being separated from family, and grief of witnessing multiple patients die alone are opinion and perspective articles.

These networks offer the space for sharing. Those who have had the experience of caring for the surge of COVID-19 patients offer advice and words of caution to those who have yet to experience it. Protocols from a multitude of institutions on triage, surge, disposition, and end-of-life care are disseminated, serving as templates for those that have not yet developed their own. There is an impressive variety of innovative, do-it-yourself projects surrounding PPE, intubation boxes, and three-dimensionally printed ventilator parts.

Finally, these networks provide emotional support. There are offers to ship additional PPE, videos of cities cheering as clinicians go to work, stories of triumph and recovery, pictures depicting ongoing wellness activities, and the occasional much-needed humorous anecdote or illustration. These networks reinforce the message that our lives continue despite this upheaval, and we are not alone in this struggle.

The end of the passage in The Great Influenza concludes with: “Ultimately a scientist has nothing to believe in but the process of inquiry. To move forcefully and aggressively even while uncertain requires a confidence and strength deeper than physical courage.”

FOAM and social networks are crucial channels for collecting and conveying up-to-date information during disasters. They represent a highly adaptable, evolving, and collaborative global community’s determination to persevere through time of uncertainty together.

Dr. Ren is a pediatric emergency medicine fellow at Children’s National Hospital, Washington. Dr. Simpson is a pediatric emergency medicine attending and medical director of emergency preparedness at the hospital. They reported that they do not have any disclosures or conflicts of interest. Email Dr. Ren and Dr. Simpson at [email protected].

References

1. “The Great Influenza: The Story of the Deadliest Pandemic in History.” (New York: Penguin Books, 2005, pp. 261-62).

2. Emerg Med J. 2014 Oct;31(e1):e76-7.

3. Acad Med. 2014 Apr;89(4):598-601.

4. “The Internet Book of Critical Care: COVID-19.” EMCrit Project.

5. “Covid-19.” REBEL EM-Emergency Medicine Blog.

6. “EM:RAP COVID-19 Resources.” EM RAP: Emergency Medicine Reviews and Perspectives.

7. “Episodes.” Peds RAP, Hippo Education.

“Uncertainty creates weakness. Uncertainty makes one tentative, if not fearful, and tentative steps, even when in the right direction, may not overcome significant obstacles.”¹

Recently, I spent my vacation time quarantined reading “The Great Influenza,” which recounts the history of the 1918 pandemic. Despite over a century of scientific and medical progress, the parallels to our current situation are indisputable. Just as in 1918, we are limiting social gatherings, quarantining, wearing face masks, and living with the fear and anxiety of keeping ourselves and our families safe. In 1918, use of aspirin, quinine, and digitalis therapies in a desperate search for relief despite limited evidence mirror the current use of hydroxychloroquine, azithromycin, and lopinavir/ritonavir. While there are many similarities between the two situations, in this pandemic our channels for dissemination of scientific literature are better developed, and online networks are enabling physicians across the globe to communicate their experience and findings in near real time.

During this time of uncertainty, our understanding of COVID-19 evolves daily. Without the advantage of robust randomized, controlled trials and large-scale studies to guide us, we are forced to rely on pattern recognition for surveillance and anecdotal or limited case-based accounts to guide clinical care. Fortunately, free open-access medical education (FOAM) and social networks offer a significant advantage in our ability to collect and disseminate information.
 

Free open access medical education

The concept of FOAM started in 2012 with the intent of creating a collaborative and constantly evolving community to provide open-access medical education. It encompasses multiple platforms – blogs, podcasts, videos, and social media – and features content experts from across the globe. Since its inception, FOAM has grown in popularity and use, especially within emergency medicine and critical care communities, as an adjunct for asynchronous learning.^2,3

In a time where knowledge of COVID-19 is dynamically changing, traditional sources like textbooks, journals, and organizational guidelines often lag behind real-time clinical experience and needs. Additionally, many clinicians are now being tasked with taking care of patient populations and a new critical illness profile with which they are not comfortable. It is challenging to find a well-curated and updated repository of information to answer questions surrounding pathophysiology, critical care, ventilator management, caring for adult patients, and personal protective equipment (PPE). During this rapidly evolving reality, FOAM is becoming the ideal modality for timely and efficient sharing of reviews of current literature, expert discussions, and clinical practice guidelines.

A few self-directed hours on EMCrit’s Internet Book of Critical Care’s COVID-19 chapter reveals a bastion of content regarding diagnosis, pathophysiology, transmission, therapies, and ventilator strategies.⁴ It includes references to major journals and recommendations from international societies. Websites like EMCrit and REBEL EM are updated daily with podcasts, videos, and blog posts surrounding the latest highly debated topics in COVID-19 management.⁵ Podcasts like EM:RAP and Peds RAP have made COVID segments discussing important topics like pharmacotherapy, telemedicine, and pregnancy available for free.^6,7 Many networks, institutions, and individual physicians have created and posted videos online on critical care topics and refreshers.
 

Social networks

Online social networks composed of international physicians within Facebook and LinkedIn serve as miniature publishing houses. First-hand accounts of patient presentations and patient care act as case reports. As similar accounts accumulate, they become case series. Patterns emerge and new hypotheses are generated, debated, and critiqued through this informal peer review. Personal accounts of frustration with lack of PPE, fear of exposing loved ones, distress at being separated from family, and grief of witnessing multiple patients die alone are opinion and perspective articles.

These networks offer the space for sharing. Those who have had the experience of caring for the surge of COVID-19 patients offer advice and words of caution to those who have yet to experience it. Protocols from a multitude of institutions on triage, surge, disposition, and end-of-life care are disseminated, serving as templates for those that have not yet developed their own. There is an impressive variety of innovative, do-it-yourself projects surrounding PPE, intubation boxes, and three-dimensionally printed ventilator parts.

Finally, these networks provide emotional support. There are offers to ship additional PPE, videos of cities cheering as clinicians go to work, stories of triumph and recovery, pictures depicting ongoing wellness activities, and the occasional much-needed humorous anecdote or illustration. These networks reinforce the message that our lives continue despite this upheaval, and we are not alone in this struggle.

The end of the passage in The Great Influenza concludes with: “Ultimately a scientist has nothing to believe in but the process of inquiry. To move forcefully and aggressively even while uncertain requires a confidence and strength deeper than physical courage.”

FOAM and social networks are crucial channels for collecting and conveying up-to-date information during disasters. They represent a highly adaptable, evolving, and collaborative global community’s determination to persevere through time of uncertainty together.

Dr. Ren is a pediatric emergency medicine fellow at Children’s National Hospital, Washington. Dr. Simpson is a pediatric emergency medicine attending and medical director of emergency preparedness at the hospital. They reported that they do not have any disclosures or conflicts of interest. Email Dr. Ren and Dr. Simpson at [email protected].

References

1. “The Great Influenza: The Story of the Deadliest Pandemic in History.” (New York: Penguin Books, 2005, pp. 261-62).

2. Emerg Med J. 2014 Oct;31(e1):e76-7.

3. Acad Med. 2014 Apr;89(4):598-601.

4. “The Internet Book of Critical Care: COVID-19.” EMCrit Project.

5. “Covid-19.” REBEL EM-Emergency Medicine Blog.

6. “EM:RAP COVID-19 Resources.” EM RAP: Emergency Medicine Reviews and Perspectives.

7. “Episodes.” Peds RAP, Hippo Education.

“Uncertainty creates weakness. Uncertainty makes one tentative, if not fearful, and tentative steps, even when in the right direction, may not overcome significant obstacles.”¹

Recently, I spent my vacation time quarantined reading “The Great Influenza,” which recounts the history of the 1918 pandemic. Despite over a century of scientific and medical progress, the parallels to our current situation are indisputable. Just as in 1918, we are limiting social gatherings, quarantining, wearing face masks, and living with the fear and anxiety of keeping ourselves and our families safe. In 1918, use of aspirin, quinine, and digitalis therapies in a desperate search for relief despite limited evidence mirror the current use of hydroxychloroquine, azithromycin, and lopinavir/ritonavir. While there are many similarities between the two situations, in this pandemic our channels for dissemination of scientific literature are better developed, and online networks are enabling physicians across the globe to communicate their experience and findings in near real time.

During this time of uncertainty, our understanding of COVID-19 evolves daily. Without the advantage of robust randomized, controlled trials and large-scale studies to guide us, we are forced to rely on pattern recognition for surveillance and anecdotal or limited case-based accounts to guide clinical care. Fortunately, free open-access medical education (FOAM) and social networks offer a significant advantage in our ability to collect and disseminate information.
 

Free open access medical education

The concept of FOAM started in 2012 with the intent of creating a collaborative and constantly evolving community to provide open-access medical education. It encompasses multiple platforms – blogs, podcasts, videos, and social media – and features content experts from across the globe. Since its inception, FOAM has grown in popularity and use, especially within emergency medicine and critical care communities, as an adjunct for asynchronous learning.^2,3

In a time where knowledge of COVID-19 is dynamically changing, traditional sources like textbooks, journals, and organizational guidelines often lag behind real-time clinical experience and needs. Additionally, many clinicians are now being tasked with taking care of patient populations and a new critical illness profile with which they are not comfortable. It is challenging to find a well-curated and updated repository of information to answer questions surrounding pathophysiology, critical care, ventilator management, caring for adult patients, and personal protective equipment (PPE). During this rapidly evolving reality, FOAM is becoming the ideal modality for timely and efficient sharing of reviews of current literature, expert discussions, and clinical practice guidelines.

A few self-directed hours on EMCrit’s Internet Book of Critical Care’s COVID-19 chapter reveals a bastion of content regarding diagnosis, pathophysiology, transmission, therapies, and ventilator strategies.⁴ It includes references to major journals and recommendations from international societies. Websites like EMCrit and REBEL EM are updated daily with podcasts, videos, and blog posts surrounding the latest highly debated topics in COVID-19 management.⁵ Podcasts like EM:RAP and Peds RAP have made COVID segments discussing important topics like pharmacotherapy, telemedicine, and pregnancy available for free.^6,7 Many networks, institutions, and individual physicians have created and posted videos online on critical care topics and refreshers.
 

Social networks

Online social networks composed of international physicians within Facebook and LinkedIn serve as miniature publishing houses. First-hand accounts of patient presentations and patient care act as case reports. As similar accounts accumulate, they become case series. Patterns emerge and new hypotheses are generated, debated, and critiqued through this informal peer review. Personal accounts of frustration with lack of PPE, fear of exposing loved ones, distress at being separated from family, and grief of witnessing multiple patients die alone are opinion and perspective articles.

These networks offer the space for sharing. Those who have had the experience of caring for the surge of COVID-19 patients offer advice and words of caution to those who have yet to experience it. Protocols from a multitude of institutions on triage, surge, disposition, and end-of-life care are disseminated, serving as templates for those that have not yet developed their own. There is an impressive variety of innovative, do-it-yourself projects surrounding PPE, intubation boxes, and three-dimensionally printed ventilator parts.

Finally, these networks provide emotional support. There are offers to ship additional PPE, videos of cities cheering as clinicians go to work, stories of triumph and recovery, pictures depicting ongoing wellness activities, and the occasional much-needed humorous anecdote or illustration. These networks reinforce the message that our lives continue despite this upheaval, and we are not alone in this struggle.

The end of the passage in The Great Influenza concludes with: “Ultimately a scientist has nothing to believe in but the process of inquiry. To move forcefully and aggressively even while uncertain requires a confidence and strength deeper than physical courage.”

FOAM and social networks are crucial channels for collecting and conveying up-to-date information during disasters. They represent a highly adaptable, evolving, and collaborative global community’s determination to persevere through time of uncertainty together.

Dr. Ren is a pediatric emergency medicine fellow at Children’s National Hospital, Washington. Dr. Simpson is a pediatric emergency medicine attending and medical director of emergency preparedness at the hospital. They reported that they do not have any disclosures or conflicts of interest. Email Dr. Ren and Dr. Simpson at [email protected].

References

1. “The Great Influenza: The Story of the Deadliest Pandemic in History.” (New York: Penguin Books, 2005, pp. 261-62).

2. Emerg Med J. 2014 Oct;31(e1):e76-7.

3. Acad Med. 2014 Apr;89(4):598-601.

4. “The Internet Book of Critical Care: COVID-19.” EMCrit Project.

5. “Covid-19.” REBEL EM-Emergency Medicine Blog.

6. “EM:RAP COVID-19 Resources.” EM RAP: Emergency Medicine Reviews and Perspectives.

7. “Episodes.” Peds RAP, Hippo Education.

As the race to develop rapid testing for COVID-19 expands, the Food and Drug Administration has granted emergency approval for an approach that uses saliva as the primary test biomaterial.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

According to a document provided to the FDA, the Rutgers Clinical Genomics Laboratory TaqPath SARS-CoV-2 Assay is intended for the qualitative detection of nucleic acid from SARS-CoV-2 in oropharyngeal (throat) swab, nasopharyngeal swab, anterior nasal swab, mid-turbinate nasal swab from individuals suspected of COVID-19 by their health care clinicians. To expand on this assay, Rutgers University–based RUCDR Infinite Biologics developed a saliva collection method in partnership with Spectrum Solutions and Accurate Diagnostic Labs.

The document states that collection of saliva specimens is limited to patients with symptoms of COVID-19 and should be performed in a health care setting under the supervision of a trained health care clinician. Samples are transported for RNA extraction and are tested within 48 hours of collection. In saliva samples obtained from 60 patients evaluated by the researchers, all were in agreement with the presence of COVID-19.

“If shown to be as accurate as nasopharyngeal and oropharyngeal samples, saliva as a biomatrix offers the advantage of not generating aerosols or creating as many respiratory droplets during specimen procurement, therefore decreasing the risk of transmission to the health care worker doing the testing,” said Matthew P. Cheng, MDCM, of the division of infectious diseases at McGill University Health Centre, Montreal, who was not involved in development of the test but who has written about diagnostic testing for the virus.

“Also, it may be easy enough for patients to do saliva self-collection at home. However, it is important to note that SARS-CoV-2 tests on saliva have not yet undergone the more rigorous evaluation of full FDA authorization, and saliva is not a preferred specimen type of the FDA nor the [Centers for Disease Control and Prevention] for respiratory virus testing.”

In a prepared statement, Andrew I. Brooks, PhD, chief operating officer at RUCDR Infinite Biologics, said the saliva collection method enables clinicians to preserve personal protective equipment for use in patient care instead of testing. “We can significantly increase the number of people tested each and every day as self-collection of saliva is quicker and more scalable than swab collections,” he said. “All of this combined will have a tremendous impact on testing in New Jersey and across the United States.”

The tests are currently available to the RWJBarnabas Health network, based in West Orange, N.J., which has partnered with Rutgers University.

[email protected]

As the race to develop rapid testing for COVID-19 expands, the Food and Drug Administration has granted emergency approval for an approach that uses saliva as the primary test biomaterial.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

According to a document provided to the FDA, the Rutgers Clinical Genomics Laboratory TaqPath SARS-CoV-2 Assay is intended for the qualitative detection of nucleic acid from SARS-CoV-2 in oropharyngeal (throat) swab, nasopharyngeal swab, anterior nasal swab, mid-turbinate nasal swab from individuals suspected of COVID-19 by their health care clinicians. To expand on this assay, Rutgers University–based RUCDR Infinite Biologics developed a saliva collection method in partnership with Spectrum Solutions and Accurate Diagnostic Labs.

The document states that collection of saliva specimens is limited to patients with symptoms of COVID-19 and should be performed in a health care setting under the supervision of a trained health care clinician. Samples are transported for RNA extraction and are tested within 48 hours of collection. In saliva samples obtained from 60 patients evaluated by the researchers, all were in agreement with the presence of COVID-19.

“If shown to be as accurate as nasopharyngeal and oropharyngeal samples, saliva as a biomatrix offers the advantage of not generating aerosols or creating as many respiratory droplets during specimen procurement, therefore decreasing the risk of transmission to the health care worker doing the testing,” said Matthew P. Cheng, MDCM, of the division of infectious diseases at McGill University Health Centre, Montreal, who was not involved in development of the test but who has written about diagnostic testing for the virus.

“Also, it may be easy enough for patients to do saliva self-collection at home. However, it is important to note that SARS-CoV-2 tests on saliva have not yet undergone the more rigorous evaluation of full FDA authorization, and saliva is not a preferred specimen type of the FDA nor the [Centers for Disease Control and Prevention] for respiratory virus testing.”

In a prepared statement, Andrew I. Brooks, PhD, chief operating officer at RUCDR Infinite Biologics, said the saliva collection method enables clinicians to preserve personal protective equipment for use in patient care instead of testing. “We can significantly increase the number of people tested each and every day as self-collection of saliva is quicker and more scalable than swab collections,” he said. “All of this combined will have a tremendous impact on testing in New Jersey and across the United States.”

The tests are currently available to the RWJBarnabas Health network, based in West Orange, N.J., which has partnered with Rutgers University.

[email protected]

As the race to develop rapid testing for COVID-19 expands, the Food and Drug Administration has granted emergency approval for an approach that uses saliva as the primary test biomaterial.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

According to a document provided to the FDA, the Rutgers Clinical Genomics Laboratory TaqPath SARS-CoV-2 Assay is intended for the qualitative detection of nucleic acid from SARS-CoV-2 in oropharyngeal (throat) swab, nasopharyngeal swab, anterior nasal swab, mid-turbinate nasal swab from individuals suspected of COVID-19 by their health care clinicians. To expand on this assay, Rutgers University–based RUCDR Infinite Biologics developed a saliva collection method in partnership with Spectrum Solutions and Accurate Diagnostic Labs.

The document states that collection of saliva specimens is limited to patients with symptoms of COVID-19 and should be performed in a health care setting under the supervision of a trained health care clinician. Samples are transported for RNA extraction and are tested within 48 hours of collection. In saliva samples obtained from 60 patients evaluated by the researchers, all were in agreement with the presence of COVID-19.

“If shown to be as accurate as nasopharyngeal and oropharyngeal samples, saliva as a biomatrix offers the advantage of not generating aerosols or creating as many respiratory droplets during specimen procurement, therefore decreasing the risk of transmission to the health care worker doing the testing,” said Matthew P. Cheng, MDCM, of the division of infectious diseases at McGill University Health Centre, Montreal, who was not involved in development of the test but who has written about diagnostic testing for the virus.

“Also, it may be easy enough for patients to do saliva self-collection at home. However, it is important to note that SARS-CoV-2 tests on saliva have not yet undergone the more rigorous evaluation of full FDA authorization, and saliva is not a preferred specimen type of the FDA nor the [Centers for Disease Control and Prevention] for respiratory virus testing.”

In a prepared statement, Andrew I. Brooks, PhD, chief operating officer at RUCDR Infinite Biologics, said the saliva collection method enables clinicians to preserve personal protective equipment for use in patient care instead of testing. “We can significantly increase the number of people tested each and every day as self-collection of saliva is quicker and more scalable than swab collections,” he said. “All of this combined will have a tremendous impact on testing in New Jersey and across the United States.”

The tests are currently available to the RWJBarnabas Health network, based in West Orange, N.J., which has partnered with Rutgers University.

[email protected]

If you are anything like me, March 1 came and went as just another first day of the month. Few of us could have imagined that our day-to-day way of life would soon be upended, and our country would be in the midst of the COVID-19 pandemic. While there is considerable anxiety around protecting our individual health, social distancing and the physical isolation that comes from it have cut off a vital source of support for many of our lesbian, gay, bisexual, transgender, and questioning (or queer) (LGBTQ) youth. Shared experiences with other young people like themselves provide these youth with a sense of community that they may not find in their schools, towns, etc.

LGBTQ youth already face increased rates of anxiety and depression compared with their heterosexual and cisgender peers. According to the 2017 Youth Risk Behavior Survey, 63% of LGB youth nationwide reported feeling sad or hopeless compared with 28% of their heterosexual peers. While quarantined at home, many of these youth now are stuck for many more hours per day with families who may not accept them for who they are. Previous research by Ryan et al. shows that LGB adolescents who have higher rates of family rejection are nearly six times more likely to have higher rates of depression and more than eight times more likely to attempt suicide than their peers who come from families with low or no levels of rejection (Pediatrics. 2009 Jan;123[1]:346-52). Going to school for roughly 8 hours a day allows some of these youth an escape from what is otherwise an unpleasant home situation. In addition, educators and other school staff may be among the only allies that a student has in his/her life, and school cancellations remove students from access to these important people.

AJ_Watt/E+

Due to stay-at-home orders and physical distancing measures, lack of in-person access to medical and psychological care can be distressing for many LGBTQ youth. While many practices have been able to convert to audiovisual telemedicine visits, not all of them have the resources or capability to do so. Consequently, LGBTQ youth may have reduced access to support services that help to bolster their social and emotional health. In addition, many trans youth suffer from physical dysphoria that can make it distressing to see themselves on camera doing teletherapy and so they wish to avoid it for this reason.

This is not to say that everything is bleak. LGBTQ youth can also be resilient in times of stress and worry. “The LGBTQ community has a long history of overcoming adversity and utilizing challenges to build an even stronger sense of community. This pandemic will create yet another opportunity for us to highlight existing health disparities and to support our LGBTQ young people in finding creative responses,” said Heather Newby, LCSW, clinical social worker for the GENECIS (GENder Education and Care Interdisciplinary Support) Program at Children’s Medical Center Dallas. In addition, she reported that many LGBTQ advocacy groups have created excellent online support networks and resources to provide nationwide, regional, and local help. By leveraging these youths’ capability for resilience, we are best able to support them during a time of crisis.

During these challenging times, there are a number of resources that LGBTQ youth can turn to while trying to maintain their connection to their peers. First, many local LGBTQ service organizations have moved their in-person support groups to a virtual or online platform. Check with your local service organization to see what they are offering during these times. National organizations, such as Gender Spectrum, continue to have online groups as well that youth can participate in. Second, many virtual mental health helplines, such as those through the Trevor Project, remain staffed should LGBTQ youth need to access their services (1-866-488-7386, plus text and chat). They can be reached 24/7 to help those whose mental health has been affected during this pandemic. Third, youth can continue to stay connected to their friends through means such as Zoom, FaceTime, or other virtual audiovisual tools. Lastly, some youth have taken to meeting in school parking lots, mall parking lots, etc., and staying at least 6 feet apart so that they can still see their friends in person.

While the current times may be challenging, they will pass and we will be able to return to those activities that bring us joy. Do not hesitate to reach out if you need help. As Rainer Maria Rilke once said, “In the difficult, we must have our joys, our happiness, our dreams: There against the depth of this background, they stand out, there for the first time we see how beautiful they are.”
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. He has no relevant financial disclosures. Dr. Cooper is on Twitter @teendocmbc. Email him at [email protected].

If you are anything like me, March 1 came and went as just another first day of the month. Few of us could have imagined that our day-to-day way of life would soon be upended, and our country would be in the midst of the COVID-19 pandemic. While there is considerable anxiety around protecting our individual health, social distancing and the physical isolation that comes from it have cut off a vital source of support for many of our lesbian, gay, bisexual, transgender, and questioning (or queer) (LGBTQ) youth. Shared experiences with other young people like themselves provide these youth with a sense of community that they may not find in their schools, towns, etc.

LGBTQ youth already face increased rates of anxiety and depression compared with their heterosexual and cisgender peers. According to the 2017 Youth Risk Behavior Survey, 63% of LGB youth nationwide reported feeling sad or hopeless compared with 28% of their heterosexual peers. While quarantined at home, many of these youth now are stuck for many more hours per day with families who may not accept them for who they are. Previous research by Ryan et al. shows that LGB adolescents who have higher rates of family rejection are nearly six times more likely to have higher rates of depression and more than eight times more likely to attempt suicide than their peers who come from families with low or no levels of rejection (Pediatrics. 2009 Jan;123[1]:346-52). Going to school for roughly 8 hours a day allows some of these youth an escape from what is otherwise an unpleasant home situation. In addition, educators and other school staff may be among the only allies that a student has in his/her life, and school cancellations remove students from access to these important people.

AJ_Watt/E+

Due to stay-at-home orders and physical distancing measures, lack of in-person access to medical and psychological care can be distressing for many LGBTQ youth. While many practices have been able to convert to audiovisual telemedicine visits, not all of them have the resources or capability to do so. Consequently, LGBTQ youth may have reduced access to support services that help to bolster their social and emotional health. In addition, many trans youth suffer from physical dysphoria that can make it distressing to see themselves on camera doing teletherapy and so they wish to avoid it for this reason.

This is not to say that everything is bleak. LGBTQ youth can also be resilient in times of stress and worry. “The LGBTQ community has a long history of overcoming adversity and utilizing challenges to build an even stronger sense of community. This pandemic will create yet another opportunity for us to highlight existing health disparities and to support our LGBTQ young people in finding creative responses,” said Heather Newby, LCSW, clinical social worker for the GENECIS (GENder Education and Care Interdisciplinary Support) Program at Children’s Medical Center Dallas. In addition, she reported that many LGBTQ advocacy groups have created excellent online support networks and resources to provide nationwide, regional, and local help. By leveraging these youths’ capability for resilience, we are best able to support them during a time of crisis.

During these challenging times, there are a number of resources that LGBTQ youth can turn to while trying to maintain their connection to their peers. First, many local LGBTQ service organizations have moved their in-person support groups to a virtual or online platform. Check with your local service organization to see what they are offering during these times. National organizations, such as Gender Spectrum, continue to have online groups as well that youth can participate in. Second, many virtual mental health helplines, such as those through the Trevor Project, remain staffed should LGBTQ youth need to access their services (1-866-488-7386, plus text and chat). They can be reached 24/7 to help those whose mental health has been affected during this pandemic. Third, youth can continue to stay connected to their friends through means such as Zoom, FaceTime, or other virtual audiovisual tools. Lastly, some youth have taken to meeting in school parking lots, mall parking lots, etc., and staying at least 6 feet apart so that they can still see their friends in person.

While the current times may be challenging, they will pass and we will be able to return to those activities that bring us joy. Do not hesitate to reach out if you need help. As Rainer Maria Rilke once said, “In the difficult, we must have our joys, our happiness, our dreams: There against the depth of this background, they stand out, there for the first time we see how beautiful they are.”
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. He has no relevant financial disclosures. Dr. Cooper is on Twitter @teendocmbc. Email him at [email protected].

If you are anything like me, March 1 came and went as just another first day of the month. Few of us could have imagined that our day-to-day way of life would soon be upended, and our country would be in the midst of the COVID-19 pandemic. While there is considerable anxiety around protecting our individual health, social distancing and the physical isolation that comes from it have cut off a vital source of support for many of our lesbian, gay, bisexual, transgender, and questioning (or queer) (LGBTQ) youth. Shared experiences with other young people like themselves provide these youth with a sense of community that they may not find in their schools, towns, etc.

LGBTQ youth already face increased rates of anxiety and depression compared with their heterosexual and cisgender peers. According to the 2017 Youth Risk Behavior Survey, 63% of LGB youth nationwide reported feeling sad or hopeless compared with 28% of their heterosexual peers. While quarantined at home, many of these youth now are stuck for many more hours per day with families who may not accept them for who they are. Previous research by Ryan et al. shows that LGB adolescents who have higher rates of family rejection are nearly six times more likely to have higher rates of depression and more than eight times more likely to attempt suicide than their peers who come from families with low or no levels of rejection (Pediatrics. 2009 Jan;123[1]:346-52). Going to school for roughly 8 hours a day allows some of these youth an escape from what is otherwise an unpleasant home situation. In addition, educators and other school staff may be among the only allies that a student has in his/her life, and school cancellations remove students from access to these important people.

AJ_Watt/E+

Due to stay-at-home orders and physical distancing measures, lack of in-person access to medical and psychological care can be distressing for many LGBTQ youth. While many practices have been able to convert to audiovisual telemedicine visits, not all of them have the resources or capability to do so. Consequently, LGBTQ youth may have reduced access to support services that help to bolster their social and emotional health. In addition, many trans youth suffer from physical dysphoria that can make it distressing to see themselves on camera doing teletherapy and so they wish to avoid it for this reason.

This is not to say that everything is bleak. LGBTQ youth can also be resilient in times of stress and worry. “The LGBTQ community has a long history of overcoming adversity and utilizing challenges to build an even stronger sense of community. This pandemic will create yet another opportunity for us to highlight existing health disparities and to support our LGBTQ young people in finding creative responses,” said Heather Newby, LCSW, clinical social worker for the GENECIS (GENder Education and Care Interdisciplinary Support) Program at Children’s Medical Center Dallas. In addition, she reported that many LGBTQ advocacy groups have created excellent online support networks and resources to provide nationwide, regional, and local help. By leveraging these youths’ capability for resilience, we are best able to support them during a time of crisis.

During these challenging times, there are a number of resources that LGBTQ youth can turn to while trying to maintain their connection to their peers. First, many local LGBTQ service organizations have moved their in-person support groups to a virtual or online platform. Check with your local service organization to see what they are offering during these times. National organizations, such as Gender Spectrum, continue to have online groups as well that youth can participate in. Second, many virtual mental health helplines, such as those through the Trevor Project, remain staffed should LGBTQ youth need to access their services (1-866-488-7386, plus text and chat). They can be reached 24/7 to help those whose mental health has been affected during this pandemic. Third, youth can continue to stay connected to their friends through means such as Zoom, FaceTime, or other virtual audiovisual tools. Lastly, some youth have taken to meeting in school parking lots, mall parking lots, etc., and staying at least 6 feet apart so that they can still see their friends in person.

While the current times may be challenging, they will pass and we will be able to return to those activities that bring us joy. Do not hesitate to reach out if you need help. As Rainer Maria Rilke once said, “In the difficult, we must have our joys, our happiness, our dreams: There against the depth of this background, they stand out, there for the first time we see how beautiful they are.”
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. He has no relevant financial disclosures. Dr. Cooper is on Twitter @teendocmbc. Email him at [email protected].

As the coronavirus pandemic has swept across America, so have advisories for social distancing. As of April 2, stay-at-home orders had been given in 38 states and parts of 7 more, affecting about 300 million people. Most of these people have been asked to maintain 6 feet of separation to anyone outside their immediate family and to avoid all avoidable contacts.

Typical hospital medicine patients at an academic hospital, however, traditionally receive visits from their hospitalist, an intern, a resident, and sometimes several medical students, pharmacists, and case managers. At University of California, San Diego, Health, many of these visits would occur during Focused Interdisciplinary Team rounds, with providers moving together in close proximity.

Asymptomatic and presymptomatic spread of coronavirus have been documented, which means distancing is a good idea for everyone. The risks of traditional patient visits during the coronavirus pandemic include spread to both patients (at high risk of complications) and staff (taken out of the workforce during surge times). Even if coronavirus were not a risk, visits to isolation rooms consume PPE, which is in short supply.

In response to the pandemic, UCSD Hospital Medicine drafted guidelines for the reduction of patient contacts. Our slide presentations and written guidelines were then distributed to physicians, nurses, pharmacists, and other staff by our pandemic response command center. Key points include the following:

• Target one in-person MD visit per day for stable patients. This means that attending reexaminations of patients seen by residents, nurse practitioners, physician assistants, and so on would not be done for billing or teaching purposes, only when clinically necessary.
• Use phone or video conferencing for follow-up discussions unless direct patient contact is needed.
• Consider skipping daily exams on patients who do not require them, such as patients awaiting placement or stably receiving long courses of antibiotics. Interview them remotely or from the door instead.
• Conduct team rounds, patient discussions, and handoffs with all members 6 feet apart or by telephone or video. Avoid shared work rooms. Substitute video conferences for in-person meetings. Use EMR embedded messaging to reduce face-to-face discussions.
• Check if a patient is ready for a visit before donning PPE to avoid waste.
• Explain to patients that distancing is being conducted to protect them. In our experience, when patients are asked about distancing, they welcome the changes.

We have also considered that most patient visits are generated by nurses and assistants. To increase distancing and reduce PPE waste, we have encouraged nurses and pharmacists to maximize their use of remote communication with patients and to suggest changes to care plans and come up with creative solutions to reduce traffic. We specifically suggested the following changes to routine care:

• Reduce frequency of taking vital signs, such as just daily or as needed, in stable patients (for example, those awaiting placement).
• Reduce checks for alcohol withdrawal and neurologic status as soon as possible, and stop fingersticks in patients with well-controlled diabetes not receiving insulin.
• Substitute less frequently administered medications where appropriate if doing so would reduce room traffic (such as enoxaparin for heparin, ceftriaxone for cefazolin, naproxen for ibuprofen, or patient-controlled analgesia for as needed morphine).
• Place intravenous pumps in halls if needed – luckily, our situation has not required these measures in San Diego.
• Explore the possibility of increased patient self-management (self-dosed insulin or inhalers) where medically appropriate.
• Eliminate food service and janitorial trips to isolation rooms unless requested by registered nurse.

There are clear downsides to medical distancing for hospital medicine patients. Patients might have delayed diagnosis of new conditions or inadequate management of conditions requiring frequent assessment, such as alcohol withdrawal. Opportunities for miscommunication (either patient-provider or provider-provider) may be increased with distancing. Isolation also comes with emotional costs such as stress and feelings of isolation or abandonment. Given the dynamic nature of the pandemic response, we are continually reevaluating our distancing guidelines to administer the safest and most effective hospital care possible as we approach California’s expected peak coronavirus infection period.

Dr. Jenkins is professor and chair of the Patient Safety Committee in the Division of Hospital Medicine at UCSD. Dr. Seymann is clinical professor and vice chief for academic affairs, UCSD division of hospital medicine. Dr. Horman and Dr. Bell are hospitalists and associate professors of medicine at UC San Diego Health.

As the coronavirus pandemic has swept across America, so have advisories for social distancing. As of April 2, stay-at-home orders had been given in 38 states and parts of 7 more, affecting about 300 million people. Most of these people have been asked to maintain 6 feet of separation to anyone outside their immediate family and to avoid all avoidable contacts.

Typical hospital medicine patients at an academic hospital, however, traditionally receive visits from their hospitalist, an intern, a resident, and sometimes several medical students, pharmacists, and case managers. At University of California, San Diego, Health, many of these visits would occur during Focused Interdisciplinary Team rounds, with providers moving together in close proximity.

Asymptomatic and presymptomatic spread of coronavirus have been documented, which means distancing is a good idea for everyone. The risks of traditional patient visits during the coronavirus pandemic include spread to both patients (at high risk of complications) and staff (taken out of the workforce during surge times). Even if coronavirus were not a risk, visits to isolation rooms consume PPE, which is in short supply.

In response to the pandemic, UCSD Hospital Medicine drafted guidelines for the reduction of patient contacts. Our slide presentations and written guidelines were then distributed to physicians, nurses, pharmacists, and other staff by our pandemic response command center. Key points include the following:

• Target one in-person MD visit per day for stable patients. This means that attending reexaminations of patients seen by residents, nurse practitioners, physician assistants, and so on would not be done for billing or teaching purposes, only when clinically necessary.
• Use phone or video conferencing for follow-up discussions unless direct patient contact is needed.
• Consider skipping daily exams on patients who do not require them, such as patients awaiting placement or stably receiving long courses of antibiotics. Interview them remotely or from the door instead.
• Conduct team rounds, patient discussions, and handoffs with all members 6 feet apart or by telephone or video. Avoid shared work rooms. Substitute video conferences for in-person meetings. Use EMR embedded messaging to reduce face-to-face discussions.
• Check if a patient is ready for a visit before donning PPE to avoid waste.
• Explain to patients that distancing is being conducted to protect them. In our experience, when patients are asked about distancing, they welcome the changes.

We have also considered that most patient visits are generated by nurses and assistants. To increase distancing and reduce PPE waste, we have encouraged nurses and pharmacists to maximize their use of remote communication with patients and to suggest changes to care plans and come up with creative solutions to reduce traffic. We specifically suggested the following changes to routine care:

• Reduce frequency of taking vital signs, such as just daily or as needed, in stable patients (for example, those awaiting placement).
• Reduce checks for alcohol withdrawal and neurologic status as soon as possible, and stop fingersticks in patients with well-controlled diabetes not receiving insulin.
• Substitute less frequently administered medications where appropriate if doing so would reduce room traffic (such as enoxaparin for heparin, ceftriaxone for cefazolin, naproxen for ibuprofen, or patient-controlled analgesia for as needed morphine).
• Place intravenous pumps in halls if needed – luckily, our situation has not required these measures in San Diego.
• Explore the possibility of increased patient self-management (self-dosed insulin or inhalers) where medically appropriate.
• Eliminate food service and janitorial trips to isolation rooms unless requested by registered nurse.

There are clear downsides to medical distancing for hospital medicine patients. Patients might have delayed diagnosis of new conditions or inadequate management of conditions requiring frequent assessment, such as alcohol withdrawal. Opportunities for miscommunication (either patient-provider or provider-provider) may be increased with distancing. Isolation also comes with emotional costs such as stress and feelings of isolation or abandonment. Given the dynamic nature of the pandemic response, we are continually reevaluating our distancing guidelines to administer the safest and most effective hospital care possible as we approach California’s expected peak coronavirus infection period.

Dr. Jenkins is professor and chair of the Patient Safety Committee in the Division of Hospital Medicine at UCSD. Dr. Seymann is clinical professor and vice chief for academic affairs, UCSD division of hospital medicine. Dr. Horman and Dr. Bell are hospitalists and associate professors of medicine at UC San Diego Health.

As the coronavirus pandemic has swept across America, so have advisories for social distancing. As of April 2, stay-at-home orders had been given in 38 states and parts of 7 more, affecting about 300 million people. Most of these people have been asked to maintain 6 feet of separation to anyone outside their immediate family and to avoid all avoidable contacts.

Typical hospital medicine patients at an academic hospital, however, traditionally receive visits from their hospitalist, an intern, a resident, and sometimes several medical students, pharmacists, and case managers. At University of California, San Diego, Health, many of these visits would occur during Focused Interdisciplinary Team rounds, with providers moving together in close proximity.

Asymptomatic and presymptomatic spread of coronavirus have been documented, which means distancing is a good idea for everyone. The risks of traditional patient visits during the coronavirus pandemic include spread to both patients (at high risk of complications) and staff (taken out of the workforce during surge times). Even if coronavirus were not a risk, visits to isolation rooms consume PPE, which is in short supply.

In response to the pandemic, UCSD Hospital Medicine drafted guidelines for the reduction of patient contacts. Our slide presentations and written guidelines were then distributed to physicians, nurses, pharmacists, and other staff by our pandemic response command center. Key points include the following:

• Target one in-person MD visit per day for stable patients. This means that attending reexaminations of patients seen by residents, nurse practitioners, physician assistants, and so on would not be done for billing or teaching purposes, only when clinically necessary.
• Use phone or video conferencing for follow-up discussions unless direct patient contact is needed.
• Consider skipping daily exams on patients who do not require them, such as patients awaiting placement or stably receiving long courses of antibiotics. Interview them remotely or from the door instead.
• Conduct team rounds, patient discussions, and handoffs with all members 6 feet apart or by telephone or video. Avoid shared work rooms. Substitute video conferences for in-person meetings. Use EMR embedded messaging to reduce face-to-face discussions.
• Check if a patient is ready for a visit before donning PPE to avoid waste.
• Explain to patients that distancing is being conducted to protect them. In our experience, when patients are asked about distancing, they welcome the changes.

We have also considered that most patient visits are generated by nurses and assistants. To increase distancing and reduce PPE waste, we have encouraged nurses and pharmacists to maximize their use of remote communication with patients and to suggest changes to care plans and come up with creative solutions to reduce traffic. We specifically suggested the following changes to routine care:

• Reduce frequency of taking vital signs, such as just daily or as needed, in stable patients (for example, those awaiting placement).
• Reduce checks for alcohol withdrawal and neurologic status as soon as possible, and stop fingersticks in patients with well-controlled diabetes not receiving insulin.
• Substitute less frequently administered medications where appropriate if doing so would reduce room traffic (such as enoxaparin for heparin, ceftriaxone for cefazolin, naproxen for ibuprofen, or patient-controlled analgesia for as needed morphine).
• Place intravenous pumps in halls if needed – luckily, our situation has not required these measures in San Diego.
• Explore the possibility of increased patient self-management (self-dosed insulin or inhalers) where medically appropriate.
• Eliminate food service and janitorial trips to isolation rooms unless requested by registered nurse.

There are clear downsides to medical distancing for hospital medicine patients. Patients might have delayed diagnosis of new conditions or inadequate management of conditions requiring frequent assessment, such as alcohol withdrawal. Opportunities for miscommunication (either patient-provider or provider-provider) may be increased with distancing. Isolation also comes with emotional costs such as stress and feelings of isolation or abandonment. Given the dynamic nature of the pandemic response, we are continually reevaluating our distancing guidelines to administer the safest and most effective hospital care possible as we approach California’s expected peak coronavirus infection period.

Dr. Jenkins is professor and chair of the Patient Safety Committee in the Division of Hospital Medicine at UCSD. Dr. Seymann is clinical professor and vice chief for academic affairs, UCSD division of hospital medicine. Dr. Horman and Dr. Bell are hospitalists and associate professors of medicine at UC San Diego Health.