CHEST Physician

Physicians in China are reporting what they believe is the first case of COVID-19 initially presenting as acute Guillain-Barré syndrome (GBS). The patient was a 61-year-old woman returning home from Wuhan during the pandemic.

“GBS is an autoimmune neuropathy, which could be triggered by various infections,” said corresponding author Sheng Chen, MD, PhD, of Shanghai Jiao Tong University School of Medicine in China. However, “Our single case report only suggests a possible association between GBS and SARS-CoV-2 infection. It may or may not have a causal relationship,” Dr. Chen noted.

The case study was published online April 1 in Lancet Neurology.
 

GBS presentation

The female patient returned from Wuhan on January 19 but denied having any fever, cough, chest pain, or diarrhea. She presented on January 23 with acute weakness in both legs and severe fatigue that progressed.

At presentation, temperature was normal, oxygen saturation was 99% on room air, and the patient’s respiratory rate was 16 breaths per minute. She was not tested for SARS-CoV-2 at that point.

A neurologic examination revealed symmetric weakness (Medical Research Council grade 4/5) and areflexia in both legs and feet. The patient’s symptoms had progressed 3 days after admission, and testing revealed decreased sensation to light touch and pinprick.

Admission laboratory test results indicated a low lymphocyte count and thrombocytopenia. Results of nerve conduction studies performed on day 5 of hospitalization were consistent with demyelinating neuropathy.

She was diagnosed with GBS and given intravenous immunoglobulin. On day 8, she developed a dry cough and fever, and a chest CT showed ground-glass opacities in both lungs. At this point, she was tested for SARS-CoV-2, and the results were positive.

The patient was immediately transferred to an isolation room and received supportive care and antiviral drugs. Her condition improved gradually, and her lymphocyte and thrombocyte counts were normal on day 20.

At discharge on day 30, she had normal muscle strength in both arms and legs, and tendon reflexes in both legs and feet had returned. Her respiratory symptoms had resolved as well. A second SARS-CoV-2 test was negative.
 

Different pattern from Zika

Two relatives of the patient who had been with her during her hospital stay also tested positive for SARS-CoV-2 and were isolated and treated. All of the hospital staff that cared for the patient, including two neurologists and six nurses, tested negative for SARS-CoV-2.

Given the temporal association, a SARS-CoV-2 infection could be responsible for the development of GBS in this patient, the investigators noted. They added that the onset of GBS symptoms overlapped with the period of SARS-CoV-2 infection.

“Hence Guillain-Barré syndrome associated with SARS-CoV-2 might follow the pattern of a parainfectious profile, instead of the classic postinfectious profile, as reported in Guillain-Barré syndrome associated with Zika virus,” the researchers wrote.

“More cases with epidemiological data are necessary to support a causal relationship” between SARS-CoV-2 infection and GBS, said Dr. Chen.

“However, we still suggest physicians who encounter an acute GBS patient from a pandemic area protect themselves carefully and test [for the] virus on admission. If the result is positive, the patient needs to be isolated,” Dr. Chen said.

This article was first published on Medscape.com.

Physicians in China are reporting what they believe is the first case of COVID-19 initially presenting as acute Guillain-Barré syndrome (GBS). The patient was a 61-year-old woman returning home from Wuhan during the pandemic.

“GBS is an autoimmune neuropathy, which could be triggered by various infections,” said corresponding author Sheng Chen, MD, PhD, of Shanghai Jiao Tong University School of Medicine in China. However, “Our single case report only suggests a possible association between GBS and SARS-CoV-2 infection. It may or may not have a causal relationship,” Dr. Chen noted.

The case study was published online April 1 in Lancet Neurology.
 

GBS presentation

The female patient returned from Wuhan on January 19 but denied having any fever, cough, chest pain, or diarrhea. She presented on January 23 with acute weakness in both legs and severe fatigue that progressed.

At presentation, temperature was normal, oxygen saturation was 99% on room air, and the patient’s respiratory rate was 16 breaths per minute. She was not tested for SARS-CoV-2 at that point.

A neurologic examination revealed symmetric weakness (Medical Research Council grade 4/5) and areflexia in both legs and feet. The patient’s symptoms had progressed 3 days after admission, and testing revealed decreased sensation to light touch and pinprick.

Admission laboratory test results indicated a low lymphocyte count and thrombocytopenia. Results of nerve conduction studies performed on day 5 of hospitalization were consistent with demyelinating neuropathy.

She was diagnosed with GBS and given intravenous immunoglobulin. On day 8, she developed a dry cough and fever, and a chest CT showed ground-glass opacities in both lungs. At this point, she was tested for SARS-CoV-2, and the results were positive.

The patient was immediately transferred to an isolation room and received supportive care and antiviral drugs. Her condition improved gradually, and her lymphocyte and thrombocyte counts were normal on day 20.

At discharge on day 30, she had normal muscle strength in both arms and legs, and tendon reflexes in both legs and feet had returned. Her respiratory symptoms had resolved as well. A second SARS-CoV-2 test was negative.
 

Different pattern from Zika

Two relatives of the patient who had been with her during her hospital stay also tested positive for SARS-CoV-2 and were isolated and treated. All of the hospital staff that cared for the patient, including two neurologists and six nurses, tested negative for SARS-CoV-2.

Given the temporal association, a SARS-CoV-2 infection could be responsible for the development of GBS in this patient, the investigators noted. They added that the onset of GBS symptoms overlapped with the period of SARS-CoV-2 infection.

“Hence Guillain-Barré syndrome associated with SARS-CoV-2 might follow the pattern of a parainfectious profile, instead of the classic postinfectious profile, as reported in Guillain-Barré syndrome associated with Zika virus,” the researchers wrote.

“More cases with epidemiological data are necessary to support a causal relationship” between SARS-CoV-2 infection and GBS, said Dr. Chen.

“However, we still suggest physicians who encounter an acute GBS patient from a pandemic area protect themselves carefully and test [for the] virus on admission. If the result is positive, the patient needs to be isolated,” Dr. Chen said.

This article was first published on Medscape.com.

Physicians in China are reporting what they believe is the first case of COVID-19 initially presenting as acute Guillain-Barré syndrome (GBS). The patient was a 61-year-old woman returning home from Wuhan during the pandemic.

“GBS is an autoimmune neuropathy, which could be triggered by various infections,” said corresponding author Sheng Chen, MD, PhD, of Shanghai Jiao Tong University School of Medicine in China. However, “Our single case report only suggests a possible association between GBS and SARS-CoV-2 infection. It may or may not have a causal relationship,” Dr. Chen noted.

The case study was published online April 1 in Lancet Neurology.
 

GBS presentation

The female patient returned from Wuhan on January 19 but denied having any fever, cough, chest pain, or diarrhea. She presented on January 23 with acute weakness in both legs and severe fatigue that progressed.

At presentation, temperature was normal, oxygen saturation was 99% on room air, and the patient’s respiratory rate was 16 breaths per minute. She was not tested for SARS-CoV-2 at that point.

A neurologic examination revealed symmetric weakness (Medical Research Council grade 4/5) and areflexia in both legs and feet. The patient’s symptoms had progressed 3 days after admission, and testing revealed decreased sensation to light touch and pinprick.

Admission laboratory test results indicated a low lymphocyte count and thrombocytopenia. Results of nerve conduction studies performed on day 5 of hospitalization were consistent with demyelinating neuropathy.

She was diagnosed with GBS and given intravenous immunoglobulin. On day 8, she developed a dry cough and fever, and a chest CT showed ground-glass opacities in both lungs. At this point, she was tested for SARS-CoV-2, and the results were positive.

The patient was immediately transferred to an isolation room and received supportive care and antiviral drugs. Her condition improved gradually, and her lymphocyte and thrombocyte counts were normal on day 20.

At discharge on day 30, she had normal muscle strength in both arms and legs, and tendon reflexes in both legs and feet had returned. Her respiratory symptoms had resolved as well. A second SARS-CoV-2 test was negative.
 

Different pattern from Zika

Two relatives of the patient who had been with her during her hospital stay also tested positive for SARS-CoV-2 and were isolated and treated. All of the hospital staff that cared for the patient, including two neurologists and six nurses, tested negative for SARS-CoV-2.

Given the temporal association, a SARS-CoV-2 infection could be responsible for the development of GBS in this patient, the investigators noted. They added that the onset of GBS symptoms overlapped with the period of SARS-CoV-2 infection.

“Hence Guillain-Barré syndrome associated with SARS-CoV-2 might follow the pattern of a parainfectious profile, instead of the classic postinfectious profile, as reported in Guillain-Barré syndrome associated with Zika virus,” the researchers wrote.

“More cases with epidemiological data are necessary to support a causal relationship” between SARS-CoV-2 infection and GBS, said Dr. Chen.

“However, we still suggest physicians who encounter an acute GBS patient from a pandemic area protect themselves carefully and test [for the] virus on admission. If the result is positive, the patient needs to be isolated,” Dr. Chen said.

This article was first published on Medscape.com.

In my New Mexico reproductive health clinic one week in early April, I saw more than twice the number of patients usually scheduled, all seeking abortion care. Two-thirds of those patients were from Texas – some came from towns as close as 6 hours away, and at least two drove for more than 11 hours to receive care at our clinic. In addition to the many reasons women pursue abortion care, all of my patients had an overriding concern about the COVID-19 pandemic. Many worried for the safety of their parents and children; some worried about the safety of continuing a pregnancy during the pandemic; and many were worried for themselves because of the risk involved in their employment or their status as the sole breadwinner for their families. One patient chose an abortion for severe fetal anomalies diagnosed in the early second trimester; she had an appointment with a provider in Texas, which was canceled the day the Texas abortion ban was reinstated. New Mexico, more than 10 hours away, was the closest location to receive the care she needed; she traveled by car with her children.

I am fortunate to live in New Mexico. On March 24, New Mexico Secretary of Health Kathyleen “Kathy” Kunkel affirmed reproductive health care as an essential service. The American College of Obstetricians and Gynecologists, the U.S. professional organization for reproductive health care, agrees. In a joint statement with seven other professional organizations, they emphasize the importance of abortion access: “Abortion is an essential component of comprehensive health care. It is also a time-sensitive service. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being.”

Anti-abortion politicians are using the crisis as an opportunity to restrict health care access as they have done for my patients who have driven hundreds of miles for essential care they should receive in their home communities. My heart goes out to our patients and the burden they have been forced to take on at a time when our politicians should be protecting and ensuring their safety. Particularly during this national emergency, we should come together to support women and families, and to ensure all of our health care needs are met.

Dr. Espey is an obstetrician and gynecologist in New Mexico. She has no relevant financial disclosures. Dr. Espey is a member of the Ob.Gyn. News Editorial Advisory Board. Email her at [email protected].

In my New Mexico reproductive health clinic one week in early April, I saw more than twice the number of patients usually scheduled, all seeking abortion care. Two-thirds of those patients were from Texas – some came from towns as close as 6 hours away, and at least two drove for more than 11 hours to receive care at our clinic. In addition to the many reasons women pursue abortion care, all of my patients had an overriding concern about the COVID-19 pandemic. Many worried for the safety of their parents and children; some worried about the safety of continuing a pregnancy during the pandemic; and many were worried for themselves because of the risk involved in their employment or their status as the sole breadwinner for their families. One patient chose an abortion for severe fetal anomalies diagnosed in the early second trimester; she had an appointment with a provider in Texas, which was canceled the day the Texas abortion ban was reinstated. New Mexico, more than 10 hours away, was the closest location to receive the care she needed; she traveled by car with her children.

I am fortunate to live in New Mexico. On March 24, New Mexico Secretary of Health Kathyleen “Kathy” Kunkel affirmed reproductive health care as an essential service. The American College of Obstetricians and Gynecologists, the U.S. professional organization for reproductive health care, agrees. In a joint statement with seven other professional organizations, they emphasize the importance of abortion access: “Abortion is an essential component of comprehensive health care. It is also a time-sensitive service. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being.”

Anti-abortion politicians are using the crisis as an opportunity to restrict health care access as they have done for my patients who have driven hundreds of miles for essential care they should receive in their home communities. My heart goes out to our patients and the burden they have been forced to take on at a time when our politicians should be protecting and ensuring their safety. Particularly during this national emergency, we should come together to support women and families, and to ensure all of our health care needs are met.

Dr. Espey is an obstetrician and gynecologist in New Mexico. She has no relevant financial disclosures. Dr. Espey is a member of the Ob.Gyn. News Editorial Advisory Board. Email her at [email protected].

In my New Mexico reproductive health clinic one week in early April, I saw more than twice the number of patients usually scheduled, all seeking abortion care. Two-thirds of those patients were from Texas – some came from towns as close as 6 hours away, and at least two drove for more than 11 hours to receive care at our clinic. In addition to the many reasons women pursue abortion care, all of my patients had an overriding concern about the COVID-19 pandemic. Many worried for the safety of their parents and children; some worried about the safety of continuing a pregnancy during the pandemic; and many were worried for themselves because of the risk involved in their employment or their status as the sole breadwinner for their families. One patient chose an abortion for severe fetal anomalies diagnosed in the early second trimester; she had an appointment with a provider in Texas, which was canceled the day the Texas abortion ban was reinstated. New Mexico, more than 10 hours away, was the closest location to receive the care she needed; she traveled by car with her children.

I am fortunate to live in New Mexico. On March 24, New Mexico Secretary of Health Kathyleen “Kathy” Kunkel affirmed reproductive health care as an essential service. The American College of Obstetricians and Gynecologists, the U.S. professional organization for reproductive health care, agrees. In a joint statement with seven other professional organizations, they emphasize the importance of abortion access: “Abortion is an essential component of comprehensive health care. It is also a time-sensitive service. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being.”

Anti-abortion politicians are using the crisis as an opportunity to restrict health care access as they have done for my patients who have driven hundreds of miles for essential care they should receive in their home communities. My heart goes out to our patients and the burden they have been forced to take on at a time when our politicians should be protecting and ensuring their safety. Particularly during this national emergency, we should come together to support women and families, and to ensure all of our health care needs are met.

Dr. Espey is an obstetrician and gynecologist in New Mexico. She has no relevant financial disclosures. Dr. Espey is a member of the Ob.Gyn. News Editorial Advisory Board. Email her at [email protected].

It is often said that a crisis brings out the best and worst in people, and I think we are definitely seeing that when it comes to the responses to reproductive health, family planning, and abortion care during this global pandemic.

Many national and international organizations have published strong statements of support for the importance of continuing reproductive health services. These organizations include the American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, the American Society for Reproductive Medicine, the Society of Family Planning, the Society for Maternal-Fetal Medicine, Society of Family Planning, American Medical Association, the World Health Organization, and the Ethiopian Society of Obstetricians and Gynecologists. They state the obvious, which is that abortion is a time-sensitive procedure, and it cannot be delayed until the end of this COVID-19 pandemic.

We do not have complete knowledge of what the novel coronavirus 2019 does to a developing pregnancy, especially early in pregnancy. Many people who are struggling with all the uncertainty of this time – job, health, housing, food, school – may decide it is not the best moment to be adding to their family.

These concerns apply as well to the need to maintain and prioritize contraceptive services. Stay-at-home orders have put people in close quarters for long periods of time, and we are already getting reports of increased sexual intercourse, as well as increased sexual violence, both of which could result in a need for abortion if contraception is not accessible. Additionally, many women are expressing a concern for whether they will still have a job or have a job again when this first wave of the crisis passes, so they are wanting to access contraception now when they can afford to do so.

I was personally very proud of and grateful to Barbara A. Goff, MD, the chair of my department at the University of Washington, Seattle, for stating clearly in the first email she sent to faculty about canceling elective procedures and visits that family planning and abortion is not elective. My heart goes out to my colleagues and the patients who are in states that are using this opportunity to act poorly and use COVID-19 as another excuse to legislate against abortion and contraception. It demonstrates horrifying gender discrimination during a time when we should really be focusing on keeping everyone healthy.

I predict there will be an increase in the numbers of abortions after this crisis ebbs, and an increase in the numbers of term deliveries. The time to influence that is now.

Dr. Prager is professor of obstetrics and gynecology, chief of the family planning division, and director of the family planning fellowship at the University of Washington, Seattle. She also is professor of obstetrics and gynecology at St. Paul’s Hospital and Millennium Medical College in Addis Ababa, Ethiopia. Dr. Prager is a member of the Ob.Gyn. News editorial advisory board. She said she has no relevant financial disclosures. Email Dr. Prager at [email protected].

It is often said that a crisis brings out the best and worst in people, and I think we are definitely seeing that when it comes to the responses to reproductive health, family planning, and abortion care during this global pandemic.

Many national and international organizations have published strong statements of support for the importance of continuing reproductive health services. These organizations include the American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, the American Society for Reproductive Medicine, the Society of Family Planning, the Society for Maternal-Fetal Medicine, Society of Family Planning, American Medical Association, the World Health Organization, and the Ethiopian Society of Obstetricians and Gynecologists. They state the obvious, which is that abortion is a time-sensitive procedure, and it cannot be delayed until the end of this COVID-19 pandemic.

We do not have complete knowledge of what the novel coronavirus 2019 does to a developing pregnancy, especially early in pregnancy. Many people who are struggling with all the uncertainty of this time – job, health, housing, food, school – may decide it is not the best moment to be adding to their family.

These concerns apply as well to the need to maintain and prioritize contraceptive services. Stay-at-home orders have put people in close quarters for long periods of time, and we are already getting reports of increased sexual intercourse, as well as increased sexual violence, both of which could result in a need for abortion if contraception is not accessible. Additionally, many women are expressing a concern for whether they will still have a job or have a job again when this first wave of the crisis passes, so they are wanting to access contraception now when they can afford to do so.

I was personally very proud of and grateful to Barbara A. Goff, MD, the chair of my department at the University of Washington, Seattle, for stating clearly in the first email she sent to faculty about canceling elective procedures and visits that family planning and abortion is not elective. My heart goes out to my colleagues and the patients who are in states that are using this opportunity to act poorly and use COVID-19 as another excuse to legislate against abortion and contraception. It demonstrates horrifying gender discrimination during a time when we should really be focusing on keeping everyone healthy.

I predict there will be an increase in the numbers of abortions after this crisis ebbs, and an increase in the numbers of term deliveries. The time to influence that is now.

Dr. Prager is professor of obstetrics and gynecology, chief of the family planning division, and director of the family planning fellowship at the University of Washington, Seattle. She also is professor of obstetrics and gynecology at St. Paul’s Hospital and Millennium Medical College in Addis Ababa, Ethiopia. Dr. Prager is a member of the Ob.Gyn. News editorial advisory board. She said she has no relevant financial disclosures. Email Dr. Prager at [email protected].

It is often said that a crisis brings out the best and worst in people, and I think we are definitely seeing that when it comes to the responses to reproductive health, family planning, and abortion care during this global pandemic.

Many national and international organizations have published strong statements of support for the importance of continuing reproductive health services. These organizations include the American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, the American Society for Reproductive Medicine, the Society of Family Planning, the Society for Maternal-Fetal Medicine, Society of Family Planning, American Medical Association, the World Health Organization, and the Ethiopian Society of Obstetricians and Gynecologists. They state the obvious, which is that abortion is a time-sensitive procedure, and it cannot be delayed until the end of this COVID-19 pandemic.

We do not have complete knowledge of what the novel coronavirus 2019 does to a developing pregnancy, especially early in pregnancy. Many people who are struggling with all the uncertainty of this time – job, health, housing, food, school – may decide it is not the best moment to be adding to their family.

These concerns apply as well to the need to maintain and prioritize contraceptive services. Stay-at-home orders have put people in close quarters for long periods of time, and we are already getting reports of increased sexual intercourse, as well as increased sexual violence, both of which could result in a need for abortion if contraception is not accessible. Additionally, many women are expressing a concern for whether they will still have a job or have a job again when this first wave of the crisis passes, so they are wanting to access contraception now when they can afford to do so.

I was personally very proud of and grateful to Barbara A. Goff, MD, the chair of my department at the University of Washington, Seattle, for stating clearly in the first email she sent to faculty about canceling elective procedures and visits that family planning and abortion is not elective. My heart goes out to my colleagues and the patients who are in states that are using this opportunity to act poorly and use COVID-19 as another excuse to legislate against abortion and contraception. It demonstrates horrifying gender discrimination during a time when we should really be focusing on keeping everyone healthy.

I predict there will be an increase in the numbers of abortions after this crisis ebbs, and an increase in the numbers of term deliveries. The time to influence that is now.

Dr. Prager is professor of obstetrics and gynecology, chief of the family planning division, and director of the family planning fellowship at the University of Washington, Seattle. She also is professor of obstetrics and gynecology at St. Paul’s Hospital and Millennium Medical College in Addis Ababa, Ethiopia. Dr. Prager is a member of the Ob.Gyn. News editorial advisory board. She said she has no relevant financial disclosures. Email Dr. Prager at [email protected].

As the coronavirus pandemic persists, insurers and the federal government are making it easier for mental health professionals to deliver safe and effective psychiatric services to patients via Zoom, FaceTime, and other conferencing tools. Many psychiatrists, meanwhile, are embracing telepsychiatry for the first time – in some cases with urgency.

Jay H. Shore, MD, MPH, said in an interview that mental health providers at his medical center have gone entirely virtual in recent weeks.

“The genie is out of the bottle on this,” said Dr. Shore, director of telemedicine at the Helen and Arthur E. Johnson Depression Center and director of telemedicine programming for the department of psychiatry at the University of Colorado at Denver, Aurora. He thinks this is the beginning of a new era that will last beyond the pandemic. “There’s going to be a much wider and diffuse acceptance of telemedicine as we go forward,” he added.

Dr. Shore and several colleagues from across the country offered several tips about factors to consider while learning to use telepsychiatry as a treatment tool.

To start, Dr. Shore advised reviewing the American Psychiatric Association’s Telepsychiatry Practice Guidelines and its Telepsychiatry Toolkit, which include dozens of brief videos about topics such as room lighting and managing the content process.

Another resource is the joint APA–American Academy of Child and Adolescent Psychiatry Telepsychiatry Toolkit, said Shabana Khan, MD, an assistant professor and director of telemedicine for the department of child and adolescent psychiatry at New York University Langone Health.

One of the challenges is managing emergencies long distance. If a patient experiences a mental health emergency in a psychiatrist’s office, the clinician can call 911 or direct staff to seek help. “When they’re at their house,” said Dr. Shore, “it’s a little different.”

Staff members are not present at home offices, for example, and the patient might live in a different city and therefore have a different 911 system. “It’s important to know your protocol about how you plan to handle these emergencies before you start working with the patient,” Dr. Shore said.

“Initially, I assumed that those with psychotic symptoms might struggle more. But I have been surprised at how well some patients have done,” said Andrew J. McLean, MD, MPH, clinical professor and chair of the department of psychiatry and behavioral science at the University of North Dakota, Grand Forks.

However, it might help to provide additional coaching to those patients, said Dr. Bristow. He offers a warning to these patients: “If you feel like you’re getting messages over the TV, my talking to you may make you feel worse.” However, “in every case, the patient was able to say, ‘I know you’re real.’ One patient even said: ‘I’ve heard these voices from my TV for years. But I know you’re a doctor, and you’re in an office trying to help me.’ ”

Dr. Shore thinks that video meetings have the potential to help psychiatrists and patients form better personal connections than in-person meetings. Patients with anxiety or PTSD, for example, “may feel safer since they’re in their own space, and they have a greater sense of control over the session than being in somebody’s office,” he said.

Dr. Khan agreed. “Some children, such as those with a significant trauma history or with significant anxiety, may feel more comfortable with this modality and may open up more during video sessions,” she said. In addition, “the distance that telepsychiatry provides may also enhance feelings of confidentiality and reduce potential stigma that may be associated with seeking mental health care.”

When it comes to using videoconferencing to treat children, take advantage of interactive features that are available, said Katherine Nguyen Williams, PhD. Zoom’s HIPAA-compliant health care software, for example, offers a “share screen” capability. “It allows for easy interactive activities,” said Dr. Nguyen Williams, director of strategic development and clinical innovation at Rady Children’s Hospital’s department of psychiatry at the University of California, San Diego. “Clinicians can play tic-tac-toe on the screen with the young patients, and they can work on cognitive-behavioral therapy worksheets together on the digital screen. Clinicians can even show a mindfulness video to the patient while actively coaching and giving feedback to the patient as they practice diaphragmatic breathing while viewing the video.

For more details about using telepsychiatry in the time of COVID-19, listen to the April 8 Psychcast Masterclass lecture by Dr. Shore.

As the coronavirus pandemic persists, insurers and the federal government are making it easier for mental health professionals to deliver safe and effective psychiatric services to patients via Zoom, FaceTime, and other conferencing tools. Many psychiatrists, meanwhile, are embracing telepsychiatry for the first time – in some cases with urgency.

Jay H. Shore, MD, MPH, said in an interview that mental health providers at his medical center have gone entirely virtual in recent weeks.

“The genie is out of the bottle on this,” said Dr. Shore, director of telemedicine at the Helen and Arthur E. Johnson Depression Center and director of telemedicine programming for the department of psychiatry at the University of Colorado at Denver, Aurora. He thinks this is the beginning of a new era that will last beyond the pandemic. “There’s going to be a much wider and diffuse acceptance of telemedicine as we go forward,” he added.

Dr. Shore and several colleagues from across the country offered several tips about factors to consider while learning to use telepsychiatry as a treatment tool.

To start, Dr. Shore advised reviewing the American Psychiatric Association’s Telepsychiatry Practice Guidelines and its Telepsychiatry Toolkit, which include dozens of brief videos about topics such as room lighting and managing the content process.

Another resource is the joint APA–American Academy of Child and Adolescent Psychiatry Telepsychiatry Toolkit, said Shabana Khan, MD, an assistant professor and director of telemedicine for the department of child and adolescent psychiatry at New York University Langone Health.

One of the challenges is managing emergencies long distance. If a patient experiences a mental health emergency in a psychiatrist’s office, the clinician can call 911 or direct staff to seek help. “When they’re at their house,” said Dr. Shore, “it’s a little different.”

Staff members are not present at home offices, for example, and the patient might live in a different city and therefore have a different 911 system. “It’s important to know your protocol about how you plan to handle these emergencies before you start working with the patient,” Dr. Shore said.

“Initially, I assumed that those with psychotic symptoms might struggle more. But I have been surprised at how well some patients have done,” said Andrew J. McLean, MD, MPH, clinical professor and chair of the department of psychiatry and behavioral science at the University of North Dakota, Grand Forks.

However, it might help to provide additional coaching to those patients, said Dr. Bristow. He offers a warning to these patients: “If you feel like you’re getting messages over the TV, my talking to you may make you feel worse.” However, “in every case, the patient was able to say, ‘I know you’re real.’ One patient even said: ‘I’ve heard these voices from my TV for years. But I know you’re a doctor, and you’re in an office trying to help me.’ ”

Dr. Shore thinks that video meetings have the potential to help psychiatrists and patients form better personal connections than in-person meetings. Patients with anxiety or PTSD, for example, “may feel safer since they’re in their own space, and they have a greater sense of control over the session than being in somebody’s office,” he said.

Dr. Khan agreed. “Some children, such as those with a significant trauma history or with significant anxiety, may feel more comfortable with this modality and may open up more during video sessions,” she said. In addition, “the distance that telepsychiatry provides may also enhance feelings of confidentiality and reduce potential stigma that may be associated with seeking mental health care.”

When it comes to using videoconferencing to treat children, take advantage of interactive features that are available, said Katherine Nguyen Williams, PhD. Zoom’s HIPAA-compliant health care software, for example, offers a “share screen” capability. “It allows for easy interactive activities,” said Dr. Nguyen Williams, director of strategic development and clinical innovation at Rady Children’s Hospital’s department of psychiatry at the University of California, San Diego. “Clinicians can play tic-tac-toe on the screen with the young patients, and they can work on cognitive-behavioral therapy worksheets together on the digital screen. Clinicians can even show a mindfulness video to the patient while actively coaching and giving feedback to the patient as they practice diaphragmatic breathing while viewing the video.

For more details about using telepsychiatry in the time of COVID-19, listen to the April 8 Psychcast Masterclass lecture by Dr. Shore.

As the coronavirus pandemic persists, insurers and the federal government are making it easier for mental health professionals to deliver safe and effective psychiatric services to patients via Zoom, FaceTime, and other conferencing tools. Many psychiatrists, meanwhile, are embracing telepsychiatry for the first time – in some cases with urgency.

Jay H. Shore, MD, MPH, said in an interview that mental health providers at his medical center have gone entirely virtual in recent weeks.

“The genie is out of the bottle on this,” said Dr. Shore, director of telemedicine at the Helen and Arthur E. Johnson Depression Center and director of telemedicine programming for the department of psychiatry at the University of Colorado at Denver, Aurora. He thinks this is the beginning of a new era that will last beyond the pandemic. “There’s going to be a much wider and diffuse acceptance of telemedicine as we go forward,” he added.

Dr. Shore and several colleagues from across the country offered several tips about factors to consider while learning to use telepsychiatry as a treatment tool.

To start, Dr. Shore advised reviewing the American Psychiatric Association’s Telepsychiatry Practice Guidelines and its Telepsychiatry Toolkit, which include dozens of brief videos about topics such as room lighting and managing the content process.

Another resource is the joint APA–American Academy of Child and Adolescent Psychiatry Telepsychiatry Toolkit, said Shabana Khan, MD, an assistant professor and director of telemedicine for the department of child and adolescent psychiatry at New York University Langone Health.

One of the challenges is managing emergencies long distance. If a patient experiences a mental health emergency in a psychiatrist’s office, the clinician can call 911 or direct staff to seek help. “When they’re at their house,” said Dr. Shore, “it’s a little different.”

Staff members are not present at home offices, for example, and the patient might live in a different city and therefore have a different 911 system. “It’s important to know your protocol about how you plan to handle these emergencies before you start working with the patient,” Dr. Shore said.

“Initially, I assumed that those with psychotic symptoms might struggle more. But I have been surprised at how well some patients have done,” said Andrew J. McLean, MD, MPH, clinical professor and chair of the department of psychiatry and behavioral science at the University of North Dakota, Grand Forks.

However, it might help to provide additional coaching to those patients, said Dr. Bristow. He offers a warning to these patients: “If you feel like you’re getting messages over the TV, my talking to you may make you feel worse.” However, “in every case, the patient was able to say, ‘I know you’re real.’ One patient even said: ‘I’ve heard these voices from my TV for years. But I know you’re a doctor, and you’re in an office trying to help me.’ ”

Dr. Shore thinks that video meetings have the potential to help psychiatrists and patients form better personal connections than in-person meetings. Patients with anxiety or PTSD, for example, “may feel safer since they’re in their own space, and they have a greater sense of control over the session than being in somebody’s office,” he said.

Dr. Khan agreed. “Some children, such as those with a significant trauma history or with significant anxiety, may feel more comfortable with this modality and may open up more during video sessions,” she said. In addition, “the distance that telepsychiatry provides may also enhance feelings of confidentiality and reduce potential stigma that may be associated with seeking mental health care.”

When it comes to using videoconferencing to treat children, take advantage of interactive features that are available, said Katherine Nguyen Williams, PhD. Zoom’s HIPAA-compliant health care software, for example, offers a “share screen” capability. “It allows for easy interactive activities,” said Dr. Nguyen Williams, director of strategic development and clinical innovation at Rady Children’s Hospital’s department of psychiatry at the University of California, San Diego. “Clinicians can play tic-tac-toe on the screen with the young patients, and they can work on cognitive-behavioral therapy worksheets together on the digital screen. Clinicians can even show a mindfulness video to the patient while actively coaching and giving feedback to the patient as they practice diaphragmatic breathing while viewing the video.

For more details about using telepsychiatry in the time of COVID-19, listen to the April 8 Psychcast Masterclass lecture by Dr. Shore.

The nation’s leading cardiology associations urged caution with hydroxychloroquine and azithromycin for COVID-19 in patients with cardiovascular disease.

Thinkstock

“Hydroxychloroquine and azithromycin have been touted for potential prophylaxis or treatment for COVID-19; both drugs are listed as definite causes of torsade de pointes” and increase in the risk of other arrhythmias and sudden death, the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society said in a joint statement April 8 in Circulation.

The statement came amid ongoing promotion by the Trump administration of hydroxychloroquine, in particular, for COVID-19 despite lack of strong data.

In addition to underlying cardiovascular disease, “seriously ill patients often have comorbidities that can increase risk of serious arrhythmias,” including hypokalemia, hypomagnesemia, fever, and systemic inflammation, the groups said.

They recommended withholding the drugs in patients with baseline QT prolongation (e.g., QTc of at least 500 msec) or with known congenital long QT syndrome; monitoring cardiac rhythm and QT interval and withdrawing hydroxychloroquine and azithromycin if QTc exceeds 500 msec; correcting hypokalemia to levels greater than 4 mEq/L and hypomagnesemia to more than 2 mg/dL; and avoiding other QTc-prolonging agents when possible.

The groups noted that, “in patients critically ill with COVID-19 infection, frequent caregiver contact may need to be minimized, so optimal electrocardiographic interval and rhythm monitoring may not be possible.” There is also a possible compounding arrhythmic effect when hydroxychloroquine and azithromycin are used together, but that has not been studied.

There’s a known risk of torsade de pointes with chloroquine and a possible risk with the antiviral HIV combination drug lopinavir-ritonavir, two other candidates for COVID-19 treatment. Hydroxychloroquine and chloroquine, both antimalarials, might help prevent or treat infection by interfering with angiotensin-converting enzyme 2 receptors, which the COVID-19 virus uses for cell entry, the groups said.

“The urgency of COVID-19 must not diminish the scientific rigor with which we approach COVID-19 treatment. While these medications may work against COVID-19 individually or in combination, we recommend caution with these medications for patients with existing cardiovascular disease,” Robert A. Harrington, MD, AHA president and chair of the department of medicine at Stanford (Calif.) University, emphasized in a press release.

[email protected]

SOURCE: Roden DM et al. Circulation. 2020 Apr 8. doi:10.1161/CIRCULATIONAHA.120.047521.

The nation’s leading cardiology associations urged caution with hydroxychloroquine and azithromycin for COVID-19 in patients with cardiovascular disease.

Thinkstock

“Hydroxychloroquine and azithromycin have been touted for potential prophylaxis or treatment for COVID-19; both drugs are listed as definite causes of torsade de pointes” and increase in the risk of other arrhythmias and sudden death, the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society said in a joint statement April 8 in Circulation.

The statement came amid ongoing promotion by the Trump administration of hydroxychloroquine, in particular, for COVID-19 despite lack of strong data.

In addition to underlying cardiovascular disease, “seriously ill patients often have comorbidities that can increase risk of serious arrhythmias,” including hypokalemia, hypomagnesemia, fever, and systemic inflammation, the groups said.

They recommended withholding the drugs in patients with baseline QT prolongation (e.g., QTc of at least 500 msec) or with known congenital long QT syndrome; monitoring cardiac rhythm and QT interval and withdrawing hydroxychloroquine and azithromycin if QTc exceeds 500 msec; correcting hypokalemia to levels greater than 4 mEq/L and hypomagnesemia to more than 2 mg/dL; and avoiding other QTc-prolonging agents when possible.

The groups noted that, “in patients critically ill with COVID-19 infection, frequent caregiver contact may need to be minimized, so optimal electrocardiographic interval and rhythm monitoring may not be possible.” There is also a possible compounding arrhythmic effect when hydroxychloroquine and azithromycin are used together, but that has not been studied.

There’s a known risk of torsade de pointes with chloroquine and a possible risk with the antiviral HIV combination drug lopinavir-ritonavir, two other candidates for COVID-19 treatment. Hydroxychloroquine and chloroquine, both antimalarials, might help prevent or treat infection by interfering with angiotensin-converting enzyme 2 receptors, which the COVID-19 virus uses for cell entry, the groups said.

“The urgency of COVID-19 must not diminish the scientific rigor with which we approach COVID-19 treatment. While these medications may work against COVID-19 individually or in combination, we recommend caution with these medications for patients with existing cardiovascular disease,” Robert A. Harrington, MD, AHA president and chair of the department of medicine at Stanford (Calif.) University, emphasized in a press release.

[email protected]

SOURCE: Roden DM et al. Circulation. 2020 Apr 8. doi:10.1161/CIRCULATIONAHA.120.047521.

The nation’s leading cardiology associations urged caution with hydroxychloroquine and azithromycin for COVID-19 in patients with cardiovascular disease.

Thinkstock

“Hydroxychloroquine and azithromycin have been touted for potential prophylaxis or treatment for COVID-19; both drugs are listed as definite causes of torsade de pointes” and increase in the risk of other arrhythmias and sudden death, the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society said in a joint statement April 8 in Circulation.

The statement came amid ongoing promotion by the Trump administration of hydroxychloroquine, in particular, for COVID-19 despite lack of strong data.

In addition to underlying cardiovascular disease, “seriously ill patients often have comorbidities that can increase risk of serious arrhythmias,” including hypokalemia, hypomagnesemia, fever, and systemic inflammation, the groups said.

They recommended withholding the drugs in patients with baseline QT prolongation (e.g., QTc of at least 500 msec) or with known congenital long QT syndrome; monitoring cardiac rhythm and QT interval and withdrawing hydroxychloroquine and azithromycin if QTc exceeds 500 msec; correcting hypokalemia to levels greater than 4 mEq/L and hypomagnesemia to more than 2 mg/dL; and avoiding other QTc-prolonging agents when possible.

The groups noted that, “in patients critically ill with COVID-19 infection, frequent caregiver contact may need to be minimized, so optimal electrocardiographic interval and rhythm monitoring may not be possible.” There is also a possible compounding arrhythmic effect when hydroxychloroquine and azithromycin are used together, but that has not been studied.

There’s a known risk of torsade de pointes with chloroquine and a possible risk with the antiviral HIV combination drug lopinavir-ritonavir, two other candidates for COVID-19 treatment. Hydroxychloroquine and chloroquine, both antimalarials, might help prevent or treat infection by interfering with angiotensin-converting enzyme 2 receptors, which the COVID-19 virus uses for cell entry, the groups said.

“The urgency of COVID-19 must not diminish the scientific rigor with which we approach COVID-19 treatment. While these medications may work against COVID-19 individually or in combination, we recommend caution with these medications for patients with existing cardiovascular disease,” Robert A. Harrington, MD, AHA president and chair of the department of medicine at Stanford (Calif.) University, emphasized in a press release.

[email protected]

SOURCE: Roden DM et al. Circulation. 2020 Apr 8. doi:10.1161/CIRCULATIONAHA.120.047521.

In the wake of the coronavirus pandemic, the rules and regulations governing telepsychiatry services have changed dramatically, the most radical of which is the introduction of a new waiver by the Centers for Medicare & Medicaid Services.

Under the 1135 emergency waiver, Medicare has expanded telehealth services to include patients across the country – not just in rural areas or under other limited conditions, as was previously the case. In addition, there’s now a waiver to the Ryan Haight Act that allows the prescribing of controlled substances via telemedicine.

Peter Yellowlees, MD, from University of California, Davis, reported that outpatient service at his center was converted to an almost 100% telepsychiatry service from mid- to late March.

He and John Torous, MD, director of digital psychiatry at Beth Israel Deaconess Medical Center, Boston, led a free webinar late last month sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

During the hour-long event, they answered questions and offered tips on changes in licensure, patient safety, new prescribing rules, and equipment needed.

“Clinicians need to be aware of these changes so they can ensure they are reaching as many people as possible and taking advantage of the reduced barriers to offering safe and effective video visits,” Dr. Torous said in an interview.
 

‘This is huge’

The new 1135 waiver “basically says CMS will pay for any patient on Medicare who is seen by video by any provider who is correctly licensed in any state in this country,” Dr. Yellowlees told webinar attendees.

“You don’t need to be licensed in the state where the patient is if the patient is on Medicare. This opens up a huge number of patients we can now see on video,” he said. “And you can bill at normal Medicare rates for whatever you normally get for your in-person patients.”

Although this temporary rule only applies to Medicare and not to private insurers, or to patients on Medicaid, “these are really big changes. This is huge,” Dr. Torous said.

Previously, the “originating site” rule stated that, for the most part, clinicians had to be licensed in the state where the patient was located and not where the physician was stationed.

Asked about college students receiving mental health care who were in school in the psychiatrist’s area but are now back home in a state where the clinician doesn’t have a license, Dr. Yellowlees said that scenario could be a bit “tricky.”

“Most of those patients probably aren’t on Medicare. Legally, you [usually] can’t see them on video if they have private insurance or Medicaid. So, hopefully you can give them a 3-month supply of medication and then recommend they see a local provider,” he said.

Still, all states have their own rules, Dr. Yellowlees said. He and Dr. Torous noted that the Federation of State Medical Boards has a “very up-to-date” listing of policies at FSMB.org, all of which are organized by state. In addition, the American Psychiatric Association provides a telepsychiatry toolkit on its website.

Ryan Haight Act and prescribing

Physicians are now permitted to prescribe medication to patients assessed via telemedicine.

For those with substance use disorders, the U.S. Drug Enforcement Administration has announced a new waiver for the Ryan Haight Online Pharmacy Consumer Protection Act.

The waiver states that “practitioners in all areas of the United States may issue prescriptions for all schedule II-V controlled substances” – as long as it’s for a legitimate medical purpose; real-time, two-way interactive communication with patients has been used; and the clinician “is acting in accordance with applicable Federal and State laws.”

“It’s now possible to prescribe all the normal psychiatric drugs but also benzodiazepines, stimulants, and potentially narcotics over telepsychiatry,” even at a first visit via video, Dr. Yellowlees said.

However, he noted at this point the waiver is current for only 60 days. “This isn’t a permanent condition. It could be extended or even shortened at any given time.”

In addition, SAMHSA has relaxed some of its own regulations regarding telehealth and opioid treatment programs. An FAQ section on the organization’s website provides guidance for providing methadone and buprenorphine treatment.

“Some of the previous regulations will probably be put back in place later on, but the new changes are helpful now,” Dr. Yellowlees said.

Simple equipment needed

Regarding equipment, Dr. Yellowlees noted that the most important component is just a laptop, tablet, or smartphone – for the clinician and for the patient.

“You don’t need fancy new technology with a separate camera or microphone,” he said. However, it might be worth investing in a little better system down the line, he added.

Simple platforms that can be used to meet virtually with patients include FaceTime, Google Hangouts, and Skype.

Although some of these (such as FaceTime) are not HIPAA compliant, “that’s okay for now” under the new rules, Dr. Yellowlees said. While the health system/commercial version of Skype is compliant, the normal consumer-downloaded version is not, he noted.

“I would still strongly suggest using HIPAA-compliant video-conferencing programs in the long run,” he added.

Either way, it’s important for various safety practices to be put into place. For example, clinicians should be careful because the consumer version of Skype can show names of patients who were previously spoken with.

A business associate agreement (BAA) is something that HIPAA-compliant video systems will offer and which should be signed. It’s an agreement that “you’ll be, essentially, looking through a tunnel at the persona at the other end, and the company cannot get inside the tunnel and watch you while you’re having your interview,” said Dr. Yellowlees.

“There are multiple videoconferencing systems around that you can use,” he added. “The three major ones are from Zoom, Vidyo, and VSee, but there are probably 40 or 50 more.”

“There are a lot out there, and we’re certainly not endorsing any one of them,” Dr. Torous added.

When evaluating potential programs, Dr. Yellowlees suggested looking at Yelp-style reviews or telemedicine review sites, or talk with colleagues.

“Basically, you want systems that offer high-definition video quality and the ability to ‘lock’ and ‘unlock’ the rooms. And you want it to have an app so mobile devices can use it,” he said.

Phone vs. video

Some patients, especially older ones, may be resistant to the idea of video chats, preferring to talk via telephone instead.

“If you can use video, it’s better to do that if you can, especially when setting up the systems are relatively simple,” Dr. Yellowlees said, adding that it might just be an issue of patients needing help to get started.

However, “for some people, this is a barrier that we have to respect,” Dr. Torous said.

Either way, clinicians should check the American Medical Association’s website for information about coding for both video and phone visits.

Asked whether a clinician needs written consent from patients for conducting telepsychiatry visits, Dr. Yellowlees said it’s important to check state-by-state rules. For example, California allows a verbal consent.

In many cases, “simply jot down a note that consent was given and how” and write down the address where the patient is located at time of visit, such as for their home, he said.

If a patient wants to conduct a telehealth session while in their car, Dr. Yellowlees suggested getting the address of the parking lot. For safety, clinicians also are advised asking for the cell phone number of the patient as well as that of a loved one.

Vital signs

When it comes to checking vital signs, Dr. Yellowlees suggested asking patients to purchase an inexpensive blood pressure (BP) monitor, thermometer, etc, prior to an appointment.

“Ask them to do a BP test on video and show you the readings. For the AIMS [Abnormal Involuntary Movement Scale] test, or to check for tardive dyskinesia, instruct patients to come close to the camera to show movement.”

In addition, most psychiatric rating scales are available online, which patients can fill out before a telehealth visit. The Serious Mental Illness (SMI) Adviser mobile app also includes several of these scales, Dr. Torous noted.

Overall, “there have been dramatic changes in the rules and regulations governing [telepsychiatry] that, for the next 60 days, make it easier to offer telehealth to patients,” Dr. Torous said.

Therefore, all psychiatrists need to “get on board,” as soon as possible, Dr. Yellowlees added.

The webinar was funded in part by a grant from SAMHSA.

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

In the wake of the coronavirus pandemic, the rules and regulations governing telepsychiatry services have changed dramatically, the most radical of which is the introduction of a new waiver by the Centers for Medicare & Medicaid Services.

Under the 1135 emergency waiver, Medicare has expanded telehealth services to include patients across the country – not just in rural areas or under other limited conditions, as was previously the case. In addition, there’s now a waiver to the Ryan Haight Act that allows the prescribing of controlled substances via telemedicine.

Peter Yellowlees, MD, from University of California, Davis, reported that outpatient service at his center was converted to an almost 100% telepsychiatry service from mid- to late March.

He and John Torous, MD, director of digital psychiatry at Beth Israel Deaconess Medical Center, Boston, led a free webinar late last month sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

During the hour-long event, they answered questions and offered tips on changes in licensure, patient safety, new prescribing rules, and equipment needed.

“Clinicians need to be aware of these changes so they can ensure they are reaching as many people as possible and taking advantage of the reduced barriers to offering safe and effective video visits,” Dr. Torous said in an interview.
 

‘This is huge’

The new 1135 waiver “basically says CMS will pay for any patient on Medicare who is seen by video by any provider who is correctly licensed in any state in this country,” Dr. Yellowlees told webinar attendees.

“You don’t need to be licensed in the state where the patient is if the patient is on Medicare. This opens up a huge number of patients we can now see on video,” he said. “And you can bill at normal Medicare rates for whatever you normally get for your in-person patients.”

Although this temporary rule only applies to Medicare and not to private insurers, or to patients on Medicaid, “these are really big changes. This is huge,” Dr. Torous said.

Previously, the “originating site” rule stated that, for the most part, clinicians had to be licensed in the state where the patient was located and not where the physician was stationed.

Asked about college students receiving mental health care who were in school in the psychiatrist’s area but are now back home in a state where the clinician doesn’t have a license, Dr. Yellowlees said that scenario could be a bit “tricky.”

“Most of those patients probably aren’t on Medicare. Legally, you [usually] can’t see them on video if they have private insurance or Medicaid. So, hopefully you can give them a 3-month supply of medication and then recommend they see a local provider,” he said.

Still, all states have their own rules, Dr. Yellowlees said. He and Dr. Torous noted that the Federation of State Medical Boards has a “very up-to-date” listing of policies at FSMB.org, all of which are organized by state. In addition, the American Psychiatric Association provides a telepsychiatry toolkit on its website.

Ryan Haight Act and prescribing

Physicians are now permitted to prescribe medication to patients assessed via telemedicine.

For those with substance use disorders, the U.S. Drug Enforcement Administration has announced a new waiver for the Ryan Haight Online Pharmacy Consumer Protection Act.

The waiver states that “practitioners in all areas of the United States may issue prescriptions for all schedule II-V controlled substances” – as long as it’s for a legitimate medical purpose; real-time, two-way interactive communication with patients has been used; and the clinician “is acting in accordance with applicable Federal and State laws.”

“It’s now possible to prescribe all the normal psychiatric drugs but also benzodiazepines, stimulants, and potentially narcotics over telepsychiatry,” even at a first visit via video, Dr. Yellowlees said.

However, he noted at this point the waiver is current for only 60 days. “This isn’t a permanent condition. It could be extended or even shortened at any given time.”

In addition, SAMHSA has relaxed some of its own regulations regarding telehealth and opioid treatment programs. An FAQ section on the organization’s website provides guidance for providing methadone and buprenorphine treatment.

“Some of the previous regulations will probably be put back in place later on, but the new changes are helpful now,” Dr. Yellowlees said.

Simple equipment needed

Regarding equipment, Dr. Yellowlees noted that the most important component is just a laptop, tablet, or smartphone – for the clinician and for the patient.

“You don’t need fancy new technology with a separate camera or microphone,” he said. However, it might be worth investing in a little better system down the line, he added.

Simple platforms that can be used to meet virtually with patients include FaceTime, Google Hangouts, and Skype.

Although some of these (such as FaceTime) are not HIPAA compliant, “that’s okay for now” under the new rules, Dr. Yellowlees said. While the health system/commercial version of Skype is compliant, the normal consumer-downloaded version is not, he noted.

“I would still strongly suggest using HIPAA-compliant video-conferencing programs in the long run,” he added.

Either way, it’s important for various safety practices to be put into place. For example, clinicians should be careful because the consumer version of Skype can show names of patients who were previously spoken with.

A business associate agreement (BAA) is something that HIPAA-compliant video systems will offer and which should be signed. It’s an agreement that “you’ll be, essentially, looking through a tunnel at the persona at the other end, and the company cannot get inside the tunnel and watch you while you’re having your interview,” said Dr. Yellowlees.

“There are multiple videoconferencing systems around that you can use,” he added. “The three major ones are from Zoom, Vidyo, and VSee, but there are probably 40 or 50 more.”

“There are a lot out there, and we’re certainly not endorsing any one of them,” Dr. Torous added.

When evaluating potential programs, Dr. Yellowlees suggested looking at Yelp-style reviews or telemedicine review sites, or talk with colleagues.

“Basically, you want systems that offer high-definition video quality and the ability to ‘lock’ and ‘unlock’ the rooms. And you want it to have an app so mobile devices can use it,” he said.

Phone vs. video

Some patients, especially older ones, may be resistant to the idea of video chats, preferring to talk via telephone instead.

“If you can use video, it’s better to do that if you can, especially when setting up the systems are relatively simple,” Dr. Yellowlees said, adding that it might just be an issue of patients needing help to get started.

However, “for some people, this is a barrier that we have to respect,” Dr. Torous said.

Either way, clinicians should check the American Medical Association’s website for information about coding for both video and phone visits.

Asked whether a clinician needs written consent from patients for conducting telepsychiatry visits, Dr. Yellowlees said it’s important to check state-by-state rules. For example, California allows a verbal consent.

In many cases, “simply jot down a note that consent was given and how” and write down the address where the patient is located at time of visit, such as for their home, he said.

If a patient wants to conduct a telehealth session while in their car, Dr. Yellowlees suggested getting the address of the parking lot. For safety, clinicians also are advised asking for the cell phone number of the patient as well as that of a loved one.

Vital signs

When it comes to checking vital signs, Dr. Yellowlees suggested asking patients to purchase an inexpensive blood pressure (BP) monitor, thermometer, etc, prior to an appointment.

“Ask them to do a BP test on video and show you the readings. For the AIMS [Abnormal Involuntary Movement Scale] test, or to check for tardive dyskinesia, instruct patients to come close to the camera to show movement.”

In addition, most psychiatric rating scales are available online, which patients can fill out before a telehealth visit. The Serious Mental Illness (SMI) Adviser mobile app also includes several of these scales, Dr. Torous noted.

Overall, “there have been dramatic changes in the rules and regulations governing [telepsychiatry] that, for the next 60 days, make it easier to offer telehealth to patients,” Dr. Torous said.

Therefore, all psychiatrists need to “get on board,” as soon as possible, Dr. Yellowlees added.

The webinar was funded in part by a grant from SAMHSA.

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

In the wake of the coronavirus pandemic, the rules and regulations governing telepsychiatry services have changed dramatically, the most radical of which is the introduction of a new waiver by the Centers for Medicare & Medicaid Services.

Under the 1135 emergency waiver, Medicare has expanded telehealth services to include patients across the country – not just in rural areas or under other limited conditions, as was previously the case. In addition, there’s now a waiver to the Ryan Haight Act that allows the prescribing of controlled substances via telemedicine.

Peter Yellowlees, MD, from University of California, Davis, reported that outpatient service at his center was converted to an almost 100% telepsychiatry service from mid- to late March.

He and John Torous, MD, director of digital psychiatry at Beth Israel Deaconess Medical Center, Boston, led a free webinar late last month sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

During the hour-long event, they answered questions and offered tips on changes in licensure, patient safety, new prescribing rules, and equipment needed.

“Clinicians need to be aware of these changes so they can ensure they are reaching as many people as possible and taking advantage of the reduced barriers to offering safe and effective video visits,” Dr. Torous said in an interview.
 

‘This is huge’

The new 1135 waiver “basically says CMS will pay for any patient on Medicare who is seen by video by any provider who is correctly licensed in any state in this country,” Dr. Yellowlees told webinar attendees.

“You don’t need to be licensed in the state where the patient is if the patient is on Medicare. This opens up a huge number of patients we can now see on video,” he said. “And you can bill at normal Medicare rates for whatever you normally get for your in-person patients.”

Although this temporary rule only applies to Medicare and not to private insurers, or to patients on Medicaid, “these are really big changes. This is huge,” Dr. Torous said.

Previously, the “originating site” rule stated that, for the most part, clinicians had to be licensed in the state where the patient was located and not where the physician was stationed.

Asked about college students receiving mental health care who were in school in the psychiatrist’s area but are now back home in a state where the clinician doesn’t have a license, Dr. Yellowlees said that scenario could be a bit “tricky.”

“Most of those patients probably aren’t on Medicare. Legally, you [usually] can’t see them on video if they have private insurance or Medicaid. So, hopefully you can give them a 3-month supply of medication and then recommend they see a local provider,” he said.

Still, all states have their own rules, Dr. Yellowlees said. He and Dr. Torous noted that the Federation of State Medical Boards has a “very up-to-date” listing of policies at FSMB.org, all of which are organized by state. In addition, the American Psychiatric Association provides a telepsychiatry toolkit on its website.

Ryan Haight Act and prescribing

Physicians are now permitted to prescribe medication to patients assessed via telemedicine.

For those with substance use disorders, the U.S. Drug Enforcement Administration has announced a new waiver for the Ryan Haight Online Pharmacy Consumer Protection Act.

The waiver states that “practitioners in all areas of the United States may issue prescriptions for all schedule II-V controlled substances” – as long as it’s for a legitimate medical purpose; real-time, two-way interactive communication with patients has been used; and the clinician “is acting in accordance with applicable Federal and State laws.”

“It’s now possible to prescribe all the normal psychiatric drugs but also benzodiazepines, stimulants, and potentially narcotics over telepsychiatry,” even at a first visit via video, Dr. Yellowlees said.

However, he noted at this point the waiver is current for only 60 days. “This isn’t a permanent condition. It could be extended or even shortened at any given time.”

In addition, SAMHSA has relaxed some of its own regulations regarding telehealth and opioid treatment programs. An FAQ section on the organization’s website provides guidance for providing methadone and buprenorphine treatment.

“Some of the previous regulations will probably be put back in place later on, but the new changes are helpful now,” Dr. Yellowlees said.

Simple equipment needed

Regarding equipment, Dr. Yellowlees noted that the most important component is just a laptop, tablet, or smartphone – for the clinician and for the patient.

“You don’t need fancy new technology with a separate camera or microphone,” he said. However, it might be worth investing in a little better system down the line, he added.

Simple platforms that can be used to meet virtually with patients include FaceTime, Google Hangouts, and Skype.

Although some of these (such as FaceTime) are not HIPAA compliant, “that’s okay for now” under the new rules, Dr. Yellowlees said. While the health system/commercial version of Skype is compliant, the normal consumer-downloaded version is not, he noted.

“I would still strongly suggest using HIPAA-compliant video-conferencing programs in the long run,” he added.

Either way, it’s important for various safety practices to be put into place. For example, clinicians should be careful because the consumer version of Skype can show names of patients who were previously spoken with.

A business associate agreement (BAA) is something that HIPAA-compliant video systems will offer and which should be signed. It’s an agreement that “you’ll be, essentially, looking through a tunnel at the persona at the other end, and the company cannot get inside the tunnel and watch you while you’re having your interview,” said Dr. Yellowlees.

“There are multiple videoconferencing systems around that you can use,” he added. “The three major ones are from Zoom, Vidyo, and VSee, but there are probably 40 or 50 more.”

“There are a lot out there, and we’re certainly not endorsing any one of them,” Dr. Torous added.

When evaluating potential programs, Dr. Yellowlees suggested looking at Yelp-style reviews or telemedicine review sites, or talk with colleagues.

“Basically, you want systems that offer high-definition video quality and the ability to ‘lock’ and ‘unlock’ the rooms. And you want it to have an app so mobile devices can use it,” he said.

Phone vs. video

Some patients, especially older ones, may be resistant to the idea of video chats, preferring to talk via telephone instead.

“If you can use video, it’s better to do that if you can, especially when setting up the systems are relatively simple,” Dr. Yellowlees said, adding that it might just be an issue of patients needing help to get started.

However, “for some people, this is a barrier that we have to respect,” Dr. Torous said.

Either way, clinicians should check the American Medical Association’s website for information about coding for both video and phone visits.

Asked whether a clinician needs written consent from patients for conducting telepsychiatry visits, Dr. Yellowlees said it’s important to check state-by-state rules. For example, California allows a verbal consent.

In many cases, “simply jot down a note that consent was given and how” and write down the address where the patient is located at time of visit, such as for their home, he said.

If a patient wants to conduct a telehealth session while in their car, Dr. Yellowlees suggested getting the address of the parking lot. For safety, clinicians also are advised asking for the cell phone number of the patient as well as that of a loved one.

Vital signs

When it comes to checking vital signs, Dr. Yellowlees suggested asking patients to purchase an inexpensive blood pressure (BP) monitor, thermometer, etc, prior to an appointment.

“Ask them to do a BP test on video and show you the readings. For the AIMS [Abnormal Involuntary Movement Scale] test, or to check for tardive dyskinesia, instruct patients to come close to the camera to show movement.”

In addition, most psychiatric rating scales are available online, which patients can fill out before a telehealth visit. The Serious Mental Illness (SMI) Adviser mobile app also includes several of these scales, Dr. Torous noted.

Overall, “there have been dramatic changes in the rules and regulations governing [telepsychiatry] that, for the next 60 days, make it easier to offer telehealth to patients,” Dr. Torous said.

Therefore, all psychiatrists need to “get on board,” as soon as possible, Dr. Yellowlees added.

The webinar was funded in part by a grant from SAMHSA.

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

The Food and Drug Administration has approved the first generic of Proventil HFA (albuterol sulfate) metered-dose inhaler, 90 mcg/inhalation, according to a release from the agency. This inhaler is indicated for prevention of bronchospasm in patients aged 4 years and older. Specifically, these are patients with reversible obstructive airway disease or exercise-induced bronchospasm.

“The FDA recognizes the increased demand for albuterol products during the novel coronavirus pandemic,” said FDA Commissioner Stephen M. Hahn, MD.

The most common side effects include upper respiratory tract infection, rhinitis, nausea, vomiting, rapid heart rate, tremor, and nervousness.

This approval comes as part of FDA’s efforts to guide industry through the development process of generic products, according to the release. Complex combination products – such as this inhaler, which comprises both medication and a delivery system – can be more challenging to develop than solid oral dosage forms, such as tablets.

The FDA released a draft guidance in March 2020 specific to proposed generic albuterol sulfate metered-dose inhalers, including drug products referencing Proventil HFA. As with other similar guidances, it details the steps companies need to take in developing generics in order to submit complete applications for those products. The full news release regarding this approval is available on the FDA website.

[email protected]

This article was updated 4/8/20.

The Food and Drug Administration has approved the first generic of Proventil HFA (albuterol sulfate) metered-dose inhaler, 90 mcg/inhalation, according to a release from the agency. This inhaler is indicated for prevention of bronchospasm in patients aged 4 years and older. Specifically, these are patients with reversible obstructive airway disease or exercise-induced bronchospasm.

“The FDA recognizes the increased demand for albuterol products during the novel coronavirus pandemic,” said FDA Commissioner Stephen M. Hahn, MD.

The most common side effects include upper respiratory tract infection, rhinitis, nausea, vomiting, rapid heart rate, tremor, and nervousness.

This approval comes as part of FDA’s efforts to guide industry through the development process of generic products, according to the release. Complex combination products – such as this inhaler, which comprises both medication and a delivery system – can be more challenging to develop than solid oral dosage forms, such as tablets.

The FDA released a draft guidance in March 2020 specific to proposed generic albuterol sulfate metered-dose inhalers, including drug products referencing Proventil HFA. As with other similar guidances, it details the steps companies need to take in developing generics in order to submit complete applications for those products. The full news release regarding this approval is available on the FDA website.

[email protected]

This article was updated 4/8/20.

The Food and Drug Administration has approved the first generic of Proventil HFA (albuterol sulfate) metered-dose inhaler, 90 mcg/inhalation, according to a release from the agency. This inhaler is indicated for prevention of bronchospasm in patients aged 4 years and older. Specifically, these are patients with reversible obstructive airway disease or exercise-induced bronchospasm.

“The FDA recognizes the increased demand for albuterol products during the novel coronavirus pandemic,” said FDA Commissioner Stephen M. Hahn, MD.

The most common side effects include upper respiratory tract infection, rhinitis, nausea, vomiting, rapid heart rate, tremor, and nervousness.

This approval comes as part of FDA’s efforts to guide industry through the development process of generic products, according to the release. Complex combination products – such as this inhaler, which comprises both medication and a delivery system – can be more challenging to develop than solid oral dosage forms, such as tablets.

The FDA released a draft guidance in March 2020 specific to proposed generic albuterol sulfate metered-dose inhalers, including drug products referencing Proventil HFA. As with other similar guidances, it details the steps companies need to take in developing generics in order to submit complete applications for those products. The full news release regarding this approval is available on the FDA website.

[email protected]

This article was updated 4/8/20.

In New York state, just over 86% of reported COVID-19 deaths involved at least one comorbidity, according to the state’s department of health.

As of midnight on April 6, there had been 5,489 fatalities caused by COVID-19 in the state, of which 86.2% (4,732) had at least one underlying condition, the New York State Department of Health reported April 7 on its COVID-19 tracker.

The leading comorbidity, seen in 55.4% of all deaths, was hypertension. In comparison, a recent estimate from the U.S. Department of Health & Human Services put the prevalence of high blood pressure at about 45% in the overall adult population.

In New York, the rest of the 10 most common comorbidities in COVID-19 fatalities were diabetes (37.3%), hyperlipidemia (18.5%), coronary artery disease (12.4%), renal disease (11.0%), dementia (9.1%), chronic obstructive pulmonary disease (8.3%), cancer (8.1%), atrial fibrillation (7.1%), and heart failure (7.1%), the NYSDOH said.

Other data on the tracker site show that 63% of all deaths involved a patient who was aged 70 years or older and that 61% of COVID-19 patients who have died in New York were male and 38.8% were female (sex unknown for 0.2%). Among all individuals who have tested positive, 54.8% were male and 44.6% were female (sex unknown for 0.6%).

As of the end of day on April 6, a total of 340,058 persons had been tested in the state and 40.8% (138,863) were positive for the SARS-CoV-2 virus. By county, the highest positive rates are in New York City: Queens at 57.4%, Brooklyn at 52.4%, and the Bronx at 52.3%, according to the NYSDOH.

[email protected]

In New York state, just over 86% of reported COVID-19 deaths involved at least one comorbidity, according to the state’s department of health.

As of midnight on April 6, there had been 5,489 fatalities caused by COVID-19 in the state, of which 86.2% (4,732) had at least one underlying condition, the New York State Department of Health reported April 7 on its COVID-19 tracker.

The leading comorbidity, seen in 55.4% of all deaths, was hypertension. In comparison, a recent estimate from the U.S. Department of Health & Human Services put the prevalence of high blood pressure at about 45% in the overall adult population.

In New York, the rest of the 10 most common comorbidities in COVID-19 fatalities were diabetes (37.3%), hyperlipidemia (18.5%), coronary artery disease (12.4%), renal disease (11.0%), dementia (9.1%), chronic obstructive pulmonary disease (8.3%), cancer (8.1%), atrial fibrillation (7.1%), and heart failure (7.1%), the NYSDOH said.

Other data on the tracker site show that 63% of all deaths involved a patient who was aged 70 years or older and that 61% of COVID-19 patients who have died in New York were male and 38.8% were female (sex unknown for 0.2%). Among all individuals who have tested positive, 54.8% were male and 44.6% were female (sex unknown for 0.6%).

As of the end of day on April 6, a total of 340,058 persons had been tested in the state and 40.8% (138,863) were positive for the SARS-CoV-2 virus. By county, the highest positive rates are in New York City: Queens at 57.4%, Brooklyn at 52.4%, and the Bronx at 52.3%, according to the NYSDOH.

[email protected]

In New York state, just over 86% of reported COVID-19 deaths involved at least one comorbidity, according to the state’s department of health.

As of midnight on April 6, there had been 5,489 fatalities caused by COVID-19 in the state, of which 86.2% (4,732) had at least one underlying condition, the New York State Department of Health reported April 7 on its COVID-19 tracker.

The leading comorbidity, seen in 55.4% of all deaths, was hypertension. In comparison, a recent estimate from the U.S. Department of Health & Human Services put the prevalence of high blood pressure at about 45% in the overall adult population.

In New York, the rest of the 10 most common comorbidities in COVID-19 fatalities were diabetes (37.3%), hyperlipidemia (18.5%), coronary artery disease (12.4%), renal disease (11.0%), dementia (9.1%), chronic obstructive pulmonary disease (8.3%), cancer (8.1%), atrial fibrillation (7.1%), and heart failure (7.1%), the NYSDOH said.

Other data on the tracker site show that 63% of all deaths involved a patient who was aged 70 years or older and that 61% of COVID-19 patients who have died in New York were male and 38.8% were female (sex unknown for 0.2%). Among all individuals who have tested positive, 54.8% were male and 44.6% were female (sex unknown for 0.6%).

As of the end of day on April 6, a total of 340,058 persons had been tested in the state and 40.8% (138,863) were positive for the SARS-CoV-2 virus. By county, the highest positive rates are in New York City: Queens at 57.4%, Brooklyn at 52.4%, and the Bronx at 52.3%, according to the NYSDOH.

[email protected]

Olfactory decline in patients with chronic rhinosinusitis (CRS) after endoscopic sinus surgery is linked to superior turbinate eosinophilia, according to recent research released as an abstract from the American Academy of Allergy, Asthma, and Immunology annual meeting. The AAAAI canceled the meeting and provided abstracts and access to presenters for press coverage.

© Siri Stafford/Thinkstock

“Superior turbinate eosinophilia is highly associated with the olfactory decline in CRS patients 3 months after endoscopic sinus surgery,” Dawei Wu, MD, of Beijing Anzhen Hospital, Capital Medical University in Beijing, China, said in an interview.

There has been some research in the literature pointing to the link between CRS-associated olfactory dysfunction and superior turbinate eosinophilia. In a 2017 study, Lavin et al. found eosinophil markers in the superior turbinate tissue were elevated in patients with CRS with nasal polyps. One of the gene expressions of the eosinophil marker Charcot Leyden crystal protein (CLC) was inversely associated with olfactory threshold, which led the researchers to believe there was a link between olfactory decline and superior turbinate eosinophilia in these patients (Laryngoscope. 2017 Oct;127[10]:2210-2218).

Olfactory decline associated with CRS is the most common reason for loss of smell in ear, nose, and throat clinics, Dr. Wu said, but predicting this olfactory decline after endoscopic sinus surgery can be clinically challenging.

“The distinct feature of this smell disorder is the fluctuation in olfactory dysfunction which is mainly due to the recurrence of inflammation within the olfactory cleft. Notably, the level of eosinophils within the olfactory cleft significantly and positively correlated with the degree of olfactory dysfunction in patients with CRS both pre- and postoperatively,” he said.

Dr. Wu and colleagues conducted a prospective study to determine whether there was a link in CRS patients between preoperative superior turbinate eosinophilia and olfactory dysfunction after endoscopic sinus surgery. “We aimed to explore potential predictors of postoperative olfactory decline,” Dr. Wu said.

Overall, the investigators enrolled 78 patients with CRS in the study, where they received an olfactory assessment prior to and 3 months after endoscopic sinus surgery. The investigators used Sniffin’ Sticks (Burghardt; Wedel, Germany), a 12-item psychophysical smell test that uses everyday odors to conduct the olfactory assessment. If patients had a decrease in their threshold-discrimination-identification (TDI) score after surgery, they were determined to have olfactory deterioration. Prior to surgery, investigators measured olfactory cleft opacification using CT, with the olfactory cleft endoscopy scale used after surgery. The investigators also sampled patients’ superior turbinates at the time of surgery.

The results showed 23 of 78 patients (29.49%) had olfactory decline at 3 months after endoscopic sinus surgery. Those patients with olfactory decline had significantly higher tissue, blood eosinophil levels, and TDI scores before surgery, compared with patients with CRS who did not have any loss of smell. Patients with olfactory decline also had olfactory cleft opacification and olfactory cleft endoscopy scale scores, compared with patients who had no loss of smell after surgery.

One factor that predicted olfactory decline in these patients was an absolute count of 23.5 eosinophils per high-power field in the superior turbinate, researchers said (area under the ROC curve, 0.901). “Continuous elimination of the eosinophilic inflammation within the olfactory cleft in CRS patients with olfactory dysfunction may prevent the olfactory fluctuation after endoscopic sinus surgery,” Dr. Wu said.

Dr. Wu reports no relevant conflicts of interest.

SOURCE: Wu D et al. AAAAI. Abstract L7.

Olfactory decline in patients with chronic rhinosinusitis (CRS) after endoscopic sinus surgery is linked to superior turbinate eosinophilia, according to recent research released as an abstract from the American Academy of Allergy, Asthma, and Immunology annual meeting. The AAAAI canceled the meeting and provided abstracts and access to presenters for press coverage.

© Siri Stafford/Thinkstock

“Superior turbinate eosinophilia is highly associated with the olfactory decline in CRS patients 3 months after endoscopic sinus surgery,” Dawei Wu, MD, of Beijing Anzhen Hospital, Capital Medical University in Beijing, China, said in an interview.

There has been some research in the literature pointing to the link between CRS-associated olfactory dysfunction and superior turbinate eosinophilia. In a 2017 study, Lavin et al. found eosinophil markers in the superior turbinate tissue were elevated in patients with CRS with nasal polyps. One of the gene expressions of the eosinophil marker Charcot Leyden crystal protein (CLC) was inversely associated with olfactory threshold, which led the researchers to believe there was a link between olfactory decline and superior turbinate eosinophilia in these patients (Laryngoscope. 2017 Oct;127[10]:2210-2218).

Olfactory decline associated with CRS is the most common reason for loss of smell in ear, nose, and throat clinics, Dr. Wu said, but predicting this olfactory decline after endoscopic sinus surgery can be clinically challenging.

“The distinct feature of this smell disorder is the fluctuation in olfactory dysfunction which is mainly due to the recurrence of inflammation within the olfactory cleft. Notably, the level of eosinophils within the olfactory cleft significantly and positively correlated with the degree of olfactory dysfunction in patients with CRS both pre- and postoperatively,” he said.

Dr. Wu and colleagues conducted a prospective study to determine whether there was a link in CRS patients between preoperative superior turbinate eosinophilia and olfactory dysfunction after endoscopic sinus surgery. “We aimed to explore potential predictors of postoperative olfactory decline,” Dr. Wu said.

Overall, the investigators enrolled 78 patients with CRS in the study, where they received an olfactory assessment prior to and 3 months after endoscopic sinus surgery. The investigators used Sniffin’ Sticks (Burghardt; Wedel, Germany), a 12-item psychophysical smell test that uses everyday odors to conduct the olfactory assessment. If patients had a decrease in their threshold-discrimination-identification (TDI) score after surgery, they were determined to have olfactory deterioration. Prior to surgery, investigators measured olfactory cleft opacification using CT, with the olfactory cleft endoscopy scale used after surgery. The investigators also sampled patients’ superior turbinates at the time of surgery.

The results showed 23 of 78 patients (29.49%) had olfactory decline at 3 months after endoscopic sinus surgery. Those patients with olfactory decline had significantly higher tissue, blood eosinophil levels, and TDI scores before surgery, compared with patients with CRS who did not have any loss of smell. Patients with olfactory decline also had olfactory cleft opacification and olfactory cleft endoscopy scale scores, compared with patients who had no loss of smell after surgery.

One factor that predicted olfactory decline in these patients was an absolute count of 23.5 eosinophils per high-power field in the superior turbinate, researchers said (area under the ROC curve, 0.901). “Continuous elimination of the eosinophilic inflammation within the olfactory cleft in CRS patients with olfactory dysfunction may prevent the olfactory fluctuation after endoscopic sinus surgery,” Dr. Wu said.

Dr. Wu reports no relevant conflicts of interest.

SOURCE: Wu D et al. AAAAI. Abstract L7.

Olfactory decline in patients with chronic rhinosinusitis (CRS) after endoscopic sinus surgery is linked to superior turbinate eosinophilia, according to recent research released as an abstract from the American Academy of Allergy, Asthma, and Immunology annual meeting. The AAAAI canceled the meeting and provided abstracts and access to presenters for press coverage.

© Siri Stafford/Thinkstock

“Superior turbinate eosinophilia is highly associated with the olfactory decline in CRS patients 3 months after endoscopic sinus surgery,” Dawei Wu, MD, of Beijing Anzhen Hospital, Capital Medical University in Beijing, China, said in an interview.

There has been some research in the literature pointing to the link between CRS-associated olfactory dysfunction and superior turbinate eosinophilia. In a 2017 study, Lavin et al. found eosinophil markers in the superior turbinate tissue were elevated in patients with CRS with nasal polyps. One of the gene expressions of the eosinophil marker Charcot Leyden crystal protein (CLC) was inversely associated with olfactory threshold, which led the researchers to believe there was a link between olfactory decline and superior turbinate eosinophilia in these patients (Laryngoscope. 2017 Oct;127[10]:2210-2218).

Olfactory decline associated with CRS is the most common reason for loss of smell in ear, nose, and throat clinics, Dr. Wu said, but predicting this olfactory decline after endoscopic sinus surgery can be clinically challenging.

“The distinct feature of this smell disorder is the fluctuation in olfactory dysfunction which is mainly due to the recurrence of inflammation within the olfactory cleft. Notably, the level of eosinophils within the olfactory cleft significantly and positively correlated with the degree of olfactory dysfunction in patients with CRS both pre- and postoperatively,” he said.

Dr. Wu and colleagues conducted a prospective study to determine whether there was a link in CRS patients between preoperative superior turbinate eosinophilia and olfactory dysfunction after endoscopic sinus surgery. “We aimed to explore potential predictors of postoperative olfactory decline,” Dr. Wu said.

Overall, the investigators enrolled 78 patients with CRS in the study, where they received an olfactory assessment prior to and 3 months after endoscopic sinus surgery. The investigators used Sniffin’ Sticks (Burghardt; Wedel, Germany), a 12-item psychophysical smell test that uses everyday odors to conduct the olfactory assessment. If patients had a decrease in their threshold-discrimination-identification (TDI) score after surgery, they were determined to have olfactory deterioration. Prior to surgery, investigators measured olfactory cleft opacification using CT, with the olfactory cleft endoscopy scale used after surgery. The investigators also sampled patients’ superior turbinates at the time of surgery.

The results showed 23 of 78 patients (29.49%) had olfactory decline at 3 months after endoscopic sinus surgery. Those patients with olfactory decline had significantly higher tissue, blood eosinophil levels, and TDI scores before surgery, compared with patients with CRS who did not have any loss of smell. Patients with olfactory decline also had olfactory cleft opacification and olfactory cleft endoscopy scale scores, compared with patients who had no loss of smell after surgery.

One factor that predicted olfactory decline in these patients was an absolute count of 23.5 eosinophils per high-power field in the superior turbinate, researchers said (area under the ROC curve, 0.901). “Continuous elimination of the eosinophilic inflammation within the olfactory cleft in CRS patients with olfactory dysfunction may prevent the olfactory fluctuation after endoscopic sinus surgery,” Dr. Wu said.

Dr. Wu reports no relevant conflicts of interest.

SOURCE: Wu D et al. AAAAI. Abstract L7.

June 9, 2020 — Editor’s note: The study on which this news story is based has been retracted by the journal. The retraction notice can be found here. 

Cotton and surgical masks were not effective at filtering SARS-CoV-2 during coughs from patients infected with the virus, according to Seongman Bae, MD, of the University of Ulsan College of Medicine in Seoul, South Korea, and associates.

The report was published in Annals of Internal Medicine.

Because the COVID-19 pandemic has caused a shortage of N95 and surgical masks, cotton masks have gained interest as a substitute, as surgical masks have been shown to effectively filter influenza virus, the researchers wrote. However, the size of and concentrations of SARS-CoV-2 in aerosols generated during coughing are unknown.

To compare the effectiveness of cotton and surgical masks, a group of patients infected with SARS-CoV-2 coughed into petri dishes while wearing no mask, a surgical mask, and a cotton mask. The mask surfaces were swabbed afterward to assess viral positivity on the mask itself.

The median nasopharyngeal and saliva viral load was 5.66 log copies/mL and 4.00 log copies/mL, respectively. The median viral loads after coughing was 2.56 log copies/mL without a mask, 2.42 log copies/mL with a surgical mask, and 1.85 log copies/mL with a cotton mask. All outer surfaces of the mask were positive for SARS-CoV-2, while most inner surfaces were negative.

The investigators acknowledged that the test did not include N95 masks and does not reflect the actual infection transmission, and that they didn’t know whether cotton or surgical masks shorten the travel distance of droplets while coughing.

“Further study is needed to recommend whether face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing,” they added.

The study was funded by a grant from the government-wide R&D Fund Project for Infectious Disease Research. The investigators reported that they had no conflicts of interest.

[email protected]

SOURCE: Bae S et al. Ann Intern Med. 2020 Apr 6. doi: 10.7326/M20-1342.

Correction, 4/9/20: The headline of an earlier version of this article misstated a finding of this study. Whether cotton and surgical masks can block transmission was not investigated.

June 9, 2020 — Editor’s note: The study on which this news story is based has been retracted by the journal. The retraction notice can be found here. 

Cotton and surgical masks were not effective at filtering SARS-CoV-2 during coughs from patients infected with the virus, according to Seongman Bae, MD, of the University of Ulsan College of Medicine in Seoul, South Korea, and associates.

The report was published in Annals of Internal Medicine.

Because the COVID-19 pandemic has caused a shortage of N95 and surgical masks, cotton masks have gained interest as a substitute, as surgical masks have been shown to effectively filter influenza virus, the researchers wrote. However, the size of and concentrations of SARS-CoV-2 in aerosols generated during coughing are unknown.

To compare the effectiveness of cotton and surgical masks, a group of patients infected with SARS-CoV-2 coughed into petri dishes while wearing no mask, a surgical mask, and a cotton mask. The mask surfaces were swabbed afterward to assess viral positivity on the mask itself.

The median nasopharyngeal and saliva viral load was 5.66 log copies/mL and 4.00 log copies/mL, respectively. The median viral loads after coughing was 2.56 log copies/mL without a mask, 2.42 log copies/mL with a surgical mask, and 1.85 log copies/mL with a cotton mask. All outer surfaces of the mask were positive for SARS-CoV-2, while most inner surfaces were negative.

The investigators acknowledged that the test did not include N95 masks and does not reflect the actual infection transmission, and that they didn’t know whether cotton or surgical masks shorten the travel distance of droplets while coughing.

“Further study is needed to recommend whether face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing,” they added.

The study was funded by a grant from the government-wide R&D Fund Project for Infectious Disease Research. The investigators reported that they had no conflicts of interest.

[email protected]

SOURCE: Bae S et al. Ann Intern Med. 2020 Apr 6. doi: 10.7326/M20-1342.

Correction, 4/9/20: The headline of an earlier version of this article misstated a finding of this study. Whether cotton and surgical masks can block transmission was not investigated.

June 9, 2020 — Editor’s note: The study on which this news story is based has been retracted by the journal. The retraction notice can be found here. 

Cotton and surgical masks were not effective at filtering SARS-CoV-2 during coughs from patients infected with the virus, according to Seongman Bae, MD, of the University of Ulsan College of Medicine in Seoul, South Korea, and associates.

The report was published in Annals of Internal Medicine.

Because the COVID-19 pandemic has caused a shortage of N95 and surgical masks, cotton masks have gained interest as a substitute, as surgical masks have been shown to effectively filter influenza virus, the researchers wrote. However, the size of and concentrations of SARS-CoV-2 in aerosols generated during coughing are unknown.

To compare the effectiveness of cotton and surgical masks, a group of patients infected with SARS-CoV-2 coughed into petri dishes while wearing no mask, a surgical mask, and a cotton mask. The mask surfaces were swabbed afterward to assess viral positivity on the mask itself.

The median nasopharyngeal and saliva viral load was 5.66 log copies/mL and 4.00 log copies/mL, respectively. The median viral loads after coughing was 2.56 log copies/mL without a mask, 2.42 log copies/mL with a surgical mask, and 1.85 log copies/mL with a cotton mask. All outer surfaces of the mask were positive for SARS-CoV-2, while most inner surfaces were negative.

The investigators acknowledged that the test did not include N95 masks and does not reflect the actual infection transmission, and that they didn’t know whether cotton or surgical masks shorten the travel distance of droplets while coughing.

“Further study is needed to recommend whether face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing,” they added.

The study was funded by a grant from the government-wide R&D Fund Project for Infectious Disease Research. The investigators reported that they had no conflicts of interest.

[email protected]

SOURCE: Bae S et al. Ann Intern Med. 2020 Apr 6. doi: 10.7326/M20-1342.

Correction, 4/9/20: The headline of an earlier version of this article misstated a finding of this study. Whether cotton and surgical masks can block transmission was not investigated.