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Transitions: From editor to president
As I transition out of the role of medical editor for The Hospitalist, and into the role of president of the Society of Hospital Medicine, it is a bittersweet but exciting transition.
In the relatively short time I have served as editor, so much has changed in our hospitalist community! In the last 4 years alone, we have increased:
• Membership from 14,000 to 20,000
• Chapters from 46 to 68
• Special Interest Groups from 8 to 22
• Subscribers to The Hospitalist from 15,000 to 30,000.
This is all a testimony to the engagement of our membership. SHM is clearly no ordinary specialty society; it is full of incredibly intelligent, invested, and talented members, who actively participate in the society for the betterment of their local teams and patients. It is such a privilege to lead this amazing team.
As for The Hospitalist, I would like to warmly welcome Weijen Chang, MD, FACP, SFHM, as the incoming editor. Weijen served as the pediatrics editor for many years and has been extensively involved on The Hospitalist’s editorial advisory board for even longer. He also has a broad track record of experience as a hospitalist in many settings; that combined with an inquisitive mind and curious spirit makes him the ideal editor for The Hospitalist. He brings energy and enthusiasm and will serve us very well.
While I will miss being intimately involved with The Hospitalist, I am very much looking forward to serving in the role of SHM president starting in April. During this pivotal year, SHM will transition from our one-and-only CEO, Larry Wellikson, MD, MHM, to our newly minted CEO Eric Howell, MD, MHM, who will officially transition in July 2020.
This is a very exciting time in the history of SHM, as we refocus on our mission, vision, values, and core activities. As a membership organization, our primary focus has been, and will always be, serving our member’s needs! As a “Big Tent” organization, we have always supported a broad and diverse set of members, ranging far beyond physician hospitalists, to trainees, medical students, nurse practitioners, physician assistants, practice administrators, and other hospital-based specialists. Being in such a dynamic industry, our diverse members needs are constantly and rapidly changing along with the dramatic transformations in the landscape, including profound shifts in care and reimbursement models that could change the very definition of a hospitalist.
While we continuously scour the landscape and anticipate our members’ needs, we will never lose sight of our core mission, which is to promote exceptional care for hospitalized patients. We will continue to do this by supporting all of our members with tools and materials to help them be the very best they can, for all of our patients. As a humble and servant leader, I am prepared to meet the demands and challenges of the year ahead, with energy and focus, and fulfill the needs of our members, so that together, we can make health care better for those we serve.
Thank you in advance for allowing me the great pleasure of serving this amazing and innovative organization!
Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and president-elect of SHM.
As I transition out of the role of medical editor for The Hospitalist, and into the role of president of the Society of Hospital Medicine, it is a bittersweet but exciting transition.
In the relatively short time I have served as editor, so much has changed in our hospitalist community! In the last 4 years alone, we have increased:
• Membership from 14,000 to 20,000
• Chapters from 46 to 68
• Special Interest Groups from 8 to 22
• Subscribers to The Hospitalist from 15,000 to 30,000.
This is all a testimony to the engagement of our membership. SHM is clearly no ordinary specialty society; it is full of incredibly intelligent, invested, and talented members, who actively participate in the society for the betterment of their local teams and patients. It is such a privilege to lead this amazing team.
As for The Hospitalist, I would like to warmly welcome Weijen Chang, MD, FACP, SFHM, as the incoming editor. Weijen served as the pediatrics editor for many years and has been extensively involved on The Hospitalist’s editorial advisory board for even longer. He also has a broad track record of experience as a hospitalist in many settings; that combined with an inquisitive mind and curious spirit makes him the ideal editor for The Hospitalist. He brings energy and enthusiasm and will serve us very well.
While I will miss being intimately involved with The Hospitalist, I am very much looking forward to serving in the role of SHM president starting in April. During this pivotal year, SHM will transition from our one-and-only CEO, Larry Wellikson, MD, MHM, to our newly minted CEO Eric Howell, MD, MHM, who will officially transition in July 2020.
This is a very exciting time in the history of SHM, as we refocus on our mission, vision, values, and core activities. As a membership organization, our primary focus has been, and will always be, serving our member’s needs! As a “Big Tent” organization, we have always supported a broad and diverse set of members, ranging far beyond physician hospitalists, to trainees, medical students, nurse practitioners, physician assistants, practice administrators, and other hospital-based specialists. Being in such a dynamic industry, our diverse members needs are constantly and rapidly changing along with the dramatic transformations in the landscape, including profound shifts in care and reimbursement models that could change the very definition of a hospitalist.
While we continuously scour the landscape and anticipate our members’ needs, we will never lose sight of our core mission, which is to promote exceptional care for hospitalized patients. We will continue to do this by supporting all of our members with tools and materials to help them be the very best they can, for all of our patients. As a humble and servant leader, I am prepared to meet the demands and challenges of the year ahead, with energy and focus, and fulfill the needs of our members, so that together, we can make health care better for those we serve.
Thank you in advance for allowing me the great pleasure of serving this amazing and innovative organization!
Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and president-elect of SHM.
As I transition out of the role of medical editor for The Hospitalist, and into the role of president of the Society of Hospital Medicine, it is a bittersweet but exciting transition.
In the relatively short time I have served as editor, so much has changed in our hospitalist community! In the last 4 years alone, we have increased:
• Membership from 14,000 to 20,000
• Chapters from 46 to 68
• Special Interest Groups from 8 to 22
• Subscribers to The Hospitalist from 15,000 to 30,000.
This is all a testimony to the engagement of our membership. SHM is clearly no ordinary specialty society; it is full of incredibly intelligent, invested, and talented members, who actively participate in the society for the betterment of their local teams and patients. It is such a privilege to lead this amazing team.
As for The Hospitalist, I would like to warmly welcome Weijen Chang, MD, FACP, SFHM, as the incoming editor. Weijen served as the pediatrics editor for many years and has been extensively involved on The Hospitalist’s editorial advisory board for even longer. He also has a broad track record of experience as a hospitalist in many settings; that combined with an inquisitive mind and curious spirit makes him the ideal editor for The Hospitalist. He brings energy and enthusiasm and will serve us very well.
While I will miss being intimately involved with The Hospitalist, I am very much looking forward to serving in the role of SHM president starting in April. During this pivotal year, SHM will transition from our one-and-only CEO, Larry Wellikson, MD, MHM, to our newly minted CEO Eric Howell, MD, MHM, who will officially transition in July 2020.
This is a very exciting time in the history of SHM, as we refocus on our mission, vision, values, and core activities. As a membership organization, our primary focus has been, and will always be, serving our member’s needs! As a “Big Tent” organization, we have always supported a broad and diverse set of members, ranging far beyond physician hospitalists, to trainees, medical students, nurse practitioners, physician assistants, practice administrators, and other hospital-based specialists. Being in such a dynamic industry, our diverse members needs are constantly and rapidly changing along with the dramatic transformations in the landscape, including profound shifts in care and reimbursement models that could change the very definition of a hospitalist.
While we continuously scour the landscape and anticipate our members’ needs, we will never lose sight of our core mission, which is to promote exceptional care for hospitalized patients. We will continue to do this by supporting all of our members with tools and materials to help them be the very best they can, for all of our patients. As a humble and servant leader, I am prepared to meet the demands and challenges of the year ahead, with energy and focus, and fulfill the needs of our members, so that together, we can make health care better for those we serve.
Thank you in advance for allowing me the great pleasure of serving this amazing and innovative organization!
Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and president-elect of SHM.
Overcoming COVID-related stress
As a department chief managing during this crisis, everyone greets me sympathetically: “This must be so stressful for you! Are you doing OK?” “Um, I’m great,” I answer contritely. Yes, this is hard, yet I feel fine. But why? Shouldn’t I be fretting the damage done by the COVID cyclone? Our operations are smashed and our staff scrambled, my family and friends are out of work; these are difficult times. But a harmful effect on my health or yours is not inevitable. There are things we can do to inoculate ourselves.
No doubt, exercise (if you can find weights!), eating well, sleeping, and meditating help, but they are secondary. None of these protect much if you still believe stress is killing you. You must first reframe what is happening. Health psychologist Kelly McGonigal, PhD, from Stanford (Calif.) University, is a world expert on this topic. If you’ve not seen her TED talk about stress, then watch it now. She teaches how stress is indeed harmful to your health – but only if you believe it to be so. Many studies have borne this out. One showed that people who reported high stress in the previous year were 43% more likely to die than those who did not. But that risk held only when they believed stress was harmful to them. Those who did not think that stress was harmful not only fared better but also had the lowest likelihood of death, lower even than those who reported little stress! So it wasn’t the stress that mattered, it was the physiologic response to it. And that you can control.
Changing your beliefs is no easy feat. There is work to be done, Dr. McGonigal would argue. You must not only reframe our stress as healthful, but also act in ways to make this true. This is easier for us as physicians. First, we understand better than most that difficulty is a normal part of life. We have countless stories of hardship, tragedy, pain and suffering from the work we do. The pandemic may be extraordinary in breadth, but not in depth. We’ve seen worse happen to patients. Second, we have firsthand experience that suffering ends and often leads to strength and resilience. Even in our own lives, it was by traveling through the extraordinary stress of medical school and residency that we arrived here.
Cortisol increases when we are under duress. So does oxytocin. The former gets most of the press, the latter is more interesting. That oxytocin release during stress conferred survival benefits to us as a species: When a threat arrived, we not only ran, but also grabbed the kids, too! Oxytocin is the “tend and befriend” compliment to cortisol’s “fight or flight.” Focusing on this priming to strengthen social ties, listen, spend (Zoom) time together, and provide emotional support is key to our recovery. Even small acts of giving for our staff, friends, family, and strangers can significantly shift consequences of this stress from harmful to beneficial.
Last year, my uncle died in a tragic accident. My aunt, who is alone, is now also isolated. She’s lost her partner, her guardian, and she is afraid. Rather than succumb to the stress, she imagined something she could do to wrest some control. Last week, she filled her minivan with pink and yellow tulips bunched in bouquets and tied with handwritten notes of encouragement. She then drove up and down the streets in her North Attleboro, Mass., neighborhood and left the flowers on doorsteps until her van was empty. She did so to share with them the bit of joy that spring brings, she says, and to encourage people to stay inside!
This is a difficult time for us, and yet even more difficult for others. Perhaps the best we can do is to find ways to bring a bit of joy or comfort to others.
“In some ways suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” – Viktor Frankl
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He had no relevant disclosures. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
As a department chief managing during this crisis, everyone greets me sympathetically: “This must be so stressful for you! Are you doing OK?” “Um, I’m great,” I answer contritely. Yes, this is hard, yet I feel fine. But why? Shouldn’t I be fretting the damage done by the COVID cyclone? Our operations are smashed and our staff scrambled, my family and friends are out of work; these are difficult times. But a harmful effect on my health or yours is not inevitable. There are things we can do to inoculate ourselves.
No doubt, exercise (if you can find weights!), eating well, sleeping, and meditating help, but they are secondary. None of these protect much if you still believe stress is killing you. You must first reframe what is happening. Health psychologist Kelly McGonigal, PhD, from Stanford (Calif.) University, is a world expert on this topic. If you’ve not seen her TED talk about stress, then watch it now. She teaches how stress is indeed harmful to your health – but only if you believe it to be so. Many studies have borne this out. One showed that people who reported high stress in the previous year were 43% more likely to die than those who did not. But that risk held only when they believed stress was harmful to them. Those who did not think that stress was harmful not only fared better but also had the lowest likelihood of death, lower even than those who reported little stress! So it wasn’t the stress that mattered, it was the physiologic response to it. And that you can control.
Changing your beliefs is no easy feat. There is work to be done, Dr. McGonigal would argue. You must not only reframe our stress as healthful, but also act in ways to make this true. This is easier for us as physicians. First, we understand better than most that difficulty is a normal part of life. We have countless stories of hardship, tragedy, pain and suffering from the work we do. The pandemic may be extraordinary in breadth, but not in depth. We’ve seen worse happen to patients. Second, we have firsthand experience that suffering ends and often leads to strength and resilience. Even in our own lives, it was by traveling through the extraordinary stress of medical school and residency that we arrived here.
Cortisol increases when we are under duress. So does oxytocin. The former gets most of the press, the latter is more interesting. That oxytocin release during stress conferred survival benefits to us as a species: When a threat arrived, we not only ran, but also grabbed the kids, too! Oxytocin is the “tend and befriend” compliment to cortisol’s “fight or flight.” Focusing on this priming to strengthen social ties, listen, spend (Zoom) time together, and provide emotional support is key to our recovery. Even small acts of giving for our staff, friends, family, and strangers can significantly shift consequences of this stress from harmful to beneficial.
Last year, my uncle died in a tragic accident. My aunt, who is alone, is now also isolated. She’s lost her partner, her guardian, and she is afraid. Rather than succumb to the stress, she imagined something she could do to wrest some control. Last week, she filled her minivan with pink and yellow tulips bunched in bouquets and tied with handwritten notes of encouragement. She then drove up and down the streets in her North Attleboro, Mass., neighborhood and left the flowers on doorsteps until her van was empty. She did so to share with them the bit of joy that spring brings, she says, and to encourage people to stay inside!
This is a difficult time for us, and yet even more difficult for others. Perhaps the best we can do is to find ways to bring a bit of joy or comfort to others.
“In some ways suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” – Viktor Frankl
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He had no relevant disclosures. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
As a department chief managing during this crisis, everyone greets me sympathetically: “This must be so stressful for you! Are you doing OK?” “Um, I’m great,” I answer contritely. Yes, this is hard, yet I feel fine. But why? Shouldn’t I be fretting the damage done by the COVID cyclone? Our operations are smashed and our staff scrambled, my family and friends are out of work; these are difficult times. But a harmful effect on my health or yours is not inevitable. There are things we can do to inoculate ourselves.
No doubt, exercise (if you can find weights!), eating well, sleeping, and meditating help, but they are secondary. None of these protect much if you still believe stress is killing you. You must first reframe what is happening. Health psychologist Kelly McGonigal, PhD, from Stanford (Calif.) University, is a world expert on this topic. If you’ve not seen her TED talk about stress, then watch it now. She teaches how stress is indeed harmful to your health – but only if you believe it to be so. Many studies have borne this out. One showed that people who reported high stress in the previous year were 43% more likely to die than those who did not. But that risk held only when they believed stress was harmful to them. Those who did not think that stress was harmful not only fared better but also had the lowest likelihood of death, lower even than those who reported little stress! So it wasn’t the stress that mattered, it was the physiologic response to it. And that you can control.
Changing your beliefs is no easy feat. There is work to be done, Dr. McGonigal would argue. You must not only reframe our stress as healthful, but also act in ways to make this true. This is easier for us as physicians. First, we understand better than most that difficulty is a normal part of life. We have countless stories of hardship, tragedy, pain and suffering from the work we do. The pandemic may be extraordinary in breadth, but not in depth. We’ve seen worse happen to patients. Second, we have firsthand experience that suffering ends and often leads to strength and resilience. Even in our own lives, it was by traveling through the extraordinary stress of medical school and residency that we arrived here.
Cortisol increases when we are under duress. So does oxytocin. The former gets most of the press, the latter is more interesting. That oxytocin release during stress conferred survival benefits to us as a species: When a threat arrived, we not only ran, but also grabbed the kids, too! Oxytocin is the “tend and befriend” compliment to cortisol’s “fight or flight.” Focusing on this priming to strengthen social ties, listen, spend (Zoom) time together, and provide emotional support is key to our recovery. Even small acts of giving for our staff, friends, family, and strangers can significantly shift consequences of this stress from harmful to beneficial.
Last year, my uncle died in a tragic accident. My aunt, who is alone, is now also isolated. She’s lost her partner, her guardian, and she is afraid. Rather than succumb to the stress, she imagined something she could do to wrest some control. Last week, she filled her minivan with pink and yellow tulips bunched in bouquets and tied with handwritten notes of encouragement. She then drove up and down the streets in her North Attleboro, Mass., neighborhood and left the flowers on doorsteps until her van was empty. She did so to share with them the bit of joy that spring brings, she says, and to encourage people to stay inside!
This is a difficult time for us, and yet even more difficult for others. Perhaps the best we can do is to find ways to bring a bit of joy or comfort to others.
“In some ways suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.” – Viktor Frankl
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He had no relevant disclosures. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
In praise of parents and children
The COVID-19 pandemic has changed the lives of children, teenagers, and parents worldwide. While some families are experiencing the unburdening of overly packed schedules and may be having a romantic or nostalgic “Little House on the Prairie” experience, for most it is at a minimum uncomfortable and inconvenient. For others it’s unbearable as they experience loss and feel relationship strain intensified by social distancing, seclusion, or quarantine. Some children have found respite from bullying at school, while other children have lost their only respite from being mistreated at home. Now may be as critical a time as ever for health care providers to listen carefully, empathize, validate, and proactively reach out to provide encouraging guidance and counsel, as well as express concern for families and children.
Many parents across the country are taking on an enormous, unanticipated task. Many parents have lost employment and income, while many mandatory professionals now struggle to keep up with increased work hours and work stress. Parents are trying to become multitaskers who assume the role of the music teacher, the soccer coach, the drama instructor, the friend, and of course their original role as a parent.
This seems an appropriate time to consider the work of Donald W. Winnicott, FRCP, the English pediatrician known for the concept of the “good enough parent.”1 This notion of parental competence was in part born out of a desire to defend parents against possible erosion of their confidence in following loving instincts by encroachment from professional expertise. The concept of the “good enough” parent is also related to the idea that young children who believe their parent is perfect will eventually know better. Now is a fitting time for pediatricians to buoy up imperfect but striving parents who are plenty “good enough” as they follow loving instincts to support their children during unforeseen changes associated with the pandemic.
Social distancing has led to family condensing. Many parents and children remain within the same four walls all day, every day. For many parents, the outlet of water cooler banter or yoga classes is gone. Even the commute home, with all its frustration, may have allowed decompression in the form of an audiobook, favorite music, or verbal transference of frustration onto the stranger who just cut you off. That commute might be gone too. Now, for many the good, bad, and the ugly is all happening at home. The 3-year-old may still adorably see a parent who can do no wrong, but in the end, the truth will prevail. A timely word of encouragement to parents: It’s okay to not be omnipotent. In fact, it will help children have a richer view of the world and more realistic expectations of themselves.
For children, they’ll need praise too, and the upheaval caused by the pandemic may be a fitting opportunity to make that praise more meaningful. But sports are off, the school musical is canceled, and the spelling bee is gone. The dojo is closed, the art fair is postponed, and the dance recital isn’t happening. Report cards in many schools may now transition from letter grades to pass/fail. Parents may be asking, “How on earth are we going to celebrate and praise the children?”
Research has shown us that praising the process is more valuable than praising the person.2 If Lucy participates in a soccer game and Javier gets his math results back, there are many possible approaches to praise. “You scored a goal!” or “You got an A on your math test!” is outcome- or product-focused praise. “You’re a good soccer player” or “You’re smart at math!” is person-focused praise. Instead, the most effective praise is process-focused praise: “You worked hard and ran hard even when it looked tiring” or “I noticed that you kept trying different strategies on those math problems until you figured them out.”
This may be a time when children face less comparison, less ranking, and receive less direct reward. With help, they can focus more on the process of learning and less on the outcomes of learning. They may more readily enjoy the efforts in their hobbies, not just the outcomes of their hobbies. When children receive praise for their work, effort, and actions rather than outcomes, externally validating things may be pleasantly replaced by internally validating traits. With process praise, children are more likely to feel self-confident, to set higher learning goals, and to accurately believe that intelligence is related to effort rather than a fixed trait that has been divided up among haves and have nots.3
Families currently face immense change, uncertainty, and discouragement largely unprecedented in their lifetimes. As care providers, we can look to lasting principles as we encourage parents in their provision of love. We can effectively provide praise and celebrate effort using evidence-based strategies uniquely fitted to our current circumstances. As we do this, we can provide healing of some of the less visible ailments associated with the COVID-19 pandemic.
Dr. Jackson is in the department of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. “The Child, the Family, and the Outside World.” London: Penguin; 1973. p. 173.
2. Dev Psychol. 1999;35(3):835-47.
3. J Exp Child Psychol. 2018;173:116-35.
The COVID-19 pandemic has changed the lives of children, teenagers, and parents worldwide. While some families are experiencing the unburdening of overly packed schedules and may be having a romantic or nostalgic “Little House on the Prairie” experience, for most it is at a minimum uncomfortable and inconvenient. For others it’s unbearable as they experience loss and feel relationship strain intensified by social distancing, seclusion, or quarantine. Some children have found respite from bullying at school, while other children have lost their only respite from being mistreated at home. Now may be as critical a time as ever for health care providers to listen carefully, empathize, validate, and proactively reach out to provide encouraging guidance and counsel, as well as express concern for families and children.
Many parents across the country are taking on an enormous, unanticipated task. Many parents have lost employment and income, while many mandatory professionals now struggle to keep up with increased work hours and work stress. Parents are trying to become multitaskers who assume the role of the music teacher, the soccer coach, the drama instructor, the friend, and of course their original role as a parent.
This seems an appropriate time to consider the work of Donald W. Winnicott, FRCP, the English pediatrician known for the concept of the “good enough parent.”1 This notion of parental competence was in part born out of a desire to defend parents against possible erosion of their confidence in following loving instincts by encroachment from professional expertise. The concept of the “good enough” parent is also related to the idea that young children who believe their parent is perfect will eventually know better. Now is a fitting time for pediatricians to buoy up imperfect but striving parents who are plenty “good enough” as they follow loving instincts to support their children during unforeseen changes associated with the pandemic.
Social distancing has led to family condensing. Many parents and children remain within the same four walls all day, every day. For many parents, the outlet of water cooler banter or yoga classes is gone. Even the commute home, with all its frustration, may have allowed decompression in the form of an audiobook, favorite music, or verbal transference of frustration onto the stranger who just cut you off. That commute might be gone too. Now, for many the good, bad, and the ugly is all happening at home. The 3-year-old may still adorably see a parent who can do no wrong, but in the end, the truth will prevail. A timely word of encouragement to parents: It’s okay to not be omnipotent. In fact, it will help children have a richer view of the world and more realistic expectations of themselves.
For children, they’ll need praise too, and the upheaval caused by the pandemic may be a fitting opportunity to make that praise more meaningful. But sports are off, the school musical is canceled, and the spelling bee is gone. The dojo is closed, the art fair is postponed, and the dance recital isn’t happening. Report cards in many schools may now transition from letter grades to pass/fail. Parents may be asking, “How on earth are we going to celebrate and praise the children?”
Research has shown us that praising the process is more valuable than praising the person.2 If Lucy participates in a soccer game and Javier gets his math results back, there are many possible approaches to praise. “You scored a goal!” or “You got an A on your math test!” is outcome- or product-focused praise. “You’re a good soccer player” or “You’re smart at math!” is person-focused praise. Instead, the most effective praise is process-focused praise: “You worked hard and ran hard even when it looked tiring” or “I noticed that you kept trying different strategies on those math problems until you figured them out.”
This may be a time when children face less comparison, less ranking, and receive less direct reward. With help, they can focus more on the process of learning and less on the outcomes of learning. They may more readily enjoy the efforts in their hobbies, not just the outcomes of their hobbies. When children receive praise for their work, effort, and actions rather than outcomes, externally validating things may be pleasantly replaced by internally validating traits. With process praise, children are more likely to feel self-confident, to set higher learning goals, and to accurately believe that intelligence is related to effort rather than a fixed trait that has been divided up among haves and have nots.3
Families currently face immense change, uncertainty, and discouragement largely unprecedented in their lifetimes. As care providers, we can look to lasting principles as we encourage parents in their provision of love. We can effectively provide praise and celebrate effort using evidence-based strategies uniquely fitted to our current circumstances. As we do this, we can provide healing of some of the less visible ailments associated with the COVID-19 pandemic.
Dr. Jackson is in the department of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. “The Child, the Family, and the Outside World.” London: Penguin; 1973. p. 173.
2. Dev Psychol. 1999;35(3):835-47.
3. J Exp Child Psychol. 2018;173:116-35.
The COVID-19 pandemic has changed the lives of children, teenagers, and parents worldwide. While some families are experiencing the unburdening of overly packed schedules and may be having a romantic or nostalgic “Little House on the Prairie” experience, for most it is at a minimum uncomfortable and inconvenient. For others it’s unbearable as they experience loss and feel relationship strain intensified by social distancing, seclusion, or quarantine. Some children have found respite from bullying at school, while other children have lost their only respite from being mistreated at home. Now may be as critical a time as ever for health care providers to listen carefully, empathize, validate, and proactively reach out to provide encouraging guidance and counsel, as well as express concern for families and children.
Many parents across the country are taking on an enormous, unanticipated task. Many parents have lost employment and income, while many mandatory professionals now struggle to keep up with increased work hours and work stress. Parents are trying to become multitaskers who assume the role of the music teacher, the soccer coach, the drama instructor, the friend, and of course their original role as a parent.
This seems an appropriate time to consider the work of Donald W. Winnicott, FRCP, the English pediatrician known for the concept of the “good enough parent.”1 This notion of parental competence was in part born out of a desire to defend parents against possible erosion of their confidence in following loving instincts by encroachment from professional expertise. The concept of the “good enough” parent is also related to the idea that young children who believe their parent is perfect will eventually know better. Now is a fitting time for pediatricians to buoy up imperfect but striving parents who are plenty “good enough” as they follow loving instincts to support their children during unforeseen changes associated with the pandemic.
Social distancing has led to family condensing. Many parents and children remain within the same four walls all day, every day. For many parents, the outlet of water cooler banter or yoga classes is gone. Even the commute home, with all its frustration, may have allowed decompression in the form of an audiobook, favorite music, or verbal transference of frustration onto the stranger who just cut you off. That commute might be gone too. Now, for many the good, bad, and the ugly is all happening at home. The 3-year-old may still adorably see a parent who can do no wrong, but in the end, the truth will prevail. A timely word of encouragement to parents: It’s okay to not be omnipotent. In fact, it will help children have a richer view of the world and more realistic expectations of themselves.
For children, they’ll need praise too, and the upheaval caused by the pandemic may be a fitting opportunity to make that praise more meaningful. But sports are off, the school musical is canceled, and the spelling bee is gone. The dojo is closed, the art fair is postponed, and the dance recital isn’t happening. Report cards in many schools may now transition from letter grades to pass/fail. Parents may be asking, “How on earth are we going to celebrate and praise the children?”
Research has shown us that praising the process is more valuable than praising the person.2 If Lucy participates in a soccer game and Javier gets his math results back, there are many possible approaches to praise. “You scored a goal!” or “You got an A on your math test!” is outcome- or product-focused praise. “You’re a good soccer player” or “You’re smart at math!” is person-focused praise. Instead, the most effective praise is process-focused praise: “You worked hard and ran hard even when it looked tiring” or “I noticed that you kept trying different strategies on those math problems until you figured them out.”
This may be a time when children face less comparison, less ranking, and receive less direct reward. With help, they can focus more on the process of learning and less on the outcomes of learning. They may more readily enjoy the efforts in their hobbies, not just the outcomes of their hobbies. When children receive praise for their work, effort, and actions rather than outcomes, externally validating things may be pleasantly replaced by internally validating traits. With process praise, children are more likely to feel self-confident, to set higher learning goals, and to accurately believe that intelligence is related to effort rather than a fixed trait that has been divided up among haves and have nots.3
Families currently face immense change, uncertainty, and discouragement largely unprecedented in their lifetimes. As care providers, we can look to lasting principles as we encourage parents in their provision of love. We can effectively provide praise and celebrate effort using evidence-based strategies uniquely fitted to our current circumstances. As we do this, we can provide healing of some of the less visible ailments associated with the COVID-19 pandemic.
Dr. Jackson is in the department of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. “The Child, the Family, and the Outside World.” London: Penguin; 1973. p. 173.
2. Dev Psychol. 1999;35(3):835-47.
3. J Exp Child Psychol. 2018;173:116-35.
COVID-19 crisis: We must care for ourselves as we care for others
“I do not shrink from this responsibility – I welcome it.” – John F. Kennedy, inaugural address
COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto.
In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said: “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”
And, of course, it is primary care providers – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses – who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.
The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call – and take care of ourselves – in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So too must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.
With this in mind, we would be wise to consider developing plans in three domains: physical, mental, and social.
With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.
To take care of our mental health, we need to have the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.
From a social standpoint, we must be proactive about preventing emotional isolation. Technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: family, coworkers, and patients.
Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.1
Life carries on amidst the pandemic. Even though the current focus is on the COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant and someone else will be diagnosed with cancer, plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.
We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946 after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”2
A version of this commentary originally appeared in the Journal of Family Practice (J Fam Pract. 2020 April;69[3]:119,153).
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.
References
1. Brockell G. “During a pandemic, Isaac Newton had to work from home, too. He used the time wisely.” The Washington Post. 2020 Mar 12.
2. Frankl VE. “Man’s Search for Meaning.” Boston: Beacon Press, 2006.
“I do not shrink from this responsibility – I welcome it.” – John F. Kennedy, inaugural address
COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto.
In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said: “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”
And, of course, it is primary care providers – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses – who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.
The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call – and take care of ourselves – in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So too must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.
With this in mind, we would be wise to consider developing plans in three domains: physical, mental, and social.
With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.
To take care of our mental health, we need to have the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.
From a social standpoint, we must be proactive about preventing emotional isolation. Technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: family, coworkers, and patients.
Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.1
Life carries on amidst the pandemic. Even though the current focus is on the COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant and someone else will be diagnosed with cancer, plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.
We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946 after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”2
A version of this commentary originally appeared in the Journal of Family Practice (J Fam Pract. 2020 April;69[3]:119,153).
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.
References
1. Brockell G. “During a pandemic, Isaac Newton had to work from home, too. He used the time wisely.” The Washington Post. 2020 Mar 12.
2. Frankl VE. “Man’s Search for Meaning.” Boston: Beacon Press, 2006.
“I do not shrink from this responsibility – I welcome it.” – John F. Kennedy, inaugural address
COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto.
In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said: “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”
And, of course, it is primary care providers – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses – who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.
The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call – and take care of ourselves – in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So too must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.
With this in mind, we would be wise to consider developing plans in three domains: physical, mental, and social.
With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.
To take care of our mental health, we need to have the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.
From a social standpoint, we must be proactive about preventing emotional isolation. Technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: family, coworkers, and patients.
Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.1
Life carries on amidst the pandemic. Even though the current focus is on the COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant and someone else will be diagnosed with cancer, plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.
We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946 after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”2
A version of this commentary originally appeared in the Journal of Family Practice (J Fam Pract. 2020 April;69[3]:119,153).
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.
References
1. Brockell G. “During a pandemic, Isaac Newton had to work from home, too. He used the time wisely.” The Washington Post. 2020 Mar 12.
2. Frankl VE. “Man’s Search for Meaning.” Boston: Beacon Press, 2006.
The necessity of being together
COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.
Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.
Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.
However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.
Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.
Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.
Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.
Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.
Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.
Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.
Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].
COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.
Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.
Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.
However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.
Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.
Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.
Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.
Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.
Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.
Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.
Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].
COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.
Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.
Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.
However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.
Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.
Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.
Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.
Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.
Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.
Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.
Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].
The resurgence of Plaquenil (hydroxychloroquine)
Two of the most unusual dermatologic drugs have resurged as possible first-line therapy for rescue treatment of hospitalized patients with SARS-CoV-2, despite extremely limited clinical data supporting their efficacy, optimal dose, treatment duration, and potential adverse effects.
Chloroquine and hydroxychloroquine were introduced as treatment and prophylaxis of malaria and approved by the Food and Drug Administration in 1949 and 1955, respectively. They belong to a class of drugs called 4-aminoquinolones and have a flat aromatic core and a basic side chain. The basic property of these drugs contribute to their ability to accumulate in lysosomes. They have a large volume of distribution in the blood and a half-life of 40-60 days. Important interactions include use with tamoxifen, proton pump inhibitors, and with smoking. Although both drugs cross the placenta, they don’t have any notable effects on the fetus.
Chloroquine and hydroxychloroquine enter the cell and accumulate in the lysosomes along a pH gradient. Within the lysosome, they increase the pH, thereby stabilizing lysosomes and inhibiting eosinophil and neutrophil chemotaxis and phagocytic activity. They also inhibit complement-mediated hemolysis, reduce acute phase reactants, and prevent MHC class II–mediated auto antigen presentation. Additionally, they decrease cell-mediated immunity by decreasing the production of interleukin-1 and plasma cell synthesis. Hydroxychloroquine can also accumulate in endosomes and inhibit toll-like receptor signaling, thereby reducing the production of proinflammatory cytokines.
One of the ways SARS-CoV-2 enters cells is by up-regulating and binding to ACE2. Chloroquine/hydroxychloroquine reduce glycosylation of ACE2 and thus inhibit viral entry. Additionally, by increasing the endosomal pH, they potentially inactivate enzymes that viruses require for replication. Their lifesaving benefits, however, are thought to involve blocking the proinflammatory cytokine IL-6 and suppressing the cytokine storm thought to induce acute respiratory distress syndrome. Interestingly, chloroquine has also been shown to allow zinc ions into the cell, and zinc is a potent inhibitor of coronavirus RNA polymerase.
Side effects of chloroquine and hydroxychloroquine include GI upset, retinal toxicity with long-term use, hypoglycemia, cardiomyopathy, QT prolongation, ventricular arrhythmias, and renal and liver toxicity. Adverse effects have been observed with long-term daily doses of more than 3.5 mg/kg of chloroquine or more than 6.5 mg/kg of hydroxychloroquine. Cutaneous effects include pruritus, morbilliform rashes (in an estimated 10% of those treated) and psoriasis flares, and blue-black hyperpigmentation (in about 25%) of the shins, face, oral palate, and nails.
Initial In February 2020, the first clinical results of 100 patients treated with chloroquine were reported in a news briefing by the Chinese government. On March 20, the first clinical trial was published offering guidelines for the treatment of COVID-19 using hydroxychloroquine and azithromycin combination therapy – albeit with many limitations and reported biases in the study. Despite the poorly designed studies and inconclusive evidence, on March 28, the FDA issued an Emergency Use Authorization that allows providers to request a supply of hydroxychloroquine or chloroquine for hospitalized patients with COVID-19 who are unable to join a clinical trial.
On April 2, the first clinical trial to evaluate the safety and efficacy of hydroxychloroquine in adults hospitalized with COVID-19 began at Vanderbilt University Medical Center, Nashville, Tenn. The ORCHID trial (Outcomes Related to COVID-19 Treated With Hydroxychloroquine Among In-patients With Symptomatic Disease), funded by the National Heart, Lung, and Blood Institute. This blinded, placebo-controlled study is evaluating hydroxychloroquine treatment of hospitalized patients with COVID-19 in hopes of treating the severe complications of acute respiratory distress syndrome. Participants are randomly assigned to receive 400 mg hydroxychloroquine twice daily as a loading dose and then 200 mg twice daily thereafter on days 2-5. As of this writing, this study is currently underway and outcomes are expected in the upcoming weeks.
There is now a shortage of chloroquine and hydroxychloroquine in patients who have severe dermatologic and rheumatologic diseases, which include some who been in remission for years because of these medications and are in grave danger of recurrence. During this crisis, we desperately need well-controlled, randomized studies to test the efficacy and prolonged safety profile of these drugs in COVID-19 patients, as well as appropriate funding to source these medications for hospitalized and nonhospitalized patients in need.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected].
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Yazdany J, Kim AHJ. Ann Intern Med. 2020 Mar 31. doi: 10.7326/M20-1334.
Xue J et al. PLoS One. 2014 Oct 1;9(10):e109180.
te Velthuis AJ et al. PLoS Pathog. 2010 Nov 4;6(11):e1001176.
Two of the most unusual dermatologic drugs have resurged as possible first-line therapy for rescue treatment of hospitalized patients with SARS-CoV-2, despite extremely limited clinical data supporting their efficacy, optimal dose, treatment duration, and potential adverse effects.
Chloroquine and hydroxychloroquine were introduced as treatment and prophylaxis of malaria and approved by the Food and Drug Administration in 1949 and 1955, respectively. They belong to a class of drugs called 4-aminoquinolones and have a flat aromatic core and a basic side chain. The basic property of these drugs contribute to their ability to accumulate in lysosomes. They have a large volume of distribution in the blood and a half-life of 40-60 days. Important interactions include use with tamoxifen, proton pump inhibitors, and with smoking. Although both drugs cross the placenta, they don’t have any notable effects on the fetus.
Chloroquine and hydroxychloroquine enter the cell and accumulate in the lysosomes along a pH gradient. Within the lysosome, they increase the pH, thereby stabilizing lysosomes and inhibiting eosinophil and neutrophil chemotaxis and phagocytic activity. They also inhibit complement-mediated hemolysis, reduce acute phase reactants, and prevent MHC class II–mediated auto antigen presentation. Additionally, they decrease cell-mediated immunity by decreasing the production of interleukin-1 and plasma cell synthesis. Hydroxychloroquine can also accumulate in endosomes and inhibit toll-like receptor signaling, thereby reducing the production of proinflammatory cytokines.
One of the ways SARS-CoV-2 enters cells is by up-regulating and binding to ACE2. Chloroquine/hydroxychloroquine reduce glycosylation of ACE2 and thus inhibit viral entry. Additionally, by increasing the endosomal pH, they potentially inactivate enzymes that viruses require for replication. Their lifesaving benefits, however, are thought to involve blocking the proinflammatory cytokine IL-6 and suppressing the cytokine storm thought to induce acute respiratory distress syndrome. Interestingly, chloroquine has also been shown to allow zinc ions into the cell, and zinc is a potent inhibitor of coronavirus RNA polymerase.
Side effects of chloroquine and hydroxychloroquine include GI upset, retinal toxicity with long-term use, hypoglycemia, cardiomyopathy, QT prolongation, ventricular arrhythmias, and renal and liver toxicity. Adverse effects have been observed with long-term daily doses of more than 3.5 mg/kg of chloroquine or more than 6.5 mg/kg of hydroxychloroquine. Cutaneous effects include pruritus, morbilliform rashes (in an estimated 10% of those treated) and psoriasis flares, and blue-black hyperpigmentation (in about 25%) of the shins, face, oral palate, and nails.
Initial In February 2020, the first clinical results of 100 patients treated with chloroquine were reported in a news briefing by the Chinese government. On March 20, the first clinical trial was published offering guidelines for the treatment of COVID-19 using hydroxychloroquine and azithromycin combination therapy – albeit with many limitations and reported biases in the study. Despite the poorly designed studies and inconclusive evidence, on March 28, the FDA issued an Emergency Use Authorization that allows providers to request a supply of hydroxychloroquine or chloroquine for hospitalized patients with COVID-19 who are unable to join a clinical trial.
On April 2, the first clinical trial to evaluate the safety and efficacy of hydroxychloroquine in adults hospitalized with COVID-19 began at Vanderbilt University Medical Center, Nashville, Tenn. The ORCHID trial (Outcomes Related to COVID-19 Treated With Hydroxychloroquine Among In-patients With Symptomatic Disease), funded by the National Heart, Lung, and Blood Institute. This blinded, placebo-controlled study is evaluating hydroxychloroquine treatment of hospitalized patients with COVID-19 in hopes of treating the severe complications of acute respiratory distress syndrome. Participants are randomly assigned to receive 400 mg hydroxychloroquine twice daily as a loading dose and then 200 mg twice daily thereafter on days 2-5. As of this writing, this study is currently underway and outcomes are expected in the upcoming weeks.
There is now a shortage of chloroquine and hydroxychloroquine in patients who have severe dermatologic and rheumatologic diseases, which include some who been in remission for years because of these medications and are in grave danger of recurrence. During this crisis, we desperately need well-controlled, randomized studies to test the efficacy and prolonged safety profile of these drugs in COVID-19 patients, as well as appropriate funding to source these medications for hospitalized and nonhospitalized patients in need.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected].
Sources
Liu J et al. Cell Discov. 2020 Mar 18. doi: 10.1038/s41421-020-0156-0.
Vincent MJ et al. Virol J. 2005 Aug 22;2:69.
Gautret P et al. Int J Antimicrob Agents. 2020 Mar 20. doi: 10.1016/j.ijantimicag.2020.105949.
Devaux CA et al. Int J Antimicrob Agents. 2020 Mar 12:105938. doi: 10.1016/j.ijantimicag.2020.105938.
Aronson J et al. COVID-19 trials registered up to 8 March 2020 – an analysis of 382 studies. 2020. Centre for Evidence-Based Medicine. https://www.cebm.net/oxford-covid-19/covid-19-registered-trials-and-analysis/
Savarino A et al. Lancet Infect Dis. 2003 Nov;3(11):722-7.
Yazdany J, Kim AHJ. Ann Intern Med. 2020 Mar 31. doi: 10.7326/M20-1334.
Xue J et al. PLoS One. 2014 Oct 1;9(10):e109180.
te Velthuis AJ et al. PLoS Pathog. 2010 Nov 4;6(11):e1001176.
Two of the most unusual dermatologic drugs have resurged as possible first-line therapy for rescue treatment of hospitalized patients with SARS-CoV-2, despite extremely limited clinical data supporting their efficacy, optimal dose, treatment duration, and potential adverse effects.
Chloroquine and hydroxychloroquine were introduced as treatment and prophylaxis of malaria and approved by the Food and Drug Administration in 1949 and 1955, respectively. They belong to a class of drugs called 4-aminoquinolones and have a flat aromatic core and a basic side chain. The basic property of these drugs contribute to their ability to accumulate in lysosomes. They have a large volume of distribution in the blood and a half-life of 40-60 days. Important interactions include use with tamoxifen, proton pump inhibitors, and with smoking. Although both drugs cross the placenta, they don’t have any notable effects on the fetus.
Chloroquine and hydroxychloroquine enter the cell and accumulate in the lysosomes along a pH gradient. Within the lysosome, they increase the pH, thereby stabilizing lysosomes and inhibiting eosinophil and neutrophil chemotaxis and phagocytic activity. They also inhibit complement-mediated hemolysis, reduce acute phase reactants, and prevent MHC class II–mediated auto antigen presentation. Additionally, they decrease cell-mediated immunity by decreasing the production of interleukin-1 and plasma cell synthesis. Hydroxychloroquine can also accumulate in endosomes and inhibit toll-like receptor signaling, thereby reducing the production of proinflammatory cytokines.
One of the ways SARS-CoV-2 enters cells is by up-regulating and binding to ACE2. Chloroquine/hydroxychloroquine reduce glycosylation of ACE2 and thus inhibit viral entry. Additionally, by increasing the endosomal pH, they potentially inactivate enzymes that viruses require for replication. Their lifesaving benefits, however, are thought to involve blocking the proinflammatory cytokine IL-6 and suppressing the cytokine storm thought to induce acute respiratory distress syndrome. Interestingly, chloroquine has also been shown to allow zinc ions into the cell, and zinc is a potent inhibitor of coronavirus RNA polymerase.
Side effects of chloroquine and hydroxychloroquine include GI upset, retinal toxicity with long-term use, hypoglycemia, cardiomyopathy, QT prolongation, ventricular arrhythmias, and renal and liver toxicity. Adverse effects have been observed with long-term daily doses of more than 3.5 mg/kg of chloroquine or more than 6.5 mg/kg of hydroxychloroquine. Cutaneous effects include pruritus, morbilliform rashes (in an estimated 10% of those treated) and psoriasis flares, and blue-black hyperpigmentation (in about 25%) of the shins, face, oral palate, and nails.
Initial In February 2020, the first clinical results of 100 patients treated with chloroquine were reported in a news briefing by the Chinese government. On March 20, the first clinical trial was published offering guidelines for the treatment of COVID-19 using hydroxychloroquine and azithromycin combination therapy – albeit with many limitations and reported biases in the study. Despite the poorly designed studies and inconclusive evidence, on March 28, the FDA issued an Emergency Use Authorization that allows providers to request a supply of hydroxychloroquine or chloroquine for hospitalized patients with COVID-19 who are unable to join a clinical trial.
On April 2, the first clinical trial to evaluate the safety and efficacy of hydroxychloroquine in adults hospitalized with COVID-19 began at Vanderbilt University Medical Center, Nashville, Tenn. The ORCHID trial (Outcomes Related to COVID-19 Treated With Hydroxychloroquine Among In-patients With Symptomatic Disease), funded by the National Heart, Lung, and Blood Institute. This blinded, placebo-controlled study is evaluating hydroxychloroquine treatment of hospitalized patients with COVID-19 in hopes of treating the severe complications of acute respiratory distress syndrome. Participants are randomly assigned to receive 400 mg hydroxychloroquine twice daily as a loading dose and then 200 mg twice daily thereafter on days 2-5. As of this writing, this study is currently underway and outcomes are expected in the upcoming weeks.
There is now a shortage of chloroquine and hydroxychloroquine in patients who have severe dermatologic and rheumatologic diseases, which include some who been in remission for years because of these medications and are in grave danger of recurrence. During this crisis, we desperately need well-controlled, randomized studies to test the efficacy and prolonged safety profile of these drugs in COVID-19 patients, as well as appropriate funding to source these medications for hospitalized and nonhospitalized patients in need.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected].
Sources
Liu J et al. Cell Discov. 2020 Mar 18. doi: 10.1038/s41421-020-0156-0.
Vincent MJ et al. Virol J. 2005 Aug 22;2:69.
Gautret P et al. Int J Antimicrob Agents. 2020 Mar 20. doi: 10.1016/j.ijantimicag.2020.105949.
Devaux CA et al. Int J Antimicrob Agents. 2020 Mar 12:105938. doi: 10.1016/j.ijantimicag.2020.105938.
Aronson J et al. COVID-19 trials registered up to 8 March 2020 – an analysis of 382 studies. 2020. Centre for Evidence-Based Medicine. https://www.cebm.net/oxford-covid-19/covid-19-registered-trials-and-analysis/
Savarino A et al. Lancet Infect Dis. 2003 Nov;3(11):722-7.
Yazdany J, Kim AHJ. Ann Intern Med. 2020 Mar 31. doi: 10.7326/M20-1334.
Xue J et al. PLoS One. 2014 Oct 1;9(10):e109180.
te Velthuis AJ et al. PLoS Pathog. 2010 Nov 4;6(11):e1001176.
Hospitalist well-being during the COVID-19 crisis
The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the spread of COVID-19, is overwhelming for many people. Health care workers in the United States and around the world are leading the battle on the front lines of the pandemic. Thus, they experience a higher level of stress, fear, and anxiety during this crisis.
Over the course of weeks, hospitalists have reviewed articles, attended webinars, and discussed institutional strategies to respond to COVID-19. They follow the most up-to-date clinical information about the approach to patient care, conserving personal protective equipment (PPE), and guidance on how to talk to patients and families during crisis situations. The safety of hospitalists has been underscored with persistent advocacy from multiple organizations, for PPE, access to testing supplies, and decreasing any unnecessary exposure.
While it is agreed that the safety and well-being of hospital medicine teams is crucial to our society’s victory over COVID-19, very little has been discussed with regards to the “hospitalist” well-being and wellness during this pandemic.
The well-being of providers is essential to the success of a health care system. Many hospitalists already experience moral injury and showed evidence of provider burnout before COVID-19. With the onset of the pandemic, this will only get worse and burnout will accelerate if nothing is done to stop it. We cannot wait for the dust to settle to help our colleagues, we must act now.
Many providers have expressed similar pandemic fears, including, uncertainty about screening and testing capability, fear of the PPE shortage, fear of being exposed and underprepared, and fear of bringing the virus home and making family members sick. This list is not exclusive, and there are so many other factors that providers are internally processing, all while continuing their commitment to patient care and safety.
Practicing medicine comes with the heaviest of responsibilities, including the defense of the health of humanity. Therefore, it is easy to understand that, while providers are on the battlefield of this pandemic as they defend the health of humanity, they are not thinking of their own wellness or well-being. Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This is already happening, with many hospitals in various cities running out of ventilators, lacking basic supplies for provider safety and leaving providers in survival mode on the front lines without their “suits of armor.” However, many providers will never recognize moral injury or burnout because they are focused on saving as many lives as possible with very limited resources.
While many websites can aid patient and community members on wellness during COVID-19, there is no specific forum or outlet for providers. We must give all hospital medicine team members a multimedia platform to address the fear, anxiety, and uncertainty of COVID-19. We must also provide them with techniques for resilience, coping strategies, and develop a network of support as the situation evolves, in real time.
We must remind hospitalists, “You may be scared, you may feel anxious, and that is okay. It is normal to have these feelings and it is healthy to acknowledge them. Fear serves as an important role in keeping us safe, but if left unchecked it can be horrifying and crippling. However, to conquer it we must face our fears together, with strategy, knowledge, and advocacy. This is the way to rebuild the current health care climate with confidence and trust.”
Although the world may seem foreign and dangerous, it is in adversity that we will find our strength as a hospital medicine community. We go to work every day because that is what we do. Your courage to come to work every day, in spite of any danger that it may present to you, is an inspiration to the world. The battle is not lost, and as individuals and as a community we must build resilience, inspire hope, and empower each other. We are stronger together than we are alone. As hospitalists around the country, and throughout the world, we must agree to uphold the moral integrity of medicine without sacrificing ourselves.
Dr. Williams is the vice-president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as the vice-president of the Medical Executive Committee.
Resource
Dean, Wendy; Talbot, Simon; and Dean, Austin. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019 Sept;36(9):400-2.
The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the spread of COVID-19, is overwhelming for many people. Health care workers in the United States and around the world are leading the battle on the front lines of the pandemic. Thus, they experience a higher level of stress, fear, and anxiety during this crisis.
Over the course of weeks, hospitalists have reviewed articles, attended webinars, and discussed institutional strategies to respond to COVID-19. They follow the most up-to-date clinical information about the approach to patient care, conserving personal protective equipment (PPE), and guidance on how to talk to patients and families during crisis situations. The safety of hospitalists has been underscored with persistent advocacy from multiple organizations, for PPE, access to testing supplies, and decreasing any unnecessary exposure.
While it is agreed that the safety and well-being of hospital medicine teams is crucial to our society’s victory over COVID-19, very little has been discussed with regards to the “hospitalist” well-being and wellness during this pandemic.
The well-being of providers is essential to the success of a health care system. Many hospitalists already experience moral injury and showed evidence of provider burnout before COVID-19. With the onset of the pandemic, this will only get worse and burnout will accelerate if nothing is done to stop it. We cannot wait for the dust to settle to help our colleagues, we must act now.
Many providers have expressed similar pandemic fears, including, uncertainty about screening and testing capability, fear of the PPE shortage, fear of being exposed and underprepared, and fear of bringing the virus home and making family members sick. This list is not exclusive, and there are so many other factors that providers are internally processing, all while continuing their commitment to patient care and safety.
Practicing medicine comes with the heaviest of responsibilities, including the defense of the health of humanity. Therefore, it is easy to understand that, while providers are on the battlefield of this pandemic as they defend the health of humanity, they are not thinking of their own wellness or well-being. Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This is already happening, with many hospitals in various cities running out of ventilators, lacking basic supplies for provider safety and leaving providers in survival mode on the front lines without their “suits of armor.” However, many providers will never recognize moral injury or burnout because they are focused on saving as many lives as possible with very limited resources.
While many websites can aid patient and community members on wellness during COVID-19, there is no specific forum or outlet for providers. We must give all hospital medicine team members a multimedia platform to address the fear, anxiety, and uncertainty of COVID-19. We must also provide them with techniques for resilience, coping strategies, and develop a network of support as the situation evolves, in real time.
We must remind hospitalists, “You may be scared, you may feel anxious, and that is okay. It is normal to have these feelings and it is healthy to acknowledge them. Fear serves as an important role in keeping us safe, but if left unchecked it can be horrifying and crippling. However, to conquer it we must face our fears together, with strategy, knowledge, and advocacy. This is the way to rebuild the current health care climate with confidence and trust.”
Although the world may seem foreign and dangerous, it is in adversity that we will find our strength as a hospital medicine community. We go to work every day because that is what we do. Your courage to come to work every day, in spite of any danger that it may present to you, is an inspiration to the world. The battle is not lost, and as individuals and as a community we must build resilience, inspire hope, and empower each other. We are stronger together than we are alone. As hospitalists around the country, and throughout the world, we must agree to uphold the moral integrity of medicine without sacrificing ourselves.
Dr. Williams is the vice-president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as the vice-president of the Medical Executive Committee.
Resource
Dean, Wendy; Talbot, Simon; and Dean, Austin. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019 Sept;36(9):400-2.
The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the spread of COVID-19, is overwhelming for many people. Health care workers in the United States and around the world are leading the battle on the front lines of the pandemic. Thus, they experience a higher level of stress, fear, and anxiety during this crisis.
Over the course of weeks, hospitalists have reviewed articles, attended webinars, and discussed institutional strategies to respond to COVID-19. They follow the most up-to-date clinical information about the approach to patient care, conserving personal protective equipment (PPE), and guidance on how to talk to patients and families during crisis situations. The safety of hospitalists has been underscored with persistent advocacy from multiple organizations, for PPE, access to testing supplies, and decreasing any unnecessary exposure.
While it is agreed that the safety and well-being of hospital medicine teams is crucial to our society’s victory over COVID-19, very little has been discussed with regards to the “hospitalist” well-being and wellness during this pandemic.
The well-being of providers is essential to the success of a health care system. Many hospitalists already experience moral injury and showed evidence of provider burnout before COVID-19. With the onset of the pandemic, this will only get worse and burnout will accelerate if nothing is done to stop it. We cannot wait for the dust to settle to help our colleagues, we must act now.
Many providers have expressed similar pandemic fears, including, uncertainty about screening and testing capability, fear of the PPE shortage, fear of being exposed and underprepared, and fear of bringing the virus home and making family members sick. This list is not exclusive, and there are so many other factors that providers are internally processing, all while continuing their commitment to patient care and safety.
Practicing medicine comes with the heaviest of responsibilities, including the defense of the health of humanity. Therefore, it is easy to understand that, while providers are on the battlefield of this pandemic as they defend the health of humanity, they are not thinking of their own wellness or well-being. Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This is already happening, with many hospitals in various cities running out of ventilators, lacking basic supplies for provider safety and leaving providers in survival mode on the front lines without their “suits of armor.” However, many providers will never recognize moral injury or burnout because they are focused on saving as many lives as possible with very limited resources.
While many websites can aid patient and community members on wellness during COVID-19, there is no specific forum or outlet for providers. We must give all hospital medicine team members a multimedia platform to address the fear, anxiety, and uncertainty of COVID-19. We must also provide them with techniques for resilience, coping strategies, and develop a network of support as the situation evolves, in real time.
We must remind hospitalists, “You may be scared, you may feel anxious, and that is okay. It is normal to have these feelings and it is healthy to acknowledge them. Fear serves as an important role in keeping us safe, but if left unchecked it can be horrifying and crippling. However, to conquer it we must face our fears together, with strategy, knowledge, and advocacy. This is the way to rebuild the current health care climate with confidence and trust.”
Although the world may seem foreign and dangerous, it is in adversity that we will find our strength as a hospital medicine community. We go to work every day because that is what we do. Your courage to come to work every day, in spite of any danger that it may present to you, is an inspiration to the world. The battle is not lost, and as individuals and as a community we must build resilience, inspire hope, and empower each other. We are stronger together than we are alone. As hospitalists around the country, and throughout the world, we must agree to uphold the moral integrity of medicine without sacrificing ourselves.
Dr. Williams is the vice-president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as the vice-president of the Medical Executive Committee.
Resource
Dean, Wendy; Talbot, Simon; and Dean, Austin. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019 Sept;36(9):400-2.
COVID-19: Press pause on assisted reproduction?
The SARS-CoV-2 novel coronavirus has dramatically altered specialty practice across the board, including the practice of infertility treatment. Reproductive medicine societies recommend suspending new infertility treatment cycles during this time. Women and couples who have already invested time and money in their treatment may be understandably frustrated and worried about the impact of this enforced – and indefinite – delay on their chances of conceiving. This puts the physician, who can’t even guarantee when treatment can resume, in the difficult position of trying to balance the patient’s needs with expert recommendations and government mandates.
Infertility Care During COVID-19
European and American reproductive medicine societies have both offered guidelines regarding infertility care during the pandemic. Both recommend shifting to the use of telehealth rather than in-person visits when possible for initial consultations and follow-up discussions.
With respect to infertility treatments during the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advises the following:
- Suspend initiation of new treatment cycles, including ovulation induction; intrauterine insemination; and in vitro fertilization, including retrievals and frozen embryo transfers, and suspend nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
In most countries, including the United States, all healthcare providers have been asked to put elective and nonurgent medical interventions on hold to ensure that personal protective equipment and other resources are available for the management of patients with COVID-19.
Infertility is a disease and, as such, not all infertility care should be considered elective. Still, for most patients, the overall chances of conceiving will not be compromised by a short delay (1-3 months) in treatment. A longer wait could have more impact on older patients or those who already have reduced ovarian reserve, but these are not indications for urgent fertility treatment.
There are clearly some cases in which infertility treatment cannot be delayed: for example, fertility preservation (oocyte or embryo vitrification) for patients who need to undergo immediate gonadotoxic oncology treatment. These patients need to be able to freeze oocytes/embryos so that later on, they have the option of having a family.
Another situation that could require new infertility treatment is a woman who needs urgent surgery for a condition such as severe symptomatic endometriosis causing ureteral or bowel stenosis/obstruction. Because the surgery itself can compromise fertility, the patient may elect to undergo oocyte embryo cryopreservation or ovarian tissue cryopreservation before the surgical procedure.
Pregnancy and COVID-19
As a precautionary measure during the COVID-19 pandemic, it is recommended that planned pregnancy be avoided. The available data on the risks presented by planning a pregnancy during the COVID pandemic are reassuring but limited.
Pregnancy itself has not been shown to alter the course of COVID-19, and most affected pregnant women will experience only mild or moderate flulike symptoms. Patients with cardiovascular or metabolic comorbidities or those requiring immunosuppressants are expected to be at increased risk for more severe forms of the infection. Currently, no strong evidence suggests a higher risk for miscarriage, stillbirth, or adverse neonatal outcomes with maternal COVID-19 infection.
A report based on 38 cases found no evidence for vertical transmission from mother to fetus, and all neonatal specimens (placental tissue) tested negative for the virus. Moreover, no maternal deaths were reported among these 38 infected women. Another study of 11 infected pregnant women likewise found no increased risk for perinatal morbidity or mortality.
On the other hand, a recent article on the perinatal outcomes of 33 neonates born to mothers with confirmed COVID-19 reported three cases of neonatal COVID-19 as a result of possible vertical transmission. In two cases, symptoms were mild and initial positive coronavirus test results turned negative within a few days. The third case – a pregnancy delivered by emergency cesarean section at 31 weeks for fetal distress – was complicated by bacterial sepsis, thrombocytopenia, and coagulopathy, but once again, the initially positive coronavirus test was negative by day 7.
No neonatal deaths were reported in these 33 cases. The authors could not rule out the possibility of vertical transmission in the three COVID-positive newborns because strict infection control measures were implemented during the care of the patients.
Counseling Patients About Suspending Infertility Treatments
Counseling women is the key to acceptance of the need to suspend or postpone infertility treatments during the pandemic. In addition to the economic hardships that some patients may face as a consequence of the pandemic, an obvious source of frustration stems from not knowing how long delays in treatment might be necessary. A discussion with patients or couples may reassure them that delaying conception is the safest route. For some women, other treatment options might be offered, such as the use of a donor gamete.
Some patients, even when counseled appropriately, may elect to accept the unknown risks. These patients should be counseled about the benefits of cryopreservation with delayed transfer. This could be a compromise, because their overall chances of pregnancy will not be affected but they will have to wait to become pregnant.
Counseling patients about the true impact of delaying treatment in their individual circumstances, providing them with emotional and (if needed) psychological support is important while they wait for their treatment to start. For now, the vast majority of the patients understand the need for delay, appreciate the opportunity to consult the physician over the phone, and are demonstrating patience as they wait for their treatment to start or resume.
Resuming Infertility Care
Recommendations could change as the pandemic continues and more information becomes available about the impact of coronavirus infection during pregnancy and the overall capacity of the healthcare system improves. ASRM acknowledges that “reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care.” If the data remain reassuring and social distancing measures are able to slow down the spread of the disease, the infertility care of those couples who would be most affected by a delay in their treatment could gradually be resumed. On April 14, ASRM updated its recommendations about resuming infertility treatment: “ While it is not yet prudent to resume nonemergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19.”
It is likely that the return to “normal” daily practice will be done in a stepwise fashion. I expect the practices first to open for diagnostic infertility testing, then for the less invasive procedures (frozen embryo transfer, intrauterine insemination) and finally for the more invasive lengthy procedures (stimulation with retrieval and embryo transfer). During the reopening of practice, strict infection control measures will need to be observed.
Dr. Kovacs is the medical director of Kaali Institute IVF Center in Budapest, Hungary. He has disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The SARS-CoV-2 novel coronavirus has dramatically altered specialty practice across the board, including the practice of infertility treatment. Reproductive medicine societies recommend suspending new infertility treatment cycles during this time. Women and couples who have already invested time and money in their treatment may be understandably frustrated and worried about the impact of this enforced – and indefinite – delay on their chances of conceiving. This puts the physician, who can’t even guarantee when treatment can resume, in the difficult position of trying to balance the patient’s needs with expert recommendations and government mandates.
Infertility Care During COVID-19
European and American reproductive medicine societies have both offered guidelines regarding infertility care during the pandemic. Both recommend shifting to the use of telehealth rather than in-person visits when possible for initial consultations and follow-up discussions.
With respect to infertility treatments during the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advises the following:
- Suspend initiation of new treatment cycles, including ovulation induction; intrauterine insemination; and in vitro fertilization, including retrievals and frozen embryo transfers, and suspend nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
In most countries, including the United States, all healthcare providers have been asked to put elective and nonurgent medical interventions on hold to ensure that personal protective equipment and other resources are available for the management of patients with COVID-19.
Infertility is a disease and, as such, not all infertility care should be considered elective. Still, for most patients, the overall chances of conceiving will not be compromised by a short delay (1-3 months) in treatment. A longer wait could have more impact on older patients or those who already have reduced ovarian reserve, but these are not indications for urgent fertility treatment.
There are clearly some cases in which infertility treatment cannot be delayed: for example, fertility preservation (oocyte or embryo vitrification) for patients who need to undergo immediate gonadotoxic oncology treatment. These patients need to be able to freeze oocytes/embryos so that later on, they have the option of having a family.
Another situation that could require new infertility treatment is a woman who needs urgent surgery for a condition such as severe symptomatic endometriosis causing ureteral or bowel stenosis/obstruction. Because the surgery itself can compromise fertility, the patient may elect to undergo oocyte embryo cryopreservation or ovarian tissue cryopreservation before the surgical procedure.
Pregnancy and COVID-19
As a precautionary measure during the COVID-19 pandemic, it is recommended that planned pregnancy be avoided. The available data on the risks presented by planning a pregnancy during the COVID pandemic are reassuring but limited.
Pregnancy itself has not been shown to alter the course of COVID-19, and most affected pregnant women will experience only mild or moderate flulike symptoms. Patients with cardiovascular or metabolic comorbidities or those requiring immunosuppressants are expected to be at increased risk for more severe forms of the infection. Currently, no strong evidence suggests a higher risk for miscarriage, stillbirth, or adverse neonatal outcomes with maternal COVID-19 infection.
A report based on 38 cases found no evidence for vertical transmission from mother to fetus, and all neonatal specimens (placental tissue) tested negative for the virus. Moreover, no maternal deaths were reported among these 38 infected women. Another study of 11 infected pregnant women likewise found no increased risk for perinatal morbidity or mortality.
On the other hand, a recent article on the perinatal outcomes of 33 neonates born to mothers with confirmed COVID-19 reported three cases of neonatal COVID-19 as a result of possible vertical transmission. In two cases, symptoms were mild and initial positive coronavirus test results turned negative within a few days. The third case – a pregnancy delivered by emergency cesarean section at 31 weeks for fetal distress – was complicated by bacterial sepsis, thrombocytopenia, and coagulopathy, but once again, the initially positive coronavirus test was negative by day 7.
No neonatal deaths were reported in these 33 cases. The authors could not rule out the possibility of vertical transmission in the three COVID-positive newborns because strict infection control measures were implemented during the care of the patients.
Counseling Patients About Suspending Infertility Treatments
Counseling women is the key to acceptance of the need to suspend or postpone infertility treatments during the pandemic. In addition to the economic hardships that some patients may face as a consequence of the pandemic, an obvious source of frustration stems from not knowing how long delays in treatment might be necessary. A discussion with patients or couples may reassure them that delaying conception is the safest route. For some women, other treatment options might be offered, such as the use of a donor gamete.
Some patients, even when counseled appropriately, may elect to accept the unknown risks. These patients should be counseled about the benefits of cryopreservation with delayed transfer. This could be a compromise, because their overall chances of pregnancy will not be affected but they will have to wait to become pregnant.
Counseling patients about the true impact of delaying treatment in their individual circumstances, providing them with emotional and (if needed) psychological support is important while they wait for their treatment to start. For now, the vast majority of the patients understand the need for delay, appreciate the opportunity to consult the physician over the phone, and are demonstrating patience as they wait for their treatment to start or resume.
Resuming Infertility Care
Recommendations could change as the pandemic continues and more information becomes available about the impact of coronavirus infection during pregnancy and the overall capacity of the healthcare system improves. ASRM acknowledges that “reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care.” If the data remain reassuring and social distancing measures are able to slow down the spread of the disease, the infertility care of those couples who would be most affected by a delay in their treatment could gradually be resumed. On April 14, ASRM updated its recommendations about resuming infertility treatment: “ While it is not yet prudent to resume nonemergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19.”
It is likely that the return to “normal” daily practice will be done in a stepwise fashion. I expect the practices first to open for diagnostic infertility testing, then for the less invasive procedures (frozen embryo transfer, intrauterine insemination) and finally for the more invasive lengthy procedures (stimulation with retrieval and embryo transfer). During the reopening of practice, strict infection control measures will need to be observed.
Dr. Kovacs is the medical director of Kaali Institute IVF Center in Budapest, Hungary. He has disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The SARS-CoV-2 novel coronavirus has dramatically altered specialty practice across the board, including the practice of infertility treatment. Reproductive medicine societies recommend suspending new infertility treatment cycles during this time. Women and couples who have already invested time and money in their treatment may be understandably frustrated and worried about the impact of this enforced – and indefinite – delay on their chances of conceiving. This puts the physician, who can’t even guarantee when treatment can resume, in the difficult position of trying to balance the patient’s needs with expert recommendations and government mandates.
Infertility Care During COVID-19
European and American reproductive medicine societies have both offered guidelines regarding infertility care during the pandemic. Both recommend shifting to the use of telehealth rather than in-person visits when possible for initial consultations and follow-up discussions.
With respect to infertility treatments during the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advises the following:
- Suspend initiation of new treatment cycles, including ovulation induction; intrauterine insemination; and in vitro fertilization, including retrievals and frozen embryo transfers, and suspend nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
In most countries, including the United States, all healthcare providers have been asked to put elective and nonurgent medical interventions on hold to ensure that personal protective equipment and other resources are available for the management of patients with COVID-19.
Infertility is a disease and, as such, not all infertility care should be considered elective. Still, for most patients, the overall chances of conceiving will not be compromised by a short delay (1-3 months) in treatment. A longer wait could have more impact on older patients or those who already have reduced ovarian reserve, but these are not indications for urgent fertility treatment.
There are clearly some cases in which infertility treatment cannot be delayed: for example, fertility preservation (oocyte or embryo vitrification) for patients who need to undergo immediate gonadotoxic oncology treatment. These patients need to be able to freeze oocytes/embryos so that later on, they have the option of having a family.
Another situation that could require new infertility treatment is a woman who needs urgent surgery for a condition such as severe symptomatic endometriosis causing ureteral or bowel stenosis/obstruction. Because the surgery itself can compromise fertility, the patient may elect to undergo oocyte embryo cryopreservation or ovarian tissue cryopreservation before the surgical procedure.
Pregnancy and COVID-19
As a precautionary measure during the COVID-19 pandemic, it is recommended that planned pregnancy be avoided. The available data on the risks presented by planning a pregnancy during the COVID pandemic are reassuring but limited.
Pregnancy itself has not been shown to alter the course of COVID-19, and most affected pregnant women will experience only mild or moderate flulike symptoms. Patients with cardiovascular or metabolic comorbidities or those requiring immunosuppressants are expected to be at increased risk for more severe forms of the infection. Currently, no strong evidence suggests a higher risk for miscarriage, stillbirth, or adverse neonatal outcomes with maternal COVID-19 infection.
A report based on 38 cases found no evidence for vertical transmission from mother to fetus, and all neonatal specimens (placental tissue) tested negative for the virus. Moreover, no maternal deaths were reported among these 38 infected women. Another study of 11 infected pregnant women likewise found no increased risk for perinatal morbidity or mortality.
On the other hand, a recent article on the perinatal outcomes of 33 neonates born to mothers with confirmed COVID-19 reported three cases of neonatal COVID-19 as a result of possible vertical transmission. In two cases, symptoms were mild and initial positive coronavirus test results turned negative within a few days. The third case – a pregnancy delivered by emergency cesarean section at 31 weeks for fetal distress – was complicated by bacterial sepsis, thrombocytopenia, and coagulopathy, but once again, the initially positive coronavirus test was negative by day 7.
No neonatal deaths were reported in these 33 cases. The authors could not rule out the possibility of vertical transmission in the three COVID-positive newborns because strict infection control measures were implemented during the care of the patients.
Counseling Patients About Suspending Infertility Treatments
Counseling women is the key to acceptance of the need to suspend or postpone infertility treatments during the pandemic. In addition to the economic hardships that some patients may face as a consequence of the pandemic, an obvious source of frustration stems from not knowing how long delays in treatment might be necessary. A discussion with patients or couples may reassure them that delaying conception is the safest route. For some women, other treatment options might be offered, such as the use of a donor gamete.
Some patients, even when counseled appropriately, may elect to accept the unknown risks. These patients should be counseled about the benefits of cryopreservation with delayed transfer. This could be a compromise, because their overall chances of pregnancy will not be affected but they will have to wait to become pregnant.
Counseling patients about the true impact of delaying treatment in their individual circumstances, providing them with emotional and (if needed) psychological support is important while they wait for their treatment to start. For now, the vast majority of the patients understand the need for delay, appreciate the opportunity to consult the physician over the phone, and are demonstrating patience as they wait for their treatment to start or resume.
Resuming Infertility Care
Recommendations could change as the pandemic continues and more information becomes available about the impact of coronavirus infection during pregnancy and the overall capacity of the healthcare system improves. ASRM acknowledges that “reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care.” If the data remain reassuring and social distancing measures are able to slow down the spread of the disease, the infertility care of those couples who would be most affected by a delay in their treatment could gradually be resumed. On April 14, ASRM updated its recommendations about resuming infertility treatment: “ While it is not yet prudent to resume nonemergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19.”
It is likely that the return to “normal” daily practice will be done in a stepwise fashion. I expect the practices first to open for diagnostic infertility testing, then for the less invasive procedures (frozen embryo transfer, intrauterine insemination) and finally for the more invasive lengthy procedures (stimulation with retrieval and embryo transfer). During the reopening of practice, strict infection control measures will need to be observed.
Dr. Kovacs is the medical director of Kaali Institute IVF Center in Budapest, Hungary. He has disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
COVID-19 mythconceptions
Let’s start with a case:
A 37-year-old woman is seen in clinic for a 5-day history of cough, fever, chest tightness, and onset of dyspnea on the day of her office visit.
An exam reveals her blood pressure is 100/60 mm Hg, her pulse is 100 beats per minute, her temperature is 38.7° C, her oxygen saturation is 93%, and her respiratory rate is 20 breaths per minute.
Auscultation of the chest revealed bilateral wheezing and rhonchi. A nasopharyngeal swab is sent for COVID-19 and is negative; she also tests negative for influenza.
Her hemoglobin level is 13 g/dL, hematocrit was 39%, platelet count was 155,000 per mcL of blood, and D-dimer level was 8.4 mcg/mL (normal is less than 0.4 mcg/mL.) Her white blood cell count was 6,000 per mcL of blood (neutrophils, 4,900; lymphocytes, 800; basophils, 200). Her chest x-ray showed bilateral lower lobe infiltrates.
What do you recommend?
A. Begin azithromycin plus ceftriaxone
B. Begin azithromycin
C. Begin oseltamivir
D. Obtain chest CT
E. Repeat COVID-19 test
With the massive amount of information coming out every day on COVID-19, it is hard to keep up with all of it, and sort out accurate, reviewed studies. We are in a position where we need to take in what we can and assess the best data available.
In the case above, I think choices D or E would make sense. This patient very likely has COVID-19 based on clinical symptoms and lab parameters. The negative COVID-19 test gives us pause, but several studies show that false negative tests are not uncommon.
Long et al. reported on 36 patients who had received both chest CT and real-time reverse transcription polymerase chain reaction (rRT-PCR) for COVID-19.1 All were eventually diagnosed with COVID-19 pneumonia. The CT scan had a very high sensitivity (35/36) of 97.2%, whereas the rRT-PCR had a lower sensitivity (30/36) of 83%. All six of the patients with a negative COVID-19 test initially were positive on repeat testing (three on the second test, three on the third test).
There are concerns about what the sensitivity of the rRT-PCR tests being run in the United States are. At this point, I think that, when the pretest probability of COVID-19 infection is very high based on local epidemiology and clinical symptoms, a negative COVID rRT-PCR does not eliminate the diagnosis. In many cases, COVID-19 may still be the most likely diagnosis.
Early in the pandemic, the symptoms that were emphasized were fever, cough, and dyspnea. Those were all crucial symptoms for a disease that causes pneumonia. GI symptoms were initially deemphasized. In an early study released from Wuhan, China, only about 5% of COVID-19 patients had nausea or diarrhea.2 In a study of 305 patients focused on gastrointestinal symptoms, half of the patients had diarrhea, half had anorexia and 30% had nausea.3 In a small series of nine patients who presented with only GI symptoms, four of these patients never developed fever or pulmonary symptoms.3
On March 14, the French health minister, Olivier Véran, tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone ...) could be an aggravating factor for the infection. If you have a fever, take paracetamol.” This was picked up by many news services, and soon became standard recommendations, despite no data.
There is reason for concern for NSAIDs, as regular NSAID use has been tied to more complications in patients with respiratory tract infections.4 I have never been a proponent of regular NSAID use in patients who are infected, because the likelihood of toxicity is elevated in patients who are volume depleted or under physiologic stress. But at this time, there is no evidence on problems with episodic NSAID use in patients with COVID-19.
Another widely disseminated decree was that patients with COVID-19 should not use ACE inhibitors and angiotensin II receptor blockers (ARBs). COVID-19 binds to their target cells through ACE2, which is expressed by epithelial cells of the lung, intestine and kidney. Patients who are treated with ACE inhibitors and ARBs have been shown to have more ACE2 expression.
In a letter to the editor by Fang et al. published in Lancet Respiratory Medicine, the authors raised the question of whether patients might be better served to be switched from ACE inhibitors and ARBs to calcium-channel blockers for the treatment of hypertension.5 A small study by Meng et al. looked at outcomes of patients on these drugs who had COVID-19 infection.6 They looked at 417 patients admitted to a hospital in China with COVID-19 infection. A total of 42 patients were on medications for hypertension. Group 1 were patients on ACE inhibitors/ARBs (17 patients) and group 2 were patients on other antihypertensives (25 patients). During hospitalization 12 patients (48%) in group 2 were categorized as having severe disease and 1 patient died. In group 1 (the ACE inhibitor/ARB–treated patients) only four (23%) were categorized as having severe disease, and no patients in this group died.
Vaduganathan et al. published a special report in the New England Journal of Medicine strongly arguing the point that “[u]ntil further data are available, we think that [renin-angiotensin-aldosterone system] inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19”.7 This position is supported by the American Heart Association, the American College of Cardiology, the American College of Physicians, and 11 other medical organizations.
Take-home messages
- Testing isn’t perfect – if you have strong suspicion for COVID-19 disease, retest.
- GI symptoms appear to be common, and rarely may be the only symptoms initially.
- NSAIDs are always risky in really sick patients, but data specific to COVID-19 is lacking.
- ACE inhibitors/ARBs should not be avoided in patients with COVID-19.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact Dr. Paauw at [email protected].
References
1. Long C et al. Diagnosis of the Coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.
2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.
3. Tian Y et al. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;00:1–9.
4. Voiriot G et al. Risks related to the use of nonsteroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients. J Clin Med. 2019;8:E786.
5. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 Mar 11. doi:10.1016/S2213-2600(20)30116-8.
6. Meng J et al. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect. 2020 Dec;9(1):757-60.
7. Vaduganathan M et al. Renin-angiotensin-aldosterone system inhibitors in patients with COVID-19. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMsr2005760.
Let’s start with a case:
A 37-year-old woman is seen in clinic for a 5-day history of cough, fever, chest tightness, and onset of dyspnea on the day of her office visit.
An exam reveals her blood pressure is 100/60 mm Hg, her pulse is 100 beats per minute, her temperature is 38.7° C, her oxygen saturation is 93%, and her respiratory rate is 20 breaths per minute.
Auscultation of the chest revealed bilateral wheezing and rhonchi. A nasopharyngeal swab is sent for COVID-19 and is negative; she also tests negative for influenza.
Her hemoglobin level is 13 g/dL, hematocrit was 39%, platelet count was 155,000 per mcL of blood, and D-dimer level was 8.4 mcg/mL (normal is less than 0.4 mcg/mL.) Her white blood cell count was 6,000 per mcL of blood (neutrophils, 4,900; lymphocytes, 800; basophils, 200). Her chest x-ray showed bilateral lower lobe infiltrates.
What do you recommend?
A. Begin azithromycin plus ceftriaxone
B. Begin azithromycin
C. Begin oseltamivir
D. Obtain chest CT
E. Repeat COVID-19 test
With the massive amount of information coming out every day on COVID-19, it is hard to keep up with all of it, and sort out accurate, reviewed studies. We are in a position where we need to take in what we can and assess the best data available.
In the case above, I think choices D or E would make sense. This patient very likely has COVID-19 based on clinical symptoms and lab parameters. The negative COVID-19 test gives us pause, but several studies show that false negative tests are not uncommon.
Long et al. reported on 36 patients who had received both chest CT and real-time reverse transcription polymerase chain reaction (rRT-PCR) for COVID-19.1 All were eventually diagnosed with COVID-19 pneumonia. The CT scan had a very high sensitivity (35/36) of 97.2%, whereas the rRT-PCR had a lower sensitivity (30/36) of 83%. All six of the patients with a negative COVID-19 test initially were positive on repeat testing (three on the second test, three on the third test).
There are concerns about what the sensitivity of the rRT-PCR tests being run in the United States are. At this point, I think that, when the pretest probability of COVID-19 infection is very high based on local epidemiology and clinical symptoms, a negative COVID rRT-PCR does not eliminate the diagnosis. In many cases, COVID-19 may still be the most likely diagnosis.
Early in the pandemic, the symptoms that were emphasized were fever, cough, and dyspnea. Those were all crucial symptoms for a disease that causes pneumonia. GI symptoms were initially deemphasized. In an early study released from Wuhan, China, only about 5% of COVID-19 patients had nausea or diarrhea.2 In a study of 305 patients focused on gastrointestinal symptoms, half of the patients had diarrhea, half had anorexia and 30% had nausea.3 In a small series of nine patients who presented with only GI symptoms, four of these patients never developed fever or pulmonary symptoms.3
On March 14, the French health minister, Olivier Véran, tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone ...) could be an aggravating factor for the infection. If you have a fever, take paracetamol.” This was picked up by many news services, and soon became standard recommendations, despite no data.
There is reason for concern for NSAIDs, as regular NSAID use has been tied to more complications in patients with respiratory tract infections.4 I have never been a proponent of regular NSAID use in patients who are infected, because the likelihood of toxicity is elevated in patients who are volume depleted or under physiologic stress. But at this time, there is no evidence on problems with episodic NSAID use in patients with COVID-19.
Another widely disseminated decree was that patients with COVID-19 should not use ACE inhibitors and angiotensin II receptor blockers (ARBs). COVID-19 binds to their target cells through ACE2, which is expressed by epithelial cells of the lung, intestine and kidney. Patients who are treated with ACE inhibitors and ARBs have been shown to have more ACE2 expression.
In a letter to the editor by Fang et al. published in Lancet Respiratory Medicine, the authors raised the question of whether patients might be better served to be switched from ACE inhibitors and ARBs to calcium-channel blockers for the treatment of hypertension.5 A small study by Meng et al. looked at outcomes of patients on these drugs who had COVID-19 infection.6 They looked at 417 patients admitted to a hospital in China with COVID-19 infection. A total of 42 patients were on medications for hypertension. Group 1 were patients on ACE inhibitors/ARBs (17 patients) and group 2 were patients on other antihypertensives (25 patients). During hospitalization 12 patients (48%) in group 2 were categorized as having severe disease and 1 patient died. In group 1 (the ACE inhibitor/ARB–treated patients) only four (23%) were categorized as having severe disease, and no patients in this group died.
Vaduganathan et al. published a special report in the New England Journal of Medicine strongly arguing the point that “[u]ntil further data are available, we think that [renin-angiotensin-aldosterone system] inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19”.7 This position is supported by the American Heart Association, the American College of Cardiology, the American College of Physicians, and 11 other medical organizations.
Take-home messages
- Testing isn’t perfect – if you have strong suspicion for COVID-19 disease, retest.
- GI symptoms appear to be common, and rarely may be the only symptoms initially.
- NSAIDs are always risky in really sick patients, but data specific to COVID-19 is lacking.
- ACE inhibitors/ARBs should not be avoided in patients with COVID-19.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact Dr. Paauw at [email protected].
References
1. Long C et al. Diagnosis of the Coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.
2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.
3. Tian Y et al. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;00:1–9.
4. Voiriot G et al. Risks related to the use of nonsteroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients. J Clin Med. 2019;8:E786.
5. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 Mar 11. doi:10.1016/S2213-2600(20)30116-8.
6. Meng J et al. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect. 2020 Dec;9(1):757-60.
7. Vaduganathan M et al. Renin-angiotensin-aldosterone system inhibitors in patients with COVID-19. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMsr2005760.
Let’s start with a case:
A 37-year-old woman is seen in clinic for a 5-day history of cough, fever, chest tightness, and onset of dyspnea on the day of her office visit.
An exam reveals her blood pressure is 100/60 mm Hg, her pulse is 100 beats per minute, her temperature is 38.7° C, her oxygen saturation is 93%, and her respiratory rate is 20 breaths per minute.
Auscultation of the chest revealed bilateral wheezing and rhonchi. A nasopharyngeal swab is sent for COVID-19 and is negative; she also tests negative for influenza.
Her hemoglobin level is 13 g/dL, hematocrit was 39%, platelet count was 155,000 per mcL of blood, and D-dimer level was 8.4 mcg/mL (normal is less than 0.4 mcg/mL.) Her white blood cell count was 6,000 per mcL of blood (neutrophils, 4,900; lymphocytes, 800; basophils, 200). Her chest x-ray showed bilateral lower lobe infiltrates.
What do you recommend?
A. Begin azithromycin plus ceftriaxone
B. Begin azithromycin
C. Begin oseltamivir
D. Obtain chest CT
E. Repeat COVID-19 test
With the massive amount of information coming out every day on COVID-19, it is hard to keep up with all of it, and sort out accurate, reviewed studies. We are in a position where we need to take in what we can and assess the best data available.
In the case above, I think choices D or E would make sense. This patient very likely has COVID-19 based on clinical symptoms and lab parameters. The negative COVID-19 test gives us pause, but several studies show that false negative tests are not uncommon.
Long et al. reported on 36 patients who had received both chest CT and real-time reverse transcription polymerase chain reaction (rRT-PCR) for COVID-19.1 All were eventually diagnosed with COVID-19 pneumonia. The CT scan had a very high sensitivity (35/36) of 97.2%, whereas the rRT-PCR had a lower sensitivity (30/36) of 83%. All six of the patients with a negative COVID-19 test initially were positive on repeat testing (three on the second test, three on the third test).
There are concerns about what the sensitivity of the rRT-PCR tests being run in the United States are. At this point, I think that, when the pretest probability of COVID-19 infection is very high based on local epidemiology and clinical symptoms, a negative COVID rRT-PCR does not eliminate the diagnosis. In many cases, COVID-19 may still be the most likely diagnosis.
Early in the pandemic, the symptoms that were emphasized were fever, cough, and dyspnea. Those were all crucial symptoms for a disease that causes pneumonia. GI symptoms were initially deemphasized. In an early study released from Wuhan, China, only about 5% of COVID-19 patients had nausea or diarrhea.2 In a study of 305 patients focused on gastrointestinal symptoms, half of the patients had diarrhea, half had anorexia and 30% had nausea.3 In a small series of nine patients who presented with only GI symptoms, four of these patients never developed fever or pulmonary symptoms.3
On March 14, the French health minister, Olivier Véran, tweeted that “taking anti-inflammatory drugs (ibuprofen, cortisone ...) could be an aggravating factor for the infection. If you have a fever, take paracetamol.” This was picked up by many news services, and soon became standard recommendations, despite no data.
There is reason for concern for NSAIDs, as regular NSAID use has been tied to more complications in patients with respiratory tract infections.4 I have never been a proponent of regular NSAID use in patients who are infected, because the likelihood of toxicity is elevated in patients who are volume depleted or under physiologic stress. But at this time, there is no evidence on problems with episodic NSAID use in patients with COVID-19.
Another widely disseminated decree was that patients with COVID-19 should not use ACE inhibitors and angiotensin II receptor blockers (ARBs). COVID-19 binds to their target cells through ACE2, which is expressed by epithelial cells of the lung, intestine and kidney. Patients who are treated with ACE inhibitors and ARBs have been shown to have more ACE2 expression.
In a letter to the editor by Fang et al. published in Lancet Respiratory Medicine, the authors raised the question of whether patients might be better served to be switched from ACE inhibitors and ARBs to calcium-channel blockers for the treatment of hypertension.5 A small study by Meng et al. looked at outcomes of patients on these drugs who had COVID-19 infection.6 They looked at 417 patients admitted to a hospital in China with COVID-19 infection. A total of 42 patients were on medications for hypertension. Group 1 were patients on ACE inhibitors/ARBs (17 patients) and group 2 were patients on other antihypertensives (25 patients). During hospitalization 12 patients (48%) in group 2 were categorized as having severe disease and 1 patient died. In group 1 (the ACE inhibitor/ARB–treated patients) only four (23%) were categorized as having severe disease, and no patients in this group died.
Vaduganathan et al. published a special report in the New England Journal of Medicine strongly arguing the point that “[u]ntil further data are available, we think that [renin-angiotensin-aldosterone system] inhibitors should be continued in patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19”.7 This position is supported by the American Heart Association, the American College of Cardiology, the American College of Physicians, and 11 other medical organizations.
Take-home messages
- Testing isn’t perfect – if you have strong suspicion for COVID-19 disease, retest.
- GI symptoms appear to be common, and rarely may be the only symptoms initially.
- NSAIDs are always risky in really sick patients, but data specific to COVID-19 is lacking.
- ACE inhibitors/ARBs should not be avoided in patients with COVID-19.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact Dr. Paauw at [email protected].
References
1. Long C et al. Diagnosis of the Coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.
2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.
3. Tian Y et al. Review article: Gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;00:1–9.
4. Voiriot G et al. Risks related to the use of nonsteroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients. J Clin Med. 2019;8:E786.
5. Fang L et al. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 Mar 11. doi:10.1016/S2213-2600(20)30116-8.
6. Meng J et al. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect. 2020 Dec;9(1):757-60.
7. Vaduganathan M et al. Renin-angiotensin-aldosterone system inhibitors in patients with COVID-19. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMsr2005760.
COVID-19 and its impact on the pediatric patient
Coronavirus disease of 2019, more commonly referred to as COVID-19, is caused by a novel coronavirus. At press time in April, its diagnosis had been confirmed in more than 2 million individuals in 185 countries and territories since first isolated in January 2020. Daily updates are provided in terms of the number of new cases, the evolving strategies to mitigate additional spread, testing, potential drug trials, and vaccine development. Risk groups for development of severe disease also have been widely publicized. Limited information has been provided about COVID-19 in children.
Terminology
Endemic. The condition is present at a stable predictable rate in a community. The number observed is what is expected.
Outbreak. The number of cases is greater than what is expected in the area.
Epidemic. An outbreak that spreads over a larger geographical area.
Pandemic. An outbreak that has spread to multiple countries and /or continents.
What we know about coronaviruses: They are host-specific RNA viruses widespread in bats, but found in many other species including humans. Previously, six species caused disease in humans. Four species: 229E, NL63, OC43, and HKU1 usually cause the common cold. Symptoms are generally self-limited and peak 3-4 days after onset. Infection rarely can be manifested as otitis media or a lower respiratory tract disease.
In February 2003, SARS-CoV, a novel coronavirus, was identified as the causative agent for an outbreak of a severe acute respiratory syndrome (SARS) which began in Guangdong, China. It became a pandemic that occurred between November 2002 and July 2003. More than 8,000 individuals from 26 countries were infected, and there were 774 deaths, according to the Centers for Disease Control and Prevention. No cases have been reported since April 2004. This virus most often infected adults, and the mortality rate was 10%. No pediatric deaths were reported. The virus was considered to have evolved from a bat CoV with civet cats as an intermediate host.
In September 2012, MERS-CoV (Middle East respiratory syndrome), another novel coronavirus also manifesting as a severe respiratory illness, was identified in Saudi Arabia. Current data suggests it evolved from a bat CoV using dromedary camels as an intermediate host. To date, more than 2,400 cases have been reported with a case fatality rate of approximately 35% (Emerg Infect Dis. 2020 Feb; 26[2]:191-8). Disease in children has been mild. Most cases have been identified in adult males with comorbidities and have been reported from Saudi Arabia (85%). To date, no sustained human-to-human transmission has been documented. However, limited nonsustained human-to-human transmission has occurred in health care settings.
Preliminary COVID-19 pediatric data
Multiple case reports and studies with limited numbers of patients have been quickly published, but limited data about children have been available. A large study by Wu et al. was released. Epidemiologic data were available for 72,314 cases (62% confirmed 22% suspected,15% diagnosed based on clinical symptoms). Only 965 (1.3%) cases occurred in persons under 19 years of age. There were no deaths reported in anyone younger than 9 years old. The authors indicated that 889 patients (1%) were asymptomatic, but the exact number of children in that group was not provided.1
Dong Y et al. reported on the epidemiologic characteristics of 2,135 children under 18 years who resided in or near an epidemic center. Data were obtained retrospectively; 34% (728) of the cases were confirmed and 66% (1,407) were suspected. In summary, 94 (4%) of all patients were asymptomatic, 1,088 (51%) had mild symptoms, and 826 (39%) had moderate symptoms at the time of diagnosis. The remaining 6% of patients (125) had severe/critical disease manifested by dyspnea and hypoxemia. Interestingly, more severe/critical cases were in the suspected group. Could another pathogen be the true etiology? Severity of illness was greatest for infants (11%). As of Feb. 8, 2020, only one child had died; he was 14 years old. This study supports the claim that COVID-19 disease in children is less severe than in adults.2
Data in U.S. children are now available. Between Feb. 12, 2020, and April 2, 2020, there were 149,770 cases of laboratory-confirmed COVID-19 reported to the CDC. Age was documented in 149,082 cases and 2, 572 (1.7%) were in persons younger than 18 years. New York had the highest percentage of reported pediatric cases at 33% from New York City, and 23% from the remainder of New York state; an additional 15% were from New Jersey and the remaining 29% of cases were from other areas. The median age was 11 years. Cases by age were 32% in teens aged 15-17 years; 27% in children aged 10-14 years; 15% in children aged 5-9 years; 11% in children aged 1-4 years; and 15% in children aged less than 1 year.
Exposure history was documented in 184 cases, of which 91% were household /community. Information regarding signs and symptoms were limited but not absent. Based on available data, 73% of children had fever, cough, or shortness of breath. When looked at independently, each of these symptoms occurred less frequently than in adults: 56% of children reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43% of adults, respectively. Also reported less frequently were myalgia, headache, sore throat, and diarrhea.
Hospitalization status was available for 745 children, with 20% being hospitalized and 2% being admitted to the ICU. Children under 1 year accounted for most of the hospitalizations. Limited information about underlying conditions was provided. Among 345 cases, 23% had at least one underlying medical condition; the most common conditions were chronic lung disease including asthma (50%), cardiovascular disease (31%), and immunosuppression (8%). Three deaths were reported in this cohort of 2,135 children; however, the final cause of death is still under review.3
There are limitations to the data. Many of the answers needed to perform adequate analysis regarding symptoms, their duration and severity, risk factors, etc., were not available. Routine testing is not currently recommended, and current practices may influence the outcomes.
What have we learned? The data suggest that most ill children may not have cough, fever, or shortness of breath; symptoms which parents will be looking for prior to even seeking medical attention. These are the individuals who may likely play a continued role with disease transmission. The need for hospitalization and the severity of illness appears to be lower than in adults but not absent. Strategies to mitigate additional spread such as social distancing, wearing facial masks, and hand washing still are important and should be encouraged.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures. Email Dr. Word at [email protected].
References
1. JAMA. 2020;323(13):1239-42.
2. Pediatrics. 2020:145(6): e20200702.
3. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69:422-6.
Coronavirus disease of 2019, more commonly referred to as COVID-19, is caused by a novel coronavirus. At press time in April, its diagnosis had been confirmed in more than 2 million individuals in 185 countries and territories since first isolated in January 2020. Daily updates are provided in terms of the number of new cases, the evolving strategies to mitigate additional spread, testing, potential drug trials, and vaccine development. Risk groups for development of severe disease also have been widely publicized. Limited information has been provided about COVID-19 in children.
Terminology
Endemic. The condition is present at a stable predictable rate in a community. The number observed is what is expected.
Outbreak. The number of cases is greater than what is expected in the area.
Epidemic. An outbreak that spreads over a larger geographical area.
Pandemic. An outbreak that has spread to multiple countries and /or continents.
What we know about coronaviruses: They are host-specific RNA viruses widespread in bats, but found in many other species including humans. Previously, six species caused disease in humans. Four species: 229E, NL63, OC43, and HKU1 usually cause the common cold. Symptoms are generally self-limited and peak 3-4 days after onset. Infection rarely can be manifested as otitis media or a lower respiratory tract disease.
In February 2003, SARS-CoV, a novel coronavirus, was identified as the causative agent for an outbreak of a severe acute respiratory syndrome (SARS) which began in Guangdong, China. It became a pandemic that occurred between November 2002 and July 2003. More than 8,000 individuals from 26 countries were infected, and there were 774 deaths, according to the Centers for Disease Control and Prevention. No cases have been reported since April 2004. This virus most often infected adults, and the mortality rate was 10%. No pediatric deaths were reported. The virus was considered to have evolved from a bat CoV with civet cats as an intermediate host.
In September 2012, MERS-CoV (Middle East respiratory syndrome), another novel coronavirus also manifesting as a severe respiratory illness, was identified in Saudi Arabia. Current data suggests it evolved from a bat CoV using dromedary camels as an intermediate host. To date, more than 2,400 cases have been reported with a case fatality rate of approximately 35% (Emerg Infect Dis. 2020 Feb; 26[2]:191-8). Disease in children has been mild. Most cases have been identified in adult males with comorbidities and have been reported from Saudi Arabia (85%). To date, no sustained human-to-human transmission has been documented. However, limited nonsustained human-to-human transmission has occurred in health care settings.
Preliminary COVID-19 pediatric data
Multiple case reports and studies with limited numbers of patients have been quickly published, but limited data about children have been available. A large study by Wu et al. was released. Epidemiologic data were available for 72,314 cases (62% confirmed 22% suspected,15% diagnosed based on clinical symptoms). Only 965 (1.3%) cases occurred in persons under 19 years of age. There were no deaths reported in anyone younger than 9 years old. The authors indicated that 889 patients (1%) were asymptomatic, but the exact number of children in that group was not provided.1
Dong Y et al. reported on the epidemiologic characteristics of 2,135 children under 18 years who resided in or near an epidemic center. Data were obtained retrospectively; 34% (728) of the cases were confirmed and 66% (1,407) were suspected. In summary, 94 (4%) of all patients were asymptomatic, 1,088 (51%) had mild symptoms, and 826 (39%) had moderate symptoms at the time of diagnosis. The remaining 6% of patients (125) had severe/critical disease manifested by dyspnea and hypoxemia. Interestingly, more severe/critical cases were in the suspected group. Could another pathogen be the true etiology? Severity of illness was greatest for infants (11%). As of Feb. 8, 2020, only one child had died; he was 14 years old. This study supports the claim that COVID-19 disease in children is less severe than in adults.2
Data in U.S. children are now available. Between Feb. 12, 2020, and April 2, 2020, there were 149,770 cases of laboratory-confirmed COVID-19 reported to the CDC. Age was documented in 149,082 cases and 2, 572 (1.7%) were in persons younger than 18 years. New York had the highest percentage of reported pediatric cases at 33% from New York City, and 23% from the remainder of New York state; an additional 15% were from New Jersey and the remaining 29% of cases were from other areas. The median age was 11 years. Cases by age were 32% in teens aged 15-17 years; 27% in children aged 10-14 years; 15% in children aged 5-9 years; 11% in children aged 1-4 years; and 15% in children aged less than 1 year.
Exposure history was documented in 184 cases, of which 91% were household /community. Information regarding signs and symptoms were limited but not absent. Based on available data, 73% of children had fever, cough, or shortness of breath. When looked at independently, each of these symptoms occurred less frequently than in adults: 56% of children reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43% of adults, respectively. Also reported less frequently were myalgia, headache, sore throat, and diarrhea.
Hospitalization status was available for 745 children, with 20% being hospitalized and 2% being admitted to the ICU. Children under 1 year accounted for most of the hospitalizations. Limited information about underlying conditions was provided. Among 345 cases, 23% had at least one underlying medical condition; the most common conditions were chronic lung disease including asthma (50%), cardiovascular disease (31%), and immunosuppression (8%). Three deaths were reported in this cohort of 2,135 children; however, the final cause of death is still under review.3
There are limitations to the data. Many of the answers needed to perform adequate analysis regarding symptoms, their duration and severity, risk factors, etc., were not available. Routine testing is not currently recommended, and current practices may influence the outcomes.
What have we learned? The data suggest that most ill children may not have cough, fever, or shortness of breath; symptoms which parents will be looking for prior to even seeking medical attention. These are the individuals who may likely play a continued role with disease transmission. The need for hospitalization and the severity of illness appears to be lower than in adults but not absent. Strategies to mitigate additional spread such as social distancing, wearing facial masks, and hand washing still are important and should be encouraged.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures. Email Dr. Word at [email protected].
References
1. JAMA. 2020;323(13):1239-42.
2. Pediatrics. 2020:145(6): e20200702.
3. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69:422-6.
Coronavirus disease of 2019, more commonly referred to as COVID-19, is caused by a novel coronavirus. At press time in April, its diagnosis had been confirmed in more than 2 million individuals in 185 countries and territories since first isolated in January 2020. Daily updates are provided in terms of the number of new cases, the evolving strategies to mitigate additional spread, testing, potential drug trials, and vaccine development. Risk groups for development of severe disease also have been widely publicized. Limited information has been provided about COVID-19 in children.
Terminology
Endemic. The condition is present at a stable predictable rate in a community. The number observed is what is expected.
Outbreak. The number of cases is greater than what is expected in the area.
Epidemic. An outbreak that spreads over a larger geographical area.
Pandemic. An outbreak that has spread to multiple countries and /or continents.
What we know about coronaviruses: They are host-specific RNA viruses widespread in bats, but found in many other species including humans. Previously, six species caused disease in humans. Four species: 229E, NL63, OC43, and HKU1 usually cause the common cold. Symptoms are generally self-limited and peak 3-4 days after onset. Infection rarely can be manifested as otitis media or a lower respiratory tract disease.
In February 2003, SARS-CoV, a novel coronavirus, was identified as the causative agent for an outbreak of a severe acute respiratory syndrome (SARS) which began in Guangdong, China. It became a pandemic that occurred between November 2002 and July 2003. More than 8,000 individuals from 26 countries were infected, and there were 774 deaths, according to the Centers for Disease Control and Prevention. No cases have been reported since April 2004. This virus most often infected adults, and the mortality rate was 10%. No pediatric deaths were reported. The virus was considered to have evolved from a bat CoV with civet cats as an intermediate host.
In September 2012, MERS-CoV (Middle East respiratory syndrome), another novel coronavirus also manifesting as a severe respiratory illness, was identified in Saudi Arabia. Current data suggests it evolved from a bat CoV using dromedary camels as an intermediate host. To date, more than 2,400 cases have been reported with a case fatality rate of approximately 35% (Emerg Infect Dis. 2020 Feb; 26[2]:191-8). Disease in children has been mild. Most cases have been identified in adult males with comorbidities and have been reported from Saudi Arabia (85%). To date, no sustained human-to-human transmission has been documented. However, limited nonsustained human-to-human transmission has occurred in health care settings.
Preliminary COVID-19 pediatric data
Multiple case reports and studies with limited numbers of patients have been quickly published, but limited data about children have been available. A large study by Wu et al. was released. Epidemiologic data were available for 72,314 cases (62% confirmed 22% suspected,15% diagnosed based on clinical symptoms). Only 965 (1.3%) cases occurred in persons under 19 years of age. There were no deaths reported in anyone younger than 9 years old. The authors indicated that 889 patients (1%) were asymptomatic, but the exact number of children in that group was not provided.1
Dong Y et al. reported on the epidemiologic characteristics of 2,135 children under 18 years who resided in or near an epidemic center. Data were obtained retrospectively; 34% (728) of the cases were confirmed and 66% (1,407) were suspected. In summary, 94 (4%) of all patients were asymptomatic, 1,088 (51%) had mild symptoms, and 826 (39%) had moderate symptoms at the time of diagnosis. The remaining 6% of patients (125) had severe/critical disease manifested by dyspnea and hypoxemia. Interestingly, more severe/critical cases were in the suspected group. Could another pathogen be the true etiology? Severity of illness was greatest for infants (11%). As of Feb. 8, 2020, only one child had died; he was 14 years old. This study supports the claim that COVID-19 disease in children is less severe than in adults.2
Data in U.S. children are now available. Between Feb. 12, 2020, and April 2, 2020, there were 149,770 cases of laboratory-confirmed COVID-19 reported to the CDC. Age was documented in 149,082 cases and 2, 572 (1.7%) were in persons younger than 18 years. New York had the highest percentage of reported pediatric cases at 33% from New York City, and 23% from the remainder of New York state; an additional 15% were from New Jersey and the remaining 29% of cases were from other areas. The median age was 11 years. Cases by age were 32% in teens aged 15-17 years; 27% in children aged 10-14 years; 15% in children aged 5-9 years; 11% in children aged 1-4 years; and 15% in children aged less than 1 year.
Exposure history was documented in 184 cases, of which 91% were household /community. Information regarding signs and symptoms were limited but not absent. Based on available data, 73% of children had fever, cough, or shortness of breath. When looked at independently, each of these symptoms occurred less frequently than in adults: 56% of children reported fever, 54% reported cough, and 13% reported shortness of breath, compared with 71%, 80%, and 43% of adults, respectively. Also reported less frequently were myalgia, headache, sore throat, and diarrhea.
Hospitalization status was available for 745 children, with 20% being hospitalized and 2% being admitted to the ICU. Children under 1 year accounted for most of the hospitalizations. Limited information about underlying conditions was provided. Among 345 cases, 23% had at least one underlying medical condition; the most common conditions were chronic lung disease including asthma (50%), cardiovascular disease (31%), and immunosuppression (8%). Three deaths were reported in this cohort of 2,135 children; however, the final cause of death is still under review.3
There are limitations to the data. Many of the answers needed to perform adequate analysis regarding symptoms, their duration and severity, risk factors, etc., were not available. Routine testing is not currently recommended, and current practices may influence the outcomes.
What have we learned? The data suggest that most ill children may not have cough, fever, or shortness of breath; symptoms which parents will be looking for prior to even seeking medical attention. These are the individuals who may likely play a continued role with disease transmission. The need for hospitalization and the severity of illness appears to be lower than in adults but not absent. Strategies to mitigate additional spread such as social distancing, wearing facial masks, and hand washing still are important and should be encouraged.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures. Email Dr. Word at [email protected].
References
1. JAMA. 2020;323(13):1239-42.
2. Pediatrics. 2020:145(6): e20200702.
3. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69:422-6.