Journal of Clinical Outcomes Management

We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.

Ryan McVay/ThinkStock

Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
 

Offer clear, open, regular, and child-centered communication

Accurate information calmly delivered is the antidote to anxiety or panic in a stressful situation. If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).

Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.

It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”

Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.

monkeybusinessimages/thinkstockphotos.com

School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.

Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
 

Be mindful of children’s vulnerabilities

Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.

Preserve routines and structure

Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.

Find opportunity in the disruption

Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.

Take care of the vulnerable and ease others’ hardships

Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected]

We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.

Ryan McVay/ThinkStock

Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
 

Offer clear, open, regular, and child-centered communication

Accurate information calmly delivered is the antidote to anxiety or panic in a stressful situation. If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).

Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.

It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”

Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.

monkeybusinessimages/thinkstockphotos.com

School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.

Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
 

Be mindful of children’s vulnerabilities

Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.

Preserve routines and structure

Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.

Find opportunity in the disruption

Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.

Take care of the vulnerable and ease others’ hardships

Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected]

We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.

Ryan McVay/ThinkStock

Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
 

Offer clear, open, regular, and child-centered communication

Accurate information calmly delivered is the antidote to anxiety or panic in a stressful situation. If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).

Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.

It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”

Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.

monkeybusinessimages/thinkstockphotos.com

School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.

Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
 

Be mindful of children’s vulnerabilities

Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.

Preserve routines and structure

Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.

Find opportunity in the disruption

Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.

Take care of the vulnerable and ease others’ hardships

Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected]

A message from a Chief Wellness Officer

We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.

Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.

It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.

First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.

Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.

So, what can physicians do?

• Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
• Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
• Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
• Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
• Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
• Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. Yoga and tai chi are great for relaxation, as are some apps. One that I use personally is CBT-I Coach, a free app made by the VA for veterans, which has a series of really excellent meditation and relaxation tools.
• Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
• Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
• Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.

Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
 

Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.

This article first appeared on Medscape.com.

A message from a Chief Wellness Officer

We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.

Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.

It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.

First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.

Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.

So, what can physicians do?

• Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
• Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
• Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
• Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
• Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
• Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. Yoga and tai chi are great for relaxation, as are some apps. One that I use personally is CBT-I Coach, a free app made by the VA for veterans, which has a series of really excellent meditation and relaxation tools.
• Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
• Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
• Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.

Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
 

Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.

This article first appeared on Medscape.com.

A message from a Chief Wellness Officer

We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.

Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.

It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.

First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.

Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.

So, what can physicians do?

• Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
• Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
• Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
• Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
• Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
• Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. Yoga and tai chi are great for relaxation, as are some apps. One that I use personally is CBT-I Coach, a free app made by the VA for veterans, which has a series of really excellent meditation and relaxation tools.
• Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
• Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
• Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.

Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
 

Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.

This article first appeared on Medscape.com.

The Food and Drug Administration has approved safety labeling changes to all sodium-glucose transporter 2 (SGLT2) inhibitors used to treat high blood sugar in patients with type 2 diabetes.

The new changes affect canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, and were made because surgery may put patients being treated with SGLT2 inhibitors at a higher risk of ketoacidosis. Canagliflozin, dapagliflozin, and empagliflozin should be discontinued 3 days before scheduled surgery, and ertugliflozin should be stopped at least 4 days before, the agency noted in a press release. Blood glucose should be monitored after drug discontinuation and appropriately managed before surgery.

“The SGLT2 inhibitor may be restarted once the patient’s oral intake is back to baseline and any other risk factors for ketoacidosis are resolved,” the agency added.

SGLT2 inhibitors lower blood sugar by causing the kidney to remove sugar from the body through urine. Side effects for the drugs vary, but include urinary tract infections and genital mycotic infection. Patients with severe renal impairment or end-stage renal disease, who are on dialysis treatment, or who have a known hypersensitivity to the medication should not take SGLT2 inhibitors, the FDA said.

[email protected]

The Food and Drug Administration has approved safety labeling changes to all sodium-glucose transporter 2 (SGLT2) inhibitors used to treat high blood sugar in patients with type 2 diabetes.

The new changes affect canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, and were made because surgery may put patients being treated with SGLT2 inhibitors at a higher risk of ketoacidosis. Canagliflozin, dapagliflozin, and empagliflozin should be discontinued 3 days before scheduled surgery, and ertugliflozin should be stopped at least 4 days before, the agency noted in a press release. Blood glucose should be monitored after drug discontinuation and appropriately managed before surgery.

“The SGLT2 inhibitor may be restarted once the patient’s oral intake is back to baseline and any other risk factors for ketoacidosis are resolved,” the agency added.

SGLT2 inhibitors lower blood sugar by causing the kidney to remove sugar from the body through urine. Side effects for the drugs vary, but include urinary tract infections and genital mycotic infection. Patients with severe renal impairment or end-stage renal disease, who are on dialysis treatment, or who have a known hypersensitivity to the medication should not take SGLT2 inhibitors, the FDA said.

[email protected]

The Food and Drug Administration has approved safety labeling changes to all sodium-glucose transporter 2 (SGLT2) inhibitors used to treat high blood sugar in patients with type 2 diabetes.

The new changes affect canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, and were made because surgery may put patients being treated with SGLT2 inhibitors at a higher risk of ketoacidosis. Canagliflozin, dapagliflozin, and empagliflozin should be discontinued 3 days before scheduled surgery, and ertugliflozin should be stopped at least 4 days before, the agency noted in a press release. Blood glucose should be monitored after drug discontinuation and appropriately managed before surgery.

“The SGLT2 inhibitor may be restarted once the patient’s oral intake is back to baseline and any other risk factors for ketoacidosis are resolved,” the agency added.

SGLT2 inhibitors lower blood sugar by causing the kidney to remove sugar from the body through urine. Side effects for the drugs vary, but include urinary tract infections and genital mycotic infection. Patients with severe renal impairment or end-stage renal disease, who are on dialysis treatment, or who have a known hypersensitivity to the medication should not take SGLT2 inhibitors, the FDA said.

[email protected]

Black and Hispanic patients under the age of 19 years are more likely to die from central nervous system (CNS) cancers than are non-Hispanic whites from the same age group, according to a study published in Scientific Reports.

While prior studies have shown the effects of racial/ethnic and socioeconomic risk factors on treatment outcomes in adult cancer populations, less is known about how these factors impact children with CNS cancers, explained study author Robert Fineberg, MD, of St. Anthony North Health Campus in Westminster, Colo., and colleagues.

The authors conducted their study to examine the effects of demographic and socioeconomic factors on survival in pediatric CNS cancers. Using data from the Surveillance, Epidemiology, and End Results database, the researchers identified 1,881 patients with CNS tumors, including both spinal and cranial neoplasms.

Data collection encompassed patient characteristics, socioeconomic parameters, tumor characteristics, treatment, and year of diagnosis. The primary outcomes were overall survival and disease stage at diagnosis.

Most patients were white (78.15%) and non-Hispanic (72.09%). The most common brain tumors were gliomas (n = 788), ependymomas (n = 418), and medulloblastomas (n = 393).

On multivariable analysis, the researchers found that black and Hispanic patients had worse survival, compared with white patients (hazard ratio, 1.39; P = .0014) and non-Hispanic patients (HR, 1.36; P = .0002).

After adjustment for socioeconomic parameters and treatment, the hazard ratios for both Hispanic (HR, 1.29; P = .0051) and black patients (HR, 1.29; P = .0206) slightly declined, but the differences remained significant.

On stratified analysis, poorer survival rates were observed for black and Hispanic patients with both metastatic and localized disease at diagnosis, compared with white non-Hispanic patients. However, after adjustment for mediating factors, the difference did not remain significant for black patients (P = .1026).

“Our findings on extent of disease at diagnosis demonstrated that neither black race nor Hispanic ethnicity increased the chance of metastatic disease at presentation when controlling for mediating variables,” the authors wrote. “These data suggest that racial and ethnic disparities appear to be partially explained by postdiagnosis mediating factors that may fall in the pathway between race/ethnicity and poorer survival.”

The researchers acknowledged that a key limitation of this study was the exclusion of insurance status because of incomplete access for some patients. As a result, potential associations between insurance and survival or extent of disease could not be determined.

“To better understand underlying causes that contribute to the disparity of outcomes in pediatric brain tumors, patient-level data should be utilized in future studies to investigate both biological factors and pre/postdiagnosis treatment gaps in the care of children diagnosed with CNS tumors in the hopes of improving outcomes,” the authors wrote.

In the meantime, collaboration among physicians could help improve outcomes for these patients, according to study author Adam Green, MD, of the University of Colorado at Denver in Aurora.

“[Clinicians] should establish good working relationships with pediatric oncology and neuro-oncology physicians in their community, and they should ask questions early of those teams when they have patients they’re concerned about,” Dr. Green said. “They can [ensure] that patients of minority race/ethnicity, nonprivate health insurance, and lower socioeconomic status have easy and timely access to appointments.”

This research was supported, in part, by grant funding from the National Institutes of Health. The authors reported having no conflicts of interest.

SOURCE: Fineberg R et al. Scientific Reports. 2020 Mar 12. doi: 10.1038/s41598-020-61237-2.

Black and Hispanic patients under the age of 19 years are more likely to die from central nervous system (CNS) cancers than are non-Hispanic whites from the same age group, according to a study published in Scientific Reports.

While prior studies have shown the effects of racial/ethnic and socioeconomic risk factors on treatment outcomes in adult cancer populations, less is known about how these factors impact children with CNS cancers, explained study author Robert Fineberg, MD, of St. Anthony North Health Campus in Westminster, Colo., and colleagues.

The authors conducted their study to examine the effects of demographic and socioeconomic factors on survival in pediatric CNS cancers. Using data from the Surveillance, Epidemiology, and End Results database, the researchers identified 1,881 patients with CNS tumors, including both spinal and cranial neoplasms.

Data collection encompassed patient characteristics, socioeconomic parameters, tumor characteristics, treatment, and year of diagnosis. The primary outcomes were overall survival and disease stage at diagnosis.

Most patients were white (78.15%) and non-Hispanic (72.09%). The most common brain tumors were gliomas (n = 788), ependymomas (n = 418), and medulloblastomas (n = 393).

On multivariable analysis, the researchers found that black and Hispanic patients had worse survival, compared with white patients (hazard ratio, 1.39; P = .0014) and non-Hispanic patients (HR, 1.36; P = .0002).

After adjustment for socioeconomic parameters and treatment, the hazard ratios for both Hispanic (HR, 1.29; P = .0051) and black patients (HR, 1.29; P = .0206) slightly declined, but the differences remained significant.

On stratified analysis, poorer survival rates were observed for black and Hispanic patients with both metastatic and localized disease at diagnosis, compared with white non-Hispanic patients. However, after adjustment for mediating factors, the difference did not remain significant for black patients (P = .1026).

“Our findings on extent of disease at diagnosis demonstrated that neither black race nor Hispanic ethnicity increased the chance of metastatic disease at presentation when controlling for mediating variables,” the authors wrote. “These data suggest that racial and ethnic disparities appear to be partially explained by postdiagnosis mediating factors that may fall in the pathway between race/ethnicity and poorer survival.”

The researchers acknowledged that a key limitation of this study was the exclusion of insurance status because of incomplete access for some patients. As a result, potential associations between insurance and survival or extent of disease could not be determined.

“To better understand underlying causes that contribute to the disparity of outcomes in pediatric brain tumors, patient-level data should be utilized in future studies to investigate both biological factors and pre/postdiagnosis treatment gaps in the care of children diagnosed with CNS tumors in the hopes of improving outcomes,” the authors wrote.

In the meantime, collaboration among physicians could help improve outcomes for these patients, according to study author Adam Green, MD, of the University of Colorado at Denver in Aurora.

“[Clinicians] should establish good working relationships with pediatric oncology and neuro-oncology physicians in their community, and they should ask questions early of those teams when they have patients they’re concerned about,” Dr. Green said. “They can [ensure] that patients of minority race/ethnicity, nonprivate health insurance, and lower socioeconomic status have easy and timely access to appointments.”

This research was supported, in part, by grant funding from the National Institutes of Health. The authors reported having no conflicts of interest.

SOURCE: Fineberg R et al. Scientific Reports. 2020 Mar 12. doi: 10.1038/s41598-020-61237-2.

Black and Hispanic patients under the age of 19 years are more likely to die from central nervous system (CNS) cancers than are non-Hispanic whites from the same age group, according to a study published in Scientific Reports.

While prior studies have shown the effects of racial/ethnic and socioeconomic risk factors on treatment outcomes in adult cancer populations, less is known about how these factors impact children with CNS cancers, explained study author Robert Fineberg, MD, of St. Anthony North Health Campus in Westminster, Colo., and colleagues.

The authors conducted their study to examine the effects of demographic and socioeconomic factors on survival in pediatric CNS cancers. Using data from the Surveillance, Epidemiology, and End Results database, the researchers identified 1,881 patients with CNS tumors, including both spinal and cranial neoplasms.

Data collection encompassed patient characteristics, socioeconomic parameters, tumor characteristics, treatment, and year of diagnosis. The primary outcomes were overall survival and disease stage at diagnosis.

Most patients were white (78.15%) and non-Hispanic (72.09%). The most common brain tumors were gliomas (n = 788), ependymomas (n = 418), and medulloblastomas (n = 393).

On multivariable analysis, the researchers found that black and Hispanic patients had worse survival, compared with white patients (hazard ratio, 1.39; P = .0014) and non-Hispanic patients (HR, 1.36; P = .0002).

After adjustment for socioeconomic parameters and treatment, the hazard ratios for both Hispanic (HR, 1.29; P = .0051) and black patients (HR, 1.29; P = .0206) slightly declined, but the differences remained significant.

On stratified analysis, poorer survival rates were observed for black and Hispanic patients with both metastatic and localized disease at diagnosis, compared with white non-Hispanic patients. However, after adjustment for mediating factors, the difference did not remain significant for black patients (P = .1026).

“Our findings on extent of disease at diagnosis demonstrated that neither black race nor Hispanic ethnicity increased the chance of metastatic disease at presentation when controlling for mediating variables,” the authors wrote. “These data suggest that racial and ethnic disparities appear to be partially explained by postdiagnosis mediating factors that may fall in the pathway between race/ethnicity and poorer survival.”

The researchers acknowledged that a key limitation of this study was the exclusion of insurance status because of incomplete access for some patients. As a result, potential associations between insurance and survival or extent of disease could not be determined.

“To better understand underlying causes that contribute to the disparity of outcomes in pediatric brain tumors, patient-level data should be utilized in future studies to investigate both biological factors and pre/postdiagnosis treatment gaps in the care of children diagnosed with CNS tumors in the hopes of improving outcomes,” the authors wrote.

In the meantime, collaboration among physicians could help improve outcomes for these patients, according to study author Adam Green, MD, of the University of Colorado at Denver in Aurora.

“[Clinicians] should establish good working relationships with pediatric oncology and neuro-oncology physicians in their community, and they should ask questions early of those teams when they have patients they’re concerned about,” Dr. Green said. “They can [ensure] that patients of minority race/ethnicity, nonprivate health insurance, and lower socioeconomic status have easy and timely access to appointments.”

This research was supported, in part, by grant funding from the National Institutes of Health. The authors reported having no conflicts of interest.

SOURCE: Fineberg R et al. Scientific Reports. 2020 Mar 12. doi: 10.1038/s41598-020-61237-2.

As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.

The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.

On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.

The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.

On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. A public health emergency like COVID-19 is a time for flexibility and thoughtful planning. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.

As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.

If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.

For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.

For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.

Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.

As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.

If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. It’s a time for flexibility but also to flex our muscles as health care professionals. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
 

Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.

As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.

The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.

On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.

The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.

On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. A public health emergency like COVID-19 is a time for flexibility and thoughtful planning. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.

As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.

If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.

For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.

For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.

Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.

As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.

If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. It’s a time for flexibility but also to flex our muscles as health care professionals. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
 

Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.

As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.

The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.

On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.

The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.

On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. A public health emergency like COVID-19 is a time for flexibility and thoughtful planning. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.

As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.

If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.

For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.

For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.

Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.

As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.

If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. It’s a time for flexibility but also to flex our muscles as health care professionals. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
 

Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.

Fear of dying is considered “normal.” However, the ongoing threat of a potentially fatal viral infection can cause panic, anxiety, and an exaggerated fear of illness and death. The relentless spread of the coronavirus infectious disease that began in late 2019 (COVID-19) is spawning widespread anxiety, panic, and worry about one’s health and the health of loved ones. The viral pandemic has triggered a parallel anxiety epidemic.

Making things worse is that no vaccine has yet been developed, and for individuals who do get infected, there are no specific treatments other than supportive care, such as ventilators. Members of the public have been urged to practice sensible preventative measures, including handwashing, sanitizing certain items and surfaces, and—particularly challenging—self-isolation and social distancing. The public has channeled its fear into frantic buying and hoarding of food and non-food items, especially masks, sanitizers, soap, disinfectant wipes, and toilet paper (perhaps preparing for gastrointestinal hyperactivity during anxiety); canceling flights; avoiding group activities; and self-isolation or, for those exposed to the virus, quarantine. Anxiety is palpable. The facial masks that people wear are ironically unmasking their inner agitation and disquietude.

Our role as psychiatrists

As psychiatrists, we have an important role to play in such times, especially for our patients who already have anxiety disorders or depression. The additional emotional burden of this escalating health crisis is exacerbating the mental anguish of our patients (in addition to those who may soon become new patients). The anxiety and panic attacks due to “imagined” doom and gloom are now intensified by anxiety due to a “real” fatal threat. The effect on some vulnerable patients can be devastating, and may culminate in an acute stress reaction and future posttraumatic stress disorder. There are also reports of “psychogenic COVID-19” conversion reaction, with symptoms of sore throat, dyspnea, and even psychogenic fever. Paradoxically, self-isolation and social distancing, which are recommended to prevent the human-to-human spread of the virus, may further worsen anxiety and depression by reducing the comfort of intimacy and social contacts.

Individuals with depression will also experience an increased risk of symptom breakthrough despite receiving treatment. Stress is well known to trigger or exacerbate depression. Thus, the sense of helplessness and hopelessness during depression may intensify among our patients with pre-existing mood disorders, and suicidal ideation may resurface. Making things worse is the unfortunate timing of the COVID-19 pandemic. Spring is the peak season for the re-emergence of depression and suicide attempts. The ongoing stress of the health crisis, coupled with the onset of spring, may coalesce into a dreadful synergy for relapse among vulnerable individuals with unipolar or bipolar depression.

Patients with obsessive-compulsive disorder (OCD) are known to be averse to imagined germs and may wash their hands multiple times a day. An epidemic in which all health officials strongly urge washing one’s hands is very likely to exacerbate the compulsive handwashing of persons with OCD and significantly increase their anxiety. Because their other obsessions and compulsions may also increase in frequency and intensity, they will need our attention as their psychiatrists.

The viral pandemic is eerily similar to a natural disaster such as a hurricane of tornado, both of which physically destroy towns and flatten homes. The COVID-19 pandemic is damaging social structures and obliterating the fabric of global human relations. Consider the previously unimaginable disruption of what makes a vibrant society: schools, colleges, sporting events, concerts, Broadway shows, houses of worship, festivals, conferences, conventions, busy airports/train stations/bus stations, and spontaneous community gatherings. The sudden shock of upheaval in our daily lives may not only cause a hollow sense of emptiness and grief, but also have residual economic and emotional consequences. Nothing can be taken for granted anymore, and nothing is permanent. Cynicism may rise about maintaining life as we know it.

Rising to the challenge

Physicians and clinicians across all specialties are rising to the challenge of the pandemic, whether to manage the immediate physical or emotional impacts of the health crisis or its anticipated consequences (including the economic sequelae). The often-demonized pharmaceutical industry is urgently summoning all its resources to develop both a vaccine as well as biologic treatments for this potentially fatal viral infection. The government is removing regulatory barriers to expedite solutions to the crisis. A welcome public-private partnership is expediting the availability of and access to testing for the virus. The toxic political partisanship has temporarily given way to collaboration in crafting laws that can mitigate the corrosive effects of the health crisis on businesses and individuals. All these salubrious repercussions of the pandemic are heartening and indicative of how a crisis can often bring out the best among us humans.

Continue to: Let's acknowledge the benefits...

Let’s acknowledge the benefits of the internet and the often-maligned social media. At a time of social isolation and cancellation of popular recreational activities (March Madness, NBA games, spring training baseball, movie theaters, concerts, religious congregations, partying with friends), the internet can offset the pain of mandated isolation by connecting all of us virtually, thus alleviating the emptiness that comes with isolation and boredom laced with anxiety. The damaging effects of a viral pandemic on human well-being would have been much worse if the internet did not exist.

Before the internet, television was a major escape, and for many it still is. But there is a downside: the wall-to-wall coverage of the local, national, and international effects of the pandemic can be alarming, and could increase distress even among persons who don’t have an anxiety disorder. Paradoxically, fear of going outdoors (agoraphobia) has suddenly become a necessary coping mechanism during a viral pandemic, instead of its traditional status as a “disabling symptom.”

Thank heavens for advances in technology. School children and college students can continue their education remotely without the risks of spreading infection by going to crowded classrooms. Scientific interactions and collaboration as well as business communications can remain active via videoconferencing technology, such as Zoom, Skype, or WebEx, without having to walk in crowded airports and fly to other cities on planes with recirculated air. Also, individuals who live far from family or friends can use their smartphones to see and chat with their loved ones. And cellphones remain a convenient method of staying in touch with the latest developments or making a “call to action” locally, national, and internationally.

During these oppressive and exceptional times, special attention and support must be provided to vulnerable populations, especially individuals with psychiatric illnesses, older adults who are physically infirm, and young children. Providing medical care, including psychiatric care, is essential to prevent the escalation of anxiety and panic among children and adults alike, and to prevent physical deterioration or death. This health crisis must be tackled with biopsychosocial approaches. And we, psychiatrists, must support and educate our patients and the public about stress management, and remind all about the transiency of epidemics as exemplified by the 1918 Spanish flu, the 1957 Asian flu, the 1968 Hong Kong flu, the 1982 human immunodeficiency virus, the 2002 severe acute respiratory syndrome virus, the 2009 Swine flu, the 2013 Ebola virus, and the 2016 Zika virus, all of which are now distant memories. The current COVID-19 pandemic should inoculate us to be more prepared and resilient for the inevitable future pandemics.

Fear of dying is considered “normal.” However, the ongoing threat of a potentially fatal viral infection can cause panic, anxiety, and an exaggerated fear of illness and death. The relentless spread of the coronavirus infectious disease that began in late 2019 (COVID-19) is spawning widespread anxiety, panic, and worry about one’s health and the health of loved ones. The viral pandemic has triggered a parallel anxiety epidemic.

Making things worse is that no vaccine has yet been developed, and for individuals who do get infected, there are no specific treatments other than supportive care, such as ventilators. Members of the public have been urged to practice sensible preventative measures, including handwashing, sanitizing certain items and surfaces, and—particularly challenging—self-isolation and social distancing. The public has channeled its fear into frantic buying and hoarding of food and non-food items, especially masks, sanitizers, soap, disinfectant wipes, and toilet paper (perhaps preparing for gastrointestinal hyperactivity during anxiety); canceling flights; avoiding group activities; and self-isolation or, for those exposed to the virus, quarantine. Anxiety is palpable. The facial masks that people wear are ironically unmasking their inner agitation and disquietude.

Our role as psychiatrists

As psychiatrists, we have an important role to play in such times, especially for our patients who already have anxiety disorders or depression. The additional emotional burden of this escalating health crisis is exacerbating the mental anguish of our patients (in addition to those who may soon become new patients). The anxiety and panic attacks due to “imagined” doom and gloom are now intensified by anxiety due to a “real” fatal threat. The effect on some vulnerable patients can be devastating, and may culminate in an acute stress reaction and future posttraumatic stress disorder. There are also reports of “psychogenic COVID-19” conversion reaction, with symptoms of sore throat, dyspnea, and even psychogenic fever. Paradoxically, self-isolation and social distancing, which are recommended to prevent the human-to-human spread of the virus, may further worsen anxiety and depression by reducing the comfort of intimacy and social contacts.

Individuals with depression will also experience an increased risk of symptom breakthrough despite receiving treatment. Stress is well known to trigger or exacerbate depression. Thus, the sense of helplessness and hopelessness during depression may intensify among our patients with pre-existing mood disorders, and suicidal ideation may resurface. Making things worse is the unfortunate timing of the COVID-19 pandemic. Spring is the peak season for the re-emergence of depression and suicide attempts. The ongoing stress of the health crisis, coupled with the onset of spring, may coalesce into a dreadful synergy for relapse among vulnerable individuals with unipolar or bipolar depression.

Patients with obsessive-compulsive disorder (OCD) are known to be averse to imagined germs and may wash their hands multiple times a day. An epidemic in which all health officials strongly urge washing one’s hands is very likely to exacerbate the compulsive handwashing of persons with OCD and significantly increase their anxiety. Because their other obsessions and compulsions may also increase in frequency and intensity, they will need our attention as their psychiatrists.

The viral pandemic is eerily similar to a natural disaster such as a hurricane of tornado, both of which physically destroy towns and flatten homes. The COVID-19 pandemic is damaging social structures and obliterating the fabric of global human relations. Consider the previously unimaginable disruption of what makes a vibrant society: schools, colleges, sporting events, concerts, Broadway shows, houses of worship, festivals, conferences, conventions, busy airports/train stations/bus stations, and spontaneous community gatherings. The sudden shock of upheaval in our daily lives may not only cause a hollow sense of emptiness and grief, but also have residual economic and emotional consequences. Nothing can be taken for granted anymore, and nothing is permanent. Cynicism may rise about maintaining life as we know it.

Rising to the challenge

Physicians and clinicians across all specialties are rising to the challenge of the pandemic, whether to manage the immediate physical or emotional impacts of the health crisis or its anticipated consequences (including the economic sequelae). The often-demonized pharmaceutical industry is urgently summoning all its resources to develop both a vaccine as well as biologic treatments for this potentially fatal viral infection. The government is removing regulatory barriers to expedite solutions to the crisis. A welcome public-private partnership is expediting the availability of and access to testing for the virus. The toxic political partisanship has temporarily given way to collaboration in crafting laws that can mitigate the corrosive effects of the health crisis on businesses and individuals. All these salubrious repercussions of the pandemic are heartening and indicative of how a crisis can often bring out the best among us humans.

Continue to: Let's acknowledge the benefits...

Let’s acknowledge the benefits of the internet and the often-maligned social media. At a time of social isolation and cancellation of popular recreational activities (March Madness, NBA games, spring training baseball, movie theaters, concerts, religious congregations, partying with friends), the internet can offset the pain of mandated isolation by connecting all of us virtually, thus alleviating the emptiness that comes with isolation and boredom laced with anxiety. The damaging effects of a viral pandemic on human well-being would have been much worse if the internet did not exist.

Before the internet, television was a major escape, and for many it still is. But there is a downside: the wall-to-wall coverage of the local, national, and international effects of the pandemic can be alarming, and could increase distress even among persons who don’t have an anxiety disorder. Paradoxically, fear of going outdoors (agoraphobia) has suddenly become a necessary coping mechanism during a viral pandemic, instead of its traditional status as a “disabling symptom.”

Thank heavens for advances in technology. School children and college students can continue their education remotely without the risks of spreading infection by going to crowded classrooms. Scientific interactions and collaboration as well as business communications can remain active via videoconferencing technology, such as Zoom, Skype, or WebEx, without having to walk in crowded airports and fly to other cities on planes with recirculated air. Also, individuals who live far from family or friends can use their smartphones to see and chat with their loved ones. And cellphones remain a convenient method of staying in touch with the latest developments or making a “call to action” locally, national, and internationally.

During these oppressive and exceptional times, special attention and support must be provided to vulnerable populations, especially individuals with psychiatric illnesses, older adults who are physically infirm, and young children. Providing medical care, including psychiatric care, is essential to prevent the escalation of anxiety and panic among children and adults alike, and to prevent physical deterioration or death. This health crisis must be tackled with biopsychosocial approaches. And we, psychiatrists, must support and educate our patients and the public about stress management, and remind all about the transiency of epidemics as exemplified by the 1918 Spanish flu, the 1957 Asian flu, the 1968 Hong Kong flu, the 1982 human immunodeficiency virus, the 2002 severe acute respiratory syndrome virus, the 2009 Swine flu, the 2013 Ebola virus, and the 2016 Zika virus, all of which are now distant memories. The current COVID-19 pandemic should inoculate us to be more prepared and resilient for the inevitable future pandemics.

Fear of dying is considered “normal.” However, the ongoing threat of a potentially fatal viral infection can cause panic, anxiety, and an exaggerated fear of illness and death. The relentless spread of the coronavirus infectious disease that began in late 2019 (COVID-19) is spawning widespread anxiety, panic, and worry about one’s health and the health of loved ones. The viral pandemic has triggered a parallel anxiety epidemic.

Making things worse is that no vaccine has yet been developed, and for individuals who do get infected, there are no specific treatments other than supportive care, such as ventilators. Members of the public have been urged to practice sensible preventative measures, including handwashing, sanitizing certain items and surfaces, and—particularly challenging—self-isolation and social distancing. The public has channeled its fear into frantic buying and hoarding of food and non-food items, especially masks, sanitizers, soap, disinfectant wipes, and toilet paper (perhaps preparing for gastrointestinal hyperactivity during anxiety); canceling flights; avoiding group activities; and self-isolation or, for those exposed to the virus, quarantine. Anxiety is palpable. The facial masks that people wear are ironically unmasking their inner agitation and disquietude.

Our role as psychiatrists

As psychiatrists, we have an important role to play in such times, especially for our patients who already have anxiety disorders or depression. The additional emotional burden of this escalating health crisis is exacerbating the mental anguish of our patients (in addition to those who may soon become new patients). The anxiety and panic attacks due to “imagined” doom and gloom are now intensified by anxiety due to a “real” fatal threat. The effect on some vulnerable patients can be devastating, and may culminate in an acute stress reaction and future posttraumatic stress disorder. There are also reports of “psychogenic COVID-19” conversion reaction, with symptoms of sore throat, dyspnea, and even psychogenic fever. Paradoxically, self-isolation and social distancing, which are recommended to prevent the human-to-human spread of the virus, may further worsen anxiety and depression by reducing the comfort of intimacy and social contacts.

Individuals with depression will also experience an increased risk of symptom breakthrough despite receiving treatment. Stress is well known to trigger or exacerbate depression. Thus, the sense of helplessness and hopelessness during depression may intensify among our patients with pre-existing mood disorders, and suicidal ideation may resurface. Making things worse is the unfortunate timing of the COVID-19 pandemic. Spring is the peak season for the re-emergence of depression and suicide attempts. The ongoing stress of the health crisis, coupled with the onset of spring, may coalesce into a dreadful synergy for relapse among vulnerable individuals with unipolar or bipolar depression.

Patients with obsessive-compulsive disorder (OCD) are known to be averse to imagined germs and may wash their hands multiple times a day. An epidemic in which all health officials strongly urge washing one’s hands is very likely to exacerbate the compulsive handwashing of persons with OCD and significantly increase their anxiety. Because their other obsessions and compulsions may also increase in frequency and intensity, they will need our attention as their psychiatrists.

The viral pandemic is eerily similar to a natural disaster such as a hurricane of tornado, both of which physically destroy towns and flatten homes. The COVID-19 pandemic is damaging social structures and obliterating the fabric of global human relations. Consider the previously unimaginable disruption of what makes a vibrant society: schools, colleges, sporting events, concerts, Broadway shows, houses of worship, festivals, conferences, conventions, busy airports/train stations/bus stations, and spontaneous community gatherings. The sudden shock of upheaval in our daily lives may not only cause a hollow sense of emptiness and grief, but also have residual economic and emotional consequences. Nothing can be taken for granted anymore, and nothing is permanent. Cynicism may rise about maintaining life as we know it.

Rising to the challenge

Physicians and clinicians across all specialties are rising to the challenge of the pandemic, whether to manage the immediate physical or emotional impacts of the health crisis or its anticipated consequences (including the economic sequelae). The often-demonized pharmaceutical industry is urgently summoning all its resources to develop both a vaccine as well as biologic treatments for this potentially fatal viral infection. The government is removing regulatory barriers to expedite solutions to the crisis. A welcome public-private partnership is expediting the availability of and access to testing for the virus. The toxic political partisanship has temporarily given way to collaboration in crafting laws that can mitigate the corrosive effects of the health crisis on businesses and individuals. All these salubrious repercussions of the pandemic are heartening and indicative of how a crisis can often bring out the best among us humans.

Continue to: Let's acknowledge the benefits...

Let’s acknowledge the benefits of the internet and the often-maligned social media. At a time of social isolation and cancellation of popular recreational activities (March Madness, NBA games, spring training baseball, movie theaters, concerts, religious congregations, partying with friends), the internet can offset the pain of mandated isolation by connecting all of us virtually, thus alleviating the emptiness that comes with isolation and boredom laced with anxiety. The damaging effects of a viral pandemic on human well-being would have been much worse if the internet did not exist.

Before the internet, television was a major escape, and for many it still is. But there is a downside: the wall-to-wall coverage of the local, national, and international effects of the pandemic can be alarming, and could increase distress even among persons who don’t have an anxiety disorder. Paradoxically, fear of going outdoors (agoraphobia) has suddenly become a necessary coping mechanism during a viral pandemic, instead of its traditional status as a “disabling symptom.”

Thank heavens for advances in technology. School children and college students can continue their education remotely without the risks of spreading infection by going to crowded classrooms. Scientific interactions and collaboration as well as business communications can remain active via videoconferencing technology, such as Zoom, Skype, or WebEx, without having to walk in crowded airports and fly to other cities on planes with recirculated air. Also, individuals who live far from family or friends can use their smartphones to see and chat with their loved ones. And cellphones remain a convenient method of staying in touch with the latest developments or making a “call to action” locally, national, and internationally.

During these oppressive and exceptional times, special attention and support must be provided to vulnerable populations, especially individuals with psychiatric illnesses, older adults who are physically infirm, and young children. Providing medical care, including psychiatric care, is essential to prevent the escalation of anxiety and panic among children and adults alike, and to prevent physical deterioration or death. This health crisis must be tackled with biopsychosocial approaches. And we, psychiatrists, must support and educate our patients and the public about stress management, and remind all about the transiency of epidemics as exemplified by the 1918 Spanish flu, the 1957 Asian flu, the 1968 Hong Kong flu, the 1982 human immunodeficiency virus, the 2002 severe acute respiratory syndrome virus, the 2009 Swine flu, the 2013 Ebola virus, and the 2016 Zika virus, all of which are now distant memories. The current COVID-19 pandemic should inoculate us to be more prepared and resilient for the inevitable future pandemics.

The Trump Administration is looking to telehealth services to play a more prominent role in helping mitigate the spread of COVID-19 by expanding existing benefits for Medicare beneficiaries.

“Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients’ places of residence, starting March 6, 2020,” the Centers for Medicare & Medicaid Services said in a fact sheet issued March 17.

Some of the existing benefits were previously limited to rural communities.

“Medicare beneficiaries across the nation, no matter where they live, will now be able to receive a wide range of services via telehealth without ever having to leave home,” CMS Administrator Seema Verma said during a March 17 White House press briefing on administration actions to contain the spread of COVID-19. “These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more.”

That means that seniors can continue to receive their routine care without having to leave the home and risk infection, or they can get medical guidance if they have mild symptoms, which would help mitigate the spread to others.

“This shift is very important for clinicians and providers who, over the coming weeks, will face considerable strain on their time and resources,” Dr. Verma said. “[It] allows the health care system to prioritize care for those who have more needs or who are in dire need, and it also preserves protective equipment.”

A range of providers will be able to deliver telehealth services, including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Visits using the telehealth services will be considered the same as in-person visits and will be paid as if the patient were seen in the office.

This expansion of Medicare telehealth services will continue for the duration of the COVID-19 public health emergency.

“In addition, the [Health and Human Services’] office of inspector general is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs,” the fact sheet states. CMS also said it will not conduct audits to ensure that an established relationship exists between the provider and the patient – a prior requirement for telehealth billing – during this public health emergency.

Billing for virtual check-ins, which are essentially brief conversations that may not require a full visit to the physician office, needs an established relationship between the practice and the patient. Likewise, for e-visits, which include non–face-to-face communications through online patient portals, billing can occur only when there is an established patient relationship.

Key to the expansion is that it will cover the entire United States and will not be limited to rural areas.

Dr. Verma also noted that the administration “will be temporarily suspending certain HIPAA requirements so that doctors can provide telehealth with their own phones.”

She noted this was all a part of mitigation efforts to limit the spread of COVID-19.

“As we are encouraging Americans to stay home whenever possible, we don’t want our Medicare policies getting in the way,” she said, adding that state Medicaid agencies can expand their telehealth services without the approval of CMS during this emergency.

[email protected]

The Trump Administration is looking to telehealth services to play a more prominent role in helping mitigate the spread of COVID-19 by expanding existing benefits for Medicare beneficiaries.

“Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients’ places of residence, starting March 6, 2020,” the Centers for Medicare & Medicaid Services said in a fact sheet issued March 17.

Some of the existing benefits were previously limited to rural communities.

“Medicare beneficiaries across the nation, no matter where they live, will now be able to receive a wide range of services via telehealth without ever having to leave home,” CMS Administrator Seema Verma said during a March 17 White House press briefing on administration actions to contain the spread of COVID-19. “These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more.”

That means that seniors can continue to receive their routine care without having to leave the home and risk infection, or they can get medical guidance if they have mild symptoms, which would help mitigate the spread to others.

“This shift is very important for clinicians and providers who, over the coming weeks, will face considerable strain on their time and resources,” Dr. Verma said. “[It] allows the health care system to prioritize care for those who have more needs or who are in dire need, and it also preserves protective equipment.”

A range of providers will be able to deliver telehealth services, including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Visits using the telehealth services will be considered the same as in-person visits and will be paid as if the patient were seen in the office.

This expansion of Medicare telehealth services will continue for the duration of the COVID-19 public health emergency.

“In addition, the [Health and Human Services’] office of inspector general is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs,” the fact sheet states. CMS also said it will not conduct audits to ensure that an established relationship exists between the provider and the patient – a prior requirement for telehealth billing – during this public health emergency.

Billing for virtual check-ins, which are essentially brief conversations that may not require a full visit to the physician office, needs an established relationship between the practice and the patient. Likewise, for e-visits, which include non–face-to-face communications through online patient portals, billing can occur only when there is an established patient relationship.

Key to the expansion is that it will cover the entire United States and will not be limited to rural areas.

Dr. Verma also noted that the administration “will be temporarily suspending certain HIPAA requirements so that doctors can provide telehealth with their own phones.”

She noted this was all a part of mitigation efforts to limit the spread of COVID-19.

“As we are encouraging Americans to stay home whenever possible, we don’t want our Medicare policies getting in the way,” she said, adding that state Medicaid agencies can expand their telehealth services without the approval of CMS during this emergency.

[email protected]

The Trump Administration is looking to telehealth services to play a more prominent role in helping mitigate the spread of COVID-19 by expanding existing benefits for Medicare beneficiaries.

“Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients’ places of residence, starting March 6, 2020,” the Centers for Medicare & Medicaid Services said in a fact sheet issued March 17.

Some of the existing benefits were previously limited to rural communities.

“Medicare beneficiaries across the nation, no matter where they live, will now be able to receive a wide range of services via telehealth without ever having to leave home,” CMS Administrator Seema Verma said during a March 17 White House press briefing on administration actions to contain the spread of COVID-19. “These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more.”

That means that seniors can continue to receive their routine care without having to leave the home and risk infection, or they can get medical guidance if they have mild symptoms, which would help mitigate the spread to others.

“This shift is very important for clinicians and providers who, over the coming weeks, will face considerable strain on their time and resources,” Dr. Verma said. “[It] allows the health care system to prioritize care for those who have more needs or who are in dire need, and it also preserves protective equipment.”

A range of providers will be able to deliver telehealth services, including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Visits using the telehealth services will be considered the same as in-person visits and will be paid as if the patient were seen in the office.

This expansion of Medicare telehealth services will continue for the duration of the COVID-19 public health emergency.

“In addition, the [Health and Human Services’] office of inspector general is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs,” the fact sheet states. CMS also said it will not conduct audits to ensure that an established relationship exists between the provider and the patient – a prior requirement for telehealth billing – during this public health emergency.

Billing for virtual check-ins, which are essentially brief conversations that may not require a full visit to the physician office, needs an established relationship between the practice and the patient. Likewise, for e-visits, which include non–face-to-face communications through online patient portals, billing can occur only when there is an established patient relationship.

Key to the expansion is that it will cover the entire United States and will not be limited to rural areas.

Dr. Verma also noted that the administration “will be temporarily suspending certain HIPAA requirements so that doctors can provide telehealth with their own phones.”

She noted this was all a part of mitigation efforts to limit the spread of COVID-19.

“As we are encouraging Americans to stay home whenever possible, we don’t want our Medicare policies getting in the way,” she said, adding that state Medicaid agencies can expand their telehealth services without the approval of CMS during this emergency.

[email protected]

The novel coronavirus, SARS-CoV-2, remains viable in aerosols for hours and on surfaces for days, according to a new study.

The data indicate that the stability of the new virus is similar to that of SARS-CoV-1, which caused the SARS epidemic, researchers report in an article published on the medRxivpreprint server. (The posted article has been submitted for journal publication but has not been peer reviewed.)

Transmission of SARS-CoV-2, which causes COVID-19, has quickly outstripped the pace of the 2003 SARS epidemic. “Superspread” of the earlier disease arose from infection during medical procedures, in which a single infected individual seeded many secondary cases. In contrast, the novel coronavirus appears to be spread more through human-to-human transmission in a variety of settings.

However, it’s not yet known the extent to which asymptomatic or presymptomatic individuals spread the new virus through daily routine.

To investigate how long SARS-CoV-2 remains infective in the environment, Neeltje van Doremalen, PhD, of the Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, in Hamilton, Montana, and colleagues conducted simulation experiments in which they compared the viability of SARS-CoV-2 with that of SARS-CoV-1 in aerosols and on surfaces.

Among patients infected with SARS-CoV-2, viral loads in the upper respiratory tract are high; as a consequence, respiratory secretion in the form of aerosols (<5 μm) or droplets (>5 mcm) is likely, the authors note.

van Doremalen and colleagues used nebulizers to generate aerosols. Samples of SARS-CoV-1 and SARS-CoV-2 were collecting at 0, 30, 60, 120, and 180 minutes on a gelatin filter. The researchers then tested the infectivity of the viruses on Vero cells grown in culture.

They found that SARS-CoV-2 was largely stable through the full 180-minute test, with only a slight decline at 3 hours. This time course is similar to that of SARS-CoV-1; both viruses have a median half-life in aerosols of 2.7 hours (range, 1.65 hr for SARS-CoV-1, vs 7.24 hr for SARS-CoV-2).

The researchers then tested the viruses on a variety of surfaces for up to 7 days, using humidity values and temperatures designed to mimic “a variety of household and hospital situations.” The volumes of viral exposures that the team used were consistent with amounts found in the human upper and lower respiratory tracts.

For example, they applied 50 mcL of virus-containing solution to a piece of cardboard and then swabbed the surface, at different times, with an additional 1 mcL of medium. Each surface assay was replicated three times.

The novel coronavirus was most stable on plastic and stainless steel, with some virus remaining viable up to 72 hours. However, by that time the viral load had fallen by about three orders of magnitude, indicating exponential decay. This profile was remarkably similar to that of SARS-CoV-1, according to the authors.

However, the two viruses differed in staying power on copper and cardboard. No viable SARS-CoV-2 was detectable on copper after 4 hours or on cardboard after 24 hours. In contrast, SARS-CoV-1 was not viable beyond 8 hours for either copper or cardboard.

“Taken together, our results indicate that aerosol and fomite transmission of HCoV-19 [SARS-CoV-2] are plausible, as the virus can remain viable in aerosols for multiple hours and on surfaces up to days,” the authors conclude.

Andrew Pekosz, PhD, codirector of the Center of Excellence in Influenza Research and Surveillance and director of the Center for Emerging Viruses and Infectious Diseases at the Johns Hopkins Center for Global Health, Baltimore, Maryland, applauds the real-world value of the experiments.

“The PCR [polymerase chain reaction] test used [in other studies] to detect SARS-CoV-2 just detects the virus genome. It doesn’t tell you if the virus was still infectious, or ‘viable.’ That’s why this study is interesting,” Pekosz said. “It focuses on infectious virus, which is the virus that has the potential to transmit and infect another person. What we don’t know yet is how much infectious (viable) virus is needed to initiate infection in another person.”

He suggests that further investigations evaluate other types of environmental surfaces, including lacquered wood that is made into desks and ceramic tiles found in bathrooms and kitchens.

One limitation of the study is that the data for experiments on cardboard were more variable than the data for other surfaces tested.

The investigators and Pekosz have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The novel coronavirus, SARS-CoV-2, remains viable in aerosols for hours and on surfaces for days, according to a new study.

The data indicate that the stability of the new virus is similar to that of SARS-CoV-1, which caused the SARS epidemic, researchers report in an article published on the medRxivpreprint server. (The posted article has been submitted for journal publication but has not been peer reviewed.)

Transmission of SARS-CoV-2, which causes COVID-19, has quickly outstripped the pace of the 2003 SARS epidemic. “Superspread” of the earlier disease arose from infection during medical procedures, in which a single infected individual seeded many secondary cases. In contrast, the novel coronavirus appears to be spread more through human-to-human transmission in a variety of settings.

However, it’s not yet known the extent to which asymptomatic or presymptomatic individuals spread the new virus through daily routine.

To investigate how long SARS-CoV-2 remains infective in the environment, Neeltje van Doremalen, PhD, of the Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, in Hamilton, Montana, and colleagues conducted simulation experiments in which they compared the viability of SARS-CoV-2 with that of SARS-CoV-1 in aerosols and on surfaces.

Among patients infected with SARS-CoV-2, viral loads in the upper respiratory tract are high; as a consequence, respiratory secretion in the form of aerosols (<5 μm) or droplets (>5 mcm) is likely, the authors note.

van Doremalen and colleagues used nebulizers to generate aerosols. Samples of SARS-CoV-1 and SARS-CoV-2 were collecting at 0, 30, 60, 120, and 180 minutes on a gelatin filter. The researchers then tested the infectivity of the viruses on Vero cells grown in culture.

They found that SARS-CoV-2 was largely stable through the full 180-minute test, with only a slight decline at 3 hours. This time course is similar to that of SARS-CoV-1; both viruses have a median half-life in aerosols of 2.7 hours (range, 1.65 hr for SARS-CoV-1, vs 7.24 hr for SARS-CoV-2).

The researchers then tested the viruses on a variety of surfaces for up to 7 days, using humidity values and temperatures designed to mimic “a variety of household and hospital situations.” The volumes of viral exposures that the team used were consistent with amounts found in the human upper and lower respiratory tracts.

For example, they applied 50 mcL of virus-containing solution to a piece of cardboard and then swabbed the surface, at different times, with an additional 1 mcL of medium. Each surface assay was replicated three times.

The novel coronavirus was most stable on plastic and stainless steel, with some virus remaining viable up to 72 hours. However, by that time the viral load had fallen by about three orders of magnitude, indicating exponential decay. This profile was remarkably similar to that of SARS-CoV-1, according to the authors.

However, the two viruses differed in staying power on copper and cardboard. No viable SARS-CoV-2 was detectable on copper after 4 hours or on cardboard after 24 hours. In contrast, SARS-CoV-1 was not viable beyond 8 hours for either copper or cardboard.

“Taken together, our results indicate that aerosol and fomite transmission of HCoV-19 [SARS-CoV-2] are plausible, as the virus can remain viable in aerosols for multiple hours and on surfaces up to days,” the authors conclude.

Andrew Pekosz, PhD, codirector of the Center of Excellence in Influenza Research and Surveillance and director of the Center for Emerging Viruses and Infectious Diseases at the Johns Hopkins Center for Global Health, Baltimore, Maryland, applauds the real-world value of the experiments.

“The PCR [polymerase chain reaction] test used [in other studies] to detect SARS-CoV-2 just detects the virus genome. It doesn’t tell you if the virus was still infectious, or ‘viable.’ That’s why this study is interesting,” Pekosz said. “It focuses on infectious virus, which is the virus that has the potential to transmit and infect another person. What we don’t know yet is how much infectious (viable) virus is needed to initiate infection in another person.”

He suggests that further investigations evaluate other types of environmental surfaces, including lacquered wood that is made into desks and ceramic tiles found in bathrooms and kitchens.

One limitation of the study is that the data for experiments on cardboard were more variable than the data for other surfaces tested.

The investigators and Pekosz have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The novel coronavirus, SARS-CoV-2, remains viable in aerosols for hours and on surfaces for days, according to a new study.

The data indicate that the stability of the new virus is similar to that of SARS-CoV-1, which caused the SARS epidemic, researchers report in an article published on the medRxivpreprint server. (The posted article has been submitted for journal publication but has not been peer reviewed.)

Transmission of SARS-CoV-2, which causes COVID-19, has quickly outstripped the pace of the 2003 SARS epidemic. “Superspread” of the earlier disease arose from infection during medical procedures, in which a single infected individual seeded many secondary cases. In contrast, the novel coronavirus appears to be spread more through human-to-human transmission in a variety of settings.

However, it’s not yet known the extent to which asymptomatic or presymptomatic individuals spread the new virus through daily routine.

To investigate how long SARS-CoV-2 remains infective in the environment, Neeltje van Doremalen, PhD, of the Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, in Hamilton, Montana, and colleagues conducted simulation experiments in which they compared the viability of SARS-CoV-2 with that of SARS-CoV-1 in aerosols and on surfaces.

Among patients infected with SARS-CoV-2, viral loads in the upper respiratory tract are high; as a consequence, respiratory secretion in the form of aerosols (<5 μm) or droplets (>5 mcm) is likely, the authors note.

van Doremalen and colleagues used nebulizers to generate aerosols. Samples of SARS-CoV-1 and SARS-CoV-2 were collecting at 0, 30, 60, 120, and 180 minutes on a gelatin filter. The researchers then tested the infectivity of the viruses on Vero cells grown in culture.

They found that SARS-CoV-2 was largely stable through the full 180-minute test, with only a slight decline at 3 hours. This time course is similar to that of SARS-CoV-1; both viruses have a median half-life in aerosols of 2.7 hours (range, 1.65 hr for SARS-CoV-1, vs 7.24 hr for SARS-CoV-2).

The researchers then tested the viruses on a variety of surfaces for up to 7 days, using humidity values and temperatures designed to mimic “a variety of household and hospital situations.” The volumes of viral exposures that the team used were consistent with amounts found in the human upper and lower respiratory tracts.

For example, they applied 50 mcL of virus-containing solution to a piece of cardboard and then swabbed the surface, at different times, with an additional 1 mcL of medium. Each surface assay was replicated three times.

The novel coronavirus was most stable on plastic and stainless steel, with some virus remaining viable up to 72 hours. However, by that time the viral load had fallen by about three orders of magnitude, indicating exponential decay. This profile was remarkably similar to that of SARS-CoV-1, according to the authors.

However, the two viruses differed in staying power on copper and cardboard. No viable SARS-CoV-2 was detectable on copper after 4 hours or on cardboard after 24 hours. In contrast, SARS-CoV-1 was not viable beyond 8 hours for either copper or cardboard.

“Taken together, our results indicate that aerosol and fomite transmission of HCoV-19 [SARS-CoV-2] are plausible, as the virus can remain viable in aerosols for multiple hours and on surfaces up to days,” the authors conclude.

Andrew Pekosz, PhD, codirector of the Center of Excellence in Influenza Research and Surveillance and director of the Center for Emerging Viruses and Infectious Diseases at the Johns Hopkins Center for Global Health, Baltimore, Maryland, applauds the real-world value of the experiments.

“The PCR [polymerase chain reaction] test used [in other studies] to detect SARS-CoV-2 just detects the virus genome. It doesn’t tell you if the virus was still infectious, or ‘viable.’ That’s why this study is interesting,” Pekosz said. “It focuses on infectious virus, which is the virus that has the potential to transmit and infect another person. What we don’t know yet is how much infectious (viable) virus is needed to initiate infection in another person.”

He suggests that further investigations evaluate other types of environmental surfaces, including lacquered wood that is made into desks and ceramic tiles found in bathrooms and kitchens.

One limitation of the study is that the data for experiments on cardboard were more variable than the data for other surfaces tested.

The investigators and Pekosz have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The novel coronavirus (2019-nCoV) shows evidence of causing gastrointestinal symptoms and has the potential to be transmitted by the fecal-oral route, according to a new report from physicians at Shanghai Jiao Tong University, published online (Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro.2020.02.054).

The virus’s respiratory symptoms are well documented and suggest primary transmission by droplet or contact, while other symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort are less common and appear to vary between populations. The SARS coronavirus showed up in stool, even sometimes in patients discharged from the hospital. In a study of hospitalized patients in Wuhan, China, 10.1% of coronavirus patients had diarrhea and nausea in the 1-2 days before onset of fever and dyspnea. The first U.S. patient to be diagnosed had a 2-day history of nausea and vomiting, and had a loose bowel movement on the second day in the hospital. Clinicians later confirmed the presence of viral RNA in both the patient’s stool and airway.

The authors say that researchers in China have isolated viral RNA from the stool of two patients (unpublished), and it has been found in saliva, suggesting the possibility of the salivary gland as an infection or transmission route.

The authors maintain that previous studies likely overlooked or neglected patients who had mild intestinal symptoms. “Many efforts should be made to be alert on the initial digestive symptoms of COVID-19 for early detection, early diagnosis, early isolation and early intervention,” the authors wrote.

Like other coronaviruses, it appears that 2019-nCoV infects cells through an interaction between viral transmembrane spike glycoprotein (S-protein) receptor-binding domain, and the cell receptors angiotensin-converting enzyme 2 (ACE-2) and host cellular transmembrane serine protease (TMPRSS). Transcriptome analysis has shown that human lung AT2 cells express ACE-2 and TMPRSS, but esophagus upper and stratified epithelial cells also express both factors, as do stratified epithelial cells and absorptive enterocytes in the ileum and colon.

The researchers call for investigation into ACE-2 fusion proteins and TMPRSS inhibitors for diagnosis, prophylaxis, or treatment of COVID-19.

The authors also noted that COVID-19 has been linked to mild to moderate liver injury as revealed by elevated aminotransferases, hypoproteinemia and prothrombin time prolongation. This also has precedent in that the SARS coronavirus can infect the liver, and biopsies revealed mitoses and apoptosis, along with other abnormalities. SARS-associated hepatitis may be the result of viral hepatitis, immune overreaction, or a secondary effect of antiviral medications or other drugs. Little is known to date about the ability of 2019-nCoV to infect the liver, but single-cell RNA sequencing data from two distinct cohorts showed more ACE-2 expression in cholangiocytes (59.7%) than hepatocytes (2.6%), which indicates that the virus might directly affect intrahepatic bile ducts.

The authors had no sources of funding or financial conflicts.

SOURCE: GU J et al. Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro.2020.02.054.

*This story was updated on 4/10.2020.

The novel coronavirus (2019-nCoV) shows evidence of causing gastrointestinal symptoms and has the potential to be transmitted by the fecal-oral route, according to a new report from physicians at Shanghai Jiao Tong University, published online (Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro.2020.02.054).

The virus’s respiratory symptoms are well documented and suggest primary transmission by droplet or contact, while other symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort are less common and appear to vary between populations. The SARS coronavirus showed up in stool, even sometimes in patients discharged from the hospital. In a study of hospitalized patients in Wuhan, China, 10.1% of coronavirus patients had diarrhea and nausea in the 1-2 days before onset of fever and dyspnea. The first U.S. patient to be diagnosed had a 2-day history of nausea and vomiting, and had a loose bowel movement on the second day in the hospital. Clinicians later confirmed the presence of viral RNA in both the patient’s stool and airway.

The authors say that researchers in China have isolated viral RNA from the stool of two patients (unpublished), and it has been found in saliva, suggesting the possibility of the salivary gland as an infection or transmission route.

The authors maintain that previous studies likely overlooked or neglected patients who had mild intestinal symptoms. “Many efforts should be made to be alert on the initial digestive symptoms of COVID-19 for early detection, early diagnosis, early isolation and early intervention,” the authors wrote.

Like other coronaviruses, it appears that 2019-nCoV infects cells through an interaction between viral transmembrane spike glycoprotein (S-protein) receptor-binding domain, and the cell receptors angiotensin-converting enzyme 2 (ACE-2) and host cellular transmembrane serine protease (TMPRSS). Transcriptome analysis has shown that human lung AT2 cells express ACE-2 and TMPRSS, but esophagus upper and stratified epithelial cells also express both factors, as do stratified epithelial cells and absorptive enterocytes in the ileum and colon.

The researchers call for investigation into ACE-2 fusion proteins and TMPRSS inhibitors for diagnosis, prophylaxis, or treatment of COVID-19.

The authors also noted that COVID-19 has been linked to mild to moderate liver injury as revealed by elevated aminotransferases, hypoproteinemia and prothrombin time prolongation. This also has precedent in that the SARS coronavirus can infect the liver, and biopsies revealed mitoses and apoptosis, along with other abnormalities. SARS-associated hepatitis may be the result of viral hepatitis, immune overreaction, or a secondary effect of antiviral medications or other drugs. Little is known to date about the ability of 2019-nCoV to infect the liver, but single-cell RNA sequencing data from two distinct cohorts showed more ACE-2 expression in cholangiocytes (59.7%) than hepatocytes (2.6%), which indicates that the virus might directly affect intrahepatic bile ducts.

The authors had no sources of funding or financial conflicts.

SOURCE: GU J et al. Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro.2020.02.054.

*This story was updated on 4/10.2020.

The novel coronavirus (2019-nCoV) shows evidence of causing gastrointestinal symptoms and has the potential to be transmitted by the fecal-oral route, according to a new report from physicians at Shanghai Jiao Tong University, published online (Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro.2020.02.054).

The virus’s respiratory symptoms are well documented and suggest primary transmission by droplet or contact, while other symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort are less common and appear to vary between populations. The SARS coronavirus showed up in stool, even sometimes in patients discharged from the hospital. In a study of hospitalized patients in Wuhan, China, 10.1% of coronavirus patients had diarrhea and nausea in the 1-2 days before onset of fever and dyspnea. The first U.S. patient to be diagnosed had a 2-day history of nausea and vomiting, and had a loose bowel movement on the second day in the hospital. Clinicians later confirmed the presence of viral RNA in both the patient’s stool and airway.

The authors say that researchers in China have isolated viral RNA from the stool of two patients (unpublished), and it has been found in saliva, suggesting the possibility of the salivary gland as an infection or transmission route.

The authors maintain that previous studies likely overlooked or neglected patients who had mild intestinal symptoms. “Many efforts should be made to be alert on the initial digestive symptoms of COVID-19 for early detection, early diagnosis, early isolation and early intervention,” the authors wrote.

Like other coronaviruses, it appears that 2019-nCoV infects cells through an interaction between viral transmembrane spike glycoprotein (S-protein) receptor-binding domain, and the cell receptors angiotensin-converting enzyme 2 (ACE-2) and host cellular transmembrane serine protease (TMPRSS). Transcriptome analysis has shown that human lung AT2 cells express ACE-2 and TMPRSS, but esophagus upper and stratified epithelial cells also express both factors, as do stratified epithelial cells and absorptive enterocytes in the ileum and colon.

The researchers call for investigation into ACE-2 fusion proteins and TMPRSS inhibitors for diagnosis, prophylaxis, or treatment of COVID-19.

The authors also noted that COVID-19 has been linked to mild to moderate liver injury as revealed by elevated aminotransferases, hypoproteinemia and prothrombin time prolongation. This also has precedent in that the SARS coronavirus can infect the liver, and biopsies revealed mitoses and apoptosis, along with other abnormalities. SARS-associated hepatitis may be the result of viral hepatitis, immune overreaction, or a secondary effect of antiviral medications or other drugs. Little is known to date about the ability of 2019-nCoV to infect the liver, but single-cell RNA sequencing data from two distinct cohorts showed more ACE-2 expression in cholangiocytes (59.7%) than hepatocytes (2.6%), which indicates that the virus might directly affect intrahepatic bile ducts.

The authors had no sources of funding or financial conflicts.

SOURCE: GU J et al. Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro.2020.02.054.

*This story was updated on 4/10.2020.

The Get With the Guidelines – Stroke program is finally turning its attention to hemorrhagic strokes after having spurred improved patient management performance from participating U.S. stroke centers since its start in 2003 with a focus on acute ischemic stroke.

The advisers who craft policy for Get With the Guidelines – Stroke (GWTG–S) are planning to launch a pilot program later in 2020 that will initiate data monitoring and quality improvement aimed at optimizing care for patients following an intracerebral hemorrhage (ICH) starting at 15 U.S. stroke centers, with announcement of these 15 participating centers expected later in 2020. The program will start by targeting nine specific, evidence-based, key aspects of the acute management of ICH patients, said Kevin N. Sheth, MD, professor of neurology and neurosurgery, and chief of neurocritical care and emergency neurology at Yale University in New Haven, Conn, and a volunteer expert who is part of the team developing the ICH initiative.

According to Dr. Sheth, the nine imperatives of acute ICH care that the program plans to monitor at participating centers are:

• Obtain a baseline severity score.
• Identify etiology as spontaneous or treatment related.
• Perform coagulopathy reversal or anticoagulant reversal.
• Administer venous thromboembolism prophylaxis.
• Apply dysphagia screening within 24 hours, and delay oral intake until patient passes dysphagia screen.
• Provide patient management in a multidisciplinary stroke or ICU unit.
• Prescribe appropriate blood pressure treatment at discharge.
• Perform assessment for rehabilitation.
• Avoid prescribing corticosteroids and other contraindicated drugs.

GWTG–S is adopting these metrics for assessing the acute care of ICH patients based largely on the recommendations of an expert 2018 panel organized by the American Heart Association and American Stroke. Association that proposed a set of performance measures for the care of ICH patients. This set of performance measures served as the primary basis for designing the new GWTG–S program, along with considerations of feasibility for collecting data on these measures, Dr. Sheth said in an interview. “We hope to make it easy” for centers to collect the data needed to participate.

The existing GWTG–S program is now 17-years old, and has spread to nearly 2,400 U.S. stroke centers as of early 2020, but the time has come to broaden its reach to patients with ICH and the programs that treat these patients, Dr. Sheth said. After years of nihilism about the prospects for patients following an ICH stroke, survival rates have increased, presenting “an opportunity to optimize care, for quality improvement,” he explained. “It’s a huge shift.” ICH patients “do better than we used to think.”

[email protected]

The Get With the Guidelines – Stroke program is finally turning its attention to hemorrhagic strokes after having spurred improved patient management performance from participating U.S. stroke centers since its start in 2003 with a focus on acute ischemic stroke.

The advisers who craft policy for Get With the Guidelines – Stroke (GWTG–S) are planning to launch a pilot program later in 2020 that will initiate data monitoring and quality improvement aimed at optimizing care for patients following an intracerebral hemorrhage (ICH) starting at 15 U.S. stroke centers, with announcement of these 15 participating centers expected later in 2020. The program will start by targeting nine specific, evidence-based, key aspects of the acute management of ICH patients, said Kevin N. Sheth, MD, professor of neurology and neurosurgery, and chief of neurocritical care and emergency neurology at Yale University in New Haven, Conn, and a volunteer expert who is part of the team developing the ICH initiative.

According to Dr. Sheth, the nine imperatives of acute ICH care that the program plans to monitor at participating centers are:

• Obtain a baseline severity score.
• Identify etiology as spontaneous or treatment related.
• Perform coagulopathy reversal or anticoagulant reversal.
• Administer venous thromboembolism prophylaxis.
• Apply dysphagia screening within 24 hours, and delay oral intake until patient passes dysphagia screen.
• Provide patient management in a multidisciplinary stroke or ICU unit.
• Prescribe appropriate blood pressure treatment at discharge.
• Perform assessment for rehabilitation.
• Avoid prescribing corticosteroids and other contraindicated drugs.

GWTG–S is adopting these metrics for assessing the acute care of ICH patients based largely on the recommendations of an expert 2018 panel organized by the American Heart Association and American Stroke. Association that proposed a set of performance measures for the care of ICH patients. This set of performance measures served as the primary basis for designing the new GWTG–S program, along with considerations of feasibility for collecting data on these measures, Dr. Sheth said in an interview. “We hope to make it easy” for centers to collect the data needed to participate.

The existing GWTG–S program is now 17-years old, and has spread to nearly 2,400 U.S. stroke centers as of early 2020, but the time has come to broaden its reach to patients with ICH and the programs that treat these patients, Dr. Sheth said. After years of nihilism about the prospects for patients following an ICH stroke, survival rates have increased, presenting “an opportunity to optimize care, for quality improvement,” he explained. “It’s a huge shift.” ICH patients “do better than we used to think.”

[email protected]

The Get With the Guidelines – Stroke program is finally turning its attention to hemorrhagic strokes after having spurred improved patient management performance from participating U.S. stroke centers since its start in 2003 with a focus on acute ischemic stroke.

The advisers who craft policy for Get With the Guidelines – Stroke (GWTG–S) are planning to launch a pilot program later in 2020 that will initiate data monitoring and quality improvement aimed at optimizing care for patients following an intracerebral hemorrhage (ICH) starting at 15 U.S. stroke centers, with announcement of these 15 participating centers expected later in 2020. The program will start by targeting nine specific, evidence-based, key aspects of the acute management of ICH patients, said Kevin N. Sheth, MD, professor of neurology and neurosurgery, and chief of neurocritical care and emergency neurology at Yale University in New Haven, Conn, and a volunteer expert who is part of the team developing the ICH initiative.

According to Dr. Sheth, the nine imperatives of acute ICH care that the program plans to monitor at participating centers are:

• Obtain a baseline severity score.
• Identify etiology as spontaneous or treatment related.
• Perform coagulopathy reversal or anticoagulant reversal.
• Administer venous thromboembolism prophylaxis.
• Apply dysphagia screening within 24 hours, and delay oral intake until patient passes dysphagia screen.
• Provide patient management in a multidisciplinary stroke or ICU unit.
• Prescribe appropriate blood pressure treatment at discharge.
• Perform assessment for rehabilitation.
• Avoid prescribing corticosteroids and other contraindicated drugs.

GWTG–S is adopting these metrics for assessing the acute care of ICH patients based largely on the recommendations of an expert 2018 panel organized by the American Heart Association and American Stroke. Association that proposed a set of performance measures for the care of ICH patients. This set of performance measures served as the primary basis for designing the new GWTG–S program, along with considerations of feasibility for collecting data on these measures, Dr. Sheth said in an interview. “We hope to make it easy” for centers to collect the data needed to participate.

The existing GWTG–S program is now 17-years old, and has spread to nearly 2,400 U.S. stroke centers as of early 2020, but the time has come to broaden its reach to patients with ICH and the programs that treat these patients, Dr. Sheth said. After years of nihilism about the prospects for patients following an ICH stroke, survival rates have increased, presenting “an opportunity to optimize care, for quality improvement,” he explained. “It’s a huge shift.” ICH patients “do better than we used to think.”

[email protected]