Ob.Gyn. News

Sequential chemoradiation may improve disease-free survival (DFS) among patients with early-stage cervical cancer who have undergone radical hysterectomy, the phase 3 STARS trial suggests.

In the study’s intent-to-treat (ITT) population, the 3-year DFS rate was significantly higher among patients who received sequential chemoradiation than among patients who received concurrent chemoradiation or radiation alone.

“After an adjustment for baseline presence of lymph node metastasis, we found that sequential chemoradiation decreased, by 40% to 50%, the recurrence risk, compared with the other two groups,” said investigator He Huang, MD, of Sun Yat-Sen University Cancer Center in Guangzhou, China.

Dr. Huang presented these findings as part of the American Society of Clinical Oncology virtual scientific program.
 

Study rationale and details

“As we know, early-stage cervical cancer can be cured after treatment,” Dr. Huang said. “However, the risk of recurrence remains higher among patients with high-risk factors, including lymph node metastases, positive surgical margins, and parametrial invasion. Postoperative adjuvant radiation and chemotherapy may result in favorable survival for patients with high-risk factors.”

Although the efficacy of concurrent radiation with single-agent cisplatin has been demonstrated in primary treatment for local advanced cervical cancer, it has not been assessed as adjuvant treatment for early-stage cervical cancer in a randomized, controlled trial, Dr. Huang explained.

“Another question is whether patients with intermediate-risk factors could benefit from the concurrent chemotherapy [with] radiation,” he said. “So far, we don’t have enough evidence.”

To gain some insight, Dr. Huang and colleagues initiated the STARS trial. The trial enrolled patients with stage IB1-IIA2 cervical cancer and at least one adverse risk factor after radical hysterectomy. Patients had a median age of 48 years, and most had stage IB1 or IIA1 disease.

The patients were randomized 1:1:1 to receive radiation alone, concurrent chemoradiation, or sequential chemoradiation.

All patients received pelvic radiation at 45-50 Gy. Patients in the concurrent chemoradiation arm also received five doses of weekly cisplatin at 30-40 mg/m².

Patients in the sequential chemoradiation arm received 60-75 mg/m² of weekly cisplatin plus 135-175 mg/m² of paclitaxel in 21-day cycles, with two cycles given before and two cycles given after radiotherapy.

The treatment groups were comparable with respect to histologic subtypes, lymphovascular invasion rates, parametrial or surgical margin involvement, deep stromal involvement, tumor grade, minimally invasive surgery rates, and neoadjuvant chemotherapy, Dr. Huang said. He added, however, that lymph node metastasis was lowest in the radiation-only arm.
 

DFS results

In the ITT population, patients who received sequential chemoradiation had significantly better DFS compared with patients in the other treatment arms. The ITT population included 353 patients in the sequential chemoradiation arm, 345 patients in the concurrent chemoradiation arm, and 350 patients in the radiation-only arm.

The 3-year DFS rates were 90% in patients randomized to sequential chemoradiation, 85% in patients randomized to concurrent chemoradiation, and 82% in patients randomized to radiation alone (hazard ratios, 0.52 for sequential chemoradiation vs. radiation alone and 0.65 for sequential vs. concurrent chemoradiation; P = .03).

Subgroup analyses showed a DFS benefit with sequential chemoradiation versus radiation alone across histology types, tumor grades, and tumor size, Dr. Huang noted.

In the per-protocol population, sequential chemoradiation was associated with better DFS when compared with radiation alone. However, there were no significant differences between the sequential and concurrent chemoradiation arms or the concurrent chemoradiation and radiation-only arms.

The per-protocol population included 235 patients in the sequential chemoradiation arm, 190 patients in the concurrent chemoradiation arm, and 324 patients in the radiation-only arm.

In the per-protocol population, the 3-year DFS rates were 91% in patients randomized to sequential chemoradiation, 86% in patients randomized to concurrent chemoradiation, and 82% in patients randomized to radiation alone (HRs, 0.47 for sequential vs. radiation alone and 0.67 for sequential vs. concurrent; P = .026).

In the overall population, DFS was superior among patients with intermediate-risk versus high-risk factors. The 3-year DFS rates were 90% and 74%, respectively (P < .05).
 

Overall survival and safety

As for overall survival (OS), sequential chemoradiation showed a trend toward improvement at 5 years, compared with the other treatment groups. However, the differences were not statistically significant in either the ITT or per-protocol populations.

In the ITT population, the 5-year OS was 92% in the sequential chemoradiation arm, 89% in the concurrent chemoradiation arm, and 88% in the radiation-only arm. In the per-protocol population, the 5-year OS rates were 93%, 90%, and 88%, respectively.

Patients with intermediate-risk factors had a more favorable OS. The 5-year OS rate was 93% in patients with intermediate-risk factors and 81% in patients with high-risk factors (P < .05).

Dr. Huang noted that patients in the radiation-only arm experienced fewer grade 3-4 adverse events than the other patients. Less neutropenia, nausea, and vomiting were observed in the radiation-only arm.

There was more grade 3-4 nausea and vomiting in the concurrent chemoradiation arm than in the sequential chemoradiation arm.

However, Dr. Huang noted that “adding chemotherapy to radiation did not impact the patients’ quality of life in the long-term compared with radiation alone.

“In this study, sequential chemoradiation resulted in a better disease-free survival and a lower risk of cancer death for cervical cancer patients with adverse pathological factors,” he said. “We believe that sequential chemoradiation could be an optimal option for post-operative adjuvant treatment.”

This study was sponsored by Sun Yat-sen University in collaboration with Guangdong Provincial People’s Hospital, First Affiliated Hospital/Sun Yat-Sen University, Shenzhen People’s Hospital, and Cancer Hospital of Guangxi Medical University. Dr. Huang reported receiving honoraria, travel, accommodations, and expenses from AstraZeneca.

sworcester@mdedge.com

SOURCE: Huang H et al. ASCO 2020, Abstract 6007.

Sequential chemoradiation may improve disease-free survival (DFS) among patients with early-stage cervical cancer who have undergone radical hysterectomy, the phase 3 STARS trial suggests.

In the study’s intent-to-treat (ITT) population, the 3-year DFS rate was significantly higher among patients who received sequential chemoradiation than among patients who received concurrent chemoradiation or radiation alone.

“After an adjustment for baseline presence of lymph node metastasis, we found that sequential chemoradiation decreased, by 40% to 50%, the recurrence risk, compared with the other two groups,” said investigator He Huang, MD, of Sun Yat-Sen University Cancer Center in Guangzhou, China.

Dr. Huang presented these findings as part of the American Society of Clinical Oncology virtual scientific program.
 

Study rationale and details

“As we know, early-stage cervical cancer can be cured after treatment,” Dr. Huang said. “However, the risk of recurrence remains higher among patients with high-risk factors, including lymph node metastases, positive surgical margins, and parametrial invasion. Postoperative adjuvant radiation and chemotherapy may result in favorable survival for patients with high-risk factors.”

Although the efficacy of concurrent radiation with single-agent cisplatin has been demonstrated in primary treatment for local advanced cervical cancer, it has not been assessed as adjuvant treatment for early-stage cervical cancer in a randomized, controlled trial, Dr. Huang explained.

“Another question is whether patients with intermediate-risk factors could benefit from the concurrent chemotherapy [with] radiation,” he said. “So far, we don’t have enough evidence.”

To gain some insight, Dr. Huang and colleagues initiated the STARS trial. The trial enrolled patients with stage IB1-IIA2 cervical cancer and at least one adverse risk factor after radical hysterectomy. Patients had a median age of 48 years, and most had stage IB1 or IIA1 disease.

The patients were randomized 1:1:1 to receive radiation alone, concurrent chemoradiation, or sequential chemoradiation.

All patients received pelvic radiation at 45-50 Gy. Patients in the concurrent chemoradiation arm also received five doses of weekly cisplatin at 30-40 mg/m².

Patients in the sequential chemoradiation arm received 60-75 mg/m² of weekly cisplatin plus 135-175 mg/m² of paclitaxel in 21-day cycles, with two cycles given before and two cycles given after radiotherapy.

The treatment groups were comparable with respect to histologic subtypes, lymphovascular invasion rates, parametrial or surgical margin involvement, deep stromal involvement, tumor grade, minimally invasive surgery rates, and neoadjuvant chemotherapy, Dr. Huang said. He added, however, that lymph node metastasis was lowest in the radiation-only arm.
 

DFS results

In the ITT population, patients who received sequential chemoradiation had significantly better DFS compared with patients in the other treatment arms. The ITT population included 353 patients in the sequential chemoradiation arm, 345 patients in the concurrent chemoradiation arm, and 350 patients in the radiation-only arm.

The 3-year DFS rates were 90% in patients randomized to sequential chemoradiation, 85% in patients randomized to concurrent chemoradiation, and 82% in patients randomized to radiation alone (hazard ratios, 0.52 for sequential chemoradiation vs. radiation alone and 0.65 for sequential vs. concurrent chemoradiation; P = .03).

Subgroup analyses showed a DFS benefit with sequential chemoradiation versus radiation alone across histology types, tumor grades, and tumor size, Dr. Huang noted.

In the per-protocol population, sequential chemoradiation was associated with better DFS when compared with radiation alone. However, there were no significant differences between the sequential and concurrent chemoradiation arms or the concurrent chemoradiation and radiation-only arms.

The per-protocol population included 235 patients in the sequential chemoradiation arm, 190 patients in the concurrent chemoradiation arm, and 324 patients in the radiation-only arm.

In the per-protocol population, the 3-year DFS rates were 91% in patients randomized to sequential chemoradiation, 86% in patients randomized to concurrent chemoradiation, and 82% in patients randomized to radiation alone (HRs, 0.47 for sequential vs. radiation alone and 0.67 for sequential vs. concurrent; P = .026).

In the overall population, DFS was superior among patients with intermediate-risk versus high-risk factors. The 3-year DFS rates were 90% and 74%, respectively (P < .05).
 

Overall survival and safety

As for overall survival (OS), sequential chemoradiation showed a trend toward improvement at 5 years, compared with the other treatment groups. However, the differences were not statistically significant in either the ITT or per-protocol populations.

In the ITT population, the 5-year OS was 92% in the sequential chemoradiation arm, 89% in the concurrent chemoradiation arm, and 88% in the radiation-only arm. In the per-protocol population, the 5-year OS rates were 93%, 90%, and 88%, respectively.

Patients with intermediate-risk factors had a more favorable OS. The 5-year OS rate was 93% in patients with intermediate-risk factors and 81% in patients with high-risk factors (P < .05).

Dr. Huang noted that patients in the radiation-only arm experienced fewer grade 3-4 adverse events than the other patients. Less neutropenia, nausea, and vomiting were observed in the radiation-only arm.

There was more grade 3-4 nausea and vomiting in the concurrent chemoradiation arm than in the sequential chemoradiation arm.

However, Dr. Huang noted that “adding chemotherapy to radiation did not impact the patients’ quality of life in the long-term compared with radiation alone.

“In this study, sequential chemoradiation resulted in a better disease-free survival and a lower risk of cancer death for cervical cancer patients with adverse pathological factors,” he said. “We believe that sequential chemoradiation could be an optimal option for post-operative adjuvant treatment.”

This study was sponsored by Sun Yat-sen University in collaboration with Guangdong Provincial People’s Hospital, First Affiliated Hospital/Sun Yat-Sen University, Shenzhen People’s Hospital, and Cancer Hospital of Guangxi Medical University. Dr. Huang reported receiving honoraria, travel, accommodations, and expenses from AstraZeneca.

sworcester@mdedge.com

SOURCE: Huang H et al. ASCO 2020, Abstract 6007.

Sequential chemoradiation may improve disease-free survival (DFS) among patients with early-stage cervical cancer who have undergone radical hysterectomy, the phase 3 STARS trial suggests.

In the study’s intent-to-treat (ITT) population, the 3-year DFS rate was significantly higher among patients who received sequential chemoradiation than among patients who received concurrent chemoradiation or radiation alone.

“After an adjustment for baseline presence of lymph node metastasis, we found that sequential chemoradiation decreased, by 40% to 50%, the recurrence risk, compared with the other two groups,” said investigator He Huang, MD, of Sun Yat-Sen University Cancer Center in Guangzhou, China.

Dr. Huang presented these findings as part of the American Society of Clinical Oncology virtual scientific program.
 

Study rationale and details

“As we know, early-stage cervical cancer can be cured after treatment,” Dr. Huang said. “However, the risk of recurrence remains higher among patients with high-risk factors, including lymph node metastases, positive surgical margins, and parametrial invasion. Postoperative adjuvant radiation and chemotherapy may result in favorable survival for patients with high-risk factors.”

Although the efficacy of concurrent radiation with single-agent cisplatin has been demonstrated in primary treatment for local advanced cervical cancer, it has not been assessed as adjuvant treatment for early-stage cervical cancer in a randomized, controlled trial, Dr. Huang explained.

“Another question is whether patients with intermediate-risk factors could benefit from the concurrent chemotherapy [with] radiation,” he said. “So far, we don’t have enough evidence.”

To gain some insight, Dr. Huang and colleagues initiated the STARS trial. The trial enrolled patients with stage IB1-IIA2 cervical cancer and at least one adverse risk factor after radical hysterectomy. Patients had a median age of 48 years, and most had stage IB1 or IIA1 disease.

The patients were randomized 1:1:1 to receive radiation alone, concurrent chemoradiation, or sequential chemoradiation.

All patients received pelvic radiation at 45-50 Gy. Patients in the concurrent chemoradiation arm also received five doses of weekly cisplatin at 30-40 mg/m².

Patients in the sequential chemoradiation arm received 60-75 mg/m² of weekly cisplatin plus 135-175 mg/m² of paclitaxel in 21-day cycles, with two cycles given before and two cycles given after radiotherapy.

The treatment groups were comparable with respect to histologic subtypes, lymphovascular invasion rates, parametrial or surgical margin involvement, deep stromal involvement, tumor grade, minimally invasive surgery rates, and neoadjuvant chemotherapy, Dr. Huang said. He added, however, that lymph node metastasis was lowest in the radiation-only arm.
 

DFS results

In the ITT population, patients who received sequential chemoradiation had significantly better DFS compared with patients in the other treatment arms. The ITT population included 353 patients in the sequential chemoradiation arm, 345 patients in the concurrent chemoradiation arm, and 350 patients in the radiation-only arm.

The 3-year DFS rates were 90% in patients randomized to sequential chemoradiation, 85% in patients randomized to concurrent chemoradiation, and 82% in patients randomized to radiation alone (hazard ratios, 0.52 for sequential chemoradiation vs. radiation alone and 0.65 for sequential vs. concurrent chemoradiation; P = .03).

Subgroup analyses showed a DFS benefit with sequential chemoradiation versus radiation alone across histology types, tumor grades, and tumor size, Dr. Huang noted.

In the per-protocol population, sequential chemoradiation was associated with better DFS when compared with radiation alone. However, there were no significant differences between the sequential and concurrent chemoradiation arms or the concurrent chemoradiation and radiation-only arms.

The per-protocol population included 235 patients in the sequential chemoradiation arm, 190 patients in the concurrent chemoradiation arm, and 324 patients in the radiation-only arm.

In the per-protocol population, the 3-year DFS rates were 91% in patients randomized to sequential chemoradiation, 86% in patients randomized to concurrent chemoradiation, and 82% in patients randomized to radiation alone (HRs, 0.47 for sequential vs. radiation alone and 0.67 for sequential vs. concurrent; P = .026).

In the overall population, DFS was superior among patients with intermediate-risk versus high-risk factors. The 3-year DFS rates were 90% and 74%, respectively (P < .05).
 

Overall survival and safety

As for overall survival (OS), sequential chemoradiation showed a trend toward improvement at 5 years, compared with the other treatment groups. However, the differences were not statistically significant in either the ITT or per-protocol populations.

In the ITT population, the 5-year OS was 92% in the sequential chemoradiation arm, 89% in the concurrent chemoradiation arm, and 88% in the radiation-only arm. In the per-protocol population, the 5-year OS rates were 93%, 90%, and 88%, respectively.

Patients with intermediate-risk factors had a more favorable OS. The 5-year OS rate was 93% in patients with intermediate-risk factors and 81% in patients with high-risk factors (P < .05).

Dr. Huang noted that patients in the radiation-only arm experienced fewer grade 3-4 adverse events than the other patients. Less neutropenia, nausea, and vomiting were observed in the radiation-only arm.

There was more grade 3-4 nausea and vomiting in the concurrent chemoradiation arm than in the sequential chemoradiation arm.

However, Dr. Huang noted that “adding chemotherapy to radiation did not impact the patients’ quality of life in the long-term compared with radiation alone.

“In this study, sequential chemoradiation resulted in a better disease-free survival and a lower risk of cancer death for cervical cancer patients with adverse pathological factors,” he said. “We believe that sequential chemoradiation could be an optimal option for post-operative adjuvant treatment.”

This study was sponsored by Sun Yat-sen University in collaboration with Guangdong Provincial People’s Hospital, First Affiliated Hospital/Sun Yat-Sen University, Shenzhen People’s Hospital, and Cancer Hospital of Guangxi Medical University. Dr. Huang reported receiving honoraria, travel, accommodations, and expenses from AstraZeneca.

sworcester@mdedge.com

SOURCE: Huang H et al. ASCO 2020, Abstract 6007.

By the time she was discharged from a suburban New Jersey hospital on April 10, Kathleen Ronan thought the worst was behind her. For a week before her husband rushed her to the emergency department (ED), incoherent and struggling to breathe, the novel coronavirus had ravaged her body. She tried to treat her fevers with acetaminophen and ice packs. Despite taking enough Tylenol to risk liver damage and packing herself on ice like the catch of the day, Ronan’s fever continued to rise. By the time her temperature reached 104.5° F, Ronan knew the time had come for more drastic measures.

A team of masked and gowned nurses greeted her at a triage tent outside the ED, and from there, everything becomes hazy for Ronan. She was immediately rushed to the hospital’s special COVID-19 intensive care unit (ICU), where she spent 5 days. But she has few distinct memories from this time. What she does remember is the exhaustion, the pain, the loneliness, and the fear. Her family couldn’t visit, and though Ronan works as a home health nurse, her brain was so addled with fever that she couldn’t make sense of what was happening. After a week in the hospital, 5 days of which were spent in the ICU, 51-year-old Ronan was discharged.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, who had supplemented long days on her feet caring for others as a nurse with regular trips to the gym, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article.

“It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

Nor is PICS simply a set of side effects that will go away on their own. It includes ongoing cognitive difficulties and physical weakness, both of which can lead to employment problems. Beyond that, depression and anxiety can exacerbate – and be exacerbated by – these challenges. Psychologist Jim Jackson, PsyD, assistant director of the ICU Recovery Center at Vanderbilt University Medical Center, Nashville, Tennessee, recently spoke with a former ICU patient who has struggled since her discharge 30 years ago.

“Her life essentially stopped with her critical care stay. She hasn’t been able to move forward,” he said. “She’s part of a whole fraternity of people who are struggling.”

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her.
 

Surviving the ICU

Although the new coronavirus has pushed the world’s critical care system to its limits, it was an outbreak in 1952 that inspired the creation of intensive care units. That summer, a wave of paralytic polio swept over Copenhagen, Denmark, and anesthesiologist Bjørn Ibsen, MD, PhD, used mechanical ventilation — physically operated by medical and dental students – to help 316 children breathe for weeks at a time while their small bodies worked to fight off the virus. The effort halved the mortality rate from polio that affected breathing, from 80% to 40%.

In these wards, dedicated to the very sickest, each patient was assigned his or her own nurse. Over the next decade, hospitals in the United Kingdom and the United States established their own ICUs to treat patients with a variety of conditions. Although it helped improve survival, mortality rates in critical care units remained stubbornly high, owing to the patients’ severe underlying illnesses.

“We thought we were doing a good job if the patient survived, but we had no idea what happened after discharge,” said Carla Sevin, MD, medical director of Vanderbilt’s ICU Recovery Center. Nor did their efforts to find out always bring answers. “We struggled to get people to come in for support — they were debilitated, physically burdened, and weak.”

Through further advances in life support, by the early 2000s, the average mortality rates in American ICUs had dropped to 8% to 19%. As the number of critical care survivors began to climb, clinical researchers noticed that the lives of these patients and their families were profoundly altered by their severe illness.

As Dale Needham, MD, PhD, began his pulmonology and critical care residency in Toronto, Canada, in 2005, a group of physicians there began a 5-year longitudinal study to assess long-term outcomes of patients who developed acute respiratory distress syndrome (ARDS). Although ARDS is an acute condition, the investigators found that patients felt effects for years. Younger patients recovered better than older ones, but none of the patients› physical functioning was equivalent to that of age-matched control persons. Even 5 years later, former ICU patients only reached 76% of expected physical functioning, according to results published in the New England Journal of Medicine. The study was a wake-up call.

At a meeting in Chicago in 2010, Needham, now an intensivist at Johns Hopkins Hospital in Baltimore, Maryland, gathered an interdisciplinary group of colleagues, including patients and caregivers, to clarify the phenomena they were seeing. What emerged from that meeting, published in 2012 in Critical Care Medicine, were the diagnostic criteria for PICS: According to the new definition, PICS is characterized by new or worsening physical and neuropsychiatric deficits that range from forgetfulness and loss of motivation to physical weakness and insomnia.

The issue, Needham says, is that although the trouble starts in the ICU, it only becomes clear once patients leave. “ICU doctors aren’t the ones dealing with this,” Needham said. “We need to build stronger bridges between critical care and other professions.” That’s where PICS comes in, a definition that exists explicitly to alert healthcare providers about the constellation of challenges many of these individuals face as they try to reenter “normal” life.
 

Defining the problem

As an ICU nurse at the Mayo Clinic in Rochester, Minnesota, Annie Johnson, ACNP-BC, knew lots about helping hospitalized patients, but she says she didn’t know anything about what to do after discharge – at least not until her own mother became a patient.

On the first day of retirement in October 2014, Johnson’s mother flatlined. Quick-thinking paramedics resuscitated her, and after several days in critical care, she was discharged. Since then, her heart has remained healthy. Johnson’s sister, who spent time worrying over her mother at the hospital, also had lingering effects. Both have since struggled, plagued by nightmares, flashbacks, and insomnia.

Johnson initially believed her mom’s and sister’s neuropsychiatric, post-ICU struggles were unique to her family. It was only a year later, at a seminar she was attending, that she first heard the words “post–intensive care syndrome.” Suddenly, Johnson had a name for her family’s experiences, and she began to create support groups and resources to help other families like hers.

“I thought of all the patients I had treated over the years who had been on ventilators for days and days and days. And if this happened to my mom after 48 hours, what must they be going through?” she asked.

Once physicians formally defined PICS, the Society for Critical Care Medicine helped create programs to educate ICU staff, patients, and families about potential post-discharge challenges. Researchers also began to investigate factors affecting post-ICU functioning. Follow-up studies of patients with delirium (ranging from general confusion about time and place to extreme agitation and violence) showed they had striking cognitive deficits. Problems with short-term memory, flexible thinking, and motivation plagued patients for years after their critical illness, similar to the physical deficiencies seen after ARDS. Delirium was one of the strongest risk factors for neuropsychiatric problems.

“Delirium is basically a stress test for the brain,” said Babar Khan, MD, a critical care specialist at Indiana University’s Regenstrief Institute, in Bloomington. But whether delirium accentuates preexisting cognitive difficulties or creates them afresh isn’t yet clear.

Sophia Wang, MD, a geriatric psychiatrist at Indiana University who works with many critical care patients, says patients who had experienced delirium in the ICU showed significant defects in memory and executive functioning long after their hospital stay. She points to a 2015 study that followed 47 ICU patients for a year post discharge. Among those who experienced delirium, brain volumes, as measured by MRI, were smaller at 3 months, something associated with cognitive problems at 1 year. Many struggled at work, and unemployment was common. Depression and posttraumatic stress compounded these difficulties. Among those with acute respiratory distress, ICU patients who are young, female, and unemployed are most likely to suffer from posttraumatic stress disorder after they are discharge.

Critical care medicine may have given these patients a second chance at life, Wang says, but the life they return to often looks nothing like the one they had before their illness.

Prolonged mechanical ventilation and the heavy sedation that often accompanies it are predictors of PICS severity. Some of these links could be explained by the gravity of the illness that landed someone in critical care, but others are more likely to be iatrogenic, says Gerald Weinhouse, MD, a pulmonology and critical care physician and co-director of the Critical Illness Recovery Program at the Brigham and Women’s Hospital in Boston. The involvement of loved ones at the patient’s bedside, however, improved the entire family’s outcome.

When Weinhouse saw those data, he and his colleagues founded a peer support program for ICU survivors. In a study published in 2019 in Critical Care Medicine, they identified six different models for peer support for those with PICS and their families, including both online and in-person approaches. An ongoing challenge for physicians, Weinhouse says, is getting patients to engage with these programs, given that their calendars are crowded with medical appointments and that they suffer from increased physical and mental disability.

Studies such as these led critical care physicians to form the ICU Liberation Collaborative to rethink critical care medicine. At Vanderbilt, Sevin and Jackson headed up one of the world’s first post-ICU clinics, which uses an interdisciplinary team to help patients maximize their functioning. They redesigned their critical care unit in a way that allows families to spend the night and that encourages patient mobility. Both Needham and Weinhouse continue tracking patient outcomes.

Even before the novel coronavirus struck, the United States — and the world — had begun to realize that graduating from the ICU was only the start of what was often an extensive recovery.
 

The long road back

When COVID-19 patients began flooding intensive care wards around the world, physicians scrambled to meet their complex and desperate acute medical needs. Over the past few months, physicians have focused on keeping these patients alive. “We’ve never seen anything like it ― not even during polio — with the sheer number of patients, all with respiratory distress,” Needham said.

But he and his colleagues know this is only the beginning.

“We’re aware that survivorship issues are coming. There’s going to be a wave of sick people who survived the coronavirus but are going to need more help,” Weinhouse said.

Intensivists have been drawing on PICS research in their fight to help COVID-19 patients. Work from the past few years has shown that although sedation is required during intubation itself, not everyone needs it while on a ventilator. Titrating down sedating medication helps reduce delirium, Wang says. Such medication has been shown to contribute to later cognitive problems. Needham’s studies showing that prolonged bedrest by ICU patients causes muscular atrophy has led him to encourage patients to move as much as possible. With the help of physical therapists, many patients on ventilators can be awake, alert, and moving around the ward.

One of the biggest challenges critical-care coronavirus patients face is prolonged isolation. The constant presence of a familiar face helps orient confused and delirious patients and provides emotional support during a frightening time. But because the immediate need for infection control outweighs these benefits, few hospitals allow visitors, especially for COVID-19 patients.

To address this, some units have been using video technology to allow loved ones to call in. At Johns Hopkins, physicians have also been relying on the expertise of occupational therapists (OTs). Needham says that one OT found that rubbing the hand and back of an agitated, delirious patient helped soothe and calm him better than many medications.

Ronan, who spent 5 days in intensive care, echoes that problem. She says she found the relative lack of human contact to be one of the most challenging parts of being in a bed on a COVID-19 ward. Separated from her husband and daughter, suffering from high fever and severe illness, she lost all track of time.

Her return home was difficult, too. Although her job as a home health nurse had prepared her on some level for the challenges she would face after discharge, Ronan says the hospital provided little practical help.

“Everything is so much harder at home, even little things like going to the bathroom,” she said. “I feel like I’m trying to bail out a sinking ship with a teacup.”

Khan and other physicians, aware of the challenges Ronan and others face once home, aim to create post-ICU clinics specifically for COVID-19 patients. They want to build what Khan calls a “one-stop shop” for all the support patients need to recover. Some of that can be provided via telehealth, which may also help ease the physical burden.

Because there’s so much physicians don’t know about the coronavirus, Johnson says, such clinics are not only a chance to help the sickest COVID-19 patients, they will also help researchers learn more about the virus and improve critical care for other illnesses.

Today, nearly 2 months after discharge, Ronan is back on the job but struggles with a persistent cough — likely due to the lung damage she sustained while ill. She has constant fatigue, as well as ongoing upset stomach from all the medications she took to reduce fever and body aches. When she dons a mask for work, the tangible reminder of her hospital stay sends her into a panic attack. Physically, she’s weaker than before.

Researchers are still trying to understand everything that Ronan and other COVID-19 patients need to move on with their lives after being in the ICU. Mysteries abound, but the ground laid by Sevin, Needham, Weinhouse, and others has provided a solid foundation on which to build.
 

This article first appeared on Medscape.com.

By the time she was discharged from a suburban New Jersey hospital on April 10, Kathleen Ronan thought the worst was behind her. For a week before her husband rushed her to the emergency department (ED), incoherent and struggling to breathe, the novel coronavirus had ravaged her body. She tried to treat her fevers with acetaminophen and ice packs. Despite taking enough Tylenol to risk liver damage and packing herself on ice like the catch of the day, Ronan’s fever continued to rise. By the time her temperature reached 104.5° F, Ronan knew the time had come for more drastic measures.

A team of masked and gowned nurses greeted her at a triage tent outside the ED, and from there, everything becomes hazy for Ronan. She was immediately rushed to the hospital’s special COVID-19 intensive care unit (ICU), where she spent 5 days. But she has few distinct memories from this time. What she does remember is the exhaustion, the pain, the loneliness, and the fear. Her family couldn’t visit, and though Ronan works as a home health nurse, her brain was so addled with fever that she couldn’t make sense of what was happening. After a week in the hospital, 5 days of which were spent in the ICU, 51-year-old Ronan was discharged.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, who had supplemented long days on her feet caring for others as a nurse with regular trips to the gym, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article.

“It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

Nor is PICS simply a set of side effects that will go away on their own. It includes ongoing cognitive difficulties and physical weakness, both of which can lead to employment problems. Beyond that, depression and anxiety can exacerbate – and be exacerbated by – these challenges. Psychologist Jim Jackson, PsyD, assistant director of the ICU Recovery Center at Vanderbilt University Medical Center, Nashville, Tennessee, recently spoke with a former ICU patient who has struggled since her discharge 30 years ago.

“Her life essentially stopped with her critical care stay. She hasn’t been able to move forward,” he said. “She’s part of a whole fraternity of people who are struggling.”

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her.
 

Surviving the ICU

Although the new coronavirus has pushed the world’s critical care system to its limits, it was an outbreak in 1952 that inspired the creation of intensive care units. That summer, a wave of paralytic polio swept over Copenhagen, Denmark, and anesthesiologist Bjørn Ibsen, MD, PhD, used mechanical ventilation — physically operated by medical and dental students – to help 316 children breathe for weeks at a time while their small bodies worked to fight off the virus. The effort halved the mortality rate from polio that affected breathing, from 80% to 40%.

In these wards, dedicated to the very sickest, each patient was assigned his or her own nurse. Over the next decade, hospitals in the United Kingdom and the United States established their own ICUs to treat patients with a variety of conditions. Although it helped improve survival, mortality rates in critical care units remained stubbornly high, owing to the patients’ severe underlying illnesses.

“We thought we were doing a good job if the patient survived, but we had no idea what happened after discharge,” said Carla Sevin, MD, medical director of Vanderbilt’s ICU Recovery Center. Nor did their efforts to find out always bring answers. “We struggled to get people to come in for support — they were debilitated, physically burdened, and weak.”

Through further advances in life support, by the early 2000s, the average mortality rates in American ICUs had dropped to 8% to 19%. As the number of critical care survivors began to climb, clinical researchers noticed that the lives of these patients and their families were profoundly altered by their severe illness.

As Dale Needham, MD, PhD, began his pulmonology and critical care residency in Toronto, Canada, in 2005, a group of physicians there began a 5-year longitudinal study to assess long-term outcomes of patients who developed acute respiratory distress syndrome (ARDS). Although ARDS is an acute condition, the investigators found that patients felt effects for years. Younger patients recovered better than older ones, but none of the patients› physical functioning was equivalent to that of age-matched control persons. Even 5 years later, former ICU patients only reached 76% of expected physical functioning, according to results published in the New England Journal of Medicine. The study was a wake-up call.

At a meeting in Chicago in 2010, Needham, now an intensivist at Johns Hopkins Hospital in Baltimore, Maryland, gathered an interdisciplinary group of colleagues, including patients and caregivers, to clarify the phenomena they were seeing. What emerged from that meeting, published in 2012 in Critical Care Medicine, were the diagnostic criteria for PICS: According to the new definition, PICS is characterized by new or worsening physical and neuropsychiatric deficits that range from forgetfulness and loss of motivation to physical weakness and insomnia.

The issue, Needham says, is that although the trouble starts in the ICU, it only becomes clear once patients leave. “ICU doctors aren’t the ones dealing with this,” Needham said. “We need to build stronger bridges between critical care and other professions.” That’s where PICS comes in, a definition that exists explicitly to alert healthcare providers about the constellation of challenges many of these individuals face as they try to reenter “normal” life.
 

Defining the problem

As an ICU nurse at the Mayo Clinic in Rochester, Minnesota, Annie Johnson, ACNP-BC, knew lots about helping hospitalized patients, but she says she didn’t know anything about what to do after discharge – at least not until her own mother became a patient.

On the first day of retirement in October 2014, Johnson’s mother flatlined. Quick-thinking paramedics resuscitated her, and after several days in critical care, she was discharged. Since then, her heart has remained healthy. Johnson’s sister, who spent time worrying over her mother at the hospital, also had lingering effects. Both have since struggled, plagued by nightmares, flashbacks, and insomnia.

Johnson initially believed her mom’s and sister’s neuropsychiatric, post-ICU struggles were unique to her family. It was only a year later, at a seminar she was attending, that she first heard the words “post–intensive care syndrome.” Suddenly, Johnson had a name for her family’s experiences, and she began to create support groups and resources to help other families like hers.

“I thought of all the patients I had treated over the years who had been on ventilators for days and days and days. And if this happened to my mom after 48 hours, what must they be going through?” she asked.

Once physicians formally defined PICS, the Society for Critical Care Medicine helped create programs to educate ICU staff, patients, and families about potential post-discharge challenges. Researchers also began to investigate factors affecting post-ICU functioning. Follow-up studies of patients with delirium (ranging from general confusion about time and place to extreme agitation and violence) showed they had striking cognitive deficits. Problems with short-term memory, flexible thinking, and motivation plagued patients for years after their critical illness, similar to the physical deficiencies seen after ARDS. Delirium was one of the strongest risk factors for neuropsychiatric problems.

“Delirium is basically a stress test for the brain,” said Babar Khan, MD, a critical care specialist at Indiana University’s Regenstrief Institute, in Bloomington. But whether delirium accentuates preexisting cognitive difficulties or creates them afresh isn’t yet clear.

Sophia Wang, MD, a geriatric psychiatrist at Indiana University who works with many critical care patients, says patients who had experienced delirium in the ICU showed significant defects in memory and executive functioning long after their hospital stay. She points to a 2015 study that followed 47 ICU patients for a year post discharge. Among those who experienced delirium, brain volumes, as measured by MRI, were smaller at 3 months, something associated with cognitive problems at 1 year. Many struggled at work, and unemployment was common. Depression and posttraumatic stress compounded these difficulties. Among those with acute respiratory distress, ICU patients who are young, female, and unemployed are most likely to suffer from posttraumatic stress disorder after they are discharge.

Critical care medicine may have given these patients a second chance at life, Wang says, but the life they return to often looks nothing like the one they had before their illness.

Prolonged mechanical ventilation and the heavy sedation that often accompanies it are predictors of PICS severity. Some of these links could be explained by the gravity of the illness that landed someone in critical care, but others are more likely to be iatrogenic, says Gerald Weinhouse, MD, a pulmonology and critical care physician and co-director of the Critical Illness Recovery Program at the Brigham and Women’s Hospital in Boston. The involvement of loved ones at the patient’s bedside, however, improved the entire family’s outcome.

When Weinhouse saw those data, he and his colleagues founded a peer support program for ICU survivors. In a study published in 2019 in Critical Care Medicine, they identified six different models for peer support for those with PICS and their families, including both online and in-person approaches. An ongoing challenge for physicians, Weinhouse says, is getting patients to engage with these programs, given that their calendars are crowded with medical appointments and that they suffer from increased physical and mental disability.

Studies such as these led critical care physicians to form the ICU Liberation Collaborative to rethink critical care medicine. At Vanderbilt, Sevin and Jackson headed up one of the world’s first post-ICU clinics, which uses an interdisciplinary team to help patients maximize their functioning. They redesigned their critical care unit in a way that allows families to spend the night and that encourages patient mobility. Both Needham and Weinhouse continue tracking patient outcomes.

Even before the novel coronavirus struck, the United States — and the world — had begun to realize that graduating from the ICU was only the start of what was often an extensive recovery.
 

The long road back

When COVID-19 patients began flooding intensive care wards around the world, physicians scrambled to meet their complex and desperate acute medical needs. Over the past few months, physicians have focused on keeping these patients alive. “We’ve never seen anything like it ― not even during polio — with the sheer number of patients, all with respiratory distress,” Needham said.

But he and his colleagues know this is only the beginning.

“We’re aware that survivorship issues are coming. There’s going to be a wave of sick people who survived the coronavirus but are going to need more help,” Weinhouse said.

Intensivists have been drawing on PICS research in their fight to help COVID-19 patients. Work from the past few years has shown that although sedation is required during intubation itself, not everyone needs it while on a ventilator. Titrating down sedating medication helps reduce delirium, Wang says. Such medication has been shown to contribute to later cognitive problems. Needham’s studies showing that prolonged bedrest by ICU patients causes muscular atrophy has led him to encourage patients to move as much as possible. With the help of physical therapists, many patients on ventilators can be awake, alert, and moving around the ward.

One of the biggest challenges critical-care coronavirus patients face is prolonged isolation. The constant presence of a familiar face helps orient confused and delirious patients and provides emotional support during a frightening time. But because the immediate need for infection control outweighs these benefits, few hospitals allow visitors, especially for COVID-19 patients.

To address this, some units have been using video technology to allow loved ones to call in. At Johns Hopkins, physicians have also been relying on the expertise of occupational therapists (OTs). Needham says that one OT found that rubbing the hand and back of an agitated, delirious patient helped soothe and calm him better than many medications.

Ronan, who spent 5 days in intensive care, echoes that problem. She says she found the relative lack of human contact to be one of the most challenging parts of being in a bed on a COVID-19 ward. Separated from her husband and daughter, suffering from high fever and severe illness, she lost all track of time.

Her return home was difficult, too. Although her job as a home health nurse had prepared her on some level for the challenges she would face after discharge, Ronan says the hospital provided little practical help.

“Everything is so much harder at home, even little things like going to the bathroom,” she said. “I feel like I’m trying to bail out a sinking ship with a teacup.”

Khan and other physicians, aware of the challenges Ronan and others face once home, aim to create post-ICU clinics specifically for COVID-19 patients. They want to build what Khan calls a “one-stop shop” for all the support patients need to recover. Some of that can be provided via telehealth, which may also help ease the physical burden.

Because there’s so much physicians don’t know about the coronavirus, Johnson says, such clinics are not only a chance to help the sickest COVID-19 patients, they will also help researchers learn more about the virus and improve critical care for other illnesses.

Today, nearly 2 months after discharge, Ronan is back on the job but struggles with a persistent cough — likely due to the lung damage she sustained while ill. She has constant fatigue, as well as ongoing upset stomach from all the medications she took to reduce fever and body aches. When she dons a mask for work, the tangible reminder of her hospital stay sends her into a panic attack. Physically, she’s weaker than before.

Researchers are still trying to understand everything that Ronan and other COVID-19 patients need to move on with their lives after being in the ICU. Mysteries abound, but the ground laid by Sevin, Needham, Weinhouse, and others has provided a solid foundation on which to build.
 

This article first appeared on Medscape.com.

By the time she was discharged from a suburban New Jersey hospital on April 10, Kathleen Ronan thought the worst was behind her. For a week before her husband rushed her to the emergency department (ED), incoherent and struggling to breathe, the novel coronavirus had ravaged her body. She tried to treat her fevers with acetaminophen and ice packs. Despite taking enough Tylenol to risk liver damage and packing herself on ice like the catch of the day, Ronan’s fever continued to rise. By the time her temperature reached 104.5° F, Ronan knew the time had come for more drastic measures.

A team of masked and gowned nurses greeted her at a triage tent outside the ED, and from there, everything becomes hazy for Ronan. She was immediately rushed to the hospital’s special COVID-19 intensive care unit (ICU), where she spent 5 days. But she has few distinct memories from this time. What she does remember is the exhaustion, the pain, the loneliness, and the fear. Her family couldn’t visit, and though Ronan works as a home health nurse, her brain was so addled with fever that she couldn’t make sense of what was happening. After a week in the hospital, 5 days of which were spent in the ICU, 51-year-old Ronan was discharged.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, who had supplemented long days on her feet caring for others as a nurse with regular trips to the gym, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article.

“It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

Nor is PICS simply a set of side effects that will go away on their own. It includes ongoing cognitive difficulties and physical weakness, both of which can lead to employment problems. Beyond that, depression and anxiety can exacerbate – and be exacerbated by – these challenges. Psychologist Jim Jackson, PsyD, assistant director of the ICU Recovery Center at Vanderbilt University Medical Center, Nashville, Tennessee, recently spoke with a former ICU patient who has struggled since her discharge 30 years ago.

“Her life essentially stopped with her critical care stay. She hasn’t been able to move forward,” he said. “She’s part of a whole fraternity of people who are struggling.”

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her.
 

Surviving the ICU

Although the new coronavirus has pushed the world’s critical care system to its limits, it was an outbreak in 1952 that inspired the creation of intensive care units. That summer, a wave of paralytic polio swept over Copenhagen, Denmark, and anesthesiologist Bjørn Ibsen, MD, PhD, used mechanical ventilation — physically operated by medical and dental students – to help 316 children breathe for weeks at a time while their small bodies worked to fight off the virus. The effort halved the mortality rate from polio that affected breathing, from 80% to 40%.

In these wards, dedicated to the very sickest, each patient was assigned his or her own nurse. Over the next decade, hospitals in the United Kingdom and the United States established their own ICUs to treat patients with a variety of conditions. Although it helped improve survival, mortality rates in critical care units remained stubbornly high, owing to the patients’ severe underlying illnesses.

“We thought we were doing a good job if the patient survived, but we had no idea what happened after discharge,” said Carla Sevin, MD, medical director of Vanderbilt’s ICU Recovery Center. Nor did their efforts to find out always bring answers. “We struggled to get people to come in for support — they were debilitated, physically burdened, and weak.”

Through further advances in life support, by the early 2000s, the average mortality rates in American ICUs had dropped to 8% to 19%. As the number of critical care survivors began to climb, clinical researchers noticed that the lives of these patients and their families were profoundly altered by their severe illness.

As Dale Needham, MD, PhD, began his pulmonology and critical care residency in Toronto, Canada, in 2005, a group of physicians there began a 5-year longitudinal study to assess long-term outcomes of patients who developed acute respiratory distress syndrome (ARDS). Although ARDS is an acute condition, the investigators found that patients felt effects for years. Younger patients recovered better than older ones, but none of the patients› physical functioning was equivalent to that of age-matched control persons. Even 5 years later, former ICU patients only reached 76% of expected physical functioning, according to results published in the New England Journal of Medicine. The study was a wake-up call.

At a meeting in Chicago in 2010, Needham, now an intensivist at Johns Hopkins Hospital in Baltimore, Maryland, gathered an interdisciplinary group of colleagues, including patients and caregivers, to clarify the phenomena they were seeing. What emerged from that meeting, published in 2012 in Critical Care Medicine, were the diagnostic criteria for PICS: According to the new definition, PICS is characterized by new or worsening physical and neuropsychiatric deficits that range from forgetfulness and loss of motivation to physical weakness and insomnia.

The issue, Needham says, is that although the trouble starts in the ICU, it only becomes clear once patients leave. “ICU doctors aren’t the ones dealing with this,” Needham said. “We need to build stronger bridges between critical care and other professions.” That’s where PICS comes in, a definition that exists explicitly to alert healthcare providers about the constellation of challenges many of these individuals face as they try to reenter “normal” life.
 

Defining the problem

As an ICU nurse at the Mayo Clinic in Rochester, Minnesota, Annie Johnson, ACNP-BC, knew lots about helping hospitalized patients, but she says she didn’t know anything about what to do after discharge – at least not until her own mother became a patient.

On the first day of retirement in October 2014, Johnson’s mother flatlined. Quick-thinking paramedics resuscitated her, and after several days in critical care, she was discharged. Since then, her heart has remained healthy. Johnson’s sister, who spent time worrying over her mother at the hospital, also had lingering effects. Both have since struggled, plagued by nightmares, flashbacks, and insomnia.

Johnson initially believed her mom’s and sister’s neuropsychiatric, post-ICU struggles were unique to her family. It was only a year later, at a seminar she was attending, that she first heard the words “post–intensive care syndrome.” Suddenly, Johnson had a name for her family’s experiences, and she began to create support groups and resources to help other families like hers.

“I thought of all the patients I had treated over the years who had been on ventilators for days and days and days. And if this happened to my mom after 48 hours, what must they be going through?” she asked.

Once physicians formally defined PICS, the Society for Critical Care Medicine helped create programs to educate ICU staff, patients, and families about potential post-discharge challenges. Researchers also began to investigate factors affecting post-ICU functioning. Follow-up studies of patients with delirium (ranging from general confusion about time and place to extreme agitation and violence) showed they had striking cognitive deficits. Problems with short-term memory, flexible thinking, and motivation plagued patients for years after their critical illness, similar to the physical deficiencies seen after ARDS. Delirium was one of the strongest risk factors for neuropsychiatric problems.

“Delirium is basically a stress test for the brain,” said Babar Khan, MD, a critical care specialist at Indiana University’s Regenstrief Institute, in Bloomington. But whether delirium accentuates preexisting cognitive difficulties or creates them afresh isn’t yet clear.

Sophia Wang, MD, a geriatric psychiatrist at Indiana University who works with many critical care patients, says patients who had experienced delirium in the ICU showed significant defects in memory and executive functioning long after their hospital stay. She points to a 2015 study that followed 47 ICU patients for a year post discharge. Among those who experienced delirium, brain volumes, as measured by MRI, were smaller at 3 months, something associated with cognitive problems at 1 year. Many struggled at work, and unemployment was common. Depression and posttraumatic stress compounded these difficulties. Among those with acute respiratory distress, ICU patients who are young, female, and unemployed are most likely to suffer from posttraumatic stress disorder after they are discharge.

Critical care medicine may have given these patients a second chance at life, Wang says, but the life they return to often looks nothing like the one they had before their illness.

Prolonged mechanical ventilation and the heavy sedation that often accompanies it are predictors of PICS severity. Some of these links could be explained by the gravity of the illness that landed someone in critical care, but others are more likely to be iatrogenic, says Gerald Weinhouse, MD, a pulmonology and critical care physician and co-director of the Critical Illness Recovery Program at the Brigham and Women’s Hospital in Boston. The involvement of loved ones at the patient’s bedside, however, improved the entire family’s outcome.

When Weinhouse saw those data, he and his colleagues founded a peer support program for ICU survivors. In a study published in 2019 in Critical Care Medicine, they identified six different models for peer support for those with PICS and their families, including both online and in-person approaches. An ongoing challenge for physicians, Weinhouse says, is getting patients to engage with these programs, given that their calendars are crowded with medical appointments and that they suffer from increased physical and mental disability.

Studies such as these led critical care physicians to form the ICU Liberation Collaborative to rethink critical care medicine. At Vanderbilt, Sevin and Jackson headed up one of the world’s first post-ICU clinics, which uses an interdisciplinary team to help patients maximize their functioning. They redesigned their critical care unit in a way that allows families to spend the night and that encourages patient mobility. Both Needham and Weinhouse continue tracking patient outcomes.

Even before the novel coronavirus struck, the United States — and the world — had begun to realize that graduating from the ICU was only the start of what was often an extensive recovery.
 

The long road back

When COVID-19 patients began flooding intensive care wards around the world, physicians scrambled to meet their complex and desperate acute medical needs. Over the past few months, physicians have focused on keeping these patients alive. “We’ve never seen anything like it ― not even during polio — with the sheer number of patients, all with respiratory distress,” Needham said.

But he and his colleagues know this is only the beginning.

“We’re aware that survivorship issues are coming. There’s going to be a wave of sick people who survived the coronavirus but are going to need more help,” Weinhouse said.

Intensivists have been drawing on PICS research in their fight to help COVID-19 patients. Work from the past few years has shown that although sedation is required during intubation itself, not everyone needs it while on a ventilator. Titrating down sedating medication helps reduce delirium, Wang says. Such medication has been shown to contribute to later cognitive problems. Needham’s studies showing that prolonged bedrest by ICU patients causes muscular atrophy has led him to encourage patients to move as much as possible. With the help of physical therapists, many patients on ventilators can be awake, alert, and moving around the ward.

One of the biggest challenges critical-care coronavirus patients face is prolonged isolation. The constant presence of a familiar face helps orient confused and delirious patients and provides emotional support during a frightening time. But because the immediate need for infection control outweighs these benefits, few hospitals allow visitors, especially for COVID-19 patients.

To address this, some units have been using video technology to allow loved ones to call in. At Johns Hopkins, physicians have also been relying on the expertise of occupational therapists (OTs). Needham says that one OT found that rubbing the hand and back of an agitated, delirious patient helped soothe and calm him better than many medications.

Ronan, who spent 5 days in intensive care, echoes that problem. She says she found the relative lack of human contact to be one of the most challenging parts of being in a bed on a COVID-19 ward. Separated from her husband and daughter, suffering from high fever and severe illness, she lost all track of time.

Her return home was difficult, too. Although her job as a home health nurse had prepared her on some level for the challenges she would face after discharge, Ronan says the hospital provided little practical help.

“Everything is so much harder at home, even little things like going to the bathroom,” she said. “I feel like I’m trying to bail out a sinking ship with a teacup.”

Khan and other physicians, aware of the challenges Ronan and others face once home, aim to create post-ICU clinics specifically for COVID-19 patients. They want to build what Khan calls a “one-stop shop” for all the support patients need to recover. Some of that can be provided via telehealth, which may also help ease the physical burden.

Because there’s so much physicians don’t know about the coronavirus, Johnson says, such clinics are not only a chance to help the sickest COVID-19 patients, they will also help researchers learn more about the virus and improve critical care for other illnesses.

Today, nearly 2 months after discharge, Ronan is back on the job but struggles with a persistent cough — likely due to the lung damage she sustained while ill. She has constant fatigue, as well as ongoing upset stomach from all the medications she took to reduce fever and body aches. When she dons a mask for work, the tangible reminder of her hospital stay sends her into a panic attack. Physically, she’s weaker than before.

Researchers are still trying to understand everything that Ronan and other COVID-19 patients need to move on with their lives after being in the ICU. Mysteries abound, but the ground laid by Sevin, Needham, Weinhouse, and others has provided a solid foundation on which to build.
 

This article first appeared on Medscape.com.

Specialty care from a cardiologist may confer clinical benefits for women with HER2-positive breast cancer treated with trastuzumab, a new study suggests.

Over 48 months of follow-up, results showed cardiology involvement prior to starting trastuzumab was associated with a higher rate of guideline-recommended cardiovascular (CV) monitoring and better systolic blood pressure (BP) control.

Trastuzumab is commonly used to treat HER2-positive breast cancer, which accounts for 20% of all breast cancers. But it carries a boxed warning for decreased left ventricular ejection fraction and heart failure (HF), and interval monitoring with echocardiography is recommended for all patients receiving the monoclonal antibody.

For the study, investigators analyzed electronic health records from 1,047 patients (mean age, 54 years) who received trastuzumab between January 2009 and July 2018 in the University of Pennsylvania health system, Philadelphia. Anthracyclines were used as part of treatment in 15% of patients.

Guideline-adherent cardiovascular monitoring was defined as echocardiography assessment in the 4 months before the initiation of trastuzumab and at least every 4 months during therapy.

Overall, 28% of patients visited a cardiology or cardio-oncology provider beginning 3 months before the baseline visit until the last contact date, the authors reported in JACC: CardioOncology.

Pre-existing HF, atrial fibrillation, and anthracycline treatment were independently associated with a cardiology visit either at baseline or during follow-up.

Patients who interacted with cardiologists, compared with those who did not, had more guideline-adherent cardiac monitoring (76.4% vs 60.1%; P = .007) and cardiac biomarker testing with troponin or N-terminal pro-B-type natriuretic peptide (27.8% vs 13.8%; P = .001).

The use of guideline-adherent cardiac monitoring was 36% to 46% in previous studies of patients with breast cancer treated with adjuvant trastuzumab-based therapy, the authors note.

Among the 5,815 echocardiographic procedures for which data on provider specialty were documented, most of the orders were authorized by oncologists (approximately 84% in those with no cardiology involvement and approximately 79% in those with cardiology involvement before trastuzumab initiation).
 

CV risk parameters

Cardiology involvement was associated with an average 1.5 mm Hg lower systolic BP, independent of baseline systolic BP and antihypertensive medication use (95% confidence interval, –2.9 to –0.1; P = .035).

The effect size was greater in patients with baseline hypertension, who had an average 2.7 mm Hg drop in systolic BP (95% CI, –4.6 to –0.7; P = .007) and were more likely to attain a target systolic BP below 140 mm Hg (odds ratio, 1.36; 95% CI, 1.06 to 1.74; P = .016).

Body mass index (BMI) did not budge significantly in the overall population when cardiologists were involved, but it dropped 0.5 kg/m2 in women who were overweight or obese at baseline.

“I think the results are encouraging,” senior author Bonnie Ky, MD, MSCE, University of Pennsylvania, told theheart.org | Medscape Cardiology. “These are modest changes but they are significant.”

These types of changes have been associated with significant reductions in cardiovascular disease risk over time in larger clinical trials, she noted. For example, a 2 mm Hg reduction in systolic BP has been linked to a 10% reduction in stroke mortality and a 7% reduction in ischemic heart disease mortality in middle-aged adults.

“We do think they are important and speak to more aggressive risk factor modification under the care of a specialist,” said Ky, who is also editor-in-chief of JACC: CardioOncology.

This broader role for cardiologists is particularly important given the burden of pre-existing CVD and CVD risk factors in patients with cancer and survivors. In the study, the baseline prevalence of hypertension was 40.6%, dyslipidemia 23.1%, HF 3.2%, atrial fibrillation 1.7%, and diabetes 5.9%.

“Ideally, collaboration between cardiology and oncology can improve the ability to cure a patient’s cancer while minimizing the risk of adverse cardiovascular occurrences,” Erica L. Mayer, MD, MPH, Dana-Farber Cancer Institute, Boston, told theheart.org | Medscape Cardiology. “Optimization of all cardiovascular parameters, including blood pressure, lipids, and weight, may allow a patient to protect her heart health while becoming a healthy cancer survivor.”

When asked about the 28% cardiology involvement at a U.S. cancer center with one of the most well-developed cardio-oncology programs, she said “the linkage with pre-existing cardiovascular conditions, as well as the likelihood of low incidence of cardiovascular disease, in the study population may have led to what appears to be a lower percentage of patients interacting with cardiology at baseline.”

In an accompanying editorial, Mayer says a case can be made from the findings that patients with pre-existing CV disease or at high risk for adverse CV events with cancer therapy should receive multidisciplinary care that involves a cardiologist. “However, for young, otherwise healthy patients with breast cancer with few or no cardiovascular risk factors, the benefits of [additional] subspecialty care may be less clear.”

Further, the rationale supporting the recommended frequency of cardiac monitoring may not be as “compelling” in this group, given the very low incidence of baseline cardiac dysfunction or cardiac events, particularly when treated with nonanthracycline regimens, she writes.

The findings are a call for further study and more personalized medicine, agreed Ky.

“I think there’s a need absolutely for established guidelines and/or expert consensus statements about who should be referred so patients can be referred more systematically,” she said. “Referral to cardiologists, however, is certainly a function of risk factors. Part of the challenge is identifying who will derive the most benefit from cardiovascular care.

“There are some obvious cases: Patients with heart failure and patients with pre-existing cardiovascular disease should be under the regular care of a cardiologist,” Ky added. “But there’s certainly a gray zone, especially as it relates, for example, to patients with hypertension and cardiovascular risk factors. It’s not a ‘one size fits all,’ and I believe it is a matter of defining who is at increased CV risk and who would derive the greatest clinical benefit.”

Researchers at the University of Pennsylvania have developed a clinical risk–prediction algorithm and are investigating both clinical- and biomarker-guided strategies to identify and treat patients at greatest risk of developing left ventricular declines and cardiac dysfunction with exposure to cancer therapies. “These studies are one step forward, but they will all need to be externally validated,” Ky said.

Ky and Mayer reported having no relevant conflicts of interest.

This article first appeared on Medscape.com.

Specialty care from a cardiologist may confer clinical benefits for women with HER2-positive breast cancer treated with trastuzumab, a new study suggests.

Over 48 months of follow-up, results showed cardiology involvement prior to starting trastuzumab was associated with a higher rate of guideline-recommended cardiovascular (CV) monitoring and better systolic blood pressure (BP) control.

Trastuzumab is commonly used to treat HER2-positive breast cancer, which accounts for 20% of all breast cancers. But it carries a boxed warning for decreased left ventricular ejection fraction and heart failure (HF), and interval monitoring with echocardiography is recommended for all patients receiving the monoclonal antibody.

For the study, investigators analyzed electronic health records from 1,047 patients (mean age, 54 years) who received trastuzumab between January 2009 and July 2018 in the University of Pennsylvania health system, Philadelphia. Anthracyclines were used as part of treatment in 15% of patients.

Guideline-adherent cardiovascular monitoring was defined as echocardiography assessment in the 4 months before the initiation of trastuzumab and at least every 4 months during therapy.

Overall, 28% of patients visited a cardiology or cardio-oncology provider beginning 3 months before the baseline visit until the last contact date, the authors reported in JACC: CardioOncology.

Pre-existing HF, atrial fibrillation, and anthracycline treatment were independently associated with a cardiology visit either at baseline or during follow-up.

Patients who interacted with cardiologists, compared with those who did not, had more guideline-adherent cardiac monitoring (76.4% vs 60.1%; P = .007) and cardiac biomarker testing with troponin or N-terminal pro-B-type natriuretic peptide (27.8% vs 13.8%; P = .001).

The use of guideline-adherent cardiac monitoring was 36% to 46% in previous studies of patients with breast cancer treated with adjuvant trastuzumab-based therapy, the authors note.

Among the 5,815 echocardiographic procedures for which data on provider specialty were documented, most of the orders were authorized by oncologists (approximately 84% in those with no cardiology involvement and approximately 79% in those with cardiology involvement before trastuzumab initiation).
 

CV risk parameters

Cardiology involvement was associated with an average 1.5 mm Hg lower systolic BP, independent of baseline systolic BP and antihypertensive medication use (95% confidence interval, –2.9 to –0.1; P = .035).

The effect size was greater in patients with baseline hypertension, who had an average 2.7 mm Hg drop in systolic BP (95% CI, –4.6 to –0.7; P = .007) and were more likely to attain a target systolic BP below 140 mm Hg (odds ratio, 1.36; 95% CI, 1.06 to 1.74; P = .016).

Body mass index (BMI) did not budge significantly in the overall population when cardiologists were involved, but it dropped 0.5 kg/m2 in women who were overweight or obese at baseline.

“I think the results are encouraging,” senior author Bonnie Ky, MD, MSCE, University of Pennsylvania, told theheart.org | Medscape Cardiology. “These are modest changes but they are significant.”

These types of changes have been associated with significant reductions in cardiovascular disease risk over time in larger clinical trials, she noted. For example, a 2 mm Hg reduction in systolic BP has been linked to a 10% reduction in stroke mortality and a 7% reduction in ischemic heart disease mortality in middle-aged adults.

“We do think they are important and speak to more aggressive risk factor modification under the care of a specialist,” said Ky, who is also editor-in-chief of JACC: CardioOncology.

This broader role for cardiologists is particularly important given the burden of pre-existing CVD and CVD risk factors in patients with cancer and survivors. In the study, the baseline prevalence of hypertension was 40.6%, dyslipidemia 23.1%, HF 3.2%, atrial fibrillation 1.7%, and diabetes 5.9%.

“Ideally, collaboration between cardiology and oncology can improve the ability to cure a patient’s cancer while minimizing the risk of adverse cardiovascular occurrences,” Erica L. Mayer, MD, MPH, Dana-Farber Cancer Institute, Boston, told theheart.org | Medscape Cardiology. “Optimization of all cardiovascular parameters, including blood pressure, lipids, and weight, may allow a patient to protect her heart health while becoming a healthy cancer survivor.”

When asked about the 28% cardiology involvement at a U.S. cancer center with one of the most well-developed cardio-oncology programs, she said “the linkage with pre-existing cardiovascular conditions, as well as the likelihood of low incidence of cardiovascular disease, in the study population may have led to what appears to be a lower percentage of patients interacting with cardiology at baseline.”

In an accompanying editorial, Mayer says a case can be made from the findings that patients with pre-existing CV disease or at high risk for adverse CV events with cancer therapy should receive multidisciplinary care that involves a cardiologist. “However, for young, otherwise healthy patients with breast cancer with few or no cardiovascular risk factors, the benefits of [additional] subspecialty care may be less clear.”

Further, the rationale supporting the recommended frequency of cardiac monitoring may not be as “compelling” in this group, given the very low incidence of baseline cardiac dysfunction or cardiac events, particularly when treated with nonanthracycline regimens, she writes.

The findings are a call for further study and more personalized medicine, agreed Ky.

“I think there’s a need absolutely for established guidelines and/or expert consensus statements about who should be referred so patients can be referred more systematically,” she said. “Referral to cardiologists, however, is certainly a function of risk factors. Part of the challenge is identifying who will derive the most benefit from cardiovascular care.

“There are some obvious cases: Patients with heart failure and patients with pre-existing cardiovascular disease should be under the regular care of a cardiologist,” Ky added. “But there’s certainly a gray zone, especially as it relates, for example, to patients with hypertension and cardiovascular risk factors. It’s not a ‘one size fits all,’ and I believe it is a matter of defining who is at increased CV risk and who would derive the greatest clinical benefit.”

Researchers at the University of Pennsylvania have developed a clinical risk–prediction algorithm and are investigating both clinical- and biomarker-guided strategies to identify and treat patients at greatest risk of developing left ventricular declines and cardiac dysfunction with exposure to cancer therapies. “These studies are one step forward, but they will all need to be externally validated,” Ky said.

Ky and Mayer reported having no relevant conflicts of interest.

This article first appeared on Medscape.com.

Specialty care from a cardiologist may confer clinical benefits for women with HER2-positive breast cancer treated with trastuzumab, a new study suggests.

Over 48 months of follow-up, results showed cardiology involvement prior to starting trastuzumab was associated with a higher rate of guideline-recommended cardiovascular (CV) monitoring and better systolic blood pressure (BP) control.

Trastuzumab is commonly used to treat HER2-positive breast cancer, which accounts for 20% of all breast cancers. But it carries a boxed warning for decreased left ventricular ejection fraction and heart failure (HF), and interval monitoring with echocardiography is recommended for all patients receiving the monoclonal antibody.

For the study, investigators analyzed electronic health records from 1,047 patients (mean age, 54 years) who received trastuzumab between January 2009 and July 2018 in the University of Pennsylvania health system, Philadelphia. Anthracyclines were used as part of treatment in 15% of patients.

Guideline-adherent cardiovascular monitoring was defined as echocardiography assessment in the 4 months before the initiation of trastuzumab and at least every 4 months during therapy.

Overall, 28% of patients visited a cardiology or cardio-oncology provider beginning 3 months before the baseline visit until the last contact date, the authors reported in JACC: CardioOncology.

Pre-existing HF, atrial fibrillation, and anthracycline treatment were independently associated with a cardiology visit either at baseline or during follow-up.

Patients who interacted with cardiologists, compared with those who did not, had more guideline-adherent cardiac monitoring (76.4% vs 60.1%; P = .007) and cardiac biomarker testing with troponin or N-terminal pro-B-type natriuretic peptide (27.8% vs 13.8%; P = .001).

The use of guideline-adherent cardiac monitoring was 36% to 46% in previous studies of patients with breast cancer treated with adjuvant trastuzumab-based therapy, the authors note.

Among the 5,815 echocardiographic procedures for which data on provider specialty were documented, most of the orders were authorized by oncologists (approximately 84% in those with no cardiology involvement and approximately 79% in those with cardiology involvement before trastuzumab initiation).
 

CV risk parameters

Cardiology involvement was associated with an average 1.5 mm Hg lower systolic BP, independent of baseline systolic BP and antihypertensive medication use (95% confidence interval, –2.9 to –0.1; P = .035).

The effect size was greater in patients with baseline hypertension, who had an average 2.7 mm Hg drop in systolic BP (95% CI, –4.6 to –0.7; P = .007) and were more likely to attain a target systolic BP below 140 mm Hg (odds ratio, 1.36; 95% CI, 1.06 to 1.74; P = .016).

Body mass index (BMI) did not budge significantly in the overall population when cardiologists were involved, but it dropped 0.5 kg/m2 in women who were overweight or obese at baseline.

“I think the results are encouraging,” senior author Bonnie Ky, MD, MSCE, University of Pennsylvania, told theheart.org | Medscape Cardiology. “These are modest changes but they are significant.”

These types of changes have been associated with significant reductions in cardiovascular disease risk over time in larger clinical trials, she noted. For example, a 2 mm Hg reduction in systolic BP has been linked to a 10% reduction in stroke mortality and a 7% reduction in ischemic heart disease mortality in middle-aged adults.

“We do think they are important and speak to more aggressive risk factor modification under the care of a specialist,” said Ky, who is also editor-in-chief of JACC: CardioOncology.

This broader role for cardiologists is particularly important given the burden of pre-existing CVD and CVD risk factors in patients with cancer and survivors. In the study, the baseline prevalence of hypertension was 40.6%, dyslipidemia 23.1%, HF 3.2%, atrial fibrillation 1.7%, and diabetes 5.9%.

“Ideally, collaboration between cardiology and oncology can improve the ability to cure a patient’s cancer while minimizing the risk of adverse cardiovascular occurrences,” Erica L. Mayer, MD, MPH, Dana-Farber Cancer Institute, Boston, told theheart.org | Medscape Cardiology. “Optimization of all cardiovascular parameters, including blood pressure, lipids, and weight, may allow a patient to protect her heart health while becoming a healthy cancer survivor.”

When asked about the 28% cardiology involvement at a U.S. cancer center with one of the most well-developed cardio-oncology programs, she said “the linkage with pre-existing cardiovascular conditions, as well as the likelihood of low incidence of cardiovascular disease, in the study population may have led to what appears to be a lower percentage of patients interacting with cardiology at baseline.”

In an accompanying editorial, Mayer says a case can be made from the findings that patients with pre-existing CV disease or at high risk for adverse CV events with cancer therapy should receive multidisciplinary care that involves a cardiologist. “However, for young, otherwise healthy patients with breast cancer with few or no cardiovascular risk factors, the benefits of [additional] subspecialty care may be less clear.”

Further, the rationale supporting the recommended frequency of cardiac monitoring may not be as “compelling” in this group, given the very low incidence of baseline cardiac dysfunction or cardiac events, particularly when treated with nonanthracycline regimens, she writes.

The findings are a call for further study and more personalized medicine, agreed Ky.

“I think there’s a need absolutely for established guidelines and/or expert consensus statements about who should be referred so patients can be referred more systematically,” she said. “Referral to cardiologists, however, is certainly a function of risk factors. Part of the challenge is identifying who will derive the most benefit from cardiovascular care.

“There are some obvious cases: Patients with heart failure and patients with pre-existing cardiovascular disease should be under the regular care of a cardiologist,” Ky added. “But there’s certainly a gray zone, especially as it relates, for example, to patients with hypertension and cardiovascular risk factors. It’s not a ‘one size fits all,’ and I believe it is a matter of defining who is at increased CV risk and who would derive the greatest clinical benefit.”

Researchers at the University of Pennsylvania have developed a clinical risk–prediction algorithm and are investigating both clinical- and biomarker-guided strategies to identify and treat patients at greatest risk of developing left ventricular declines and cardiac dysfunction with exposure to cancer therapies. “These studies are one step forward, but they will all need to be externally validated,” Ky said.

Ky and Mayer reported having no relevant conflicts of interest.

This article first appeared on Medscape.com.

The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.¹ The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.

The necessity of a new care model

Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications² was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.

Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
 

The preparatory phase: From “Hospitalists” to “COVIDists”

As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.

COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.

In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).

The execution phase

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.

Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,³ and helped with hospital capacity and patient flow (Tables 2 and 3).

The maintenance phase

It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.

Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”⁴ In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
 

Conclusion

The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.

The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
 

Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at Venkatrao.MedarametlaMD@Baystatehealth.org. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.

References

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.

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

3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.

4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi

The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.¹ The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.

The necessity of a new care model

Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications² was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.

Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
 

The preparatory phase: From “Hospitalists” to “COVIDists”

As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.

COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.

In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).

The execution phase

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.

Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,³ and helped with hospital capacity and patient flow (Tables 2 and 3).

The maintenance phase

It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.

Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”⁴ In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
 

Conclusion

The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.

The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
 

Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at Venkatrao.MedarametlaMD@Baystatehealth.org. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.

References

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.

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

3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.

4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi

The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.¹ The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.

The necessity of a new care model

Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications² was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.

Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
 

The preparatory phase: From “Hospitalists” to “COVIDists”

As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.

COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.

In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).

The execution phase

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.

Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,³ and helped with hospital capacity and patient flow (Tables 2 and 3).

The maintenance phase

It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.

Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”⁴ In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
 

Conclusion

The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.

The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
 

Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at Venkatrao.MedarametlaMD@Baystatehealth.org. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.

References

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.

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

3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.

4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi

Here are the stories our MDedge editors across specialties think you need to know about today:

Lung ultrasound works well in children with COVID-19

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19 and offers benefits over other imaging techniques, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” wrote Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy. “Secondly, when performed at the bedside, [lung ultrasound] allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].” The findings of the small, observational study were published in Pediatrics. Read more.

New hypertension definitions reveal preclampsia risk

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure are at increased risk for preeclampsia, according to results from a large retrospective cohort study. Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby. The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy, which are not well studied” in comparison to nonpregnant hypertensive states. Read more.

Face mask type matters when sterilizing

When sterilizing face masks, the type of mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to new research published in JAMA Network Open. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks. With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%. Read more.

FDA approves first treatment for adult-onset Still’s disease

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA). That makes Ilaris the first approved treatment for AOSD. The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab. Read more.

Intranasal DHE shows promise in migraine

An intranasal form of dihydroergotamine (DHE) targeting the upper nasal region is safe and effective for the treatment of migraine, according to results from a phase 3 clinical trial. The new formulation could offer patients an at-home alternative to intramuscular infusions or intravenous injections currently used to deliver DHE. The STOP 301 phase 3 open-label safety and tolerability trial treated over 5,650 migraine attacks in 354 patients who self-administered INP104 for up to 52 weeks. They were provided up to three doses per week (1.45 mg in a dose of two puffs, one per nostril). A total of 66.3% of participants reported pain relief by 2 hours following a dose, and 38% had freedom from pain. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Lung ultrasound works well in children with COVID-19

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19 and offers benefits over other imaging techniques, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” wrote Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy. “Secondly, when performed at the bedside, [lung ultrasound] allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].” The findings of the small, observational study were published in Pediatrics. Read more.

New hypertension definitions reveal preclampsia risk

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure are at increased risk for preeclampsia, according to results from a large retrospective cohort study. Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby. The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy, which are not well studied” in comparison to nonpregnant hypertensive states. Read more.

Face mask type matters when sterilizing

When sterilizing face masks, the type of mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to new research published in JAMA Network Open. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks. With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%. Read more.

FDA approves first treatment for adult-onset Still’s disease

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA). That makes Ilaris the first approved treatment for AOSD. The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab. Read more.

Intranasal DHE shows promise in migraine

An intranasal form of dihydroergotamine (DHE) targeting the upper nasal region is safe and effective for the treatment of migraine, according to results from a phase 3 clinical trial. The new formulation could offer patients an at-home alternative to intramuscular infusions or intravenous injections currently used to deliver DHE. The STOP 301 phase 3 open-label safety and tolerability trial treated over 5,650 migraine attacks in 354 patients who self-administered INP104 for up to 52 weeks. They were provided up to three doses per week (1.45 mg in a dose of two puffs, one per nostril). A total of 66.3% of participants reported pain relief by 2 hours following a dose, and 38% had freedom from pain. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Lung ultrasound works well in children with COVID-19

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19 and offers benefits over other imaging techniques, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” wrote Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy. “Secondly, when performed at the bedside, [lung ultrasound] allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].” The findings of the small, observational study were published in Pediatrics. Read more.

New hypertension definitions reveal preclampsia risk

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure are at increased risk for preeclampsia, according to results from a large retrospective cohort study. Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby. The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy, which are not well studied” in comparison to nonpregnant hypertensive states. Read more.

Face mask type matters when sterilizing

When sterilizing face masks, the type of mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to new research published in JAMA Network Open. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks. With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%. Read more.

FDA approves first treatment for adult-onset Still’s disease

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA). That makes Ilaris the first approved treatment for AOSD. The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab. Read more.

Intranasal DHE shows promise in migraine

An intranasal form of dihydroergotamine (DHE) targeting the upper nasal region is safe and effective for the treatment of migraine, according to results from a phase 3 clinical trial. The new formulation could offer patients an at-home alternative to intramuscular infusions or intravenous injections currently used to deliver DHE. The STOP 301 phase 3 open-label safety and tolerability trial treated over 5,650 migraine attacks in 354 patients who self-administered INP104 for up to 52 weeks. They were provided up to three doses per week (1.45 mg in a dose of two puffs, one per nostril). A total of 66.3% of participants reported pain relief by 2 hours following a dose, and 38% had freedom from pain. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure (BP) are at increased risk for preeclampsia, according to results from a large retrospective cohort study.

American Heart Association

In a 2017 guideline, the American College of Cardiology and American Heart Association changed clinical definitions of hypertension in adults. People previously deemed to have prehypertension were classed as having elevated blood pressure (systolic BP 120-129 mm Hg and diastolic BP >80 mm Hg) or stage 1 hypertension (systolic 130-139 mm Hg or diastolic 80-89 mm Hg).

And while hypertension as earlier defined (at or above systolic 140 mm Hg or at or above diastolic 90 mm Hg; now called stage 2 hypertension) has been long associated with adverse maternal and fetal effects, it was unclear whether lesser elevations in blood pressure also are linked to the same.

For their research published in Obstetrics & Gynecology, Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby and had two or more prenatal appointments before week 20 of pregnancy. The women in the study were seen at the same institution over a 3-year period ending in 2018. Three-quarters of the cohort had normal blood pressure, while 14% had elevated blood pressure and 5% had stage 1 hypertension before 20 weeks. Another 6% of the cohort had stage 2 hypertension.

The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did with 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Both term and preterm preeclampsia were factors in women with stage 1 and stage 2 hypertension, but preterm preeclampsia was associated with a higher risk. Although black race was associated with a higher risk of preeclampsia, the pattern of increasing risk with higher blood pressure category was similar in both black and white women.

Researchers also looked at gestational diabetes, severe maternal morbidity, neonatal morbidity, and placental abruption as secondary outcomes. They found the risk of gestational diabetes increased in a stepwise fashion as blood pressure increased, compared with normotensive women. Higher risk of severe maternal and neonatal morbidities was seen only in women with stage 2 hypertension. Placental abruption was rare in this cohort and the odds were not increased in any group.

The findings “highlight the importance of early pregnancy BP elevations, which may reflect prepregnancy BP status,” and suggest that the new guidelines “can identify women early in pregnancy who may benefit from increased surveillance,” Dr. Sutton and colleagues wrote.

Although randomized trials will be needed to identify the best prevention and management strategies for this patient group, they added, some clinicians may want to consider low-dose aspirin – an intervention shown to safely reduce preeclampsia risk among women with stage 2 hypertension – for women with elevated BP or stage 1 hypertension.

Dr. Sutton and colleagues acknowledged that its retrospective design is among the limitations of their study, and that use of antihypertensive medications could not be captured in their study.

Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy which are not well studied” in comparison to nonpregnant hypertensive states.

“Are these seemingly normal blood pressures associated with poor outcomes, maternal or neonatal? I think that this paper strongly tells us yes,” Dr. Santillan added. “But does that mean we have to do more aggressive blood pressure monitoring, seeing your doctor every month or so? Maybe we should change the way we’re treating people early on in gestation.”

The question of whether aspirin helps reduce preeclampsia risk in women with elevated blood pressure or stage 1 hypertension needs to be resolved in studies, Dr. Santillan said. But because of its favorable risk profile, “if I consider that if a patient has significant risk factors for developing preeclampsia, baby aspirin is fine.”

Postpregnancy blood pressure management is something that should also be reconsidered in light of the findings, Dr. Santillan said. Half of women with preeclampsia will have chronic hypertension after they deliver, increasing their risk of adverse cardiovascular outcomes later in life. But because most are young and otherwise healthy, they often are lost to follow-up.

“I think this paper has helped open up that conversation, that there is probably a link between what we’re doing in pregnancy to what we should be doing in the postpartum period,” he said.

Dr. Sutton and colleagues’ study received funding from the Richard King Mellon Foundation, the American Heart Association; and the National Institutes of Health. None of its authors had relevant disclosures. Dr. Santillan disclosed holding U.S. and international patents for preeclampsia prediction, diagnosis, and treatment.

SOURCE: Sutton et al. Obstet Gynecol. 2020;136:129-39.

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure (BP) are at increased risk for preeclampsia, according to results from a large retrospective cohort study.

American Heart Association

In a 2017 guideline, the American College of Cardiology and American Heart Association changed clinical definitions of hypertension in adults. People previously deemed to have prehypertension were classed as having elevated blood pressure (systolic BP 120-129 mm Hg and diastolic BP >80 mm Hg) or stage 1 hypertension (systolic 130-139 mm Hg or diastolic 80-89 mm Hg).

And while hypertension as earlier defined (at or above systolic 140 mm Hg or at or above diastolic 90 mm Hg; now called stage 2 hypertension) has been long associated with adverse maternal and fetal effects, it was unclear whether lesser elevations in blood pressure also are linked to the same.

For their research published in Obstetrics & Gynecology, Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby and had two or more prenatal appointments before week 20 of pregnancy. The women in the study were seen at the same institution over a 3-year period ending in 2018. Three-quarters of the cohort had normal blood pressure, while 14% had elevated blood pressure and 5% had stage 1 hypertension before 20 weeks. Another 6% of the cohort had stage 2 hypertension.

The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did with 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Both term and preterm preeclampsia were factors in women with stage 1 and stage 2 hypertension, but preterm preeclampsia was associated with a higher risk. Although black race was associated with a higher risk of preeclampsia, the pattern of increasing risk with higher blood pressure category was similar in both black and white women.

Researchers also looked at gestational diabetes, severe maternal morbidity, neonatal morbidity, and placental abruption as secondary outcomes. They found the risk of gestational diabetes increased in a stepwise fashion as blood pressure increased, compared with normotensive women. Higher risk of severe maternal and neonatal morbidities was seen only in women with stage 2 hypertension. Placental abruption was rare in this cohort and the odds were not increased in any group.

The findings “highlight the importance of early pregnancy BP elevations, which may reflect prepregnancy BP status,” and suggest that the new guidelines “can identify women early in pregnancy who may benefit from increased surveillance,” Dr. Sutton and colleagues wrote.

Although randomized trials will be needed to identify the best prevention and management strategies for this patient group, they added, some clinicians may want to consider low-dose aspirin – an intervention shown to safely reduce preeclampsia risk among women with stage 2 hypertension – for women with elevated BP or stage 1 hypertension.

Dr. Sutton and colleagues acknowledged that its retrospective design is among the limitations of their study, and that use of antihypertensive medications could not be captured in their study.

Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy which are not well studied” in comparison to nonpregnant hypertensive states.

“Are these seemingly normal blood pressures associated with poor outcomes, maternal or neonatal? I think that this paper strongly tells us yes,” Dr. Santillan added. “But does that mean we have to do more aggressive blood pressure monitoring, seeing your doctor every month or so? Maybe we should change the way we’re treating people early on in gestation.”

The question of whether aspirin helps reduce preeclampsia risk in women with elevated blood pressure or stage 1 hypertension needs to be resolved in studies, Dr. Santillan said. But because of its favorable risk profile, “if I consider that if a patient has significant risk factors for developing preeclampsia, baby aspirin is fine.”

Postpregnancy blood pressure management is something that should also be reconsidered in light of the findings, Dr. Santillan said. Half of women with preeclampsia will have chronic hypertension after they deliver, increasing their risk of adverse cardiovascular outcomes later in life. But because most are young and otherwise healthy, they often are lost to follow-up.

“I think this paper has helped open up that conversation, that there is probably a link between what we’re doing in pregnancy to what we should be doing in the postpartum period,” he said.

Dr. Sutton and colleagues’ study received funding from the Richard King Mellon Foundation, the American Heart Association; and the National Institutes of Health. None of its authors had relevant disclosures. Dr. Santillan disclosed holding U.S. and international patents for preeclampsia prediction, diagnosis, and treatment.

SOURCE: Sutton et al. Obstet Gynecol. 2020;136:129-39.

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure (BP) are at increased risk for preeclampsia, according to results from a large retrospective cohort study.

American Heart Association

In a 2017 guideline, the American College of Cardiology and American Heart Association changed clinical definitions of hypertension in adults. People previously deemed to have prehypertension were classed as having elevated blood pressure (systolic BP 120-129 mm Hg and diastolic BP >80 mm Hg) or stage 1 hypertension (systolic 130-139 mm Hg or diastolic 80-89 mm Hg).

And while hypertension as earlier defined (at or above systolic 140 mm Hg or at or above diastolic 90 mm Hg; now called stage 2 hypertension) has been long associated with adverse maternal and fetal effects, it was unclear whether lesser elevations in blood pressure also are linked to the same.

For their research published in Obstetrics & Gynecology, Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby and had two or more prenatal appointments before week 20 of pregnancy. The women in the study were seen at the same institution over a 3-year period ending in 2018. Three-quarters of the cohort had normal blood pressure, while 14% had elevated blood pressure and 5% had stage 1 hypertension before 20 weeks. Another 6% of the cohort had stage 2 hypertension.

The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did with 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Both term and preterm preeclampsia were factors in women with stage 1 and stage 2 hypertension, but preterm preeclampsia was associated with a higher risk. Although black race was associated with a higher risk of preeclampsia, the pattern of increasing risk with higher blood pressure category was similar in both black and white women.

Researchers also looked at gestational diabetes, severe maternal morbidity, neonatal morbidity, and placental abruption as secondary outcomes. They found the risk of gestational diabetes increased in a stepwise fashion as blood pressure increased, compared with normotensive women. Higher risk of severe maternal and neonatal morbidities was seen only in women with stage 2 hypertension. Placental abruption was rare in this cohort and the odds were not increased in any group.

The findings “highlight the importance of early pregnancy BP elevations, which may reflect prepregnancy BP status,” and suggest that the new guidelines “can identify women early in pregnancy who may benefit from increased surveillance,” Dr. Sutton and colleagues wrote.

Although randomized trials will be needed to identify the best prevention and management strategies for this patient group, they added, some clinicians may want to consider low-dose aspirin – an intervention shown to safely reduce preeclampsia risk among women with stage 2 hypertension – for women with elevated BP or stage 1 hypertension.

Dr. Sutton and colleagues acknowledged that its retrospective design is among the limitations of their study, and that use of antihypertensive medications could not be captured in their study.

Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy which are not well studied” in comparison to nonpregnant hypertensive states.

“Are these seemingly normal blood pressures associated with poor outcomes, maternal or neonatal? I think that this paper strongly tells us yes,” Dr. Santillan added. “But does that mean we have to do more aggressive blood pressure monitoring, seeing your doctor every month or so? Maybe we should change the way we’re treating people early on in gestation.”

The question of whether aspirin helps reduce preeclampsia risk in women with elevated blood pressure or stage 1 hypertension needs to be resolved in studies, Dr. Santillan said. But because of its favorable risk profile, “if I consider that if a patient has significant risk factors for developing preeclampsia, baby aspirin is fine.”

Postpregnancy blood pressure management is something that should also be reconsidered in light of the findings, Dr. Santillan said. Half of women with preeclampsia will have chronic hypertension after they deliver, increasing their risk of adverse cardiovascular outcomes later in life. But because most are young and otherwise healthy, they often are lost to follow-up.

“I think this paper has helped open up that conversation, that there is probably a link between what we’re doing in pregnancy to what we should be doing in the postpartum period,” he said.

Dr. Sutton and colleagues’ study received funding from the Richard King Mellon Foundation, the American Heart Association; and the National Institutes of Health. None of its authors had relevant disclosures. Dr. Santillan disclosed holding U.S. and international patents for preeclampsia prediction, diagnosis, and treatment.

SOURCE: Sutton et al. Obstet Gynecol. 2020;136:129-39.

I have an automatic preference for white people over black people. This isn’t my opinion; rather, it is my implicit bias test result. I didn’t believe it at first. Trying hard to not be biased, I took the test again and received the same outcome. My reaction – disbelief – is typical for those like me: White people who believe they are good human beings. I might be good, but that doesn’t mean I’m free of bias or exonerated from the harm being inflicted on people of color.

We’ve all watched in horror the acts of violence against blacks in the news. I was shocked and disgusted. It was easy to believe, however, that I am in no way complicit in the injustice and racism I was watching. I think I’m fair and without prejudice. I have never intentionally discriminated against someone. Wanting to help, I listened to my black colleagues, staff, and patients. What I learned made me uncomfortable.

Through all this news, I’d said little to my colleagues and friends. I cannot identify with how a black person has felt recently. What if I said the wrong thing or caused offense? The safe option is to say nothing. I learned that this is a common reaction and the least helpful. The advice from one black colleague was simple: “Just ask us.” Instead of ignoring the issue, she advised me to say: “I wonder what this experience has been like for you. Would you like to share?” And, if you mean it, to add, “I stand with you.” The latter should be followed by “What can I do to help?” Or, more powerfully, “What have I done that makes me complicit?”

Some of these conversations will be uncomfortable. If you want to help, then sit with that. Feeling uncomfortable might mean you are beginning to understand.

I also heard about the excellent book “White Fragility,” by Robin DiAngelo, PhD. In it, she argues that it is difficult for white people to talk about racism because of a tendency to react with defensiveness, guilt, and sometimes anger.

Many of the chapters in the book were easy to read because they didn’t apply to me: I don’t get angry in equity, inclusion, and diversity meetings. I don’t resent affirmative action programs. But then Dr. DiAngelo got me: I believed because I’m a good person and I have no intention of being racist, I’m absolved. Her argument was enlightening. Like all white people in the United States, I have benefited from white privilege. Yes, I’ve worked hard, but I also grew up in a white family with a college-educated father. That alone afforded me academic and financial advantages, which pushed me ahead. I’ve benefited from the status quo.

I have also failed to speak up when white friends carried on about how unnecessary affirmative action programs have become. I’ve sat with sealed lips when I’ve heard comments like “As a white male, it’s a lot harder to get into prestigious schools now.” Having no intention to harm doesn’t matter; plenty of harm is done unintentionally.

I also believed that because I have good intentions, I have no racial bias. I was wrong. The test I took online is an excellent tool to combat this blind spot. It was created by Harvard researchers and is available to everyone: Take a Test. It asks you to categorize faces as good or bad and records your tiny reaction times. Based on these and other questions, it provides feedback on your personal biases.

I was surprised that I have an implicit preference for white people over black people. That’s the point. Most of us are unaware of our biases and falsely believe we are free of them. I encourage you to take the test and learn about yourself. If the result makes you uncomfortable, then sit with it. Try not to be defensive, as I was, and accept that, even if you are a good person, you can become a better one.

Based on what I’ve learned and heard in the last few weeks, I’ve committed to a few things: To acknowledge the harm done to my black and brown colleagues and my complicity even by acts of omission. To not avoid uncomfortable feelings or uncomfortable conversations. As a leader, to use my organizational status to advocate. To stand by my partners of color not only in dramatic one-time marches but also against the everyday perpetrators of microaggressions. To create a safe space and invite my colleagues, staff, friends, and patients to share.

Standing up against racism is all our responsibility. As Dr. Martin Luther King Jr. reminds us: “In the end, we will remember not the words of our enemies, but the silence of our friends.”
 

Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no disclosures related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

I have an automatic preference for white people over black people. This isn’t my opinion; rather, it is my implicit bias test result. I didn’t believe it at first. Trying hard to not be biased, I took the test again and received the same outcome. My reaction – disbelief – is typical for those like me: White people who believe they are good human beings. I might be good, but that doesn’t mean I’m free of bias or exonerated from the harm being inflicted on people of color.

We’ve all watched in horror the acts of violence against blacks in the news. I was shocked and disgusted. It was easy to believe, however, that I am in no way complicit in the injustice and racism I was watching. I think I’m fair and without prejudice. I have never intentionally discriminated against someone. Wanting to help, I listened to my black colleagues, staff, and patients. What I learned made me uncomfortable.

Through all this news, I’d said little to my colleagues and friends. I cannot identify with how a black person has felt recently. What if I said the wrong thing or caused offense? The safe option is to say nothing. I learned that this is a common reaction and the least helpful. The advice from one black colleague was simple: “Just ask us.” Instead of ignoring the issue, she advised me to say: “I wonder what this experience has been like for you. Would you like to share?” And, if you mean it, to add, “I stand with you.” The latter should be followed by “What can I do to help?” Or, more powerfully, “What have I done that makes me complicit?”

Some of these conversations will be uncomfortable. If you want to help, then sit with that. Feeling uncomfortable might mean you are beginning to understand.

I also heard about the excellent book “White Fragility,” by Robin DiAngelo, PhD. In it, she argues that it is difficult for white people to talk about racism because of a tendency to react with defensiveness, guilt, and sometimes anger.

Many of the chapters in the book were easy to read because they didn’t apply to me: I don’t get angry in equity, inclusion, and diversity meetings. I don’t resent affirmative action programs. But then Dr. DiAngelo got me: I believed because I’m a good person and I have no intention of being racist, I’m absolved. Her argument was enlightening. Like all white people in the United States, I have benefited from white privilege. Yes, I’ve worked hard, but I also grew up in a white family with a college-educated father. That alone afforded me academic and financial advantages, which pushed me ahead. I’ve benefited from the status quo.

I have also failed to speak up when white friends carried on about how unnecessary affirmative action programs have become. I’ve sat with sealed lips when I’ve heard comments like “As a white male, it’s a lot harder to get into prestigious schools now.” Having no intention to harm doesn’t matter; plenty of harm is done unintentionally.

I also believed that because I have good intentions, I have no racial bias. I was wrong. The test I took online is an excellent tool to combat this blind spot. It was created by Harvard researchers and is available to everyone: Take a Test. It asks you to categorize faces as good or bad and records your tiny reaction times. Based on these and other questions, it provides feedback on your personal biases.

I was surprised that I have an implicit preference for white people over black people. That’s the point. Most of us are unaware of our biases and falsely believe we are free of them. I encourage you to take the test and learn about yourself. If the result makes you uncomfortable, then sit with it. Try not to be defensive, as I was, and accept that, even if you are a good person, you can become a better one.

Based on what I’ve learned and heard in the last few weeks, I’ve committed to a few things: To acknowledge the harm done to my black and brown colleagues and my complicity even by acts of omission. To not avoid uncomfortable feelings or uncomfortable conversations. As a leader, to use my organizational status to advocate. To stand by my partners of color not only in dramatic one-time marches but also against the everyday perpetrators of microaggressions. To create a safe space and invite my colleagues, staff, friends, and patients to share.

Standing up against racism is all our responsibility. As Dr. Martin Luther King Jr. reminds us: “In the end, we will remember not the words of our enemies, but the silence of our friends.”
 

Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no disclosures related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

I have an automatic preference for white people over black people. This isn’t my opinion; rather, it is my implicit bias test result. I didn’t believe it at first. Trying hard to not be biased, I took the test again and received the same outcome. My reaction – disbelief – is typical for those like me: White people who believe they are good human beings. I might be good, but that doesn’t mean I’m free of bias or exonerated from the harm being inflicted on people of color.

We’ve all watched in horror the acts of violence against blacks in the news. I was shocked and disgusted. It was easy to believe, however, that I am in no way complicit in the injustice and racism I was watching. I think I’m fair and without prejudice. I have never intentionally discriminated against someone. Wanting to help, I listened to my black colleagues, staff, and patients. What I learned made me uncomfortable.

Through all this news, I’d said little to my colleagues and friends. I cannot identify with how a black person has felt recently. What if I said the wrong thing or caused offense? The safe option is to say nothing. I learned that this is a common reaction and the least helpful. The advice from one black colleague was simple: “Just ask us.” Instead of ignoring the issue, she advised me to say: “I wonder what this experience has been like for you. Would you like to share?” And, if you mean it, to add, “I stand with you.” The latter should be followed by “What can I do to help?” Or, more powerfully, “What have I done that makes me complicit?”

Some of these conversations will be uncomfortable. If you want to help, then sit with that. Feeling uncomfortable might mean you are beginning to understand.

I also heard about the excellent book “White Fragility,” by Robin DiAngelo, PhD. In it, she argues that it is difficult for white people to talk about racism because of a tendency to react with defensiveness, guilt, and sometimes anger.

Many of the chapters in the book were easy to read because they didn’t apply to me: I don’t get angry in equity, inclusion, and diversity meetings. I don’t resent affirmative action programs. But then Dr. DiAngelo got me: I believed because I’m a good person and I have no intention of being racist, I’m absolved. Her argument was enlightening. Like all white people in the United States, I have benefited from white privilege. Yes, I’ve worked hard, but I also grew up in a white family with a college-educated father. That alone afforded me academic and financial advantages, which pushed me ahead. I’ve benefited from the status quo.

I have also failed to speak up when white friends carried on about how unnecessary affirmative action programs have become. I’ve sat with sealed lips when I’ve heard comments like “As a white male, it’s a lot harder to get into prestigious schools now.” Having no intention to harm doesn’t matter; plenty of harm is done unintentionally.

I also believed that because I have good intentions, I have no racial bias. I was wrong. The test I took online is an excellent tool to combat this blind spot. It was created by Harvard researchers and is available to everyone: Take a Test. It asks you to categorize faces as good or bad and records your tiny reaction times. Based on these and other questions, it provides feedback on your personal biases.

I was surprised that I have an implicit preference for white people over black people. That’s the point. Most of us are unaware of our biases and falsely believe we are free of them. I encourage you to take the test and learn about yourself. If the result makes you uncomfortable, then sit with it. Try not to be defensive, as I was, and accept that, even if you are a good person, you can become a better one.

Based on what I’ve learned and heard in the last few weeks, I’ve committed to a few things: To acknowledge the harm done to my black and brown colleagues and my complicity even by acts of omission. To not avoid uncomfortable feelings or uncomfortable conversations. As a leader, to use my organizational status to advocate. To stand by my partners of color not only in dramatic one-time marches but also against the everyday perpetrators of microaggressions. To create a safe space and invite my colleagues, staff, friends, and patients to share.

Standing up against racism is all our responsibility. As Dr. Martin Luther King Jr. reminds us: “In the end, we will remember not the words of our enemies, but the silence of our friends.”
 

Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no disclosures related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19, researchers wrote in Pediatrics.

They also noted the benefits that modality provides over other imaging techniques.

Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy, performed an observational study of eight children aged 0-17 years who were admitted to the hospital for COVID-19 between March 8 and 26, 2020. In seven of eight patients, the findings were concordant between imaging modalities; in the remaining patient, lung ultrasound (LUS) found an interstitial B-lines pattern that was not seen on radiography. In seven patients with pathologic ultrasound findings at baseline, the improvement or resolution of the subpleural consolidations or interstitial patterns was consistent with concomitant radiologic findings.

The authors cited the benefits of using point-of-care ultrasound instead of other modalities, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” they wrote. “Secondly, when performed at the bedside, LUS allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].”

One limitation of the study is the small sample size; however, the researchers felt the high concordance still suggests LUS is a reasonable method for COVID-19 patients.

There was no external funding for this study and the investigators had no relevant financial disclosures.

cpalmer@mdedge.com

SOURCE: Denina M et al. Pediatrics. 2020 Jun. doi: 10.1542/peds.2020-1157.

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19, researchers wrote in Pediatrics.

They also noted the benefits that modality provides over other imaging techniques.

Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy, performed an observational study of eight children aged 0-17 years who were admitted to the hospital for COVID-19 between March 8 and 26, 2020. In seven of eight patients, the findings were concordant between imaging modalities; in the remaining patient, lung ultrasound (LUS) found an interstitial B-lines pattern that was not seen on radiography. In seven patients with pathologic ultrasound findings at baseline, the improvement or resolution of the subpleural consolidations or interstitial patterns was consistent with concomitant radiologic findings.

The authors cited the benefits of using point-of-care ultrasound instead of other modalities, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” they wrote. “Secondly, when performed at the bedside, LUS allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].”

One limitation of the study is the small sample size; however, the researchers felt the high concordance still suggests LUS is a reasonable method for COVID-19 patients.

There was no external funding for this study and the investigators had no relevant financial disclosures.

cpalmer@mdedge.com

SOURCE: Denina M et al. Pediatrics. 2020 Jun. doi: 10.1542/peds.2020-1157.

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19, researchers wrote in Pediatrics.

They also noted the benefits that modality provides over other imaging techniques.

Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy, performed an observational study of eight children aged 0-17 years who were admitted to the hospital for COVID-19 between March 8 and 26, 2020. In seven of eight patients, the findings were concordant between imaging modalities; in the remaining patient, lung ultrasound (LUS) found an interstitial B-lines pattern that was not seen on radiography. In seven patients with pathologic ultrasound findings at baseline, the improvement or resolution of the subpleural consolidations or interstitial patterns was consistent with concomitant radiologic findings.

The authors cited the benefits of using point-of-care ultrasound instead of other modalities, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” they wrote. “Secondly, when performed at the bedside, LUS allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].”

One limitation of the study is the small sample size; however, the researchers felt the high concordance still suggests LUS is a reasonable method for COVID-19 patients.

There was no external funding for this study and the investigators had no relevant financial disclosures.

cpalmer@mdedge.com

SOURCE: Denina M et al. Pediatrics. 2020 Jun. doi: 10.1542/peds.2020-1157.