Given the possibility that children with hematologic malignancies may have increased susceptibility to coronavirus disease 2019 (COVID-19), clinicians from China and the United States have proposed a plan for preventing and managing outbreaks in hospitals’ pediatric hematology and oncology departments.

The plan is focused primarily on infection prevention and control strategies, Yulei He, MD, of Chengdu (China) Women’s and Children’s Central Hospital and colleagues explained in an article published in The Lancet Haematology.

The authors noted that close contact with COVID-19 patients is thought to be the main route of transmission, and a retrospective study indicated that 41.3% of initial COVID-19 cases were caused by hospital-related transmission.

“Children with hematological malignancies might have increased susceptibility to infection with SARS-CoV-2 because of immunodeficiency; therefore, procedures are needed to avoid hospital-related transmission and infection for these patients,” the authors wrote.
 

Preventing the spread of infection

Dr. He and colleagues advised that medical staff be kept up-to-date with the latest information about COVID-19 and perform assessments regularly to identify cases in their departments.

The authors also recommended establishing a COVID-19 expert committee – consisting of infectious disease physicians, hematologists, oncologists, radiologists, pharmacists, and hospital infection control staff – to make medical decisions in multidisciplinary consultation meetings. In addition, the authors recommended regional management strategies be adopted to minimize cross infection within the hospital. Specifically, the authors proposed creating the following four zones:

1. A surveillance and screening zone for patients potentially infected with SARS-CoV-2

2. A suspected-case quarantine zone where patients thought to have COVID-19 are isolated in single rooms

3. A confirmed-case quarantine zone where patients are treated for COVID-19

4. A hematology/oncology ward for treating non–COVID-19 patients with malignancies.

Dr. He and colleagues also stressed the importance of providing personal protective equipment for all zones, along with instructions for proper use and disposal. The authors recommended developing and following specific protocols for outpatient visits in the hematology/oncology ward, and providing COVID-19 prevention and control information to families and health care workers.
 

Managing cancer treatment

For patients with acute leukemias who have induction chemotherapy planned, Dr. He and colleagues argued that scheduled chemotherapy should not be interrupted unless COVID-19 is suspected or diagnosed. The authors said treatment should not be delayed more than 7 days during induction, consolidation, or the intermediate phase of chemotherapy because the virus has an incubation period of 2-7 days. This will allow a short period of observation to screen for potential infection.

The authors recommended that patients with lymphoma and solid tumors first undergo COVID-19 screening and then receive treatment in hematology/oncology wards “according to their chemotherapy schedule, and without delay, until they are in complete remission.”

“If the patient is in complete remission, we recommend a treatment delay of no more than 7 days to allow a short period of observation to screen for COVID-19,” the authors added.

Maintenance chemotherapy should not be delayed for more than 14 days, Dr. He and colleagues wrote. “This increase in the maximum delay before chemotherapy strikes a balance between the potential risk of SARS-CoV-2 infection and tumor recurrence, since pediatric patients in this phase of treatment have a reduced risk of tumor recurrence,” the authors added.
 

Caring for patients with COVID-19

For inpatients diagnosed with COVID-19, Dr. He and colleagues recommended the following:

• Prioritize COVID-19 treatment for children with primary disease remission.
• For children not in remission, prioritize treatment for critical patients.
• Isolated patients should be treated for COVID-19, and their chemotherapy should be temporarily suspended or reduced in intensity..

Dr. He and colleagues noted that, by following these recommendations for infection prevention, they had no cases of COVID-19 among children in their hematology/oncology departments. However, the authors said the recommendations “could fail to some extent” based on “differences in medical resources, health care settings, and the policy of the specific government.”

The authors said their recommendations should be updated continuously as new information and clinical evidence emerges.

Dr. He and colleagues reported having no conflicts of interest.

sworcester@mdedge.com

SOURCE: He Y et al. Lancet Haematol. doi: 10/1016/s2352-3026(20)30104-6.

Given the possibility that children with hematologic malignancies may have increased susceptibility to coronavirus disease 2019 (COVID-19), clinicians from China and the United States have proposed a plan for preventing and managing outbreaks in hospitals’ pediatric hematology and oncology departments.

The plan is focused primarily on infection prevention and control strategies, Yulei He, MD, of Chengdu (China) Women’s and Children’s Central Hospital and colleagues explained in an article published in The Lancet Haematology.

The authors noted that close contact with COVID-19 patients is thought to be the main route of transmission, and a retrospective study indicated that 41.3% of initial COVID-19 cases were caused by hospital-related transmission.

“Children with hematological malignancies might have increased susceptibility to infection with SARS-CoV-2 because of immunodeficiency; therefore, procedures are needed to avoid hospital-related transmission and infection for these patients,” the authors wrote.
 

Preventing the spread of infection

Dr. He and colleagues advised that medical staff be kept up-to-date with the latest information about COVID-19 and perform assessments regularly to identify cases in their departments.

The authors also recommended establishing a COVID-19 expert committee – consisting of infectious disease physicians, hematologists, oncologists, radiologists, pharmacists, and hospital infection control staff – to make medical decisions in multidisciplinary consultation meetings. In addition, the authors recommended regional management strategies be adopted to minimize cross infection within the hospital. Specifically, the authors proposed creating the following four zones:

1. A surveillance and screening zone for patients potentially infected with SARS-CoV-2

2. A suspected-case quarantine zone where patients thought to have COVID-19 are isolated in single rooms

3. A confirmed-case quarantine zone where patients are treated for COVID-19

4. A hematology/oncology ward for treating non–COVID-19 patients with malignancies.

Dr. He and colleagues also stressed the importance of providing personal protective equipment for all zones, along with instructions for proper use and disposal. The authors recommended developing and following specific protocols for outpatient visits in the hematology/oncology ward, and providing COVID-19 prevention and control information to families and health care workers.
 

Managing cancer treatment

For patients with acute leukemias who have induction chemotherapy planned, Dr. He and colleagues argued that scheduled chemotherapy should not be interrupted unless COVID-19 is suspected or diagnosed. The authors said treatment should not be delayed more than 7 days during induction, consolidation, or the intermediate phase of chemotherapy because the virus has an incubation period of 2-7 days. This will allow a short period of observation to screen for potential infection.

The authors recommended that patients with lymphoma and solid tumors first undergo COVID-19 screening and then receive treatment in hematology/oncology wards “according to their chemotherapy schedule, and without delay, until they are in complete remission.”

“If the patient is in complete remission, we recommend a treatment delay of no more than 7 days to allow a short period of observation to screen for COVID-19,” the authors added.

Maintenance chemotherapy should not be delayed for more than 14 days, Dr. He and colleagues wrote. “This increase in the maximum delay before chemotherapy strikes a balance between the potential risk of SARS-CoV-2 infection and tumor recurrence, since pediatric patients in this phase of treatment have a reduced risk of tumor recurrence,” the authors added.
 

Caring for patients with COVID-19

For inpatients diagnosed with COVID-19, Dr. He and colleagues recommended the following:

• Prioritize COVID-19 treatment for children with primary disease remission.
• For children not in remission, prioritize treatment for critical patients.
• Isolated patients should be treated for COVID-19, and their chemotherapy should be temporarily suspended or reduced in intensity..

Dr. He and colleagues noted that, by following these recommendations for infection prevention, they had no cases of COVID-19 among children in their hematology/oncology departments. However, the authors said the recommendations “could fail to some extent” based on “differences in medical resources, health care settings, and the policy of the specific government.”

The authors said their recommendations should be updated continuously as new information and clinical evidence emerges.

Dr. He and colleagues reported having no conflicts of interest.

sworcester@mdedge.com

SOURCE: He Y et al. Lancet Haematol. doi: 10/1016/s2352-3026(20)30104-6.

Given the possibility that children with hematologic malignancies may have increased susceptibility to coronavirus disease 2019 (COVID-19), clinicians from China and the United States have proposed a plan for preventing and managing outbreaks in hospitals’ pediatric hematology and oncology departments.

The plan is focused primarily on infection prevention and control strategies, Yulei He, MD, of Chengdu (China) Women’s and Children’s Central Hospital and colleagues explained in an article published in The Lancet Haematology.

The authors noted that close contact with COVID-19 patients is thought to be the main route of transmission, and a retrospective study indicated that 41.3% of initial COVID-19 cases were caused by hospital-related transmission.

“Children with hematological malignancies might have increased susceptibility to infection with SARS-CoV-2 because of immunodeficiency; therefore, procedures are needed to avoid hospital-related transmission and infection for these patients,” the authors wrote.
 

Preventing the spread of infection

Dr. He and colleagues advised that medical staff be kept up-to-date with the latest information about COVID-19 and perform assessments regularly to identify cases in their departments.

The authors also recommended establishing a COVID-19 expert committee – consisting of infectious disease physicians, hematologists, oncologists, radiologists, pharmacists, and hospital infection control staff – to make medical decisions in multidisciplinary consultation meetings. In addition, the authors recommended regional management strategies be adopted to minimize cross infection within the hospital. Specifically, the authors proposed creating the following four zones:

1. A surveillance and screening zone for patients potentially infected with SARS-CoV-2

2. A suspected-case quarantine zone where patients thought to have COVID-19 are isolated in single rooms

3. A confirmed-case quarantine zone where patients are treated for COVID-19

4. A hematology/oncology ward for treating non–COVID-19 patients with malignancies.

Dr. He and colleagues also stressed the importance of providing personal protective equipment for all zones, along with instructions for proper use and disposal. The authors recommended developing and following specific protocols for outpatient visits in the hematology/oncology ward, and providing COVID-19 prevention and control information to families and health care workers.
 

Managing cancer treatment

For patients with acute leukemias who have induction chemotherapy planned, Dr. He and colleagues argued that scheduled chemotherapy should not be interrupted unless COVID-19 is suspected or diagnosed. The authors said treatment should not be delayed more than 7 days during induction, consolidation, or the intermediate phase of chemotherapy because the virus has an incubation period of 2-7 days. This will allow a short period of observation to screen for potential infection.

The authors recommended that patients with lymphoma and solid tumors first undergo COVID-19 screening and then receive treatment in hematology/oncology wards “according to their chemotherapy schedule, and without delay, until they are in complete remission.”

“If the patient is in complete remission, we recommend a treatment delay of no more than 7 days to allow a short period of observation to screen for COVID-19,” the authors added.

Maintenance chemotherapy should not be delayed for more than 14 days, Dr. He and colleagues wrote. “This increase in the maximum delay before chemotherapy strikes a balance between the potential risk of SARS-CoV-2 infection and tumor recurrence, since pediatric patients in this phase of treatment have a reduced risk of tumor recurrence,” the authors added.
 

Caring for patients with COVID-19

For inpatients diagnosed with COVID-19, Dr. He and colleagues recommended the following:

• Prioritize COVID-19 treatment for children with primary disease remission.
• For children not in remission, prioritize treatment for critical patients.
• Isolated patients should be treated for COVID-19, and their chemotherapy should be temporarily suspended or reduced in intensity..

Dr. He and colleagues noted that, by following these recommendations for infection prevention, they had no cases of COVID-19 among children in their hematology/oncology departments. However, the authors said the recommendations “could fail to some extent” based on “differences in medical resources, health care settings, and the policy of the specific government.”

The authors said their recommendations should be updated continuously as new information and clinical evidence emerges.

Dr. He and colleagues reported having no conflicts of interest.

sworcester@mdedge.com

SOURCE: He Y et al. Lancet Haematol. doi: 10/1016/s2352-3026(20)30104-6.

Background

As of April 2020, the United States is faced with the early stages of the coronavirus disease 2019 (COVID-19) pandemic. Experts predict up to 60% of the population will become infected with a fatality rate of 1% and a hospitalization rate of approximately 20%. Efforts to suppress viral spread have been unsuccessful as cases are reported in all 50 states, and fatalities are rising. Currently many American hospitals are ill-prepared for a significant increase in their census of critically ill and contagious patients, i.e., hospitals lack adequate surge capacity to safely handle a nationwide outbreak of COVID-19. As seen in other nations such as Italy, China, and Iran, this leads to rationing of life-saving health care and potentially preventable morbidity and mortality.

Introduction

Hospitals will be unable to provide the current standard of care to patients as the rate of infection with coronavirus disease 2019 (COVID-19) escalates. As of April 9, the World Health Organization has confirmed 1,539,118 cases and 89,998 deaths globally; and the Centers for Disease Control and Prevention has confirmed 435,941 cases and 14,865 deaths in the United States.^1,2 Experts predict up to 60% of the population will eventually become infected with a fatality rate of about 1% and a hospitalization rate of approximately 20%.^3,4

In the United States, with a population of 300 million people, this represents up to 180 million infected, 36 million requiring hospitalization, 11 million requiring intensive care, and 2 million fatalities over the duration of the pandemic. On March 13, President Donald Trump declared a state of national emergency, authorizing $50 billion dollars in emergency health care spending as well as asking every hospital in the country to immediately activate its emergency response plan. The use of isolation and quarantine may space out casualties over time, however high rates and volumes of hospitalizations are still expected.^4,5

As the influx of patients afflicted with COVID-19 grows, needs will outstrip hospital resources forcing clinicians to ration beds and supplies. In Italy, China, and Iran, physicians are already faced with these difficult decisions. Antonio Pesenti, head of the Italian Lombardy regional crisis response unit, characterized the change in health care delivery: “We’re now being forced to set up intensive care treatment in corridors, in operating theaters, in recovery rooms. We’ve emptied entire hospital sections to make space for seriously sick people.”⁶
 

Surge capacity

Surge capacity is a hospital’s ability to adequately care for a significant influx of patients.⁷ Since 2011, the American College of Emergency Physicians has published guidelines calling for hospitals to have a surge capacity accounting for infectious disease outbreaks, and demands on supplies, personnel, and physical space.⁷ Even prior to the development of COVID-19, many hospitals faced emergency department crowding and strains on hospital capacity.⁸ The Organization for Economic Co-operation and Development (OECD) estimates hospital beds per 1,000 inhabitants at 2.77 for the USA, 3.18 for Italy, 4.34 for China, and 13.05 for Japan.⁹ Before COVID-19 many American hospitals had an insufficient number of beds. Now, in the initial phase of the pandemic, it is even more important to optimize surge capacity across the American health care system.

Requirements for COVID-19 preparation

To prepare for the increased number of seriously and critically ill patients, individual hospitals and regions must perform a needs assessment. The fundamental disease process of COVID-19 is a contagious viral pneumonia; treatment hinges on four major categories of intervention: spatial isolation (including physical space, beds, partitions, droplet precautions, food, water, and sanitation), oxygenation (including wall and portable oxygen, nasal canulae, and masks), mechanical ventilation (including ventilator machines, tubing, anesthetics, and reliable electrical power) and personnel (including physicians, nurses, technicians, and adequate personal protective equipment).¹⁰ In special circumstances and where available, extra corporeal membrane oxygenation may be considered.¹⁰ The necessary interventions are summarized in Table 1.

Emergency, critical care, nursing, and medical leadership should consider what sort of space, personnel, and supplies will be needed to care for a large volume of patients with contagious viral pneumonia at the same time as other hospital patients. Attention should also be given to potential need for morgue expansion. Hospitals must be proactive in procuring supplies and preparing for demands on beds and physical space. Specifically, logistics coordinators should start stockpiling ventilators, oxygen, respiratory equipment, and personal protective equipment. Reallocating supplies from other regions of the hospital such as operating rooms and ambulatory surgery centers may be considered. These resources, particularly ventilators and ventilator supplies, are already in disturbingly limited supply, and they are likely to be single most important limiting factor for survival rates. To prevent regional shortages, stockpiling efforts should ideally be aided by state and federal governments. The production and acquisition of ventilators should be immediately and significantly increased.

Hospitals must additionally prepare for demands for physical space and beds. Techniques to maximize space and bed availability (see Table 2) include discharging patients who do not require hospitalization, and canceling elective procedures and admissions. Additional methods would be to utilize unconventional preexisting spaces such as hallways, operating rooms, recovery rooms, hallways, closed hospital wards, basements, lobbies, cafeterias, and parking lots. Administrators should also consider establishing field hospitals or field wards, such as tents in open spaces and nearby roads. Medical care performed in unconventional environments will need to account for electricity, temperature control, oxygen delivery, and sanitation.

Conclusion

To minimize unnecessary loss of life and suffering, hospitals must expand their surge capacities in preparation for the predictable rise in demand for health care resources related to COVID-19. Numerous hospitals, particularly those that serve low-income and underserved communities, operate with a narrow financial margin.¹¹ Independently preparing for the surge capacity needed to face COVID-19 may be infeasible for several hospitals. As a result, many health care systems will rely on government aid during this period for financial and material support. To maximize preparedness and response, hospitals should ask for and receive aid from the Federal Emergency Management Agency (FEMA), American Red Cross, state governments, and the military; these resources should be mobilized now.

Dr. Blumenberg, Dr. Noble, and Dr. Hendrickson are based in the department of emergency medicine & toxicology, Oregon Health and Science University, Portland.

References

1. Coronavirus disease 2019 (COVID-19) situation report – 60. 2020 Mar 19.

2. Coronavirus disease 2019 (COVID-19) Cases in the U.S. CDC. 2020 Apr 8.

3. Li Q et al. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020 Jan. doi: 10.1056/NEJMoa2001316.

4. Anderson RM et al. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020 Mar. doi: 10.1016/S0140-6736(20)30567-5.

5. Fraser C et al. Factors that make an infectious disease outbreak controllable. Proc Natl Acad Sci U S A. 2004;101(16):6146-51. doi: 10.1073/pnas.0307506101.

6. Mackenzie J and Balmer C. Italy locks down millions as its coronavirus deaths jump. Reuters. 2020 Mar 9.

7. Health care system surge capacity recognition, preparedness, and response. Ann Emerg Med. 2012;59(3):240-1. doi: 10.1016/j.annemergmed.2011.11.030.

8. Pitts SR et al. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21(5):497-503. doi: 10.1111/acem.12375.

9. Health at a Glance 2019. OECD; 2019. doi: 10.1787/4dd50c09-en.

10. Murthy S et al. Care for critically ill patients with COVID-19. JAMA. 2020 Mar. doi: 10.1001/jama.2020.3633.

11. Ly DP et al. The association between hospital margins, quality of care, and closure or other change in operating status. J Gen Intern Med. 2011;26(11):1291-6. doi: 10.1007/s11606-011-1815-5.

Background

As of April 2020, the United States is faced with the early stages of the coronavirus disease 2019 (COVID-19) pandemic. Experts predict up to 60% of the population will become infected with a fatality rate of 1% and a hospitalization rate of approximately 20%. Efforts to suppress viral spread have been unsuccessful as cases are reported in all 50 states, and fatalities are rising. Currently many American hospitals are ill-prepared for a significant increase in their census of critically ill and contagious patients, i.e., hospitals lack adequate surge capacity to safely handle a nationwide outbreak of COVID-19. As seen in other nations such as Italy, China, and Iran, this leads to rationing of life-saving health care and potentially preventable morbidity and mortality.

Introduction

Hospitals will be unable to provide the current standard of care to patients as the rate of infection with coronavirus disease 2019 (COVID-19) escalates. As of April 9, the World Health Organization has confirmed 1,539,118 cases and 89,998 deaths globally; and the Centers for Disease Control and Prevention has confirmed 435,941 cases and 14,865 deaths in the United States.^1,2 Experts predict up to 60% of the population will eventually become infected with a fatality rate of about 1% and a hospitalization rate of approximately 20%.^3,4

In the United States, with a population of 300 million people, this represents up to 180 million infected, 36 million requiring hospitalization, 11 million requiring intensive care, and 2 million fatalities over the duration of the pandemic. On March 13, President Donald Trump declared a state of national emergency, authorizing $50 billion dollars in emergency health care spending as well as asking every hospital in the country to immediately activate its emergency response plan. The use of isolation and quarantine may space out casualties over time, however high rates and volumes of hospitalizations are still expected.^4,5

As the influx of patients afflicted with COVID-19 grows, needs will outstrip hospital resources forcing clinicians to ration beds and supplies. In Italy, China, and Iran, physicians are already faced with these difficult decisions. Antonio Pesenti, head of the Italian Lombardy regional crisis response unit, characterized the change in health care delivery: “We’re now being forced to set up intensive care treatment in corridors, in operating theaters, in recovery rooms. We’ve emptied entire hospital sections to make space for seriously sick people.”⁶
 

Surge capacity

Surge capacity is a hospital’s ability to adequately care for a significant influx of patients.⁷ Since 2011, the American College of Emergency Physicians has published guidelines calling for hospitals to have a surge capacity accounting for infectious disease outbreaks, and demands on supplies, personnel, and physical space.⁷ Even prior to the development of COVID-19, many hospitals faced emergency department crowding and strains on hospital capacity.⁸ The Organization for Economic Co-operation and Development (OECD) estimates hospital beds per 1,000 inhabitants at 2.77 for the USA, 3.18 for Italy, 4.34 for China, and 13.05 for Japan.⁹ Before COVID-19 many American hospitals had an insufficient number of beds. Now, in the initial phase of the pandemic, it is even more important to optimize surge capacity across the American health care system.

Requirements for COVID-19 preparation

To prepare for the increased number of seriously and critically ill patients, individual hospitals and regions must perform a needs assessment. The fundamental disease process of COVID-19 is a contagious viral pneumonia; treatment hinges on four major categories of intervention: spatial isolation (including physical space, beds, partitions, droplet precautions, food, water, and sanitation), oxygenation (including wall and portable oxygen, nasal canulae, and masks), mechanical ventilation (including ventilator machines, tubing, anesthetics, and reliable electrical power) and personnel (including physicians, nurses, technicians, and adequate personal protective equipment).¹⁰ In special circumstances and where available, extra corporeal membrane oxygenation may be considered.¹⁰ The necessary interventions are summarized in Table 1.

Emergency, critical care, nursing, and medical leadership should consider what sort of space, personnel, and supplies will be needed to care for a large volume of patients with contagious viral pneumonia at the same time as other hospital patients. Attention should also be given to potential need for morgue expansion. Hospitals must be proactive in procuring supplies and preparing for demands on beds and physical space. Specifically, logistics coordinators should start stockpiling ventilators, oxygen, respiratory equipment, and personal protective equipment. Reallocating supplies from other regions of the hospital such as operating rooms and ambulatory surgery centers may be considered. These resources, particularly ventilators and ventilator supplies, are already in disturbingly limited supply, and they are likely to be single most important limiting factor for survival rates. To prevent regional shortages, stockpiling efforts should ideally be aided by state and federal governments. The production and acquisition of ventilators should be immediately and significantly increased.

Hospitals must additionally prepare for demands for physical space and beds. Techniques to maximize space and bed availability (see Table 2) include discharging patients who do not require hospitalization, and canceling elective procedures and admissions. Additional methods would be to utilize unconventional preexisting spaces such as hallways, operating rooms, recovery rooms, hallways, closed hospital wards, basements, lobbies, cafeterias, and parking lots. Administrators should also consider establishing field hospitals or field wards, such as tents in open spaces and nearby roads. Medical care performed in unconventional environments will need to account for electricity, temperature control, oxygen delivery, and sanitation.

Conclusion

To minimize unnecessary loss of life and suffering, hospitals must expand their surge capacities in preparation for the predictable rise in demand for health care resources related to COVID-19. Numerous hospitals, particularly those that serve low-income and underserved communities, operate with a narrow financial margin.¹¹ Independently preparing for the surge capacity needed to face COVID-19 may be infeasible for several hospitals. As a result, many health care systems will rely on government aid during this period for financial and material support. To maximize preparedness and response, hospitals should ask for and receive aid from the Federal Emergency Management Agency (FEMA), American Red Cross, state governments, and the military; these resources should be mobilized now.

Dr. Blumenberg, Dr. Noble, and Dr. Hendrickson are based in the department of emergency medicine & toxicology, Oregon Health and Science University, Portland.

References

1. Coronavirus disease 2019 (COVID-19) situation report – 60. 2020 Mar 19.

2. Coronavirus disease 2019 (COVID-19) Cases in the U.S. CDC. 2020 Apr 8.

3. Li Q et al. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020 Jan. doi: 10.1056/NEJMoa2001316.

4. Anderson RM et al. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020 Mar. doi: 10.1016/S0140-6736(20)30567-5.

5. Fraser C et al. Factors that make an infectious disease outbreak controllable. Proc Natl Acad Sci U S A. 2004;101(16):6146-51. doi: 10.1073/pnas.0307506101.

6. Mackenzie J and Balmer C. Italy locks down millions as its coronavirus deaths jump. Reuters. 2020 Mar 9.

7. Health care system surge capacity recognition, preparedness, and response. Ann Emerg Med. 2012;59(3):240-1. doi: 10.1016/j.annemergmed.2011.11.030.

8. Pitts SR et al. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21(5):497-503. doi: 10.1111/acem.12375.

9. Health at a Glance 2019. OECD; 2019. doi: 10.1787/4dd50c09-en.

10. Murthy S et al. Care for critically ill patients with COVID-19. JAMA. 2020 Mar. doi: 10.1001/jama.2020.3633.

11. Ly DP et al. The association between hospital margins, quality of care, and closure or other change in operating status. J Gen Intern Med. 2011;26(11):1291-6. doi: 10.1007/s11606-011-1815-5.

Background

As of April 2020, the United States is faced with the early stages of the coronavirus disease 2019 (COVID-19) pandemic. Experts predict up to 60% of the population will become infected with a fatality rate of 1% and a hospitalization rate of approximately 20%. Efforts to suppress viral spread have been unsuccessful as cases are reported in all 50 states, and fatalities are rising. Currently many American hospitals are ill-prepared for a significant increase in their census of critically ill and contagious patients, i.e., hospitals lack adequate surge capacity to safely handle a nationwide outbreak of COVID-19. As seen in other nations such as Italy, China, and Iran, this leads to rationing of life-saving health care and potentially preventable morbidity and mortality.

Introduction

Hospitals will be unable to provide the current standard of care to patients as the rate of infection with coronavirus disease 2019 (COVID-19) escalates. As of April 9, the World Health Organization has confirmed 1,539,118 cases and 89,998 deaths globally; and the Centers for Disease Control and Prevention has confirmed 435,941 cases and 14,865 deaths in the United States.^1,2 Experts predict up to 60% of the population will eventually become infected with a fatality rate of about 1% and a hospitalization rate of approximately 20%.^3,4

In the United States, with a population of 300 million people, this represents up to 180 million infected, 36 million requiring hospitalization, 11 million requiring intensive care, and 2 million fatalities over the duration of the pandemic. On March 13, President Donald Trump declared a state of national emergency, authorizing $50 billion dollars in emergency health care spending as well as asking every hospital in the country to immediately activate its emergency response plan. The use of isolation and quarantine may space out casualties over time, however high rates and volumes of hospitalizations are still expected.^4,5

As the influx of patients afflicted with COVID-19 grows, needs will outstrip hospital resources forcing clinicians to ration beds and supplies. In Italy, China, and Iran, physicians are already faced with these difficult decisions. Antonio Pesenti, head of the Italian Lombardy regional crisis response unit, characterized the change in health care delivery: “We’re now being forced to set up intensive care treatment in corridors, in operating theaters, in recovery rooms. We’ve emptied entire hospital sections to make space for seriously sick people.”⁶
 

Surge capacity

Surge capacity is a hospital’s ability to adequately care for a significant influx of patients.⁷ Since 2011, the American College of Emergency Physicians has published guidelines calling for hospitals to have a surge capacity accounting for infectious disease outbreaks, and demands on supplies, personnel, and physical space.⁷ Even prior to the development of COVID-19, many hospitals faced emergency department crowding and strains on hospital capacity.⁸ The Organization for Economic Co-operation and Development (OECD) estimates hospital beds per 1,000 inhabitants at 2.77 for the USA, 3.18 for Italy, 4.34 for China, and 13.05 for Japan.⁹ Before COVID-19 many American hospitals had an insufficient number of beds. Now, in the initial phase of the pandemic, it is even more important to optimize surge capacity across the American health care system.

Requirements for COVID-19 preparation

To prepare for the increased number of seriously and critically ill patients, individual hospitals and regions must perform a needs assessment. The fundamental disease process of COVID-19 is a contagious viral pneumonia; treatment hinges on four major categories of intervention: spatial isolation (including physical space, beds, partitions, droplet precautions, food, water, and sanitation), oxygenation (including wall and portable oxygen, nasal canulae, and masks), mechanical ventilation (including ventilator machines, tubing, anesthetics, and reliable electrical power) and personnel (including physicians, nurses, technicians, and adequate personal protective equipment).¹⁰ In special circumstances and where available, extra corporeal membrane oxygenation may be considered.¹⁰ The necessary interventions are summarized in Table 1.

Emergency, critical care, nursing, and medical leadership should consider what sort of space, personnel, and supplies will be needed to care for a large volume of patients with contagious viral pneumonia at the same time as other hospital patients. Attention should also be given to potential need for morgue expansion. Hospitals must be proactive in procuring supplies and preparing for demands on beds and physical space. Specifically, logistics coordinators should start stockpiling ventilators, oxygen, respiratory equipment, and personal protective equipment. Reallocating supplies from other regions of the hospital such as operating rooms and ambulatory surgery centers may be considered. These resources, particularly ventilators and ventilator supplies, are already in disturbingly limited supply, and they are likely to be single most important limiting factor for survival rates. To prevent regional shortages, stockpiling efforts should ideally be aided by state and federal governments. The production and acquisition of ventilators should be immediately and significantly increased.

Hospitals must additionally prepare for demands for physical space and beds. Techniques to maximize space and bed availability (see Table 2) include discharging patients who do not require hospitalization, and canceling elective procedures and admissions. Additional methods would be to utilize unconventional preexisting spaces such as hallways, operating rooms, recovery rooms, hallways, closed hospital wards, basements, lobbies, cafeterias, and parking lots. Administrators should also consider establishing field hospitals or field wards, such as tents in open spaces and nearby roads. Medical care performed in unconventional environments will need to account for electricity, temperature control, oxygen delivery, and sanitation.

Conclusion

To minimize unnecessary loss of life and suffering, hospitals must expand their surge capacities in preparation for the predictable rise in demand for health care resources related to COVID-19. Numerous hospitals, particularly those that serve low-income and underserved communities, operate with a narrow financial margin.¹¹ Independently preparing for the surge capacity needed to face COVID-19 may be infeasible for several hospitals. As a result, many health care systems will rely on government aid during this period for financial and material support. To maximize preparedness and response, hospitals should ask for and receive aid from the Federal Emergency Management Agency (FEMA), American Red Cross, state governments, and the military; these resources should be mobilized now.

Dr. Blumenberg, Dr. Noble, and Dr. Hendrickson are based in the department of emergency medicine & toxicology, Oregon Health and Science University, Portland.

References

1. Coronavirus disease 2019 (COVID-19) situation report – 60. 2020 Mar 19.

2. Coronavirus disease 2019 (COVID-19) Cases in the U.S. CDC. 2020 Apr 8.

3. Li Q et al. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020 Jan. doi: 10.1056/NEJMoa2001316.

4. Anderson RM et al. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020 Mar. doi: 10.1016/S0140-6736(20)30567-5.

5. Fraser C et al. Factors that make an infectious disease outbreak controllable. Proc Natl Acad Sci U S A. 2004;101(16):6146-51. doi: 10.1073/pnas.0307506101.

6. Mackenzie J and Balmer C. Italy locks down millions as its coronavirus deaths jump. Reuters. 2020 Mar 9.

7. Health care system surge capacity recognition, preparedness, and response. Ann Emerg Med. 2012;59(3):240-1. doi: 10.1016/j.annemergmed.2011.11.030.

8. Pitts SR et al. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21(5):497-503. doi: 10.1111/acem.12375.

9. Health at a Glance 2019. OECD; 2019. doi: 10.1787/4dd50c09-en.

10. Murthy S et al. Care for critically ill patients with COVID-19. JAMA. 2020 Mar. doi: 10.1001/jama.2020.3633.

11. Ly DP et al. The association between hospital margins, quality of care, and closure or other change in operating status. J Gen Intern Med. 2011;26(11):1291-6. doi: 10.1007/s11606-011-1815-5.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

A woman presented to the emergency department with high liver enzyme levels and dark urine. She developed fever on day 2 of care, and then tested positive for the new coronavirus, researchers at Northwell Health, in Hempstead, New York, report.

The authors say the case, published online in the American Journal of Gastroenterology, is the first documented instance of a patient with COVID-19 presenting with acute hepatitis as the primary symptom before developing respiratory symptoms.

Prior data show that the most common early indications of COVID-19 are respiratory symptoms with fever, shortness of breath, sore throat, and cough, and with imaging results consistent with pneumonia. However, liver enzyme abnormalities are not uncommon in the disease course.

“In patients who are now presenting with acute hepatitis, people need to think of COVID,” senior author David Bernstein, MD, chief of the Division of Hepatology at Northwell Health, told Medscape Medical News.

In addition to Bernstein, Praneet Wander, MD, also in Northwell’s hepatology division, and Marcia Epstein, MD, with Northwell’s Department of Infectious Disease, authored the case report.

Bernstein said Northwell currently has the largest number of COVID-19 cases in the nation and that many patients are presenting with abnormal liver test results and COVID-19 symptoms.

He said that anecdotally, colleagues elsewhere in the United States are also reporting the connection.

“It seems to be that the liver enzyme elevations are part and parcel of this disease,” he said.

Case Details

According to the case report, the 59-year-old woman, who lives alone, came to the emergency department with a chief complaint of dark urine. She was given a face mask and was isolated, per protocol.

“She denied cough, sore throat, shortness of breath, diarrhea, nausea, vomiting or abdominal pain,” the authors wrote. She denied having been in contact with someone who was sick.

She had well-controlled HIV, and recent outpatient liver test results were normal. Eighteen hours after she came to the ED, she was admitted, owing to concern regarding rising liver enzyme levels in conjunction with her being HIV positive.

On presentation, her temperature was 98.9° F. There were no skin indications, lungs were normal, and “there was no jaundice, right upper quadrant tenderness, hepatomegaly or splenomegaly.”

Liver enzyme levels were as follows: aspartate aminotransferase (AST), 1230 (IU/L); alanine aminotransferase (ALT), 697 IU/L (normal for both is < 50 IU/L); alkaline phosphatase, 141 IU/L (normal, < 125 IU/L).

The patient tested negative for hepatitis A, B, C, E, cytomegalovirus, and Epstein-Barr virus. A respiratory viral panel and autoimmune markers were normal.
 

Fever Appeared on Day 2

She was admitted, and 18 hours after she came to the ED, she developed a fever of 102.2° F. A chest x-ray showed interstitial opacities in both lungs.

Nasopharyngeal samples were taken, and polymerase chain reaction test results were positive for the novel coronavirus. The patient was placed on 3 L of oxygen.

On post admission day 4, a 5-day course of hydroxychloroquine (200 mg twice a day) was initiated.

The patient was discharged to home on hospital day 8. The serum bilirubin level was 0.6 mg/dL; AST, 114 IU/L; ALT, 227 IU/L; and alkaline phosphatase, 259 IU/L.

According to Bernstein, it’s hard to tell in what order COVID-19 symptoms occur because people are staying home with other complaints. They may only present to the emergency department after they develop more typical COVID-19 symptoms, such as shortness of breath.

In this case, the patient noticed a darkening of her urine, “but if she had come the next day, she would have had fever. I think we just happened to catch it early,” Bernstein said.

He added that he saw no connection between the underlying HIV and her liver abnormalities or COVID-19 diagnosis.

Bernstein notes that most COVID-19 patients are not admitted, and he said he worries that a COVID-19 test might not be on the radar of providers in the outpatient setting when a patient presents with elevated liver enzymes levels.

If elevated liver enzyme levels can predict disease course, the information could alter how and where the disease is treated, Bernstein said.

“This is a first report. We’re really right now in the beginning of learning,” he said.

This article first appeared on Medscape.com.

A woman presented to the emergency department with high liver enzyme levels and dark urine. She developed fever on day 2 of care, and then tested positive for the new coronavirus, researchers at Northwell Health, in Hempstead, New York, report.

The authors say the case, published online in the American Journal of Gastroenterology, is the first documented instance of a patient with COVID-19 presenting with acute hepatitis as the primary symptom before developing respiratory symptoms.

Prior data show that the most common early indications of COVID-19 are respiratory symptoms with fever, shortness of breath, sore throat, and cough, and with imaging results consistent with pneumonia. However, liver enzyme abnormalities are not uncommon in the disease course.

“In patients who are now presenting with acute hepatitis, people need to think of COVID,” senior author David Bernstein, MD, chief of the Division of Hepatology at Northwell Health, told Medscape Medical News.

In addition to Bernstein, Praneet Wander, MD, also in Northwell’s hepatology division, and Marcia Epstein, MD, with Northwell’s Department of Infectious Disease, authored the case report.

Bernstein said Northwell currently has the largest number of COVID-19 cases in the nation and that many patients are presenting with abnormal liver test results and COVID-19 symptoms.

He said that anecdotally, colleagues elsewhere in the United States are also reporting the connection.

“It seems to be that the liver enzyme elevations are part and parcel of this disease,” he said.

Case Details

According to the case report, the 59-year-old woman, who lives alone, came to the emergency department with a chief complaint of dark urine. She was given a face mask and was isolated, per protocol.

“She denied cough, sore throat, shortness of breath, diarrhea, nausea, vomiting or abdominal pain,” the authors wrote. She denied having been in contact with someone who was sick.

She had well-controlled HIV, and recent outpatient liver test results were normal. Eighteen hours after she came to the ED, she was admitted, owing to concern regarding rising liver enzyme levels in conjunction with her being HIV positive.

On presentation, her temperature was 98.9° F. There were no skin indications, lungs were normal, and “there was no jaundice, right upper quadrant tenderness, hepatomegaly or splenomegaly.”

Liver enzyme levels were as follows: aspartate aminotransferase (AST), 1230 (IU/L); alanine aminotransferase (ALT), 697 IU/L (normal for both is < 50 IU/L); alkaline phosphatase, 141 IU/L (normal, < 125 IU/L).

The patient tested negative for hepatitis A, B, C, E, cytomegalovirus, and Epstein-Barr virus. A respiratory viral panel and autoimmune markers were normal.
 

Fever Appeared on Day 2

She was admitted, and 18 hours after she came to the ED, she developed a fever of 102.2° F. A chest x-ray showed interstitial opacities in both lungs.

Nasopharyngeal samples were taken, and polymerase chain reaction test results were positive for the novel coronavirus. The patient was placed on 3 L of oxygen.

On post admission day 4, a 5-day course of hydroxychloroquine (200 mg twice a day) was initiated.

The patient was discharged to home on hospital day 8. The serum bilirubin level was 0.6 mg/dL; AST, 114 IU/L; ALT, 227 IU/L; and alkaline phosphatase, 259 IU/L.

According to Bernstein, it’s hard to tell in what order COVID-19 symptoms occur because people are staying home with other complaints. They may only present to the emergency department after they develop more typical COVID-19 symptoms, such as shortness of breath.

In this case, the patient noticed a darkening of her urine, “but if she had come the next day, she would have had fever. I think we just happened to catch it early,” Bernstein said.

He added that he saw no connection between the underlying HIV and her liver abnormalities or COVID-19 diagnosis.

Bernstein notes that most COVID-19 patients are not admitted, and he said he worries that a COVID-19 test might not be on the radar of providers in the outpatient setting when a patient presents with elevated liver enzymes levels.

If elevated liver enzyme levels can predict disease course, the information could alter how and where the disease is treated, Bernstein said.

“This is a first report. We’re really right now in the beginning of learning,” he said.

This article first appeared on Medscape.com.

A woman presented to the emergency department with high liver enzyme levels and dark urine. She developed fever on day 2 of care, and then tested positive for the new coronavirus, researchers at Northwell Health, in Hempstead, New York, report.

The authors say the case, published online in the American Journal of Gastroenterology, is the first documented instance of a patient with COVID-19 presenting with acute hepatitis as the primary symptom before developing respiratory symptoms.

Prior data show that the most common early indications of COVID-19 are respiratory symptoms with fever, shortness of breath, sore throat, and cough, and with imaging results consistent with pneumonia. However, liver enzyme abnormalities are not uncommon in the disease course.

“In patients who are now presenting with acute hepatitis, people need to think of COVID,” senior author David Bernstein, MD, chief of the Division of Hepatology at Northwell Health, told Medscape Medical News.

In addition to Bernstein, Praneet Wander, MD, also in Northwell’s hepatology division, and Marcia Epstein, MD, with Northwell’s Department of Infectious Disease, authored the case report.

Bernstein said Northwell currently has the largest number of COVID-19 cases in the nation and that many patients are presenting with abnormal liver test results and COVID-19 symptoms.

He said that anecdotally, colleagues elsewhere in the United States are also reporting the connection.

“It seems to be that the liver enzyme elevations are part and parcel of this disease,” he said.

Case Details

According to the case report, the 59-year-old woman, who lives alone, came to the emergency department with a chief complaint of dark urine. She was given a face mask and was isolated, per protocol.

“She denied cough, sore throat, shortness of breath, diarrhea, nausea, vomiting or abdominal pain,” the authors wrote. She denied having been in contact with someone who was sick.

She had well-controlled HIV, and recent outpatient liver test results were normal. Eighteen hours after she came to the ED, she was admitted, owing to concern regarding rising liver enzyme levels in conjunction with her being HIV positive.

On presentation, her temperature was 98.9° F. There were no skin indications, lungs were normal, and “there was no jaundice, right upper quadrant tenderness, hepatomegaly or splenomegaly.”

Liver enzyme levels were as follows: aspartate aminotransferase (AST), 1230 (IU/L); alanine aminotransferase (ALT), 697 IU/L (normal for both is < 50 IU/L); alkaline phosphatase, 141 IU/L (normal, < 125 IU/L).

The patient tested negative for hepatitis A, B, C, E, cytomegalovirus, and Epstein-Barr virus. A respiratory viral panel and autoimmune markers were normal.
 

Fever Appeared on Day 2

She was admitted, and 18 hours after she came to the ED, she developed a fever of 102.2° F. A chest x-ray showed interstitial opacities in both lungs.

Nasopharyngeal samples were taken, and polymerase chain reaction test results were positive for the novel coronavirus. The patient was placed on 3 L of oxygen.

On post admission day 4, a 5-day course of hydroxychloroquine (200 mg twice a day) was initiated.

The patient was discharged to home on hospital day 8. The serum bilirubin level was 0.6 mg/dL; AST, 114 IU/L; ALT, 227 IU/L; and alkaline phosphatase, 259 IU/L.

According to Bernstein, it’s hard to tell in what order COVID-19 symptoms occur because people are staying home with other complaints. They may only present to the emergency department after they develop more typical COVID-19 symptoms, such as shortness of breath.

In this case, the patient noticed a darkening of her urine, “but if she had come the next day, she would have had fever. I think we just happened to catch it early,” Bernstein said.

He added that he saw no connection between the underlying HIV and her liver abnormalities or COVID-19 diagnosis.

Bernstein notes that most COVID-19 patients are not admitted, and he said he worries that a COVID-19 test might not be on the radar of providers in the outpatient setting when a patient presents with elevated liver enzymes levels.

If elevated liver enzyme levels can predict disease course, the information could alter how and where the disease is treated, Bernstein said.

“This is a first report. We’re really right now in the beginning of learning,” he said.

This article first appeared on Medscape.com.

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

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

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

GBS presentation

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

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

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

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

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

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

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

Different pattern from Zika

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

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

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

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

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

This article was first published on Medscape.com.

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

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

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

GBS presentation

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

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

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

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

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

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

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

Different pattern from Zika

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

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

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

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

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

This article was first published on Medscape.com.

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

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

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

GBS presentation

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

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

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

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

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

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

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

Different pattern from Zika

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

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

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

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

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

This article was first published on Medscape.com.

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

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

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

Dr. Espey is an obstetrician and gynecologist in New Mexico. She has no relevant financial disclosures. Dr. Espey is a member of the Ob.Gyn. News Editorial Advisory Board. Email her at obnews@mdedge.com.

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

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

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

Dr. Espey is an obstetrician and gynecologist in New Mexico. She has no relevant financial disclosures. Dr. Espey is a member of the Ob.Gyn. News Editorial Advisory Board. Email her at obnews@mdedge.com.

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

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

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

Dr. Espey is an obstetrician and gynecologist in New Mexico. She has no relevant financial disclosures. Dr. Espey is a member of the Ob.Gyn. News Editorial Advisory Board. Email her at obnews@mdedge.com.

Maternal preconception exposure to phthalates was associated with increased risk of preterm birth, according to a study of 420 births to subfertile couples over a 13-year period.

Previous studies have shown increased risk of preterm birth associated with prenatal exposure to phthalates, which are commonly found in a range of household and commercial products as well as medical equipment and some pharmaceuticals.

“Our results suggest that female exposure to [4 di(2-ethylhexyl) phthalate] DEHP before conception might be an unrecognized risk factor for adverse pregnancy outcomes, often overlooked in clinical practice,” wrote Yu Zhang of the department of environmental health at Harvard T.H. Chan School of Public Health, Boston, and colleagues.

The prospective cohort study evaluated preconception urinary levels of phthalates and phthalate substitutes in 419 women and 229 men participating in the Environment and Reproductive Health (EARTH) study, a cohort of couples seeking fertility care at the Massachusetts General Hospital Fertility Center. The study cohort gave birth during 2005-2018. The average gestational age of the 420 singleton children born to this cohort was 39 weeks, with 8% (n = 34) born preterm.

Adjusted models showed that maternal preconception urinary concentrations of phthalates and of cyclohexane-1, 2-dicarboxylic acid monohydroxy isononyl ester (MHiNCH), a metabolite of a nonphthalate plasticizer substitute, were associated with a 50% and 70% increased risk of preterm birth, respectively (P = .01, .11), according to results published in JAMA Network Open .

Sensitivity analysis showed that maternal preconception MHiNCH concentrations above the median were associated with a fourfold increased risk of preterm birth (risk ratio, 4.02; P = .08), Maternal preconception MHiNCH concentrations were associated with an average 2-day reduction in gestational age (P = .02).

Covariate-adjusted models found that paternal urinary phthalate metabolite concentrations were associated with an increased risk of preterm birth (RR, 1.41; P = .09), but this association was attenuated toward zero (RR, 1.06) in models that accounted for maternal preconception phthalate concentrations. Sensitivity analysis of 228 couples found the associations of maternal preconception phthalate metabolite concentrations and preterm birth remained robust in three different models: a twofold increased risk in covariate-adjusted models (P < .001); an almost fivefold increased risk in adjusting for prenatal levels (RR, 4.98; P < .001); and a twofold risk (P = .001) in adjusting for paternal levels. “Couple-based analyses confirmed the results for an association between maternal preconception DEHP concentrations and increased risk of preterm birth,” the investigators said.

“To our knowledge, this is the first study evaluating couples’ exposure to phthalate metabolites during the preconception window and its association with preterm birth,” the researchers wrote. “Our findings support a novel hypothesis: Maternal phthalate exposure during the critical period before conception may be associated with shorter gestation.”

“This study is consistent with several, but not all, prior studies supporting maternal prenatal exposure to phthalates increase preterm birth,” said Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida, Orlando. “The uniqueness of the current study was the assessment of couples’ exposures and the outcome, though paternal exposure to phthalates did not demonstrate a significant association.”

Dr. Trolice noted that about 25% of women in the study were smokers, but the study didn’t adjust for tobacco use and phthalate exposure, and 85% of the women were white. He urged caution in applying the study results in practice, adding that the study didn’t adjust for method of conception. “Assisted reproductive technology, multiple gestation, and advanced age are all known risk factors for preterm birth,”

The National Institute of Environmental Health Science funded the study. Two study coauthors received grants from the NIEHS, one coauthor received grants from the National Institutes of Health, and one received a grant from the Canadian Institutes of Health Research. No other disclosures were reported. Dr. Trolice has no financial relationships to disclose.

SOURCE: Zhang Y et al. JAMA Network Open. 2020; doi: 10.1001/jamanetworkopen.2020.2159.

Maternal preconception exposure to phthalates was associated with increased risk of preterm birth, according to a study of 420 births to subfertile couples over a 13-year period.

Previous studies have shown increased risk of preterm birth associated with prenatal exposure to phthalates, which are commonly found in a range of household and commercial products as well as medical equipment and some pharmaceuticals.

“Our results suggest that female exposure to [4 di(2-ethylhexyl) phthalate] DEHP before conception might be an unrecognized risk factor for adverse pregnancy outcomes, often overlooked in clinical practice,” wrote Yu Zhang of the department of environmental health at Harvard T.H. Chan School of Public Health, Boston, and colleagues.

The prospective cohort study evaluated preconception urinary levels of phthalates and phthalate substitutes in 419 women and 229 men participating in the Environment and Reproductive Health (EARTH) study, a cohort of couples seeking fertility care at the Massachusetts General Hospital Fertility Center. The study cohort gave birth during 2005-2018. The average gestational age of the 420 singleton children born to this cohort was 39 weeks, with 8% (n = 34) born preterm.

Adjusted models showed that maternal preconception urinary concentrations of phthalates and of cyclohexane-1, 2-dicarboxylic acid monohydroxy isononyl ester (MHiNCH), a metabolite of a nonphthalate plasticizer substitute, were associated with a 50% and 70% increased risk of preterm birth, respectively (P = .01, .11), according to results published in JAMA Network Open .

Sensitivity analysis showed that maternal preconception MHiNCH concentrations above the median were associated with a fourfold increased risk of preterm birth (risk ratio, 4.02; P = .08), Maternal preconception MHiNCH concentrations were associated with an average 2-day reduction in gestational age (P = .02).

Covariate-adjusted models found that paternal urinary phthalate metabolite concentrations were associated with an increased risk of preterm birth (RR, 1.41; P = .09), but this association was attenuated toward zero (RR, 1.06) in models that accounted for maternal preconception phthalate concentrations. Sensitivity analysis of 228 couples found the associations of maternal preconception phthalate metabolite concentrations and preterm birth remained robust in three different models: a twofold increased risk in covariate-adjusted models (P < .001); an almost fivefold increased risk in adjusting for prenatal levels (RR, 4.98; P < .001); and a twofold risk (P = .001) in adjusting for paternal levels. “Couple-based analyses confirmed the results for an association between maternal preconception DEHP concentrations and increased risk of preterm birth,” the investigators said.

“To our knowledge, this is the first study evaluating couples’ exposure to phthalate metabolites during the preconception window and its association with preterm birth,” the researchers wrote. “Our findings support a novel hypothesis: Maternal phthalate exposure during the critical period before conception may be associated with shorter gestation.”

“This study is consistent with several, but not all, prior studies supporting maternal prenatal exposure to phthalates increase preterm birth,” said Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida, Orlando. “The uniqueness of the current study was the assessment of couples’ exposures and the outcome, though paternal exposure to phthalates did not demonstrate a significant association.”

Dr. Trolice noted that about 25% of women in the study were smokers, but the study didn’t adjust for tobacco use and phthalate exposure, and 85% of the women were white. He urged caution in applying the study results in practice, adding that the study didn’t adjust for method of conception. “Assisted reproductive technology, multiple gestation, and advanced age are all known risk factors for preterm birth,”

The National Institute of Environmental Health Science funded the study. Two study coauthors received grants from the NIEHS, one coauthor received grants from the National Institutes of Health, and one received a grant from the Canadian Institutes of Health Research. No other disclosures were reported. Dr. Trolice has no financial relationships to disclose.

SOURCE: Zhang Y et al. JAMA Network Open. 2020; doi: 10.1001/jamanetworkopen.2020.2159.

Maternal preconception exposure to phthalates was associated with increased risk of preterm birth, according to a study of 420 births to subfertile couples over a 13-year period.

Previous studies have shown increased risk of preterm birth associated with prenatal exposure to phthalates, which are commonly found in a range of household and commercial products as well as medical equipment and some pharmaceuticals.

“Our results suggest that female exposure to [4 di(2-ethylhexyl) phthalate] DEHP before conception might be an unrecognized risk factor for adverse pregnancy outcomes, often overlooked in clinical practice,” wrote Yu Zhang of the department of environmental health at Harvard T.H. Chan School of Public Health, Boston, and colleagues.

The prospective cohort study evaluated preconception urinary levels of phthalates and phthalate substitutes in 419 women and 229 men participating in the Environment and Reproductive Health (EARTH) study, a cohort of couples seeking fertility care at the Massachusetts General Hospital Fertility Center. The study cohort gave birth during 2005-2018. The average gestational age of the 420 singleton children born to this cohort was 39 weeks, with 8% (n = 34) born preterm.

Adjusted models showed that maternal preconception urinary concentrations of phthalates and of cyclohexane-1, 2-dicarboxylic acid monohydroxy isononyl ester (MHiNCH), a metabolite of a nonphthalate plasticizer substitute, were associated with a 50% and 70% increased risk of preterm birth, respectively (P = .01, .11), according to results published in JAMA Network Open .

Sensitivity analysis showed that maternal preconception MHiNCH concentrations above the median were associated with a fourfold increased risk of preterm birth (risk ratio, 4.02; P = .08), Maternal preconception MHiNCH concentrations were associated with an average 2-day reduction in gestational age (P = .02).

Covariate-adjusted models found that paternal urinary phthalate metabolite concentrations were associated with an increased risk of preterm birth (RR, 1.41; P = .09), but this association was attenuated toward zero (RR, 1.06) in models that accounted for maternal preconception phthalate concentrations. Sensitivity analysis of 228 couples found the associations of maternal preconception phthalate metabolite concentrations and preterm birth remained robust in three different models: a twofold increased risk in covariate-adjusted models (P < .001); an almost fivefold increased risk in adjusting for prenatal levels (RR, 4.98; P < .001); and a twofold risk (P = .001) in adjusting for paternal levels. “Couple-based analyses confirmed the results for an association between maternal preconception DEHP concentrations and increased risk of preterm birth,” the investigators said.

“To our knowledge, this is the first study evaluating couples’ exposure to phthalate metabolites during the preconception window and its association with preterm birth,” the researchers wrote. “Our findings support a novel hypothesis: Maternal phthalate exposure during the critical period before conception may be associated with shorter gestation.”

“This study is consistent with several, but not all, prior studies supporting maternal prenatal exposure to phthalates increase preterm birth,” said Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida, Orlando. “The uniqueness of the current study was the assessment of couples’ exposures and the outcome, though paternal exposure to phthalates did not demonstrate a significant association.”

Dr. Trolice noted that about 25% of women in the study were smokers, but the study didn’t adjust for tobacco use and phthalate exposure, and 85% of the women were white. He urged caution in applying the study results in practice, adding that the study didn’t adjust for method of conception. “Assisted reproductive technology, multiple gestation, and advanced age are all known risk factors for preterm birth,”

The National Institute of Environmental Health Science funded the study. Two study coauthors received grants from the NIEHS, one coauthor received grants from the National Institutes of Health, and one received a grant from the Canadian Institutes of Health Research. No other disclosures were reported. Dr. Trolice has no financial relationships to disclose.

SOURCE: Zhang Y et al. JAMA Network Open. 2020; doi: 10.1001/jamanetworkopen.2020.2159.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

People living with dementia and their caregivers urgently need mental health and psychosocial support during the coronavirus pandemic, according to a letter published online ahead of print March 30 in Lancet. Consistent with recommendations from Alzheimer’s Disease International and other dementia experts, teams that include mental health professionals, social workers, nursing home administrators, and volunteers should collaborate to provide mental health care for people with dementia. Experts in dementia should lead each team and support team members from other disciplines, wrote Huali Wang, MD, chair of clinical research at Peking University Institute of Mental Health in Beijing, and colleagues.

Interventions could be administered through telehealth, said the authors. Teams led by mental health professionals could use electronic media to provide self-help guidance for reducing stress, such as relaxation or meditation exercise. These teams also could use telephone hotlines to support behavioral management, and psychological counselors could provide online consultations for caregivers in nursing homes or in the community. “We encourage people who have a parent with dementia to have more frequent contact or spend more time with their parent, or to take on some of the caregiving duties so as to give the carer some respite time,” wrote Dr. Wang and colleagues.

Many local authorities are banning visits to nursing home residents to reduce the latter’s risk of COVID-19 infection. As a consequence, these elderly people are becoming more isolated, and anxiety is increasing among nursing home staffs.

In China, five organizations, including the Chinese Society of Geriatric Psychiatry and Alzheimer’s Disease Chinese, responded to the COVID-19 outbreak by publishing recommendations for providing mental health and psychosocial support. Groups of providers from various disciplines offered free counseling services for people with dementia and their caregivers. “These approaches minimized the complex impact of both COVID-19 outbreak and dementia,” wrote the authors.

“China has contained the epidemic, and business is starting to return to normal,” they continued. “We believe that learning lessons from China would empower the world to tackle the COVID-19 pandemic, with little risk of compromising the quality of life of people living with dementia and their carers.”

Dr. Wang has received lecture fees from Eisai China and Lundbeck China. She owns the copyright for the neuropsychiatric symptoms individualized management system. Her coauthors reported serving as advisory board members and receiving fees from companies such as Biogen, Novartis, and Genentech.

egreb@mdedge.com

SOURCE: Wang H et al. Lancet. 2020 Mar 30. doi: 10.1016/S0140-6736(20)30755-8.

People living with dementia and their caregivers urgently need mental health and psychosocial support during the coronavirus pandemic, according to a letter published online ahead of print March 30 in Lancet. Consistent with recommendations from Alzheimer’s Disease International and other dementia experts, teams that include mental health professionals, social workers, nursing home administrators, and volunteers should collaborate to provide mental health care for people with dementia. Experts in dementia should lead each team and support team members from other disciplines, wrote Huali Wang, MD, chair of clinical research at Peking University Institute of Mental Health in Beijing, and colleagues.

Interventions could be administered through telehealth, said the authors. Teams led by mental health professionals could use electronic media to provide self-help guidance for reducing stress, such as relaxation or meditation exercise. These teams also could use telephone hotlines to support behavioral management, and psychological counselors could provide online consultations for caregivers in nursing homes or in the community. “We encourage people who have a parent with dementia to have more frequent contact or spend more time with their parent, or to take on some of the caregiving duties so as to give the carer some respite time,” wrote Dr. Wang and colleagues.

Many local authorities are banning visits to nursing home residents to reduce the latter’s risk of COVID-19 infection. As a consequence, these elderly people are becoming more isolated, and anxiety is increasing among nursing home staffs.

In China, five organizations, including the Chinese Society of Geriatric Psychiatry and Alzheimer’s Disease Chinese, responded to the COVID-19 outbreak by publishing recommendations for providing mental health and psychosocial support. Groups of providers from various disciplines offered free counseling services for people with dementia and their caregivers. “These approaches minimized the complex impact of both COVID-19 outbreak and dementia,” wrote the authors.

“China has contained the epidemic, and business is starting to return to normal,” they continued. “We believe that learning lessons from China would empower the world to tackle the COVID-19 pandemic, with little risk of compromising the quality of life of people living with dementia and their carers.”

Dr. Wang has received lecture fees from Eisai China and Lundbeck China. She owns the copyright for the neuropsychiatric symptoms individualized management system. Her coauthors reported serving as advisory board members and receiving fees from companies such as Biogen, Novartis, and Genentech.

egreb@mdedge.com

SOURCE: Wang H et al. Lancet. 2020 Mar 30. doi: 10.1016/S0140-6736(20)30755-8.

People living with dementia and their caregivers urgently need mental health and psychosocial support during the coronavirus pandemic, according to a letter published online ahead of print March 30 in Lancet. Consistent with recommendations from Alzheimer’s Disease International and other dementia experts, teams that include mental health professionals, social workers, nursing home administrators, and volunteers should collaborate to provide mental health care for people with dementia. Experts in dementia should lead each team and support team members from other disciplines, wrote Huali Wang, MD, chair of clinical research at Peking University Institute of Mental Health in Beijing, and colleagues.

Interventions could be administered through telehealth, said the authors. Teams led by mental health professionals could use electronic media to provide self-help guidance for reducing stress, such as relaxation or meditation exercise. These teams also could use telephone hotlines to support behavioral management, and psychological counselors could provide online consultations for caregivers in nursing homes or in the community. “We encourage people who have a parent with dementia to have more frequent contact or spend more time with their parent, or to take on some of the caregiving duties so as to give the carer some respite time,” wrote Dr. Wang and colleagues.

Many local authorities are banning visits to nursing home residents to reduce the latter’s risk of COVID-19 infection. As a consequence, these elderly people are becoming more isolated, and anxiety is increasing among nursing home staffs.

In China, five organizations, including the Chinese Society of Geriatric Psychiatry and Alzheimer’s Disease Chinese, responded to the COVID-19 outbreak by publishing recommendations for providing mental health and psychosocial support. Groups of providers from various disciplines offered free counseling services for people with dementia and their caregivers. “These approaches minimized the complex impact of both COVID-19 outbreak and dementia,” wrote the authors.

“China has contained the epidemic, and business is starting to return to normal,” they continued. “We believe that learning lessons from China would empower the world to tackle the COVID-19 pandemic, with little risk of compromising the quality of life of people living with dementia and their carers.”

Dr. Wang has received lecture fees from Eisai China and Lundbeck China. She owns the copyright for the neuropsychiatric symptoms individualized management system. Her coauthors reported serving as advisory board members and receiving fees from companies such as Biogen, Novartis, and Genentech.

egreb@mdedge.com

SOURCE: Wang H et al. Lancet. 2020 Mar 30. doi: 10.1016/S0140-6736(20)30755-8.

In light of the rapid changes affecting cancer clinics due to the COVID-19 pandemic, Dr. David Kerr and Dr. Rachel Kerr, both specialists in gastrointestinal cancers at the University of Oxford in Oxford, United Kingdom, drafted these guidelines for the use of chemotherapy in colorectal cancer patients. Dr. Kerr and Dr. Kerr are putting forth this guidance as a topic for discussion and debate.

Our aim in developing these recommendations for the care of colorectal cancer patients in areas affected by the COVID-19 outbreak is to reduce the comorbidity of chemotherapy and decrease the risk of patients dying from COVID-19, weighed against the potential benefits of receiving chemotherapy. These recommendations are also designed to reduce the burden on chemotherapy units during a time of great pressure.

We have modified the guidelines in such a way that, we believe, will decrease the total number of patients receiving chemotherapy – particularly in the adjuvant setting – and reduce the overall immune impact of chemotherapy on these patients. Specifically, we suggest changing doublet chemotherapy to single-agent chemotherapy for some groups; changing to combinations involving capecitabine rather than bolus and infusional 5-FU for other patients; and, finally, making reasonable dose reductions upfront to reduce the risk for cycle 1 complications.

By changing from push-and-pump 5-FU to capecitabine for the vast majority of patients, we will both reduce the rates of neutropenia and decrease throughput in chemotherapy outpatient units, reducing requirements for weekly line flushing, pump disconnections, and other routine maintenance.

We continue to recommend the use of ToxNav germline genetic testing as a genetic screen for DPYD/ENOSF1 single-nucleotide polymorphisms (SNPs) to identify patients at high risk for fluoropyrimidine toxicity.

Use of biomarkers to sharpen prognosis should also be considered to refine therapeutic decisions.
 

Recommendations for stage II-III colorectal cancer

Recommendations for advanced colorectal cancer

Which regimen? Capecitabine/oxaliplatin should be the default backbone chemotherapy (rather than FOLFOX) in order to decrease the stress on infusion units.

Capecitabine plus irinotecan should be considered rather than FOLFIRI. However, in order to increase safety, reduce the dose of the capecitabine and the irinotecan, both to 80%, in all patient groups; and perhaps reduce the capecitabine dose further to 60% in those over the age of 70 or with significant comorbid conditions.

Treatment breaks. Full treatment breaks should be considered after 3 months of treatment in most patients with lower-volume, more indolent disease.

Treatment deintensification to capecitabine alone should be used in those with higher-volume disease (for example, more than 50% of liver replaced by tumor) at the beginning of treatment.

Deferring the start of any chemotherapy. Some older patients, or those with significant other comorbidities (that is, those who will be at increased risk for COVID-19 complications and death); who have low-volume disease, such as a couple of small lung metastases or a single liver metastasis; or who were diagnosed more than 12 months since adjuvant chemotherapy may decide to defer any chemotherapy for a period of time.

In these cases, we suggest rescanning at 3 months and discussing further treatment at that point. Some of these patients will be eligible for other interventions, such as resection, ablation, or stereotactic body radiation therapy. However, it will be important to consider the pressures on these other services during this unprecedented time.

Chemotherapy after resection of metastases. Given the lack of evidence and the present extenuating circumstances, we would not recommend any chemotherapy in this setting.


David J. Kerr, MD, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer, and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth. Rachel S. Kerr, MBChB, is a medical oncologist and associate professor of gastrointestinal oncology at the University of Oxford. She holds a UK Department of Health Fellowship, where she is clinical director of phase 3 trials in the oncology clinical trials office.

This article first appeared on Medscape.com.

In light of the rapid changes affecting cancer clinics due to the COVID-19 pandemic, Dr. David Kerr and Dr. Rachel Kerr, both specialists in gastrointestinal cancers at the University of Oxford in Oxford, United Kingdom, drafted these guidelines for the use of chemotherapy in colorectal cancer patients. Dr. Kerr and Dr. Kerr are putting forth this guidance as a topic for discussion and debate.

Our aim in developing these recommendations for the care of colorectal cancer patients in areas affected by the COVID-19 outbreak is to reduce the comorbidity of chemotherapy and decrease the risk of patients dying from COVID-19, weighed against the potential benefits of receiving chemotherapy. These recommendations are also designed to reduce the burden on chemotherapy units during a time of great pressure.

We have modified the guidelines in such a way that, we believe, will decrease the total number of patients receiving chemotherapy – particularly in the adjuvant setting – and reduce the overall immune impact of chemotherapy on these patients. Specifically, we suggest changing doublet chemotherapy to single-agent chemotherapy for some groups; changing to combinations involving capecitabine rather than bolus and infusional 5-FU for other patients; and, finally, making reasonable dose reductions upfront to reduce the risk for cycle 1 complications.

By changing from push-and-pump 5-FU to capecitabine for the vast majority of patients, we will both reduce the rates of neutropenia and decrease throughput in chemotherapy outpatient units, reducing requirements for weekly line flushing, pump disconnections, and other routine maintenance.

We continue to recommend the use of ToxNav germline genetic testing as a genetic screen for DPYD/ENOSF1 single-nucleotide polymorphisms (SNPs) to identify patients at high risk for fluoropyrimidine toxicity.

Use of biomarkers to sharpen prognosis should also be considered to refine therapeutic decisions.
 

Recommendations for stage II-III colorectal cancer

Recommendations for advanced colorectal cancer

Which regimen? Capecitabine/oxaliplatin should be the default backbone chemotherapy (rather than FOLFOX) in order to decrease the stress on infusion units.

Capecitabine plus irinotecan should be considered rather than FOLFIRI. However, in order to increase safety, reduce the dose of the capecitabine and the irinotecan, both to 80%, in all patient groups; and perhaps reduce the capecitabine dose further to 60% in those over the age of 70 or with significant comorbid conditions.

Treatment breaks. Full treatment breaks should be considered after 3 months of treatment in most patients with lower-volume, more indolent disease.

Treatment deintensification to capecitabine alone should be used in those with higher-volume disease (for example, more than 50% of liver replaced by tumor) at the beginning of treatment.

Deferring the start of any chemotherapy. Some older patients, or those with significant other comorbidities (that is, those who will be at increased risk for COVID-19 complications and death); who have low-volume disease, such as a couple of small lung metastases or a single liver metastasis; or who were diagnosed more than 12 months since adjuvant chemotherapy may decide to defer any chemotherapy for a period of time.

In these cases, we suggest rescanning at 3 months and discussing further treatment at that point. Some of these patients will be eligible for other interventions, such as resection, ablation, or stereotactic body radiation therapy. However, it will be important to consider the pressures on these other services during this unprecedented time.

Chemotherapy after resection of metastases. Given the lack of evidence and the present extenuating circumstances, we would not recommend any chemotherapy in this setting.


David J. Kerr, MD, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer, and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth. Rachel S. Kerr, MBChB, is a medical oncologist and associate professor of gastrointestinal oncology at the University of Oxford. She holds a UK Department of Health Fellowship, where she is clinical director of phase 3 trials in the oncology clinical trials office.

This article first appeared on Medscape.com.

In light of the rapid changes affecting cancer clinics due to the COVID-19 pandemic, Dr. David Kerr and Dr. Rachel Kerr, both specialists in gastrointestinal cancers at the University of Oxford in Oxford, United Kingdom, drafted these guidelines for the use of chemotherapy in colorectal cancer patients. Dr. Kerr and Dr. Kerr are putting forth this guidance as a topic for discussion and debate.

Our aim in developing these recommendations for the care of colorectal cancer patients in areas affected by the COVID-19 outbreak is to reduce the comorbidity of chemotherapy and decrease the risk of patients dying from COVID-19, weighed against the potential benefits of receiving chemotherapy. These recommendations are also designed to reduce the burden on chemotherapy units during a time of great pressure.

We have modified the guidelines in such a way that, we believe, will decrease the total number of patients receiving chemotherapy – particularly in the adjuvant setting – and reduce the overall immune impact of chemotherapy on these patients. Specifically, we suggest changing doublet chemotherapy to single-agent chemotherapy for some groups; changing to combinations involving capecitabine rather than bolus and infusional 5-FU for other patients; and, finally, making reasonable dose reductions upfront to reduce the risk for cycle 1 complications.

By changing from push-and-pump 5-FU to capecitabine for the vast majority of patients, we will both reduce the rates of neutropenia and decrease throughput in chemotherapy outpatient units, reducing requirements for weekly line flushing, pump disconnections, and other routine maintenance.

We continue to recommend the use of ToxNav germline genetic testing as a genetic screen for DPYD/ENOSF1 single-nucleotide polymorphisms (SNPs) to identify patients at high risk for fluoropyrimidine toxicity.

Use of biomarkers to sharpen prognosis should also be considered to refine therapeutic decisions.
 

Recommendations for stage II-III colorectal cancer

Recommendations for advanced colorectal cancer

Which regimen? Capecitabine/oxaliplatin should be the default backbone chemotherapy (rather than FOLFOX) in order to decrease the stress on infusion units.

Capecitabine plus irinotecan should be considered rather than FOLFIRI. However, in order to increase safety, reduce the dose of the capecitabine and the irinotecan, both to 80%, in all patient groups; and perhaps reduce the capecitabine dose further to 60% in those over the age of 70 or with significant comorbid conditions.

Treatment breaks. Full treatment breaks should be considered after 3 months of treatment in most patients with lower-volume, more indolent disease.

Treatment deintensification to capecitabine alone should be used in those with higher-volume disease (for example, more than 50% of liver replaced by tumor) at the beginning of treatment.

Deferring the start of any chemotherapy. Some older patients, or those with significant other comorbidities (that is, those who will be at increased risk for COVID-19 complications and death); who have low-volume disease, such as a couple of small lung metastases or a single liver metastasis; or who were diagnosed more than 12 months since adjuvant chemotherapy may decide to defer any chemotherapy for a period of time.

In these cases, we suggest rescanning at 3 months and discussing further treatment at that point. Some of these patients will be eligible for other interventions, such as resection, ablation, or stereotactic body radiation therapy. However, it will be important to consider the pressures on these other services during this unprecedented time.

Chemotherapy after resection of metastases. Given the lack of evidence and the present extenuating circumstances, we would not recommend any chemotherapy in this setting.


David J. Kerr, MD, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer, and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth. Rachel S. Kerr, MBChB, is a medical oncologist and associate professor of gastrointestinal oncology at the University of Oxford. She holds a UK Department of Health Fellowship, where she is clinical director of phase 3 trials in the oncology clinical trials office.

This article first appeared on Medscape.com.