COVID-19 and the role of medical professional societies

Responding to the coronavirus disease 2019 pandemic has helped craft a global medical community of medical professional society members and nonmembers alike in ways previously unanticipated. The public-facing elements of medical professional societies include their websites, official organs, and educational elements that have been liberated using a Free Open-Access Medical education approach. Work products including guidelines, blogs, and social media offerings have helped clinicians to prepare for pandemic care or refine existing practices to support outcome excellence. Often, that guidance has flowed from collaborations between medical professional organizations, some of which are novel and might not have occurred outside of a dire global need. Leaders of such organizations have been catapulted into the spotlight by the universal need for information and guidance—including that of one’s home government—and appeared quite regularly in print and digital media as well as live radio broadcasts. Finally, the need to pursue remote medical professional organization work as well as education has developed member and nonmember facilities with a host of digital platforms. Such skill sets have also helped to maintain communication between clinicians and patient's remote family members to support patient- and family-centered care while maintaining shared decision making. The flexibility and innovation that characterize medical professional organizations have been highlighted by the realities of providing pandemic care. © 2022 Elsevier Inc. All rights reserved.

A uniquely violent year: The impact of social and political events on 2020 urban injury patterns

INTRODUCTION/HYPOTHESIS: 2020 was marked by social and political events that substantially disrupted healthcare. The COVID-19 pandemic, lockdown, public health measures, as well as civic and political unrest over racial tensions during an election year could plausibly impact injury care. We hypothesized that increased injuries related to high-risk activities during 2020 was temporally related to sociopolitical unrest and pandemic public health measures. METHODS: Retrospective data from two Level 1 urban, adult trauma centers in different US states (City A population:1.6M, City B:0.21M) were assessed (1/1/2020- 12/31/2020). Calendar months were divided into quartiles and compared to analogous quartiles in years 2016 -2019. Variables studied (demographics, injury mechanisms and outcomes) were compared between years, and across 2020 quartiles, against a backdrop of key sociopolitical events. RESULTS: More patients presented for injury in 2020 (A: n=1057, B: n= 1053) than in prior years (p< 0.05). Compared to 2016-2019, 2020, patients were more often black (A:63.1% vs. 69.8% p< 0.001;B:31.0% vs. 34.3%, p=0.02). Institution A patients were more likely to be male (p=0.002) & younger (p< 0.001) in 2020 vs. 2016-2019. Both institutions noted a steep rise in gunshot wound (GSW) and motor vehicle collision (MVC) injuries following state lockdowns (Fig A, B) with a persistent rise in GSWs until late fall (Fig C). CONCLUSIONS: 2020 was a unique year of sociopolitical unrest interwoven with a pandemic. Most affected populations were young, black males in two different urban centers and primarily involved GSWs and MVCs. Future disaster response planning should consider the drivers of these trends to mitigate their impact, especially in vulnerable populations.

Effect of the COVID-19 pandemic on ICU ischemic and hemorrhagic stroke outcomes

Objective: Evaluate impact of COVID-19 pandemic on mortality and care limitations in critically-ill stroke patients. Background: COVID-19 pandemic overwhelmed medical systems leading to resource shortages in many regions, which may impact care limitations and mortality in non-COVID patients. This is of particular concern in severe stroke population where perceived poor prognosis can lead to early care limitations and the self-fulfilling prophecy of worse outcomes. Design/Methods: During first 3 months of COVID-19 pandemic (03/28/30-06/28/20) we prospectively enrolled consecutive adults with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) meeting pre-pandemic criterial for intensive care unit (ICU) admission at single comprehensive stroke center, systematically recorded COVID-19 status, pre-existing code status, disease severity, transition to do-notresuscitate (DNR), do-not-intubate (DNI), and comfort measures (CMO) code status and inhospital mortality. Results were compared with a 3-months retrospective cohort from prior to global COVID-19 pandemic (10/1/19-12/31/19). Results: Pandemic cohort (N=196, mean age 63, 48% female, 60% AIS, 26% ICH, 14% SAH, 22% COVID-19 person-under-investigation) and pre-pandemic cohort (N=199, mean age 63, 46% female, 58% AIS, 26% ICH, 16% SAH) were similar. Our hospital did not experience resource shortages during peak pandemic. Compared with the pandemic cohort, pre-pandemic cohort had similar stroke severity scores but more pre-existing care limitations at admission (90% vs. 98% full code, p=0.005), more frequent transition to DNR (13% vs. 5%, p=0.0025), DNI (10% vs. 3%, p=0.0078), and higher in-hospital mortality (21% vs. 9%, p=0.0012). Conclusions: COVID-19 pandemic was associated with lower incidence of care limitations and in-hospital mortality in severe stroke patients at a stroke center that did not experience resource shortages. Further studies are needed to determine whether these results are due to in-person family visit restrictions during the pandemic. Multicenter studies are needed to determine whether these observations hold true in centers impacted by resource shortages.

Persistent dyspnea and accompanying negative emotions after COVID-19 associated respiratory failure

INTRODUCTION: Dyspnea is common and distressing in patients with acute critical illness who require mechanical ventilation (MV), and is often a presenting symptom for COVID-19. However, little is known about the long-term persistence of dyspnea or its impact on patients recovering from mechanical ventilation. This study sought to evaluate early and persistent dyspnea, and its emotional impact, among survivors of respiratory failure due to COVID-19. METHODS: We conducted a prospective observational cohort study at Beth Israel Deaconess Medical Center. We identified ICU survivors who underwent at least 48 hours of MV for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. We assessed the presence and severity of dyspnea throughout their illness (ICU, hospital floor, hospital discharge, 6 months post-discharge) using components of the Multidimensional Dyspnea Profile (MDP), a validated instrument. Additionally, we asked patients with persistent dyspnea at the time of follow up whether dyspnea triggered specific emotional responses, using the MDP. Data are means + standard deviation or number (percent). RESULTS: Forty of 43 patients contacted by telephone completed interviews and 3 declined. Twenty-three patients (58%) were male, 7 (18%) had COPD, 9 (22%) had obstructive sleep apnea, and 11 (28%) had active tobacco use. The duration of invasive MV was 14+7.1 days and hospital length of stay was 24.7+9.6 days. Six-month post-discharge data revealed 25 patients (62.5%) with any dyspnea, and 10 (25%) with moderate to severe dyspnea (10-point severity scale score > 4). Among patients with persistent dyspnea at 6 months, the majority reported fear (60%), anxiety (57.5%), or frustration (52.5%). Depression was the most common severe emotional response accompanying dyspnea (10-point severity scale score of 7-10), reported by 9 patients (22.5%). CONCLUSIONS: Six months after COVID-19-associated respiratory failure, dyspnea was persistent in the majority of patients and commonly associated with negative emotions. Fear and anxiety were most commonly reported. Prior to COVID-19, long-term dyspnea had been described in up to 40% of patients after respiratory failure, though data are limited. Thus dyspnea appears as, or more, common after COVID-19. In addition to the typical components of post-intensive care syndrome (PICS), dyspnea and the negative emotional states it evokes may impair quality-of-life for COVID-19 survivors and should be specifically assessed during post-hospital care visits.

Long-term impairment in cognition, mental health, and physical function following covid-19-associated respiratory failure

RATIONALE: Prior to the emergence of coronavirus disease 2019 (COVID-19), critical illness survivors were known to suffer long-term impairments in physical function, mental health, and cognition. These deficits, collectively termed the post-intensive care syndrome (PICS), impact health-related quality-of-life. Survivors of COVID-19-associated respiratory failure may be at particularly high risk of PICS due to delirium and prolonged mechanical ventilation, and factors unique to the pandemic, including physical isolation from medical staff, lack of in-hospital family presence, limited post-acute care rehabilitation, and widespread economic recession. Given this context, we describe the prevalence of PICS 6 months following hospital discharge among survivors of COVID-19-associated respiratory failure. METHODS: We conducted a multicenter prospective cohort study from March to December 2020 at Beth Israel Deaconess Medical Center and the Hospital of the University of Pennsylvania. We identified ICU survivors who underwent at least 48 hours of mechanical ventilation for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. Sample size was determined by thematic saturation of interviews within a concurrent qualitative assessment. We used the Society of Critical Care Medicine international consensus recommendations for PICS assessment. We assessed anxiety, depression, and post-traumatic stress disorder (PTSD) using the Hospital Anxiety and Depression Scale and Impact-of-Events Scale, respectively. We assessed physical impairment with the EQ-5D questionnaire, and cognitive impairment using the Montreal Cognitive Assessment-Blind. Data are means + standard deviation or number (percent). RESULTS: We completed telephone interviews with 50 of 173 eligible patients (53 contacted, 3 declined). Age was 57+13 years, duration of invasive mechanical ventilation was 14+8.2 days and PaO2:FiO2 ratio at intubation was 174±46. Delirium developed in 35 patients (70%). Six months post-discharge, 38 patients (76%) met criteria for PICS, with 1 or more domains impaired. Among patients with PICS, 22 (44%) were impaired in at least 2 domains, and 9 (18%) impaired in all 3 domains. PTSD was present in 17 patients (34%), anxiety in 19 (38%), and depression in 20 (40%). Twenty-four patients (48%) had impairments in activities of daily living. Nineteen patients (37%) demonstrated cognitive impairment. CONCLUSIONS Over three quarters of COVID-19-associated respiratory failure survivors demonstrated PICS 6 months after hospital discharge. Patients were commonly impaired in at least two domains. These estimates of PICS prevalence appear broadly similar to those reported in the pre-COVID-19 literature and should drive focused efforts to identify COVID-19 survivors at high risk for PICS prior to discharge.

COVID-19 from the frontlines: Reports from over 14,000 ICU clinicians

INTRODUCTION: Global cases of COVID-19 continue to increase despite mitigation and containment efforts. As a large proportion of COVID-19 patients require hospitalization and treatment in an intensive care unit (ICU), understanding the impact on ICU clinicians remains an essential component of meeting current and projected needs during pandemic care. In order to capture the ongoing impact on COVID-19 patient care on ICU resources and clinicians, the Society of Critical Care Medicine (SCCM), an international organization of healthcare professionals including physicians, nurses, pharmacists, respiratory therapists, and others deployed a series of rapid cycle surveys. METHODS: A descriptive cross-sectional survey methodology was used. Three national web-based anonymous surveys launched beginning March 18, 2020. The brief (12 question) rapid cycle (open for 2 weeks) descriptive surveys assessed ICU clinician's perceptions of the impact of the ongoing COVID-19 pandemic on ICU care and demographic information related to respondent profession, geographic location, and if they had cared for a suspected or confirmed COVID-19 patient. SurveyMonkey® was used to distribute the surveys via email and newsletter blasts. RESULTS: Collectively, over 14,000 multi-professional ICU clinicians practicing in all 50 United States (U.S.) responded, including ICU physicians (n=876, 7.1%), nurses (n=10,201, 83%), advanced practice providers [nurse practitioners and physician assistants] (n=668, 5.5%), respiratory therapists (n=267, 2.2%), and pharmacists (n=109, 0.9%). Majority (n=8762;62.6%) reported having cared for a patient with presumed or confirmed COVID-19. ICU clinicians report that the most challenging aspects of COVID-19 are related to caring for critically ill patients, minimizing staff exposure to SARS-CoV-2 during the course of direct care, and communication with patient's family members while visitation is restricted, among others. CONCLUSIONS: As the ICU workforce represents the foundation for caring for critically ill COVID-19 patients, monitoring the impact of sustained stress on the critical care workforce warrants surveillance and the elaboration of mitigation strategies in order to ensure critical care clinician health, and the ability to continue to serve at the frontlines of COVID-19 patient care.

Outcomes of convalescent plasma transfusion for SARS-CoV2 patients in the intensive care unit

Background: SARS-CoV2 is a grave illness and few therapeutic agents have yielded benefit or reduced mortality. Administration of convalescent plasma (CP) in viral illnesses in the past, including SARS, before day 14, has been associated with a shorter hospital course. In the present study, we are interested in determining the benefit of administering CP to critically ill patients in the intensive care unit, and the impact on mortality and other clinical markers. Methods: 5 critically ill patients with confirmed SARS-CoV2 infection were observed in the uncontrolled case series study. Mechanically ventilated patients with severe ARDS (PaO2/FiO2 < 100) were eligible to receive CP transfusion. We reviewed daily vital signs, inflammatory markers, PaO2/FiO2 ratio and SOFA scores before and after CP transfusions. SARS-CoV2 PCR viral load testing was completed on day 0 of transfusion and repeated on day 3 and 6. Complications during the hospitalization and 30-day mortality were assessed. Results: All 5 patients were mechanically ventilated at the time of transfusion and between day 7 to 31 of their illness. Following plasma transfusion, body temperature and inflammatory markers remained elevated in four patients (figure 1). SOFA score and PaO2/FiO2 ratios continued to worsen in three and four patients respectively (figure 2). SARS-CoV2 PCR remained positive in 4 patients. 4 of the 5 patients had died at the end of the follow up period. One patient was successfully extubated on day 29 (table 1) and discharged after a long hospital course. Conclusion: In our patient cohort, the administration of CP did not improve laboratory markers or clinical outcomes. Some notable limitations of this study are the small sample size, and that the patients received CP late in their disease course. Further investigation is necessary to draw definitive conclusions about the utility of CP in the treatment of SARS-CoV2. (Table Presented).

A Guide for Urogynecologic Patient Care Utilizing Telemedicine during the COVID-19 Pandemic: Review of Existing Evidence

The novel coronavirus (COVID-19) pandemic has had a major impact on how patients are evaluated and treated for diseases and conditions in normal patient care. Due to lack of effective treatments for this virus or vaccines to prevent infection, focus is placed on infection prevention through use of social distancing, quarantine, and face masks. To prevent COVID-19 infections in healthcare settings, the Centers for Disease Control and Prevention has recommended decreasing or eliminating nonurgent office visits. Telehealth has emerged as an alternative way to deliver effective patient care, while reducing patient and physician exposure to the virus. Telehealth is any remote healthcare process, including provider training or team meetings, whereas telemedicine refers to use of specific technology to connect a patient to a provider. High quality of care can and must be provided by Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) as well as other specialists and health professionals using telemedicine. Because of the health care emergency during the pandemic, the Centers for Medicare and Medicaid Services have broadened access to and reimbursement for telemedicine services. Rapid advances in communications technology and widespread wireless access in many modern households have allowed the adoption and integration of telemedicine into urogynecology and other health practices. There are no clear guidelines for the use of telemedicine in FPMRS. The aim of this study was to conduct an expedited review of the evidence and to provide guidance for managing common outpatient FPRMS conditions during the COVID pandemic using telemedicine. FPMRS conditions were grouped into those that likely to require different treatment with virtual management compared with in-person visits, and those that could use accepted behavioral counseling and not deviate from current management paradigms. Rapid systematic review methodology was used to screen for articles related to 4 topics: (1) telemedicine in FPMRS, (2) pessary management, (3) urinary tract infections, and (4) urinary retention. In addition, 4 other topics were addressed (based on past systematic reviews and national or international society guidelines): (1) urinary incontinence, (2) vaginal prolapse, (3) fecal incontinence, and (4) defecatory dysfunction. Finally, clinical experience and expertise were pooled to reach consensus on 4 remaining areas: (1) FPMRS conditions amenable to virtual management, (2) urgent care scenarios requiring in-person visits, (3) symptoms that should alert providers to a possible COVID infection, and (4) special consideration for managing patients with known or suspected COVID-19. Overall, behavioral, medical, and conservative management provided in a virtual setting (via phone or Internet communication) will be valuable as first-line treatments. Certain situations were identified that require different treatments in the virtual setting than in person, whereas others were shown to require an in-person visit despite risks of COVID-19 exposure and spread of infection. This study presents guidance for treating FPMRS conditions via telemedicine in a format that can be actively referenced. The strengths of the study include use of an expedited review method, extensive experience of the authors in conducting systematic reviews, as well as being seasoned FPMRS practitioners. Main limitations include the rapid methodology, lack of data regarding many of the pertinent questions, and missed salient studies, because of the expedited evidence methods.