Experiences from the implementation of physical therapy via telehealth for individuals with Parkinson disease during the COVID-19 pandemic.

PURPOSE: To (1) determine the characteristics and participation rate of adults with Parkinson disease (PD) in physical therapy (PT) delivered via telehealth, (2) identify the outcome measures and interventions implemented, (3) determine the safety of and (4) patient and therapist satisfaction with PT via telehealth in a clinic specializing in the care of people with PD during the coronavirus pandemic. MATERIALS & METHODS: A retrospective analysis of PT services via telehealth was conducted. Participating patients completed a satisfaction survey. Physical therapists (PTs) who delivered this care were interviewed. Three coders conducted thematic analysis of interviews. Descriptive statistics described the participation rate, demographics, outcome measures, interventions, and safety. RESULTS: There was a 71.4% participation rate. Participants (n = 55) were white (96%), non-Hispanic (100%), older adult (mean = 69.5 years (8.3)) males (65.5%). Non-participants (n = 22) had similar demographics. Therapists selected patient-reported measures more often than performance-based measures. Therapeutic exercise was the most common intervention. All patients (80% response rate) reported satisfaction with their experience. PTs reported the home enhanced specificity of training but impeded evaluation. Therapists endorsed a hybrid model for future practice. CONCLUSIONS: Patients reported satisfaction with PT via telehealth during the pandemic. A hybrid model may support optimal delivery of PT.IMPLICATIONS FOR REHABILITATIONPhysical therapy via telehealth for patients with Parkinson disease was acceptable to patients and physical therapists in our study.Physical therapy via telehealth was safe for people with Parkinson disease in our study, although availability and benefits may not be reaching all populations equitably.Both physical therapists and patients endorse a hybrid model of care (a combination of in-person and remote assessment and treatment) to profit from the strengths of in-person and virtual formats while minimizing barriers to access.

Trends in low-value oncology care during the COVID-19 pandemic

Background: Low-value services, which provide minimal patient benefit while entailing costs and risks, are prevalent in cancer care. Shifts in cancer care delivery during the COVID-19 pandemic to minimize exposure provided opportunities for health systems and clinicians to prioritize higher-value over lowvalue oncology services. Methods: In this retrospective cohort study, we investigated the association between the COVID-19 pandemic period and low-value cancer care practices using administrative claims from the HealthCore Integrated Research Environment, consisting of ∼65 million members managed by 14 health plans across the US. We identified commercial or Medicare Advantage members diagnosed with breast, colorectal, or lung cancer between January 2015 and March 2021. Low-value cancer care practices were identified from peer-reviewed medical literature, including ASCO and ASTRO Choosing Wisely campaigns and evidence-based pathways. Five low-value practices were studied: (1) conventional fractionation instead of hypofractionation for early-stage breast cancer;(2) off-pathway systemic therapy;(3) non-guideline-based antiemetic use for minimal-, low-, or moderate-to-high-risk chemotherapies;(4) Positron Emission Tomography/Computed Tomography (PET/CT) instead of conventional CT for staging;and (5) aggressive end-of-life care (chemotherapy ≤14 days, multiple emergency department visits ≤30 days, ICU utilization ≤30 days, hospice initiation ≤3 days, and/or no hospice before death). We used linear probability models to evaluate the association between the COVID- 19 period (March to December 2020) and the 5 outcomes, adjusting for patient, facility, geographic and temporal characteristics. Results: Among 204,581 members (mean age 63.1, 139,488 [68.1%] female), 83,593 (40.8%) had breast cancer, 56,373 (27.5%) had colon cancer, and 64,615 (31.5%) had lung cancer. Rates of low-value care were similar in pre-COVID vs. COVID periods: conventional radiotherapy: 22.1% vs. 9.4%;off-pathway systemic therapy: 36.7% vs. 43.2%;non-guideline-based antiemetics: 61.2% vs. 58.1%;PET/CT imaging: 39.9% vs. 41.3%;aggressive end-of-life care: 75.8% vs. 73.3%. In adjusted analyses, the COVID-19 period was associated with no changes in off-pathway therapy (adjusted percentage point difference [aPPD] 0.82, SD 0.08, p = 0.33), PET/CT imaging (aPPD 0.10, SD 0.005, p = 0.83), and aggressive end-of-life care (aPPD 2.71, SD 0.02, p = 0.16). Small changes in conventional radiotherapy (aPPD 3.93, SD 0.01, p < 0.01) and non-guideline-based antiemetics (aPPD -3.62, SD 0.006, p < 0.01), were noted. Conclusions: The shock of the COVID-19 pandemic did not meaningfully change several metrics of low-value cancer care. Broader changes to payment and incentive design should be considered to turn the tide toward higher-value cancer care.

A Survey of Adult Psychiatry Residency Programs About Training in C-L Psychiatry

Background: Despite training in consultation-liaison (CL) psychiatry representing a core requirement for general residency training in psychiatry, there is significant variation in the structure, timing, length, setting, and educational components for residents in programs throughout the country. The last official survey of CL training in residency was conducted by the Academy of Consultation-Liaison Psychiatry (ACLP) in 2010 with responses from 92 residency programs across the country (Heinrich 2013). Based on the results of that survey, recommendations were issued by the ACLP in 2014 concerning best practices for residency training in CL psychiatry (Heinrich 2014). Methods: Members of the ACLP Residency Education Subcommittee designed an updated survey based on the survey tool used in 2013. In addition to questions about the structure of residency training, we also asked questions about CL fellowships and their relationship to the CL experience of residents attending structures on CL services, learners from other health professions, educational content, and modifications made during the COVID-19 pandemic. Following exemption by the Partners Institutional Review Board, we distributed the survey in anonymous and confidential format through RedCap to 273 adult psychiatry residency program directors using the American Medical Association’s FREIDATM database. Program directors were instructed that they could complete the survey themselves or forward to relevant faculty. Results: We will discuss the results of the survey including the response rate;distribution of programs in terms of geography, size and focus;length, timing, structure and setting of CL rotation;presence and role of fellows and other learners;model of attending staffing;educational and didactic components;and modifications made in the setting of COVID-19. Discussion: Based on the findings, we anticipate a discussion of trends in residency CL education over the past decade. Specifically, we anticipate focus on earlier CL training, novel training patterns, CL rotations spread across multiple years, increasing focus on outpatient CL experiences, and increased learners and other staff on services. The topic is of immediate relevance to training in CL psychiatry and thus to developing careers in CL psychiatry, a meeting theme. Conclusion: We expect these findings will provide important information for issuing an updated set of guidelines for CL training in residency for the next decade. References: 1. Heinrich TW, Schwartz AC, Zimbrean PC, Lolak S, Wright MT, Brooks KB, Ernst CL, Gitlin DF. “Recommendations for training psychiatry residents in psychosomatic medicine.” Psychosomatics 2014;55:438-449. 2. Heinrich TW, Schwartz AC, Zimbrean PC, Wright MT;Academy of Psychosomatic Medicine's Residency Education Subcommittee. The state of the service: a survey of psychiatry resident education in psychosomatic medicine. Psychosomatics. 2013 Nov-Dec;54(6):560-6. doi: 10.1016/j.psym.2013.07.005.

The impact of the COVID-19 pandemic on African American cancer survivors living in metropolitan Detroit

Background: COVID-19 has had profound direct and indirect effects on population health to date and long-term effects are anticipated. Vulnerabilities to the most serious consequences of infection include older age, obesity, African American race and the presence of comorbid conditions. African American cancer survivors represent a particularly high-risk group, therefore understanding the impact of the virus and our strategies to prevent its spread on this patient population is important. Methods: The Detroit Research on Cancer Survivors (ROCS) cohort is a unique effort to understand the determinants of poor outcomes in African American cancer survivors. Eligible participants were diagnosed with breast, prostate, colorectal, or lung cancer on or after 1/1/2013, or with endometrial or any other cancer before age 50 on or after 01/01/2016 and were identified through the Metropolitan Detroit Cancer Surveillance System cancer registry. To date, we have enrolled 4173 survivors. Full participation includes completion of a baseline survey, and collection of biospecimens, medical records and tumor tissue, if available. Participants are also followed annually for outcomes and changes in history. A supplemental survey focused on the impact of COVID-19 was offered to enrolled participants beginning in the spring of 2020. The results presented here include data from 890 survivors who also completed the ROCS COVID survey. Results: Nearly all ( > 99%) survivors reported some change in their daily activities in an effort to reduce the risk of infection. At the time of survey, just over 1/3 of participants reported being tested for the virus and among those, 12% reported positive results. More than 40% of survivors reported some disruption in their access to medical care. A substantial ( > 40%) proportion of survivors reported feeling anxious, depressed and/or isolated during the COVID-19 pandemic. Approximately 40% of patients reported changes in health behaviors as a direct result of the pandemic that are known to negatively affect survivorship outcomes (physical inactivity, smoking, alcohol use). Notably, 30% of survivors reported declines in physical activity and these declines were significantly associated with increased anxiety (p = 0.008), depression (p = 0.005) and poorer healthrelated quality of life (p < 0.001). Conclusions: The influence of the COVID- 19 pandemic on African American cancer survivors has been substantial, affecting both their physical and mental health and access to needed medical care. Coupled with changes in health behaviors as a direct result of the pandemic, these factors will likely affect outcomes in this high-risk patient population making further study and interventions necessary to mitigate the long-term impact of the pandemic on cancer outcomes.

A roadmap for patient- and family-centered care during the pandemic

The COVID-19 pandemic has affected profoundly all parties and health-care delivery. Most hospitalized patients find that separation from loved ones takes a toll on them and the safety measures instituted come at a huge cost to their physical and emotional well-being. Family members are distressed and traumatized because they are unable to support or advocate for their loved ones and feel disconnected from the health-care team. Health-care professionals (HCPs) experience psychological and moral distress because the absence of families negatively affects their ability to provide quality, compassionate, and timely care. As a result, there have been calls for revisions of policies and procedures to reprioritize patient- and family-centered care (PFCC). Building upon their experience as frontline HCPs, health-care team leaders, and patients and family members who are also frontline HCPs, the interprofessional team (psychologists, psychiatrists, hospitalists, nurses, and specialists) of co-authors reviewed the literature and developed collegial consensus on a roadmap for PFCC during the pandemic that includes guiding principles along with associated best practices and implementation strategies for their operationalization. The guiding principles focus on providing safe yet compassionate and ethical PFCC;balancing community health and the mitigation of viral transmission with appreciating family members as essential partners in care;fostering communication between patients and their families;and promoting interactions and decision-making among HCPs, patients, and families. We hope this roadmap facilitates the transformation of the health-care culture during the pandemic to one that is truly patient and family centered. (PsycInfo Database Record (c) 2021 APA, all rights reserved) © 2021 American Psychological Association

Financial and employment impacts of cancer and COVID-19 among african american cancer survivors

Purpose: Financial hardship due to cancer is more common among African American than White survivors. The COVID-19 pandemic and its economic fallout have also disproportionately affected African Americans. The purpose of this study is to describe the financial and employment impacts of COVID-19 in a population of African American cancer survivors and to compare those impacts with those experienced after a cancer diagnosis. Methods: Results include survey data from 593 participants in the population-based Detroit Research on Cancer Survivors (ROCS) cohort who completed the ROCS enrollment survey and a supplemental questionnaire related to the impact of the COVID-19 pandemic on their financial wellbeing and employment. Most participants (96%) were not diagnosed with COVID-19 by the time they completed the supplement and reflect the societal impact of the pandemic rather than a personal COVID-19 diagnosis. Analyses compare reports of financial hardship (using assets, borrowing money, experiencing debt, decreases in income) and employment impacts (changes to work schedules, duties, hours, employment status) due to cancer and due to the COVID-19 pandemic. Results: A similar proportion of ROCS participants reported financial hardship (41% vs. 42%) and borrowing money (5% vs. 6%) related to the COVID pandemic and their cancer diagnosis, respectively. Fewer survivors reported borrowing money (9% vs. 17%;p<0.001) or experiencing a decrease in income due to COVID than cancer (20% vs. 28%;p = 0.001);however;more reported debt associated with COVID (30% vs. 17%;p<0.001). Changes to work schedules (44% vs. 36%) and hours worked (44% vs. 28%) related to the COVID pandemic and cancer were common, and not statistically different from one another. More survivors changed their work duties due to the COVID pandemic (20%) than cancer (12%;p = 0.048). Prevalence of changes to employment status were similar for cancer (6%) and COVID (11%). Conclusions: The COVID-19 pandemic was associated with similar levels of overall financial hardship, and higher prevalence of debt and some work changes, than individual cancer experiences. These additional burdens on a financially vulnerable population could exacerbate existing cancer-related inequities.

Out of the classroom and into the home: A mixed methods analysis of medical students' lessons learned from geriatric home visits

Home visits are an important and positive part of geriatric education for medical students (MS), but the main lessons learned by MS are not known. As part of the new Aging/End of Life Care curricular theme at Harvard Medical School, first year medical and dental students participate in older adult home visits with geriatrics faculty to learn about the geriatric assessment. Our mixed methods analysis explores students' main lessons learned. We collected anonymous evaluation forms from 310 students following a one-time geriatric home visit over a 3 year period. Using a 5-point Likert scale, MS rated their comfort with various aspects of geriatric assessment and rated whether their interest in geriatrics increased after the home visit. MS described two lessons learned. Two coders analyzed 604 lessons learned and identified major themes which were then organized into the Geriatric 5Ms Framework (Multicomplexity, Mobility, Mind, Matters Most, Medications). Qualitative and quantitative data were analyzed using Excel, Dedoose and JMP statistical software. A majority of MS (72%) reported their interest in geriatrics somewhat or greatly increased after the home visit. Of the 604 lessons learned that were coded, 51% related to mobility. 56% of responses related to multicomplexity, of which the most common was understanding different living facilities (43%). After a geriatric home visit, MS interest in geriatrics increases as they learn about applying the Geriatric 5Ms Framework. The most common lessons learned related to mobility and multicomplexity, essential areas of focus in a geriatrics curriculum. Though more difficult to arrange in the COVID-19 era, educational home visits are an important opportunity to increase MS interest in geriatrics and build their skills to improve the care of older adults.

Complementary application of the ozonized saline solution in mild and severe patients with pneumonia COVID-19: A non-randomized pilot study

Context: Currently, there is no effective antiviral therapy recommended for novel coronavirus pneumonia 2019 (COVID-19). Aims: To assess the safety of ozonized saline solution (O3SS) used as a complementary therapy in adult COVID-19 patients. Methods: Twenty-five adult patients hospitalized with mild to severe symptoms of COVID-19, who met the inclusion criteria and were treated from April 18 to April 26, 2020, at Virgen De La Paloma Hospital, Madrid, Spain were included in this study. Patients were assigned to receive standard care consisting ceftriaxone (250 mg – 2 g twice daily for 7 days) plus azithromycin (500 mg once daily for 5 days), of 200 - 400 mg hydroxychloroquine twice daily for 5-7 days plus tocilizumab 400 mg twice daily for 5 days, low molecular weight heparin and 40 to 60 mg metil-prednisone plus O3SS, 200 mL, 3-5 µg/mL per day for 10 days. No control group was included, the data was compared to clinical trials in this subject. Secondary endpoints assessed included the clinical status of participants, laboratory examinations, and duration of viral shedding. Results: Patients with COVID-19 with mild to severe symptoms who received intravenous O3SS as an adjunct treatment experienced no side effects. The main results of O3SS treatment were a tendency to improve clinical symptoms without side effects. None of the patients treated died. Conclusions: Early evidence of efficacy shown improvements in symptoms such as dyspnea, weakness, and reduction in body temperature were observed and corresponded to improvements in laboratory results including D-dimer, fibrinogen, lactate dehydrogenase, and C-reactive protein. These preliminary data will serve as the basis for a future study of the effectiveness of this therapy.

Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vaginal swabs of women with acute SARS-CoV-2 infection: a prospective study.

OBJECTIVE: To determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is present in the vaginal secretions of both reproductive-aged and postmenopausal women during acute SARS-CoV-2 infection. DESIGN: Prospective study. SETTING: A single tertiary, university-affiliated medical centre in Israel. Time period, 1 June 2020 through to 31 July 2020. POPULATION: Women who were hospitalised in a single tertiary medical centre, who were diagnosed with acute SARS-CoV-2 infection by a nasopharyngeal RT-PCR test. METHODS: Women were diagnosed with acute SARS-CoV-2 infection by a nasopharyngeal RT-PCR test. Vaginal RT-PCR swabs were obtained from all study participants after a proper cleansing of the perineum. MAIN OUTCOME MEASURES: Detection of SARS-CoV-2 in vaginal RT-PCR swabs. RESULTS: Vaginal and nasopharyngeal swabs were obtained from 35 women, aged 21-93 years. Twenty-one women (60%) were in their reproductive years, of whom, five were in their third trimester of pregnancy. Most of the participants (57%) were healthy without any underlying medical conditions. Of the 35 patients sampled, 2 (5.7%) had a positive vaginal RT-PCR for SARS-CoV-2, one was premenopausal and the other was a postmenopausal woman. Both women had mild disease. CONCLUSION: Our findings contradict most previous reports, which did not detect the presence of viral colonisation in the vagina. Although passage through the birth canal exposes neonates to the vaginal polymicrobial flora, an acquisition of pathogens does not necessarily mandate neonatal infection or clinical disease. Nevertheless, when delivering the infant of a woman with acute SARS-CoV-2 infection, a clinician should consider the possibility of vaginal colonisation, even if it is uncommon. TWEETABLE ABSTRACT: When delivering the infant of a woman with acute SARS-CoV-2 infection, a clinician should consider the possibility of vaginal colonisation.