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Don’t miss other important issues facing hospitalists. Battling the other epidemic: opioids


June 15, 2021

Vaccination disparities

Burlington-Vermont

Big vaccination milestones: An AMA survey finds that 96% of practicing physicians in the U.S. have been vaccinated, and Vermont is the first state to have 80% of its population age 12 and older at least partially vaccinated. But a report from Kaiser Family Foundation finds that vaccination rates in communities of color are still lagging, with only 63% of Hispanics and 51% of African-Americans expected to be vaccinated by July 4. As for when those communities will be 70% vaccinated, the report claims that will be the end of July for Hispanics and the beginning of September for Blacks. The report also notes that many states aren’t on track to achieve 70% vaccination rates with at least one shot by July 4.

June 14, 2021

Judge tosses anti-vaxx lawsuit brought by hospital workers

A federal judge this weekend threw out a lawsuit brought by more than 100 hospital workers who were suspended from Houston Methodist Hospital for refusing to be vaccinated against covid. The workers, who say they will appeal, claimed in their suit that they did not believe the vaccines were safe because they’d been issued only EUAs by the FDA, not full approvals. In his ruling, the judge rejected the argument that the hospital’s policy of mandatory covid vaccinations was forcing workers to take part in a “human trial”—and called “reprehensible” the plaintiffs’ complaint that the vaccine mandate was similar to medical experiments done during the Holocaust. USA Today reports that a growing number of hospitals around the country are beginning to require vaccination among their workers.

Link between second dose and heart inflammation in young people?

myocarditis-covid

It’s rare but higher than expected, according to CDC and FDA officials. While the data are still preliminary, the agencies are investigating 573 cases of myocarditis and pericarditis reported in younger patients after receiving the second dose of either mRNA vaccine. (After the first dose, 216 cases have been reported.) The cases appear to be more common in men than in women, and most cases are mild. STAT reports that Israeli officials are also investigating “a possible link” between myocarditis and a second vaccine dose among men ages 16 to 30. According to agency officials, most of the patients for whom cases have been reported have fully recovered.

June 11, 2021

The push to vaccinate teens

teen-covid-vaccination

Adults are more than 10 times more likely to be hospitalized for covid than patients under age 18. But a new report from the CDC points out that covid hospitalization rates among those ages 12 to 17 is twice that for seasonal flu, and that adolescents with chronic health issues are a big concern. Among teenagers hospitalized with covid from early January 2021 through April 2021, nearly one-third required ICU care and 5% needed to be on a ventilator, however none died. About 70% had underlying health issues, with obesity being the most common and chronic lung diseases, including asthma, and neurological conditions also occurring. As for vaccinations among teens, the Kaiser Family Foundation looked at state laws around needing parental consent. Most states—41 of them—require teens younger than 18 to get parental consent, while Nebraska mandates parental consent for those below age 19. But many states allow teens who are emancipated or homeless to self-consent, as do two cities: San Francisco and Philadelphia, where minors age 12 and older can themselves decide to be vaccinated.

Analysis argues for continued use of convalescent plasma

Hospitals’ use of convalescent plasma to treat covid dropped after several published studies found no apparent benefit. But new research from Johns Hopkins makes the case for clinicians taking another look. The authors compared data on both the number of plasma units distributed to hospitals and of covid hospital deaths, finding a strong negative correlation. According to the model that researchers devised, every 10% increase in the rate of plasma used in hospitals cut covid fatalities by 1.8%—while the decline in plasma use between November 2020 and February 2021 may have contributed to more than 29,000 excess covid deaths. As to why some studies found no therapeutic benefit, the authors note that in many of the negative trials, convalescent plasma was administered relatively late in the course of the illness when patients were too sick to benefit and their immune responses were driving their disease.

Urban-rural gap in death rates is getting worse

The good news is that mortality rates for both urban and rural Americans are falling. The bad news: A new JAMA research letter finds a widening gap in the rate of those declines. Looking at 1999-2019 data, the authors found that the mortality gap between those two areas grew by more than 170%. In 2019, the death rate was close to 665 deaths per 100,000 in urban America but 834 deaths per 100,000 in rural areas. While men had higher mortality rates than women, both men and women in rural areas died at higher rates than their urban counterparts. In related news, the CDC reports that U.S. death rates for nine conditions climbed last year during the pandemic. The AP reports that the common killers with spiking rates last year included diabetes, heart disease, Alzheimer’s, stroke and hypertension. Some experts chalk those increases up to patients delaying care for fear of becoming infected.

Did pandemic precautions kill off some flu strains?

Some possible positive fallout from all the masking and physical distancing: Certain flu strains may have become extinct that in turn could make it easier to develop a more effective flu shot. That’s according to a STAT article, which notes that certain strains of the flu haven’t been recorded in databases since March 2020. While flu shots typically are quadrivalent—targeting four separate flu viruses—trivalent ones may be OK going forward. But not all flu epidemiologists are convinced the strains are gone for good, and experts point out that very few cases actually undergo genetic sequencing. In a typical year, about 20,000 undergo such sequencing—but this year, only 200 were uploaded to a repository.

June 9, 2021

Hospitalizations jump in areas with low vaccination rates

The seven-day averages for both new covid cases and deaths have dropped, with most states seeing a 5% or greater decline in new cases. But vaccination rates have also fallen off dramatically, and the New York Times reports that covid hospitalizations are on the rise in areas with low vaccination rates. One Tennessee county where only 20% of the population is fully vaccinated, for instance, has seen a close to 700% increase in covid hospitalizations over the past two weeks. Part of the problem is the spread of variants, with the highly transmissible Delta strain from India now accounting for more than 6% of the cases sequenced in the U.S. Another part of the problem is highlighted in an article from The Center for Public Integrity: People who have established profitable businesses selling vaccine skepticism and conspiracies.

June 8, 2021

How does covid affect the brain?

That question still remains unanswered a year and a half into the pandemic. Autopsies of patients who’ve died of severe covid show acute damage in their brains, including clotting and “swarms of immune cells,” according to the Washington Post. And patients report a host of seeming neurological symptoms such as disturbances of vision and hearing, as well as vertigo. Experts quoted in the article, including UCSF’s S. Andrew Josephson, MD, editor in chief of JAMA Neurology, suspect the virus does attack the brain, but they’re not sure of the mechanism. Perhaps covid acts like herpes simplex, sometimes causing dangerous swelling of the brain that in turn triggers an autoimmune attack. Experts disagree on whether the virus invades the brain directly. The NYU Grossman School of Medicine has received federal funding for four years to develop a databank of neurological studies and a biobank of tissue samples.

Pandemic precautions may have killed off some flu strains

Some possible positive fallout from all the masking and physical distancing that’s taken place over the past 18 months: Certain flu strains may have become extinct, and that in turn could make it easier to develop a more effective flu shot. That’s according to a STAT article, which notes that certain strains of the flu haven’t been record in databases since March 2020. While flu shots typically are quadrivalent—targeting four separate flu viruses—trivalent ones may be OK going forward. However, not all flu epidemiologists are convinced the strains are gone for good, and experts point out that very few actually undergo genetic sequencing. In a typical year, about 20,000 undergo such sequencing—but this year, only 200 were uploaded to a repository.

June 4, 2021

Good riddance to the (in-person) med school interview

med school virtual interviewA new article in Slate highlights what may be positive fallout from the pandemic: the end of the expensive cycle of in-person interviews for those applying to medical schools. According to the article, candidates apply to an average of 17 medical schools; back in the day, applicants went in person to every interview they were able to get. That added up to a very expensive application process, discouraging those with lower incomes or those who couldn’t take time off work when applying. “It might be no surprise at all,” the article noted, “that 51 percent of medical students come from the wealthiest quintile of households, with 24 percent from the top 5 percent alone.” This year, however, the entire interview process went virtual, which some sources in the article believe may disadvantage newer and rural medical schools. However, the majority of candidates and admission officers quoted welcomed the change.

Study: Close to half of discharged patients suffer functional decline

A recent study from University of Michigan delivers this snapshot of what may be an underreported covid complication: Close to half—45%—of all covid patients discharged had significant functional decline. The study, published in PM&R, found that 20% of patients who experienced functional decline were no longer able to live independently after discharge and needed to either enter a post-acute facility or go live with a family member. Researchers looked at charts for close to 300 patients discharged between March and May 2020, the pandemic’s first wave. During that time, the study notes that clinicians were struggling to maintain hospital capacity and to minimize their own and colleagues’ exposure; as a result, 40% of the patients in the study didn’t receive a rehab evaluation while hospitalized. Among patients in the study who suffered functional decline, more than two-thirds (68%) needed to be discharged with some form of durable medical equipment.

June 2, 2021

Hospital employees push back against vaccine mandate

vaccine mandateMore than 100 unvaccinated staff members at Houston Methodist Hospital signed onto a lawsuit filed late last week, pushing back against that hospital’s vaccine mandate. The Washington Post reports that the suit likens mandatory covid vaccination to medical experimentation without consent. The lawsuit states that the hospital—through compulsory vaccination—”is forcing its employees to be human ‘guinea pigs’ as a condition for continued employment.” Experts quoted in the article point out that the “experimentation” charge is absurd, given that the vaccines now in use went through rigorous clinical trials. Among staff members at the hospital, 99% have been vaccinated. According to the EEOC, companies can mandate vaccinations for employees within a workspace. However, employers must also meet a host of legal considerations, including accommodating employees’ health concerns—which encompass having disabilities as well as religious reasons against being vaccinated—and keeping vaccination information confidential. While most employers aren’t mandating vaccinations, many are offering incentives to encourage employees to get them.

Covid variants get new names

Can’t remember which variant is the B.1.1.7 or the B.1.671.2? While members of the medical community may be able to recognize the various variant designations, the World Health Organization has announced a new naming system for important variants, going with the Greek alphabet instead of the current system that relies on numbers and periods. The variant first identified in Britain (B.1.1.7) will now be known as Alpha because it was the first major one to be identified; the Indian variant (B.1.671.2), which was the fourth strain to be identified, will now be known as Delta. Once the number of variants exceeds the 24 letters in the Greek alphabet, a new naming system will be called for. STAT reports that the new nomenclature is a bid to make it easier for the public to keep important variants straight. It’s also a move to encourage reporting of new variants because the names of countries of origin now won’t be associated with an emerging mutation.

June 1, 2021

The ongoing search for effective treatments

covid research

Coronavirus spurred an unprecedented wave of targeted research into possible treatments. But according to a Wired writer looking at covid trials, most of those studies “were crap.” Despite a few standout trials, including those that showed the efficacy of steroids, most covid studies were either not randomized or were so small as to reach no solid conclusions. Now, however, large randomized trials being conducted in both the U.S. and Europe are looking at therapies with real potential: infliximab, an immune-suppressant; the anti-inflammatory imatinib; and artesunate, an antimalarial. In the U.S., another series of trials is gearing up to look at repurposed drugs that may be effective against mild or early covid. The chaos in covid trials might yield another important future change: master protocols to allow trials to test more than one drug at a time. During covid, the U.S. government spent $18 billion researching vaccines and only $8 billion on therapeutics. The article points out that the federal government needs to step up and sponsor more trials on repurposed drugs because such drugs don’t represent enough profit for Big Pharma to fund.

Study: Close to half of discharged patients suffer functional decline

A recent study from University of Michigan delivers this snapshot of what may be an underreported covid complication: Close to half—45%—of all covid patients discharged had significant functional decline. The study, published in PM&R, found that 20% of patients who experienced functional decline were no longer able to live independently after discharge and needed to either enter a post-acute facility or go live with a family member. Researchers looked at charts for close to 300 patients discharged between March and May 2020, the pandemic’s first wave. During that time, the study notes that clinicians were struggling to maintain hospital capacity and to minimize their own and colleagues’ exposure; as a result, 40% of the patients in the study didn’t receive a rehab evaluation while hospitalized. Among patients in the study who suffered functional decline, more than two-thirds (68%) needed to be discharged with some form of durable medical equipment.

May 28, 2021

How much delayed care wasn’t needed?

Will care delayed during the pandemic help researchers shine a light on low-value health care? A Kaiser Health News article examines the growing body of evidence on outcomes for people who delayed care during the pandemic to determine if that care is unnecessary. One study, for example, found that VA patients who had elective surgeries canceled because of covid showed no increased use of the ED compared to patients who had undergone the same surgeries two years before. A HealthAffairs article suggests that researchers could study differences in pre-pandemic and current outcomes for screening colonoscopy (particularly among older patients), regular measurements of hemoglobin A1c for diabetics and knee arthroscopy for articular cartilage repair. In related news, a recent study found that while routine preop testing before low-risk surgery is common, it adds little value. A study in JAMA Internal Medicine found that of people undergoing preop testing for three low-risk surgeries, half had one or more preop tests while 29% had two or more tests. Older patients were the most likely to receive testing, and the most common tests were CBC counts and electrocardiograms.

“Burnout” doesn’t really cover it

Before the pandemic, many health care workers were already struggling with burnout. But to be able to communicate and work through what health care professionals have experienced in the past 18 months, “leaders and organizations need expanded vocabularies, strategies and resources.” That’s according to a Becker’s Hospital Review editorial, which delves into the many facets of clinicians’ experience since the pandemic began. Labeling all of those reactions—fear, moral injury, invalidation, isolation, exhaustion—as “burnout” prevents groups and organizations from addressing specific factors that drive those different feelings. Making matters worse: Some organizations try to meet the current mental and emotional challenges with the same menu of strategies they used pre-pandemic, as if those experiences could be managed through yoga classes or more workouts. Instead, the editorial argues, health care organizations need to offer new kinds of resources for mental health and emotional support. They also shouldn’t expect the difficult effects of working through the pandemic to subside when covid patients stop being hospitalized. “Naming distinct emotions or experiences helps diffuse their charge and gives us a say in what we do with them,” the editorial concludes.

Lotteries, other incentives, drive vaccination rates

A recent college grad in Ohio is $1 million richer this week, the first of five winners to be named in Ohio’s “Vax-a-Million” lottery. Also named: The first of what will be five teenagers awarded a full scholarship to Ohio public colleges, all part of that state’s drive to boost vaccination rates among those age 16 and older. In the week after it was rolled out, Ohio’s lottery drive increased vaccinations in that state by more than 30%. Colorado, Oregon, New York and California have followed suit, announcing big-cash lotteries, while Maryland will hold drawings for 40 days straight, giving vaccinated state residents 18 and older a chance to win portions of a total $2 million pot. The lotteries are part of an array of vaccination incentives, ranging from new cars and sporting goods to a chance to win a year of free domestic airline travel. (All vaccinated members of United’s MileagePlus program can enter that travel lottery by June 22.) In other vaccination efforts, states and cities are switching from having only mass vaccination sites to mobile campaigns. The New York Times reports, for instance, that Los Angeles will move to mobile vaccine vans and trailers by Aug. 1, using mobile units to target communities with the lowest vaccination rates. Similar mobile clinics have been set up in Washington state, Delaware and Minnesota.

With breakthrough infections, the CDC courts controversy

The CDC continues to provide state-level data on breakthrough infections, which occur in people who are fully vaccinated. But the agency is drawing fire for its decision to, starting this month, collect data and report on only those breakthrough cases severe enough to result in hospitalizations or deaths. As of the end of April, the CDC had received reports on more than 10,200 breakthrough infections (out of more than 100 million full vaccinations), with 63% occurring in women. Based on preliminary data, 27% of those cases were asymptomatic, while 10% were hospitalized and 2% died. As for the CDC’s decision to stop collecting data on all breakthrough infections, those who support the change say that only cases that tax the health care system are worth monitoring. But critics believe the CDC is losing the opportunity to learn whether breakthrough infections are associated with a specific vaccine and whether mild or even asymptomatic cases produce long-term complications.

May 24, 2021

Huge health care meeting says only vaccinated can attend

speaker for continuing medical education in hospital medicineOne of the biggest medical meetings to return after the pandemic has announced that all attendees will need to provide proof that they’re vaccinated. The Healthcare Information and Management Systems Society (HIMSS), whose meetings before covid routinely drew 40,000-plus attendees, will host its next meeting this August in Las Vegas. An article in Heathcare Innovation says the meeting will consider attendees fully vaccinated if two weeks have passed since their last shot of the Moderna or Pfizer/BioNTech vaccines or if two weeks have passed since their single dose of the J&J vaccine. HIMSS says it is currently evaluating how it will require attendees to prove their vaccination status, but it will likely use digital technology that protects the privacy of attendees. Meeting organizers say they plan to keep an appropriate amount of space on the exhibit hall floor between exhibitors and to use social-distancing strategies during educational sessions.

Vaccines help vaccinated and unvaccinated nursing home residents

New data show that covid vaccines are slowing down spread of the virus in vaccinated and unvaccinated residents of nursing homes. A correspondence published in The New England Journal of Medicine found that in more than 13,000 nursing home residents vaccinated with the Moderna or Pfizer/BioNTech vaccine, cases of the virus dropped from 822 within two weeks of the first shot to 38 cases two weeks after the second shot. Among nearly 4,000 unvaccinated residents, cases of the virus dropped from 173 within 14 days of the vaccination clinic to 12 cases after the second vaccination clinic. There was more good news: 66% of cases were asymptomatic in the two weeks after the first vaccination clinic, and 83% were asymptomatic after the second vaccination clinic.

May 21, 2021

CDC details more cases of blood clots after J&J vaccine

Late last week, the CDC announced that it had found more cases of “potentially life-threatening” blood clots among people who received the J&J shot. A Medscape article says that the CDC has identified 28 cases of thrombosis with thrombocytopenia syndrome out of the nearly 3 million people who received the J&J vaccine. Three of those people died. The agency noted that the side effects resemble those found in a small number of Europeans who received the AstraZeneca vaccine. Both shots use adenovirus technology to deliver messages that instruct the body to make covid proteins to help the body fight the infection.

Fauci says vaccines offering “near-complete protection” against variants

During the keynote address before the American Thoracic Society meeting, Anthony Fauci, MD, said new data show the vaccines being used in the U.S. are offering “near-complete protection” against the U.K. and South African covid variants. According to a MedPage Today report, Dr. Fauci cited data from a research letter published in The New England Journal of Medicine. That letter found that that the Pfizer/BioNTech vaccine was 90% effective against the U.K. variant and 70% effective against the South Africa variant. The data come from a study of nearly 400,000 people in Qatar. Dr. Fauci added that preliminary data on the vaccines’ effectiveness against the Brazil and India variants are similarly promising, although he warned that the situation could change.

May 14, 2021

More data on vaccines’ effectiveness in protecting health care workers

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If you have colleagues who are refusing to get a covid shot, you can point to a new study that shows the Pfizer/BioNTech vaccine will keep them safe. A JAMA study found that in a group of health care workers in Israel, only eight of 5,500 fully vaccinated workers got symptomatic covid, compared to 38 of nearly 760 unvaccinated workers. The study also found that asymptomatic infections occurred in 19 fully vaccinated health care workers and 17 unvaccinated workers. Because the group of vaccinated workers was so much larger than the number of unvaccinated workers, the data showed that unvaccinated workers were 14% more likely to have asymptomatic cases of covid. A research letter in the same issue of JAMA similarly found fewer symptomatic infections among vaccinated health care workers, but it also found more asymptomatic infections among the vaccinated.

CDC releases report on “stark differences” in vaccination rates

While nearly 80% of Americans 65 and over have received at least one dose of the covid vaccine, there are gaps in vaccine coverage that illustrate some of the geographic, racial and social disparities the country faces as it tries to reign in the pandemic. A CDC report says that vaccinated Americans are overwhelmingly white, although demographic data weren’t available for everyone in the study population. The report also found stark differences by geography. In Alabama, for example, fewer than 70% of seniors have received at least one dose of the vaccine, compared to nearly 100% of older adults in New Hampshire. Counties with lower vaccination rates tended to have higher numbers of older adults with “social vulnerabilities,” such as a lack of access to the Internet and living alone.

Most docs vaccinated, support mandatory vaccines for clinicians

A Medscape poll provides data on vaccination rates for physicians and what they think of mandatory vaccinations for health care workers. The survey of nearly 1,000 physicians found that 79% are partially vaccinated and that 75% are fully vaccinated. That leaves 16% who have no plans to get vaccinated and 5% who are planning on getting the shot. In the survey, 69% of physicians said they believe employers should require clinicians to get a shot. Seventy percent of those physicians said the shots should be required immediately; the other 30% advocated for waiting for full FDA approval before requiring vaccinations for health care workers. Seventy-five percent of female physicians supported the idea of mandatory vaccines for clinicians compared to 67% of male physicians, and support was highest among physicians 65 and older. Among nurses, 62% were already vaccinated, but only half supported the idea of mandatory vaccines for clinicians.

CDC’s messaging a mess, according to critics

While the CDC has made major announcements in the last week about the nature of how the covid virus spreads (via aerosolized particles) and the need—or lack thereof—for masks, critics are complaining that the agency’s messaging has been too conservative and is confusing the public. A STAT article outlines the issues the CDC has had with its messaging, pointing that its mask guidance a week or so ago was so conservative that it was lampooned on The Daily Show. A poll conducted by the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that only 52% of Americans said they have “a great deal of trust” in the CDC, and only 37% said the same thing about the NIH or FDA. An NPR article says those sentiments extend to state and local health agencies, which are trusted by just over 40% of Americans.

I hate myself on screens! The psychologic fallout of covid

One side effect of the pandemic appears to be a growing interest in cosmetic surgery. A MedPage Today article explains that as people have been staring at images of themselves on platforms like Zoom, many haven’t liked what they’ve seen. “Zoom dysmorphia” is a term dermatologists are using to describe the fallout, which one small study found was associated with a 57% increase in cosmetic consultations. In that study, 86% of patients cited video conferencing as the reason they were seeking a consult. The study found that the most common concerns cited by patients were wrinkles on their upper face, circles under the eyes, dark spots on the face, and sagging necks.

May 9, 2021

Can the J&J vaccine cause anxiety-related adverse events?

vaccination-anxietyThe pandemic has clearly challenged the mental health of many people, but can the stress of covid produce a physical response to a vaccine? Researchers claim that’s exactly what happened when dozens of Americans had post-vaccine symptoms this spring that included fainting or dizziness. According to a Modern Healthcare article, 64 people who received the J&J vaccine in five states experienced problems, but experts from the CDC say those issues were not caused directly by the vaccine. CDC researchers suspect that the people who experienced issues had specifically sought out the J&J’s one-dose shot because they were anxious about getting a vaccine. This anxiety, the researchers claim, likely made these people “more highly predisposed to anxiety-related events” when getting vaccinated. CDC researchers also discovered that about one-quarter of people who experienced problems after getting the covid shot said that they had experienced similar side effects after getting other vaccines. According to a MedPage Today article, data published this week in the MMWR found that there were 8.2 anxiety-related episodes for every 1,000 people who received the J&J vaccine, compared to 0.05 episodes per 1,000 people who received the flu vaccine. Concerns that people are anxious about the J&J vaccine are backed up by recent polling data, which found that about three in four Americans who haven’t yet been vaccinated said they won’t get the J&J vaccine. Those same Americans rated the J&J vaccine as less safe than the Moderna and Pfizer vaccines.

Report names hospitals performing the most unnecessary procedures

A group is naming what it says are the best and worst 50 hospitals when it comes to 12 procedures that are widely regarded as unnecessary. The report, which was issued by the Lown Institute, focuses on inappropriate procedures like the use of carotid artery imaging and head CTs/MRIs to examine patients who present after fainting but had no other risk factors. For those patients, carotid imaging was used by all hospitals on average 7% of the time; CTs/MRIs of the head were used on average 23% of the time. A MedPage Today article says that at the hospital designated the worst offender by the report, carotid imaging was used for 23% of the above patients and head CTs/MRIs were given to 75% of the above patients. Other inappropriately used procedures cited by the report include hysterectomy and vertebroplasty.

May 5, 2021

What do Leapfrog safety grades look like during a pandemic? (updated 5/7/2021)

hospital-safety-ratingNew safety ratings from the Leapfrog Group gave 906 hospitals its top rating and more than 1,000 hospitals a “C” grade or worse. While the ratings have been around for 20 years, the group says that its current ratings serve as a proxy for safety during the pandemic. The report ranks states with top-performing and low-performing hospitals, noting that four states—Idaho, Maine, Massachusetts and Virginia—had more than half of their hospitals scoring an “A” grade. The organization has also posted testimonials from hospitals explaining what they have done during the pandemic to keep patients safe. Fierce Healthcare notes that the Leapfrog Group’s reporting methods have been challenged by hospitals and researchers.

30-days post-diagnosis, covid patients face “excess” health issues, increased death

A study in Nature found that more than 30 days after being diagnosed with covid, patients face an “excess burden” of a variety of problems, and that even patients with mild infections face an increased risk of death within six months of a diagnosis. A Healio article says that researchers found that 30 days after a diagnosis, covid patients who were not hospitalized had a nearly 60% increased risk of death, with 8.39 excess deaths per 1,000 people. Patients hospitalized after 30 days faced a 51% increased risk of death, with excess deaths in this group estimated about 29 per 1,000 people. The researchers also found that beyond 30 days, covid patients faced a “substantial burden of health loss” involving nearly every organ in the body. The most common issues were respiratory conditions, but researchers also saw nervous system issues, cardiovascular problems and GI issues.

April 30, 2021

Real-world data confirm efficacy of covid vaccines

Real-world data from a small trial show that the Pfizer-BioNTech and Moderna vaccines are 94% effective in reducing hospitalization among Americans 65 and older who got both shots. A report in MMWR notes that in people who received only one shot, the vaccine was 64% effective. The study represents the first real-world data. While another Israeli study had come up with similar results, it looked at only the Pfizer-BioNTech vaccine. The MMWR study looked at 417 adults hospitalized with COVID-19–like illness in 14 states between January and March 2021.

Creative strategies to get more Americans vaccinated

money-incentiveAs vaccination rates in the U.S. begin to wane, a long list of organizations is coming up with creative strategies to vaccinate more Americans. A hospital in Jackson Hole, Wyo., for example, is giving its employees a $600 bonus if they’re fully vaccinated by May 31. A Houston health system is not only using a carrot to encourage vaccinations (by offering $500 payments), but it is also threatening to fire employees who can’t provide proof of vaccination by June 7. The giant insurer Cigna is offering U.S. employees $200 in their health savings accounts and paid time off to get vaccinated. And on the national level, President Biden has announced tax credits that businesses can take if they give employees paid time off to get vaccinated.

FDA “encourages” hospitals to return to one-and-done for N95s

In another sign that some signs of normalcy are on the horizon, the FDA is encouraging health care workers to return to the pre-pandemic policy of using N95 masks once and then discarding them. While hospitals are still legally allowed to sterilize and re-use N95s, the FDA is currently recommending a one-use policy and in the coming weeks is expected to begin requiring health care facilities to discard masks after one use. A Modern Healthcare article says that the announcement comes on the heels of word that U.S. manufacturers have surpluses of PPE for sale. Many hospitals say they have three to 12 months of PPE stockpiled.

Rules for buprenorphine relaxed as opioid use rises in long haulers

The Biden administration will make it easier for physicians to prescribe buprenorphine to treat opioid disorder. A Fierce Healthcare article says that the HHS has released new guidelines that exempt physicians and other clinicians from some certification requirements to prescribe the drug that were viewed as onerous. The Trump administration had announced the changes earlier this year, but the current administration put them on hold until now. The change is significant given the rise in overdose deaths during the pandemic. A Kaiser Health News article notes that a new study found “alarmingly high rates” of opioid use among covid long haulers at VA hospitals around the country. The study is raising alarms about a new epidemic of opioid addiction.

April 28, 2021

Good, bad news about your chances of getting covid

First, the good news: Health care providers rarely get covid on the job. In a study published this month in Clinical Infectious Diseases, researchers performed viral sequencing to determine the origins of covid in health care workers. They found no signs of healthcare-associated transmission in “the majority” of infections they evaluated. A Medscape article says that 11% of the infections studied in health care workers could be attributed to one of their coworkers and 4% could be attributed to one of their patients.

The not-so-good news is for health care professionals who work a lot of nights. A study in the journal Thorax found that people who worked some shifts outside of a traditional 9-5 schedule were more than twice as likely to get covid as people who work during the day. People who only worked nontraditional shifts were 2.5 times more likely to be diagnosed with covid. Researchers found these risks persisted even after controlling for known risk factors like BMI and smoking. They hypothesized that shift work’s effects on the circadian rhythm may alter the body’s response to the covid virus.

April 26, 2021

One unvaccinated nursing home worker; dozens of infections and three deaths

nursing-home-importance-vaccinationA covid outbreak in March in a nursing home in Kentucky is a stark reminder of the consequences of continuing to work with vulnerable patients while not being vaccinated. The New York Times reports that while 90% of the residents in that home had been vaccinated, that was the case for only half the staff. One unvaccinated worker who became infected caused 26 infections among residents (including 18 among those vaccinated) and 20 infections among other staff members. Three of the infected residents died, including one who’d had vaccine. A CDC write-up of the outbreak notes that the infections were “a newly introduced variant to the region.” The New York Times points out that resistance to being vaccinated has been high around the country among nursing home staff.

Even mild covid cases are linked to higher mortality risk

New VA data deliver this bad news: Being infected with covid—even without needing to be hospitalized—leads to a 59% greater risk of death within six months than among those who don’t become infected. Further, six-month mortality risk is also high among covid patients who are hospitalized, running 51% more than among patients with seasonal flu. Published in Nature, the study is based on data from more than 70,000 VA patients; fewer than 20% of those patients were women, and most were over age 60, according to Forbes. The study is one of the largest to look at “long covid,” those symptoms patients suffer long after their acute infection. And speaking of seasonal flu, here’s a New York Times headline from last week: “The Flu Vanished During Covid.” While recent flu seasons in the U.S. have each produced more than 200,000 recorded cases a year, the 2020-21 season saw only 2,000.

Bamlanivimab is out as a monotherapy

Earlier this month, the FDA revoked its EUA for bamlanivimab when administered alone, saying that the covid variants that are on the rise are resistant to being treated with the monoclonal antibody alone. As a result, Medicare will pay for bamlanivimab as a monotherapy only if administered between Nov. 10, 2020, and April 16, 2021. But there’s good news: The FDA also indicated that alternative therapies consisting of combined monoclonal antibodies are still appropriate. Those include casirivimab/imdevimab as well as bamlanivimab/etesevimab, and fact sheets about the use of those combinations can be found here and here. The FDA has issued EUAs for those combinations for the same indications that bamlanivimab alone used to have: for adult and certain pediatric patients with mild to moderate covid.

 April 23, 2021

More younger people are being hospitalized

young-adult-covid-hospitalA handful of states—many of them hard hit with covid a year ago—are once again the country’s hotspots, according to the Wall Street Journal (subscription required). About three-quarters of all new cases last week were reported in five states: Michigan, Florida, New York, Pennsylvania and New Jersey. CNN reports that, due to the U.K. variant being more contagious and more older patients being vaccinated, hospitalizations are on the rise among younger patients, who are suffering more severe complications than expected. Last month, for instance, New Jersey saw a 31% jump in covid hospitalizations among patients ages 20 to 29 and a 48% increase in covid hospitalizations among ages 40 to 49. An article in The Atlantic posits a future in which adults stop worrying about their elder parents becoming infected and start worrying about their children under age 12, who will be the last group vaccinated. Around the world, India is in crisis, setting global records for new daily cases (more than 300,000). The CDC is warning against traveling to India, saying that if a trip in unavoidable, only fully vaccinated people should travel there. The U.K. is now banning all travelers from India.

How soon will vaccine supply in the U.S. catch up to demand?

As of Monday, all adults in all states are eligible for vaccine and vaccine supplies have bumped up significantly from just a month ago. Kaiser Family Foundation now predicts that within the next two to four weeks, the U.S. will likely hit a tipping point where finding Americans who want to be vaccinated will become much harder. “Federal, state, and local officials, and the private sector,” the foundation writes in a policy statement, “will face the challenge of having to figure out how to increase willingness to get vaccinated among those still on the fence.” In addition to those hesitating to get vaccine, 20% of Americans polled claim they won’t be vaccinated or will only if required. The Cleveland Clinic is partnering with Mayo and more than 50 other hospitals and health systems on the “Get the Vaccine to Save Lives” campaign, producing public service announcements to convince those who haven’t yet been vaccinated to step up. And to entice employees to be vaccinated, one hospital in Wyoming—St. John’s Health in Jackson Hole—is giving each full-time vaccinated employee a $600 bonus—and offering the same to those who’ve held off, as long as they’re fully vaccinated by May 31. The goal is to have as many employees vaccinated as possible before summer tourists start to arrive. Meanwhile, while the FDA and CDC may decide later today whether to end the pause in using the J&J vaccine, phase 3 trial results for that vaccine have been published in the NEJM. The results: 75% efficacy at more than 28 days, and 85% against severe or critical disease.

April 22, 2021

Nursing vacancies grow, and burnout is widespread

covid-icuHospitals are reporting a spike in unfilled nursing positions, a dilemma that hospitals have increasingly tried to meet with growing numbers of (expensive) traveling nurses. In a survey of 100 hospital executives, 36% said they expect to have more than 25 nursing positions open this year, a rate more than twice what it was in 2020 (17%). Among respondents, 70% reported losing between 5% and 30% of their nursing staff as a result of covid. In other news, a Washington Post-Kaiser Family Foundation poll found that three out of every 10 health care workers are considering leaving the profession, due to burnout and stress. While 55% of all health care workers surveyed reported burnout, younger people had higher levels: 69% among those age 18 to 29 and 61% among those age 30 to 39. Mona Masood, DO, a Philadelphia psychiatrist, started the Physician Support Line (1-888-409-0141) a year ago, staffing it with hundreds of volunteer psychiatrists and fielding more than 2,500 calls. Dr. Masood told the Washington Post that she is most concerned about health care workers when the pandemic ends, likening them to soldiers returning from war.

April 19, 2021

New variant tracking system will target biological threats

biological-threat-protectionThe White House last week announced a $1.7 billion federal program to track covid mutations. As proposed, the program would establish the first permanent national infrastructure to tackle biological threats. AP reports that the network has three components: directing the CDC and state health departments to map genetic samples (to be funded with $1 billion); partnering with universities to create six research and development centers to identify emerging pathogens ($400 million); and creating a national data-sharing network ($300 million). According to the AP, the funds are part of the recently approved coronavirus relief package and are designed to “break what experts say is a feast-or-famine cycle in U.S. preparedness for disease threats.”

Why are vaccinated people getting infected?

Their numbers are tiny, which is reassuring. But a very few cases are being recorded of fully vaccinated patients coming down with what are being called “breakthrough infections” and testing positive for covid. In rare cases, some even have been hospitalized and a few deaths have occurred, according to ProPublica. Experts don’t know why; further, they are concerned that many cases of breakthrough infections aren’t being sampled and analyzed to find out which variants, if any, may be driving the very few reported cases. Another problem: Some states aren’t reporting the level of symptoms that patients with breakthrough infections are having. South Carolina’s health department has reported 155 cases of breakthrough infections out of 950,500 full vaccinated patients, an infection rate of 0.02%. MedPage Today coverage points out that the number of breakthrough cases are as expected.

April 16, 2021

Working nights alters your genetic “circadian rhythmicity”

how nocturnists manage difficult night admissions?We all know that working nights stinks, but new research yields data on how night work may increase your risk for cancer. An MDedge article says that researchers have found that a simulation of night work changed “the normal circadian rhythmicity of genes,” which can lead to hallmarks of cancer. The study, which appeared in the Journal of Pineal Research, concluded that night work reduces the ability of the body’s RNA to repair genes affected by working at night. During the simulation, some of the genes of participants lost their normal day-shift rhythmicity. The study also found that night work increases endogenous and exogenous DNA damage. The next step, researchers say, is to test real-world night-shift workers to see if the damage from unrepaired DNA builds up over time, increasing cancer risk.

Pandemic spurs rapid evolution of chief wellness officer role

survey done last summer at University of Utah Health about the pandemic came to this conclusion: “a substantial number of employees and trainees experienced major stress and work disruptions.” In fact, one in five reported considering leaving the health care workforce because of covid-related challenges, particularly around child care, and 30% considered cutting their work hours. It’s results like these that underscore the importance of wellness efforts in health care, while a new NEJM article highlights the evolving role of chief wellness officers during the pandemic. The authors, who are chief wellness officers from health systems and academic centers around the country, say that support services in many of their institutions were underutilized even during the pandemic, due in part to the ongoing stigma over using mental health resources. Successful outreach deployed during the pandemic included in-person wellness rounds. Importantly, the authors note that the intensity of treating covid patients hasn’t allowed clinicians to process their experiences.

April 13, 2021

FDA, CDC recommend a pause on the J&J vaccine

pause-buttonU.S. agencies are recommending halting the use of Johnson & Johnson’s one-dose covid vaccine pending the results of an investigation into six cases of clotting among recipients. STAT reports that the recommendation stops short of pulling the vaccine off the market, even temporarily. The clotting incidents, which all occurred in women, are similar to those found with AstraZeneca’s vaccine. All six cases were rare cerebral venous sinus thromboses in combination with thrombocytopenia. The six women affected were between the ages of 18 and 48, and their symptoms occurred between six and 13 days after they received the vaccine. As of this week, more than 6.8 J&J doses have been administered in the U.S. Two studies in NEJM—one looking at 11 patients in Germany and Austria, the other on five patients in Norway—delved into the clotting problems with AstraZeneca’s vaccine. The authors of both studies implicate platelet-activating antibodies targeting platelet factor 4 (PF4)-heparin, and they speculate that the antibodies are triggered by free DNA in the vaccine.

Prophylactic monoclonal antibodies?

A monoclonal antibody combination developed by Regeneron is being touted as a prophylaxis for household members of infected covid patients. According to a company press release, phase 3 trial results indicate that giving household contacts the casirivimab-imdevimab cocktail cut their risk of developing symptoms 72% during the first week and 93% in subsequent weeks. By day 29, only 1.5% of those who received the monoclonal antibodies had developed symptomatic infection vs. 7.8% of those given placebo. In addition, among those receiving the cocktail who developed symptoms, those symptoms lasted only one week vs. three weeks among those on placebo who became symptomatic.

April 12, 2021

OK to ease up on conserving N95s?

n95-face-maskThe FDA last week issued guidance that says it is now OK for health care personnel and facilities to transition away from conservation strategies with N95s and other filtering respirators. Included in the recommendations: Facilities can move away from using a crisis capacity strategy of conservation, and they can limit their decontamination of disposable respirators. They can also increase their inventory of available NIOSH-approved respirators and PAPRs. According to a press release, both the FDA and the CDC believe U.S. hospitals now have an adequate respirator supply. At the same time, the FDA made it clear that the agency is not revoking its current authorization of decontamination and bioburden reduction systems.

Covid pneumonia: Researchers find good results with home oxygen

According to a recent study, researchers in southern California got good results—low all-cause mortality and 30-day readmission rates—by discharging patients with covid pneumonia home with supplemental oxygen. Writing in JAMA Network Open, the authors detail the retrospective results of a program launched by the Los Angeles health department that included more than 620 patients. All needed at least 3L per minute of supplemental oxygen, and all were stable without any other indication for inpatient care. (Nurses followed up with patients within 12 to 18 hours of discharge from either the hospital or ED, and that back-up continued if indicated.) Followed for close to 30 days, patients had a mortality rate of 1.3% and a readmission rate of 8.5%. The authors point out that the intervention helped preserve inpatient beds for sicker patients, had an adequate safety profile and “may help optimize outcomes.”

April 9, 2021

Video games to treat brain fog?

A Boston-based startup made news last summer as the first company to get FDA clearance to market a video game as a prescription therapeutic. While that indication was for children with ADHD, Fierce Healthcare reports that the same company is now working with several major academic centers to test whether that digital treatment can improve covid “brain fog,” cognitive and mental effects that linger in some covid patients months after respiratory symptoms resolve. The company, Akili Interactive, is working with Vanderbilt University Medical Center, NewYork-Presbyterian Hospital and Well Cornell Medicine to design randomized trials. Those trials will test the ability of the video game which is marketed as EndeavorRx—to improve cognitive functioning. “The software,” according to the coverage, “provides challenges and stimuli that target the brain’s neural systems linked to focus, cognitive function and multitasking.” The academic centers plan to begin enrolling patients in the studies next month. A study published this February in Neuropsychopharmacology found that among patients with severe covid and prolonged hospitalizations, 81% had cognitive impairment that ranged from mild to severe.

U.K. variant: spiking cases, vaccine strategies, hospital testing

The spring’s steady downtick of cases is long over, with close to 65,000 cases a day now being reported. Many are occurring in cities in Michigan and New York, and experts say that most are being caused by the U. K. variant, although a variant first identified in New York City is behind outbreaks in Connecticut, New Jersey and Pennsylvania. Hospitalizations in areas with spiking cases are also rising, particularly among middle aged patients under age 50—a group that’s not close to being vaccinated. Some public health officials are urging the administration to divert vaccine supplies to Michigan, a move the Biden administration so far has rebuffed. Other experts have renewed calls made earlier this year to switch for now to a one-dose vaccine strategy, delaying second doses of both the Pfizer-BioNTech and Moderna vaccines for 12 weeks to allow more people to receive at least one dose. In other variant news, MedPage Today reports that the FDA is cautioning about possible problems with a molecular test brand popular in hospitals. Three Cepheid PCR tests (Xpert Xpress, Xpert Xpress DoD and Xpert Omni) pinpoint the N2 and E targets within viral RNA, according to the coverage, but the U.K. variant may reduce test sensitivity for the N2 target. Microbiologists quoted in the article, however, say they’re not worried about the accuracy of test results because the tests have multiple targets.

More setbacks for AstraZeneca

Another week, more AstraZeneca drama: A European agency now says that blood clots should be listed among the very rare side effects of that company’s covid vaccine. According to the European Medicines Agency, its members investigated more than 80 cases of thrombosis (out of 25 million doses administered) among patients given the AstraZeneca vaccine, 18 of which were fatal. Most of those cases were in women under age 60, and they occurred within two weeks of being vaccinated. While the agency noted “a possible link,” it did not recommend limiting the use of that vaccine, which is the go-to in European vaccination efforts. The WHO, meanwhile, notes that no causal relationship between the vaccine and clotting has yet been confirmed, although such a relationship is plausible. CNN reports that U.K. officials now recommend that people under age 30 look for alternative vaccines. While the AstraZeneca vaccine isn’t approved for use in the U.S., experts worry that concerns here about side effects, even when very rare, could spur vaccine hesitancy.

April 7, 2021

Up to 43,000 children in the U.S. have lost a parent to covid

shadow-parent-childrenA new research letter delivers this heartbreaking statistic: Tens of thousands of American children had lost at least one parent to coronavirus as of February 2021. Depending on the estimation model used by the authors, the number of children in the U.S. who have lost a parent ranges between 37,300 and 43,000. About three-quarters of them are adolescents, while 20,600 were non-Hispanic White and 7,600 were Black. Black children represent 20% of those who have lost a parent although they make up only 14% of the pediatric population. Due to covid, the tally indicates a 17.5%-20.2% increase in expected parental deaths. The letter, which was published by JAMA Pediatrics, estimated the number of affected children based on demographic simulation of several mortality scenarios, and the authors point out that the estimates don’t account for nonparental primary caregivers. “Sweeping national reforms,” they write, “are needed to address the health, educational, and economic fallout affecting children.”

Excess deaths last year jumped more than 20%

Another grim tally of coronavirus in 2020: All-cause mortality rates in the U.S. last year jumped 23%, with close to three-quarters of those deaths chalked up to covid. The number of excess deaths from March 2020 through the beginning of January this year was 522,000, according to a JAMA research letter. The authors found that death rates for Alzheimer’s, diabetes and heart disease also rose over the course of last year, particularly during covid surges. They also pointed out the racial disparities they uncovered in their analysis: While Blacks make up only 12.5% of the U.S. population, they account for close to 17% of the excess deaths recorded. An accompanying editorial points out that covid—despite the advances over the past century in public health, medicine and science—will likely contribute to almost as many deaths in the U.S. as the 1918 influenza pandemic.

April 6, 2021

Pfizer vaccine effective against South Africa, New York variants

In the fight against the South Africa variant, data show that the Pfizer-BioNTech vaccine is effective. Pfizer-BioNTech released data last week showing that its vaccine appeared to be 100% effective in preventing the South Africa variant of covid from spreading in a trial of 800 people. In addition, a MedPage Today article notes that data from a larger study showed that the vaccine had 91.3% efficacy in preventing symptomatic illness after a second dose was administered. In other variant news, data also show that both the Pfizer-BioNTech and Moderna vaccines appear to be effective against a New York variant of covid. A Medscape article says that a team of New York researchers exposed replicas of the New York variant to blood from people who had been vaccinated (and also to the Regeneron antibody therapy used to treat infected patients) to determine whether the variant could be “neutralized.” The study, which has not been peer-reviewed, found that antibodies induced by the vaccines were effective in blocking the variant. Finally, an Axios article offers an excellent overview of covid variants and strategies to stop them.

Videos help educate minorities about the basics of covid

covid-education-videoAn Annals of Internal Medicine study has found that giving basic information about pandemic protocols via video “modestly improved” knowledge among Black and Latino patients regardless of the race of the clinicians presenting information in the videos. A JAMA Network article says that when 15,000 participants viewed three videos covering pandemic basics like social distancing, hygiene and face masks, the control group did better on a short questionnaire. While 80% of people in the intervention group answered all questions correctly, 73% of people in the control group got all answers right. Researchers also found that Black participants who spoke via video to a Black physician were more likely to request more information about covid.

April 5, 2021

Vaccines: Calls grow in the U.S. for a dose-sparing strategy

Using a one-dose strategy—and delaying a second dose of either the Moderna or Pfizer-BioNTech vaccine so more people would receive a single dose—is now getting a renewed push. While advocates for such an approach went public earlier this year, the Biden administration along with the FDA and Anthony Fauci, MD, decided to stay the course, ensuring second doses for those who’d already received one dose three or four weeks earlier. But new daily cases are up 18% over the last two weeks, with alarming outbreaks reminiscent of July 2020 and December 2020 taking place around the country, including in Michigan. STAT reports that the U.K. has had a great deal of success by delaying second doses of both the Pfizer-BioNTech and AstraZeneca vaccines, and 47% of that population has received at least one dose amid falling caseloads. (By contrast, only 31% of the U.S. population has received at least one dose.) Advocates for the one-dose strategy in the U.S. include former Biden advisory board members Atul Gawande, MD; Zeke Emanuel, MD. PhD; and Michael Osterholm, PhD, MPH.

CDC issues new travel guidance for the vaccinated

Good news for those who are desperate to get away: The CDC last week issued updated guidance, saying that fully vaccinated travelers inside the U.S. don’t need to get tested before or after their trip, unless such testing is required by their travel destination. (People are considered to be fully vaccinated two weeks after their last required dose.) Those with full vaccinations also don’t need to quarantine in the U.S. after they travel. As for international trips, fully vaccinated travelers don’t need to be tested before travel (unless required to do so by their destination). But they do need a negative test result within three to five days after returning to the U.S. They do not, however, need to quarantine upon their return. All travelers, including those who are fully vaccinated, should continue to mask, stay physically distanced and wash their hands frequently.

April 2, 2021

J1 visas: Make convoluted process more simple

foreign-medical-doctor-conceptIn a new JAMA perspective, a urology fellow with a J-1 waiver points out that, as a resident, he worked in the trenches with his colleagues during last spring’s covid crisis in New York. But as that surge subsided and other residents could take time off to visit family, that wasn’t available to him. Instead, both colleagues and the ECGME warned J-1s to not travel outside the country because re-entry couldn’t be guaranteed, making homesickness a hallmark of his pandemic experience as well. Complicating matters: U.S. immigration and customs has proposed having doctors extend their visas either through that agency—a process that can take up to 19 months—or at a consulate in their home country. The author calls on health care workers and institutions to advocate with lawmakers to make the visa renewal process easier, not more difficult. He writes that the French government is fast-tracking citizenship applications from front-line health care workers to show its appreciation for care rendered during the pandemic. The author also calls on hospitals to reach out to their IMG physicians proactively to offer mental health and emotional support. The number of J-1 physicians working in the U.S. has grown 62% over the last decade.

What’s hot, what’s not in covid spending

report from MarketWatch details how the pandemic has changed Americans’ shopping habits, with televisions flying off shelves and pet, plant and cleaning supplies in high demand. At the same time, movie theaters saw their revenue tank from $12.2 billion in January 2020 to just over $825 million this February, while spending on cold and flu medications fell so hard that chain pharmacies saw a drop in profits last year. Spending on beer is up as is that for specialty cheeses—and also for kidney beans, an indication that many households are strapped for cash. Spending on sunscreen and cosmetics declined over the past year, while sales of books and musical instruments have grown.

April 1, 2021

One in five Americans polled isn’t interested in vaccine

As the number of covid cases rose 10% this week, more states are rapidly expanding vaccine eligibility, with all 50 states announcing plans to offer vaccine to anyone eligible for vaccine under FDA authorizations. That comes as Kaiser Health News reports that vaccine hesitancy continues to shrink in the U.S., with the “I’ll wait and see group” falling from 39% of those polled in December 2020 to 17% in March 2021. But the “definitely not” group that doesn’t intend to be vaccinated at all was 13% in March, with another 7% saying they’ll get vaccine only if it’s required. Hesitancy levels were high among white evangelicals and rural populations. Between December and March, 32% of all those polled had received at least one dose. Experts say the vaccination gap is particularly troubling among Hispanic patients, who are running into barriers to vaccine access. Often, communications about vaccine availability and registration are in English only, and many older people in the Hispanic community don’t have access to computers.

In vaccine development, good news for parents: Pfizer-BioNTech reports that its vaccine has been found to be 100% effective in adolescents ages 12 through 15. The randomized trial the results were based on—which have not yet been peer-reviewed—included more than 2,200 adolescents. None in the vaccine arm developed symptomatic disease nor had side effects. The two companies have started testing its vaccine in children under 12. (Moderna is also testing its vaccine in children of all ages.) Pfizer-BioNTech expects to ask the FDA to amend their EUA to have the vaccine available to older children before school starts in September.

Covid and post-discharge dysfunction

A new JAMA article spells out the troubling long-term neuropsychiatric toll of covid, with long-term symptoms among patients “suggesting brain involvement persists,” the authors write. Symptoms range from loss of taste and smell and brain fog to psychosis, seizures and thoughts of suicide. While experts still aren’t sure if the virus invades the brain, the article discusses several possible mechanisms that could be at play including crossing the brain-blood barrier or having inflammation and clots combine to cause microstrokes and other damage. Another study, this one out of Britain and published in The BMJ, describes other types of longer-term multiorgan dysfunction after discharge. Among close to 48,000 patients in NHS hospitals followed for more than four months, close to one-third were readmitted while more than 10% died, much higher rates than among non-covid controls. Those who developed multiorgan dysfunction post-discharge weren’t limited to the elderly. Becker’s Hospital Review reports that at least 24 hospitals and health systems around the U.S. have launched covid recovery programs for covid patients who have been discharged but need longer-term treatment. Most of those programs involve an initial evaluation and specialist referral including to neurologists, pulmonologists and cardiologists.

March 31, 2021

What did the pandemic do to hospital finances?

A new report from HHS’ OIG paints a gloomy picture of hospitals struggling after their plague year, saying that hospitals now are in “survival mode.” HealthLeaders notes that the report is based on survey responses gathered in February from more than 300 hospital administrators across 45 states. According to many of those administrators, hospitals are suffering financial instability due to higher expenses as well as staffing shortages and exhaustion. Particularly trying for hospitals, the report says, is how to balance ongoing covid treatment with regular hospital care. At the same time, some hospital systems seem to be doing fine. In a new podcast, two Modern Healthcare finance reporters point out that some large health systems—both for-profit and not-for-profit—actually saw their margins grow in 2020. Factors driving that increased profit (other than government grants) include higher acuity patients translating into more revenue and effective cost-cutting. The speakers also believe one pandemic-driven trend may become permanent: less ED traffic. Patients afraid of coming to EDs sought care in other settings, including urgent care, a shift that may persist.

March 30, 2021

Can an extra hour of sleep help prevent covid?

doctor-sleepA new study says that getting an extra hour of sleep a night could go a long way to helping health care workers fight off covid. A study published in BMJ Nutrition, Prevention & Health found that a one-hour longer duration of sleep among health care workers was associated with a 12% reduction in the odds of getting covid. In individuals who reported three kinds of issues with sleeping (difficulty sleeping at night, poor continuity of sleep, and frequent use of sleeping pills), there was a nearly twofold increased risk of getting covid when compared with people who had no sleep issues. And in some countries in which health workers were studied, researchers found that daytime napping was associated with a 6% increase in the chance of getting covid. A MedPage Today article notes that the study also found health care workers who reported feeling daily burnout at work had not only a higher risk of covid, but a longer duration of infection and greater severity.

March 29, 2021

New data: Vaccines prevent 90% of covid infections (updated 3/30/2020)

New data found that the vaccine was 90% effective in preventing covid infection in people who were fully vaccinated (they had received two shots at least 14 days before) and 80% effective in people who were partially vaccinated (they had received one of two shots at least 14 days before). A CDC study looked at nearly 4,000 health care workers who received either the Pfizer or Moderna vaccines who had not previously been infected with covid. Nearly two-thirds of the group received two shots. For every 1,000 subjects who were fully vaccinated, researchers found 0.04 infections, compared to 1.38 infections per 1,000 people who had not been vaccinated. Among subjects who had received only one vaccine, researchers found 0.19 infections per 1,000 people.

A Medscape article says that more data may soon be available looking at how well vaccines prevent the transmission of covid. A trial that began last week is examining transmission of the virus among 12,000 college students. Half will receive the Moderna vaccine immediately, while the other half will receive the vaccine in four months.

March 26, 2021

Deaths are down, but case numbers are on the rise

According to the New York Times, the number of covid deaths over the past two weeks has fallen 31% while hospitalizations have dropped 10%. At the same time, officials note that case numbers are on the rise for the first time since January. Reuters this week reports that cases are trending up in 30 out of 50 states, with health officials hoping the increase in vaccinations will prevent a corresponding rise in covid deaths. A growing number of states have lowered the age of vaccine eligibility, with Alaska the first to offer vaccine to every resident 16 and older.

Covid burden linked to mortality in hospitals

What effect does “covid burden”—the number of covid patients in a given hospital, divided by that hospital’s number of beds—have on patient mortality? Writing in the Journal of Hospital Medicine, UCSF researchers looked at data on more than 14,200 covid patients admitted last April across 117 U.S. hospitals. They found that individual hospitals’ covid burden increased the odds of patients dying of covid, suggesting “that patient surges may be an independent risk factor for in-hospital death among patients with COVID-19.” In coverage of the study, Fierce Healthcare notes that the research adds to literature linking heavy covid surges to poor outcomes. The study authors also point out that their results could underscore the impact of a strained health care workforce on patient outcomes.

Surgeon general deja vu

surgeon-general-vivek-murthyFor the second time in his career, former hospitalist Vivek Murthy, MD, MBA, has been confirmed and sworn in as the nation’s top doctor. Dr. Murthy, who previously filled the post of surgeon general during the Obama administration, proved to be a more controversial nominee this time around. During his confirmation hearings, some senators disapproved of Dr. Murthy’s support for gun reform (as they did during his first confirmation hearings), while other critics—including some in the medical community—questioned how much he’d earned from corporations as a consultant during the pandemic. The son of immigrant physicians, Dr. Murthy noted in a Twitter post that he has lost members of his own family to the pandemic. Once a hospitalist at Boston’s Brigham and Women’s, Dr. Murthy dealt with the Zika pandemic in 2016 and the opioid crisis during his first stint as surgeon general.

March 23, 2021

Good news for AstraZeneca? Not so fast

Yesterday’s announcement from AstraZeneca—that interim trial results of its vaccine indicate 79% efficacy against symptomatic covid, 100% efficacy against severe covid and hospitalization—was welcomed news. But in what news coverage claims is an unprecedented step, an NIH panel has weighed in with a “not so fast.” The problem, according to a NIH letter released late yesterday, is that those interim results may be based on “outdated and potentially misleading” data. But according to the Washington Post, the NIH panel has been working with AstraZeneca and has found the vaccine to be between 69% and 74% effective. Anthony Fauci, MD, is quoted as saying that the problem is probably not with the vaccine—”very likely a very good vaccine”—but with the rollout of trial data.

Almost half of all health care workers have not been vaccinated

While health care workers have been at the front of the line to receive vaccine, a new poll indicates that more than four out of 10 health care workers have not been vaccinated. The poll, which was put out by both the Kaiser Family Foundation and the Washington Post, finds that just a bare majority (52%) of health care workers across the country have received at least one dose of covid vaccine. While an additional 19% were either scheduled to be vaccinated or planned to, 18% did not plan on being vaccinated while another 12% remained undecided. More than one in three surveyed health care workers reported not being confident that the vaccines were safe and effective. The survey, which was held mid-February to early-March, gathered responses from more than 1,300 health care workers. In related news, Kaiser Health News reports that new covid cases among nursing home staff members have plummeted by more than 80%. That’s despite the vaccine hesitancy felt by many staff members, with some nursing homes reporting that only half their staff have been vaccinated so far.

Yes, there are covid stamps

https://jamanetwork.com/journals/jama/fullarticle/2777922
Image from JAMA

None of them, unfortunately, have yet been issued in the U.S. But a piece in JAMA written by French researchers points out that 21 countries as well as the U.N. have issued dozens of different stamps commemorating the pandemic. Iran was the first to do so last March. Many of the stamps depict clinicians, scientists or first responders, while a few contain public health messages about hand-washing and social distancing. Some also show patients being ventilated and attended to by health care workers. One in a series of covid-related stamps issued by the Isle of Man has an illustration of a clinician in scrubs and a red cape.

 

March 22, 2021

A drive-in Match?

It was once again a remote Match Day last Friday for more than 33,000 medical students and the more than 2,600 candidates around the world looking for residency slots. It was also an historic one that offered the most positions in Match history, with the number of slots up 3% from last year. MedPage Today reports that the need to hold a virtual Match Day led many medical schools to become creative, with at least one school holding a drive-in Match ceremony while another sent bottles of champagne or cookies to students’ homes. As for remote matching, students noted that not being able to travel to in-person interviews allowed them to apply to more programs. Internal medicine drew one-quarter of all applicants, with the number of internal medicine positions up 25% over five years ago. Over that same time frame, the number of family medicine positions increased 44%.

Study: Good news for the AstraZeneca vaccine (updated above)

After a tough week last week, the AstraZeneca vaccine has garnered some good news, showing 79% efficacy against symptomatic covid and 100% efficacy against severe covid and hospitalization. The vaccine’s manufacturer delivered the interim results of its phase 3 trial in a press release, saying the data were based on results from more than 32,000 participants. The two-dose vaccine was found to be just as efficacious in patients over age 65. STAT reports that the study also uncovered no safety problems, including any with blood clots; concerns about clotting led the AstraZeneca vaccine rollout being suspended in several European countries. Based on the results, the vaccine manufacturer intends to ask the FDA for emergency use authorization in the U.S.

March 19, 2021

Getting covid helps prevent reinfection for about six months

fight-covid-reinfectionResearch published in The Lancet found that most people who get covid have some protection from the virus for at least six months, although older people saw less immunity from becoming re-infected. The study found that being infected with covid reduced subjects’ chances of being infected again by 80%, but that figure fell to 50% for people over 65. A New York Times article says that the study is unique because it has been difficult to study reinfection rates, which require access to testing and genetic sequencing to confirm reinfections. The study was also conducted on a small population, and because researchers weren’t able to talk to the study’s subjects, it’s possible that people who became infected were asymptomatic and didn’t feel any ill effects of covid. The study also doesn’t take into account the possibility that people who have had covid and have some immunity can get reinfected in less than six months if they’re exposed to a different variant of the virus. A Newsweek article notes that Anthony Fauci, MD, warned of this scenario this week during congressional testimony.

Patients prefer clear (not cloth) masks when talking to docs

study published in JAMA Open Network found that surgeons who talked to their patients wearing clear masks, not standard cloth masks, saw better patient ratings. Researchers studied 200 patients from 15 surgery clinics in seven different subspecialties. When it came to providing clear explanations, surgeons with clear masks received a score of 95% compared to 78% for surgeons wearing cloth masks. Patients rated surgeons wearing clear masks higher on empathy (99% vs. 85%) and on building trust (94% vs. 72%). While patients said they preferred clear masks, 53% of surgeons said they were unlikely to replace their traditional masks with clear masks.

March 17, 2021

It’s been a tough week for the AstraZeneca vaccine (updated)

empty-vaccination-centerAstraZeneca’s covid vaccine took a beating this week on multiple fronts. The week began with European countries banning AstraZeneca’s vaccine because of concerns about blood clots, claims that an article in Science examines. Europe’s equivalent of the FDA offered its support for the vaccine later in the week, but much of the damage had already been done. Things got worse when a study concluded that the vaccine doesn’t do very well in preventing infection from the South African (B.1.351) variant of corona. Data published in the New England Journal of Medicine found that more than 90% of the cases in the study were caused by the variant, and that the vaccine’s efficacy against that variant was only about 10%. The study found that the AstraZeneca vaccine had an overall efficacy of 22% for all cases (not just cases caused by the variant) of mild to moderate covid. Finally, the U.S. announced yesterday that it is planning to send millions of doses of the AstraZeneca vaccine to Mexico and Canada. Federal officials have been sitting on a stockpile of the shots while awaiting FDA approval of the vaccine.

March 16, 2021

Are we giving the best PPE to the wrong people?

doctor-hospital-roomNew data show that we may be giving the best PPE to the wrong health care workers. An article from Kaiser Health News notes that while “aerosol-generating procedures” (think intubating patients) have been viewed as the most dangerous in terms of spreading covid, recent data say that a basic cough produces 20 times as many particles as an intubation. As a result, health care workers wearing a surgical mask (as recommended by the CDC) have a higher risk of infection by being in the same room as a covid patient than being near a patient during an intubation. While the thinking on covid risk is slowly shifting, a group of health care experts has stuck to the position that it’s safe for front-line workers to be around covid patients wearing only a surgical mask, while N95s be reserved for covid ICUs. One source in the Kaiser article said that the thinking about PPE during covid has been “upside down.”

Nurses exhausted and stressed, but staying in health care

A new survey of 22,000 nurses has found that younger workers seem to be bearing the emotional brunt of the pandemic. The survey found that among early-career nurses (those under 34), 81% reported exhaustion, 71% reported feeling overwhelmed, 65% were anxious or unable to react, and 47% felt sad. Among older nurses (those over 55), by comparison, about half (47%) reported exhaustion and 37% reported feeling overwhelmed. A Health Leaders article notes the survey also found that nearly 20% of nurses indicated they are financially worse off since the beginning of the pandemic, but most said they don’t plan to leave their current job or the profession. About 30% of surveyed nurses haven’t received a vaccine, and about 25% say they are undecided about getting vaccinated. Finally, only 73% say they have adequate PPE.

March 13, 2021

 Are you giving covid patients too many antibiotics?

Prescribing prophylactic antibiotics and surgeryNew data show that while more than half of covid patients last spring received antibiotics, only a “fraction” of them had bacterial infections. A MedPage Today article said that data show that most antibiotics were given within 48 hours of admission, before most physicians know their patients’ infection status. The data from a Pew Charitable Trusts project found that 36% of covid patients received more than one antibiotic and that only 20% of admissions had suspected or confirmed bacterial pneumonia. The MedPage Today article notes that a study found that VA hospitals used more antibiotics in the first five months of 2020 than in any year since 2016.

March 11, 2021

Study: Working at the hospital doesn’t increase your covid risk

New data claim that hospital workers don’t have a higher risk of getting covid at work,
proof that infection prevention practices are working. The study, which was published by JAMA Network Open, found that even nurses, who have the most direct contact with patients, don’t face a greater risk of getting the virus at work as shown by the presence of covid antibodies.

Among the 25,000 hospital workers studied, the overall positivity rate for covid antibodies was 4%. Physicians had a positivity rate of 3.7%, nurses had a positivity rate of 4.8%, and NPs/PAs had a positivity rate of 3.5%. Nonclinical staff had a positivity rate of 3.9%, but the highest rates were found among environmental service workers (7.4%). The study came out at about the same time as the release of a database of more than 3,500 U.S. health care workers who have died of covid. The list, compiled by a partnership between the Guardian and Kaiser Health News, analyzes the deaths by demographics including occupation, state and race/ethnicity.

March 10, 2021

Colchicine lacks mortality benefit

A trial looking at covid treatments has dropped an arm testing the drug colchicine, which is widely used to treat gout and other inflammatory conditions, because of a lack of a mortality benefit. The RECOVERY trial, which is evaluating potential covid treatments at hospitals in the UK, Indonesia and Nepal, found colchicine produced no 28-day mortality benefit when compared to usual care. An article on MDedge notes that the RECOVERY trial has already identified two anti-inflammatory drugs, dexamethasone and tocilizumab, that can help the survival rates of covid patients. A statement is online.

March 8, 2021

A look at whether vaccines can help long haulers

With the U.S. now giving 2 million vaccines a day, limited evidence suggests that the vaccines may be offering covid long haulers relief from their symptoms. A MedPage Today article cites anecdotal evidence of the recently vaccinated getting some relief from long-term effects of covid, but it also points out that the data are preliminary. A survey of nearly 500 covid long haulers found that 27% of respondents reported feeling “slightly better,” while 16% said their symptoms were “much better” and 5% said they were back to normal. Several experts interviewed for the article endorsed the idea of further studying the impact that the vaccine may be having on long haulers, noting that there are multiple reasons that a vaccine would provide those patients with relief. One recent study on long haulers found that up to one-third of covid patients with severe infections may suffer from post-traumatic stress disorder.

Is delaying second dose of vaccine a good idea?

Health experts are batting down the idea of delaying a second covid vaccine in order to get at least one vaccine into a bigger group of people. The CDC’s Advisory Committee on Immunization Practices recently ruled that there’s not enough evidence to delay a second vaccine or to give only one dose to people who have already had covid. A MedPage Today article says that members of that committee worried that estimates of the effectiveness of the protection offered by one dose are imprecise, and also that one dose may not sufficiently protect people from emerging variants. Last week, Anthony Fauci, MD, warned that delaying a second dose puts Americans at risk and urged health officials to continue with a two-dose schedule. A Medscape article says that while Dr. Fauci has spoken to health officials from the U.K. about their strategy of delaying second doses of the vaccine, he said he didn’t believe the strategy was a good choice for the U.S.

March 4, 2021

Asthma doesn’t increase hospitalizations, serious illness in covid

asthma patientData from patients tested for covid in California earlier this year found that asthma is not an independent risk factor for developing a severe case of the infection or increased risk hospitalization. Researchers at Stanford University found that out of nearly 170,000 people who received a covid test between March and September of 2000, there were no differences in hospitalization rates based on whether people had asthma. An article in MDedge said that 28% of patients with asthma had asymptomatic covid compared to 36% of people without asthma. While 53% of people with asthma had severe or critical cases of covid, so did 51% of people without asthma. The data were released as part of a poster presentation at the American Academy of Allergy, Asthma and Immunology’s virtual meeting this year.

Do lockdowns lead to more alcohol withdrawals?

Covid lockdowns seem to be leading to more cases of alcohol withdrawal. Data from a single-center study of hospitalized patients found that between March and September of 2020, rates of alcohol withdrawal jumped by 34% when compared to 2019. A MedPage Today article says that while rates of withdrawal were higher in all of 2020, they were higher immediately after lockdown periods. Researchers accounted for seasonal fluctuations in rates of alcohol withdrawal by comparing data from the same biweekly periods in 2019 and 2020. The data come from a sample size of 340 patients and were published in JAMA Network Open.

March 3, 2021

A look at pandemic-related violence against health care workers

health-worker-covid-confrontationOut of more than 1,000 reported attacks on health care workers in 2020, more than 400 were directly related to the covid pandemic. Incidents included arson at testing facilities, health care workers targeted on their way home after work because of fears that they would spread the virus, and violent responses to workers trying to enforce mask requirements. Individual health care workers were also arrested and assaulted after going public with concerns about the safety of PPE or criticizing government policies about the pandemic. The report, published by Data from Safeguarding Health in Conflict, found that health care workers “frequently” reported being attacked on their way to and from work. The report notes that hotspots for violence included India and Mexico, but violence against health care workers was reported in 79 countries.

WHO issues “strong recommendation” against hydroxychloroquine

The World Health Organization has made a strong recommendation against using hydroxychloroquine to prevent covid. An article in New England Journal says that the recommendation, which was published in the BMJ, is based on a meta-analysis of six clinical trials. The analysis found that hydroxychloroquine had “little to no effect” on covid patients’ mortality or admission rates. Researchers also found that hydroxychloroquine didn’t reduce rates of covid as confirmed by lab results.

March 2, 2021

The five diseases that are associated with covid hospitalizations

heavy-woman-covid-vaccinationA new study found that about one-third of covid hospitalizations were attributable to obesity. Researchers examining a little more than 900,000 U.S. covid hospitalizations found that 30.2% were attributable to obesity/severe obesity, followed by hypertension (26.2%), diabetes (20.5%), chronic kidney disease (12.9%), and heart failure (11.7%). Researchers also looked at the impact that combinations of disease had on covid hospitalizations and found that 40.7% of admissions were attributable to diabetes/hypertension, followed by diabetes/obesity (44.%), diabetes/hypertension/obesity (58.7%), and diabetes/hypertension/obesity/heart failure (63.5%). The study was published by the Journal of the American Heart Association.

Can vaccines in older people prevent the need for ventilators?

New data from Israel have found that older people given a covid vaccine were less likely to require mechanical ventilation to treat the virus than younger people who haven’t been vaccinated. Data from Israel found that Israelis 70 and older who had received the Pfizer vaccine were 67% less likely to need a ventilator than Israelis under 50. The study, which was published in MMWR, compared ventilation rates from February 2021 with rates from October-December of 2020. A Medscape article says that researchers found 80% of older Israelis had received the vaccine compared to only about 10% of people under 50.

February 27, 2021

“Vaccinated Volunteers” bring comfort, aid to isolated patients

With hospitalized covid patients around the country languishing alone in ICUs and medical units, a hospital program in the South Shore of Massachusetts has come up with a solution that it hopes catches on nationwide: using vaccinated health care workers who volunteer to visit with the infected. As reported by the Boston Globe, the “Vaccinated Volunteers” program at Beth Israel Deaconess Hospital-Plymouth is the brainchild of an anesthesiologist who, once he was fully vaccinated, began spending his spare minutes in the hospital visiting with covid patients. Since he sent out a hospital-wide e-mail asking for more volunteers, dozens have come forward, talking to patients and acting as liaisons for family members who can’t come into the hospital. The program has a few simple rules: Volunteers must be at least 10 days past their second vaccine dose, they have to wear full PPE at all times with covid patients, and volunteers work with the same patient and family throughout a hospital stay.

Will covid change how glucose is monitored in hospitals?

One positive development coming out of the pandemic: Last spring, the FDA began allowing hospitals to monitor glucose levels among diabetic patients, particularly those with covid, with continuous glucose monitors—even though those devices are approved for only home use. Using receivers to collect data from the monitors has made it possible for nurses to not have to continuously take blood draws and, if needed, administer insulin remotely. According to STAT, hospitals so far have done only small studies on the monitors’ in-hospital use, but results reported indicate reduced glucose levels and better times in range. Several hospitals using the monitors—including Ohio State University’s Wexner Medical Center and Mount Sinai—are pooling their data on outcomes, while one device manufacturer is also maintaining a registry. The hope: Those data will eventually be submitted to the FDA for permanent approval in hospitals.

February 26, 2021

Study: Children with covid can have different presentations

hospital-child-covidChildren and young people hospitalized with covid present with two major and different sets of symptoms, according to a new study. The research, which appeared this week in JAMA, reported on more than 1,100 patients younger than age 21 across 31 states. Just under half were diagnosed with MIS-C  (multisystem inflammatory syndrome in children), while the rest had acute covid, the same predominately lung-affecting illness found in adults. Those diagnosed with MIS-C tended to be between the ages of 6 and 12, but more than 80% of those with acute covid were younger than 6 or older than 12. The study also underscored marked racial disparities, which likely reflect socioeconomic factors: More than two-thirds of those hospitalized with either condition were Black or Hispanic. While Hispanic children and adolescents seemed to run an equal risk of either condition, Black children were found to face a higher risk of the inflammatory condition than the acute syndrome. Many patients in both groups needed ICU care, although that was more common among those with MIS-C.

February 24, 2021

U.S. covid deaths pass 500,000

states affected by coronavirusThis week, the number of deaths due to covid in the U.S. surpassed 500,000—making covid what one California ED physician called “our generation’s D-Day.” It’s notable, however, that more Americans have died of covid in one year than the number of service members in World War II. To memorialize the mortality milestone, The Nocturnists—a California-based collaborative of health care storytellers—issued “No Words” a three-minute illustrated video made to honor those lost. The video also honors the health care workers who cared for those patients and acknowledges, as a panel in the video states, “the pain for bearing witness.”

“Vaccinated Volunteers” bring comfort, aid to isolated patients

With hospitalized covid patients around the country languishing alone in ICUs and medical units, a hospital program in the South Shore of Massachusetts has come up with a solution that it hopes catches on nationwide: using vaccinated health care workers who volunteer to visit with the infected. As reported by the Boston Globe, the “Vaccinated Volunteers” program at Beth Israel Deaconess Hospital-Plymouth is the brainchild of an anesthesiologist who, once he was fully vaccinated, began spending his spare minutes in the hospital visiting with covid patients. Since he sent out a hospital-wide e-mail asking for more volunteers, dozens have come forward, talking to patients and acting as liaisons for family members who can’t come into the hospital. The program has a few simple rules: Volunteers must be at least 10 days past their second vaccine dose, they have to wear full PPE at all times with covid patients, and volunteers get to work with the same patient and family throughout a hospital stay

February 23, 2021

Who in health care is getting—and avoiding—the vaccine

male health care worker vaccinationWhen it comes to health care workers getting the covid vaccine, men are more likely toget vaccinated, in part because they are less hesitant—and opposed to—the idea of a covid vaccine. Preprint survey data from The Covid States Project found that 18% of surveyed male health care workers were vaccinated, compared to 9% of women. The survey found that those preferences translated into some trends about who in health care is and isn’t getting vaccinated. The data show that a 50-year-old white male doctor in the Northeast had a 45% chance of being vaccinated, while a 45-year-old Black female nursing assistant in the south had only a 6% chance. Finally, the survey found that among surveyed health care workers, 37% were hesitant about getting vaccinated and 21% were resistant. Survey data were collected between Dec. 16 last year and Jan. 11 this year.

Covid hospitalizations reach a low not seen since early November

New data show that U.S. covid hospitalizations have dropped to levels not seen since early November. A WebMD report says that since peaking on Jan. 6 at 132,000, covid hospitalizations have fallen for 40 days in a row. As of this week, about 56,000 Americans are hospitalized with covid. Hospitalizations from the virus haven’t been below 60,000 since Nov. 9. The data were published by the Covid Tracking Project.

A report from analyst firm Kaufman Hall notes that while that trend is good news from a public health perspective, it is further hurting hospitals’ finances. Operating margins for U.S. hospitals fell 4.6% from January 2020 to January 2021, in large part because patient volumes are still lagging. The report found that discharges last month were down 12.7% from the previous year, and ED visits plummeted by 25% during the same period. At the same time, hospitals’ total expenses increased 4.5% and labor costs jumped by 6%.

February 19, 2021

Is your health system (inadvertently) promoting misinformation?

Coronavirus MisinformationThey are some of the most respected names in American medicine: Northwell Health, Emory, Stanford, Mayo Clinic. Yet a new report from an online information watchdog has found that ads for these brands—as well as for Pfizer, the CDC and a host of consumer products—regularly appear on Web sites that peddle covid misinformation. NewsGuard, which monitors the content of Web news sites, reports that such health systems are inadvertently funding sites that claim that masks are dangerous and vaccines contain tracking microchips, due to their ads being placed by platforms like Google to reach target audiences. More than 4,000 brands, the report says, have run more than 42,000 ads on Web sites flagged by NewsGuard for covid misinformation. In related news, doctors and nurses are forming online networks to champion vaccines and drown out anti-vaxxers. Politico reports that public health groups are mobilizing vaccine advocates to respond when they are attacked online. An anesthesiologist who helped develop #ThisIsOurShot claims that batting down the anti-vaccine activists, who swarm advocacy sites with comments, is turning into something akin to “a military campaign.”

Round-up: anticoagulants, remdesivir, famotidine

Studies this week weighed in on several treatments, finding benefit to some but giving a thumbs-down to at least one. Some good news: A BMJ study of blood thinners in covid patients found that prophylactic anticoagulants within 24 hours of being admitted reduced 30-mortality from 19% to 14%. Researchers looked at data on more than 4,000 VA patients treated for covid between March and July last year. The group receiving the anticoagulants didn’t see an increased risk of serious bleeds, defined as an event requiring transfusion. As for remdesivir, a systematic review in Annals found that the drug “probably” improves recovery by 7%-10% and may reduce mortality by 1% or less. The review of four trials also found that remdesivir has little to no effect on length of stay, although it probably reduces serious adverse events by a “moderate amount.” And newly published data don’t paint a very positive picture on treating covid patients with the drug famotidine. A study in The American Journal of Gastroenterology compared patients given famotidine during their covid hospitalization to three groups: patients who didn’t take famotidine before or during hospitalization; patients who used PPIs; and patients who used hydroxychloroquine. Researchers found no mortality reduction in patients on famotidine and no difference in their use of “intensive services.”

Booster shots may be in order for Pfizer, Moderna vaccines

Correspondence from both Pfizer and Moderna this week suggest their vaccines, while highly effective against the U.K. variant, may not be as protective against the one from South Africa. Writing in NEJM, Moderna and NIH researchers say that the “protection … ” conferred by Moderna’s vaccine against the South African variant “remains to be determined,” although they did observe decreased neutralizing antibody titers. The results of a lab study done by Pfizer, also published in NEJM, likewise suggest the South African variant may reduce antibody protection from the vaccine. The vaccines’ limited availability is informing the debate over whether to delay second doses, allowing more people to at least receive one dose and some protection. In a case vignette in NEJM, hospital medicine’s own Robert Wachter, MD, argues for delaying second doses. In other covid news, the CDC finds that the life expectancy of Americans dropped a full year in 2020. The news was even worse for minorities and people of color: Life expectancy for Latinos last year fell almost two years (1.9), while the drop was almost three years (2.7) for Black Americans.

One-third of nurses, allied health providers leery of vaccine

A large survey of health care personnel found a lot of variation in what health care workers think about the covid vaccine—and whether they plan to get it—based on their roles. Perhaps most surprising, direct-care providers appear to be less likely to get the vaccine than workers who don’t provide direct care. An MDedge report says that while 62% of personnel not providing direct care would get the vaccine, only 54% direct care providers said they would get the shot. And among providers who had already cared for covid patients, only 52% said they would get the vaccine. While 80% of physicians and scientists said they would be vaccinated, one-third of RNs and allied health professionals were unsure. The data were published in Clinical Infectious Diseases.

February 17, 2021

Millions of fake N95 masks circulating through U.S. hospitals

A wave of fake N95 masks circulating throughout the U.S. has doctors and nurses worried about how much protection their PPE is offering. A Medscape report says that nearly 2 million of the fakes have been sent to hospitals in Washington state alone, and PPE manufacturer 3M says that nearly 10 million of the knockoffs have been confiscated in at least six states. The masks have also been confirmed in hospitals in Ohio, New Jersey and Minnesota. Some of the masks have been described as “odd-smelling” and “misshapen.” Some of the masks offer relatively high levels of filtration, but make breathing difficult. The fakes echo concerns about Chinese-made KN95 masks, which have sometimes turned out to be less effective than they claimed to be.

February 16, 2021

Good news, bad news about covid variants

woman-vaccinatedFirst the bad news: Early data show that covid’s U.K. variant may be significantly deadlier than thought and puts more people in the hospital than non-variant forms of the infection. According to a MedPage Today article, the British government published data on the Web last week, claiming that U.K.-variant cases are between 30%-70% deadlier than non-variant cases. One study cited by the report found a relative death hazard of 1.58 within 28 days. Other studies cited found that the risk of hospitalization and admission to an ICU was higher for patients with the U.K. variant.

On a more positive note, British researchers have concluded in a preprint that two shots of the Pfizer vaccine may provide significant protection against both the U.K. and South African variants. Researchers found, according to a report from The Guardian, that while the vaccine’s protection was limited, it may still be strong enough to keep most people from becoming infected once they have received both doses. One study—one of the first to test a vaccine’s ability to fight off covid variants—used engineered viruses, not actual viruses from patients. Researchers also found that antibody responses received a significant boost in 90% of those who received a second dose.

Study: Famotidine shows no benefit in treating covid

Newly published data don’t paint a very positive picture on giving covid patients the drug famotidine. A study in The American Journal of Gastroenterology compared patients given famotidine during their covid hospitalization to three groups: patients who didn’t take famotidine before or during hospitalization; patients who used PPIs; and patients who used hydroxychloroquine. Researchers found no mortality reduction in patients given famotidine and no difference in their use of “intensive services.” A Healio report notes that data for the observational study came from electronic health records on covid patients.

February 15, 2021

New data: Prophylactic anticoagulants reduce covid mortality

A new study of using blood thinners in covid patients found that giving prophylactic anticoagulants within 24 hours reduced 30-mortality from 19% to 14%. Researchers looked at the electronic health records of more than 4,000 VA patients treated for covid between March and July. The study, which was published in the BMJ, found that the group that received the anticoagulants faced a 27% reduced risk of 30-day mortality and didn’t see an increased risk of serious bleeding events, which researchers defined as an event that required transfusion. The authors said the data shows a need for more randomized clinical trials.

Tocilizumab offers small but significant mortality benefit in covid

The drug tocilizumab, which is approved to treat rheumatoid arthritis, offers a small but statistically significant mortality benefit in treating covid. Data from the RECOVERY trial showed that 29% of covid patients treated with tocilizumab died within 28 days compared to 33% of patients treated with usual care. While the difference is small, researchers pointed out that the data show that for every 25 patients treated with the drug, one life will be saved. A MedPage Today article said that use of the drug also improved the probability of discharging patients alive after 28 days from 47% to 54%. That statistic applies to a large group, from covid patients who needed supplemental oxygen to those requiring intubation. Previous trials of tocilizumab have shown less clear results in treating covid.

February 13, 2021

Once vaccinated, should you quarantine after exposure?

So you’ve been vaccinated; do you still need to quarantine if you’re exposed? Not according to new guidance from the CDC, as long as you meet the following criteria: at least two weeks have passed since your second dose but not three months or more, and you’ve remained asymptomatic since the exposure. If you don’t meet those conditions, you’ll need to follow standard guidance and quarantine for two weeks, as long as you haven’t had covid within the previous three months. In other news, data hint that covid immunity—at least for those who’ve been infected—likely lasts six months. A new study from the U.K. found that 99% of patients who tested positive for covid retained antibodies for three months after being infected, while 88% remained seropositive for six months. Researchers think those data show that infected people retain some immunity. The researchers note that they weren’t able to assess antibody levels over time in patients who have been vaccinated rather than infected, but they call the data on immunity “encouraging” for those who’ve received vaccine.

Pulse oximeters may be missing hypoxemia in Black patients

oxygen-level-hospital.While pulse oximeters are used everywhere to assess patients’ oxygen levels, they may not be accurately measuring those levels in Black patients and others of color. In NEJM in December, University of Michigan researchers detail their findings among ICU patients receiving supplemental oxygen. Those patients’ oxygen levels were measured both by pulse oximetry and by arterial oxygen saturation in arterial blood gas. Among Black patients, close to 12% of those with pulse oximetry readings between 92% and 96% were found to have arterial oxygen saturations of less than 88%, a percentage that fell to less than 4% among Whites. In a multicenter trial, those figures were 17% among Blacks and 6% among Whites. STAT reports that several senators have called on the FDA to review the devices, while “our findings highlight,” the authors wrote in NEJM, “an ongoing need to understand and correct racial bias in pulse oximetry and other forms of medical technology.”

February 10, 2021

How lethal is the U.K. variant?

Among countries moving swiftly with mass vaccinations, Britain may be the most successful, with experts saying the country may be able to vaccinate its entire population—at least with one dose—by the start of this summer. That’s good news for Britain because a new preprint based on an analysis of community test results and covid deaths in England suggests a 35% increase in death hazard with the U.K. variant over non-variant covid infections. Those data, the authors say, suggest the new variant is not only more transmissible but “may cause more severe disease.” Another preprint estimates that the number of covid cases caused by the U.K. variant in the U.S. is doubling every 10 days, due to a 35%-45% projected transmission rate increase.

Editorial: time to revisit no-visitation policies (updated)

A doctor at Mass General has penned an editorial saying that it’s time for hospitals to end their no-visitor policies. Trisha Pasricha, MD, writes that such policies were justifiable in the early days of the pandemic when hospitals were struggling with widespread shortages of PPE and testing supplies. But now, she argues, such policies only increase the trauma of patients and their families, and she cites her own experience: Last year, her grandmother was admitted to a hospital and died from covid, while all of her relatives (including Dr. Pasricha) were barred from visiting. In her hospital where she works, she writes, she sees her own loss “repeat itself in devastating variations” as visitors are either severely restricted or outlawed altogether.

“Of every mistake we’ve made in the pandemic, there is perhaps none I regret more than having inflicted this pain on families in their darkest hours.” She notes that most covid outbreaks in hospitals are being traced to health care workers not wearing masks; one commenter did point out that perhaps that is because no-visitation policies have been in force. Still, the author believes that universal masking, rapid test results and protective clothing for visitors would reduce transmission risks.

February 9, 2021

FDA revises authorization of convalescent plasma (updated) 

The FDA has revised its emergency authorization for using convalescent plasma to treat covid. The agency now states that only high-titer convalescent plasma can be used to treat covid patients in the early stages of infection. The FDA also says the therapy can be used for inpatients who have impaired humoral immunity and can’t produce an antibody response. As MD Edge reports, the revised authorization is based on data from a new clinical trial. The FDA originally issued an emergency authorization for convalescent plasma last August, but a revised fact sheet from the agency now notes that giving convalescent plasma late in covid infections hasn’t produced any significant clinical benefit. In other news, the NIH recently updated its recommendations on tocilizumab. Previously, the agency had recommended against its use (and that of other anti-interleukin-6 receptor monoclonal antibodies) outside clinical trials. But with new evidence, the NIH now says it can’t recommend either for or against its use in patients admitted to an ICU within 24 hours who need either a ventilator or high-flow oxygen. Some members of the NIH guideline panel say they would give patients who meet those criteria and are rapidly progressing to respiratory failure a dose of tocilizumab plus dexamethasone. Panel members continue to not recommend using the drug outside the ICU.

Booster shots for variants will undergo faster approval process (updated)

If booster shots are needed to help covid vaccines fight variant strains, the FDA will not require the same lengthy process that was needed to approve the original vaccines. The agency said it will unveil the review process for approving booster shots in the next few weeks. Reuters reports that acting commissioner of the FDA Janet Woodcock says that the Pfizer and Moderna vaccines still provide protection against existing covid variants, but both manufacturers have said they are bracing for the possibility that variants may require a booster shot. This week, South Africa announced that it will no longer use the Astra Zeneca vaccine because it is not effective enough in stopping the covid variant prevalent in that country. Meanwhile, a preprint estimates that the number of covid cases caused by the U.K. variant in the U.S. is doubling every 10 days, due to a 35%-45% projected transmission rate increase. Another preprint, which is based on an analysis of community test results and covid deaths in England, suggests a 35% increase in death hazard with the U.K. variant over non-variant covid infections. Those data, authors say, suggest the new variant is not only more transmissible but “may cause more severe disease.” Also in response to the spread of new variants in the U.S.: The CDC this week recommended wearing two masks or knotting the loops and tucking in the sides of surgical masks so they fit more tightly.

February 8, 2021

Most physician getting the vaccine for themselves, but not for patients

A new survey finds that 81% of physicians have received at least one dose of the covid vaccine and that 44% have received both doses. According to a survey by Medical Economics, only 5% of responding physicians decided to not get vaccinated, and 14% said they were still waiting. The survey also asked outpatient physicians about their experience administering the covid vaccine to patients, and the results weren’t particularly impressive. Only 11% said their practices have received vaccines to give to patients, and only 26% said that their patients have accurate knowledge about the vaccine.

Data hint that covid immunity likely lasts for six months

A new study from the UK found that 99% of patients who tested positive for covid retained antibodies for three months after being infected and that 88% remained seropositive for six months. Researchers think their data show that covid produces antibodies that give people who have been infected some immunity to the virus. The data found that seroprevalence varied by age, with 13.5% of people under 30 retaining antibodies vs. 6.7% of people over 70. A Medscape article notes that the results match up with data released last month, which found that patients who had recovered from covid had significant immunity to the disease.

February 5, 2021

Lull before the storm?

CDC director Rochelle Walensky, MD, MPH, announced this week that new covid cases and hospitalizations had fallen off since their peak in early January, with the number of daily infections dropping more than 13%. Further, while the number of deaths continues to rise, the pace of that increase has become less steep. But infectious diseases expert Michael Osterholm, PhD, MPH, of the University of Minnesota, is warning of a “Category 5” hurricane of new cases that could develop over the next several weeks and months due to covid variants. Among those, the U.K. variant is expected to become the dominant strain in the U.S., with the CDC’s variant-case tracker this morning reporting 611 cases across 33 states. As the pandemic enters its second year, CDC researchers writing in JAMA find that ED visits for mental health, suicide attempts, overdoses and violence rose last year between March and October compared to the same period the previous year. And the New York Times reports on a “parallel pandemic” of exhaustion and trauma among front-line clinicians.

Unprecedented jump seen in medical, nursing school applications

Applications to medical and nursing schools are seeing double-digit increases, with the AAMC noting that the number of applications to U.S. medical schools has jumped as much as 35%. Newsday reports that application numbers at some medical schools in New York state are almost 30% higher than usual, while the number of those applying to state nursing schools is likewise at an all-time high. As to why so many people want to start training, experts point to several factors, including the need for job security as well as wanting to serve patients during the pandemic. Also on the rise: applications for second nursing degrees as well as those in public health, pharmaceutics and respiratory care.

February 3, 2021

Link between covid and diabetes?

Physicians and researchers don’t have clear answers yet, but some inpatient physicians are reporting a sharp uptick in the number of covid patients with new-onset type 1 or
type 2 diabetes. As reported in the Washington Post, some patients’ blood sugar levels return to normal at discharge, while others are being discharged with diabetes. An international analysis, published last November, found that 14.4% of covid patients are newly diagnosed with diabetes. Meanwhile, it’s unclear whether covid patients developing diabetes have predisposing conditions, such as obesity, or if blood sugars are elevated due to steroids—or if covid is triggering a new type of diabetes. Some diabetes diagnoses are being reported in patients with mild or asymptomatic covid.

More big tech firms sign on to help with vaccines

News on the vaccine front: First, big tech is lending some of its considerable muscle to vaccine allocation, distribution, screening and management. FierceHealthcare
reports that Google Cloud is only the latest among the tech giants (others include
Microsoft and IBM) to bring its AI and machine-learning tools to bear on what’s been a bumpy rollout. Another recent article, this one in Kaiser Health News, describes how allocation can go wrong, as one small hospital in Michigan in December ended up with more than twice as many doses than it had requested. The extra doses helped vaccinate the administrators and faculty of a small nearby college and beauty school, while public health officials in that county received only 400 doses, not enough to vaccinate frontline health care workers. In other vaccine news, a CDC report outlines who received vaccine in the first month (Dec. 14-Jan. 14) of administration in the U.S. Nearly 13 million people that month—health care workers, as well as nursing-home residents and staff— were vaccinated. Among them, 63% were women while 55% were over age 50. The report notes, however, that race and ethnicity were reported for only half of those vaccinated. That breakdown: 60% were White, 12% were Latino, 6% were Asian, 5% were Black and 2% were Native American.

February 2, 2021

Health care workers’ risk factors, hospital outcomes

Data from Emory University on covid risk factors among its health care workforce find that demographic and community factors—including being Black and having contact with positive patients outside work—were more strongly linked to contracting covid than exposure on the job. In their study, which was published in Annals, researchers looked at serology tests and surveys completed by about one-third of Emory’s health care workers. Among them, 3.8% were found to be positive. Another study, this one in JAMA that focused on health care workers hospitalized with covid in North America, looked at those workers’ outcomes compared to hospitalized covid patients who don’t work in health care. The good news: Hospitalized health care workers had shorter lengths of stay vs. non-health care workers and were less likely to be admitted to the ICU. But no differences were found between those two groups in terms of mortality or need for mechanical ventilation or vasopressors.

Who got mitigation right? The NFL

A new CDC report details just how effective extensive surveillance and mitigation measures can be in stopping the spread of covid—as demonstrated by the NFL. Instead of capturing players in a bubble, the NFL launched its season last July, implementing strict mask requirements, closing off eating areas and quarantining high-risk contacts, with protocols modified over the course of the season. The league also implemented daily testing for more than 11,000 players and staff for a total of 623,000 PCR tests. And it used proximity tracking devices with expanded definitions of “contact” to include distance, time, mask use, and ventilation and air flow. That intensive contact tracing added to the literature on transmissions occurring during less than 15 minutes of cumulative interaction.

February 1, 2021

“Long covid” is difficult to define—and treat

While there’s a lot of attention being paid to “long covid,” physicians are stymied by its lack of identifying symptoms, which makes treating it more difficult. A MedPage Today article says that long covid adheres to no known pattern, and that many of its signs overlap with other complications of covid, from post-ICU syndrome to multisystem inflammatory disorder. Symptoms such as persistent, severe headache and “brain fog” are common, but they can be new or recurring symptoms and they can occur independent of the severity of the initial episode of covid. Data from China found that three-quarters of patients hospitalized with covid had one ongoing symptom, and 20% of patients who didn’t require supplemental oxygen during hospitalization reported decreased lung function six months later.

Two weeks after acute covid, 80% of patients have lingering symptoms

New data show that 80% of covid patients had “lingering” symptoms two weeks after an acute case of the infection. While more than 50 symptoms linked to covid were found post-infection, the most common were fatigue (58%), headache (44%), attention disorder (27%), hair loss (25%), dyspnea (24%), and anosmia (24%). The data were published as a non-peer-reviewed preprint on medRxiv. A MedPage Today article notes that a widely cited survey released last year found that 35% of covid patients had not returned to normal two to three weeks after testing positive, but those were mild infections treated in the outpatient setting.

January 28, 2021

New cases falling in half of states while vaccine acceptance grows

covid falling numberWhile most of the news surrounding covid has been nothing but bleak, there were two positive developments in covid news this week. HHS data show that a dozen states and more than 1,200 counties saw drops in new covid cases of 25% or more. Experts attribute the reduction not to the results of newly administered vaccines (it’s too soon), but to improved behavior by Americans. A HealthLeaders article says improvements include more social distancing and more mask-wearing. In the other piece of good news, the number of Americans on board with getting a covid vaccine is growing and reached 69% last week. The Harris Poll found the number of Americans interested in a vaccine was near the April peak of 73%. A FiercePharma article says that as recently as October, the number of Americans who said they would get a vaccine was at a low of 58%.

Read this Auschwitz survivor’s advice on dealing with covid grief

A 93-year-old Auschwitz survivor has a message for physicians who are suffering from PTSD as a result of treating covid patients for the better part of a year: Don’t blame yourself for surviving in the midst of so much death. Psychiatrist Edith Eger, PhD, watched Josef Mengele send her mother to the gas chambers while she and her sister were spared. A Newsweek article explains that Dr. Eger knows first-hand that survivor’s guilt can be a real part of PTSD. She tells clinicians to not say, “I’m fine but…” and to instead change it, “I’m fine and.” She says that clinicians can’t blame themselves for surviving when so many of their patients have died.

Biden reverses course on expanding buprenorphine

The Trump administration’s plans to allow more physicians to prescribe buprenorphine were put on hold this week. A Washington Post report says that while the new administration vowed in a statement to work to increase the use of buprenorphine to reduce overdoses, it also said that the guidelines expanding the number of physicians who could prescribe it was “premature.” The Washington Post article says that the Trump administration’s plan was plagued by legal and operational problems, including a lack of approval from the White House budget office. Stay tuned for more information.

January 27, 2021

Questioning early anticoagulation in critically ill covid patients

New data indicate that the early empiric use of anticoagulation in critically ill adults with
covid does not improve survival in these patients. An observational study in Annals of Internal Medicine found VTE in 6.3% of critically ill covid patients and major bleeding in 2.8% of these patients. Patients who were and weren’t anticoagulated in the first two days after being admitted to the ICU had similar in-hospitality mortality rates. Researchers say the data suggest that not only are the rates of VTE in critically ill covid patients lower than previously estimated, but that early anticoagulation may not produce any survival benefit.

Teaching hospitalists, locums hospitalists reduce LOS for covid patients

Covid patients seen by academic internists and locums physicians had a shorter LOS than patients seen by non-teaching hospitalists. Teaching internists reduced LOS for covid patients by 0.6 days when compared to non-teaching hospitalists. Locum hospitalists reduced LOS for covid patients by a full day when compared to employed hospitalists. The study, which appeared in the Journal of General Internal Medicine, found that there was no increase in costs, readmission rates or mortality for patients with a shorter LOS.

January 25, 2021

One in four HF patients hospitalized with covid will die

death-covidNew data show that nearly one in four heart failure patients hospitalized for covid will die in the hospital. The study found an in-hospital mortality rate of 2.6% for patients hospitalized for acute heart failure compared to an in-hospital mortality rate of 24.2% for HF patients hospitalized with covid. A report from Healio says that the study examined a group of more than 130,000 heart failure patients hospitalized between April and September. Of those patients, nearly 24,000 were hospitalized with acute heart failure, just more than 8,000 were hospitalized with covid, and just over 100,000 were hospitalized for other reasons. An editorial in the same issue points out that HF patients hospitalized with covid tended to be Black and/or Hispanic, which is consistent with previous data about the prevalence of covid among minority groups.

NIH on using ivermectin for covid: Figure it out yourself

The NIH is now taking a neutral stance on using the antiparasitic drug ivermectin to treat covid, neither weighing in for or against the drug. As a result, it is leaving the decision about whether to use the drug to physicians and their patients. An NIH statement says the agency needs more data before it can provide guidance. A Medscape report notes that while some physician groups have adamantly supported using the drug to treat covid, critics compare it to the discredited drug hydroxychloroquine, which was promoted early in the pandemic. A middle-of-the road view appeared in a recent issue of NEJM, which argued that while there’s more evidence for ivermectin than ever existed for hydroxychloroquine, more data are needed.

January 22, 2021

CA nurses cry foul as they’re asked to see more patients

Faced with a covid surge, hospitals in California are relaxing restrictions on nursing-patient ratios, creating what nurses say are extreme working conditions, and leading to protests. California, which is the only state that legally regulates nursing-patient ratios, relaxed some of those rules in early December. A Kaiser Health News report says that ICU nurses can now be required to care for three patients instead of two, ED nurses and telemetry nurses can be required to care for six patients instead of four, and med-surg nurses can care for seven patients instead of five. While the change has some nurses protesting in the street, hospitals insist they need the flexibility to handle what could be as much as 7,000 new patients a day because of covid. The report says that the state has exhausted the supply of travel nurses and is considering pulling nurses from other units to care for covid patients. Nurses are concerned that the rules will not be returned to pre-covid levels after the pandemic is over.

Federal rules for prescribing buprenorphine loosened

Under a ruling issued in the final week of the Trump administration, nearly all physicians will now be able to prescribe the addiction treatment buprenorphine. Under the previous rules, physicians needed to undergo eight hours of training and receive an “X waiver” to prescribe the drug. Addiction treatment advocates have long complained that the rules prevented the drug from being given to more patients who need it. Under the new rules, physicians with only a DEA prescriber license will be able to treat up to 30 patients in a state, although that cap does not apply to hospital-based physicians. NPs and PAs will still need to apply for a waiver to prescribe the drug.

January 21, 2021

ED docs don’t always take the proper covid precautions

coronavirus eating moneyNearly one-third of ED physicians don’t always use the correct PPE at work, and more than half have knowingly taken personal safety risks when treating patients. A Medscape survey asked ED doctors how often they practiced without the appropriate PPE and found that 21% of respondents said sometimes, 7% said often and 1% said always. A MD Edge report notes that more than half (54%) said that they’ve knowingly risked their personal safety to treat a covid “emergency,” and 74% said that their burnout has become more intense since the pandemic began. The survey also found that 71% of respondents had their income drop between 11% and 50% since the pandemic began.

January 20, 2021

Mortality rates for covid higher when ICUs are packed

covid-icuIt may not come as a surprise, but new data show that the ICUs that are the most packed with covid patients tend to have the highest mortality rates for those patients. A study in JAMA Network Open that looked at VA medical centers with 10 or more covid patients between March and April of 2020 found that mortality rates were twice as high in April (25%) as in July (12.5%). In April, covid populations were at their highest in those ICUs. By July, one-seventh of covid patients were in those ICUs. Researchers concluded that mortality rates for critically ill covid patients may be associated with the number of other covid patients in the ICU at the same time.

What does life look like inside a covid field hospital?

A team of physicians working at a field in hospital in Baltimore offers a window into their experience in the latest issue of the Journal of Hospital Medicine. The Baltimore Convention Center Field Hospital opened in April of 2020 as a 252-bed facility located on a single exhibit hall floor of the convention center. The hospital cares for stable adults with covid from any hospital or ED in Maryland and has cared for more than 500 patients, with 80% successfully discharged to outpatient care. The article explains that the hospital has experienced no cardiac arrests or on-site deaths in large part due to its use of rapid response teams to manage decompensating covid patients. The authors talk about the importance of early identification of decompensation in covid patients, particularly with individuals in their third or fourth week of illness. (The article cites data from Wuhan, China, which indicate that decompensation occurs predictably at day nine of symptoms.) The article offers two case studies from the physicians’ experience.

January 18, 2021

How health care is reaching out to vaccine-resistant workers

While there’s been a lot of attention paid to patients who don’t want to get a covid vaccine, health systems are also busy confronting the problem of workers who refuse to get vaccinated. Instead of forcing them to get the vaccine, some are trying to break through with reasoning. And when that approach doesn’t work, some health care facilities are resorting to bribes. A New York Times article says that to reach medical workers wary of getting a covid vaccine, some hospitals and long-term care centers are offering cash, extra time off and even Waffle House gift cards. The report says that in multiple cities, up to 30% of health care workers are not getting vaccinated. Some are worried about the newness of the vaccine; others cite a general lack of trust in the government.

When it comes to working with a different group of vaccine resisters—patients—an ID physician from Yale New Haven Health says that physicians need to try a multipronged approach. A HealthLeaders article offers four tips to help overcome patients’ objections to the covid vaccine that include casting the covid vaccine as part of a broader infection-prevention strategy and trying to understand patients’ values and goals to make a stronger case for getting the vaccine.

January 15, 2021

Surging covid cases force U.S. institutions to consider rationing care

coronavirus surgeIn areas hard hit by the pandemic, health care institutions are beginning to raise the specter of rationing the care they provide covid patients. A ModernHealthcare report says that Arizona, which is facing one of the worst infection rates in the U.S., is nearing the day when its hospitals will have “triage officers” decide who gets treatment when there’s a shortage of staff, beds or ventilators. The leadership of five of the state’s biggest hospitals held a news conference to beg residents to mask up, socially distance and avoid large gatherings. The state has no mask mandate. In nearby Las Vegas, one hospital declared a disaster over the weekend after a covid surge left its ICU overflowing with patients. And in Atlanta, Grady Health System released a simple statement this week: “Grady is full.” For two weeks, the system’s daily count of covid patients has topped its peak numbers from the summer.

Are hospitals distributing the vaccine fairly? Critics cry foul

The sometimes-troubled rollout of the covid vaccine has some critics complaining that hospitals, which have been given tremendous authority in dispensing the vaccines, aren’t always doling the shots out fairly. A Kaiser Health News article says that in some hospitals, administrators and other workers who have no contact with patients have received the vaccine while patients and front-line staff have not. Other reports talk about the pressure that wealthy donors are placing on health care systems to jump the line. While the CDC and states have issued guidance on who should be vaccinated first, the report says those guidelines aren’t always followed. A New York Times report gives examples of healthy 20-somethings working in IT and research labs getting vaccinated before front-line workers and at-risk Americans. And a MedPage Today editorial says that hospitals need to stop “playing vaccine games” and show leadership in the often-absent lack of clear guidelines from states. The editorial says that when faced with issues like a surplus of vaccines, health systems are reluctant to go beyond the recommendations of their state and do the right thing (like ship those extra doses to a pharmacy with experience with vaccinations).

Which covid tests do doctors trust the most?

A new survey of 100 physicians in the U.S. and Europe found that most physicians (82%) trust the molecular (PCR) test to confirm active covid infections. When it comes to \ serology testing, by comparison, only 56% of physicians said they were confident in its accuracy and/or utility in confirming PCR results or identifying patients suspected of having a prior infection. The survey, which was conducted by the diagnostics company Oxford Immunotec Global PLC, asked physicians whether, when and how frequently they used four types of covid tests. More than 60% of respondents said they could use alternatives to serology and new tests to assess immunity and vaccine responses. Full results of the survey are available online. (Click on the link “December 2020, 100 Physicians Find raw data” on the bottom right side of the page.)

Federal government wins award for worst profiteering of 2020

This year’s Shkreli Awards find the federal government and Jared Kushner, President Trump’s son-in-law, at the top of the list of the worst examples of profiteering and dysfunction in health care. The awards are named after Martin Shkreli, the so-called “Pharma Bro” who earned public scorn—and jail time—for raising the price of an antiparasitic drug from $13.50 to $750 per pill. According to a MedPage Today report, Project Airbridge airlifted PPE from overseas, but instead of delivering the supplies to the neediest states, the PPE was given to six private medical supply companies to sell to the highest bidder. The Shkreli awards claim that action set in motion a bidding war among the states and blames the federal government and Kushner, who led Project Airbridge. Not only did the federal government end up outbidding states for PPE, but it seized PPE that states had managed to purchase on their own, exacerbating the shortage. A full list of all 10 Shkreli Awards for 2020 is online.

January 14, 2021

More data on what covid looks like post-discharge

covid-patient-dischargeSeveral new studies provide data, giving a picture of what covid looks like after discharge. Chinese researchers have found that three-quarters of people hospitalized with covid are still reporting at least one symptom six months later. The study, which was published in The Lancet, found that the most common symptoms were fatigue or weakness (reported by 63% of patients). Sleep difficulties were reported by 26% of patients and anxiety or depression was reported by 23% of patients. Researchers examined nearly 2,500 patients discharged between January and May of 2020.

An Annals of Internal Medicine article published in November found that 40% of discharged covid patients had not returned to normal activity 60 days after discharge. Researchers found that out of 1,648 patients who were admitted to Michigan hospitals, 13% were treated in ICUs, 70% received supplemental oxygen and 24% died. After discharge, 7% died and 15% were readmitted. After 60 days after discharge, 20% had no follow-up, 33% had persistent symptoms, and 20% had new or worsening symptoms.

A preprint published by medRxiv found that six months after discharge, 37.4% of patients exhibited neurological abnormalities during a neurological exam. The most common were cognitive deficits (17.5%), hyposmia (15.7%) and postural tremor (13.8%). Overall, patients displayed “a wide array” of neurological symptoms including fatigue (34% of patients), memory/attention issues (31%) and sleep disorders (30%). Researchers said that patients who experienced these symptoms tended to have experienced more severe respiratory signs of covid while hospitalized.

Better news came from a study in Annals of American Thoracic Society. Researchers found that while there was fatigue and deconditioning in post-discharge covid patients, only a small number faced persistent lung problems in the months after leaving the hospital. A Medscape article says that in 4% of patients presenting for follow-up evaluations, repeated chest imaging found persistent infiltrate or atelectasis. Researchers concluded that clinically relevant fibrosis is an uncommon consequence of covid.

January 12, 2021

Will the U.S. have enough doses of the vaccine for a second shot?

delivery-covid-19-vaccineAs the country struggles to get covid vaccines into the arms of the most vulnerable Americans, the federal government will recommend that states give all doses of the vaccine they have immediately, and not worry about saving doses for a second shot. While 22 million doses of the vaccine have been shipped to the states, only about 9 million have been given to individuals to date, according to CDC data.

To speed up the delivery of the vaccine, the federal government will recommend that Americans over 65 and all Americans with pre-existing conditions should receive the vaccine as soon as possible. That changes the previous policy, which said that states should save a second dose for everyone who had received the first shot.

According to a New York Times report,  second doses will be provided as vaccine manufacturers restock the government’s supplies. The announcement comes on the heels of President-elect Biden announcing that he would release all doses of the vaccine immediately after taking office.

There are concerns about administering all vaccines in stock without holding back doses for a second shot. A Medscape report quotes officials who are concerned that if future batches of vaccine fail quality control inspections, second shots for Americans could be delayed or missed altogether. The president elect’s transition team has said that it plans to boost production to make sure that second doses are available in time.

The President-elect has vowed that 100 million doses of the vaccine will be given in his first 100 days.

January 11, 2021

How covid testing and vaccines work with the variant strain

The emergence of a highly contagious strain of covid has policymakers and researchers scrambling to make sure that covid vaccines and covid tests would be effective in combatting the virus. There were two developments last week.

Vaccine effectiveness. New data show that the vaccine from Pfizer and BioNTech appears to be effective in combatting a variation on covid engineered by researchers. The study, which has not been peer-reviewed, found that in lab dishes, the vaccine was able to neutralize the variation of the virus. While this was not the same variation seen in South Africa and the UK, researchers said they were confident the vaccine would “highly likely” work against many variations. Officials with BioNTech said that if necessary, they could reconfigure the vaccine to target variations within six weeks.

Testing. The FDA last week said that mutations in covid can produce false negative results. While the risks were described as low, the FDA said three tests—TaqPath from Thermo Fisher, the handheld Accula test from Mesa Biotech and the Linea assay from Applied DNA Sciences—may be compromised by genetic variations in covid.

January 8, 2021

CDC: Reactions to the vaccine don’t outweigh the benefits

receiving covid -19 vaccineAs government officials predict that the U.S. could soon give 1 million covid vaccines a day, there have been media reports detailing severe allergic reactions to various versions of the vaccine. This week, the CDC reported that while 29 Americans have developed anaphylaxis after getting either the Pfizer or Modern vaccine, it is not scaling back its recommendations about who should receive the vaccine. Senior officials say that the risk of morbidity and mortality from covid still outweighs the risks of adverse events from the vaccine. CDC officials have said, however, that patients who experience a reaction after the first dose of the vaccine should not receive a second dose. A report from FierceHealthcare says that the average time between receiving the vaccine and having a symptom of an allergic reaction was 13 minutes, and most patients saw symptoms within 15 minutes. Most patients who had a reaction had a documented history of allergic reactions to drugs, medical products, food and/or insect stings. The rate of reactions to covid vaccines is 11.1 cases per million vaccines given; for influenza, the rate is 1.3 cases per million doses.

Community-based docs shut out of the vaccine

Critics say that as hospitals are given broad discretion over who to vaccinate, PCPs and physicians who are unaffiliated with hospitals are being shut out of vaccine plans. That’s despite the fact that these physicians often see patients with covid before they present to the ED. According to the CDC, PCPs are supposed to be among the first in line for the covid vaccine, but a STAT article says that many physicians who practice independently are left relying on the goodwill of hospitals to be vaccinated. Sources report that some hospitals are vaccinating all their staff, including nonclinical personnel, before turning their attention to outpatient physicians. A report out of San Diego, for example, says that hospitals vaccinated staff including IT workers, billing staff and engineering employees before independent physicians in the community were considered for a vaccination. An official with a large health system told reporters that it simply can’t vaccinate physicians who aren’t affiliated with it. A FierceHealthcare report says that one recent survey found that only 23% of PCPs know where are they going to get the vaccine.

Number of hospitals at or near covid capacity grew by 90%

With more than 100,000 Americans hospitalized on most days recently, it’s probably no surprise that the number of hospitals at or near covid capacity grew by 90% between July and December. A study by the Epic Health Network found that by the middle of November—just before the Thanksgiving-fueled surge—the number of hospitals that reached 80%-100% capacity had doubled. The problem is worst at rural hospitals, which tend to have fewer ICU beds. U.S. hospitals have seen a 245% increase in the number of nurses caring for covid patients between September and December. One bright spot is that rural hospitals have seen a bigger expansion in their nursing staffs (46%) than metropolitan and suburban hospitals (24%).

How dangerous is the air in your hospital?

A review of studies looking at the air in hospitals has found that viable virus particles typically exist only close to patients. The authors say their review, which appeared in JAMA Network Open, shows that surgical masks are a safe precaution for staff working in most areas of hospitals, and that N95s can be saved for respiratory procedures where clinicians may be exposed to aerosols from patients. A Medscape article says that the review data make sense because covid patients are believed to shed higher quantities of infectious viruses shortly before and after symptoms begin. By the time they’re hospitalized, the thinking goes, these patients may be less contagious and have a smaller impact on the air in hospitals.

Job market: ED residents have trouble finding jobs

While hospitalists have encountered hard times in parts of the country, your colleagues in the ED may be having a significantly worse time. A Washington Post article describes one ED resident who can’t find a full-time job in his hometown of Houston and examines the career challenges other young ED physicians are facing. Besides a drop in patients going to the ED, staffing companies are losing contracts with financially stressed health systems and therefore cutting back on hiring physicians. Experts quoted in the Post article estimate that at least one-quarter of third-year ED residents are having trouble finding work. Many have had their contracts changed or had job offers rescinded altogether. An article in Slate tries to put the problem in perspective by comparing ED physicians, who it claims are functioning like members of the “gig economy” because so many work for third-party corporations and not hospitals, to people who deliver groceries.

Today’s Hospitalist has been reporting on covid-19 since January 2020. Click here for earlier updates. 

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