Rutgers Robert Wood Johnson Medical School student Paul Lavadera expected his career would put him on the front lines of dealing with medical emergencies.
31 may 2020--But he never could have imagined he'd be graduating during the biggest global pandemic in a century when he joined forces two years ago with Tracey Shors, Distinguished Professor of Neuroscience and Psychology, on a study to find out whetheraerobic exerciseand meditation would reduce stress and improve the quality of life for medical students like him.
Now Lavadera, who begins a four-year emergency medicine residency on June 29 at a COVID-19 only hospital in Brooklyn and Shors, who thinks she may have battled a case of the coronavirus, are using the stress-reducing technique taught to RWJMS medical school students to help them each deal with the anxiety and uncertainty left in the path of the crisis.
"I am isolating alone in my apartment and keeping myself up to date on the evolving guidelines on treatments and recommendations regarding COVID19, but I'm making a conscious decision to avoid sensational and minute-by-minute news," says Lavadera who will split his time between two Brooklyn hospitals—Kings County Hospital in Flatbush and SUNY Downstate Medical Center, one of only three New York hospitals treating COVID-19 only patients. "I am working out, mediating and doing the training program that I helped to promote to medical school students. I think it keeps me afloat and helps to keep my stress level down."
The new Rutgers study in the Journal of Alternative and Complementary Medicine, Lavadera coauthored with Shors and doctoral student Emma Millon, documents the effectiveness of the technique that helped them both through this difficult time. The researchers found that meditation combined with aerobic exercise reduces stress and rumination while enhancing the quality of life for medical students.
Over an eight-week period first and second-year medical school students participated in the intervention called MAP Train My Brain, twice a week, which included 30 minutes of meditation followed by 30 minutes of aerobic exercise compared to a control group of student who did neither.
Shors—who developed the MAP (mental and physical) Training for those with depression, trauma and stress-related symptoms—has studied the effects of this training on different groups, including women who have been sexually assaulted and most recently women living with HIV, a study which has not yet been published.
When Shors began the study on medical school students with Lavadera she thought she understood how stressful treating patients could be for physicians. But she gained deeper insight during her recent illness.
For about six weeks from late February to early April, Shors suffered with coronavirus symptoms at home: trouble breathing, a persistent cough, and debilitating fatigue. She went to packed emergency departments twice, got a chest X-ray that showed no pneumonia and was sent home to isolate without getting a COVID-19 test because she didn't have a fever.
Shors remembers the doctors and nurses. "Behind their masks, I could see in their eyes the stress and anxiety that they are feeling, but I also experienced the professionalism and compassion that they bring to each person coming in for help," said Shors, vice chair/director of Graduate Studies in the department of psychology Center for Collaborative Neuroscience in the School of Arts and Sciences at Rutgers University-New Brunswick.
The study, which researchers believe is the first to document positive outcomes with such an intervention on medical students, found that the students doing the MAP Training experienced significantly less stress and were approximately 20 percent less likely to ruminate with depressive and brooding thoughts, when compared to medical students in the control group who did not participate in the program.
Most importantly, researchers say, is that those involved in the study said the training improved their quality of life, with 84 percent of the medical school students saying that they would recommend MAP Train My BrainTM to future patients as a way to alleviate anxiety and stress and improve overall health.
Shors and Lavadera say while the aim of the study was to provide a program for medical school students that would keep them physically and mentally healthy, they also hoped that it would be a program that they would want to recommend to future patients.
As the uncertainty of what lies ahead with the global COVID-19 pandemic continues, both Shors, who at the height of what she believes was her bout with coronavirus, worried that she would have to be hooked to a ventilator, and Lavadera, who has been trying to stay away from the daily drumbeat of coronavirus news before he has to deal with it firsthand, says this meditation and aerobic exercise program allows them to do it at home, alone.
"It is always important to reduce stress but especially important and difficult to do during this traumatic time," says Shors. "We are living with the threat of illness and even death for ourselves and our loved ones. There is nothing more stressful than that."
More information: Paul Lavadera et al, MAP Train My Brain: Meditation Combined with Aerobic Exercise Reduces Stress and Rumination While Enhancing Quality of Life in Medical Students, The Journal of Alternative and Complementary Medicine (2020). DOI: 10.1089/acm.2019.0281
Journal information: Journal of Alternative and Complementary Medicine
Provided by Rutgers University
Despite millennial stereotypes, burnout just as bad for Gen X doctors in training
Despite the seemingly pervasive opinion that millennial physicians are more prone to burnout and a lack of empathy compared to older generations, a new study by researchers at Northwestern Medicine and Cleveland Clinic found that no such generational gap exists.
31 may 2020--According to the study of 588millennialand Generation X residents and fellows, millennial physicians in training did not show increased vulnerability toburnoutor differentempathyskills compared to a demographic-matched sample of Generation-X physicians.
It is the first study to evaluate the impact of generation affiliation (millennial vs. Generation X) on physician qualities, specifically empathy and burnout—a state of emotional, physical and mental exhaustion caused by excessive and prolonged stress. Both empathy and burnout have been demonstrated to impact the quality of patient care.
The study was published today, May 5, in the journal Academic Psychiatry.
This study's findings cannot be extrapolated beyond the context of physicians in training. However, the statistical approach used in this study, controlling for other factors like level of experience in the field, could be used in studies of other professional fields to provide further clarity on the broader impact of generation affiliation on professional qualities.
"As millennial physicians are increasingly entering the workforce, people seem to be wondering what millennial doctors will be like, and I've heard older physicians opine that physician burnout is a bigger problem now due to generation vulnerability," said lead author Dr. Brandon Hamm, instructor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine. Hamm conducted the research while he was at Cleveland Clinic.
"Our study provides a little more transparency that it's medical-system exposure—not generational traits—that is more likely to contribute to the burnout seen in today's doctors," Hamm said.
Consistent with other studies, this paper found empathy decreases over the course of physician training, Hamm said. Additionally, Hispanic/Latino physicians in training demonstrated higher empathy scores and lower depersonalization burnout experience than Caucasian physicians in training. Depersonalization includes psychological withdrawal from relationships and the development of a negative, cynical or callous attitude.
What can be done to slow physician burnout?
"The first year of residency can be really rigorous and have a negative psychological impact on physicians in training, which can lead to dysfunctional coping strategies like substance abuse," Hamm said. "We need to be researching interventions that not only slow this empathy decline but bolster physicians' communities so they feel supported and less isolated."
More information: Brandon Hamm et al, Comparison of Burnout and Empathy Among Millennial and Generation X Residents and Fellows: Associations with Training Level and Race but Not Generation Affiliation, Academic Psychiatry (2020). DOI: 10.1007/s40596-020-01226-9
Provided by Northwestern University
Is it safe to go to my doctor's office? Your questions answered
by Sarah Gantz
Credit: CC0 Public Domain
Hospitals are resuming non-urgent procedures, and doctor's offices are reopening as the peak of the coronavirus pandemic appears to be passing in the Philadelphia-area.
31 may 2020--Pennsylvania Gov. Tom Wolf has authorized providers to reopen so long as they have sufficient protective equipment, staff, and capacity to treat both patients who are positive for COVID-19 and those who are not.
Here's what you need to know about going back to the doctor.
Without a vaccine for COVID-19, there is a risk of exposure anywhere you go—including the doctor's office. But hospitals and doctor's offices are taking extra steps to reduce that possibility (more on those steps below).
It is important to weigh the risk of contracting the virus with the risk of other health conditions worsening by not seeking medical treatment. Talk to your doctor about your medical concerns, and together you can decide whether an in-person visit is a good idea or whether you may be a good candidate for a video or telephone visit.
"Don't be reluctant to return if you haven't been there in a while," said Lawrence John, president of the Pennsylvania Medical Society and a family physician in Pittsburgh. "Continuity of care is important, especially for a chronic condition like diabetes, hypertension, and heart disease."
You can limit your risk of contracting the virus by practicing social distancing, wearing a face mask, and using hand sanitizer liberally, especially after handling high-touch surfaces like doors, elevator buttons, and shared office objects, such as a clipboard and pen.
Hospitals treating COVID-19 patients have designated care units for those patients, often with dedicated entrances, to ensure they do not come into contact with patients at the hospital for other reasons. Doctors, nurses, and other medical staff in direct contact with COVID-19 patients do not cross back and forth between coronavirus units and non-coronavirus units.
Doctor's offices are limiting the number of people in the office at one time by spreading out appointments, asking patients to wait outside or in their car after checking in, spreading out waiting room chairs, and removing their troves of communal waiting room magazines.Both hospitals and medical offices have stepped up cleaning and disinfecting routines, are requiring patients to come alone, and are screening everyone who walks in the door for COVID-19 symptoms.
Telemedicine has dramatically expanded during the pandemic as a way for doctors to keep in touch with patients without seeing them in person. Doctors have been pleased with how much they can accomplish through a video visit, and many hope to continue using telemedicine when possible to reduce the number of patients coming to their offices.
If you are interested in a virtual visit, ask your doctor if it's an option. Doctors can evaluate, for example, back pain, a rash or a swollen joint; go over results from an X-ray or MRI; and complete routine check-ups for chronic conditions through video visits. Other types of services, such as a colonoscopy or mammogram, will require an in-person appointment.
Most major health insurers and Medicare have agreed to cover telemedicine visits during the pandemic, but it's a good idea to double check with your insurer or benefit manager.
People who will be having surgery will likely need to be tested for COVID-19 a day or two before the procedure. On the day of your procedure, be prepared to go alone, as visitors are still not permitted at most medical centers. It may be a good idea to plan in advance how you will connect with family afterward—can you bring a cell phone and charger? Or can the surgeon or a nurse contact your family immediately after the procedure with a status update?
When you arrive, someone will take your temperature and ask screening questions about your potential exposure to the virus, such as whether you or anyone you've been in contact with has tested positive, whether you've had a cough or fever in recent days, and about any recent travel. If you're not wearing a mask, you will probably be given one.
Interacting with your doctor may seem different, too: he or she will limit physical contact, including forgoing a welcome handshake, and may want to keep conversation brief, to limit the amount of time you're in the office. Doctors and office staff will be wearing masks, which can make reading facial cues difficult. It's always a good idea to write down your questions in advance to make sure even the most efficient appointment gets you the answers you need.
The Philadelphia Inquirer
Tuesday, May 26, 2020
Dutch mink workers may be first known humans infected by animals: WHO
Credit: CC0 Public Domain
The World Health Organization said Tuesday that Dutch workers apparently infected with the coronavirus by minks could be the first known cases of animal-to-human transmission.
26 may 2020--The WHO told AFP that it was in close contact with Dutch researchers investigating three cases where thevirusappears to have been passed to humans from minks.
"This would be the first known cases of animal-to-human transmission," the UN health agency told AFP in an email.
"But we are still collecting and reviewing more data to understand if animals and pets can spread the disease," it said.
Dutch Agriculture Minister Carola Schouten said Monday that a second worker had likely contracted COVID-19 on a mink farm, while stressing that the risk of further contagion remained low.
An initial infection was reported last week on one of two farms near the southern city of Eindhoven, where the disease was discovered in April among mink that are bred for their valuable fur.
The infection happened before it was known that the mink were carrying the virus, meaning that workers did not wear protective clothing at the time.
The health ministry said that three people on the farm tested positive for the virus, but said that it remained unclear if more than one of the cases had come directly from a mink.
Infected pets
The exact source of the virus, which first appeared in China late last year, remains unknown, and there is growing pressure for an international probe to determine its origin.
In a matter of months, the virus has infected more than 5.5 million people, killing nearly 350,000 of them.
Most scientists believe the virus jumped from animals to humans, possibly in a market that sells exotic animals for meat in the city of Wuhan.
WHO chief Tedros Adhanom Ghebreyesus indicated Monday that China had agreed that an investigation of the origin was needed, but did not say when one might begin.
"All stakeholders understand the importance of studying the origin, because it's by studying the origin that we can prevent it from happening in the future," he told a virtual press conference.
Since the initial jump to humans, there have been no previous reports of animals being the source of infections.
The WHO said however that there have been some instances of COVID-19 patients infecting their pets.
"A number of susceptibility studies have shown that other animal species are also susceptible to the virus and can be infected, including cats, ferrets," it said.
The agency stressed that necessary precautions should be taken to avoid infection of pets from close contacts with humans with COVID-19, but insisted that "there is no reason or justification to take measures against companion animals."
2020 AFP
Saturday, May 23, 2020
Brazil emerges as a top global coronavirus hotspot
Experts predict death toll will top 100,000 in the coming months
In new Practice Points, the American College of Physicians (ACP) says that evidence does not support the use of chloroquine or hydroxychloroquine alone or in combination with azithromycin to prevent COVID-19 after infection with novel coronavirus (SARS-CoV-2), or for treatment of patients with COVID-19. The ACP Practice Points also state that physicians, in light of known harms and very uncertain evidence of benefit, may choose to treat the hospitalized COVID-19 positive patients with chloroquine or hydroxychloroquine alone or in combination with azithromycin in the context of a clinical trial using shared and informed decision-making with patients and their families. "Should Clinicians Use Chloroquine or Hydroxychloroquine Alone or In Combination with Azithromycin for the Prophylaxis or Treatment of COVID-19? Living Practice Points from the American College of Physicians (Version 1)" was published today in Annals of Internal Medicine.
15 may 2020--The ACP Practice Points provide rapid clinical advice based on a concise summary of the best available evidence on the benefits and harms of the use of chloroquine orhydroxychloroquinealone or in combination with azithromycin for the prophylaxis or treatment of COVID-19. The Practice Points are based on a rapid systematic review conducted by the University of Connecticut Health Outcomes, Policy, and Evidence Synthesis Group.
ACP Practice Points are developed by ACP's Scientific Medical Policy Committee and provide advice to improve the health of individuals and populations and promote high value care based on the best available evidence derived from assessment of scientific work (e.g. clinical guidelines, systematic reviews, individual studies). ACP Practice Points aim to address the value of screening and diagnostic tests and therapeutic interventions for various diseases, and consider known determinants of health, including but not limited to genetic variability, environment, and lifestyle.
"With the rapid emergence of COVID-19, physicians and clinicians have found themselves managing the frontlines of the pandemic with a paucity of evidence available to inform treatment decisions," said Jacqueline W. Fincher, MD, MACP, president, ACP. "ACP rapidly developed its Practice Points as concise, synthesized summaries of the current state of evidence in order to address urgent questions related to the transmission, diagnosis, and treatment of COVID-19. As such, these Practice Points give frontline physicians guidance to provide patients with the care based on the best available evidence."
Chloroquine and hydroxychloroquine are used to manage other major ailments with a known benefit and are in short supply in the United States. These medications also have known harms in non-COVID patients such as cardiovascular effects; diarrhea; abnormal liver function; rash; headache; ocular issues; and anemia.
Using chloroquine or hydroxychloroquine, with or without azithromycin, to prevent or treat COVID-19 infection began to receive attention following preliminary reports from in vitro and human studies. While several studies are planned or underway, the Practice Points provide details about the lack of and/or insufficient current research about the benefits and harms for prevention and treatment of COVID-19.
At this time, the authors of the Practice Points have identified that chloroquine or hydroxychloroquine alone or in combination with azithromycin to prevent COVID-19 after infection with novel coronavirus (SARS-CoV-2), or for treatment of patients with COVID-19 should not be used. The Practice Points also state that the drugs may only be used to treat hospitalized COVID-19 positive patients in the context of a clinical trial following shared and informed decision-making between clinicians and patients (and their families) that includes a discussion of known harms of chloroquine and hydroxychloroquine and very uncertain evidence of benefit for COVID-19 patients.
The ACP Practice Points will be maintained as a "living" document and ACP's Scientific Medical Policy Committee will monitor emerging evidence to determine its impact on the main findings and conclusions, and issue updates as needed.
More information: Amir Qaseem, et al. Should Clinicians Use Chloroquine or Hydroxychloroquine Alone or in Combination With Azithromycin for the Prophylaxis or Treatment of COVID-19? Annals of Internal Medicine. DOI: 10.7326/M20-1998
Journal information: Annals of Internal Medicine
Thursday, May 14, 2020
Infecting the mind: Burnout in health care workers during COVID-19
Health care workers are fighting two pandemics: COVID-19 and burnout. Credit: Texas A&M University College of Engineering
Doctors and nurses across the country are experiencing occupational burnout and fatigue from the increased stress caused by the COVID-19 pandemic. A team of researchers and medical professionals at Texas A&M University and Houston Methodist Hospital are working together to fight two afflictions: COVID-19 and the mental strain experienced by medical professionals.
14 may 2020--In an article recently published in the journalAnesthesia & Analgesia, Dr. Farzan Sasangohar, assistant professor in the Department of Industrial and Systems Engineering and colleagues at Houston Methodist Hospital, outline the effects of fatigue and burnout onintensive care unit(ICU) workers, and the steps that can be taken to mitigate these symptoms.
"The COVID-19 pandemic exacerbated an already existing problem within our health care systems and is exposing the pernicious implications of provider burnout," Sasangohar said.
Health care workers are experiencing added stress from multiple areas. Many of them are working longer shifts and experiencing more loss of life. The lack of personal protective equipment (PPE) and training on how to use new equipment causes many professionals to question if they have been exposed. This leads to fear that they could infect their family and loved ones. In addition to those fears, there is anxiety surrounding job security. To reduce the spread of infection, many states have stopped elective procedures and consequently, many health care professionals have been laid off or had their hours reduced.
Sasangohar and the research team documented four major areas of stress with the goal of identifying mitigation strategies to reduce burnout among these life-saving workers. The four areas identified by the researchers include occupational hazards, national versus locally scaled responses, process inefficiencies and financial instability.
The symptoms
Health care workers need effective PPE readily accessible and available to ensure their safety and that of their patients. Getting the necessary equipment has been challenging due to the low numbers of PPE and ventilators in the U.S. Strategic National Stockpile and delays getting equipment into local areas. This slow response, which has caused some providers to reuse PPE past the point of safety and warranty protections, can contribute to anxiety in providers.
"Minimizing occupational hazard is the most important criteria to assure that our health care workforce is fully equipped and assured to be safe in order to face the battle against this virus," said Dr. Bita Kash, professor of health policy and management in the Texas A&M School of Public Health and director of the Joint Center for Outcomes Research at Houston Methodist Hospital.
The process to secure assistance from federal authorities has been cumbersome and slow for providers. Many requests for additional ventilators and PPE are not being met. These uncertainties about when assistance will arrive has resulted in widespread anxiety among providers.
Process inefficiencies have also contributed to fatigue and burnout due to misinformation or conflicting information given between different specialties. While one subspecialty's professional organization recommends a certain guideline, another specialty could recommend something else, which leads to confusion.
Anxiety and worry about future career prospects and the overall economy can also lead to provider burnout. Elective surgeries have been canceled or delayed, causing financial stress on some physicians. Others not directly affected by financial hardship may be worried about loved ones or their own family and how they will weather a coming economic recession.
Prescription for the future
While this is the first world-wide pandemic in many years, there will be more. Working together, local researchers, health care professionals and government officials can prepare for future pandemics and subsequent waves of the COVID-19 pandemic. Houston Methodist Hospital has already begun learning from this pandemic and making changes to be more resilient in response to the current crisis and prepared for similar crises in the future.
In response to the pandemic, Houston Methodist Hospital adapted their policies and focused on constant and responsive communication from leadership to their employees. Proactive and positive responses have allowed the hospital to adapt quickly during the pandemic and reduce employee stress overall. This success has led to recommendations for future preparations.
The researchers' recommendations to reduce provider burnout and fatigue:
Pandemic plans should include guidance for relevant industries to quickly transition into producing needed medical supplies
National and regional disaster mitigation plans to help shorten the time needed to provide necessary equipment and testing
Provision of adequate numbers of test kits and PPE
Training on disaster management and response for medical professionals
Relaxing licensing restrictions for individuals licensed outside their state of residence
Creating a medical reserve corps of these licensed individuals
Using wearable sensors to monitor health care workers' mental health and provide simple ways to mitigate anxiety and stress
"There is much to learn from the response to COVID-19," said Sasangohar. "In our approach, we used a multi-disciplinary systems approach to learn not just from failures and shortcomings, but also from successful adaptations and improvised interventions at the individual, team and system levels to improve our resilience."
While ICU workers in Houston have weathered many storms, including Hurricanes Ike and Harvey, the COVID-19 pandemic has brought new challenges to already challenging work. The areas identified by the researchers can help make this work safer, more effective and reduce burnout in these critical roles.
More information: Farzan Sasangohar et al, Provider Burnout and Fatigue During the COVID-19 Pandemic, Anesthesia & Analgesia (2020). DOI: 10.1213/ANE.0000000000004866
Journal information: Anesthesia & Analgesia
Tuesday, May 12, 2020
Coronavirus 'not yet under control' in Brazil, scientists warn
Centro de São Paulo, Brasil. Ana Paula Hirama/Wikipedia
The coronavirus epidemic in Brazil is not yet under control according to a report from Imperial researchers.
12 May 2020--The findings suggest that the rate of transmission, or the R number, is still above 1 in all states.
The team's latest study, Report 21, from the WHO Collaborating Centre for Infectious Disease Modelling within the MRC Centre for Global Infectious Disease Analysis, the Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), Imperial College London in collaboration with Imperial's Department of Mathematics. presents estimates of COVID-19 cases and transmission in Brazil.
The researchers, from the Imperial College COVID-19 Response Team, also estimated that Brazil's R number has dropped substantially by 54 percent following interventions.
Infection levels
Since the first case was reported in Brazil on 25 February, Brazil has become the epicentre for COVID-19 in South America.
In the past 10 days, the number of reported infections more than doubled. The country is now reporting more than 135,000 cases and 9,000 deaths.
Of the 16 states analysed, five states account for 81% of all reported deaths. Brazilian state and city officials have mandated extensive public health measures (so-called non-pharmaceutical interventions, or NPIs) to reduce the transmission of COVID-19.
The team looked at the five states in Brazil with the highest number of deaths and estimate that the population infection levels range from 3.3% in São Paulo to 10.6% in Amazonas.
Government measures
Following the implementation of NPIs such as school closures and decreases in population mobility, the authors estimate that the reproduction number has dropped substantially.
However, in all 16 states analysed, the reproduction number remains above one, suggesting that the epidemic is not yet controlled and will continue to grow.
These results suggest that further action is needed to limit spread and prevent health system overload.
Virus spread 'not under control'
Dr. Thomas Mellan, from the School of Public Health, said: "We estimate the reproduction number is greater than one, meaning that the spread of the virus in Brazil is not under control."
Dr. Henrique Helfer Hoeltgebaum, from the Department of Mathematics, said: "Conditional on current mobility patterns in Brazil, we find that the transmission of SARS-CoV-2 is still not under control."
Dr. Swapnil Mishra, from the School of Public Health, said: "Our analysis clearly shows that Brazilian governmental measures have had an effect on the reduction of transmission of SARS-CoV-2. However, at the same time, we see that the epidemic is still not under control in Brazil and is spreading. We hope with more measures in place Brazil can contain the spread of the pandemic."
Since the emergence of the new coronavirus (COVID-19) in December 2019, the Imperial College COVID-19 Response Team has adopted a policy of immediately sharing research findings on the developing pandemic.
Coronavirus was in Brazil before carnival: study
Credit: CC0 Public Domain
The new coronavirus was circulating in Brazil in early February, weeks earlier than initially detected, and just before millions of people were partying in the streets for carnival, according to a new study.
12 May 2020-Brazil is the Latin American country hardest hit in the pandemic, with more than 11,500 deaths and 168,000 infections so far. Experts say under-testing means the real figures are probably far higher.
The study used statistical analysis to work backwards from the number of reported COVID-19 deaths and establish the probable time-frame of the virus' early spread in Brazil and other countries, said the Oswaldo Cruz Foundation (Fiocruz), the country's leading public health institute.
"The new coronavirus began spreading in Brazil around the first week of February. That is to say, more than 20 days before the first case was diagnosed in a traveler returning from Italy, on February 26... and more than 40 days before the first official confirmation of communal transmission," the institute said.
That means the local outbreak was already well under way when Brazil celebrated carnival from February 21 to 25, an event that draws millions of tourists and brings throngs of revelers into the streets in Rio de Janeiro, Sao Paulo, Salvador and other cities.
The study, which also analyzed data from Europe and the United States, found the virus was probably also spreading locally two to four weeks before the first cases were detected in Italy, the Netherlands and the United States.
"This lengthy phase of hidden communal transmission of the new coronavirus... indicates that containment measures should be taken at least as soon as the first imported cases are detected," said the lead researcher on the study, Gonzalo Bello.
Before becoming a professor, Sarah Szanton made house calls to older adults as a nurse practitioner. On her visits, she saw how an older person's home environment can contribute to health outcomes. Now, as the Endowed Professor for Health Equity and Social Justice at the Johns Hopkins School of Nursing and the director of the Center for Innovative Care in Aging, Szanton works to identify solutions to narrow racial and socioeconomic disparities for older people.
11 may 2020--Szanton joined one of her Ph.D. student mentees, Sarah LaFave, to discuss the challenges that COVID-19 poses forolder adults. This conversation has been edited for length and clarity.
How is the COVID-19 pandemic affecting older people differently than younger generations?
Older adults are more likely to have dire outcomes from the virus. It can also be a challenge to prevent older people from being exposed to the virus because they may not be be fully independent. For example, a mother might rely on her adult daughter to come and help her with groceries or take a shower. As another example, some older people depend on help from a family member or friend with sorting mail and sending in checks to pay bills. At this point, people may not have had someone come into the home to help with those kinds of things for many weeks. What happens if one of those unpaid bills is for an essential resource or accrues a lot of interest during this time?
We also have to think about all of the ways that the pandemic affects older people's lives beyond morbidity and mortality from the virus itself. I am concerned about people experiencing social isolation as a result of not being able to have visitors and not being able to go out and do things with other people. The effects are compounded for any older person who doesn't have access to technology platforms like Skype and FaceTime or who has limited access to phone calls. Many lower-income older people have pay-per-minute phone plans, for example, and may have to choose between using their limited minutes for a phone visit with a doctor or a conversation with a grandchild. So we can't assume that a switch to virtual socialization or virtual access to resources is going to work for all older people.
Also, I think there's a fair amount of ageism—of people thinking right now, even if they aren't saying it out loud, "Well, older people are going to die anyway." But who are we to say that an 80-year-old wouldn't have otherwise lived to be 100 and done a lot of wonderful things in those 20 years? We would never think that the first 20 years of someone's life don't matter; we should recognize that the last 20 years are just as valuable.
Has the pandemic exacerbated health disparities for older adults?
Every experience in life is influenced by a person's access to resources and, in the United States, a person's race, socioeconomic status, and other characteristics have profound impacts on access to resources. It can be easy to jump to saying, "Oh, well, that person was older and had diabetes, so of course they had a worse outcome from COVID." But you have to take a step back and ask what contributed to the person having diabetes in the first place. Because race is not biological, we know that it's not race itself that causes disparities in co-morbidities and in COVID outcomes—it's the relationship between race and resources. For example, my colleague Laura Samuel has found that the counties that have a high proportion of people who have to spend more than a third of their income on housing have higher COVID mortality rates. If we had a society that was structured so that everyone had the same chance at health, we would not see the disparities we are seeing.
A lot of the potential solutions to health disparities among older adults don't exist in the health care system itself—they occur further upstream. Things like widening access to the federal Supplemental Nutrition Assistance Program, addressing food deserts, and supporting returning citizens in the workforce all relate directly to health, but we don't always think that way.
What challenges has COVID-19 raised for family caregivers of older adults?
First, if family caregivers have jobs that require them to be in regular contact with others, such as bus drivers or nurses, they may have to decide between not providing essential help to an older loved one and risking passing the virus to that person.
Second, direct care workers continue to come in and out of hospitals, nursing homes, and senior living buildings and are being screened upon entrance, but very few family caregivers are allowed into these same facilities right now. In some cases, family caregivers are not being recognized as essential parts of the health care team, and I think they should be. Hospitals and nursing homes have had to place restrictions on visitors for safety reasons, but I think some of those policies may be too limiting. For example, delirium is a very common and very costly issue for older adults who are admitted to hospitals. There is a better chance of preventing and managing delirium if a family member can help attend to the day-night sleep cycle, keep the person oriented, hydrated, and so on. True delirium uses so many health care resources that it can benefit all of us if an older person has a familiar caregiver with them during an inpatient stay. Of course, a major limitation is that there isn't enough personal protective equipment right now, so you have to weigh the risks and benefits of tapping into a finite supply of protective equipment.
What can people do right now to support older adults in their communities during this crisis?
There are many volunteer opportunities. For example, Baltimore Neighbors Network is a coalition of community partners that trains and supports volunteers to provide companionship and resource navigation assistance to older adults in Baltimore, which includes remote options such as phone calls. If people can't volunteer for a program like that right now, maybe they can give blood, or maybe they can take the money they would usually spend eating out each month and instead contribute financially to a food pantry. People can also support their older family members or friends by asking the person what would be most helpful to them—maybe it's dropping off a meal on a front porch, maybe it's mailing a letter. It's really important to remember, even during a crisis, to make time for our elders.
Provided by Johns Hopkins University
Monitoring COVID-19 from hospital to home: First wearable device continuously tracks key symptoms
The more we learn about the novel coronavirus (COVID-19), the more unknowns seem to arise. These ever-emerging mysteries highlight the desperate need for more data to help researchers and physicians better understand—and treat—the extremely contagious and deadly disease.
11 MAY 2020--Researchers at Northwestern University and Shirley Ryan AbilityLab in Chicago have developed a novelwearable deviceand are creating a set of data algorithms specifically tailored to catch early signs and symptoms associated with COVID-19 and to monitor patients as the illness progresses.
Capable of being worn 24/7, the device produces continuous streams of data and uses artificial intelligence to uncover subtle, but potentially life-saving, insights. Filling a vital data gap, it continuously measures and interprets coughing and respiratory activity in ways that are impossible with traditional monitoring systems.
Developed in an engineering laboratory at Northwestern and using custom algorithms being created by Shirley Ryan AbilityLab scientists, the devices are currently being used at Shirley Ryan AbilityLab by COVID-19 patients and the healthcare workers who treat them. About 25 affected individuals began using the devices two weeks ago. They are being monitored both in the clinic and at home, totaling more than 1,500 cumulative hours and generating more than one terabyte of data.
About the size of a postage stamp, the soft, flexible, wireless, thin device sits just below the suprasternal notch—the visible dip at the base of the throat. From this location, the device monitors coughing intensity and patterns, chest wall movements (which indicate labored or irregular breathing), respiratory sounds, heart rate and body temperature, including fever. From there, it wirelessly transmits data to a HIPAA-protected cloud, where automated algorithms produce graphical summaries tailored to facilitate rapid, remote monitoring.
"The most recent studies published in the Journal of the American Medical Association suggest that the earliest signs of a COVID-19 infection are fever, coughing and difficulty in breathing. Our device sits at the perfect location on the body—the suprasternal notch—to measure respiratory rate, sounds and activity because that's where airflow occurs near the surface of the skin," said Northwestern's John A. Rogers, who led the technology development. "We developed customized devices, data algorithms, user interfaces and cloud-based data systems in direct response to specific needs brought to us by frontline healthcare workers. We're fully engaged in contributing our expertise in bioelectronic engineering to help address the pandemic, using technologies that we are able to deploy now, for immediate use on actual patients and other affected individuals. The measurement capabilities are unique to this device platform—they cannot be accomplished using traditional watch or ring-style wearables that mount on the wrist or the finger."
"We anticipate that the advanced algorithms we are developing will extract COVID-like signs and symptoms from the raw data insights and symptoms even before individuals may perceive them," said Arun Jayaraman, a research scientist at Shirley Ryan AbilityLab, who is leading the algorithm development. "These sensors have the potential to unlock information that will protect frontline medical workers and patients alike—informing interventions in a timely manner to reduce the risk of transmission and increase the likelihood of better outcomes."
Continuous monitoring from hospital to home
The mysterious ways that COVID-19 affects the body seem to get stranger and stranger. Many patients' symptoms fully disappear before they suddenly and unexpectedly begin deteriorating—sometimes within a matter of hours. Other patients have recovered and tested "negative" but later test "positive" again.
The unknowns underscore the need for continuous patient monitoring to ensure that physicians can intervene at the slightest sign of trouble. The Northwestern and Shirley Ryan AbilityLab teams' device provides around-the-clock monitoring for COVID-19 patients and those exposed to them.
"Having the ability to monitor ourselves and our patients—and being alerted to changing conditions in real time—will give clinicians a new and important tool in the fight against COVID-19," said Dr. Mark Huang, a physician at Shirley Ryan AbilityLab, who has worn the sensor. "The sensor also will offer clinicians and patients peace of mind as it monitors COVID-like symptoms, potentially prompting earlier intervention and treatment."
The device can monitor hospitalized patients and then be taken home to continue 24/7 supervision. The real-time data streaming from patients gives insights into their health and outcomes that is currently not being captured or analyzed by traditional monitoring systems.
"Nobody has ever collected this type of data before," Rogers said. "Earlier detection is always better and our devices provide important and unique capabilities in that context. For patients who have contracted the disease, the value is even more clear, as the data represent quantitative information on respiratory behavior, as a mechanism to track the progression and/or the effects of treatments."
"This opens up new telemedicine strategies as we won't have to bring in patients for monitoring," Jayaraman said. "Physicians can potentially review the patients' data for hours, days or weeks, immediately through a customized graphical user interface to a cloud data management system that is being set up for this purpose, to see an overall image of how the patient is doing."
Although the wearable device is currently unable to measure blood oxygenation levels, which is an important component of lung health, the team plans to incorporate this capability in its next round of devices. The Rogers lab has already suc … ntensive care units. Rogers believes they can easily apply that research to the COVID-tailored devices.
Warning system for the most at-risk
Not only can the device monitor the progress of COVID-19 patients, it could also provide early warning signals to the frontline workers who are most at risk for catching this remarkably infectious disease. The device offers the potential to identify symptoms and to pick up trends before the workers notice them, thereby providing an opportunity to engage in appropriate precautionary measures and to seek further testing as quickly as possible.
"People with obvious, severe symptoms are going to the hospital, being tested or being told to self-isolate," Jayaraman said. "For those who have symptoms they perceive as mild or seasonal allergies, there is no warning system. They could be in contact with others and unknowingly spread infection."
Assessing efficacy of new therapeutics
As researchers rush for a COVID-19 cure, physicians have been trying exploratory, sometimes unproven, treatments to help their patients. This is another area where Rogers' and Jayaraman's device can play a role.
"Early reports of certain proposed treatments suggest that they can eliminate coughing symptoms more quickly than a placebo," Rogers said. "Nobody, however, is quantifying certain key symptoms, such as coughing—duration, frequency, amplitude, sounds, etc. Our device allows for precision measurement of this essential, yet currently unquantified, aspect of the disease."
In the future, this sensor package could help researchers and physicians quantify which therapeutics are working best.
"At the simplest level, our systems allow assessments based on data, in a quantitative way, without relying on human judgment of whether a patient is coughing more or less," Rogers said.
Device initially conceived for stroke patients
The new device builds on recent research from a collaboration between Rogers' and Jayaraman's labs, first published on the cover of the February 2020 issue of Nature Biomedical Engineering, with a focus on monitoring swallowing and speech disorders in patients recovering from stroke. These sensors work by precisely measuring vibratory signatures from the throat and chest. By measuring vibrations rather than acoustics, the team avoids noise from background sounds and it bypasses privacy issues.
In response to requests and inquiries from the medical community, Rogers and Jayaraman realized they could use this technology to measure the vibratory signatures of COVID-like symptoms, including chest wall movements and cough.
Jayaraman's team is developing custom signal processing and machine-learning algorithms to train the device how to recognize coughs in the data.
"As the algorithm becomes smarter, our hope is that it will begin to discriminate among which coughs are COVID-like and which are from something more benign," Jayaraman said. "The most basic approach, already deployed on COVID-19 patients and health care workers, simply counts coughs and their intensity."
More advanced analytics packages will be available within the next few weeks.
Bypassing already-stressed supply chains
Thanks to a generous gift from Northwestern University trustees Kimberly K. Querrey and Louis A. Simpson, Rogers and his team are able to respond quickly to requests for devices. Leveraging a set of manufacturing tools available in the
new Simpson Querrey Biomedical Research Building in Chicago, the team is already producing dozens of devices per week. Rogers estimates that his team could produce up to hundreds of devices per week—all in house, largely bypassing the need for external vendors and complex supply chains.
"Quickly developing new technologies internally has never been more crucial," Querrey said. "This work proves the power of STEM and why it's so critical to the University and beyond to have world-class researchers like John. I am so proud of John and his team, while working remotely, for thinking outside the box and using their collaborations to help protect our healthcare workers. We are excited to be able to develop these devices within the University and get them in the hands of those needing them most. The ability to measure vibratory signatures could really help with early detection of COVID-19."
"This crucial philanthropic support has allowed us to develop and deploy the devices and an associated software infrastructure almost immediately, within days, after we started receiving requests from the medical community—without waiting for external vendors, most of which are mostly shut down with the stay-at-home orders," Rogers said. "In this way, we avoid already-stressed supply chains. We just do it ourselves."
Comfortable and easy to use
In mid-March, Kelly McKenzie felt foggy and developed a low-grade headache. Having recently returned from a work-related trip overseas, she assumed it was jetlag. But as her symptoms progressed to include cough and congestion, she started to worry. Although her symptoms were not severe enough to seek COVID-19 testing, she knew she should self-isolate.
"Between my international travel and the symptoms, my director and I decided it was best for me to stay home from work, so I wasn't bringing anything contagious into the hospital," said McKenzie, who is a research physical therapist at Shirley Ryan AbilityLab.
McKenzie joined the pilot study to test the device and train the algorithm with her symptoms. After wearing the sensor around the clock for a week, she was amazed by the comfort of the soft silicone material and ease of use. Wearers simply charge the device, put it on and it immediately begins to work—streaming real-time data to a smartphone or tablet.
"When you first put it on, you can feel it just because it's new and different," McKenzie said. "But after you have worn it for a while, you don't even notice it."
Because it is fully encased without wires, electrodes, charge ports or removable batteries, the device can be worn while exercising or in the shower. It turns out this also is important for sterilization and reuse.
"This is absolutely critical for use in the context of this extremely contagious disease," Rogers said. "Because it is fully sealed in a soft biocompatible silicone material, it can be completely immersed in alcohol, and then exposed to a gas-based system for rigorous sterilization. If there were exposed regions, or plugs or ports or other physical interfaces, the device would not be relevant for this application."
What's next?
In the coming weeks, the Northwestern and Shirley Ryan AbilityLab teams will continue collecting patient data to strengthen their algorithms—through deployments both in the clinic and at home. They also are responding to other requests for access to the technology, across the medical complex in Chicago. Additional deployments are starting now.
Rogers and Jayaraman also are examining data from patients recovering from COVID-19, attempting to determine when they are no longer contagious. Some of the patients wearing the device have been dismissed from the acute-care hospital and are rehabilitating at Shirley Ryan AbilityLab. In the future, this device could help determine whether post-COVID patients still have minor, perhaps imperceptible symptoms.
Rogers hopes the device will not just tell physicians how to best treat COVID-19 but also inform researchers about the nature of the virus itself.
"The growing amount of information and understanding around COVID-19 as a disease will be critically important to containing and treating the current outbreak as well as those that might occur in the future," he said. "We hope, and we believe, that these devices may help in these efforts by identifying and quantifying characteristics and essential features of cough and respiratory activity associated with this disease."
To accelerate the deployment of this device, the team recently launched a lean engineering-centric company, Sonica Health, based on intellectual property jointly developed by Northwestern and the Shirley Ryan AbilityLab and licensed through Northwestern's Innovation and New Ventures Office. Exploring use of the device for the COVID-19 response is supported by the Biomedical Advanced Research and Development Authority (BARDA), part of the Office of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services.
BARDA invests in the innovation, advanced research and development, acquisition and manufacturing of medical countermeasures—vaccines, drugs, therapeutics, diagnostic tools and non-pharmaceutical products needed to combat health security threats. To date, 54 BARDA-supported products have achieved regulatory approval, licensure or clearance. DRIVe (Division of Research, Innovation and Ventures) within BARDA, catalyzes the development of innovative products and approaches, like the Sonica Health technology, with the aim of solving major health security challenges.
