This page contains links suggested by our members. Please do send suggestions about links you have found particularly useful to our email for website submissions, email@example.com(this is different from the list server email, firstname.lastname@example.org you must subscribe to at http://list.clpsychiatry.org/scripts/wa.exe?SUBED1=COVID-19&A=1). Thank you to members who have submitted the following links.
Excellent Update from a Physician on the Front Lines in NYC
This video from Dr. David Price of Weill Cornell Medical Center describes the typical course of the illness, steps to take to protect yourself in the community, and actions needed if you have symptoms.
Well-Illustrated Summary of the Viral Proteins from the NYT
Reviews for Clinicians Assisting in ICU Settings
Ventilation 101 with Dr. Hala Karnib, Louisville Lectures Int Med Lecture Series Podcast
The Seriously Ill Patient with Dr. Nunley, Louisville Lectures Int Med Lecture Series Podcast
Acute Respiratory Distress Syndrome with Dr. Cavallazzi, Louisville Lectures Int Med Lecture Series Podcast
Sepsis with Dr. Sally Suliman, Louisville Lectures Int Med Lecture Series Podcast
Critical Care for the Non-ICU Clinician provides online education to healthcare professionals who could benefit from critical care training. Access to this important resource is complimentary.
Visit https://sccm.org/covid19 to access
Neurological complications of Covid-19 Infection
Chinese investigators studied CNS, PNS, and muscular neurological complications in 214 cases of Covid-19 infection, reporting overall rates of 11% for muscle injury, 7% for altered alertness, 6% for hypogeusia, 5% for hyposmia, and 3% for CVA and/or intracranial hemorrhage. Neurologists in NY, NY also report encountering Covid-related stroke.
This case report indicates that Covid-19 infection can present as encephalopathy.
Clinicians at the Henry Ford Health System in MI report a case of acute necrotizing hemorrhagic encephalitis, most likely a manifestation of cytokine storm.
Chinese clinicians report a single case of apparent acute Guillain-Barré syndrome related to Covid-19 infection.
Covid-19 as an Upper Respiratory Infection
This new study in Nature argues that Covid-19 is in many patients an upper respiratory infection, with variable extension to the lower respiratory tract.
Nature Virological Assessment of hospitalized patients with COVID-2019.pdf
Alpha-2 Agonists in Critical Care
This is an excellent discussion of: clonidine, guanfacine, lofexidine, ketamine, and dexmedetomidine in the ICU, from Dr. Josh Farkas, MD, Associate Professor, Pulmonary and Critical Care Medicine, University of Vermont.
Use of Valproate for Agitation in the ICU
As we see valproate used in increasing rates for Covid-19 patients, this interesting study emphasizes the need for adequate dosing of the agent, with median dose of 23 mg/kg/d
Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19
These guidelines from an authoritative professional group will be continually updated.
Internet Book of Critical Care (IBCC): Covid-19
This is an excellent and continually updated summary of Covid-19 from the intensivist perspective, managed by Dr. Josh Farkas, MD, Associate Professor, Pulmonary and Critical Care Medicine, University of Vermont (whose PulmCrit blog is referenced in an earlier link on this page).
Ongoing Clinical Trials of Interventions, by Stage of Illness
ACLP member Dr Hindi Mermelstein MD, FACLP, of the Long Island Jewish Medical Center sent us this interesting link.
Cytokine Storm and Covid-19 Infection
ACLP member Dr Avram Mack, MD, of the Children’s Hospital of Philadelphia sent us these though-provoking links about cytokine release syndrome after Chimeric Antigen Receptor T-cell therapy and about the use of IL-6 blockade in Covid-19 infection.
Five Additional Cases of Guillain–Barré Syndrome Related to Covid-19 Infection
Dr Toscano and colleagues from Italy describe 5 more cases of Guillain–Barré Syndrome appearing typically 5 to 10 days after viral symptom onset, verifying that Covid-19 infection can produce autoimmune reactions in the CNS. Note that other autoimmune CNS reactions to Covid-19 infection are appearing in preliminary case reports.
Neuropsychiatric Sequelae of Viral Infection
Drs Emily Troyer, Jordan Kohn, and Suzi Hong note that previous viral epidemics have been followed by neuropsychiatric sequelae such as insomnia, anxiety, depression, mania, psychosis, suicidality, and delirium. For example, cases of Von Economo encephalitis (encephalitis lethargica), marked by hypersomnolence and catatonia, followed the 1918 viral epidemic. These authors provide a detailed review of viral interaction with the CNS.
No Indication ACEi or ARB Increase Risk in Covid-19 Infection
A large study with 1128 Covid-19 patients with hypertension shows decreased mortality (HR 0.37) with ACEi/ARB use. Increased risk with these agents was originally hypothesized, but now seems unlikely.
Large Outcome Study of Covid-19 Patients Hospitalized in New York City
Dr Safiya Richardson, MD, MPH, and others from Northwell Health, Manhasset, NY, report on 5700 patients hospitalized with Covid-19 in NYC. Of 2634 patients discharged or died, 12% were intubated, of whom 88% died (but this statistic may be misleading as it does not reflect patients still intubated at time of publication).
NEJM Illustrates Proper Collection of Nasopharyngeal Samples
A video is included in:
The Untold Toll — The Pandemic’s Effects on Patients without Covid-19
CL psychiatrists should be aware that acutely ill individuals are now avoiding the hospital due to fear of viral contagion. See this piece by Lisa Rosenbaum, MD, in JAMA.
Coagulopathy Emerges as Key Aspect of Covid-19 Pathology
Dr Klok and coworkers describe thrombotic complications in 31% of Covid-19 pneumonia admissions to 3 Dutch hospitals, including several ischemic CVA. Dr Llitjos and coworkers describe a 69% incidence of venous thromboembolic events in 2 French ICUs. A letter in the NEJM from Mount Sinai Hospital in NYC describes 5 cases in young adults of new large-vessel occlusive CVA related to Covid-19 infection.
High Rates of Neurological Features in Covid-19 Cases in ICU
French neurologists describe high rates of agitation, confusion, and corticospinal tract signs with enhanced tendon reflexes, ankle clonus, and bilateral extensor plantar reflexes in 58 Covid-19 ICU patients. In 13 patients with MRI imaging, leptomeningeal enhancement was noted in 8 and CVA in 3. At discharge, 15 of 45 (33%) had a dysexecutive syndrome with inattention, disorientation, or poorly organized movements in response to command.
Mixed Results in Clinical Trials with Remdesivir
Remdesivir, prodrug for an adenosine nucleoside analog which interferes with viral RNA-dependent RNA polymerase, significantly shortened time to recovery, median 11 vs 15 days, the primary endpoint in a large clinical trial with 1,063 subjects, and mortality was lower, 8.0% vs 11.6% (missing significance at p = 0.059), according to a summary announcement by the NIAID. By contrast, a clinical trial in China with 237 subjects just appearing in in The Lancetfound a non-significant improvement in time to clinical improvement, median 21.0 vs 23.0 days, and no improvement in mortality, 14% vs 13%.
Convalescent Plasma Ineffective in End-stage Covid-19 Infection
Five of 6 patients expired despite treatment with convalescent plasma at a median 21 days of infection, and the authors discuss that earlier treatment should be tried.
Comments about CAR-T Neurotoxicity and Covid-19 Infection
ACLP member Dr Avram Mack, MD, and his colleague, Dr Hannah-Lise Schofield, PhD, of the Children’s Hospital of Philadelphia have published a letter in Psychosomatics, “Applying (or not?) CAR-T Neurotoxicity Experience to COVID19 Delirium and Agitation.”
Early Treatment with Corticosteroids Improves Disease Course
Dr. Raef Fadel, DO, and coworkers at the Henry Ford Hospital describe improved mortality and other disease outcomes with prompt corticosteroid treatment in moderate to severe Covid-19 infection in this quasi-experimental study with 213 subjects.
New Review of Covid-19 Psychopharmacology in Psychosomatics
ACLP members Drs. Anna Kim and Carrie Ernst and others provide an analysis of psychopharmacology in the Covid-19 patient.
More on Psychiatric Sequelae of Covid-19 Infection
Chinese investigators find a 96% incidence of supra-threshold score on a post-traumatic symptom checklist in over 700 hospitalized recovering Covid-19 patients, consistent with other reports emphasizing the likely burden of symptoms in this domain in survivors.
More on Neurological Sequelae of Covid-19 Infection
Dr. Pablo Rábano-Suárez, MD, et al. describe 3 elderly patients with myclonus of the nasopharynx, face, and upper extremities, and Dr. Alireza Radmanesh, MD, et al. describe MRI features of 11 mechanically ventilated ICU patients with Covid-19 infection, with 10 having diffuse leukoencephalopathy and and 7 having juxtacortical/callosal microhemorrhages.
Mental Status Changes in Covid-19 InfectionACLP members Erica Baller, MD, Ana Ivkovic, MD, Elizabeth Madva, MD, Mladen Nisavic, MD, Nathan Praschan, MPH, MD, Scott Beach MD, FACLP, Felicia Smith, MD, and some other physicians review the published literature and the MGH experience, describing a high incidence of delirium in Covid-19 infection. They offer a 5-step algorithm for treatment.
More Evidence for Neurological Presentations of Covid-19
In the most recent issue of the journal General Hospital Psychiatry, ACLP members Drs. Scott R. Beach, MD, FACLP, Nathan C. Praschan, MPH, MD, Flannery Merideth, MD, Nicholas Kontos, MD, FACLP, Gregory L. Fricchione, MD, FACLP, Felicia A. Smith, MD, and two other physicians present 4 cases with combinations of altered mental status, myoclonus, rigidity/cogwheeling, alogia/mutism, or abulia related to Covid-19 infection: only one had significant respiratory symptoms, and only two had fevers (which were mild and transient).
More on Treatment of Agitation in Covid Infection
ACLP members Kimberly Yonkers, MD, and Seth Powsner, MD, FACLP, and others pen a commentary on the treatment of agitation in Covid-19 infection.
More Evidence for Widespread Vascular Infection in Covid-19 Disease
Varga et al. describe Covid-19 viral inclusion structures in endothelial cells, and endotheliitis in heart, lung, bowel, kidney, and lung in 3 post-mortem cases, pointing to Covid-19 endothelial infection, likely by ACE2 receptors.
Covid-19 Infection Associated with Toxic Elevation of Serum Clozapine Levels
The authors describe three cases with marked elevations of serum clozapine level induced by Covid-19 infection and note that severe systemic inflammation can increase clozapine levels, perhaps due to cytokine-mediated inhibition of CYP1A2. Clinicians should decrease clozapine dose in patients with Covid-19 infection or consider closely monitoring drug levels.
IgM in CSF Demonstrated in Covid-19 Encephalopathy
Karima Benameur, MD, et al. describe 3 patients with Covid-19 infection, encephalopathy, myoclonus, and other neurological symptoms who were found to have viral anti-S1 IgM in CSF, consistent with brain infection, although only one patient had significantly elevated protein (>200 mg/dl) and pleiocytosis (115 nucleated cells/ml).
Persistent Symptoms after Covid-19 Infection
In a study of 143 patients hospitalized for Covid-19 in Italy followed up at a mean of 60 days, all Covid-, only 13% were symptom-free, with the most common symptoms being (53%), dyspnea (43%), joint pain, (27%) and chest pain (22%).
Teenagers Efficiently Transmitter Covid-19
Dr. Young Joon Park et al analyze contact tracing data in South Korea to conclude that Covid+ subjects age 10 to 19 had the highest rate of transmission to housemates compared to any age group, destroying the notion that school reopening will not affect control of the pandemic.
Longevity of Antibody Response to Covid-19 Infection
A widely cited study argues that antibodies to Covid-19 are relatively short-lived in some patients: many patients with lower intensity of response had neutralizing potency at baseline by 50 days. This resembles antibody response to the corona viruses causing the common cold.
Visualizing and Measuring Droplet Spread with Different Mask Types
Drs. Siddhartha Verma, Manhar Dhanak, and John Frankenfield show that without a mask droplets travel up to 12 feet after a simulated cough, but masks of two layers of quilting cotton or a commercial cone mask are highly effective in limiting spread.
ADEM Emerging as Covid-19 Effect
Neurologists in the UK describe 43 consultations for neurological symptoms in 43 adults with Covid-19 infection: 10 with delirium, chiefly reversible; 12 with inflammatory CNS syndromes: 2 encephalitis, 9 acute disseminated encephalomyelitis (ADEM), 1 Isolated myelitis; 8 with ischemic strokes; 8 with peripheral neurological disorders: 7 Guillain-Barré Syndrome (GBS), 1 brachial plexopathy. Of the 12 with autoimmune presentations, 10 were treated with corticosteroids and other immunosuppressants, most making a partial recovery. Strokes and GBS are known complications but this incidence of ADEM is noteworthy.
Dexamethasone improves survival in Covid-19 Infection
In a trial with over 6,000 randomized subjects just published in NEJM, the RECOVERY Collaborative Group reports increased survival in subjects treated with corticosteroid, particularly in mechanically-ventilated patients (deaths 29% vs. 41%), one of the few trials to report meaningful survival benefit for any treatment in Covid-19 infection.
CDC Finds High Covid-19 Seroprevalence in Some Parts of US
Seroprevalence of Covid-19 antibodies was higher than case rates in some areas of the US, eg, as high as 23% in New York City in samples collected in late April to early May. In no part of the country did seroprevalence approach the 60% estimated to be needed for herd immunity.
Aerosol Transmission of Covid-19
Over 200 scientists urge the WHO to emphasize aerosol transmission in this statement which garnered wide attention.
This article in The Atlantic eloquently explains aerosol (floating in air) versus droplet (ballistically propelled but falling to ground) theories about Covid-19 contagion and their policy implications.
A scientific formulation is offered by Dr. Milton here.
Estrogen Protective in Covid-19 Infection
In a new study published in Clinical Infectious Diseases, Dr. T. Ding and co-authors show that age-matched women have lower severity of Covid-19 infection, but this difference disappears after menopause, and also find that estradiol levels are negatively correlated with infection severity and levels of certain cytokines.
Proper Study of Hydroxychloroquine Indicates No Clinical Benefit
Alexandre B. Cavalcanti, MD, PhD, and coworkers randomize 667 patients to standard care, hydroxychloroquine, or hydroxychloroquine plus azithromycin. At day 15 there is no clinical difference.
Psychiatric Aspects of Chloroquine and Hydroxychloroquine Treatment
ACLP members Drs. Brandon S. Hamm, MD, MS, and Lisa J. Rosenthal, MD, FACLP, update us about drug-drug interactions, QT prolongation, and neuropsychiatric effects of these agents in an article in an upcoming issue of Psychosomatics.
Involuntary Containment for Persons with Severe Psychiatric Impairment and COVID-19
Dr. Carmen Black Parker MD, and five other non-ACLP members discuss commitment and Covid-19 issues in this upcoming paper in Psychosomatics.
Video Conferencing Support Groups and Individual Mental Health Care for Covid-19 Clinicians
ACLP member Dr. Ramaswamy Viswanathan, MD, DMSc, FACLP, and two others discuss the use of telemedicine to support our colleagues in an upcoming Psychosomatics issue.
Capacity and the COVID Surge
ACLP member Dr. J.J. Rasimas, MD, PhD, FACLP, argues that consults for capacity in obviously impaired patients may be meaningful and not necessarily inappropriate.
American Psychiatric Association
The APA website contains an array of useful links for practitioners, including resources related to telepsychiatry. Notable content includes links to government guidance on practice: note that Medicare and Medicaid in many states now cover telepsychiatry more fully; the Office of Civil Rights has announced that HIPAA regulations will be enforced with discretion so that providers may provide needed medical care; the DEA has suspended enforcement of the Ryan Haight Act that required in-person assessment prior to prescribing controlled substances; SAMSHA has loosened requirements for medication-assisted treatment of opioid dependence; the FDA permits use of best medical judgment with regard to REMS requirements regarding clozapine and other drugs.
APA’s Telepsychiatry Toolkit
American Medical Association
This site is assembled from their resources and continually updated.
A physician’s guide to COVID-19.
APA Coronavirus Resources
Practice Guidance for COVID-19
NEJM resource page on Covid-19
American College of Physicians Website
This is one of the most comprehensive and frequently updated sources for clinical information (along with the Covid-19 entry in Up-To-Date).
American Academy of Child and Adolescent Psychiatry
Many Coronavirus resources for working with children and adolescents are found at:
TELEPSYCHIATRY, VIDEOCONFERENCING, AND REMOTE PATIENT CARE
How to Integrate Video Teleconferencing into Inpatient Rounds from Johns Hopkins
This video gives hints for protecting the medical team by telerounding. The use of a headstrap-mounted cell phone is particularly novel (around minute 12).
Hints for Effective Use of Zoom
“Zoom hackers” have been invading teleconferences. Consider making your default settings to (1) Enable screen sharing only for the host, who can then allow other participants to share their screen by “managing participants in a meeting” – host can put meeting participants on hold or remove them from the meeting and (2) Allow only host to use the annotation tools to add information to shared screens. Hints on managing participants are available here.
More hints on using Zoom:
Hints for effective use of Zoom 033120.pdf
American Association of Child and Adolescent Psychiatry Telepsychiatry Toolkit
The AACAP provides an extensive collection of resources for telepsychiatry. Please particularly see their page on “Coding for Telemedicine Services” regarding the use of the .95 modifier. https://www.aacap.org/AACAP/Clinical_Practice_Center/Business_of_Practice/Telepsychiatry/toolkit_videos.aspx
American College of Physicians Advice on Telemedicine
Two excellent pages of resources are below.
American Psychiatric Association Resources for Telepsychiatry
Many resources for telepsychiatry are now covered in the APA practice pages. NOTE THAT ON MAY 1, CMS ANNOUNCED THAT PSYCHIATRIC VISITS CONDUCTED BY TELEPHONE, USING AUDIO ONLY, WOULD BE COVERED RETROACTIVE TO MARCH 1, 2020.
Telehealth in a Post-Pandemic Future: Regulatory and Privacy Issues
Carmel Shachar, JD, MPH, Jaclyn Engel, and Glyn Elwyn, MD, PhD, MSc, of Harvard Law School, Cambridge, MA, and Geisel School of Medicine at Dartmouth, Lebanon, NH, argue in this piece in JAMA that new regulatory standards should be continued after the Covid-19 crisis ends.
Centers for Medicare and Medicaid Services Allows Billing for Audio-only Telehealth
CMS announced on April 30 that it would permit billing for telephone remote services (without video), retroactively effective to March 1, under Medicare. See the APA webpage for details:
Dr. Rachel Anne Caravella, MD, NYU Langone Medical Center, sends this photo of a MyWall device attached to a patient tray table. Televisits can be done directly through this device.
Over One Quarter of US Adults Using Telepsychiatry
A new survey of over 2,000 US adults by Alkermes and Harris Poll found that 27% were using telepsychiatry services, with 74% of these hoping to continue such telehealth after the Covid-19 crisis.
SYSTEM RESPONSES AND PLANNING
SAMSHA Handbook: TAP 34:Disaster Planning Handbook for Behavioral Health Treatment Programs
This 2013 resource seems prescient.
Supply Chain Planning
This video explains some of the challenges in supplying PPE and other consumables.
Editorial from Member in Boston Globe
Dr. Rebecca Brendel, JD, MD, FACLP, and others from the Harvard Medical School Center for Bioethics have published a statement about the ethics of medical care in conditions of limited resources.
Fair Allocation of Scarce Medical Resources in the Time of Covid-19
This article from Ezekiel J. Emanuel, MD, PhD, and colleagues on March 23, 2020, is a widely-referenced classic in the discussion of possible Covid-19 health care rationing.