Omission and Commission in Morally Injurious Experiences Among COVID-19 Health Care Professionals.

Objective: To produce a qualitative description of the impact of moral injury on medical providers during the COVID-19 pandemic.Methods: A convergent mixed-methods study design was used to explore experiences of health care workers during the first 12 months of the COVID-19 pandemic. Participants completed the Moral Injury Symptom Scale-HP (MISS-HP) and a 60-minute interview, in which they described their work experiences from March 2020 through January 2021. The study was conducted between May 2021 and August 2021.Results: Eight physicians and 6 nurses were interviewed. Most participants (71%) worked in the emergency department, while 29% worked in the medical intensive care unit (MICU). MISS-HP scores were 49 on average and ranged from 29 to 73. Among the demographic groups, MICU participants scored the highest (56) and men scored the lowest (40). There were no significant differences in scores between any demographic group. The analysis of interview data showed how omissions and commissions in one's professional duties created internal conflicts, which were inextricably linked to a deeper sense of feelings of guilt and blame around experiences of betraying or being betrayed and an inability to uphold one's moral values.Conclusions: The pandemic upended a previously reliable and imperceptible experience of a background of safety, in which the provision of both material resources and human presence was expected without question. Future directions generated from this study might examine the role of dependency on leadership structures and relationships with self and others that create the conditions for moral injury.Prim Care Companion CNS Disord 2024;26(1):23m03651. Author affiliations are listed at the end of this article.

Association of post-COVID phenotypic manifestations with new-onset psychiatric disease.

Acute COVID-19 infection can be followed by diverse clinical manifestations referred to as Post Acute Sequelae of SARS-CoV2 Infection (PASC). Studies have shown an increased risk of being diagnosed with new-onset psychiatric disease following a diagnosis of acute COVID-19. However, it was unclear whether non-psychiatric PASC-associated manifestations (PASC-AMs) are associated with an increased risk of new-onset psychiatric disease following COVID-19. A retrospective electronic health record (EHR) cohort study of 2,391,006 individuals with acute COVID-19 was performed to evaluate whether non-psychiatric PASC-AMs are associated with new-onset psychiatric disease. Data were obtained from the National COVID Cohort Collaborative (N3C), which has EHR data from 76 clinical organizations. EHR codes were mapped to 151 non-psychiatric PASC-AMs recorded 28-120 days following SARS-CoV-2 diagnosis and before diagnosis of new-onset psychiatric disease. Association of newly diagnosed psychiatric disease with age, sex, race, pre-existing comorbidities, and PASC-AMs in seven categories was assessed by logistic regression. There were significant associations between a diagnosis of any psychiatric disease and five categories of PASC-AMs with odds ratios highest for neurological, cardiovascular, and constitutional PASC-AMs with odds ratios of 1.31, 1.29, and 1.23 respectively. Secondary analysis revealed that the proportions of 50 individual clinical features significantly differed between patients diagnosed with different psychiatric diseases. Our study provides evidence for association between non-psychiatric PASC-AMs and the incidence of newly diagnosed psychiatric disease. Significant associations were found for features related to multiple organ systems. This information could prove useful in understanding risk stratification for new-onset psychiatric disease following COVID-19. Prospective studies are needed to corroborate these findings.

Return-to-work with long COVID: An Episodic Disability and Total Worker Health® analysis.

A growing number of working individuals have developed long COVID (LC) after COVID-19 infection. Economic analyses indicate that workers' LC symptoms contribute to workforce shortages. However, factors that affect return-to-work from perspectives of people with LC remain largely underexplored. This qualitative study of people with LC conducted by researchers living with LC aimed to identify participants' return-to-work experiences using Total Worker Health® and Episodic Disability frameworks. 10% of participants who participated in a mixed-method global internet survey, had LC symptoms >3 months, and responded in English were randomly selected for thematic analysis using NVivo12. 15% of responses were independently double-coded to identify coding discrepancies. Participants (N = 510) were predominately white and had at least a baccalaureate degree. Four primary work-related themes emerged: 1) strong desire and need to return to work motivated by sense of purpose and financial precarity; 2) diverse and episodic LC symptoms intersect with organization of work and home life; 3) pervasiveness of LC disbelief and stigma at work and in medical settings; and 4) support of medical providers is key to successful return-to-work. Participants described how fluctuation of symptoms, exacerbated by work-related tasks, made returning to work challenging. Participants' ability to work was often predicated on job accommodations and support. Non-work factors were also essential, especially being able to receive an LC medical diagnosis (key to accessing leave and accommodations) and help at home to manage non-work activities. Many participants described barriers accessing these supports, illuminating stigma and disbelief in LC as a medical condition. Qualitative findings indicate needs for workplace accommodations tailored to fluctuating symptoms, continuously re-evaluated by workers and supervisors together. Reductions in medical barriers to access work accommodations is also critical since many medical providers remain unaware of LC, and workers may lack a positive COVID test result.

Patient and provider experiences of telemental health during the COVID-19 pandemic in a New York City academic medical center.

OBJECTIVE: We aimed to evaluate patient and provider experiences with telemental health (TMH) at an academic outpatient psychiatry department in New York City during the first wave of the COVID-19 pandemic. METHODS: Patients and providers completed online surveys evaluating their experience with TMH during the first wave of the COVID-19 pandemic. Surveys were distributed to 1,178 patients and 287 providers from July 2020 through October 2020. RESULTS: 42.5% of providers and 21% of patients responded to the survey. The majority of patient and provider respondents rated the quality of phone and video visits as "equally good" or "somewhat worse" than in-person visits, while the majority of respondents were "somewhat satisfied" or "very satisfied" with video visits. Patients and providers preferred a hybrid model for future care. Common barriers to TMH included privacy, technical difficulties, and wi-fi access. CONCLUSIONS: Patients and providers appeared willing to exchange some degree of quality for satisfaction with TMH. This study did not demonstrate with statistical significance any specific patient populations that would benefit more or less from TMH, suggesting that TMH may be a successful model for diverse patient populations. Our results suggest that providers, payors, and regulators should facilitate hybrid care delivery models that incorporate TMH beyond the pandemic.

A new clinical challenge: supporting patients coping with the long-term effects of COVID-19.

Mental Health Practitioners (MHPs) have a unique opportunity to provide resources and support to those suffering from Long COVID (LC), the post infectious illness that often follows an acute SARS-CoV-2 infection. In working with these individuals, MHPs can learn from the experiences of patients with another post-infectious disease known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). ME/CFS was once thought to be a psychologically mediated disorder caused by deconditioning and the fear of exertion following a precipitating event such as a viral infection. Research now shows that LC and ME/CFS are biomedical, multisystem, complex physiologic diseases. This article provides a framework to MHPs for the treatment of LC patients using knowledge derived from three decades of research on ME/CFS.

Characterizing long COVID in an international cohort: 7 months of symptoms and their impact.

BACKGROUND: A significant number of patients with COVID-19 experience prolonged symptoms, known as Long COVID. Few systematic studies have investigated this population, particularly in outpatient settings. Hence, relatively little is known about symptom makeup and severity, expected clinical course, impact on daily functioning, and return to baseline health. METHODS: We conducted an online survey of people with suspected and confirmed COVID-19, distributed via COVID-19 support groups (e.g. Body Politic, Long COVID Support Group, Long Haul COVID Fighters) and social media (e.g. Twitter, Facebook). Data were collected from September 6, 2020 to November 25, 2020. We analyzed responses from 3762 participants with confirmed (diagnostic/antibody positive; 1020) or suspected (diagnostic/antibody negative or untested; 2742) COVID-19, from 56 countries, with illness lasting over 28 days and onset prior to June 2020. We estimated the prevalence of 203 symptoms in 10 organ systems and traced 66 symptoms over seven months. We measured the impact on life, work, and return to baseline health. FINDINGS: For the majority of respondents (>91%), the time to recovery exceeded 35 weeks. During their illness, participants experienced an average of 55.9+/- 25.5 (mean+/-STD) symptoms, across an average of 9.1 organ systems. The most frequent symptoms after month 6 were fatigue, post-exertional malaise, and cognitive dysfunction. Symptoms varied in their prevalence over time, and we identified three symptom clusters, each with a characteristic temporal profile. 85.9% of participants (95% CI, 84.8% to 87.0%) experienced relapses, primarily triggered by exercise, physical or mental activity, and stress. 86.7% (85.6% to 92.5%) of unrecovered respondents were experiencing fatigue at the time of survey, compared to 44.7% (38.5% to 50.5%) of recovered respondents. 1700 respondents (45.2%) required a reduced work schedule compared to pre-illness, and an additional 839 (22.3%) were not working at the time of survey due to illness. Cognitive dysfunction or memory issues were common across all age groups (~88%). Except for loss of smell and taste, the prevalence and trajectory of all symptoms were similar between groups with confirmed and suspected COVID-19. INTERPRETATION: Patients with Long COVID report prolonged, multisystem involvement and significant disability. By seven months, many patients have not yet recovered (mainly from systemic and neurological/cognitive symptoms), have not returned to previous levels of work, and continue to experience significant symptom burden. FUNDING: All authors contributed to this work in a voluntary capacity. The cost of survey hosting (on Qualtrics) and publication fee was covered by AA's research grant (Wellcome Trust/Gatsby Charity via Sainsbury Wellcome center, UCL).

Acanthosis nigricans, vitamin D, and insulin resistance in obese children and adolescents.

OBJECTIVES: The aim of this study is to identify factors accounting for the variation in 25-hydroxyvitamin D levels in a pediatric obese population. PATIENTS AND METHODS: One hundred and forty-nine obese children and adolescents (BMI ≥95th percentile) were evaluated in a pediatric endocrine office. Acanthosis nigricans (AN) skin lesions were rated on a 4-point scale. RESULTS: The 25-hydroxyvitamin D levels were significantly different between those without AN and those with any severity of AN (p=<0.001). Insulin levels were only significantly different between those with no and severe AN (p=0.007). A general linear model showed that month of visit predicted 19.0% of the variation and AN an additional 2.2%. When AN was dropped from the full model, log-transformed HOMA-IR remained insignificant (p=0.164). CONCLUSIONS: Season of evaluation was the main determinant of 25-hydroxyvitamin D levels. Severity of AN was a stronger predictor of 25-hydroxyvitamin D level variation than the measure of insulin resistance HOMA-IR.

Increased hunger and speed of eating in obese children and adolescents.

OBJECTIVES: This quality improvement program examined self-reported hunger, over-eating, and eating speed in obese and normal-weight children and adolescents prior to an interventional component. PATIENTS AND METHODS: Food frequency questionnaires were presented to 127 obese and 42 normal-weight patients, and perceived hunger, food intake and eating speed were rated. RESULTS: Obese patients reported significantly greater hunger than normal-weight patients (62.2% vs. 21.4%, p<0.001) and faster eating (55.7% vs. 23.3%, p<0.001). Patients reporting being "always" or "often hungry" were more than six times likely to be obese (OR=6.49, 2.86-14.73, p<0.001), while rapid speed of eating yielded a four-fold increase in likelihood of obesity (OR=4.15, 1.77-9.72, p<0.001). Hunger and speed of eating were also highly associated (p<0.001). CONCLUSIONS: Increased hunger and eating speed were highly prevalent in these obese pediatric patients and may reflect abnormalities of satiety and satiation.