Given the emphasis on social distancing and the possibility of a resurgence of COVID-19, we aim to highlight the evidence and best practices to continue comprehensive and effective opioid management during remote patient interactions to maximize safety for patients and providers, with an emphasis on drug monitoring regimens, while remaining cognizant of the public health challenges at hand. "
Introduction: Magnetic resonance imaging (MRI) conditional modes are a novel feature for certain Food and Drug Administration (FDA)approved spinal cord stimulation (SCS) devices. However, there is a paucity of literature around the limitation of MRI-conditional modes (''MRI safe''), specifically in clinical scenarios where urgent MRIs may be needed. One such limitation is load impedance, referring to the circuit's resistance to the current being generated by the system. High impedance can limit the MRIconditional mode capability, presenting potential harm to a patient undergoing an MRI or make an MRI unable to be completed. Methods: Three cases were identified, and informed consent was obtained. All information was obtained via retrospective chart review. Results: In this case series of three patients where MRI-conditional SCS systems were unable to be placed in ''MRI safe'' settings, preventing timely MRI study completion in the setting of high impedance, all three were required to undergo alternative imaging including CT scans, and two patients ultimately had the system explanted and one chose to be re-implanted after completion of scans. Conclusion: This case series highlights the need for further investigation of impedance in SCS systems and potential limitations for future MRI usage. The review of literature of impedance in SCS shows both device-and physiologic-related etiologies for changes in impedance that warrant consideration by the implanting physician.
significant associations with psychological distress were found for the presence of multiple co-morbidities in staff, direct involvement in COVID-19 patient care, receiving a quarantine order, and redeployment outside normal professional boundaries (Table 1). Insomnia, based on the first item of the GHQ-12, was reported by 45 participants (16.7%). Redeployment to work outside areas of usual clinical practice was reported by 41.9% of participants. The majority (59.3%) perceived their workload to be similar to pre-pandemic levels. Just 12.2% of participants had family, friends, or colleagues diagnosed with COVID-19. Formal PPE training was received by 256 (94.8%) participants with 149 (55.2%) being confident in correct usage and their ability to protect from infection. Situations where recommended PPE was unavailable were encountered by 46 (17.0%). Risks of getting infected (83.6%) and infecting family members (78.0%) were the top two concerns (Supplementary Appendix 2). This study shows significant psychological distress amongst anaesthesiologists and nurses working in ICUs in the context of the COVID-19 pandemic. While lower than reported in the outbreak epicentre in China, which reported depression in 50.4% and anxiety in 44.6% of healthcare workers, we found a twofold higher prevalence of anxiety and up to threefold higher prevalence of depression than reported amongst general healthcare workers in Singapore and Italy during this pandemic. 3,4,7 Many would regard even pre-pandemic work in such high-acuity environments as stressful and emotionally exhausting, thus potentially accounting for the differences compared with general healthcare workers. Indeed, pre-pandemic studies of occupational stress identified similar levels of anxiety and stress (29.0e35.7%) in ICU physicians and nurses using the GHQ-12. 5,8 Thus, the contention that COVID-19 has provoked all the elements of psychological distress in respondents still requires testing. Our study has limitations. Socioeconomic status, which may influence outcomes and intervention planning, was not assessed. Neither a pre-crisis baseline nor follow-up to assess the temporal changes in psychological distress was available. Being a single-centre snapshot, further studies in other populations are necessary for generalisability. Lastly, clinical interviews by a psychiatrist would have been ideal. Nonetheless, we identified risk factors for psychological distress that may be useful for identifying at-risk individuals, and respondent concerns of the infection risk, adequacy of PPE, and redeployment outside normal professional boundaries are still issues that need to be addressed. The psychological distress prevalent amongst providing anaesthesia and intensive care providers during this pandemic necessitates policies for screening of at-risk individuals and adoption of early psychological support interventions for affected staff. 9,10
The COVID-19 pandemic is revealing the unacceptable health disparities across New York City and in this country. The mortality rates of vulnerable and minority populations alone suggest a need to re-evaluate clinical decision making protocols, especially given the recently passed Emergency or Disaster Treatment Protection Act, which grants healthcare institutions full immunity from liability stemming from resource allocation/triage decisions. Here we examine the disparity literature against resource allocation guidelines, contending that these guidelines may propagate allocation of resources along ableist, ageist and racial biases. Finally, we make the claim that the state must successfully develop ones that ensure the just treatment of our most vulnerable.
Fortunately, all opioid screening tools can be completed remotely, either by the patient independently or with a provider via telemedicine. This process can be streamlined by integrating the screening tool into an electronic patient portal, where patients have access to their medical information, so that both the tool can be completed and the results are readily available for review and to be tracked. "Practice points• Many routine practices of chronic pain management have had to be adjusted in the COVID-19 era.• There are multiple validated risk assessment tools established to screen for patients at high risk for opioid misuse as well as maintain opioid therapy. • The pain medication questionnaire and brief risk questionnaire are the best supported tools for initiating opioid therapy in the in-person outpatient setting, therefore either of them would make a good choice as part of a telehealth visit for starting patients on opioids. • The Current Opioid Misuse Measure and the Screener and Opioid Assessment for Patients with Pain-Revised have performed well in the outpatient setting for maintaining patients on opioid therapy; together they would provide the best information at a telehealth visit. • The Current Opioid Misuse Measure may help indicate who has developed aberrant behavior, while the Screener and Opioid Assessment for Patients with Pain-Revised can predict future misuse. • As most studies performed on risk assessment tools were not tested in telemedicine settings, there is a need for direct studies to better evaluate their use in telemedicine.
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