Ob.Gyn. News

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].

Adding trastuzumab to carboplatin/paclitaxel improved survival in patients with advanced or recurrent HER2/Neu-positive uterine serous carcinoma (USC), according to an updated analysis from a phase 2 trial.

Dr Amanda Nickles Fader

At a median follow-up of 25.9 months, the median progression-free survival (PFS) was 12.9 months in patients who received trastuzumab plus carboplatin/paclitaxel and 8.0 months in patients who received only carboplatin/paclitaxel. The median overall survival (OS) was 29.6 months and 24.4 months, respectively.

Amanda Nickles Fader, MD, of Johns Hopkins Medicine, Baltimore, and colleagues reported these findings in an abstract that was slated for presentation at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer. The meeting was canceled because of the COVID-19 pandemic.
 

Confirmed benefit

The phase 2 trial was designed to assess whether trastuzumab, a humanized monoclonal antibody that targets HER2/neu – a growth factor receptor found in almost all USC cases and overexpressed in 30% of cases – would improve survival in patients with USC, Dr. Nickles Fader explained in an interview. She noted that trastuzumab has been shown to provide benefit in breast cancer patients with HER2/neu overexpression.

“[U]terine serous carcinoma ... is a very aggressive high-grade endometrial cancer subtype that is associated with really poor clinical outcomes and significant mortality,” Dr. Nickles Fader said. “It represents fewer than 10% of all uterine cancer cases, but it actually accounts for a disproportionate 40% of all deaths from uterine cancer.”

The overall survival among USC patients is about 45%, compared with 91% for more common lower-grade types of uterine cancers, she added.

“The conventional treatments for uterine serous carcinoma include surgery and then chemotherapy, but we’ve only really gotten so far by using a sort of one-size-fits-all treatment philosophy,” Dr. Nickles Fader said.

Based on preliminary findings from the current trial (J Clin Oncol. 2018 Jul 10;36[20]:2044-51), trastuzumab plus carboplatin/paclitaxel is now recognized as an alternative standard in treating advanced or recurrent HER2/Neu-positive USC, and this updated analysis confirms the benefits of adding trastuzumab, she said.
 

PFS, OS, and toxicity

There were 58 evaluable patients with primary stage III-IV or recurrent USC who were randomized to receive six cycles of carboplatin/paclitaxel alone or in combination with intravenous trastuzumab given until toxicity or progression.

The median PFS at a median follow-up of 25.9 months “very significantly favored” the trastuzumab arm, Dr. Nickles Fader said. The median PFS was 12.9 months in the trastuzumab arm and 8.0 months in the carboplatin/paclitaxel arm (hazard ratio, 0.46; P = .005).

In the 41 patients undergoing primary treatment, the median PFS was 17.7 months in the trastuzumab arm and 9.3 months in the control arm (HR, 0.44; P = .015). In the 17 patients with recurrent disease, the median PFS was 9.2 months and 7.0 months, respectively (HR, 0.12; P = .004).

“We were very pleased to see that there was also an overall survival benefit of about 5 months in the trastuzumab arm, compared to the control arm,” Dr. Nickles Fader said. The median OS was 29.6 months and 24.4 months, respectively (HR, 0.58; P = .046).

The PFS and OS benefit was “particularly striking” in the stage III-IV patients, according to Dr. Nickles Fader and colleagues. In this subgroup, the median OS was not reached in the trastuzumab arm, and it was 25.4 months in the control arm (HR, 0.49; P = .041).

Long-term toxicity did not differ between the treatment arms.
 

Applications and next steps

“The take-home message here is women should be tested if they have this subtype,” Dr. Nickles Fader said. “If they’re newly diagnosed, they should be tested for the HER2/neu receptor, and if [it is overexpressed] and they have advanced disease, we do recommend treatment with not only the conventional treatment, but with trastuzumab added to that, because that’s where we saw the most benefit.”

This is the only trial that has ever shown a major PFS and OS difference with combination targeted therapy and conventional chemotherapy in USC, Dr. Nickles Fader noted.

“So it was really exciting to see that,” she said, adding that a “much larger cooperative group trial” is being designed by the National Cancer Institute and NRG Oncology Group to look at this approach in HER2-positive, advanced-stage uterine cancers. The trial will include patients with USC, but it will extend to other uterine cancer types as well.

“We’re looking at different combinations of anti-HER2 therapies to sort of validate the results of this trial, but also to study this in other tumors that are HER2 positive,” Dr. Nickles Fader explained.

She also stressed the importance of addressing racial disparities in survival among women with USC, as African American women have higher rates of USC and related mortality than do other groups.

“It’s going to be important to look at not only molecular targets and improving survival but also racial inequalities and potentially epigenetics to really improve survival across the board,” Dr. Nickles Fader said.

She reported having no disclosures. The trial was sponsored by Yale University in collaboration with Genentech.

[email protected]

SOURCE: Nickles Fader A et al. SGO 2020, Abstract 12.

Adding trastuzumab to carboplatin/paclitaxel improved survival in patients with advanced or recurrent HER2/Neu-positive uterine serous carcinoma (USC), according to an updated analysis from a phase 2 trial.

Dr Amanda Nickles Fader

At a median follow-up of 25.9 months, the median progression-free survival (PFS) was 12.9 months in patients who received trastuzumab plus carboplatin/paclitaxel and 8.0 months in patients who received only carboplatin/paclitaxel. The median overall survival (OS) was 29.6 months and 24.4 months, respectively.

Amanda Nickles Fader, MD, of Johns Hopkins Medicine, Baltimore, and colleagues reported these findings in an abstract that was slated for presentation at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer. The meeting was canceled because of the COVID-19 pandemic.
 

Confirmed benefit

The phase 2 trial was designed to assess whether trastuzumab, a humanized monoclonal antibody that targets HER2/neu – a growth factor receptor found in almost all USC cases and overexpressed in 30% of cases – would improve survival in patients with USC, Dr. Nickles Fader explained in an interview. She noted that trastuzumab has been shown to provide benefit in breast cancer patients with HER2/neu overexpression.

“[U]terine serous carcinoma ... is a very aggressive high-grade endometrial cancer subtype that is associated with really poor clinical outcomes and significant mortality,” Dr. Nickles Fader said. “It represents fewer than 10% of all uterine cancer cases, but it actually accounts for a disproportionate 40% of all deaths from uterine cancer.”

The overall survival among USC patients is about 45%, compared with 91% for more common lower-grade types of uterine cancers, she added.

“The conventional treatments for uterine serous carcinoma include surgery and then chemotherapy, but we’ve only really gotten so far by using a sort of one-size-fits-all treatment philosophy,” Dr. Nickles Fader said.

Based on preliminary findings from the current trial (J Clin Oncol. 2018 Jul 10;36[20]:2044-51), trastuzumab plus carboplatin/paclitaxel is now recognized as an alternative standard in treating advanced or recurrent HER2/Neu-positive USC, and this updated analysis confirms the benefits of adding trastuzumab, she said.
 

PFS, OS, and toxicity

There were 58 evaluable patients with primary stage III-IV or recurrent USC who were randomized to receive six cycles of carboplatin/paclitaxel alone or in combination with intravenous trastuzumab given until toxicity or progression.

The median PFS at a median follow-up of 25.9 months “very significantly favored” the trastuzumab arm, Dr. Nickles Fader said. The median PFS was 12.9 months in the trastuzumab arm and 8.0 months in the carboplatin/paclitaxel arm (hazard ratio, 0.46; P = .005).

In the 41 patients undergoing primary treatment, the median PFS was 17.7 months in the trastuzumab arm and 9.3 months in the control arm (HR, 0.44; P = .015). In the 17 patients with recurrent disease, the median PFS was 9.2 months and 7.0 months, respectively (HR, 0.12; P = .004).

“We were very pleased to see that there was also an overall survival benefit of about 5 months in the trastuzumab arm, compared to the control arm,” Dr. Nickles Fader said. The median OS was 29.6 months and 24.4 months, respectively (HR, 0.58; P = .046).

The PFS and OS benefit was “particularly striking” in the stage III-IV patients, according to Dr. Nickles Fader and colleagues. In this subgroup, the median OS was not reached in the trastuzumab arm, and it was 25.4 months in the control arm (HR, 0.49; P = .041).

Long-term toxicity did not differ between the treatment arms.
 

Applications and next steps

“The take-home message here is women should be tested if they have this subtype,” Dr. Nickles Fader said. “If they’re newly diagnosed, they should be tested for the HER2/neu receptor, and if [it is overexpressed] and they have advanced disease, we do recommend treatment with not only the conventional treatment, but with trastuzumab added to that, because that’s where we saw the most benefit.”

This is the only trial that has ever shown a major PFS and OS difference with combination targeted therapy and conventional chemotherapy in USC, Dr. Nickles Fader noted.

“So it was really exciting to see that,” she said, adding that a “much larger cooperative group trial” is being designed by the National Cancer Institute and NRG Oncology Group to look at this approach in HER2-positive, advanced-stage uterine cancers. The trial will include patients with USC, but it will extend to other uterine cancer types as well.

“We’re looking at different combinations of anti-HER2 therapies to sort of validate the results of this trial, but also to study this in other tumors that are HER2 positive,” Dr. Nickles Fader explained.

She also stressed the importance of addressing racial disparities in survival among women with USC, as African American women have higher rates of USC and related mortality than do other groups.

“It’s going to be important to look at not only molecular targets and improving survival but also racial inequalities and potentially epigenetics to really improve survival across the board,” Dr. Nickles Fader said.

She reported having no disclosures. The trial was sponsored by Yale University in collaboration with Genentech.

[email protected]

SOURCE: Nickles Fader A et al. SGO 2020, Abstract 12.

Adding trastuzumab to carboplatin/paclitaxel improved survival in patients with advanced or recurrent HER2/Neu-positive uterine serous carcinoma (USC), according to an updated analysis from a phase 2 trial.

Dr Amanda Nickles Fader

At a median follow-up of 25.9 months, the median progression-free survival (PFS) was 12.9 months in patients who received trastuzumab plus carboplatin/paclitaxel and 8.0 months in patients who received only carboplatin/paclitaxel. The median overall survival (OS) was 29.6 months and 24.4 months, respectively.

Amanda Nickles Fader, MD, of Johns Hopkins Medicine, Baltimore, and colleagues reported these findings in an abstract that was slated for presentation at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer. The meeting was canceled because of the COVID-19 pandemic.
 

Confirmed benefit

The phase 2 trial was designed to assess whether trastuzumab, a humanized monoclonal antibody that targets HER2/neu – a growth factor receptor found in almost all USC cases and overexpressed in 30% of cases – would improve survival in patients with USC, Dr. Nickles Fader explained in an interview. She noted that trastuzumab has been shown to provide benefit in breast cancer patients with HER2/neu overexpression.

“[U]terine serous carcinoma ... is a very aggressive high-grade endometrial cancer subtype that is associated with really poor clinical outcomes and significant mortality,” Dr. Nickles Fader said. “It represents fewer than 10% of all uterine cancer cases, but it actually accounts for a disproportionate 40% of all deaths from uterine cancer.”

The overall survival among USC patients is about 45%, compared with 91% for more common lower-grade types of uterine cancers, she added.

“The conventional treatments for uterine serous carcinoma include surgery and then chemotherapy, but we’ve only really gotten so far by using a sort of one-size-fits-all treatment philosophy,” Dr. Nickles Fader said.

Based on preliminary findings from the current trial (J Clin Oncol. 2018 Jul 10;36[20]:2044-51), trastuzumab plus carboplatin/paclitaxel is now recognized as an alternative standard in treating advanced or recurrent HER2/Neu-positive USC, and this updated analysis confirms the benefits of adding trastuzumab, she said.
 

PFS, OS, and toxicity

There were 58 evaluable patients with primary stage III-IV or recurrent USC who were randomized to receive six cycles of carboplatin/paclitaxel alone or in combination with intravenous trastuzumab given until toxicity or progression.

The median PFS at a median follow-up of 25.9 months “very significantly favored” the trastuzumab arm, Dr. Nickles Fader said. The median PFS was 12.9 months in the trastuzumab arm and 8.0 months in the carboplatin/paclitaxel arm (hazard ratio, 0.46; P = .005).

In the 41 patients undergoing primary treatment, the median PFS was 17.7 months in the trastuzumab arm and 9.3 months in the control arm (HR, 0.44; P = .015). In the 17 patients with recurrent disease, the median PFS was 9.2 months and 7.0 months, respectively (HR, 0.12; P = .004).

“We were very pleased to see that there was also an overall survival benefit of about 5 months in the trastuzumab arm, compared to the control arm,” Dr. Nickles Fader said. The median OS was 29.6 months and 24.4 months, respectively (HR, 0.58; P = .046).

The PFS and OS benefit was “particularly striking” in the stage III-IV patients, according to Dr. Nickles Fader and colleagues. In this subgroup, the median OS was not reached in the trastuzumab arm, and it was 25.4 months in the control arm (HR, 0.49; P = .041).

Long-term toxicity did not differ between the treatment arms.
 

Applications and next steps

“The take-home message here is women should be tested if they have this subtype,” Dr. Nickles Fader said. “If they’re newly diagnosed, they should be tested for the HER2/neu receptor, and if [it is overexpressed] and they have advanced disease, we do recommend treatment with not only the conventional treatment, but with trastuzumab added to that, because that’s where we saw the most benefit.”

This is the only trial that has ever shown a major PFS and OS difference with combination targeted therapy and conventional chemotherapy in USC, Dr. Nickles Fader noted.

“So it was really exciting to see that,” she said, adding that a “much larger cooperative group trial” is being designed by the National Cancer Institute and NRG Oncology Group to look at this approach in HER2-positive, advanced-stage uterine cancers. The trial will include patients with USC, but it will extend to other uterine cancer types as well.

“We’re looking at different combinations of anti-HER2 therapies to sort of validate the results of this trial, but also to study this in other tumors that are HER2 positive,” Dr. Nickles Fader explained.

She also stressed the importance of addressing racial disparities in survival among women with USC, as African American women have higher rates of USC and related mortality than do other groups.

“It’s going to be important to look at not only molecular targets and improving survival but also racial inequalities and potentially epigenetics to really improve survival across the board,” Dr. Nickles Fader said.

She reported having no disclosures. The trial was sponsored by Yale University in collaboration with Genentech.

[email protected]

SOURCE: Nickles Fader A et al. SGO 2020, Abstract 12.

As an Episcopal priest, Father Robert Pace of Fort Worth, TX, is used to putting others first and reaching out to help. So when the pulmonologist who helped him through his ordeal with COVID-19 asked if he would like to donate blood to help other patients, he did not hesitate.

“I said, ‘Absolutely,’” Pace, 53, recalls. He says the idea was ‘very appealing.’ ” During his ordeal with COVID-19 in March, he had spent 3 days in the hospital, isolated and on IV fluids and oxygen. He was short of breath, with a heartbeat more rapid than usual.

Now, fully recovered, his blood was a precious commodity, antibody-rich and potentially life-saving.

As researchers scramble to test drugs to fight COVID-19, others are turning to an age-old treatment. They’re collecting the blood of survivors and giving it to patients in the throes of a severe infection, a treatment known as convalescent plasma therapy.

Doctors say the treatment will probably serve as a bridge until other drugs and a vaccine become available.

Although the FDA considers the treatment investigational, in late March, it eased access to it. Patients can get it as part of a clinical trial or through an expanded access program overseen by hospitals or universities. A doctor can also request permission to use the treatment for a single patient.

“It is considered an emergent, compassionate need,” says John Burk, MD, a pulmonologist at Texas Health Harris Methodist Hospital, Fort Worth, who treated Pace. “It is a way to bring it to the bedside.” And the approval can happen quickly. Burk says he got one from the FDA just 20 minutes after requesting it for a severely ill patient.
 

How it works

The premise of how it works is “quite straightforward,” says Michael Joyner, MD, a professor of anesthesiology at the Mayo Clinic, Rochester, MN. “When someone is recovered and no longer symptomatic, you can harvest those antibodies from their blood and give them to someone else, and hopefully alter the course of their disease.” Joyner is the principal investigator for the FDA’s national Expanded Access to Convalescent Plasma for the Treatment of Patients with COVID-19, with 1,000 sites already signed on.

Convalescent therapy has been used to fight many other viruses, including Ebola, severe acute respiratory syndrome (SARS), the “bird” flu, H1N1 flu, and during the 1918 flu pandemic. Joyner says the strongest evidence for it comes from the 1950s, when it was used to treat a rodent-borne illness called Argentine hemorrhagic fever. Using convalescent plasma therapy for this infection reduced the death rate from nearly 43% before the treatment became common in the late 1950s to about 3% after it was widely used, one report found.

Data about convalescent therapy specifically for COVID-19 is limited. Chinese researchers reported on five critically ill patients, all on mechanical ventilation, treated with convalescent plasma after they had received antiviral and anti-inflammatory medicines. Three could leave the hospital after 51-55 days, and two were in stable condition in the hospital 37 days after the transfusion.

In another study of 10 severely ill patients, symptoms went away or improved in all 10 within 1 to 3 days after the transfusion. Two of the three on ventilators were weaned off and put on oxygen instead. None died.

Chinese researchers also reported three cases of patients with COVID-19 given the convalescent therapy who had a satisfactory recovery.

Researchers who reviewed the track record of convalescent therapy for other conditions recently concluded that the treatment doesn’t appear to cause severe side effects and it should be studied for COVID-19.

Although information on side effects specific to this treatment is evolving, Joyner says they are “very, very low.”

According to the FDA, allergic reactions can occur with plasma therapies. Because the treatment for COVID-19 is new, it is not known if patients might have other types of reactions.
 

Who can donate?

Blood bank officials and researchers running the convalescent plasma programs say the desire to help is widespread, and they’ve been deluged with offers to donate. But requirements are strict.

Donors must have evidence of COVID-19 infection, documented in a variety of ways, such as a diagnostic test by nasal swab or a blood test showing antibodies. And they must be symptom-free for 14 days, with test results, or 28 days without.

The treatment involves collecting plasma, not whole blood. Plasma, the liquid part of the blood, helps with clotting and supports immunity. During the collection, a donor’s blood is put through a machine that collects the plasma only and sends the red blood cells and platelets back to the donor.
 

Clinical trials

Requirements may be more stringent for donors joining a formal clinical trial rather than an expanded access program. For instance, potential donors in a randomized clinical trial underway at Stony Brook University must have higher antibody levels than required by the FDA, says study leader Elliott Bennett-Guerrero, MD, medical director of perioperative quality and patient safety and professor at the Renaissance School of Medicine.

He hopes to enroll up to 500 patients from the Long Island, NY, area. While clinical trials typically have a 50-50 split, with half of subjects getting a treatment and half a placebo, Bennett-Guerrero’s study will give 80% of patients the convalescent plasma and 20% standard plasma.

Julia Sabia Motley, 57, of Merrick, NY, is hoping to become a donor for the Stony Brook study. She and her husband, Sean Motley, 59, tested positive in late March. She has to pass one more test to join the trial. Her husband is also planning to try to donate. “I can finally do something,” Sabia Motley says. Her son is in the MD-PhD program at Stony Brook and told her about the study.
 

Many questions remain

The treatment for COVID-19 is in its infancy. Burk has given the convalescent plasma to two patients. One is now recovering at home, and the other is on a ventilator but improving, he says.

About 200 nationwide have received the therapy, Joyner says. He expects blood supplies to increase as more people are eligible to donate.

Questions remain about how effective the convalescent therapy will be. While experts know that the COVID-19 antibodies “can be helpful in fighting the virus, we don’t know how long the antibodies in the plasma would stay in place,” Bennett-Guerrero says.

Nor do doctors know who the therapy might work best for, beyond people with a severe or life-threatening illness. When it’s been used for other infections, it’s generally given in early stages once someone has symptoms, Joyner says.

Joyner says he sees the treatment as a stopgap ‘’until concentrated antibodies are available.” Several drug companies are working to retrieve antibodies from donors and make concentrated antibody drugs.

“Typically we would think convalescent plasma might be a helpful bridge until therapies that are safe and effective and can be mass-produced are available, such as a vaccine or a drug,” Bennett-Guerrero says.

Even so, he says that he doesn’t think he will have a problem attracting donors, and that he will have repeat donors eager to help.
 

More information for potential donors

Blood banks, the American Red Cross, and others involved in convalescent plasma therapy have posted information online for potential donors. People who don’t meet the qualifications for COVID-19 plasma donations are welcomed as regular blood donors if they meet those criteria

According to the FDA, a donation could potentially help save the lives of up to four COVID-19 patients.

Father Pace is already planning another visit to the blood bank. To pass the time last time, he says, he prayed for the person who would eventually get his blood.

This article first appeared on WebMD.com.

As an Episcopal priest, Father Robert Pace of Fort Worth, TX, is used to putting others first and reaching out to help. So when the pulmonologist who helped him through his ordeal with COVID-19 asked if he would like to donate blood to help other patients, he did not hesitate.

“I said, ‘Absolutely,’” Pace, 53, recalls. He says the idea was ‘very appealing.’ ” During his ordeal with COVID-19 in March, he had spent 3 days in the hospital, isolated and on IV fluids and oxygen. He was short of breath, with a heartbeat more rapid than usual.

Now, fully recovered, his blood was a precious commodity, antibody-rich and potentially life-saving.

As researchers scramble to test drugs to fight COVID-19, others are turning to an age-old treatment. They’re collecting the blood of survivors and giving it to patients in the throes of a severe infection, a treatment known as convalescent plasma therapy.

Doctors say the treatment will probably serve as a bridge until other drugs and a vaccine become available.

Although the FDA considers the treatment investigational, in late March, it eased access to it. Patients can get it as part of a clinical trial or through an expanded access program overseen by hospitals or universities. A doctor can also request permission to use the treatment for a single patient.

“It is considered an emergent, compassionate need,” says John Burk, MD, a pulmonologist at Texas Health Harris Methodist Hospital, Fort Worth, who treated Pace. “It is a way to bring it to the bedside.” And the approval can happen quickly. Burk says he got one from the FDA just 20 minutes after requesting it for a severely ill patient.
 

How it works

The premise of how it works is “quite straightforward,” says Michael Joyner, MD, a professor of anesthesiology at the Mayo Clinic, Rochester, MN. “When someone is recovered and no longer symptomatic, you can harvest those antibodies from their blood and give them to someone else, and hopefully alter the course of their disease.” Joyner is the principal investigator for the FDA’s national Expanded Access to Convalescent Plasma for the Treatment of Patients with COVID-19, with 1,000 sites already signed on.

Convalescent therapy has been used to fight many other viruses, including Ebola, severe acute respiratory syndrome (SARS), the “bird” flu, H1N1 flu, and during the 1918 flu pandemic. Joyner says the strongest evidence for it comes from the 1950s, when it was used to treat a rodent-borne illness called Argentine hemorrhagic fever. Using convalescent plasma therapy for this infection reduced the death rate from nearly 43% before the treatment became common in the late 1950s to about 3% after it was widely used, one report found.

Data about convalescent therapy specifically for COVID-19 is limited. Chinese researchers reported on five critically ill patients, all on mechanical ventilation, treated with convalescent plasma after they had received antiviral and anti-inflammatory medicines. Three could leave the hospital after 51-55 days, and two were in stable condition in the hospital 37 days after the transfusion.

In another study of 10 severely ill patients, symptoms went away or improved in all 10 within 1 to 3 days after the transfusion. Two of the three on ventilators were weaned off and put on oxygen instead. None died.

Chinese researchers also reported three cases of patients with COVID-19 given the convalescent therapy who had a satisfactory recovery.

Researchers who reviewed the track record of convalescent therapy for other conditions recently concluded that the treatment doesn’t appear to cause severe side effects and it should be studied for COVID-19.

Although information on side effects specific to this treatment is evolving, Joyner says they are “very, very low.”

According to the FDA, allergic reactions can occur with plasma therapies. Because the treatment for COVID-19 is new, it is not known if patients might have other types of reactions.
 

Who can donate?

Blood bank officials and researchers running the convalescent plasma programs say the desire to help is widespread, and they’ve been deluged with offers to donate. But requirements are strict.

Donors must have evidence of COVID-19 infection, documented in a variety of ways, such as a diagnostic test by nasal swab or a blood test showing antibodies. And they must be symptom-free for 14 days, with test results, or 28 days without.

The treatment involves collecting plasma, not whole blood. Plasma, the liquid part of the blood, helps with clotting and supports immunity. During the collection, a donor’s blood is put through a machine that collects the plasma only and sends the red blood cells and platelets back to the donor.
 

Clinical trials

Requirements may be more stringent for donors joining a formal clinical trial rather than an expanded access program. For instance, potential donors in a randomized clinical trial underway at Stony Brook University must have higher antibody levels than required by the FDA, says study leader Elliott Bennett-Guerrero, MD, medical director of perioperative quality and patient safety and professor at the Renaissance School of Medicine.

He hopes to enroll up to 500 patients from the Long Island, NY, area. While clinical trials typically have a 50-50 split, with half of subjects getting a treatment and half a placebo, Bennett-Guerrero’s study will give 80% of patients the convalescent plasma and 20% standard plasma.

Julia Sabia Motley, 57, of Merrick, NY, is hoping to become a donor for the Stony Brook study. She and her husband, Sean Motley, 59, tested positive in late March. She has to pass one more test to join the trial. Her husband is also planning to try to donate. “I can finally do something,” Sabia Motley says. Her son is in the MD-PhD program at Stony Brook and told her about the study.
 

Many questions remain

The treatment for COVID-19 is in its infancy. Burk has given the convalescent plasma to two patients. One is now recovering at home, and the other is on a ventilator but improving, he says.

About 200 nationwide have received the therapy, Joyner says. He expects blood supplies to increase as more people are eligible to donate.

Questions remain about how effective the convalescent therapy will be. While experts know that the COVID-19 antibodies “can be helpful in fighting the virus, we don’t know how long the antibodies in the plasma would stay in place,” Bennett-Guerrero says.

Nor do doctors know who the therapy might work best for, beyond people with a severe or life-threatening illness. When it’s been used for other infections, it’s generally given in early stages once someone has symptoms, Joyner says.

Joyner says he sees the treatment as a stopgap ‘’until concentrated antibodies are available.” Several drug companies are working to retrieve antibodies from donors and make concentrated antibody drugs.

“Typically we would think convalescent plasma might be a helpful bridge until therapies that are safe and effective and can be mass-produced are available, such as a vaccine or a drug,” Bennett-Guerrero says.

Even so, he says that he doesn’t think he will have a problem attracting donors, and that he will have repeat donors eager to help.
 

More information for potential donors

Blood banks, the American Red Cross, and others involved in convalescent plasma therapy have posted information online for potential donors. People who don’t meet the qualifications for COVID-19 plasma donations are welcomed as regular blood donors if they meet those criteria

According to the FDA, a donation could potentially help save the lives of up to four COVID-19 patients.

Father Pace is already planning another visit to the blood bank. To pass the time last time, he says, he prayed for the person who would eventually get his blood.

This article first appeared on WebMD.com.

As an Episcopal priest, Father Robert Pace of Fort Worth, TX, is used to putting others first and reaching out to help. So when the pulmonologist who helped him through his ordeal with COVID-19 asked if he would like to donate blood to help other patients, he did not hesitate.

“I said, ‘Absolutely,’” Pace, 53, recalls. He says the idea was ‘very appealing.’ ” During his ordeal with COVID-19 in March, he had spent 3 days in the hospital, isolated and on IV fluids and oxygen. He was short of breath, with a heartbeat more rapid than usual.

Now, fully recovered, his blood was a precious commodity, antibody-rich and potentially life-saving.

As researchers scramble to test drugs to fight COVID-19, others are turning to an age-old treatment. They’re collecting the blood of survivors and giving it to patients in the throes of a severe infection, a treatment known as convalescent plasma therapy.

Doctors say the treatment will probably serve as a bridge until other drugs and a vaccine become available.

Although the FDA considers the treatment investigational, in late March, it eased access to it. Patients can get it as part of a clinical trial or through an expanded access program overseen by hospitals or universities. A doctor can also request permission to use the treatment for a single patient.

“It is considered an emergent, compassionate need,” says John Burk, MD, a pulmonologist at Texas Health Harris Methodist Hospital, Fort Worth, who treated Pace. “It is a way to bring it to the bedside.” And the approval can happen quickly. Burk says he got one from the FDA just 20 minutes after requesting it for a severely ill patient.
 

How it works

The premise of how it works is “quite straightforward,” says Michael Joyner, MD, a professor of anesthesiology at the Mayo Clinic, Rochester, MN. “When someone is recovered and no longer symptomatic, you can harvest those antibodies from their blood and give them to someone else, and hopefully alter the course of their disease.” Joyner is the principal investigator for the FDA’s national Expanded Access to Convalescent Plasma for the Treatment of Patients with COVID-19, with 1,000 sites already signed on.

Convalescent therapy has been used to fight many other viruses, including Ebola, severe acute respiratory syndrome (SARS), the “bird” flu, H1N1 flu, and during the 1918 flu pandemic. Joyner says the strongest evidence for it comes from the 1950s, when it was used to treat a rodent-borne illness called Argentine hemorrhagic fever. Using convalescent plasma therapy for this infection reduced the death rate from nearly 43% before the treatment became common in the late 1950s to about 3% after it was widely used, one report found.

Data about convalescent therapy specifically for COVID-19 is limited. Chinese researchers reported on five critically ill patients, all on mechanical ventilation, treated with convalescent plasma after they had received antiviral and anti-inflammatory medicines. Three could leave the hospital after 51-55 days, and two were in stable condition in the hospital 37 days after the transfusion.

In another study of 10 severely ill patients, symptoms went away or improved in all 10 within 1 to 3 days after the transfusion. Two of the three on ventilators were weaned off and put on oxygen instead. None died.

Chinese researchers also reported three cases of patients with COVID-19 given the convalescent therapy who had a satisfactory recovery.

Researchers who reviewed the track record of convalescent therapy for other conditions recently concluded that the treatment doesn’t appear to cause severe side effects and it should be studied for COVID-19.

Although information on side effects specific to this treatment is evolving, Joyner says they are “very, very low.”

According to the FDA, allergic reactions can occur with plasma therapies. Because the treatment for COVID-19 is new, it is not known if patients might have other types of reactions.
 

Who can donate?

Blood bank officials and researchers running the convalescent plasma programs say the desire to help is widespread, and they’ve been deluged with offers to donate. But requirements are strict.

Donors must have evidence of COVID-19 infection, documented in a variety of ways, such as a diagnostic test by nasal swab or a blood test showing antibodies. And they must be symptom-free for 14 days, with test results, or 28 days without.

The treatment involves collecting plasma, not whole blood. Plasma, the liquid part of the blood, helps with clotting and supports immunity. During the collection, a donor’s blood is put through a machine that collects the plasma only and sends the red blood cells and platelets back to the donor.
 

Clinical trials

Requirements may be more stringent for donors joining a formal clinical trial rather than an expanded access program. For instance, potential donors in a randomized clinical trial underway at Stony Brook University must have higher antibody levels than required by the FDA, says study leader Elliott Bennett-Guerrero, MD, medical director of perioperative quality and patient safety and professor at the Renaissance School of Medicine.

He hopes to enroll up to 500 patients from the Long Island, NY, area. While clinical trials typically have a 50-50 split, with half of subjects getting a treatment and half a placebo, Bennett-Guerrero’s study will give 80% of patients the convalescent plasma and 20% standard plasma.

Julia Sabia Motley, 57, of Merrick, NY, is hoping to become a donor for the Stony Brook study. She and her husband, Sean Motley, 59, tested positive in late March. She has to pass one more test to join the trial. Her husband is also planning to try to donate. “I can finally do something,” Sabia Motley says. Her son is in the MD-PhD program at Stony Brook and told her about the study.
 

Many questions remain

The treatment for COVID-19 is in its infancy. Burk has given the convalescent plasma to two patients. One is now recovering at home, and the other is on a ventilator but improving, he says.

About 200 nationwide have received the therapy, Joyner says. He expects blood supplies to increase as more people are eligible to donate.

Questions remain about how effective the convalescent therapy will be. While experts know that the COVID-19 antibodies “can be helpful in fighting the virus, we don’t know how long the antibodies in the plasma would stay in place,” Bennett-Guerrero says.

Nor do doctors know who the therapy might work best for, beyond people with a severe or life-threatening illness. When it’s been used for other infections, it’s generally given in early stages once someone has symptoms, Joyner says.

Joyner says he sees the treatment as a stopgap ‘’until concentrated antibodies are available.” Several drug companies are working to retrieve antibodies from donors and make concentrated antibody drugs.

“Typically we would think convalescent plasma might be a helpful bridge until therapies that are safe and effective and can be mass-produced are available, such as a vaccine or a drug,” Bennett-Guerrero says.

Even so, he says that he doesn’t think he will have a problem attracting donors, and that he will have repeat donors eager to help.
 

More information for potential donors

Blood banks, the American Red Cross, and others involved in convalescent plasma therapy have posted information online for potential donors. People who don’t meet the qualifications for COVID-19 plasma donations are welcomed as regular blood donors if they meet those criteria

According to the FDA, a donation could potentially help save the lives of up to four COVID-19 patients.

Father Pace is already planning another visit to the blood bank. To pass the time last time, he says, he prayed for the person who would eventually get his blood.

This article first appeared on WebMD.com.

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the spread of COVID-19, is overwhelming for many people. Health care workers in the United States and around the world are leading the battle on the front lines of the pandemic. Thus, they experience a higher level of stress, fear, and anxiety during this crisis.

Over the course of weeks, hospitalists have reviewed articles, attended webinars, and discussed institutional strategies to respond to COVID-19. They follow the most up-to-date clinical information about the approach to patient care, conserving personal protective equipment (PPE), and guidance on how to talk to patients and families during crisis situations. The safety of hospitalists has been underscored with persistent advocacy from multiple organizations, for PPE, access to testing supplies, and decreasing any unnecessary exposure.

While it is agreed that the safety and well-being of hospital medicine teams is crucial to our society’s victory over COVID-19, very little has been discussed with regards to the “hospitalist” well-being and wellness during this pandemic.

The well-being of providers is essential to the success of a health care system. Many hospitalists already experience moral injury and showed evidence of provider burnout before COVID-19. With the onset of the pandemic, this will only get worse and burnout will accelerate if nothing is done to stop it. We cannot wait for the dust to settle to help our colleagues, we must act now.

Many providers have expressed similar pandemic fears, including, uncertainty about screening and testing capability, fear of the PPE shortage, fear of being exposed and underprepared, and fear of bringing the virus home and making family members sick. This list is not exclusive, and there are so many other factors that providers are internally processing, all while continuing their commitment to patient care and safety.

Practicing medicine comes with the heaviest of responsibilities, including the defense of the health of humanity. Therefore, it is easy to understand that, while providers are on the battlefield of this pandemic as they defend the health of humanity, they are not thinking of their own wellness or well-being. Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This is already happening, with many hospitals in various cities running out of ventilators, lacking basic supplies for provider safety and leaving providers in survival mode on the front lines without their “suits of armor.” However, many providers will never recognize moral injury or burnout because they are focused on saving as many lives as possible with very limited resources.

While many websites can aid patient and community members on wellness during COVID-19, there is no specific forum or outlet for providers. We must give all hospital medicine team members a multimedia platform to address the fear, anxiety, and uncertainty of COVID-19. We must also provide them with techniques for resilience, coping strategies, and develop a network of support as the situation evolves, in real time.

We must remind hospitalists, “You may be scared, you may feel anxious, and that is okay. It is normal to have these feelings and it is healthy to acknowledge them. Fear serves as an important role in keeping us safe, but if left unchecked it can be horrifying and crippling. However, to conquer it we must face our fears together, with strategy, knowledge, and advocacy. This is the way to rebuild the current health care climate with confidence and trust.”

Although the world may seem foreign and dangerous, it is in adversity that we will find our strength as a hospital medicine community. We go to work every day because that is what we do. Your courage to come to work every day, in spite of any danger that it may present to you, is an inspiration to the world. The battle is not lost, and as individuals and as a community we must build resilience, inspire hope, and empower each other. We are stronger together than we are alone. As hospitalists around the country, and throughout the world, we must agree to uphold the moral integrity of medicine without sacrificing ourselves.
 

Dr. Williams is the vice-president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as the vice-president of the Medical Executive Committee.

Resource

Dean, Wendy; Talbot, Simon; and Dean, Austin. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019 Sept;36(9):400-2.

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the spread of COVID-19, is overwhelming for many people. Health care workers in the United States and around the world are leading the battle on the front lines of the pandemic. Thus, they experience a higher level of stress, fear, and anxiety during this crisis.

Over the course of weeks, hospitalists have reviewed articles, attended webinars, and discussed institutional strategies to respond to COVID-19. They follow the most up-to-date clinical information about the approach to patient care, conserving personal protective equipment (PPE), and guidance on how to talk to patients and families during crisis situations. The safety of hospitalists has been underscored with persistent advocacy from multiple organizations, for PPE, access to testing supplies, and decreasing any unnecessary exposure.

While it is agreed that the safety and well-being of hospital medicine teams is crucial to our society’s victory over COVID-19, very little has been discussed with regards to the “hospitalist” well-being and wellness during this pandemic.

The well-being of providers is essential to the success of a health care system. Many hospitalists already experience moral injury and showed evidence of provider burnout before COVID-19. With the onset of the pandemic, this will only get worse and burnout will accelerate if nothing is done to stop it. We cannot wait for the dust to settle to help our colleagues, we must act now.

Many providers have expressed similar pandemic fears, including, uncertainty about screening and testing capability, fear of the PPE shortage, fear of being exposed and underprepared, and fear of bringing the virus home and making family members sick. This list is not exclusive, and there are so many other factors that providers are internally processing, all while continuing their commitment to patient care and safety.

Practicing medicine comes with the heaviest of responsibilities, including the defense of the health of humanity. Therefore, it is easy to understand that, while providers are on the battlefield of this pandemic as they defend the health of humanity, they are not thinking of their own wellness or well-being. Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This is already happening, with many hospitals in various cities running out of ventilators, lacking basic supplies for provider safety and leaving providers in survival mode on the front lines without their “suits of armor.” However, many providers will never recognize moral injury or burnout because they are focused on saving as many lives as possible with very limited resources.

While many websites can aid patient and community members on wellness during COVID-19, there is no specific forum or outlet for providers. We must give all hospital medicine team members a multimedia platform to address the fear, anxiety, and uncertainty of COVID-19. We must also provide them with techniques for resilience, coping strategies, and develop a network of support as the situation evolves, in real time.

We must remind hospitalists, “You may be scared, you may feel anxious, and that is okay. It is normal to have these feelings and it is healthy to acknowledge them. Fear serves as an important role in keeping us safe, but if left unchecked it can be horrifying and crippling. However, to conquer it we must face our fears together, with strategy, knowledge, and advocacy. This is the way to rebuild the current health care climate with confidence and trust.”

Although the world may seem foreign and dangerous, it is in adversity that we will find our strength as a hospital medicine community. We go to work every day because that is what we do. Your courage to come to work every day, in spite of any danger that it may present to you, is an inspiration to the world. The battle is not lost, and as individuals and as a community we must build resilience, inspire hope, and empower each other. We are stronger together than we are alone. As hospitalists around the country, and throughout the world, we must agree to uphold the moral integrity of medicine without sacrificing ourselves.
 

Dr. Williams is the vice-president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as the vice-president of the Medical Executive Committee.

Resource

Dean, Wendy; Talbot, Simon; and Dean, Austin. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019 Sept;36(9):400-2.

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the spread of COVID-19, is overwhelming for many people. Health care workers in the United States and around the world are leading the battle on the front lines of the pandemic. Thus, they experience a higher level of stress, fear, and anxiety during this crisis.

Over the course of weeks, hospitalists have reviewed articles, attended webinars, and discussed institutional strategies to respond to COVID-19. They follow the most up-to-date clinical information about the approach to patient care, conserving personal protective equipment (PPE), and guidance on how to talk to patients and families during crisis situations. The safety of hospitalists has been underscored with persistent advocacy from multiple organizations, for PPE, access to testing supplies, and decreasing any unnecessary exposure.

While it is agreed that the safety and well-being of hospital medicine teams is crucial to our society’s victory over COVID-19, very little has been discussed with regards to the “hospitalist” well-being and wellness during this pandemic.

The well-being of providers is essential to the success of a health care system. Many hospitalists already experience moral injury and showed evidence of provider burnout before COVID-19. With the onset of the pandemic, this will only get worse and burnout will accelerate if nothing is done to stop it. We cannot wait for the dust to settle to help our colleagues, we must act now.

Many providers have expressed similar pandemic fears, including, uncertainty about screening and testing capability, fear of the PPE shortage, fear of being exposed and underprepared, and fear of bringing the virus home and making family members sick. This list is not exclusive, and there are so many other factors that providers are internally processing, all while continuing their commitment to patient care and safety.

Practicing medicine comes with the heaviest of responsibilities, including the defense of the health of humanity. Therefore, it is easy to understand that, while providers are on the battlefield of this pandemic as they defend the health of humanity, they are not thinking of their own wellness or well-being. Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This is already happening, with many hospitals in various cities running out of ventilators, lacking basic supplies for provider safety and leaving providers in survival mode on the front lines without their “suits of armor.” However, many providers will never recognize moral injury or burnout because they are focused on saving as many lives as possible with very limited resources.

While many websites can aid patient and community members on wellness during COVID-19, there is no specific forum or outlet for providers. We must give all hospital medicine team members a multimedia platform to address the fear, anxiety, and uncertainty of COVID-19. We must also provide them with techniques for resilience, coping strategies, and develop a network of support as the situation evolves, in real time.

We must remind hospitalists, “You may be scared, you may feel anxious, and that is okay. It is normal to have these feelings and it is healthy to acknowledge them. Fear serves as an important role in keeping us safe, but if left unchecked it can be horrifying and crippling. However, to conquer it we must face our fears together, with strategy, knowledge, and advocacy. This is the way to rebuild the current health care climate with confidence and trust.”

Although the world may seem foreign and dangerous, it is in adversity that we will find our strength as a hospital medicine community. We go to work every day because that is what we do. Your courage to come to work every day, in spite of any danger that it may present to you, is an inspiration to the world. The battle is not lost, and as individuals and as a community we must build resilience, inspire hope, and empower each other. We are stronger together than we are alone. As hospitalists around the country, and throughout the world, we must agree to uphold the moral integrity of medicine without sacrificing ourselves.
 

Dr. Williams is the vice-president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as the vice-president of the Medical Executive Committee.

Resource

Dean, Wendy; Talbot, Simon; and Dean, Austin. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019 Sept;36(9):400-2.

The SARS-CoV-2 novel coronavirus has dramatically altered specialty practice across the board, including the practice of infertility treatment. Reproductive medicine societies recommend suspending new infertility treatment cycles during this time. Women and couples who have already invested time and money in their treatment may be understandably frustrated and worried about the impact of this enforced – and indefinite – delay on their chances of conceiving. This puts the physician, who can’t even guarantee when treatment can resume, in the difficult position of trying to balance the patient’s needs with expert recommendations and government mandates.

Infertility Care During COVID-19

European and American reproductive medicine societies have both offered guidelines regarding infertility care during the pandemic. Both recommend shifting to the use of telehealth rather than in-person visits when possible for initial consultations and follow-up discussions.

With respect to infertility treatments during the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advises the following:

• Suspend initiation of new treatment cycles, including ovulation induction; intrauterine insemination; and in vitro fertilization, including retrievals and frozen embryo transfers, and suspend nonurgent gamete cryopreservation.
• Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
• Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
• Suspend elective surgeries and nonurgent diagnostic procedures.

In most countries, including the United States, all healthcare providers have been asked to put elective and nonurgent medical interventions on hold to ensure that personal protective equipment and other resources are available for the management of patients with COVID-19.

Infertility is a disease and, as such, not all infertility care should be considered elective. Still, for most patients, the overall chances of conceiving will not be compromised by a short delay (1-3 months) in treatment. A longer wait could have more impact on older patients or those who already have reduced ovarian reserve, but these are not indications for urgent fertility treatment.

There are clearly some cases in which infertility treatment cannot be delayed: for example, fertility preservation (oocyte or embryo vitrification) for patients who need to undergo immediate gonadotoxic oncology treatment. These patients need to be able to freeze oocytes/embryos so that later on, they have the option of having a family.

Another situation that could require new infertility treatment is a woman who needs urgent surgery for a condition such as severe symptomatic endometriosis causing ureteral or bowel stenosis/obstruction. Because the surgery itself can compromise fertility, the patient may elect to undergo oocyte embryo cryopreservation or ovarian tissue cryopreservation before the surgical procedure.
 

Pregnancy and COVID-19

As a precautionary measure during the COVID-19 pandemic, it is recommended that planned pregnancy be avoided. The available data on the risks presented by planning a pregnancy during the COVID pandemic are reassuring but limited.

Pregnancy itself has not been shown to alter the course of COVID-19, and most affected pregnant women will experience only mild or moderate flulike symptoms. Patients with cardiovascular or metabolic comorbidities or those requiring immunosuppressants are expected to be at increased risk for more severe forms of the infection. Currently, no strong evidence suggests a higher risk for miscarriage, stillbirth, or adverse neonatal outcomes with maternal COVID-19 infection.

A report based on 38 cases found no evidence for vertical transmission from mother to fetus, and all neonatal specimens (placental tissue) tested negative for the virus. Moreover, no maternal deaths were reported among these 38 infected women. Another study of 11 infected pregnant women likewise found no increased risk for perinatal morbidity or mortality.

On the other hand, a recent article on the perinatal outcomes of 33 neonates born to mothers with confirmed COVID-19 reported three cases of neonatal COVID-19 as a result of possible vertical transmission. In two cases, symptoms were mild and initial positive coronavirus test results turned negative within a few days. The third case – a pregnancy delivered by emergency cesarean section at 31 weeks for fetal distress – was complicated by bacterial sepsis, thrombocytopenia, and coagulopathy, but once again, the initially positive coronavirus test was negative by day 7.

No neonatal deaths were reported in these 33 cases. The authors could not rule out the possibility of vertical transmission in the three COVID-positive newborns because strict infection control measures were implemented during the care of the patients.
 

Counseling Patients About Suspending Infertility Treatments

Counseling women is the key to acceptance of the need to suspend or postpone infertility treatments during the pandemic. In addition to the economic hardships that some patients may face as a consequence of the pandemic, an obvious source of frustration stems from not knowing how long delays in treatment might be necessary. A discussion with patients or couples may reassure them that delaying conception is the safest route. For some women, other treatment options might be offered, such as the use of a donor gamete.

Some patients, even when counseled appropriately, may elect to accept the unknown risks. These patients should be counseled about the benefits of cryopreservation with delayed transfer. This could be a compromise, because their overall chances of pregnancy will not be affected but they will have to wait to become pregnant.

Counseling patients about the true impact of delaying treatment in their individual circumstances, providing them with emotional and (if needed) psychological support is important while they wait for their treatment to start. For now, the vast majority of the patients understand the need for delay, appreciate the opportunity to consult the physician over the phone, and are demonstrating patience as they wait for their treatment to start or resume.
 

Resuming Infertility Care

Recommendations could change as the pandemic continues and more information becomes available about the impact of coronavirus infection during pregnancy and the overall capacity of the healthcare system improves. ASRM acknowledges that “reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care.” If the data remain reassuring and social distancing measures are able to slow down the spread of the disease, the infertility care of those couples who would be most affected by a delay in their treatment could gradually be resumed. On April 14, ASRM updated its recommendations about resuming infertility treatment: “ While it is not yet prudent to resume nonemergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19.”

It is likely that the return to “normal” daily practice will be done in a stepwise fashion. I expect the practices first to open for diagnostic infertility testing, then for the less invasive procedures (frozen embryo transfer, intrauterine insemination) and finally for the more invasive lengthy procedures (stimulation with retrieval and embryo transfer). During the reopening of practice, strict infection control measures will need to be observed.

Dr. Kovacs is the medical director of Kaali Institute IVF Center in Budapest, Hungary. He has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The SARS-CoV-2 novel coronavirus has dramatically altered specialty practice across the board, including the practice of infertility treatment. Reproductive medicine societies recommend suspending new infertility treatment cycles during this time. Women and couples who have already invested time and money in their treatment may be understandably frustrated and worried about the impact of this enforced – and indefinite – delay on their chances of conceiving. This puts the physician, who can’t even guarantee when treatment can resume, in the difficult position of trying to balance the patient’s needs with expert recommendations and government mandates.

Infertility Care During COVID-19

European and American reproductive medicine societies have both offered guidelines regarding infertility care during the pandemic. Both recommend shifting to the use of telehealth rather than in-person visits when possible for initial consultations and follow-up discussions.

With respect to infertility treatments during the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advises the following:

• Suspend initiation of new treatment cycles, including ovulation induction; intrauterine insemination; and in vitro fertilization, including retrievals and frozen embryo transfers, and suspend nonurgent gamete cryopreservation.
• Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
• Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
• Suspend elective surgeries and nonurgent diagnostic procedures.

In most countries, including the United States, all healthcare providers have been asked to put elective and nonurgent medical interventions on hold to ensure that personal protective equipment and other resources are available for the management of patients with COVID-19.

Infertility is a disease and, as such, not all infertility care should be considered elective. Still, for most patients, the overall chances of conceiving will not be compromised by a short delay (1-3 months) in treatment. A longer wait could have more impact on older patients or those who already have reduced ovarian reserve, but these are not indications for urgent fertility treatment.

There are clearly some cases in which infertility treatment cannot be delayed: for example, fertility preservation (oocyte or embryo vitrification) for patients who need to undergo immediate gonadotoxic oncology treatment. These patients need to be able to freeze oocytes/embryos so that later on, they have the option of having a family.

Another situation that could require new infertility treatment is a woman who needs urgent surgery for a condition such as severe symptomatic endometriosis causing ureteral or bowel stenosis/obstruction. Because the surgery itself can compromise fertility, the patient may elect to undergo oocyte embryo cryopreservation or ovarian tissue cryopreservation before the surgical procedure.
 

Pregnancy and COVID-19

As a precautionary measure during the COVID-19 pandemic, it is recommended that planned pregnancy be avoided. The available data on the risks presented by planning a pregnancy during the COVID pandemic are reassuring but limited.

Pregnancy itself has not been shown to alter the course of COVID-19, and most affected pregnant women will experience only mild or moderate flulike symptoms. Patients with cardiovascular or metabolic comorbidities or those requiring immunosuppressants are expected to be at increased risk for more severe forms of the infection. Currently, no strong evidence suggests a higher risk for miscarriage, stillbirth, or adverse neonatal outcomes with maternal COVID-19 infection.

A report based on 38 cases found no evidence for vertical transmission from mother to fetus, and all neonatal specimens (placental tissue) tested negative for the virus. Moreover, no maternal deaths were reported among these 38 infected women. Another study of 11 infected pregnant women likewise found no increased risk for perinatal morbidity or mortality.

On the other hand, a recent article on the perinatal outcomes of 33 neonates born to mothers with confirmed COVID-19 reported three cases of neonatal COVID-19 as a result of possible vertical transmission. In two cases, symptoms were mild and initial positive coronavirus test results turned negative within a few days. The third case – a pregnancy delivered by emergency cesarean section at 31 weeks for fetal distress – was complicated by bacterial sepsis, thrombocytopenia, and coagulopathy, but once again, the initially positive coronavirus test was negative by day 7.

No neonatal deaths were reported in these 33 cases. The authors could not rule out the possibility of vertical transmission in the three COVID-positive newborns because strict infection control measures were implemented during the care of the patients.
 

Counseling Patients About Suspending Infertility Treatments

Counseling women is the key to acceptance of the need to suspend or postpone infertility treatments during the pandemic. In addition to the economic hardships that some patients may face as a consequence of the pandemic, an obvious source of frustration stems from not knowing how long delays in treatment might be necessary. A discussion with patients or couples may reassure them that delaying conception is the safest route. For some women, other treatment options might be offered, such as the use of a donor gamete.

Some patients, even when counseled appropriately, may elect to accept the unknown risks. These patients should be counseled about the benefits of cryopreservation with delayed transfer. This could be a compromise, because their overall chances of pregnancy will not be affected but they will have to wait to become pregnant.

Counseling patients about the true impact of delaying treatment in their individual circumstances, providing them with emotional and (if needed) psychological support is important while they wait for their treatment to start. For now, the vast majority of the patients understand the need for delay, appreciate the opportunity to consult the physician over the phone, and are demonstrating patience as they wait for their treatment to start or resume.
 

Resuming Infertility Care

Recommendations could change as the pandemic continues and more information becomes available about the impact of coronavirus infection during pregnancy and the overall capacity of the healthcare system improves. ASRM acknowledges that “reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care.” If the data remain reassuring and social distancing measures are able to slow down the spread of the disease, the infertility care of those couples who would be most affected by a delay in their treatment could gradually be resumed. On April 14, ASRM updated its recommendations about resuming infertility treatment: “ While it is not yet prudent to resume nonemergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19.”

It is likely that the return to “normal” daily practice will be done in a stepwise fashion. I expect the practices first to open for diagnostic infertility testing, then for the less invasive procedures (frozen embryo transfer, intrauterine insemination) and finally for the more invasive lengthy procedures (stimulation with retrieval and embryo transfer). During the reopening of practice, strict infection control measures will need to be observed.

Dr. Kovacs is the medical director of Kaali Institute IVF Center in Budapest, Hungary. He has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The SARS-CoV-2 novel coronavirus has dramatically altered specialty practice across the board, including the practice of infertility treatment. Reproductive medicine societies recommend suspending new infertility treatment cycles during this time. Women and couples who have already invested time and money in their treatment may be understandably frustrated and worried about the impact of this enforced – and indefinite – delay on their chances of conceiving. This puts the physician, who can’t even guarantee when treatment can resume, in the difficult position of trying to balance the patient’s needs with expert recommendations and government mandates.

Infertility Care During COVID-19

European and American reproductive medicine societies have both offered guidelines regarding infertility care during the pandemic. Both recommend shifting to the use of telehealth rather than in-person visits when possible for initial consultations and follow-up discussions.

With respect to infertility treatments during the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advises the following:

• Suspend initiation of new treatment cycles, including ovulation induction; intrauterine insemination; and in vitro fertilization, including retrievals and frozen embryo transfers, and suspend nonurgent gamete cryopreservation.
• Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
• Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
• Suspend elective surgeries and nonurgent diagnostic procedures.

In most countries, including the United States, all healthcare providers have been asked to put elective and nonurgent medical interventions on hold to ensure that personal protective equipment and other resources are available for the management of patients with COVID-19.

Infertility is a disease and, as such, not all infertility care should be considered elective. Still, for most patients, the overall chances of conceiving will not be compromised by a short delay (1-3 months) in treatment. A longer wait could have more impact on older patients or those who already have reduced ovarian reserve, but these are not indications for urgent fertility treatment.

There are clearly some cases in which infertility treatment cannot be delayed: for example, fertility preservation (oocyte or embryo vitrification) for patients who need to undergo immediate gonadotoxic oncology treatment. These patients need to be able to freeze oocytes/embryos so that later on, they have the option of having a family.

Another situation that could require new infertility treatment is a woman who needs urgent surgery for a condition such as severe symptomatic endometriosis causing ureteral or bowel stenosis/obstruction. Because the surgery itself can compromise fertility, the patient may elect to undergo oocyte embryo cryopreservation or ovarian tissue cryopreservation before the surgical procedure.
 

Pregnancy and COVID-19

As a precautionary measure during the COVID-19 pandemic, it is recommended that planned pregnancy be avoided. The available data on the risks presented by planning a pregnancy during the COVID pandemic are reassuring but limited.

Pregnancy itself has not been shown to alter the course of COVID-19, and most affected pregnant women will experience only mild or moderate flulike symptoms. Patients with cardiovascular or metabolic comorbidities or those requiring immunosuppressants are expected to be at increased risk for more severe forms of the infection. Currently, no strong evidence suggests a higher risk for miscarriage, stillbirth, or adverse neonatal outcomes with maternal COVID-19 infection.

A report based on 38 cases found no evidence for vertical transmission from mother to fetus, and all neonatal specimens (placental tissue) tested negative for the virus. Moreover, no maternal deaths were reported among these 38 infected women. Another study of 11 infected pregnant women likewise found no increased risk for perinatal morbidity or mortality.

On the other hand, a recent article on the perinatal outcomes of 33 neonates born to mothers with confirmed COVID-19 reported three cases of neonatal COVID-19 as a result of possible vertical transmission. In two cases, symptoms were mild and initial positive coronavirus test results turned negative within a few days. The third case – a pregnancy delivered by emergency cesarean section at 31 weeks for fetal distress – was complicated by bacterial sepsis, thrombocytopenia, and coagulopathy, but once again, the initially positive coronavirus test was negative by day 7.

No neonatal deaths were reported in these 33 cases. The authors could not rule out the possibility of vertical transmission in the three COVID-positive newborns because strict infection control measures were implemented during the care of the patients.
 

Counseling Patients About Suspending Infertility Treatments

Counseling women is the key to acceptance of the need to suspend or postpone infertility treatments during the pandemic. In addition to the economic hardships that some patients may face as a consequence of the pandemic, an obvious source of frustration stems from not knowing how long delays in treatment might be necessary. A discussion with patients or couples may reassure them that delaying conception is the safest route. For some women, other treatment options might be offered, such as the use of a donor gamete.

Some patients, even when counseled appropriately, may elect to accept the unknown risks. These patients should be counseled about the benefits of cryopreservation with delayed transfer. This could be a compromise, because their overall chances of pregnancy will not be affected but they will have to wait to become pregnant.

Counseling patients about the true impact of delaying treatment in their individual circumstances, providing them with emotional and (if needed) psychological support is important while they wait for their treatment to start. For now, the vast majority of the patients understand the need for delay, appreciate the opportunity to consult the physician over the phone, and are demonstrating patience as they wait for their treatment to start or resume.
 

Resuming Infertility Care

Recommendations could change as the pandemic continues and more information becomes available about the impact of coronavirus infection during pregnancy and the overall capacity of the healthcare system improves. ASRM acknowledges that “reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care.” If the data remain reassuring and social distancing measures are able to slow down the spread of the disease, the infertility care of those couples who would be most affected by a delay in their treatment could gradually be resumed. On April 14, ASRM updated its recommendations about resuming infertility treatment: “ While it is not yet prudent to resume nonemergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19.”

It is likely that the return to “normal” daily practice will be done in a stepwise fashion. I expect the practices first to open for diagnostic infertility testing, then for the less invasive procedures (frozen embryo transfer, intrauterine insemination) and finally for the more invasive lengthy procedures (stimulation with retrieval and embryo transfer). During the reopening of practice, strict infection control measures will need to be observed.

Dr. Kovacs is the medical director of Kaali Institute IVF Center in Budapest, Hungary. He has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Although priority number one lies in controlling the spread of COVID-19, public health researchers are calling attention to the long-term repercussions of the pandemic on children’s health.

School closures could noticeably worsen the epidemic of childhood obesity that already threatens many children in the United States, say Paul Rundle, DrPH, and colleagues from Columbia University Mailman School of Public Health, New York City, in a perspective published online March 30 in Obesity.

“In part, we wrote the perspective to remind people that summer unhealthy weight gain seems to accumulate year to year,” he told Medscape Medical News in an email.

Rundle and colleagues estimate that time spent out of school will double this year because of school closures due to COVID-19. That, along with shelter-in-place orders, will pose challenges both for physical activity and healthy eating among children.

In addition, playgrounds have closed in many areas, and even where parks remain open, social distancing decreases opportunities for exercise. Team sports are on hold, and without physical education taught in schools, many children will not be getting as much active outdoor play as needed.

That’s especially true for children in urban areas, who may find it even more difficult to exercise inside cramped apartments, they add.

As a result, more and more children may turn to sedentary activities, and increased screen time goes hand in hand with childhood overweight and obesity, not just because of the lack of exercise but also because of snacking on unhealthy, empty-calorie foods while glued to the screen.

“We were hoping to get the word out on this issue, do some education or reminding, and at least let people know that this should be something to keep an eye on, among so many other things,” Rundle added.

Excess Eating Because of Stress and Boredom

Jessica Sparks Lilley, MD, director of the Pediatric Diabetes and Lipid Program at the Mississippi Center for Advanced Medicine in Madison, agrees that it is crucial to address these issues.

“Just like adults, children eat in response to emotions, including stress and boredom, and stress levels are high during these uncertain times,” she told Medscape Medical News.

Although both Rundle and Sparks Lilley acknowledged the challenges of finding good solutions at this time, they do offer some tips.

Schools should make physical education and at-home exercise a priority alongside other remote teaching. Physical education teachers could even stream exercise classes to children at home.

Even just walking in the park while maintaining social distancing could be better than nothing, and a brisk walk is probably even better.

Depending on the age of the child, online yoga may also be useful. Even though yoga burns relatively few calories, it incorporates mindfulness training that may be helpful.

“I think focusing on promoting mindful eating as compared to mindless or distracted eating is important. Even in the best of circumstances, it is hard to exercise enough to burn off high energy snacks,” Rundle said.

Additional Stressors From Poverty: Schools Can Help With Meals

Children living in poverty, already the most vulnerable to obesity and related health problems, have additional stressors, add the two experts.

“As more Americans are losing jobs, poverty is a real threat to many of the children I care for. Families living in poverty often rely on processed, high-calorie, low-nutrient foods for survival, because they are inexpensive and shelf-stable,” Sparks Lilley said.

Rundle and colleagues agree: “Our own experiences in supermarkets show...shelves that held...crackers, chips, ramen noodles, soda, sugary cereals, and processed ready-to-eat meals are quite empty. We anticipate that many children will experience higher calorie diets during the pandemic response.”

Similar to how they address food insecurity during summer holidays, school districts have responded by offering grab-and-go meals, Rundle and colleagues note.

To maintain social distancing for people with vulnerable family members, some school districts have also started delivering food using school buses that run along regularly scheduled routes.

Rundle also stresses that farmers’ markets, which often provide foods that appeal to immigrant and ethnic communities, should be considered part of essential food services.

As such, social distancing protocols should be established for them and they should be allowed to stay open, he argues.

“The safety of American children is at stake in many ways. The threat to themselves or their caregivers being infected with COVID-19 is rightly foremost in our concerns,” Sparks Lilley stressed.

“However, there is other fallout to consider. We’ve seen very clearly the need for public health and preventive medicine and can’t let vulnerable children fall through the cracks.”

Rundle agrees. Although it is a “priority” to mitigate the immediate impact of COVID-19, “it is important to consider ways to prevent its long-term effects, including new risks for childhood obesity.”

Rundle and coauthors, as well as Sparks Lilley, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Although priority number one lies in controlling the spread of COVID-19, public health researchers are calling attention to the long-term repercussions of the pandemic on children’s health.

School closures could noticeably worsen the epidemic of childhood obesity that already threatens many children in the United States, say Paul Rundle, DrPH, and colleagues from Columbia University Mailman School of Public Health, New York City, in a perspective published online March 30 in Obesity.

“In part, we wrote the perspective to remind people that summer unhealthy weight gain seems to accumulate year to year,” he told Medscape Medical News in an email.

Rundle and colleagues estimate that time spent out of school will double this year because of school closures due to COVID-19. That, along with shelter-in-place orders, will pose challenges both for physical activity and healthy eating among children.

In addition, playgrounds have closed in many areas, and even where parks remain open, social distancing decreases opportunities for exercise. Team sports are on hold, and without physical education taught in schools, many children will not be getting as much active outdoor play as needed.

That’s especially true for children in urban areas, who may find it even more difficult to exercise inside cramped apartments, they add.

As a result, more and more children may turn to sedentary activities, and increased screen time goes hand in hand with childhood overweight and obesity, not just because of the lack of exercise but also because of snacking on unhealthy, empty-calorie foods while glued to the screen.

“We were hoping to get the word out on this issue, do some education or reminding, and at least let people know that this should be something to keep an eye on, among so many other things,” Rundle added.

Excess Eating Because of Stress and Boredom

Jessica Sparks Lilley, MD, director of the Pediatric Diabetes and Lipid Program at the Mississippi Center for Advanced Medicine in Madison, agrees that it is crucial to address these issues.

“Just like adults, children eat in response to emotions, including stress and boredom, and stress levels are high during these uncertain times,” she told Medscape Medical News.

Although both Rundle and Sparks Lilley acknowledged the challenges of finding good solutions at this time, they do offer some tips.

Schools should make physical education and at-home exercise a priority alongside other remote teaching. Physical education teachers could even stream exercise classes to children at home.

Even just walking in the park while maintaining social distancing could be better than nothing, and a brisk walk is probably even better.

Depending on the age of the child, online yoga may also be useful. Even though yoga burns relatively few calories, it incorporates mindfulness training that may be helpful.

“I think focusing on promoting mindful eating as compared to mindless or distracted eating is important. Even in the best of circumstances, it is hard to exercise enough to burn off high energy snacks,” Rundle said.

Additional Stressors From Poverty: Schools Can Help With Meals

Children living in poverty, already the most vulnerable to obesity and related health problems, have additional stressors, add the two experts.

“As more Americans are losing jobs, poverty is a real threat to many of the children I care for. Families living in poverty often rely on processed, high-calorie, low-nutrient foods for survival, because they are inexpensive and shelf-stable,” Sparks Lilley said.

Rundle and colleagues agree: “Our own experiences in supermarkets show...shelves that held...crackers, chips, ramen noodles, soda, sugary cereals, and processed ready-to-eat meals are quite empty. We anticipate that many children will experience higher calorie diets during the pandemic response.”

Similar to how they address food insecurity during summer holidays, school districts have responded by offering grab-and-go meals, Rundle and colleagues note.

To maintain social distancing for people with vulnerable family members, some school districts have also started delivering food using school buses that run along regularly scheduled routes.

Rundle also stresses that farmers’ markets, which often provide foods that appeal to immigrant and ethnic communities, should be considered part of essential food services.

As such, social distancing protocols should be established for them and they should be allowed to stay open, he argues.

“The safety of American children is at stake in many ways. The threat to themselves or their caregivers being infected with COVID-19 is rightly foremost in our concerns,” Sparks Lilley stressed.

“However, there is other fallout to consider. We’ve seen very clearly the need for public health and preventive medicine and can’t let vulnerable children fall through the cracks.”

Rundle agrees. Although it is a “priority” to mitigate the immediate impact of COVID-19, “it is important to consider ways to prevent its long-term effects, including new risks for childhood obesity.”

Rundle and coauthors, as well as Sparks Lilley, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Although priority number one lies in controlling the spread of COVID-19, public health researchers are calling attention to the long-term repercussions of the pandemic on children’s health.

School closures could noticeably worsen the epidemic of childhood obesity that already threatens many children in the United States, say Paul Rundle, DrPH, and colleagues from Columbia University Mailman School of Public Health, New York City, in a perspective published online March 30 in Obesity.

“In part, we wrote the perspective to remind people that summer unhealthy weight gain seems to accumulate year to year,” he told Medscape Medical News in an email.

Rundle and colleagues estimate that time spent out of school will double this year because of school closures due to COVID-19. That, along with shelter-in-place orders, will pose challenges both for physical activity and healthy eating among children.

In addition, playgrounds have closed in many areas, and even where parks remain open, social distancing decreases opportunities for exercise. Team sports are on hold, and without physical education taught in schools, many children will not be getting as much active outdoor play as needed.

That’s especially true for children in urban areas, who may find it even more difficult to exercise inside cramped apartments, they add.

As a result, more and more children may turn to sedentary activities, and increased screen time goes hand in hand with childhood overweight and obesity, not just because of the lack of exercise but also because of snacking on unhealthy, empty-calorie foods while glued to the screen.

“We were hoping to get the word out on this issue, do some education or reminding, and at least let people know that this should be something to keep an eye on, among so many other things,” Rundle added.

Excess Eating Because of Stress and Boredom

Jessica Sparks Lilley, MD, director of the Pediatric Diabetes and Lipid Program at the Mississippi Center for Advanced Medicine in Madison, agrees that it is crucial to address these issues.

“Just like adults, children eat in response to emotions, including stress and boredom, and stress levels are high during these uncertain times,” she told Medscape Medical News.

Although both Rundle and Sparks Lilley acknowledged the challenges of finding good solutions at this time, they do offer some tips.

Schools should make physical education and at-home exercise a priority alongside other remote teaching. Physical education teachers could even stream exercise classes to children at home.

Even just walking in the park while maintaining social distancing could be better than nothing, and a brisk walk is probably even better.

Depending on the age of the child, online yoga may also be useful. Even though yoga burns relatively few calories, it incorporates mindfulness training that may be helpful.

“I think focusing on promoting mindful eating as compared to mindless or distracted eating is important. Even in the best of circumstances, it is hard to exercise enough to burn off high energy snacks,” Rundle said.

Additional Stressors From Poverty: Schools Can Help With Meals

Children living in poverty, already the most vulnerable to obesity and related health problems, have additional stressors, add the two experts.

“As more Americans are losing jobs, poverty is a real threat to many of the children I care for. Families living in poverty often rely on processed, high-calorie, low-nutrient foods for survival, because they are inexpensive and shelf-stable,” Sparks Lilley said.

Rundle and colleagues agree: “Our own experiences in supermarkets show...shelves that held...crackers, chips, ramen noodles, soda, sugary cereals, and processed ready-to-eat meals are quite empty. We anticipate that many children will experience higher calorie diets during the pandemic response.”

Similar to how they address food insecurity during summer holidays, school districts have responded by offering grab-and-go meals, Rundle and colleagues note.

To maintain social distancing for people with vulnerable family members, some school districts have also started delivering food using school buses that run along regularly scheduled routes.

Rundle also stresses that farmers’ markets, which often provide foods that appeal to immigrant and ethnic communities, should be considered part of essential food services.

As such, social distancing protocols should be established for them and they should be allowed to stay open, he argues.

“The safety of American children is at stake in many ways. The threat to themselves or their caregivers being infected with COVID-19 is rightly foremost in our concerns,” Sparks Lilley stressed.

“However, there is other fallout to consider. We’ve seen very clearly the need for public health and preventive medicine and can’t let vulnerable children fall through the cracks.”

Rundle agrees. Although it is a “priority” to mitigate the immediate impact of COVID-19, “it is important to consider ways to prevent its long-term effects, including new risks for childhood obesity.”

Rundle and coauthors, as well as Sparks Lilley, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

A consensus statement on the role of imaging during the acute work-up of COVID-19 patients called for liberal use in patients with moderate to severe clinical features indicative of infection, regardless of their COVID-19 test results, but limited use in patients who present with mild symptoms or are asymptomatic.

The consensus statement on The Role of Imaging in Patient Management during the COVID-19 Pandemic released by the Fleischner Society on April 7 was designed to highlight the “key decision points around imaging” in COVID-19 patients.

“We developed the statement to be applicable across settings” so that each clinic or hospital managing COVID-19 patients could decide the situations where chest radiography (CXR) or CT would work best, said Geoffrey D. Rubin, MD, professor of cardiovascular research, radiology, and bioengineering at Duke University in Durham, N.C., and lead author of the statement.

Written by 15 thoracic radiologists and 10 pulmonologists/intensivists including an anesthesiologist, a pathologist, and additional experts in emergency medicine, infection control, and laboratory medicine, and with members from any of 10 countries on three continents, the panel arrived at agreement by more than 70% for each of the 14 questions.

“I was impressed and a little surprised that consensus was achieved for every question” posed to the panel by the Fleischner Society for Thoracic Imaging and Diagnosis, Dr. Rubin said in an interview. The panel also placed their 14 decisions about imaging within the context of three distinct clinical scenarios chosen to mirror common real-world situations: mild COVID-19 features, moderate to severe features with no critical-resource constraints, and moderate to severe features with constrained resources. The statement also summarized its conclusions as five main recommendations and three additional recommendations.
 

Main recommendations

• Imaging is not routinely indicated for COVID-19 screening in asymptomatic people.
• Imaging is not indicated for patients with mild features of COVID-19 unless they are at risk for disease progression.
• Imaging is indicated for patients with features of moderate to severe COVID-19 regardless of COVID-19 test results.
• Imaging is indicated for patients with COVID-19 and evidence of worsening respiratory status.
• When access to CT is limited, chest radiography may be preferred for COVID-19 patients unless features of respiratory worsening warrant using CT.

Additional recommendations

• Daily chest radiographs are not indicated in stable, intubated patients with COVID-19.
• CT is indicated in patients with functional impairment, hypoxemia, or both, after COVID-19 recovery.
• COVID-19 testing is warranted in patients incidentally found to have findings suggestive of COVID-19 on a CT scan.

The statement particularly called out one of its recommendations – that a COVID-19 diagnosis “may be presumed when imaging findings are strongly suggestive of COVID-19 despite negative COVID-19 testing” in a patient who has moderate to severe clinical features of COVID-19 and whose pretest probability is high. The panel voted unanimously in favor of this concept, that imaging is “indicated” in hospitalized patients with moderate to severe symptoms consistent with COVID-19 despite a negative COVID-19 test result. “This guidance represents variance from other published recommendations which advise against the use of imaging for the initial diagnosis of COVID-19,” the statement acknowledged and specifically cited the recommendations issued in March 2020 by the American College of Radiology. Despite that, the ACR and Fleischner recommendations “are not at odds with one another,” maintained Dr. Rubin. The panel based its take on this question on the “direct experience” of its members caring for COVID-19 patients, according to the statement.

“I wholeheartedly agree with the suggested uses of imaging outlined by the panel,” commented Sachin Gupta, MD, FCCP, a pulmonologist and critical care physician in San Francisco. “The consensus statement brings a practical way to consider obtaining imaging. It leaves the door open to local standards and best judgment for using CXR or CT. Many physicians are unclear whether to image low-risk and mildly symptomatic patients. This statement gives support to a watchful waiting approach.” Another recommendation advises against daily CXR in stable, intubated COVID-19 patients. This “now gives backing from an important society and thought leaders while giving an explanation” for why daily imaging is problematic, he noted in an interview. The daily CXR in these patients adds no value, and skipping unneeded imaging minimizes SARS-CoV-2 exposure to radiology personnel, and conserves personal protection equipment, said the statement.

“The Fleischner Society is known worldwide for its recommendations. Having the society lend its weight on triage with imaging for COVID-19 patients is important. I suspect it will help standardize practice.”

Dr. Gupta also highlighted that lung imaging with a portable ultrasound unit has quickly become recognized as a very useful imaging tool with increasing use as the pandemic has unfolded, an option not covered by the Fleischner statement. Study results have “confirmed excellent sensitivity, specificity, and reproducibility” with lung ultrasound, and it’s also “easy to use,” Dr. Gupta said.

Ultrasound chest imaging of COVID-19 patients did not get included in the statement despite the reliance some U.S. sites have already placed on it largely because few on the panel had direct experience using it. “We didn’t feel we could contribute” to a discussion of ultrasound, Dr. Rubin said.

The statement’s recommendations appear to have already begun influencing practice. “The feedback I’ve gotten is that people are relying on them,” said Dr. Rubin, and some programs have sent him screen shots of the recommendations embedded in their local electronic health record.

The Radiological Society of North America is hosting a webinar on the statement on April 17.

[email protected]

A consensus statement on the role of imaging during the acute work-up of COVID-19 patients called for liberal use in patients with moderate to severe clinical features indicative of infection, regardless of their COVID-19 test results, but limited use in patients who present with mild symptoms or are asymptomatic.

The consensus statement on The Role of Imaging in Patient Management during the COVID-19 Pandemic released by the Fleischner Society on April 7 was designed to highlight the “key decision points around imaging” in COVID-19 patients.

“We developed the statement to be applicable across settings” so that each clinic or hospital managing COVID-19 patients could decide the situations where chest radiography (CXR) or CT would work best, said Geoffrey D. Rubin, MD, professor of cardiovascular research, radiology, and bioengineering at Duke University in Durham, N.C., and lead author of the statement.

Written by 15 thoracic radiologists and 10 pulmonologists/intensivists including an anesthesiologist, a pathologist, and additional experts in emergency medicine, infection control, and laboratory medicine, and with members from any of 10 countries on three continents, the panel arrived at agreement by more than 70% for each of the 14 questions.

“I was impressed and a little surprised that consensus was achieved for every question” posed to the panel by the Fleischner Society for Thoracic Imaging and Diagnosis, Dr. Rubin said in an interview. The panel also placed their 14 decisions about imaging within the context of three distinct clinical scenarios chosen to mirror common real-world situations: mild COVID-19 features, moderate to severe features with no critical-resource constraints, and moderate to severe features with constrained resources. The statement also summarized its conclusions as five main recommendations and three additional recommendations.
 

Main recommendations

• Imaging is not routinely indicated for COVID-19 screening in asymptomatic people.
• Imaging is not indicated for patients with mild features of COVID-19 unless they are at risk for disease progression.
• Imaging is indicated for patients with features of moderate to severe COVID-19 regardless of COVID-19 test results.
• Imaging is indicated for patients with COVID-19 and evidence of worsening respiratory status.
• When access to CT is limited, chest radiography may be preferred for COVID-19 patients unless features of respiratory worsening warrant using CT.

Additional recommendations

• Daily chest radiographs are not indicated in stable, intubated patients with COVID-19.
• CT is indicated in patients with functional impairment, hypoxemia, or both, after COVID-19 recovery.
• COVID-19 testing is warranted in patients incidentally found to have findings suggestive of COVID-19 on a CT scan.

The statement particularly called out one of its recommendations – that a COVID-19 diagnosis “may be presumed when imaging findings are strongly suggestive of COVID-19 despite negative COVID-19 testing” in a patient who has moderate to severe clinical features of COVID-19 and whose pretest probability is high. The panel voted unanimously in favor of this concept, that imaging is “indicated” in hospitalized patients with moderate to severe symptoms consistent with COVID-19 despite a negative COVID-19 test result. “This guidance represents variance from other published recommendations which advise against the use of imaging for the initial diagnosis of COVID-19,” the statement acknowledged and specifically cited the recommendations issued in March 2020 by the American College of Radiology. Despite that, the ACR and Fleischner recommendations “are not at odds with one another,” maintained Dr. Rubin. The panel based its take on this question on the “direct experience” of its members caring for COVID-19 patients, according to the statement.

“I wholeheartedly agree with the suggested uses of imaging outlined by the panel,” commented Sachin Gupta, MD, FCCP, a pulmonologist and critical care physician in San Francisco. “The consensus statement brings a practical way to consider obtaining imaging. It leaves the door open to local standards and best judgment for using CXR or CT. Many physicians are unclear whether to image low-risk and mildly symptomatic patients. This statement gives support to a watchful waiting approach.” Another recommendation advises against daily CXR in stable, intubated COVID-19 patients. This “now gives backing from an important society and thought leaders while giving an explanation” for why daily imaging is problematic, he noted in an interview. The daily CXR in these patients adds no value, and skipping unneeded imaging minimizes SARS-CoV-2 exposure to radiology personnel, and conserves personal protection equipment, said the statement.

“The Fleischner Society is known worldwide for its recommendations. Having the society lend its weight on triage with imaging for COVID-19 patients is important. I suspect it will help standardize practice.”

Dr. Gupta also highlighted that lung imaging with a portable ultrasound unit has quickly become recognized as a very useful imaging tool with increasing use as the pandemic has unfolded, an option not covered by the Fleischner statement. Study results have “confirmed excellent sensitivity, specificity, and reproducibility” with lung ultrasound, and it’s also “easy to use,” Dr. Gupta said.

Ultrasound chest imaging of COVID-19 patients did not get included in the statement despite the reliance some U.S. sites have already placed on it largely because few on the panel had direct experience using it. “We didn’t feel we could contribute” to a discussion of ultrasound, Dr. Rubin said.

The statement’s recommendations appear to have already begun influencing practice. “The feedback I’ve gotten is that people are relying on them,” said Dr. Rubin, and some programs have sent him screen shots of the recommendations embedded in their local electronic health record.

The Radiological Society of North America is hosting a webinar on the statement on April 17.

[email protected]

A consensus statement on the role of imaging during the acute work-up of COVID-19 patients called for liberal use in patients with moderate to severe clinical features indicative of infection, regardless of their COVID-19 test results, but limited use in patients who present with mild symptoms or are asymptomatic.

The consensus statement on The Role of Imaging in Patient Management during the COVID-19 Pandemic released by the Fleischner Society on April 7 was designed to highlight the “key decision points around imaging” in COVID-19 patients.

“We developed the statement to be applicable across settings” so that each clinic or hospital managing COVID-19 patients could decide the situations where chest radiography (CXR) or CT would work best, said Geoffrey D. Rubin, MD, professor of cardiovascular research, radiology, and bioengineering at Duke University in Durham, N.C., and lead author of the statement.

Written by 15 thoracic radiologists and 10 pulmonologists/intensivists including an anesthesiologist, a pathologist, and additional experts in emergency medicine, infection control, and laboratory medicine, and with members from any of 10 countries on three continents, the panel arrived at agreement by more than 70% for each of the 14 questions.

“I was impressed and a little surprised that consensus was achieved for every question” posed to the panel by the Fleischner Society for Thoracic Imaging and Diagnosis, Dr. Rubin said in an interview. The panel also placed their 14 decisions about imaging within the context of three distinct clinical scenarios chosen to mirror common real-world situations: mild COVID-19 features, moderate to severe features with no critical-resource constraints, and moderate to severe features with constrained resources. The statement also summarized its conclusions as five main recommendations and three additional recommendations.
 

Main recommendations

• Imaging is not routinely indicated for COVID-19 screening in asymptomatic people.
• Imaging is not indicated for patients with mild features of COVID-19 unless they are at risk for disease progression.
• Imaging is indicated for patients with features of moderate to severe COVID-19 regardless of COVID-19 test results.
• Imaging is indicated for patients with COVID-19 and evidence of worsening respiratory status.
• When access to CT is limited, chest radiography may be preferred for COVID-19 patients unless features of respiratory worsening warrant using CT.

Additional recommendations

• Daily chest radiographs are not indicated in stable, intubated patients with COVID-19.
• CT is indicated in patients with functional impairment, hypoxemia, or both, after COVID-19 recovery.
• COVID-19 testing is warranted in patients incidentally found to have findings suggestive of COVID-19 on a CT scan.

The statement particularly called out one of its recommendations – that a COVID-19 diagnosis “may be presumed when imaging findings are strongly suggestive of COVID-19 despite negative COVID-19 testing” in a patient who has moderate to severe clinical features of COVID-19 and whose pretest probability is high. The panel voted unanimously in favor of this concept, that imaging is “indicated” in hospitalized patients with moderate to severe symptoms consistent with COVID-19 despite a negative COVID-19 test result. “This guidance represents variance from other published recommendations which advise against the use of imaging for the initial diagnosis of COVID-19,” the statement acknowledged and specifically cited the recommendations issued in March 2020 by the American College of Radiology. Despite that, the ACR and Fleischner recommendations “are not at odds with one another,” maintained Dr. Rubin. The panel based its take on this question on the “direct experience” of its members caring for COVID-19 patients, according to the statement.

“I wholeheartedly agree with the suggested uses of imaging outlined by the panel,” commented Sachin Gupta, MD, FCCP, a pulmonologist and critical care physician in San Francisco. “The consensus statement brings a practical way to consider obtaining imaging. It leaves the door open to local standards and best judgment for using CXR or CT. Many physicians are unclear whether to image low-risk and mildly symptomatic patients. This statement gives support to a watchful waiting approach.” Another recommendation advises against daily CXR in stable, intubated COVID-19 patients. This “now gives backing from an important society and thought leaders while giving an explanation” for why daily imaging is problematic, he noted in an interview. The daily CXR in these patients adds no value, and skipping unneeded imaging minimizes SARS-CoV-2 exposure to radiology personnel, and conserves personal protection equipment, said the statement.

“The Fleischner Society is known worldwide for its recommendations. Having the society lend its weight on triage with imaging for COVID-19 patients is important. I suspect it will help standardize practice.”

Dr. Gupta also highlighted that lung imaging with a portable ultrasound unit has quickly become recognized as a very useful imaging tool with increasing use as the pandemic has unfolded, an option not covered by the Fleischner statement. Study results have “confirmed excellent sensitivity, specificity, and reproducibility” with lung ultrasound, and it’s also “easy to use,” Dr. Gupta said.

Ultrasound chest imaging of COVID-19 patients did not get included in the statement despite the reliance some U.S. sites have already placed on it largely because few on the panel had direct experience using it. “We didn’t feel we could contribute” to a discussion of ultrasound, Dr. Rubin said.

The statement’s recommendations appear to have already begun influencing practice. “The feedback I’ve gotten is that people are relying on them,” said Dr. Rubin, and some programs have sent him screen shots of the recommendations embedded in their local electronic health record.

The Radiological Society of North America is hosting a webinar on the statement on April 17.

[email protected]

Patients infected by the COVID-19 virus may benefit from treatments that dampen the renin-angiotensin system, according to a review of several animal studies. These preclinical findings generally support the positions taken in recent week by several cardiology societies that recommended patients taking drugs that moderate the renin-angiotensin system stay on these treatments.

“In patients with cardiovascular disease and SARS-CoV2, the use of ACE inhibitors, ARBs [angiotensin receptor blockers], or MRAs [mineralocorticoid-receptor antagonists] may be favorable as a method to endogenously upregulate ACE2 as a compensatory mechanism that provides anti-inflammatory, antifibrotic, and antithrombotic support as well as reduction in progression of vascular/cardiac remodeling and heart failure,” wrote Jeffrey Bander, MD, and his associates in a report published online (J Am Coll Cardiol. 2020 Apr 15. doi: 10.1016/j.jacc.2020.04.028).

“Based on our review, we hypothesize cardiovascular patients with COVID-19 should remain on RAS [renin-angiotensin system] inhibitors given the protective effects of the ACE2 pathway until RAS blockade is proven to increase the risk to COVID-19,” said the researchers, who are affiliated with the Icahn School of Medicine at Mount Sinai in New York.

The ACE2 protein, found both in human blood as well as in cell membranes, especially cells of the lungs, heart, kidneys, and gastrointestinal tissues, functions as both a key enzyme in RAS regulation as well as the primary cell receptor for entry of SARS-CoV2.

Their conclusion jibed with both a joint statement in March from the American College of Cardiology, American Heart Association, and the Heart Failure Society of America; and with the conclusions of a review organized by the European Society of Hypertension’s COVID-19 Task Force (Cardiovasc Res. 2020 Apr 15. doi: 10.1093/cvr/cvaa097).

In their review, the Mount Sinai authors described results from several animal studies suggesting that ACE2 and its associated signaling proteins could potentially be a “valuable therapeutic target.” They also highlighted several clinical intervention studies recently launched to target ACE2, related proteins, and regulation of this arm of the RAS.

Currently, “no data support any conclusive effects of the use of RAS inhibitors in patients with COVID-19,” they concluded. They acknowledged that “the question remains whether the use of ACE inhibitors, ARBs, and MRAs should be avoided in the setting of SARS-CoV infection,” but emphasized that “adequate data on the effects of RAS inhibition in COVID-19 patients is not available,” with more data becoming available soon from ongoing clinical studies.

None of the authors had any disclosures.

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