Ob.Gyn. News

Physicians in the COVID-19 trenches are beginning to question whether standard respiratory therapy protocols for acute respiratory distress syndrome (ARDS) are the best approach for treating patients with COVID-19 pneumonia.

Courtesy Dr. Luciano Gattinoni

At issue is the standard use of ventilators for a virus whose presentation has not followed the standard for ARDS, but is looking more like high-altitude pulmonary edema (HAPE) in some patients.

In a letter to the editor published in the American Journal of Respiratory and Critical Care Medicine on March 30, and in an editorial accepted for publication in Intensive Care Medicine, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues make the case that protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good.

Dr. Gattinoni noted that COVID-19 patients in ICUs in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation–practicing patience to “buy time with minimum additional damage.”

Similar observations were made by Cameron Kyle-Sidell, MD, a critical care physician working in New York City, who has been speaking out about this issue on Twitter and who shared his own experiences in this video interview with WebMD chief medical officer John Whyte, MD.

The bottom line, as Dr. Kyle-Sidell and Dr. Gattinoni agree, is that protocol-driven ventilator use may be causing lung injury in COVID-19 patients.
 

Consider disease phenotype

In the editorial, Dr. Gattinoni and colleagues explained further that ventilator settings should be based on physiological findings – with different respiratory treatment based on disease phenotype rather than using standard protocols.

‘“This, of course, is a conceptual model, but based on the observations we have this far, I don’t know of any model which is better,” he said in an interview.

Anecdotal evidence has increasingly demonstrated that this proposed physiological approach is associated with much lower mortality rates among COVID-19 patients, he said.

While not willing to name the hospitals at this time, he said that one center in Europe has had a 0% mortality rate among COVID-19 patients in the ICU when using this approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach.

In his editorial, Dr. Gattinoni disputed the recently published recommendation from the Surviving Sepsis Campaign that “mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.”

“Yet, COVID-19 pneumonia, despite falling in most of the circumstances under the Berlin definition of ARDS, is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance,” Dr. Gattinoni and colleagues wrote, noting that this was true for more than half of the 150 patients he and his colleagues had assessed, and that several other colleagues in northern Italy reported similar findings. “This remarkable combination is almost never seen in severe ARDS.”

Dr. Gattinoni and colleagues hypothesized that COVID-19 patterns at patient presentation depend on interaction between three sets of factors: 1) disease severity, host response, physiological reserve and comorbidities; 2) ventilatory responsiveness of the patient to hypoxemia; and 3) time elapsed between disease onset and hospitalization.

They identified two primary phenotypes based on the interaction of these factors: Type L, characterized by low elastance, low ventilator perfusion ratio, low lung weight, and low recruitability; and Type H, characterized by high elastance, high right-to-left shunt, high lung weight, and high recruitability.

“Given this conceptual model, it follows that the respiratory treatment offered to Type L and Type H patients must be different,” Dr. Gattinoni said.

Patients may transition between phenotypes as their disease evolves. “If you start with the wrong protocol, at the end they become similar,” he said.

Rather, it is important to identify the phenotype at presentation to understand the pathophysiology and treat accordingly, he advised.

The phenotypes are best identified by CT scan, but signs implicit in each of the phenotypes, including respiratory system elastance and recruitability, can be used as surrogates if CT is unavailable, he noted.

“This is a kind of disease in which you don’t have to follow the protocol – you have to follow the physiology,” he said. “Unfortunately, many, many doctors around the world cannot think outside the protocol.”

In his interview with Dr. Whyte, Dr. Kyle-Sidell stressed that doctors must begin to consider other approaches. “We are desperate now, in the sense that everything we are doing does not seem to be working,” Dr. Kyle-Sidell said, noting that the first step toward improving outcomes is admitting that “this is something new.”

“I think it all starts from there, and I think we have the kind of scientific technology and the human capital in this country to solve this or at least have a very good shot at it,” he said.
 

Proposed treatment model

Dr. Gattinoni and his colleagues offered a proposed treatment model based on their conceptualization:

• Reverse hypoxemia through an increase in FiO₂ to a level at which the Type L patient responds well, particularly for Type L patients who are not experiencing dyspnea.
• In Type L patients with dyspnea, try noninvasive options such as high-flow nasal cannula, continuous positive airway pressure, or noninvasive ventilation, and be sure to measure inspiratory esophageal pressure using esophageal manometry or surrogate measures. In intubated patients, determine P0.1 and P occlusion. High PEEP may decrease pleural pressure swings “and stop the vicious cycle that exacerbates lung injury,” but may be associated with high failure rates and delayed intubation.
• Intubate as soon as possible for esophageal pressure swings that increase from 5-10 cm H₂O to above 15 cm H₂O, which marks a transition from Type L to Type H phenotype and represents the level at which lung injury risk increases.
• For intubated and deeply sedated Type L patients who are hypercapnic, ventilate with volumes greater than 6 mL/kg up to 8-9 mL/kg as this high compliance results in tolerable strain without risk of ventilator-associated lung injury. Prone positioning should be used only as a rescue maneuver. Reduce PEEP to 8-10 cm H₂O, given that the recruitability is low and the risk of hemodynamic failure increases at higher levels. Early intubation may avert the transition to Type H phenotype.
• Treat Type H phenotype like severe ARDS, including with higher PEEP if compatible with hemodynamics, and with prone positioning and extracorporeal support.

Dr. Gattinoni reported having no financial disclosures.

[email protected]

Physicians in the COVID-19 trenches are beginning to question whether standard respiratory therapy protocols for acute respiratory distress syndrome (ARDS) are the best approach for treating patients with COVID-19 pneumonia.

Courtesy Dr. Luciano Gattinoni

At issue is the standard use of ventilators for a virus whose presentation has not followed the standard for ARDS, but is looking more like high-altitude pulmonary edema (HAPE) in some patients.

In a letter to the editor published in the American Journal of Respiratory and Critical Care Medicine on March 30, and in an editorial accepted for publication in Intensive Care Medicine, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues make the case that protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good.

Dr. Gattinoni noted that COVID-19 patients in ICUs in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation–practicing patience to “buy time with minimum additional damage.”

Similar observations were made by Cameron Kyle-Sidell, MD, a critical care physician working in New York City, who has been speaking out about this issue on Twitter and who shared his own experiences in this video interview with WebMD chief medical officer John Whyte, MD.

The bottom line, as Dr. Kyle-Sidell and Dr. Gattinoni agree, is that protocol-driven ventilator use may be causing lung injury in COVID-19 patients.
 

Consider disease phenotype

In the editorial, Dr. Gattinoni and colleagues explained further that ventilator settings should be based on physiological findings – with different respiratory treatment based on disease phenotype rather than using standard protocols.

‘“This, of course, is a conceptual model, but based on the observations we have this far, I don’t know of any model which is better,” he said in an interview.

Anecdotal evidence has increasingly demonstrated that this proposed physiological approach is associated with much lower mortality rates among COVID-19 patients, he said.

While not willing to name the hospitals at this time, he said that one center in Europe has had a 0% mortality rate among COVID-19 patients in the ICU when using this approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach.

In his editorial, Dr. Gattinoni disputed the recently published recommendation from the Surviving Sepsis Campaign that “mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.”

“Yet, COVID-19 pneumonia, despite falling in most of the circumstances under the Berlin definition of ARDS, is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance,” Dr. Gattinoni and colleagues wrote, noting that this was true for more than half of the 150 patients he and his colleagues had assessed, and that several other colleagues in northern Italy reported similar findings. “This remarkable combination is almost never seen in severe ARDS.”

Dr. Gattinoni and colleagues hypothesized that COVID-19 patterns at patient presentation depend on interaction between three sets of factors: 1) disease severity, host response, physiological reserve and comorbidities; 2) ventilatory responsiveness of the patient to hypoxemia; and 3) time elapsed between disease onset and hospitalization.

They identified two primary phenotypes based on the interaction of these factors: Type L, characterized by low elastance, low ventilator perfusion ratio, low lung weight, and low recruitability; and Type H, characterized by high elastance, high right-to-left shunt, high lung weight, and high recruitability.

“Given this conceptual model, it follows that the respiratory treatment offered to Type L and Type H patients must be different,” Dr. Gattinoni said.

Patients may transition between phenotypes as their disease evolves. “If you start with the wrong protocol, at the end they become similar,” he said.

Rather, it is important to identify the phenotype at presentation to understand the pathophysiology and treat accordingly, he advised.

The phenotypes are best identified by CT scan, but signs implicit in each of the phenotypes, including respiratory system elastance and recruitability, can be used as surrogates if CT is unavailable, he noted.

“This is a kind of disease in which you don’t have to follow the protocol – you have to follow the physiology,” he said. “Unfortunately, many, many doctors around the world cannot think outside the protocol.”

In his interview with Dr. Whyte, Dr. Kyle-Sidell stressed that doctors must begin to consider other approaches. “We are desperate now, in the sense that everything we are doing does not seem to be working,” Dr. Kyle-Sidell said, noting that the first step toward improving outcomes is admitting that “this is something new.”

“I think it all starts from there, and I think we have the kind of scientific technology and the human capital in this country to solve this or at least have a very good shot at it,” he said.
 

Proposed treatment model

Dr. Gattinoni and his colleagues offered a proposed treatment model based on their conceptualization:

• Reverse hypoxemia through an increase in FiO₂ to a level at which the Type L patient responds well, particularly for Type L patients who are not experiencing dyspnea.
• In Type L patients with dyspnea, try noninvasive options such as high-flow nasal cannula, continuous positive airway pressure, or noninvasive ventilation, and be sure to measure inspiratory esophageal pressure using esophageal manometry or surrogate measures. In intubated patients, determine P0.1 and P occlusion. High PEEP may decrease pleural pressure swings “and stop the vicious cycle that exacerbates lung injury,” but may be associated with high failure rates and delayed intubation.
• Intubate as soon as possible for esophageal pressure swings that increase from 5-10 cm H₂O to above 15 cm H₂O, which marks a transition from Type L to Type H phenotype and represents the level at which lung injury risk increases.
• For intubated and deeply sedated Type L patients who are hypercapnic, ventilate with volumes greater than 6 mL/kg up to 8-9 mL/kg as this high compliance results in tolerable strain without risk of ventilator-associated lung injury. Prone positioning should be used only as a rescue maneuver. Reduce PEEP to 8-10 cm H₂O, given that the recruitability is low and the risk of hemodynamic failure increases at higher levels. Early intubation may avert the transition to Type H phenotype.
• Treat Type H phenotype like severe ARDS, including with higher PEEP if compatible with hemodynamics, and with prone positioning and extracorporeal support.

Dr. Gattinoni reported having no financial disclosures.

[email protected]

Physicians in the COVID-19 trenches are beginning to question whether standard respiratory therapy protocols for acute respiratory distress syndrome (ARDS) are the best approach for treating patients with COVID-19 pneumonia.

Courtesy Dr. Luciano Gattinoni

At issue is the standard use of ventilators for a virus whose presentation has not followed the standard for ARDS, but is looking more like high-altitude pulmonary edema (HAPE) in some patients.

In a letter to the editor published in the American Journal of Respiratory and Critical Care Medicine on March 30, and in an editorial accepted for publication in Intensive Care Medicine, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues make the case that protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good.

Dr. Gattinoni noted that COVID-19 patients in ICUs in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation–practicing patience to “buy time with minimum additional damage.”

Similar observations were made by Cameron Kyle-Sidell, MD, a critical care physician working in New York City, who has been speaking out about this issue on Twitter and who shared his own experiences in this video interview with WebMD chief medical officer John Whyte, MD.

The bottom line, as Dr. Kyle-Sidell and Dr. Gattinoni agree, is that protocol-driven ventilator use may be causing lung injury in COVID-19 patients.
 

Consider disease phenotype

In the editorial, Dr. Gattinoni and colleagues explained further that ventilator settings should be based on physiological findings – with different respiratory treatment based on disease phenotype rather than using standard protocols.

‘“This, of course, is a conceptual model, but based on the observations we have this far, I don’t know of any model which is better,” he said in an interview.

Anecdotal evidence has increasingly demonstrated that this proposed physiological approach is associated with much lower mortality rates among COVID-19 patients, he said.

While not willing to name the hospitals at this time, he said that one center in Europe has had a 0% mortality rate among COVID-19 patients in the ICU when using this approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach.

In his editorial, Dr. Gattinoni disputed the recently published recommendation from the Surviving Sepsis Campaign that “mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.”

“Yet, COVID-19 pneumonia, despite falling in most of the circumstances under the Berlin definition of ARDS, is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance,” Dr. Gattinoni and colleagues wrote, noting that this was true for more than half of the 150 patients he and his colleagues had assessed, and that several other colleagues in northern Italy reported similar findings. “This remarkable combination is almost never seen in severe ARDS.”

Dr. Gattinoni and colleagues hypothesized that COVID-19 patterns at patient presentation depend on interaction between three sets of factors: 1) disease severity, host response, physiological reserve and comorbidities; 2) ventilatory responsiveness of the patient to hypoxemia; and 3) time elapsed between disease onset and hospitalization.

They identified two primary phenotypes based on the interaction of these factors: Type L, characterized by low elastance, low ventilator perfusion ratio, low lung weight, and low recruitability; and Type H, characterized by high elastance, high right-to-left shunt, high lung weight, and high recruitability.

“Given this conceptual model, it follows that the respiratory treatment offered to Type L and Type H patients must be different,” Dr. Gattinoni said.

Patients may transition between phenotypes as their disease evolves. “If you start with the wrong protocol, at the end they become similar,” he said.

Rather, it is important to identify the phenotype at presentation to understand the pathophysiology and treat accordingly, he advised.

The phenotypes are best identified by CT scan, but signs implicit in each of the phenotypes, including respiratory system elastance and recruitability, can be used as surrogates if CT is unavailable, he noted.

“This is a kind of disease in which you don’t have to follow the protocol – you have to follow the physiology,” he said. “Unfortunately, many, many doctors around the world cannot think outside the protocol.”

In his interview with Dr. Whyte, Dr. Kyle-Sidell stressed that doctors must begin to consider other approaches. “We are desperate now, in the sense that everything we are doing does not seem to be working,” Dr. Kyle-Sidell said, noting that the first step toward improving outcomes is admitting that “this is something new.”

“I think it all starts from there, and I think we have the kind of scientific technology and the human capital in this country to solve this or at least have a very good shot at it,” he said.
 

Proposed treatment model

Dr. Gattinoni and his colleagues offered a proposed treatment model based on their conceptualization:

• Reverse hypoxemia through an increase in FiO₂ to a level at which the Type L patient responds well, particularly for Type L patients who are not experiencing dyspnea.
• In Type L patients with dyspnea, try noninvasive options such as high-flow nasal cannula, continuous positive airway pressure, or noninvasive ventilation, and be sure to measure inspiratory esophageal pressure using esophageal manometry or surrogate measures. In intubated patients, determine P0.1 and P occlusion. High PEEP may decrease pleural pressure swings “and stop the vicious cycle that exacerbates lung injury,” but may be associated with high failure rates and delayed intubation.
• Intubate as soon as possible for esophageal pressure swings that increase from 5-10 cm H₂O to above 15 cm H₂O, which marks a transition from Type L to Type H phenotype and represents the level at which lung injury risk increases.
• For intubated and deeply sedated Type L patients who are hypercapnic, ventilate with volumes greater than 6 mL/kg up to 8-9 mL/kg as this high compliance results in tolerable strain without risk of ventilator-associated lung injury. Prone positioning should be used only as a rescue maneuver. Reduce PEEP to 8-10 cm H₂O, given that the recruitability is low and the risk of hemodynamic failure increases at higher levels. Early intubation may avert the transition to Type H phenotype.
• Treat Type H phenotype like severe ARDS, including with higher PEEP if compatible with hemodynamics, and with prone positioning and extracorporeal support.

Dr. Gattinoni reported having no financial disclosures.

[email protected]

The rapid spread of COVID-19 forced Seemal Desai, MD, to make an excruciating choice; he could either shutter his busy dermatology practice in Plano, Tex., or switch most patient consults to telemedicine, which he’d never used.

But as soon as he learned that telehealth regulations had been relaxed by the Centers for Medicare & Medicaid Services and that reimbursement had been broadened, Dr. Desai, a dermatologist in private practice and his staff began to mobilize.

“Kaboom! We made the decision to start doing it,” he said in an interview. “We drafted a consent form, uploaded it to our website, called patients, changed our voice greeting, and got clarity on insurance coverage. We’ve been flying by the seat of our pants.”

“I’m doing it because I don’t have a choice at this point,” said Dr. Desai, who is a member of the American Academy of Dermatology board of directors and its coronavirus task force. “I’m very worried about continuing to be able to meet our payroll expenses for staff and overhead to keep the office open.”
 

“Flying by the seat of our pants” to see patients virtually

Dermatologists have long been considered pioneers in telemedicine. They have, since the 1990s, capitalized on the visual nature of the specialty to diagnose and treat skin diseases by incorporating photos, videos, and virtual-patient visits. But the pandemic has forced the hands of even holdouts like Dr. Desai, who clung to in-person consults because of confusion related to HIPAA compliance issues and the sense that teledermatology “really dehumanizes patient interaction” for him.

In fact, as of 2017, only 15% of the nation’s 11,000 or so dermatologists had implemented telehealth into their practices, according to an AAD practice survey. In the wake of COVID-19, however, that percentage has likely more than tripled, experts estimate.

Now, dermatologists are assuming the mantle of educators for other specialists who never considered telehealth before in-person visits became fraught with concerns about the spread of the virus. And some are publishing guidelines for colleagues on how to prioritize teledermatology to stem transmission and conserve personal protective equipment (PPE) and hospital beds.

User-friendly technology and the relaxed telehealth restrictions have made it fairly simple for patients and physicians to connect. Facetime and other once-prohibited platforms are all currently permissible, although physicians are encouraged to notify patients about potential privacy risks, according to an AAD teledermatology tool kit.
 

Teledermatology innovators

“We’ve moved 10 years in telemedicine policy in 2 weeks,” said Karen Edison, MD, of the University of Missouri, Columbia. “The federal government has really loosened the reins.”

At least half of all dermatologists in the United States have adopted telehealth since the pandemic emerged, she estimated. And most, like Dr. Desai, have done so in just the last several weeks.

“You can do about 90% of what you need to do as a dermatologist using the technology,” said Dr. Edison, who launched the first dermatology Extension for Community Healthcare Outcomes, or ECHO, program in the Midwest. That telehealth model was originally developed to connect rural general practitioners with specialists at academic medical centers or large health systems.

“People are used to taking pictures with their phones. In some ways, this crisis may change the face of our specialty,” she said in an interview.

“As we’re all practicing social distancing, I think physicians and patients are rethinking how we can access healthcare without pursuing traditional face-to-face interactions,” said Ivy Lee, MD, from the University of California, San Francisco, who is past chair of the AAD telemedicine task force and current chair of the teledermatology committee at the American Telemedicine Association. “Virtual health and telemedicine fit perfectly with that.”

Even before the pandemic, the innovative ways dermatologists were using telehealth were garnering increasing acclaim. All four clinical groups short-listed for dermatology team of the year at the BMJ Awards 2020 employed telehealth to improve patient services in the United Kingdom.

In the United States, dermatologists are joining forces to boost understanding of how telehealth can protect patients and clinicians from some of the ravages of the virus.

The Society of Dermatology Hospitalists has developed an algorithm – built on experiences its members have had caring for hospitalized patients with acute dermatologic conditions – to provide a “logical way” to triage telemedicine consults in multiple hospital settings during the coronavirus crisis, said President-Elect Daniela Kroshinsky, MD, from Massachusetts General Hospital in Boston.

Telemedicine consultation is prioritized and patients at high risk for COVID-19 exposure are identified so that exposure time and resource use are limited and patient and staff safety are maximized.

“We want to empower our colleagues in community hospitals to play a role in safely providing care for patients in need but to be mindful about preserving resources,” said Dr. Kroshinsky, who reported that the algorithm will be published imminently.

“If you don’t have to see a patient in person and can offer recommendations through telederm, you don’t need to put on a gown, gloves, mask, or goggles,” she said in an interview. “If you’re unable to assess photos, then of course you’ll use the appropriate protective wear, but it will be better if you can obtain the same result” without having to do so.
 

Sharing expertise

After the first week of tracking data to gauge the effectiveness of the algorithm at Massachusetts General, Dr. Kroshinsky said she is buoyed.

Of the 35 patients assessed electronically – all of whom would previously have been seen in person – only 4 ended up needing a subsequent in-person consult, she reported.

“It’s worked out great,” said Dr. Kroshinsky, who noted that the pandemic is a “nice opportunity” to test different telehealth platforms and improve quality down the line. “We never had to use any excessive PPE, beyond what was routine, and the majority of patients were able to be staffed remotely. All patients had successful outcomes.”

With telehealth more firmly established in dermatology than in most other specialties, dermatologists are now helping clinicians in other fields who are rapidly ramping up their own telemedicine offerings.

These might include obstetrics and gynecology or “any medical specialty where they need to do checkups with their patients and don’t want them coming in for nonemergent visits,” said Carrie L. Kovarik, MD, of the University of Pennsylvania, Philadelphia.

In addition to fielding many recent calls and emails from physicians seeking guidance on telehealth, Dr. Kovarik, Dr. Lee, and colleagues have published the steps required to integrate the technology into outpatient practices.

“Now that there’s a time for broad implementation, our colleagues are looking to us for help and troubleshooting advice,” said Dr. Kovarik, who is also a member of the AAD COVID-19 response task force.

Various specialties “lend themselves to telehealth, depending on how image- or data-dependent they are,” Dr. Lee said in an interview. “But all specialists thinking of limiting or shutting down their practices are thinking about how they can provide continuity of care without exposing patients or staff to the risk of contracting the coronavirus.”
 

After-COVID goals

In his first week of virtual patient consults, Dr. Desai said he saw about 50 patients, which is still far fewer than the 160-180 he sees in person during a normal week.

“The problem is that patients don’t really want to do telehealth. You’d think it would be a good option,” he said, “but patients hesitate because they don’t really know how to use their device.” Some have instead rescheduled in-person appointments for months down the line.

Although telehealth has enabled Dr. Desai to readily assess patients with acne, hair loss, psoriasis, rashes, warts, and eczema, he’s concerned that necessary procedures, such as biopsies and dermoscopies, could be dangerously delayed. It’s also hard to assess the texture and thickness of certain skin lesions in photos or videos, he said.

“I’m trying to stay optimistic that this will get better and we’re able to move back to taking care of patients the way we need to,” he said.

Like Dr. Desai, other dermatologists who’ve implemented telemedicine during the pandemic have largely been swayed by the relaxed CMS regulations. “It’s made all the difference,” Dr. Kovarik said. “It has brought down the anxiety level and decreased questions about platforms and concentrated them on how to code the visits.”

And although it’s difficult to envision post-COVID medical practice in the thick of the pandemic, dermatologists expect the current strides in telemedicine will stick.

“I’m hoping that telehealth use isn’t dialed back all the way to baseline” after the pandemic eases, Dr. Kovarik said. “The cat’s out of the bag, and now that it is, hopefully it won’t be put back in.”

“If there’s a silver lining to this,” Dr. Kroshinsky said, “I hope it’s that we’ll be able to innovate around health care in a fashion we wouldn’t have seen otherwise.”

A version of this article originally appeared on Medscape.com.

The rapid spread of COVID-19 forced Seemal Desai, MD, to make an excruciating choice; he could either shutter his busy dermatology practice in Plano, Tex., or switch most patient consults to telemedicine, which he’d never used.

But as soon as he learned that telehealth regulations had been relaxed by the Centers for Medicare & Medicaid Services and that reimbursement had been broadened, Dr. Desai, a dermatologist in private practice and his staff began to mobilize.

“Kaboom! We made the decision to start doing it,” he said in an interview. “We drafted a consent form, uploaded it to our website, called patients, changed our voice greeting, and got clarity on insurance coverage. We’ve been flying by the seat of our pants.”

“I’m doing it because I don’t have a choice at this point,” said Dr. Desai, who is a member of the American Academy of Dermatology board of directors and its coronavirus task force. “I’m very worried about continuing to be able to meet our payroll expenses for staff and overhead to keep the office open.”
 

“Flying by the seat of our pants” to see patients virtually

Dermatologists have long been considered pioneers in telemedicine. They have, since the 1990s, capitalized on the visual nature of the specialty to diagnose and treat skin diseases by incorporating photos, videos, and virtual-patient visits. But the pandemic has forced the hands of even holdouts like Dr. Desai, who clung to in-person consults because of confusion related to HIPAA compliance issues and the sense that teledermatology “really dehumanizes patient interaction” for him.

In fact, as of 2017, only 15% of the nation’s 11,000 or so dermatologists had implemented telehealth into their practices, according to an AAD practice survey. In the wake of COVID-19, however, that percentage has likely more than tripled, experts estimate.

Now, dermatologists are assuming the mantle of educators for other specialists who never considered telehealth before in-person visits became fraught with concerns about the spread of the virus. And some are publishing guidelines for colleagues on how to prioritize teledermatology to stem transmission and conserve personal protective equipment (PPE) and hospital beds.

User-friendly technology and the relaxed telehealth restrictions have made it fairly simple for patients and physicians to connect. Facetime and other once-prohibited platforms are all currently permissible, although physicians are encouraged to notify patients about potential privacy risks, according to an AAD teledermatology tool kit.
 

Teledermatology innovators

“We’ve moved 10 years in telemedicine policy in 2 weeks,” said Karen Edison, MD, of the University of Missouri, Columbia. “The federal government has really loosened the reins.”

At least half of all dermatologists in the United States have adopted telehealth since the pandemic emerged, she estimated. And most, like Dr. Desai, have done so in just the last several weeks.

“You can do about 90% of what you need to do as a dermatologist using the technology,” said Dr. Edison, who launched the first dermatology Extension for Community Healthcare Outcomes, or ECHO, program in the Midwest. That telehealth model was originally developed to connect rural general practitioners with specialists at academic medical centers or large health systems.

“People are used to taking pictures with their phones. In some ways, this crisis may change the face of our specialty,” she said in an interview.

“As we’re all practicing social distancing, I think physicians and patients are rethinking how we can access healthcare without pursuing traditional face-to-face interactions,” said Ivy Lee, MD, from the University of California, San Francisco, who is past chair of the AAD telemedicine task force and current chair of the teledermatology committee at the American Telemedicine Association. “Virtual health and telemedicine fit perfectly with that.”

Even before the pandemic, the innovative ways dermatologists were using telehealth were garnering increasing acclaim. All four clinical groups short-listed for dermatology team of the year at the BMJ Awards 2020 employed telehealth to improve patient services in the United Kingdom.

In the United States, dermatologists are joining forces to boost understanding of how telehealth can protect patients and clinicians from some of the ravages of the virus.

The Society of Dermatology Hospitalists has developed an algorithm – built on experiences its members have had caring for hospitalized patients with acute dermatologic conditions – to provide a “logical way” to triage telemedicine consults in multiple hospital settings during the coronavirus crisis, said President-Elect Daniela Kroshinsky, MD, from Massachusetts General Hospital in Boston.

Telemedicine consultation is prioritized and patients at high risk for COVID-19 exposure are identified so that exposure time and resource use are limited and patient and staff safety are maximized.

“We want to empower our colleagues in community hospitals to play a role in safely providing care for patients in need but to be mindful about preserving resources,” said Dr. Kroshinsky, who reported that the algorithm will be published imminently.

“If you don’t have to see a patient in person and can offer recommendations through telederm, you don’t need to put on a gown, gloves, mask, or goggles,” she said in an interview. “If you’re unable to assess photos, then of course you’ll use the appropriate protective wear, but it will be better if you can obtain the same result” without having to do so.
 

Sharing expertise

After the first week of tracking data to gauge the effectiveness of the algorithm at Massachusetts General, Dr. Kroshinsky said she is buoyed.

Of the 35 patients assessed electronically – all of whom would previously have been seen in person – only 4 ended up needing a subsequent in-person consult, she reported.

“It’s worked out great,” said Dr. Kroshinsky, who noted that the pandemic is a “nice opportunity” to test different telehealth platforms and improve quality down the line. “We never had to use any excessive PPE, beyond what was routine, and the majority of patients were able to be staffed remotely. All patients had successful outcomes.”

With telehealth more firmly established in dermatology than in most other specialties, dermatologists are now helping clinicians in other fields who are rapidly ramping up their own telemedicine offerings.

These might include obstetrics and gynecology or “any medical specialty where they need to do checkups with their patients and don’t want them coming in for nonemergent visits,” said Carrie L. Kovarik, MD, of the University of Pennsylvania, Philadelphia.

In addition to fielding many recent calls and emails from physicians seeking guidance on telehealth, Dr. Kovarik, Dr. Lee, and colleagues have published the steps required to integrate the technology into outpatient practices.

“Now that there’s a time for broad implementation, our colleagues are looking to us for help and troubleshooting advice,” said Dr. Kovarik, who is also a member of the AAD COVID-19 response task force.

Various specialties “lend themselves to telehealth, depending on how image- or data-dependent they are,” Dr. Lee said in an interview. “But all specialists thinking of limiting or shutting down their practices are thinking about how they can provide continuity of care without exposing patients or staff to the risk of contracting the coronavirus.”
 

After-COVID goals

In his first week of virtual patient consults, Dr. Desai said he saw about 50 patients, which is still far fewer than the 160-180 he sees in person during a normal week.

“The problem is that patients don’t really want to do telehealth. You’d think it would be a good option,” he said, “but patients hesitate because they don’t really know how to use their device.” Some have instead rescheduled in-person appointments for months down the line.

Although telehealth has enabled Dr. Desai to readily assess patients with acne, hair loss, psoriasis, rashes, warts, and eczema, he’s concerned that necessary procedures, such as biopsies and dermoscopies, could be dangerously delayed. It’s also hard to assess the texture and thickness of certain skin lesions in photos or videos, he said.

“I’m trying to stay optimistic that this will get better and we’re able to move back to taking care of patients the way we need to,” he said.

Like Dr. Desai, other dermatologists who’ve implemented telemedicine during the pandemic have largely been swayed by the relaxed CMS regulations. “It’s made all the difference,” Dr. Kovarik said. “It has brought down the anxiety level and decreased questions about platforms and concentrated them on how to code the visits.”

And although it’s difficult to envision post-COVID medical practice in the thick of the pandemic, dermatologists expect the current strides in telemedicine will stick.

“I’m hoping that telehealth use isn’t dialed back all the way to baseline” after the pandemic eases, Dr. Kovarik said. “The cat’s out of the bag, and now that it is, hopefully it won’t be put back in.”

“If there’s a silver lining to this,” Dr. Kroshinsky said, “I hope it’s that we’ll be able to innovate around health care in a fashion we wouldn’t have seen otherwise.”

A version of this article originally appeared on Medscape.com.

The rapid spread of COVID-19 forced Seemal Desai, MD, to make an excruciating choice; he could either shutter his busy dermatology practice in Plano, Tex., or switch most patient consults to telemedicine, which he’d never used.

But as soon as he learned that telehealth regulations had been relaxed by the Centers for Medicare & Medicaid Services and that reimbursement had been broadened, Dr. Desai, a dermatologist in private practice and his staff began to mobilize.

“Kaboom! We made the decision to start doing it,” he said in an interview. “We drafted a consent form, uploaded it to our website, called patients, changed our voice greeting, and got clarity on insurance coverage. We’ve been flying by the seat of our pants.”

“I’m doing it because I don’t have a choice at this point,” said Dr. Desai, who is a member of the American Academy of Dermatology board of directors and its coronavirus task force. “I’m very worried about continuing to be able to meet our payroll expenses for staff and overhead to keep the office open.”
 

“Flying by the seat of our pants” to see patients virtually

Dermatologists have long been considered pioneers in telemedicine. They have, since the 1990s, capitalized on the visual nature of the specialty to diagnose and treat skin diseases by incorporating photos, videos, and virtual-patient visits. But the pandemic has forced the hands of even holdouts like Dr. Desai, who clung to in-person consults because of confusion related to HIPAA compliance issues and the sense that teledermatology “really dehumanizes patient interaction” for him.

In fact, as of 2017, only 15% of the nation’s 11,000 or so dermatologists had implemented telehealth into their practices, according to an AAD practice survey. In the wake of COVID-19, however, that percentage has likely more than tripled, experts estimate.

Now, dermatologists are assuming the mantle of educators for other specialists who never considered telehealth before in-person visits became fraught with concerns about the spread of the virus. And some are publishing guidelines for colleagues on how to prioritize teledermatology to stem transmission and conserve personal protective equipment (PPE) and hospital beds.

User-friendly technology and the relaxed telehealth restrictions have made it fairly simple for patients and physicians to connect. Facetime and other once-prohibited platforms are all currently permissible, although physicians are encouraged to notify patients about potential privacy risks, according to an AAD teledermatology tool kit.
 

Teledermatology innovators

“We’ve moved 10 years in telemedicine policy in 2 weeks,” said Karen Edison, MD, of the University of Missouri, Columbia. “The federal government has really loosened the reins.”

At least half of all dermatologists in the United States have adopted telehealth since the pandemic emerged, she estimated. And most, like Dr. Desai, have done so in just the last several weeks.

“You can do about 90% of what you need to do as a dermatologist using the technology,” said Dr. Edison, who launched the first dermatology Extension for Community Healthcare Outcomes, or ECHO, program in the Midwest. That telehealth model was originally developed to connect rural general practitioners with specialists at academic medical centers or large health systems.

“People are used to taking pictures with their phones. In some ways, this crisis may change the face of our specialty,” she said in an interview.

“As we’re all practicing social distancing, I think physicians and patients are rethinking how we can access healthcare without pursuing traditional face-to-face interactions,” said Ivy Lee, MD, from the University of California, San Francisco, who is past chair of the AAD telemedicine task force and current chair of the teledermatology committee at the American Telemedicine Association. “Virtual health and telemedicine fit perfectly with that.”

Even before the pandemic, the innovative ways dermatologists were using telehealth were garnering increasing acclaim. All four clinical groups short-listed for dermatology team of the year at the BMJ Awards 2020 employed telehealth to improve patient services in the United Kingdom.

In the United States, dermatologists are joining forces to boost understanding of how telehealth can protect patients and clinicians from some of the ravages of the virus.

The Society of Dermatology Hospitalists has developed an algorithm – built on experiences its members have had caring for hospitalized patients with acute dermatologic conditions – to provide a “logical way” to triage telemedicine consults in multiple hospital settings during the coronavirus crisis, said President-Elect Daniela Kroshinsky, MD, from Massachusetts General Hospital in Boston.

Telemedicine consultation is prioritized and patients at high risk for COVID-19 exposure are identified so that exposure time and resource use are limited and patient and staff safety are maximized.

“We want to empower our colleagues in community hospitals to play a role in safely providing care for patients in need but to be mindful about preserving resources,” said Dr. Kroshinsky, who reported that the algorithm will be published imminently.

“If you don’t have to see a patient in person and can offer recommendations through telederm, you don’t need to put on a gown, gloves, mask, or goggles,” she said in an interview. “If you’re unable to assess photos, then of course you’ll use the appropriate protective wear, but it will be better if you can obtain the same result” without having to do so.
 

Sharing expertise

After the first week of tracking data to gauge the effectiveness of the algorithm at Massachusetts General, Dr. Kroshinsky said she is buoyed.

Of the 35 patients assessed electronically – all of whom would previously have been seen in person – only 4 ended up needing a subsequent in-person consult, she reported.

“It’s worked out great,” said Dr. Kroshinsky, who noted that the pandemic is a “nice opportunity” to test different telehealth platforms and improve quality down the line. “We never had to use any excessive PPE, beyond what was routine, and the majority of patients were able to be staffed remotely. All patients had successful outcomes.”

With telehealth more firmly established in dermatology than in most other specialties, dermatologists are now helping clinicians in other fields who are rapidly ramping up their own telemedicine offerings.

These might include obstetrics and gynecology or “any medical specialty where they need to do checkups with their patients and don’t want them coming in for nonemergent visits,” said Carrie L. Kovarik, MD, of the University of Pennsylvania, Philadelphia.

In addition to fielding many recent calls and emails from physicians seeking guidance on telehealth, Dr. Kovarik, Dr. Lee, and colleagues have published the steps required to integrate the technology into outpatient practices.

“Now that there’s a time for broad implementation, our colleagues are looking to us for help and troubleshooting advice,” said Dr. Kovarik, who is also a member of the AAD COVID-19 response task force.

Various specialties “lend themselves to telehealth, depending on how image- or data-dependent they are,” Dr. Lee said in an interview. “But all specialists thinking of limiting or shutting down their practices are thinking about how they can provide continuity of care without exposing patients or staff to the risk of contracting the coronavirus.”
 

After-COVID goals

In his first week of virtual patient consults, Dr. Desai said he saw about 50 patients, which is still far fewer than the 160-180 he sees in person during a normal week.

“The problem is that patients don’t really want to do telehealth. You’d think it would be a good option,” he said, “but patients hesitate because they don’t really know how to use their device.” Some have instead rescheduled in-person appointments for months down the line.

Although telehealth has enabled Dr. Desai to readily assess patients with acne, hair loss, psoriasis, rashes, warts, and eczema, he’s concerned that necessary procedures, such as biopsies and dermoscopies, could be dangerously delayed. It’s also hard to assess the texture and thickness of certain skin lesions in photos or videos, he said.

“I’m trying to stay optimistic that this will get better and we’re able to move back to taking care of patients the way we need to,” he said.

Like Dr. Desai, other dermatologists who’ve implemented telemedicine during the pandemic have largely been swayed by the relaxed CMS regulations. “It’s made all the difference,” Dr. Kovarik said. “It has brought down the anxiety level and decreased questions about platforms and concentrated them on how to code the visits.”

And although it’s difficult to envision post-COVID medical practice in the thick of the pandemic, dermatologists expect the current strides in telemedicine will stick.

“I’m hoping that telehealth use isn’t dialed back all the way to baseline” after the pandemic eases, Dr. Kovarik said. “The cat’s out of the bag, and now that it is, hopefully it won’t be put back in.”

“If there’s a silver lining to this,” Dr. Kroshinsky said, “I hope it’s that we’ll be able to innovate around health care in a fashion we wouldn’t have seen otherwise.”

A version of this article originally appeared on Medscape.com.

Many emergency room workers remove their clothes as soon as they get home – some before they even enter. Does that mean you should worry about COVID-19 transmission from your own clothing, towels, and other textiles?

While researchers found that the virus can remain on some surfaces for up to 72 hours, the study didn’t include fabric. “So far, evidence suggests that it’s harder to catch the virus from a soft surface (such as fabric) than it is from frequently touched hard surfaces like elevator buttons or door handles,” wrote Lisa Maragakis, MD, senior director of infection prevention at the Johns Hopkins Health System.

One thing experts do know: At this point, transmission happens mostly through close contact, not from touching hard surfaces or clothing. The best thing you can do to protect yourself is to stay home. And if you do go out, practice social distancing.

“This is a very powerful weapon,” Robert Redfield, MD, director of the CDC, told National Public Radio. “This virus cannot go from person to person that easily. It needs us to be close. It needs us to be within 6 feet.”

And don’t forget to use hand sanitizer while you’re out, avoid touching your face, and wash your hands when you get home.

If nobody in your home has symptoms of COVID-19 and you’re all staying home, the CDC recommends routine cleaning, including laundry. Even if you go out and maintain good social distancing – at least 6 feet from anyone who’s not in your household – you should be fine.

But if you suspect you got too close for too long, or someone coughed on you, there’s no harm in changing your clothing and washing it right away, especially if there are hard surfaces like buttons and zippers where the virus might linger. Wash your hands again after you put everything into the machine. Dry everything on high, since the virus dies at temperatures above 133 F. File these steps under “abundance of caution”: They’re not necessary, but if it gives you peace of mind, it may be worth it.

Using the laundromat

Got your own washer and dryer? You can just do your laundry. But for those who share a communal laundry room or visit the laundromat, some extra precautions make sense:

• Consider social distancing. Is your building’s laundry room so small that you can’t stand 6 feet away from anyone else? Don’t enter if someone’s already in there. You may want to ask building management to set up a schedule for laundry, to keep everyone safe.
• Sort your laundry before you go, and fold clean laundry at home, to lessen the amount of time you spend there and the number of surfaces you touch, suggests a report in The New York Times.
• Bring sanitizing wipes or hand sanitizer with you to wipe down the machines’ handles and buttons before you use them. Or, since most laundry spaces have a sink, wash your hands with soap right after loading the machines.
• If you have your own cart, use it. A communal cart shouldn’t infect your clothes, but touching it with your hands may transfer the virus to you.
• Don’t touch your face while doing laundry. (You should be getting good at this by now.)
• Don’t hang out in the laundry room or laundromat while your clothes are in the machines. The less time you spend close to others, the better. Step outside, go back to your apartment, or wait in your car.

Courtesy WebMD

If someone is sick

The guidelines change when someone in your household has a confirmed case or symptoms. The CDC recommends:

• Wear disposable gloves when handling dirty laundry, and wash your hands right after you take them off.
• Try not to shake the dirty laundry to avoid sending the virus into the air.
• Follow the manufacturers’ instructions for whatever you’re cleaning, using the warmest water possible. Dry everything completely.
• It’s fine to mix your own laundry in with the sick person’s. And don’t forget to include the laundry bag, or use a disposable garbage bag instead.

Wipe down the hamper, following the appropriate instructions.

This article first appeared on WebMD.

Many emergency room workers remove their clothes as soon as they get home – some before they even enter. Does that mean you should worry about COVID-19 transmission from your own clothing, towels, and other textiles?

While researchers found that the virus can remain on some surfaces for up to 72 hours, the study didn’t include fabric. “So far, evidence suggests that it’s harder to catch the virus from a soft surface (such as fabric) than it is from frequently touched hard surfaces like elevator buttons or door handles,” wrote Lisa Maragakis, MD, senior director of infection prevention at the Johns Hopkins Health System.

One thing experts do know: At this point, transmission happens mostly through close contact, not from touching hard surfaces or clothing. The best thing you can do to protect yourself is to stay home. And if you do go out, practice social distancing.

“This is a very powerful weapon,” Robert Redfield, MD, director of the CDC, told National Public Radio. “This virus cannot go from person to person that easily. It needs us to be close. It needs us to be within 6 feet.”

And don’t forget to use hand sanitizer while you’re out, avoid touching your face, and wash your hands when you get home.

If nobody in your home has symptoms of COVID-19 and you’re all staying home, the CDC recommends routine cleaning, including laundry. Even if you go out and maintain good social distancing – at least 6 feet from anyone who’s not in your household – you should be fine.

But if you suspect you got too close for too long, or someone coughed on you, there’s no harm in changing your clothing and washing it right away, especially if there are hard surfaces like buttons and zippers where the virus might linger. Wash your hands again after you put everything into the machine. Dry everything on high, since the virus dies at temperatures above 133 F. File these steps under “abundance of caution”: They’re not necessary, but if it gives you peace of mind, it may be worth it.

Using the laundromat

Got your own washer and dryer? You can just do your laundry. But for those who share a communal laundry room or visit the laundromat, some extra precautions make sense:

• Consider social distancing. Is your building’s laundry room so small that you can’t stand 6 feet away from anyone else? Don’t enter if someone’s already in there. You may want to ask building management to set up a schedule for laundry, to keep everyone safe.
• Sort your laundry before you go, and fold clean laundry at home, to lessen the amount of time you spend there and the number of surfaces you touch, suggests a report in The New York Times.
• Bring sanitizing wipes or hand sanitizer with you to wipe down the machines’ handles and buttons before you use them. Or, since most laundry spaces have a sink, wash your hands with soap right after loading the machines.
• If you have your own cart, use it. A communal cart shouldn’t infect your clothes, but touching it with your hands may transfer the virus to you.
• Don’t touch your face while doing laundry. (You should be getting good at this by now.)
• Don’t hang out in the laundry room or laundromat while your clothes are in the machines. The less time you spend close to others, the better. Step outside, go back to your apartment, or wait in your car.

Courtesy WebMD

If someone is sick

The guidelines change when someone in your household has a confirmed case or symptoms. The CDC recommends:

• Wear disposable gloves when handling dirty laundry, and wash your hands right after you take them off.
• Try not to shake the dirty laundry to avoid sending the virus into the air.
• Follow the manufacturers’ instructions for whatever you’re cleaning, using the warmest water possible. Dry everything completely.
• It’s fine to mix your own laundry in with the sick person’s. And don’t forget to include the laundry bag, or use a disposable garbage bag instead.

Wipe down the hamper, following the appropriate instructions.

This article first appeared on WebMD.

Many emergency room workers remove their clothes as soon as they get home – some before they even enter. Does that mean you should worry about COVID-19 transmission from your own clothing, towels, and other textiles?

While researchers found that the virus can remain on some surfaces for up to 72 hours, the study didn’t include fabric. “So far, evidence suggests that it’s harder to catch the virus from a soft surface (such as fabric) than it is from frequently touched hard surfaces like elevator buttons or door handles,” wrote Lisa Maragakis, MD, senior director of infection prevention at the Johns Hopkins Health System.

One thing experts do know: At this point, transmission happens mostly through close contact, not from touching hard surfaces or clothing. The best thing you can do to protect yourself is to stay home. And if you do go out, practice social distancing.

“This is a very powerful weapon,” Robert Redfield, MD, director of the CDC, told National Public Radio. “This virus cannot go from person to person that easily. It needs us to be close. It needs us to be within 6 feet.”

And don’t forget to use hand sanitizer while you’re out, avoid touching your face, and wash your hands when you get home.

If nobody in your home has symptoms of COVID-19 and you’re all staying home, the CDC recommends routine cleaning, including laundry. Even if you go out and maintain good social distancing – at least 6 feet from anyone who’s not in your household – you should be fine.

But if you suspect you got too close for too long, or someone coughed on you, there’s no harm in changing your clothing and washing it right away, especially if there are hard surfaces like buttons and zippers where the virus might linger. Wash your hands again after you put everything into the machine. Dry everything on high, since the virus dies at temperatures above 133 F. File these steps under “abundance of caution”: They’re not necessary, but if it gives you peace of mind, it may be worth it.

Using the laundromat

Got your own washer and dryer? You can just do your laundry. But for those who share a communal laundry room or visit the laundromat, some extra precautions make sense:

• Consider social distancing. Is your building’s laundry room so small that you can’t stand 6 feet away from anyone else? Don’t enter if someone’s already in there. You may want to ask building management to set up a schedule for laundry, to keep everyone safe.
• Sort your laundry before you go, and fold clean laundry at home, to lessen the amount of time you spend there and the number of surfaces you touch, suggests a report in The New York Times.
• Bring sanitizing wipes or hand sanitizer with you to wipe down the machines’ handles and buttons before you use them. Or, since most laundry spaces have a sink, wash your hands with soap right after loading the machines.
• If you have your own cart, use it. A communal cart shouldn’t infect your clothes, but touching it with your hands may transfer the virus to you.
• Don’t touch your face while doing laundry. (You should be getting good at this by now.)
• Don’t hang out in the laundry room or laundromat while your clothes are in the machines. The less time you spend close to others, the better. Step outside, go back to your apartment, or wait in your car.

Courtesy WebMD

If someone is sick

The guidelines change when someone in your household has a confirmed case or symptoms. The CDC recommends:

• Wear disposable gloves when handling dirty laundry, and wash your hands right after you take them off.
• Try not to shake the dirty laundry to avoid sending the virus into the air.
• Follow the manufacturers’ instructions for whatever you’re cleaning, using the warmest water possible. Dry everything completely.
• It’s fine to mix your own laundry in with the sick person’s. And don’t forget to include the laundry bag, or use a disposable garbage bag instead.

Wipe down the hamper, following the appropriate instructions.

This article first appeared on WebMD.

COVID-19 is less severe in children, compared with adults, early data suggest. “Yet many questions remain, especially regarding the effects on children with special health care needs,” according to a viewpoint recently published in JAMA Pediatrics.

Courtesy NIAID-RML

The COVID-19 pandemic also raises questions about clinic visits for healthy children in communities with widespread transmission and about the unintended effects of school closures and other measures aimed at slowing the spread of the disease, wrote Sonja A. Rasmussen, MD, and Lindsay A. Thompson, MD, both of the University of Florida, Gainesville.

In communities with widespread outbreaks, telephone triage and expanded use of telehealth may be needed to limit nonurgent clinic visits, they suggested.

“Community mitigation interventions, such as school closures, cancellation of mass gatherings, and closure of public places are appropriate” in places with widespread transmission, Dr. Rasmussen and Dr. Thompson wrote. “If these measures are required, pediatricians need to advocate to alleviate unintended consequences or inadvertent expansion of health disparities on children, such as by finding ways to maintain nutrition for those who depend on school lunches and provide online mental health services for stress management for families whose routines might be severely interrupted for an extended period of time.”

Continued preventive care for infants and vaccinations for younger children may be warranted, they wrote.
 

Clinical course

Overall, children have experienced lower-than-expected rates of COVID-19 disease, and deaths in this population appear to be rare, Dr. Rasmussen and Dr. Thompson wrote.

Common symptoms of COVID-19 in adults include fever, cough, myalgia, shortness of breath, headache, and diarrhea, and children have similar manifestations. In adults, older age and underlying illness increase the risk of severe disease. There has not been convincing evidence of intrauterine transmission of COVID-19, and whether breastfeeding can transmit the virus is unknown, they noted.

An analysis of more than 72,000 cases from China found that 1.2% were in patients aged 10-19 years, and 0.9% were in patients younger than 10 years. One death occurred in the adolescent age range. A separate analysis of 2,143 confirmed and suspected pediatric cases in China indicated that infants were at higher risk of severe disease (11%), compared with older children – 4% for those aged 11-15 years, and 3% in those 16 years and older.

There is less data available about the clinical course of COVID-19 in children in the United States, the authors noted. But among more than 4,000 patients with COVID-19 in the United States through March 16, no ICU admissions or deaths were reported for patients aged younger than 19 years (MMWR Morb Mortal Wkly Rep. 2020 Mar 26;69[12]:343-6).

Still, researchers have suggested that children with underlying illness may be at greater risk of COVID-19. In a study of 20 children with COVID-19 in China, 7 of the patients had a history of congenital or acquired disease, potentially indicating that they were more susceptible to the virus (Pediatr Pulmonol. 2020 Mar 5. doi: 10.1002/ppul.24718). Chest CT consolidations with surrounding halo sign was evident in half of the patients, and procalcitonin elevation was seen in 80% of the children; these were signs common in children, but not in adults with COVID-19.

“About 10% of children in the U.S. have asthma; many children live with other pulmonary, cardiac, neuromuscular, or genetic diseases that affect their ability to handle respiratory disease, and other children are immunosuppressed because of illness or its treatment,” Dr. Rasmussen and Dr. Thompson wrote. “It is possible that these children will experience COVID-19 differently than counterparts of the same ages who are healthy.”

The authors reported that they had no financial disclosures.

[email protected]

SOURCE: Rasmussen SA, Thompson LA. JAMA Pediatr. 2020 Apr 3. doi: 10.1001/jamapediatrics.2020.1224.

COVID-19 is less severe in children, compared with adults, early data suggest. “Yet many questions remain, especially regarding the effects on children with special health care needs,” according to a viewpoint recently published in JAMA Pediatrics.

Courtesy NIAID-RML

The COVID-19 pandemic also raises questions about clinic visits for healthy children in communities with widespread transmission and about the unintended effects of school closures and other measures aimed at slowing the spread of the disease, wrote Sonja A. Rasmussen, MD, and Lindsay A. Thompson, MD, both of the University of Florida, Gainesville.

In communities with widespread outbreaks, telephone triage and expanded use of telehealth may be needed to limit nonurgent clinic visits, they suggested.

“Community mitigation interventions, such as school closures, cancellation of mass gatherings, and closure of public places are appropriate” in places with widespread transmission, Dr. Rasmussen and Dr. Thompson wrote. “If these measures are required, pediatricians need to advocate to alleviate unintended consequences or inadvertent expansion of health disparities on children, such as by finding ways to maintain nutrition for those who depend on school lunches and provide online mental health services for stress management for families whose routines might be severely interrupted for an extended period of time.”

Continued preventive care for infants and vaccinations for younger children may be warranted, they wrote.
 

Clinical course

Overall, children have experienced lower-than-expected rates of COVID-19 disease, and deaths in this population appear to be rare, Dr. Rasmussen and Dr. Thompson wrote.

Common symptoms of COVID-19 in adults include fever, cough, myalgia, shortness of breath, headache, and diarrhea, and children have similar manifestations. In adults, older age and underlying illness increase the risk of severe disease. There has not been convincing evidence of intrauterine transmission of COVID-19, and whether breastfeeding can transmit the virus is unknown, they noted.

An analysis of more than 72,000 cases from China found that 1.2% were in patients aged 10-19 years, and 0.9% were in patients younger than 10 years. One death occurred in the adolescent age range. A separate analysis of 2,143 confirmed and suspected pediatric cases in China indicated that infants were at higher risk of severe disease (11%), compared with older children – 4% for those aged 11-15 years, and 3% in those 16 years and older.

There is less data available about the clinical course of COVID-19 in children in the United States, the authors noted. But among more than 4,000 patients with COVID-19 in the United States through March 16, no ICU admissions or deaths were reported for patients aged younger than 19 years (MMWR Morb Mortal Wkly Rep. 2020 Mar 26;69[12]:343-6).

Still, researchers have suggested that children with underlying illness may be at greater risk of COVID-19. In a study of 20 children with COVID-19 in China, 7 of the patients had a history of congenital or acquired disease, potentially indicating that they were more susceptible to the virus (Pediatr Pulmonol. 2020 Mar 5. doi: 10.1002/ppul.24718). Chest CT consolidations with surrounding halo sign was evident in half of the patients, and procalcitonin elevation was seen in 80% of the children; these were signs common in children, but not in adults with COVID-19.

“About 10% of children in the U.S. have asthma; many children live with other pulmonary, cardiac, neuromuscular, or genetic diseases that affect their ability to handle respiratory disease, and other children are immunosuppressed because of illness or its treatment,” Dr. Rasmussen and Dr. Thompson wrote. “It is possible that these children will experience COVID-19 differently than counterparts of the same ages who are healthy.”

The authors reported that they had no financial disclosures.

[email protected]

SOURCE: Rasmussen SA, Thompson LA. JAMA Pediatr. 2020 Apr 3. doi: 10.1001/jamapediatrics.2020.1224.

COVID-19 is less severe in children, compared with adults, early data suggest. “Yet many questions remain, especially regarding the effects on children with special health care needs,” according to a viewpoint recently published in JAMA Pediatrics.

Courtesy NIAID-RML

The COVID-19 pandemic also raises questions about clinic visits for healthy children in communities with widespread transmission and about the unintended effects of school closures and other measures aimed at slowing the spread of the disease, wrote Sonja A. Rasmussen, MD, and Lindsay A. Thompson, MD, both of the University of Florida, Gainesville.

In communities with widespread outbreaks, telephone triage and expanded use of telehealth may be needed to limit nonurgent clinic visits, they suggested.

“Community mitigation interventions, such as school closures, cancellation of mass gatherings, and closure of public places are appropriate” in places with widespread transmission, Dr. Rasmussen and Dr. Thompson wrote. “If these measures are required, pediatricians need to advocate to alleviate unintended consequences or inadvertent expansion of health disparities on children, such as by finding ways to maintain nutrition for those who depend on school lunches and provide online mental health services for stress management for families whose routines might be severely interrupted for an extended period of time.”

Continued preventive care for infants and vaccinations for younger children may be warranted, they wrote.
 

Clinical course

Overall, children have experienced lower-than-expected rates of COVID-19 disease, and deaths in this population appear to be rare, Dr. Rasmussen and Dr. Thompson wrote.

Common symptoms of COVID-19 in adults include fever, cough, myalgia, shortness of breath, headache, and diarrhea, and children have similar manifestations. In adults, older age and underlying illness increase the risk of severe disease. There has not been convincing evidence of intrauterine transmission of COVID-19, and whether breastfeeding can transmit the virus is unknown, they noted.

An analysis of more than 72,000 cases from China found that 1.2% were in patients aged 10-19 years, and 0.9% were in patients younger than 10 years. One death occurred in the adolescent age range. A separate analysis of 2,143 confirmed and suspected pediatric cases in China indicated that infants were at higher risk of severe disease (11%), compared with older children – 4% for those aged 11-15 years, and 3% in those 16 years and older.

There is less data available about the clinical course of COVID-19 in children in the United States, the authors noted. But among more than 4,000 patients with COVID-19 in the United States through March 16, no ICU admissions or deaths were reported for patients aged younger than 19 years (MMWR Morb Mortal Wkly Rep. 2020 Mar 26;69[12]:343-6).

Still, researchers have suggested that children with underlying illness may be at greater risk of COVID-19. In a study of 20 children with COVID-19 in China, 7 of the patients had a history of congenital or acquired disease, potentially indicating that they were more susceptible to the virus (Pediatr Pulmonol. 2020 Mar 5. doi: 10.1002/ppul.24718). Chest CT consolidations with surrounding halo sign was evident in half of the patients, and procalcitonin elevation was seen in 80% of the children; these were signs common in children, but not in adults with COVID-19.

“About 10% of children in the U.S. have asthma; many children live with other pulmonary, cardiac, neuromuscular, or genetic diseases that affect their ability to handle respiratory disease, and other children are immunosuppressed because of illness or its treatment,” Dr. Rasmussen and Dr. Thompson wrote. “It is possible that these children will experience COVID-19 differently than counterparts of the same ages who are healthy.”

The authors reported that they had no financial disclosures.

[email protected]

SOURCE: Rasmussen SA, Thompson LA. JAMA Pediatr. 2020 Apr 3. doi: 10.1001/jamapediatrics.2020.1224.

A major comprehensive cancer center at the epicenter of the New York City COVID-19 storm is preparing to scale back palliative radiation therapy (RT), anticipating a focus on only oncologic emergencies.

“We’re not there yet, but we’re anticipating when the time comes in the next few weeks that we will have a system in place so we are able to handle it,” Jonathan Yang, MD, PhD, of Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, told Medscape Medical News.

Yang and an expert panel of colleagues reviewed high-impact evidence, prior systematic reviews, and national guidelines to compile a set of recommendations for triage and shortened palliative rRT at their center, should the need arise.

The recommendations on palliative radiotherapy for oncologic emergencies in the setting of COVID-19 appear in a preprint version in Advances in Radiation Oncology, released by the American Society of Radiation Oncology.

Yang says the recommendations are a careful balance between the risk of COVID-19 exposure of staff and patients with the potential morbidity of delaying treatment.

“Everyone is conscious of decisions about whether patients need treatment now or can wait,” he told Medscape Medical News. “It’s a juggling act every single day, but by having this guideline in place, when we face the situation where we do have to make decisions, is helpful.”

The document aims to enable swift decisions based on best practice, including a three-tiered system prioritizing only “clinically urgent cases, in which delaying treatment would result in compromised outcomes or serious morbidity.”

“It’s brutal, that’s the only word for it. Not that I disagree with it,” commented Padraig Warde, MB BCh, professor, Department of Radiation Oncology, University of Toronto, and radiation oncologist, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.

Like many places, Toronto is not yet experiencing the COVID-19 burden of New York City, but Warde says the MSKCC guideline is useful for everyone. “Other centers should review it and see how they could deal with resource limitations,” he said. “It’s sobering and sad, but if you don’t have the staff to treat all patients, which particular patients do you choose to treat?”

In a nutshell, the MSKCC recommendations defines Tier 1 patients as having oncologic emergencies that require palliative RT, including “cord compression, symptomatic brain metastases requiring whole-brain radiotherapy, life-threatening tumor bleeding, and malignant airway obstruction.”

According to the decision-making guideline, patients in Tiers 2 and 3 would have their palliative RT delayed. This would include Tier 2 patients whose needs are not classified as emergencies, but who have either symptomatic disease for which RT is usually the standard of care or asymptomatic disease for which RT is recommended “to prevent imminent functional deficits.” Tier 3 would be symptomatic or asymptomatic patients for whom RT is “one of the effective treatment options.”

“Rationing is always very difficult because as physicians you always want to do everything you can for your patients but we really have to strike the balance on when to do what, said Yang. The plan that he authored anticipates both reduced availability of radiation therapists as well as aggressive attempts to limit patients’ infection exposure.

“If a patient’s radiation is being considered for delay due to COVID-19, other means are utilized to achieve the goal of palliation in the interim, and in addition to the tier system, this decision is also made on a case-by-case basis with departmental discussion on the risks and benefits,” he explained.

“There are layers of checks and balances for these decisions...Obviously for oncologic emergencies, radiation will be implemented. However for less urgent situations, bringing them into the hospital when there are other ways to achieve the same goal, potential risk of exposure to COVID-19 is higher than the benefit we would be able to provide.”

The document also recommends shorter courses of RT when radiation is deemed appropriate.

“We have good evidence showing shorter courses of radiation can effectively treat the goal of palliation compared to longer courses of radiation,” he explained. “Going through this pandemic actually forces radiation oncologists in the United States to put that evidence into practice. It’s not suboptimal care in the sense that we are achieving the same goal — palliation. This paper is to remind people there are equally effective courses of palliation we can be using.”

“[There’s] nothing like a crisis to get people to do the right thing,” commented Louis Potters, MD, professor and chair of radiation medicine at the Feinstein Institutes, the research arm of Northwell Health, New York’s largest healthcare provider.

Northwell Health has been at the epicenter of the New York outbreak of COVID-19. Potters writes on an ASTRO blog that, as of March 26, Northwell Health “has diagnosed 4399 positive COVID-19 patients, which is about 20% of New York state and 1.2% of all cases in the world. All cancer surgery was discontinued as of March 20 and all of our 23 hospitals are seeing COVID-19 admissions, and ICU care became the primary focus of the entire system. As of today, we have reserved one floor in two hospitals for non-COVID care such as trauma. That’s it.”

Before the crisis, radiation medicine at Northwell consisted of eight separate locations treating on average 280 EBRT cases a day, not including SBRT/SRS and brachytherapy cases. “That of course was 3 weeks ago,” he notes.

Commenting on the recommendations from the MSKCC group, Potters told Medscape Medical News that the primary goal “was to document what are acceptable alternatives for accelerated care.”

“Ironically, these guidelines represent best practices with evidence that — in a non–COVID-19 world — make sense for the majority of patients requiring palliative radiotherapy,” he said.

Potters said there has been hesitance to transition to shorter radiation treatments for several reasons.

“Historically, palliative radiotherapy has been delivered over 2 to 4 weeks with good results. And, as is typical in medicine, the transition to shorter course care is slowed by financial incentives to protract care,” he explained.

“In a value-based future where payment is based on outcomes, this transition to shorter care will evolve very quickly. But given the current COVID-19 crisis, and the risk to patients and staff, the incentive for shorter treatment courses has been thrust upon us and the MSKCC outline helps to define how to do this safely and with evidence-based expected efficacy.”
 

This article first appeared on Medscape.com.

A major comprehensive cancer center at the epicenter of the New York City COVID-19 storm is preparing to scale back palliative radiation therapy (RT), anticipating a focus on only oncologic emergencies.

“We’re not there yet, but we’re anticipating when the time comes in the next few weeks that we will have a system in place so we are able to handle it,” Jonathan Yang, MD, PhD, of Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, told Medscape Medical News.

Yang and an expert panel of colleagues reviewed high-impact evidence, prior systematic reviews, and national guidelines to compile a set of recommendations for triage and shortened palliative rRT at their center, should the need arise.

The recommendations on palliative radiotherapy for oncologic emergencies in the setting of COVID-19 appear in a preprint version in Advances in Radiation Oncology, released by the American Society of Radiation Oncology.

Yang says the recommendations are a careful balance between the risk of COVID-19 exposure of staff and patients with the potential morbidity of delaying treatment.

“Everyone is conscious of decisions about whether patients need treatment now or can wait,” he told Medscape Medical News. “It’s a juggling act every single day, but by having this guideline in place, when we face the situation where we do have to make decisions, is helpful.”

The document aims to enable swift decisions based on best practice, including a three-tiered system prioritizing only “clinically urgent cases, in which delaying treatment would result in compromised outcomes or serious morbidity.”

“It’s brutal, that’s the only word for it. Not that I disagree with it,” commented Padraig Warde, MB BCh, professor, Department of Radiation Oncology, University of Toronto, and radiation oncologist, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.

Like many places, Toronto is not yet experiencing the COVID-19 burden of New York City, but Warde says the MSKCC guideline is useful for everyone. “Other centers should review it and see how they could deal with resource limitations,” he said. “It’s sobering and sad, but if you don’t have the staff to treat all patients, which particular patients do you choose to treat?”

In a nutshell, the MSKCC recommendations defines Tier 1 patients as having oncologic emergencies that require palliative RT, including “cord compression, symptomatic brain metastases requiring whole-brain radiotherapy, life-threatening tumor bleeding, and malignant airway obstruction.”

According to the decision-making guideline, patients in Tiers 2 and 3 would have their palliative RT delayed. This would include Tier 2 patients whose needs are not classified as emergencies, but who have either symptomatic disease for which RT is usually the standard of care or asymptomatic disease for which RT is recommended “to prevent imminent functional deficits.” Tier 3 would be symptomatic or asymptomatic patients for whom RT is “one of the effective treatment options.”

“Rationing is always very difficult because as physicians you always want to do everything you can for your patients but we really have to strike the balance on when to do what, said Yang. The plan that he authored anticipates both reduced availability of radiation therapists as well as aggressive attempts to limit patients’ infection exposure.

“If a patient’s radiation is being considered for delay due to COVID-19, other means are utilized to achieve the goal of palliation in the interim, and in addition to the tier system, this decision is also made on a case-by-case basis with departmental discussion on the risks and benefits,” he explained.

“There are layers of checks and balances for these decisions...Obviously for oncologic emergencies, radiation will be implemented. However for less urgent situations, bringing them into the hospital when there are other ways to achieve the same goal, potential risk of exposure to COVID-19 is higher than the benefit we would be able to provide.”

The document also recommends shorter courses of RT when radiation is deemed appropriate.

“We have good evidence showing shorter courses of radiation can effectively treat the goal of palliation compared to longer courses of radiation,” he explained. “Going through this pandemic actually forces radiation oncologists in the United States to put that evidence into practice. It’s not suboptimal care in the sense that we are achieving the same goal — palliation. This paper is to remind people there are equally effective courses of palliation we can be using.”

“[There’s] nothing like a crisis to get people to do the right thing,” commented Louis Potters, MD, professor and chair of radiation medicine at the Feinstein Institutes, the research arm of Northwell Health, New York’s largest healthcare provider.

Northwell Health has been at the epicenter of the New York outbreak of COVID-19. Potters writes on an ASTRO blog that, as of March 26, Northwell Health “has diagnosed 4399 positive COVID-19 patients, which is about 20% of New York state and 1.2% of all cases in the world. All cancer surgery was discontinued as of March 20 and all of our 23 hospitals are seeing COVID-19 admissions, and ICU care became the primary focus of the entire system. As of today, we have reserved one floor in two hospitals for non-COVID care such as trauma. That’s it.”

Before the crisis, radiation medicine at Northwell consisted of eight separate locations treating on average 280 EBRT cases a day, not including SBRT/SRS and brachytherapy cases. “That of course was 3 weeks ago,” he notes.

Commenting on the recommendations from the MSKCC group, Potters told Medscape Medical News that the primary goal “was to document what are acceptable alternatives for accelerated care.”

“Ironically, these guidelines represent best practices with evidence that — in a non–COVID-19 world — make sense for the majority of patients requiring palliative radiotherapy,” he said.

Potters said there has been hesitance to transition to shorter radiation treatments for several reasons.

“Historically, palliative radiotherapy has been delivered over 2 to 4 weeks with good results. And, as is typical in medicine, the transition to shorter course care is slowed by financial incentives to protract care,” he explained.

“In a value-based future where payment is based on outcomes, this transition to shorter care will evolve very quickly. But given the current COVID-19 crisis, and the risk to patients and staff, the incentive for shorter treatment courses has been thrust upon us and the MSKCC outline helps to define how to do this safely and with evidence-based expected efficacy.”
 

This article first appeared on Medscape.com.

A major comprehensive cancer center at the epicenter of the New York City COVID-19 storm is preparing to scale back palliative radiation therapy (RT), anticipating a focus on only oncologic emergencies.

“We’re not there yet, but we’re anticipating when the time comes in the next few weeks that we will have a system in place so we are able to handle it,” Jonathan Yang, MD, PhD, of Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, told Medscape Medical News.

Yang and an expert panel of colleagues reviewed high-impact evidence, prior systematic reviews, and national guidelines to compile a set of recommendations for triage and shortened palliative rRT at their center, should the need arise.

The recommendations on palliative radiotherapy for oncologic emergencies in the setting of COVID-19 appear in a preprint version in Advances in Radiation Oncology, released by the American Society of Radiation Oncology.

Yang says the recommendations are a careful balance between the risk of COVID-19 exposure of staff and patients with the potential morbidity of delaying treatment.

“Everyone is conscious of decisions about whether patients need treatment now or can wait,” he told Medscape Medical News. “It’s a juggling act every single day, but by having this guideline in place, when we face the situation where we do have to make decisions, is helpful.”

The document aims to enable swift decisions based on best practice, including a three-tiered system prioritizing only “clinically urgent cases, in which delaying treatment would result in compromised outcomes or serious morbidity.”

“It’s brutal, that’s the only word for it. Not that I disagree with it,” commented Padraig Warde, MB BCh, professor, Department of Radiation Oncology, University of Toronto, and radiation oncologist, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.

Like many places, Toronto is not yet experiencing the COVID-19 burden of New York City, but Warde says the MSKCC guideline is useful for everyone. “Other centers should review it and see how they could deal with resource limitations,” he said. “It’s sobering and sad, but if you don’t have the staff to treat all patients, which particular patients do you choose to treat?”

In a nutshell, the MSKCC recommendations defines Tier 1 patients as having oncologic emergencies that require palliative RT, including “cord compression, symptomatic brain metastases requiring whole-brain radiotherapy, life-threatening tumor bleeding, and malignant airway obstruction.”

According to the decision-making guideline, patients in Tiers 2 and 3 would have their palliative RT delayed. This would include Tier 2 patients whose needs are not classified as emergencies, but who have either symptomatic disease for which RT is usually the standard of care or asymptomatic disease for which RT is recommended “to prevent imminent functional deficits.” Tier 3 would be symptomatic or asymptomatic patients for whom RT is “one of the effective treatment options.”

“Rationing is always very difficult because as physicians you always want to do everything you can for your patients but we really have to strike the balance on when to do what, said Yang. The plan that he authored anticipates both reduced availability of radiation therapists as well as aggressive attempts to limit patients’ infection exposure.

“If a patient’s radiation is being considered for delay due to COVID-19, other means are utilized to achieve the goal of palliation in the interim, and in addition to the tier system, this decision is also made on a case-by-case basis with departmental discussion on the risks and benefits,” he explained.

“There are layers of checks and balances for these decisions...Obviously for oncologic emergencies, radiation will be implemented. However for less urgent situations, bringing them into the hospital when there are other ways to achieve the same goal, potential risk of exposure to COVID-19 is higher than the benefit we would be able to provide.”

The document also recommends shorter courses of RT when radiation is deemed appropriate.

“We have good evidence showing shorter courses of radiation can effectively treat the goal of palliation compared to longer courses of radiation,” he explained. “Going through this pandemic actually forces radiation oncologists in the United States to put that evidence into practice. It’s not suboptimal care in the sense that we are achieving the same goal — palliation. This paper is to remind people there are equally effective courses of palliation we can be using.”

“[There’s] nothing like a crisis to get people to do the right thing,” commented Louis Potters, MD, professor and chair of radiation medicine at the Feinstein Institutes, the research arm of Northwell Health, New York’s largest healthcare provider.

Northwell Health has been at the epicenter of the New York outbreak of COVID-19. Potters writes on an ASTRO blog that, as of March 26, Northwell Health “has diagnosed 4399 positive COVID-19 patients, which is about 20% of New York state and 1.2% of all cases in the world. All cancer surgery was discontinued as of March 20 and all of our 23 hospitals are seeing COVID-19 admissions, and ICU care became the primary focus of the entire system. As of today, we have reserved one floor in two hospitals for non-COVID care such as trauma. That’s it.”

Before the crisis, radiation medicine at Northwell consisted of eight separate locations treating on average 280 EBRT cases a day, not including SBRT/SRS and brachytherapy cases. “That of course was 3 weeks ago,” he notes.

Commenting on the recommendations from the MSKCC group, Potters told Medscape Medical News that the primary goal “was to document what are acceptable alternatives for accelerated care.”

“Ironically, these guidelines represent best practices with evidence that — in a non–COVID-19 world — make sense for the majority of patients requiring palliative radiotherapy,” he said.

Potters said there has been hesitance to transition to shorter radiation treatments for several reasons.

“Historically, palliative radiotherapy has been delivered over 2 to 4 weeks with good results. And, as is typical in medicine, the transition to shorter course care is slowed by financial incentives to protract care,” he explained.

“In a value-based future where payment is based on outcomes, this transition to shorter care will evolve very quickly. But given the current COVID-19 crisis, and the risk to patients and staff, the incentive for shorter treatment courses has been thrust upon us and the MSKCC outline helps to define how to do this safely and with evidence-based expected efficacy.”
 

This article first appeared on Medscape.com.

Average measures of bone mineral density were similar for individuals with high-trauma and low-trauma fractures, and both were significantly distinct from those with no fracture history, based on data from a cohort study of adults aged 40 years and older.

©eranicle/Thinkstock

In the past, low-trauma fractures have typically been associated with osteoporosis, wrote William D. Leslie, MD, of the University of Manitoba, Canada, and his colleagues. However, features distinguishing between low- and high-trauma fractures are often arbitrary and “empirical data have questioned whether distinguishing low-trauma from high-trauma fractures is clinically useful for purposes of risk assessment and treatment,” they wrote.

In a study published in Osteoporosis International, the researchers reviewed data from 64,626 individuals with no prior fracture, 858 with high-trauma fractures, and 14,758 with low-trauma fractures. Overall, the average BMD Z-scores for individuals with no previous fracture were slightly positive, while those with either a high-trauma or low-trauma fracture were negative. The scores for individuals with high-trauma fractures or major osteoporotic fractures were similar to those with low-trauma fractures, and significantly lower (P less than .001) than among individuals with no prior fractures.

The study population included adults aged 40 years and older with baseline DXA scans between Jan. 1, 1996, and Mar. 31, 2016. Those with high-trauma fractures were younger than those with low-trauma fractures (65 years vs. 67 years), and fewer individuals with high-trauma fractures were women (77% vs. 87%).

Both high-trauma and low-trauma fractures were similarly and significantly associated with increased risk for incident major osteoporotic fractures (adjusted hazard ratios 1.31 and 1.55, respectively).

The study findings were limited by several factors including incomplete data on external injury codes, the retrospective study design, and the lack of analysis of the time since prior fractures, the researchers noted. However, the results were strengthened by the large sample size, long-term follow-up, and large numbers of incident fractures, they wrote.

The results support data from previous studies and support “the inclusion of high-trauma clinical fractures in clinical assessment for underlying osteoporosis and in the evaluation for intervention to reduce future fracture risk,” they wrote.

In an accompanying editorial, Steven R. Cummings, MD, of California Pacific Medical Center Research Institute, San Francisco, and Richard Eastell, MD, of the University of Sheffield, England, wrote that the practice of rating fractures according to degree of trauma should be eliminated.

“The study adds evidence to the case that it is time to abandon the mistaken beliefs that fractures rated as high trauma are not associated with decreased BMD, indicate no higher risk of subsequent fracture, or are less likely to be prevented by treatments for osteoporosis,” they wrote.

Describing some fractures as due to trauma reinforces the mistaken belief that the fractures are simply due to the trauma, not decreased bone strength, they noted.

“Indeed, we recommend that people stop attempting to rate or record degree of trauma because such ratings are at best inaccurate and would promote the continued neglect of those patients who are misclassified as having fractures that do not warrant evaluation and treatment,” they concluded.

The study received no outside funding. Dr. Leslie, the study’s first author, reported having no financial conflicts to disclose.

Dr. Cummings disclosed consultancy and grant funding from Amgen and Radius. Dr. Eastell disclosed consultancy funding from IDS, Roche Diagnostics, GSK Nutrition, FNIH, Mereo, Lilly, Sandoz, Nittobo, Abbvie, Samsung, and Haoma Medica and grant funding from Nittobo, IDS, Roche, Amgen, and Alexion.

SOURCE: Leslie WD et al. Osteroporos Int. 2020 Mar 16. doi: 10.1007/s00198-019-05274-2.

Average measures of bone mineral density were similar for individuals with high-trauma and low-trauma fractures, and both were significantly distinct from those with no fracture history, based on data from a cohort study of adults aged 40 years and older.

©eranicle/Thinkstock

In the past, low-trauma fractures have typically been associated with osteoporosis, wrote William D. Leslie, MD, of the University of Manitoba, Canada, and his colleagues. However, features distinguishing between low- and high-trauma fractures are often arbitrary and “empirical data have questioned whether distinguishing low-trauma from high-trauma fractures is clinically useful for purposes of risk assessment and treatment,” they wrote.

In a study published in Osteoporosis International, the researchers reviewed data from 64,626 individuals with no prior fracture, 858 with high-trauma fractures, and 14,758 with low-trauma fractures. Overall, the average BMD Z-scores for individuals with no previous fracture were slightly positive, while those with either a high-trauma or low-trauma fracture were negative. The scores for individuals with high-trauma fractures or major osteoporotic fractures were similar to those with low-trauma fractures, and significantly lower (P less than .001) than among individuals with no prior fractures.

The study population included adults aged 40 years and older with baseline DXA scans between Jan. 1, 1996, and Mar. 31, 2016. Those with high-trauma fractures were younger than those with low-trauma fractures (65 years vs. 67 years), and fewer individuals with high-trauma fractures were women (77% vs. 87%).

Both high-trauma and low-trauma fractures were similarly and significantly associated with increased risk for incident major osteoporotic fractures (adjusted hazard ratios 1.31 and 1.55, respectively).

The study findings were limited by several factors including incomplete data on external injury codes, the retrospective study design, and the lack of analysis of the time since prior fractures, the researchers noted. However, the results were strengthened by the large sample size, long-term follow-up, and large numbers of incident fractures, they wrote.

The results support data from previous studies and support “the inclusion of high-trauma clinical fractures in clinical assessment for underlying osteoporosis and in the evaluation for intervention to reduce future fracture risk,” they wrote.

In an accompanying editorial, Steven R. Cummings, MD, of California Pacific Medical Center Research Institute, San Francisco, and Richard Eastell, MD, of the University of Sheffield, England, wrote that the practice of rating fractures according to degree of trauma should be eliminated.

“The study adds evidence to the case that it is time to abandon the mistaken beliefs that fractures rated as high trauma are not associated with decreased BMD, indicate no higher risk of subsequent fracture, or are less likely to be prevented by treatments for osteoporosis,” they wrote.

Describing some fractures as due to trauma reinforces the mistaken belief that the fractures are simply due to the trauma, not decreased bone strength, they noted.

“Indeed, we recommend that people stop attempting to rate or record degree of trauma because such ratings are at best inaccurate and would promote the continued neglect of those patients who are misclassified as having fractures that do not warrant evaluation and treatment,” they concluded.

The study received no outside funding. Dr. Leslie, the study’s first author, reported having no financial conflicts to disclose.

Dr. Cummings disclosed consultancy and grant funding from Amgen and Radius. Dr. Eastell disclosed consultancy funding from IDS, Roche Diagnostics, GSK Nutrition, FNIH, Mereo, Lilly, Sandoz, Nittobo, Abbvie, Samsung, and Haoma Medica and grant funding from Nittobo, IDS, Roche, Amgen, and Alexion.

SOURCE: Leslie WD et al. Osteroporos Int. 2020 Mar 16. doi: 10.1007/s00198-019-05274-2.

Average measures of bone mineral density were similar for individuals with high-trauma and low-trauma fractures, and both were significantly distinct from those with no fracture history, based on data from a cohort study of adults aged 40 years and older.

©eranicle/Thinkstock

In the past, low-trauma fractures have typically been associated with osteoporosis, wrote William D. Leslie, MD, of the University of Manitoba, Canada, and his colleagues. However, features distinguishing between low- and high-trauma fractures are often arbitrary and “empirical data have questioned whether distinguishing low-trauma from high-trauma fractures is clinically useful for purposes of risk assessment and treatment,” they wrote.

In a study published in Osteoporosis International, the researchers reviewed data from 64,626 individuals with no prior fracture, 858 with high-trauma fractures, and 14,758 with low-trauma fractures. Overall, the average BMD Z-scores for individuals with no previous fracture were slightly positive, while those with either a high-trauma or low-trauma fracture were negative. The scores for individuals with high-trauma fractures or major osteoporotic fractures were similar to those with low-trauma fractures, and significantly lower (P less than .001) than among individuals with no prior fractures.

The study population included adults aged 40 years and older with baseline DXA scans between Jan. 1, 1996, and Mar. 31, 2016. Those with high-trauma fractures were younger than those with low-trauma fractures (65 years vs. 67 years), and fewer individuals with high-trauma fractures were women (77% vs. 87%).

Both high-trauma and low-trauma fractures were similarly and significantly associated with increased risk for incident major osteoporotic fractures (adjusted hazard ratios 1.31 and 1.55, respectively).

The study findings were limited by several factors including incomplete data on external injury codes, the retrospective study design, and the lack of analysis of the time since prior fractures, the researchers noted. However, the results were strengthened by the large sample size, long-term follow-up, and large numbers of incident fractures, they wrote.

The results support data from previous studies and support “the inclusion of high-trauma clinical fractures in clinical assessment for underlying osteoporosis and in the evaluation for intervention to reduce future fracture risk,” they wrote.

In an accompanying editorial, Steven R. Cummings, MD, of California Pacific Medical Center Research Institute, San Francisco, and Richard Eastell, MD, of the University of Sheffield, England, wrote that the practice of rating fractures according to degree of trauma should be eliminated.

“The study adds evidence to the case that it is time to abandon the mistaken beliefs that fractures rated as high trauma are not associated with decreased BMD, indicate no higher risk of subsequent fracture, or are less likely to be prevented by treatments for osteoporosis,” they wrote.

Describing some fractures as due to trauma reinforces the mistaken belief that the fractures are simply due to the trauma, not decreased bone strength, they noted.

“Indeed, we recommend that people stop attempting to rate or record degree of trauma because such ratings are at best inaccurate and would promote the continued neglect of those patients who are misclassified as having fractures that do not warrant evaluation and treatment,” they concluded.

The study received no outside funding. Dr. Leslie, the study’s first author, reported having no financial conflicts to disclose.

Dr. Cummings disclosed consultancy and grant funding from Amgen and Radius. Dr. Eastell disclosed consultancy funding from IDS, Roche Diagnostics, GSK Nutrition, FNIH, Mereo, Lilly, Sandoz, Nittobo, Abbvie, Samsung, and Haoma Medica and grant funding from Nittobo, IDS, Roche, Amgen, and Alexion.

SOURCE: Leslie WD et al. Osteroporos Int. 2020 Mar 16. doi: 10.1007/s00198-019-05274-2.

The U.S. Food and Drug Administration has granted Cellex an emergency use authorization to market a rapid antibody test for COVID-19, the first antibody test released amidst the pandemic.

“It is reasonable to believe that your product may be effective in diagnosing COVID-19,” and “there is no adequate, approved, and available alternative,” the agency said in a letter to Cellex.

A drop of serum, plasma, or whole blood is placed into a well on a small cartridge, and the results are read 15-20 minutes later; lines indicate the presence of IgM, IgG, or both antibodies against the SARS-CoV-2 virus.

Of 128 samples confirmed positive by reverse transcription polymerase chain reaction in premarket testing, 120 tested positive by IgG, IgM, or both. Of 250 confirmed negative, 239 were negative by the rapid test.

The numbers translated to a positive percent agreement with RT-PCR of 93.8% (95% CI: 88.06-97.26%) and a negative percent agreement of 96.4% (95% CI: 92.26-97.78%), according to labeling.

“Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection,” the labeling states.

Negative results do not rule out infection; antibodies might not have had enough time to form or the virus could have had a minor amino acid mutation in the epitope recognized by the antibodies screened for in the test. False positives can occur due to cross-reactivity with antibodies from previous infections, such as from other coronaviruses.

Labeling suggests that people who test negative should be checked again in a few days, and positive results should be confirmed by other methods. Also, the intensity of the test lines do not necessarily correlate with SARS-CoV-2 antibody titers.

As part of its authorization, the FDA waived good manufacturing practice requirements, but stipulated that advertising must state that the test has not been formally approved by the agency.

Testing is limited to Clinical Laboratory Improvement Amendments-certified labs. Positive results are required to be reported to public health authorities. The test can be ordered through Cellex distributors or directly from the company.

IgM antibodies are generally detectable several days after the initial infection, while IgG antibodies take longer. It’s not known how long COVID-19 antibodies persist after the infection has cleared, the agency said.

[email protected]

The U.S. Food and Drug Administration has granted Cellex an emergency use authorization to market a rapid antibody test for COVID-19, the first antibody test released amidst the pandemic.

“It is reasonable to believe that your product may be effective in diagnosing COVID-19,” and “there is no adequate, approved, and available alternative,” the agency said in a letter to Cellex.

A drop of serum, plasma, or whole blood is placed into a well on a small cartridge, and the results are read 15-20 minutes later; lines indicate the presence of IgM, IgG, or both antibodies against the SARS-CoV-2 virus.

Of 128 samples confirmed positive by reverse transcription polymerase chain reaction in premarket testing, 120 tested positive by IgG, IgM, or both. Of 250 confirmed negative, 239 were negative by the rapid test.

The numbers translated to a positive percent agreement with RT-PCR of 93.8% (95% CI: 88.06-97.26%) and a negative percent agreement of 96.4% (95% CI: 92.26-97.78%), according to labeling.

“Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection,” the labeling states.

Negative results do not rule out infection; antibodies might not have had enough time to form or the virus could have had a minor amino acid mutation in the epitope recognized by the antibodies screened for in the test. False positives can occur due to cross-reactivity with antibodies from previous infections, such as from other coronaviruses.

Labeling suggests that people who test negative should be checked again in a few days, and positive results should be confirmed by other methods. Also, the intensity of the test lines do not necessarily correlate with SARS-CoV-2 antibody titers.

As part of its authorization, the FDA waived good manufacturing practice requirements, but stipulated that advertising must state that the test has not been formally approved by the agency.

Testing is limited to Clinical Laboratory Improvement Amendments-certified labs. Positive results are required to be reported to public health authorities. The test can be ordered through Cellex distributors or directly from the company.

IgM antibodies are generally detectable several days after the initial infection, while IgG antibodies take longer. It’s not known how long COVID-19 antibodies persist after the infection has cleared, the agency said.

[email protected]

The U.S. Food and Drug Administration has granted Cellex an emergency use authorization to market a rapid antibody test for COVID-19, the first antibody test released amidst the pandemic.

“It is reasonable to believe that your product may be effective in diagnosing COVID-19,” and “there is no adequate, approved, and available alternative,” the agency said in a letter to Cellex.

A drop of serum, plasma, or whole blood is placed into a well on a small cartridge, and the results are read 15-20 minutes later; lines indicate the presence of IgM, IgG, or both antibodies against the SARS-CoV-2 virus.

Of 128 samples confirmed positive by reverse transcription polymerase chain reaction in premarket testing, 120 tested positive by IgG, IgM, or both. Of 250 confirmed negative, 239 were negative by the rapid test.

The numbers translated to a positive percent agreement with RT-PCR of 93.8% (95% CI: 88.06-97.26%) and a negative percent agreement of 96.4% (95% CI: 92.26-97.78%), according to labeling.

“Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection,” the labeling states.

Negative results do not rule out infection; antibodies might not have had enough time to form or the virus could have had a minor amino acid mutation in the epitope recognized by the antibodies screened for in the test. False positives can occur due to cross-reactivity with antibodies from previous infections, such as from other coronaviruses.

Labeling suggests that people who test negative should be checked again in a few days, and positive results should be confirmed by other methods. Also, the intensity of the test lines do not necessarily correlate with SARS-CoV-2 antibody titers.

As part of its authorization, the FDA waived good manufacturing practice requirements, but stipulated that advertising must state that the test has not been formally approved by the agency.

Testing is limited to Clinical Laboratory Improvement Amendments-certified labs. Positive results are required to be reported to public health authorities. The test can be ordered through Cellex distributors or directly from the company.

IgM antibodies are generally detectable several days after the initial infection, while IgG antibodies take longer. It’s not known how long COVID-19 antibodies persist after the infection has cleared, the agency said.

[email protected]