MDedge Pediatrics

Pityriasis rubra pilaris (PRP) is the name given to a heterogeneous group of rare inflammatory papulosquamous dermatoses. There are six sub-types that can present with various skin findings, however, the cardinal features across sub-types include well-defined, red-orange hued plaques with varying scale, palmoplantar keratoderma, and follicular keratosis. In the more generalized subtypes, there is a characteristic feature of intervening areas of unaffected skin often referred to as “islands of sparing.” The plaques may cover the entire body or just parts of the body such as the elbows and knees, palms and soles. Lesions are generally asymptomatic; occasionally patients complain of mild pruritus. 

Photos courtesy of Robert Silverman, MD

The etiology and pathophysiology of this group of disorders is not well understood. However, there are several hypotheses including dysfunction in vitamin A metabolism, autoimmune dysregulation, as well as environmental and immunologic triggers such as infection and ultraviolet exposure. Although most cases are sporadic, genetics do seem to play a role in the development of some cases. Caspase recruitment domain-containing protein 14 (CARD14) mutations are seen in familial PRP, and occasionally in patients with sporadic PRP, with gain of function mutations. Interestingly, CARD14 mutations are also associated with psoriasis in some individuals.¹ The type-VI PRP variant has been associated with HIV, although this is incredibly rare in pediatrics.²

PRP shows significant clinical diversity, with six subtypes defined by age of onset, distribution, and appearance of lesions, and presence of HIV. This includes type I (classical adult onset), type II (atypical adult onset), type III (classical juvenile onset), type IV (circumscribed juvenile onset), type V (atypical juvenile onset), and type VI (HIV-associated). As mentioned earlier, shared features that appear across subtypes in variable degrees include red-orange papules and plaques, hyperkeratotic follicular papules, and palmoplantar hyperkeratosis.

Of the six subtypes, type III, IV, and V occur in the pediatric population. Type III, classic juvenile PRP, typically occurs within the first 2 years of life or in adolescence. Only 10% of cases fall into this category. It shares similar features to type I PRP including red-orange plaques; islands of sparing, perifollicular hyperkeratotic papules; waxy palmoplantar keratoderma; and the distribution of affected skin is more diffuse overall. While some children clear within a few years, more recent studies stress a more prolonged course similar to the type IV variant.²

Type-IV PRP, also known as circumscribed juvenile PRP, is a focal variant, usually seen in prepubertal children and making up 25% of total cases. Clinically, these patients tend to have sharply demarcated grouped erythematous, follicular papules on the elbows, knees and over bony prominences.²

Type-V PRP is an atypical generalized juvenile variant which affects 5% of patients. It is a non-remitting hereditary condition with classic characteristics similar to type III with additional scleroderma-like changes involving the palms and soles.²

Diagnosis of PRP is based on clinical recognition and biopsy can be important to secure a diagnosis.

PRP, in many cases is self-limited and asymptomatic, and therefore does not necessarily require treatment. In other patients treatment can be challenging, and referral to a pediatric dermatology specialist is reasonable. Most practitioners recommend combination therapy with topical agents (emollients, topical corticosteroids, tazarotene, topical calcineurin inhibitors, and keratolytic agents such as urea, salicylic acid, or alpha-hydroxy acids) for symptomatic management and systemic therapies (methotrexate, isotretinoin) aimed at reducing inflammation. There is some data that CARD14-associated PRP can respond well to targeted biologic therapies.¹

The subtypes of PRP can present in a myriad of ways and often the disease is misdiagnosed. Depending on the particular subtype and findings present, the differential can vary considerably. Commonly, physicians need to consider: psoriasis, seborrheic dermatitis, atopic dermatitis, ichthyoses, and other conditions which can cause erythroderma.³ The characteristic red-orange color and variable associated edema helps to distinguish keratoderma of PRP from psoriasis, atopic dermatitis, ichthyosis, and hereditary palmoplantar keratoderma. Scalp involvement of PRP should be differentiated from the waxy scale of seborrheic dermatitis and the well demarcated silvery scale of psoriasis. History alone may assist in distinguishing PRP from other major causes of generalized erythroderma, although biopsy is warranted in these cases.
 

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Tracy is a research fellow in pediatric dermatology at Rady Children’s Hospital-San Diego and the University of California, San Diego. They have no relevant financial disclosures. Email them at [email protected].

References

1. J Am Acad Dermatol. 2018 Sep;79(3):487-94.

2. “Pityriasis Rubra Pilaris” (Treasure Island, Fla.: StatPearls Publishing, July 20, 2019). 3. JAMA Dermatol. 2016 Jun 1;152(6):670-5.

Pityriasis rubra pilaris (PRP) is the name given to a heterogeneous group of rare inflammatory papulosquamous dermatoses. There are six sub-types that can present with various skin findings, however, the cardinal features across sub-types include well-defined, red-orange hued plaques with varying scale, palmoplantar keratoderma, and follicular keratosis. In the more generalized subtypes, there is a characteristic feature of intervening areas of unaffected skin often referred to as “islands of sparing.” The plaques may cover the entire body or just parts of the body such as the elbows and knees, palms and soles. Lesions are generally asymptomatic; occasionally patients complain of mild pruritus. 

Photos courtesy of Robert Silverman, MD

The etiology and pathophysiology of this group of disorders is not well understood. However, there are several hypotheses including dysfunction in vitamin A metabolism, autoimmune dysregulation, as well as environmental and immunologic triggers such as infection and ultraviolet exposure. Although most cases are sporadic, genetics do seem to play a role in the development of some cases. Caspase recruitment domain-containing protein 14 (CARD14) mutations are seen in familial PRP, and occasionally in patients with sporadic PRP, with gain of function mutations. Interestingly, CARD14 mutations are also associated with psoriasis in some individuals.¹ The type-VI PRP variant has been associated with HIV, although this is incredibly rare in pediatrics.²

PRP shows significant clinical diversity, with six subtypes defined by age of onset, distribution, and appearance of lesions, and presence of HIV. This includes type I (classical adult onset), type II (atypical adult onset), type III (classical juvenile onset), type IV (circumscribed juvenile onset), type V (atypical juvenile onset), and type VI (HIV-associated). As mentioned earlier, shared features that appear across subtypes in variable degrees include red-orange papules and plaques, hyperkeratotic follicular papules, and palmoplantar hyperkeratosis.

Of the six subtypes, type III, IV, and V occur in the pediatric population. Type III, classic juvenile PRP, typically occurs within the first 2 years of life or in adolescence. Only 10% of cases fall into this category. It shares similar features to type I PRP including red-orange plaques; islands of sparing, perifollicular hyperkeratotic papules; waxy palmoplantar keratoderma; and the distribution of affected skin is more diffuse overall. While some children clear within a few years, more recent studies stress a more prolonged course similar to the type IV variant.²

Type-IV PRP, also known as circumscribed juvenile PRP, is a focal variant, usually seen in prepubertal children and making up 25% of total cases. Clinically, these patients tend to have sharply demarcated grouped erythematous, follicular papules on the elbows, knees and over bony prominences.²

Type-V PRP is an atypical generalized juvenile variant which affects 5% of patients. It is a non-remitting hereditary condition with classic characteristics similar to type III with additional scleroderma-like changes involving the palms and soles.²

Diagnosis of PRP is based on clinical recognition and biopsy can be important to secure a diagnosis.

PRP, in many cases is self-limited and asymptomatic, and therefore does not necessarily require treatment. In other patients treatment can be challenging, and referral to a pediatric dermatology specialist is reasonable. Most practitioners recommend combination therapy with topical agents (emollients, topical corticosteroids, tazarotene, topical calcineurin inhibitors, and keratolytic agents such as urea, salicylic acid, or alpha-hydroxy acids) for symptomatic management and systemic therapies (methotrexate, isotretinoin) aimed at reducing inflammation. There is some data that CARD14-associated PRP can respond well to targeted biologic therapies.¹

The subtypes of PRP can present in a myriad of ways and often the disease is misdiagnosed. Depending on the particular subtype and findings present, the differential can vary considerably. Commonly, physicians need to consider: psoriasis, seborrheic dermatitis, atopic dermatitis, ichthyoses, and other conditions which can cause erythroderma.³ The characteristic red-orange color and variable associated edema helps to distinguish keratoderma of PRP from psoriasis, atopic dermatitis, ichthyosis, and hereditary palmoplantar keratoderma. Scalp involvement of PRP should be differentiated from the waxy scale of seborrheic dermatitis and the well demarcated silvery scale of psoriasis. History alone may assist in distinguishing PRP from other major causes of generalized erythroderma, although biopsy is warranted in these cases.
 

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Tracy is a research fellow in pediatric dermatology at Rady Children’s Hospital-San Diego and the University of California, San Diego. They have no relevant financial disclosures. Email them at [email protected].

References

1. J Am Acad Dermatol. 2018 Sep;79(3):487-94.

2. “Pityriasis Rubra Pilaris” (Treasure Island, Fla.: StatPearls Publishing, July 20, 2019). 3. JAMA Dermatol. 2016 Jun 1;152(6):670-5.

Pityriasis rubra pilaris (PRP) is the name given to a heterogeneous group of rare inflammatory papulosquamous dermatoses. There are six sub-types that can present with various skin findings, however, the cardinal features across sub-types include well-defined, red-orange hued plaques with varying scale, palmoplantar keratoderma, and follicular keratosis. In the more generalized subtypes, there is a characteristic feature of intervening areas of unaffected skin often referred to as “islands of sparing.” The plaques may cover the entire body or just parts of the body such as the elbows and knees, palms and soles. Lesions are generally asymptomatic; occasionally patients complain of mild pruritus. 

Photos courtesy of Robert Silverman, MD

The etiology and pathophysiology of this group of disorders is not well understood. However, there are several hypotheses including dysfunction in vitamin A metabolism, autoimmune dysregulation, as well as environmental and immunologic triggers such as infection and ultraviolet exposure. Although most cases are sporadic, genetics do seem to play a role in the development of some cases. Caspase recruitment domain-containing protein 14 (CARD14) mutations are seen in familial PRP, and occasionally in patients with sporadic PRP, with gain of function mutations. Interestingly, CARD14 mutations are also associated with psoriasis in some individuals.¹ The type-VI PRP variant has been associated with HIV, although this is incredibly rare in pediatrics.²

PRP shows significant clinical diversity, with six subtypes defined by age of onset, distribution, and appearance of lesions, and presence of HIV. This includes type I (classical adult onset), type II (atypical adult onset), type III (classical juvenile onset), type IV (circumscribed juvenile onset), type V (atypical juvenile onset), and type VI (HIV-associated). As mentioned earlier, shared features that appear across subtypes in variable degrees include red-orange papules and plaques, hyperkeratotic follicular papules, and palmoplantar hyperkeratosis.

Of the six subtypes, type III, IV, and V occur in the pediatric population. Type III, classic juvenile PRP, typically occurs within the first 2 years of life or in adolescence. Only 10% of cases fall into this category. It shares similar features to type I PRP including red-orange plaques; islands of sparing, perifollicular hyperkeratotic papules; waxy palmoplantar keratoderma; and the distribution of affected skin is more diffuse overall. While some children clear within a few years, more recent studies stress a more prolonged course similar to the type IV variant.²

Type-IV PRP, also known as circumscribed juvenile PRP, is a focal variant, usually seen in prepubertal children and making up 25% of total cases. Clinically, these patients tend to have sharply demarcated grouped erythematous, follicular papules on the elbows, knees and over bony prominences.²

Type-V PRP is an atypical generalized juvenile variant which affects 5% of patients. It is a non-remitting hereditary condition with classic characteristics similar to type III with additional scleroderma-like changes involving the palms and soles.²

Diagnosis of PRP is based on clinical recognition and biopsy can be important to secure a diagnosis.

PRP, in many cases is self-limited and asymptomatic, and therefore does not necessarily require treatment. In other patients treatment can be challenging, and referral to a pediatric dermatology specialist is reasonable. Most practitioners recommend combination therapy with topical agents (emollients, topical corticosteroids, tazarotene, topical calcineurin inhibitors, and keratolytic agents such as urea, salicylic acid, or alpha-hydroxy acids) for symptomatic management and systemic therapies (methotrexate, isotretinoin) aimed at reducing inflammation. There is some data that CARD14-associated PRP can respond well to targeted biologic therapies.¹

The subtypes of PRP can present in a myriad of ways and often the disease is misdiagnosed. Depending on the particular subtype and findings present, the differential can vary considerably. Commonly, physicians need to consider: psoriasis, seborrheic dermatitis, atopic dermatitis, ichthyoses, and other conditions which can cause erythroderma.³ The characteristic red-orange color and variable associated edema helps to distinguish keratoderma of PRP from psoriasis, atopic dermatitis, ichthyosis, and hereditary palmoplantar keratoderma. Scalp involvement of PRP should be differentiated from the waxy scale of seborrheic dermatitis and the well demarcated silvery scale of psoriasis. History alone may assist in distinguishing PRP from other major causes of generalized erythroderma, although biopsy is warranted in these cases.
 

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Tracy is a research fellow in pediatric dermatology at Rady Children’s Hospital-San Diego and the University of California, San Diego. They have no relevant financial disclosures. Email them at [email protected].

References

1. J Am Acad Dermatol. 2018 Sep;79(3):487-94.

2. “Pityriasis Rubra Pilaris” (Treasure Island, Fla.: StatPearls Publishing, July 20, 2019). 3. JAMA Dermatol. 2016 Jun 1;152(6):670-5.

Hazard pay for frontline health care workers – an idea that has been championed by President Donald J. Trump and Senate Minority Leader Chuck Schumer, among others – is included in a just-released COVID-19 relief package assembled by Democrats in the House of Representatives.

The $3 trillion HEROES Act requests a reported $200 billion for a Heroes Fund that would award hazard pay to essential workers, including those in the health field, according to a report in the Washington Post.

But it is far from a done deal. “The Democrats’ spending bill is a Pelosi-led pipe dream written in private,” said House Republican Leader Kevin McCarthy (Calif.) in a Fox News interview posted May 12 on Facebook.

Senate Majority Leader Mitch McConnell condemned the package. “This is exactly the wrong approach,” he said in a prepared statement that instead laid out a variety of liability protections, which he said should be the first priority.

“We are not going to let health care heroes emerge from this crisis facing a tidal wave of medical malpractice lawsuits so that trial lawyers can line their pockets,” said Sen. McConnell, adding that his plan would “raise the liability threshold for COVID-related malpractice lawsuits.”

Ingrida Lusis, vice president of government affairs and health policy at the American Nurses Association, said in an interview that the ANA had lobbied for hazard pay and was told it would be in the next relief package.

“Though there is an inherent risk in the nursing profession, we think that this is really critical to ensuring that we have a workforce to meet the intense demands of this pandemic,” said Ms. Lusis.

“If health care workers are not treated and compensated appropriately for what they’re going through right now, then we may not have a next generation that will want to enter the field,” she said.

Various nursing organizations, nurses’ unions, and health care unions, such as the American Federation of State, County and Municipal Employees (AFSCME) and the Service Employees International Union, have advocated for hazard pay.

Physicians’ organizations have not been vocal on the issue, however. The American Medical Association, for instance, pushed for hazard pay for residents but has not made any further public statements. An AMA spokesman said that the group was monitoring the situation but declined further comment.

Multiple online petitions seeking hazard pay for health care workers have been circulated, including one seeking the same $600 bump for essential workers that was given out as part of unemployment benefits in the first COVID-19 relief package. More than 1.2 million had signed the petition as of May 12.
 

‘Heroes fund’

The president first suggested hazard pay for health care workers on March 30 Fox News broadcast. “These are really brave people,” he said, adding that the administration was considering different ways of boosting pay, primarily through hospitals.

“We are asking the hospitals to do it and to consider something, including bonuses,” said Trump. “If anybody’s entitled to it, they are.”

On April 7, Sen. Schumer proposed a “Heroes Fund.” It would give public, private, and tribal frontline employees – including doctors, nurses, first responders, and transit, grocery, and postal workers – a $13 per hour raise up to $25,000 in additional pay through Dec. 31 for workers earning up to $200,000 and $5,000 in additional pay for those earning more than $200,000. It would also provide a $15,000 signing bonus to those who agree to take on such a position.

Rep. Matt Cartwright (D-Pa.) introduced a bill in mid-April, the Coronavirus Frontline Workers Fair Pay Act (HR 6709), that would provide similar pay increases. Health care workers would receive an additional $13 per hour. It would be retroactive to Jan. 31, 2020, and would be available through the end of 2020.

Molly Kinder of the Brookings Institution, a self-described nonpartisan Washington policy institute, estimates that Sen. Schumer’s proposal would represent the equivalent of double-time pay for the average low-wage worker, a 50% pay increase for a mail carrier, a 20% boost for a pharmacist, and less than a 15% increase for a surgeon, as determined from median 2018 wages.

Before the House Democrats unveiled their bill, Isabel Soto of the center-right group American Action Forum estimated that a $13 per hour wage increase could cost $398.9 billion just from the end of March to the end of September. A great proportion of that amount – $264 billion – would go to some 10 million health care workers, Ms. Soto calculated.
 

Some already offering pay boost

A few states and hospital systems are already offering hazard pay.

On April 12, Massachusetts agreed to give about 6,500 AFSCME union members who work at state human services facilities and group homes a $5 or a $10 per hour pay increase, depending on duties. It was to stay in effect until at least May 30.

Maine Governor Janet Mills (D) also agreed to increase pay by $3-$5 an hour for AFSCME workers in state correctional and mental health facilities beginning March 29.

In New York City, the biggest hospital network, Northwell Health, in late April gave 45,000 workers – including nurses, physicians, respiratory therapists, environmental services workers, housekeepers, and people in outpatient and corporate roles – a lump sum bonus payment of up to $2,500 and 1 week of paid time off. The money came out of the system’s general fund.

“As an organization, we want to continue to support, motivate and inspire our team members,” said Northwell President and CEO Michael Dowling in a statement at the time.

On April 2, New York–Presbyterian Hospital’s chair of the department of surgery, Craig Smith, MD, announced that the facility was “providing a $1,250 bonus for everyone who has worked in or supported the COVID-19 front lines, for at least 1 week.”

Advocate Aurora, with 15 hospitals and 32,000 employees in Wisconsin, said in early April that it was giving increases of $6.25-$15.00 an hour at least through the end of May.

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

Hazard pay for frontline health care workers – an idea that has been championed by President Donald J. Trump and Senate Minority Leader Chuck Schumer, among others – is included in a just-released COVID-19 relief package assembled by Democrats in the House of Representatives.

The $3 trillion HEROES Act requests a reported $200 billion for a Heroes Fund that would award hazard pay to essential workers, including those in the health field, according to a report in the Washington Post.

But it is far from a done deal. “The Democrats’ spending bill is a Pelosi-led pipe dream written in private,” said House Republican Leader Kevin McCarthy (Calif.) in a Fox News interview posted May 12 on Facebook.

Senate Majority Leader Mitch McConnell condemned the package. “This is exactly the wrong approach,” he said in a prepared statement that instead laid out a variety of liability protections, which he said should be the first priority.

“We are not going to let health care heroes emerge from this crisis facing a tidal wave of medical malpractice lawsuits so that trial lawyers can line their pockets,” said Sen. McConnell, adding that his plan would “raise the liability threshold for COVID-related malpractice lawsuits.”

Ingrida Lusis, vice president of government affairs and health policy at the American Nurses Association, said in an interview that the ANA had lobbied for hazard pay and was told it would be in the next relief package.

“Though there is an inherent risk in the nursing profession, we think that this is really critical to ensuring that we have a workforce to meet the intense demands of this pandemic,” said Ms. Lusis.

“If health care workers are not treated and compensated appropriately for what they’re going through right now, then we may not have a next generation that will want to enter the field,” she said.

Various nursing organizations, nurses’ unions, and health care unions, such as the American Federation of State, County and Municipal Employees (AFSCME) and the Service Employees International Union, have advocated for hazard pay.

Physicians’ organizations have not been vocal on the issue, however. The American Medical Association, for instance, pushed for hazard pay for residents but has not made any further public statements. An AMA spokesman said that the group was monitoring the situation but declined further comment.

Multiple online petitions seeking hazard pay for health care workers have been circulated, including one seeking the same $600 bump for essential workers that was given out as part of unemployment benefits in the first COVID-19 relief package. More than 1.2 million had signed the petition as of May 12.
 

‘Heroes fund’

The president first suggested hazard pay for health care workers on March 30 Fox News broadcast. “These are really brave people,” he said, adding that the administration was considering different ways of boosting pay, primarily through hospitals.

“We are asking the hospitals to do it and to consider something, including bonuses,” said Trump. “If anybody’s entitled to it, they are.”

On April 7, Sen. Schumer proposed a “Heroes Fund.” It would give public, private, and tribal frontline employees – including doctors, nurses, first responders, and transit, grocery, and postal workers – a $13 per hour raise up to $25,000 in additional pay through Dec. 31 for workers earning up to $200,000 and $5,000 in additional pay for those earning more than $200,000. It would also provide a $15,000 signing bonus to those who agree to take on such a position.

Rep. Matt Cartwright (D-Pa.) introduced a bill in mid-April, the Coronavirus Frontline Workers Fair Pay Act (HR 6709), that would provide similar pay increases. Health care workers would receive an additional $13 per hour. It would be retroactive to Jan. 31, 2020, and would be available through the end of 2020.

Molly Kinder of the Brookings Institution, a self-described nonpartisan Washington policy institute, estimates that Sen. Schumer’s proposal would represent the equivalent of double-time pay for the average low-wage worker, a 50% pay increase for a mail carrier, a 20% boost for a pharmacist, and less than a 15% increase for a surgeon, as determined from median 2018 wages.

Before the House Democrats unveiled their bill, Isabel Soto of the center-right group American Action Forum estimated that a $13 per hour wage increase could cost $398.9 billion just from the end of March to the end of September. A great proportion of that amount – $264 billion – would go to some 10 million health care workers, Ms. Soto calculated.
 

Some already offering pay boost

A few states and hospital systems are already offering hazard pay.

On April 12, Massachusetts agreed to give about 6,500 AFSCME union members who work at state human services facilities and group homes a $5 or a $10 per hour pay increase, depending on duties. It was to stay in effect until at least May 30.

Maine Governor Janet Mills (D) also agreed to increase pay by $3-$5 an hour for AFSCME workers in state correctional and mental health facilities beginning March 29.

In New York City, the biggest hospital network, Northwell Health, in late April gave 45,000 workers – including nurses, physicians, respiratory therapists, environmental services workers, housekeepers, and people in outpatient and corporate roles – a lump sum bonus payment of up to $2,500 and 1 week of paid time off. The money came out of the system’s general fund.

“As an organization, we want to continue to support, motivate and inspire our team members,” said Northwell President and CEO Michael Dowling in a statement at the time.

On April 2, New York–Presbyterian Hospital’s chair of the department of surgery, Craig Smith, MD, announced that the facility was “providing a $1,250 bonus for everyone who has worked in or supported the COVID-19 front lines, for at least 1 week.”

Advocate Aurora, with 15 hospitals and 32,000 employees in Wisconsin, said in early April that it was giving increases of $6.25-$15.00 an hour at least through the end of May.

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

Hazard pay for frontline health care workers – an idea that has been championed by President Donald J. Trump and Senate Minority Leader Chuck Schumer, among others – is included in a just-released COVID-19 relief package assembled by Democrats in the House of Representatives.

The $3 trillion HEROES Act requests a reported $200 billion for a Heroes Fund that would award hazard pay to essential workers, including those in the health field, according to a report in the Washington Post.

But it is far from a done deal. “The Democrats’ spending bill is a Pelosi-led pipe dream written in private,” said House Republican Leader Kevin McCarthy (Calif.) in a Fox News interview posted May 12 on Facebook.

Senate Majority Leader Mitch McConnell condemned the package. “This is exactly the wrong approach,” he said in a prepared statement that instead laid out a variety of liability protections, which he said should be the first priority.

“We are not going to let health care heroes emerge from this crisis facing a tidal wave of medical malpractice lawsuits so that trial lawyers can line their pockets,” said Sen. McConnell, adding that his plan would “raise the liability threshold for COVID-related malpractice lawsuits.”

Ingrida Lusis, vice president of government affairs and health policy at the American Nurses Association, said in an interview that the ANA had lobbied for hazard pay and was told it would be in the next relief package.

“Though there is an inherent risk in the nursing profession, we think that this is really critical to ensuring that we have a workforce to meet the intense demands of this pandemic,” said Ms. Lusis.

“If health care workers are not treated and compensated appropriately for what they’re going through right now, then we may not have a next generation that will want to enter the field,” she said.

Various nursing organizations, nurses’ unions, and health care unions, such as the American Federation of State, County and Municipal Employees (AFSCME) and the Service Employees International Union, have advocated for hazard pay.

Physicians’ organizations have not been vocal on the issue, however. The American Medical Association, for instance, pushed for hazard pay for residents but has not made any further public statements. An AMA spokesman said that the group was monitoring the situation but declined further comment.

Multiple online petitions seeking hazard pay for health care workers have been circulated, including one seeking the same $600 bump for essential workers that was given out as part of unemployment benefits in the first COVID-19 relief package. More than 1.2 million had signed the petition as of May 12.
 

‘Heroes fund’

The president first suggested hazard pay for health care workers on March 30 Fox News broadcast. “These are really brave people,” he said, adding that the administration was considering different ways of boosting pay, primarily through hospitals.

“We are asking the hospitals to do it and to consider something, including bonuses,” said Trump. “If anybody’s entitled to it, they are.”

On April 7, Sen. Schumer proposed a “Heroes Fund.” It would give public, private, and tribal frontline employees – including doctors, nurses, first responders, and transit, grocery, and postal workers – a $13 per hour raise up to $25,000 in additional pay through Dec. 31 for workers earning up to $200,000 and $5,000 in additional pay for those earning more than $200,000. It would also provide a $15,000 signing bonus to those who agree to take on such a position.

Rep. Matt Cartwright (D-Pa.) introduced a bill in mid-April, the Coronavirus Frontline Workers Fair Pay Act (HR 6709), that would provide similar pay increases. Health care workers would receive an additional $13 per hour. It would be retroactive to Jan. 31, 2020, and would be available through the end of 2020.

Molly Kinder of the Brookings Institution, a self-described nonpartisan Washington policy institute, estimates that Sen. Schumer’s proposal would represent the equivalent of double-time pay for the average low-wage worker, a 50% pay increase for a mail carrier, a 20% boost for a pharmacist, and less than a 15% increase for a surgeon, as determined from median 2018 wages.

Before the House Democrats unveiled their bill, Isabel Soto of the center-right group American Action Forum estimated that a $13 per hour wage increase could cost $398.9 billion just from the end of March to the end of September. A great proportion of that amount – $264 billion – would go to some 10 million health care workers, Ms. Soto calculated.
 

Some already offering pay boost

A few states and hospital systems are already offering hazard pay.

On April 12, Massachusetts agreed to give about 6,500 AFSCME union members who work at state human services facilities and group homes a $5 or a $10 per hour pay increase, depending on duties. It was to stay in effect until at least May 30.

Maine Governor Janet Mills (D) also agreed to increase pay by $3-$5 an hour for AFSCME workers in state correctional and mental health facilities beginning March 29.

In New York City, the biggest hospital network, Northwell Health, in late April gave 45,000 workers – including nurses, physicians, respiratory therapists, environmental services workers, housekeepers, and people in outpatient and corporate roles – a lump sum bonus payment of up to $2,500 and 1 week of paid time off. The money came out of the system’s general fund.

“As an organization, we want to continue to support, motivate and inspire our team members,” said Northwell President and CEO Michael Dowling in a statement at the time.

On April 2, New York–Presbyterian Hospital’s chair of the department of surgery, Craig Smith, MD, announced that the facility was “providing a $1,250 bonus for everyone who has worked in or supported the COVID-19 front lines, for at least 1 week.”

Advocate Aurora, with 15 hospitals and 32,000 employees in Wisconsin, said in early April that it was giving increases of $6.25-$15.00 an hour at least through the end of May.

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

The Infectious Diseases Society of America (IDSA) recently issued guidelines on the diagnosis of COVID-19.

Courtesy NIAID-RML

These guidelines were developed using a rigorous evidence-based approach, the GRADE framework, which involved identifying the important questions that need to be addressed ahead of time and, later, integrating the best available evidence into the recommendations.

The Food and Drug Administration’s Emergency Use Authorization is useful for understanding any recommendations related to COVID-19 testing. Under usual FDA approval, a manufacturer has to submit data on the performance of a test in human subjects. Under the Emergency Use Authorization for development and approval of SARS-CoV-2 testing, approval is based on “acceptable analytical accuracy,” meaning that a test is assessed using manufactured reagents. The approved test is not tested in real-world clinical situations prior to FDA approval, and the test’s sensitivity and specificity are not well described.

IDSA formulated 15 recommendations, of which the most relevant to primary care clinicians are described and discussed below. The complete set of recommendations can be viewed on the IDSA website:

Recommendation 1

The IDSA panel recommends a SARS-CoV-2 nucleic acid amplification test in symptomatic individuals in the community suspected of having COVID-19, even when the clinical suspicion is low (strong recommendation, very low certainty of evidence). The panel placed a high value on accurate assessment of COVID-19 with the intent of minimizing overdiagnosis of COVID-19 using clinical diagnosis alone. Without testing, the rate of overdiagnosis ranges from 62% to 98%.

If patients are misdiagnosed as having COVID-19, they may spend unnecessary time in quarantine and then may stop taking appropriate safety precautions to protect themselves from infection.

Recommendation 2

The IDSA panel suggests collecting nasopharyngeal, or mid-turbinate or nasal swabs, rather than oropharyngeal swabs or saliva alone for SARS-CoV-2 RNA testing in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, very low certainty of evidence).

The rationale for this recommendation is that comparative data showed a much lower sensitivity for oral sampling, compared with nasopharyngeal, mid-turbinate, or nasal sampling.

The average sensitivity of oral swabs is 56%, compared with nasopharyngeal at 97%, mid-turbinate at 100%, and nasal sampling at 95%. Given these test characteristics, there are far less false-negative tests with nasopharyngeal, mid-turbinate, and nasal swabs. Fewer false negatives means fewer instances of incorrectly telling COVID-19–positive patients that they do not have the illness. An exciting new area of testing that is being evaluated is saliva, which appears to have a sensitivity of 85%.

Recommendation 3

The IDSA panel suggests that nasal and mid-turbinate swab specimens may be collected for SARS-CoV-2 RNA testing by either patients or health care providers in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, low certainty of evidence).

This recommendation is particularly exciting because patient self-collection provides the potential for health care personnel to avoid exposure to infection, as can occur when health care personnel are swabbing a patient; this is ow testing has been done at most testing centers.

While the data are limited, it appears that patient self-collection of nasal or mid-turbinate swabs results in similar detection rates as occurs with health care personnel–collected nasopharyngeal swabs.

Recommendation 6

The IDSA panel suggests repeating viral RNA testing when the initial test is negative (versus performing a single test) in symptomatic individuals with an intermediate or high clinical suspicion of COVID-19 (conditional recommendation, low certainty of evidence).

Since none of the tests are perfect and any can have false negatives, the panel places a high value on detecting infection when present. If there is a low clinical likelihood of disease, the panel recommends not retesting. When the clinical likelihood of COVID-19 is moderate to high, in the event that the initial test is negative, the panel recommends retesting for COVID-19 1-2 days after the initial test.

Recommendation 8

The IDSA panel suggests SARS-CoV-2 RNA testing in asymptomatic individuals who are either known or suspected to have been exposed to COVID-19 (conditional recommendation, very low certainty of evidence).

For this recommendation, a known contact is defined as someone who has had direct contact with a confirmed case.

A suspected exposure occurs when someone is working or living in a congregate setting such as long-term care, a correctional facility, or a cruise ship in which there is an outbreak. The time frame during which to do post-exposure testing is five to seven days after the exposure.

Recommendation 10

The IDSA panel recommends direct SARS-CoV-2 RNA testing in asymptomatic individuals with no known contact with COVID-19 who are being hospitalized in areas with a high prevalence of COVID-19 in the community (conditional recommendation, very low certainty of evidence).

The idea is to do rapid testing to identify individuals entering the hospital either for other illnesses or for procedures, in order to be able to institute appropriate precautions and decrease the likelihood of nosocomial transmission and/or transmission to health care personnel. It is worth noting that the recommendations do not address testing in areas with a low or intermediate prevalence of COVID-19. In the absence of an official guideline-based-recommendation, the decision about testing needs to made by the local hospital system.

Recommendations 11, 12, and 13

The IDSA panel recommends SARS-CoV-2 RNA testing in immunocompromised asymptomatic individuals who are being admitted to the hospital and in asymptomatic individuals prior to receiving immunosuppressive therapy regardless of exposure to COVID-19. It is also recommended to test asymptomatic individuals planning to undergo major surgery.

The rationale for this recommendation is that patients who are to receive chemotherapy, other immunosuppressive procedures, or surgery are at high risk if they have COVID-19 and may be better off delaying the procedure.

Some additional issues were addressed, though not in the form of additional recommendations. It was clarified that some individuals remain nucleic acid positive after their symptoms resolve, and sometimes even after seroconversion. It is not clear if those individuals remain infectious to others. The recommendations did not address serologic testing for public health surveillance.
 

Dr. Skolnik is professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.

SOURCE: Hanson KE et al. Infectious Diseases Society of America guidelines on the diagnosis of COVID-19.




 

The Infectious Diseases Society of America (IDSA) recently issued guidelines on the diagnosis of COVID-19.

Courtesy NIAID-RML

These guidelines were developed using a rigorous evidence-based approach, the GRADE framework, which involved identifying the important questions that need to be addressed ahead of time and, later, integrating the best available evidence into the recommendations.

The Food and Drug Administration’s Emergency Use Authorization is useful for understanding any recommendations related to COVID-19 testing. Under usual FDA approval, a manufacturer has to submit data on the performance of a test in human subjects. Under the Emergency Use Authorization for development and approval of SARS-CoV-2 testing, approval is based on “acceptable analytical accuracy,” meaning that a test is assessed using manufactured reagents. The approved test is not tested in real-world clinical situations prior to FDA approval, and the test’s sensitivity and specificity are not well described.

IDSA formulated 15 recommendations, of which the most relevant to primary care clinicians are described and discussed below. The complete set of recommendations can be viewed on the IDSA website:

Recommendation 1

The IDSA panel recommends a SARS-CoV-2 nucleic acid amplification test in symptomatic individuals in the community suspected of having COVID-19, even when the clinical suspicion is low (strong recommendation, very low certainty of evidence). The panel placed a high value on accurate assessment of COVID-19 with the intent of minimizing overdiagnosis of COVID-19 using clinical diagnosis alone. Without testing, the rate of overdiagnosis ranges from 62% to 98%.

If patients are misdiagnosed as having COVID-19, they may spend unnecessary time in quarantine and then may stop taking appropriate safety precautions to protect themselves from infection.

Recommendation 2

The IDSA panel suggests collecting nasopharyngeal, or mid-turbinate or nasal swabs, rather than oropharyngeal swabs or saliva alone for SARS-CoV-2 RNA testing in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, very low certainty of evidence).

The rationale for this recommendation is that comparative data showed a much lower sensitivity for oral sampling, compared with nasopharyngeal, mid-turbinate, or nasal sampling.

The average sensitivity of oral swabs is 56%, compared with nasopharyngeal at 97%, mid-turbinate at 100%, and nasal sampling at 95%. Given these test characteristics, there are far less false-negative tests with nasopharyngeal, mid-turbinate, and nasal swabs. Fewer false negatives means fewer instances of incorrectly telling COVID-19–positive patients that they do not have the illness. An exciting new area of testing that is being evaluated is saliva, which appears to have a sensitivity of 85%.

Recommendation 3

The IDSA panel suggests that nasal and mid-turbinate swab specimens may be collected for SARS-CoV-2 RNA testing by either patients or health care providers in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, low certainty of evidence).

This recommendation is particularly exciting because patient self-collection provides the potential for health care personnel to avoid exposure to infection, as can occur when health care personnel are swabbing a patient; this is ow testing has been done at most testing centers.

While the data are limited, it appears that patient self-collection of nasal or mid-turbinate swabs results in similar detection rates as occurs with health care personnel–collected nasopharyngeal swabs.

Recommendation 6

The IDSA panel suggests repeating viral RNA testing when the initial test is negative (versus performing a single test) in symptomatic individuals with an intermediate or high clinical suspicion of COVID-19 (conditional recommendation, low certainty of evidence).

Since none of the tests are perfect and any can have false negatives, the panel places a high value on detecting infection when present. If there is a low clinical likelihood of disease, the panel recommends not retesting. When the clinical likelihood of COVID-19 is moderate to high, in the event that the initial test is negative, the panel recommends retesting for COVID-19 1-2 days after the initial test.

Recommendation 8

The IDSA panel suggests SARS-CoV-2 RNA testing in asymptomatic individuals who are either known or suspected to have been exposed to COVID-19 (conditional recommendation, very low certainty of evidence).

For this recommendation, a known contact is defined as someone who has had direct contact with a confirmed case.

A suspected exposure occurs when someone is working or living in a congregate setting such as long-term care, a correctional facility, or a cruise ship in which there is an outbreak. The time frame during which to do post-exposure testing is five to seven days after the exposure.

Recommendation 10

The IDSA panel recommends direct SARS-CoV-2 RNA testing in asymptomatic individuals with no known contact with COVID-19 who are being hospitalized in areas with a high prevalence of COVID-19 in the community (conditional recommendation, very low certainty of evidence).

The idea is to do rapid testing to identify individuals entering the hospital either for other illnesses or for procedures, in order to be able to institute appropriate precautions and decrease the likelihood of nosocomial transmission and/or transmission to health care personnel. It is worth noting that the recommendations do not address testing in areas with a low or intermediate prevalence of COVID-19. In the absence of an official guideline-based-recommendation, the decision about testing needs to made by the local hospital system.

Recommendations 11, 12, and 13

The IDSA panel recommends SARS-CoV-2 RNA testing in immunocompromised asymptomatic individuals who are being admitted to the hospital and in asymptomatic individuals prior to receiving immunosuppressive therapy regardless of exposure to COVID-19. It is also recommended to test asymptomatic individuals planning to undergo major surgery.

The rationale for this recommendation is that patients who are to receive chemotherapy, other immunosuppressive procedures, or surgery are at high risk if they have COVID-19 and may be better off delaying the procedure.

Some additional issues were addressed, though not in the form of additional recommendations. It was clarified that some individuals remain nucleic acid positive after their symptoms resolve, and sometimes even after seroconversion. It is not clear if those individuals remain infectious to others. The recommendations did not address serologic testing for public health surveillance.
 

Dr. Skolnik is professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.

SOURCE: Hanson KE et al. Infectious Diseases Society of America guidelines on the diagnosis of COVID-19.




 

The Infectious Diseases Society of America (IDSA) recently issued guidelines on the diagnosis of COVID-19.

Courtesy NIAID-RML

These guidelines were developed using a rigorous evidence-based approach, the GRADE framework, which involved identifying the important questions that need to be addressed ahead of time and, later, integrating the best available evidence into the recommendations.

The Food and Drug Administration’s Emergency Use Authorization is useful for understanding any recommendations related to COVID-19 testing. Under usual FDA approval, a manufacturer has to submit data on the performance of a test in human subjects. Under the Emergency Use Authorization for development and approval of SARS-CoV-2 testing, approval is based on “acceptable analytical accuracy,” meaning that a test is assessed using manufactured reagents. The approved test is not tested in real-world clinical situations prior to FDA approval, and the test’s sensitivity and specificity are not well described.

IDSA formulated 15 recommendations, of which the most relevant to primary care clinicians are described and discussed below. The complete set of recommendations can be viewed on the IDSA website:

Recommendation 1

The IDSA panel recommends a SARS-CoV-2 nucleic acid amplification test in symptomatic individuals in the community suspected of having COVID-19, even when the clinical suspicion is low (strong recommendation, very low certainty of evidence). The panel placed a high value on accurate assessment of COVID-19 with the intent of minimizing overdiagnosis of COVID-19 using clinical diagnosis alone. Without testing, the rate of overdiagnosis ranges from 62% to 98%.

If patients are misdiagnosed as having COVID-19, they may spend unnecessary time in quarantine and then may stop taking appropriate safety precautions to protect themselves from infection.

Recommendation 2

The IDSA panel suggests collecting nasopharyngeal, or mid-turbinate or nasal swabs, rather than oropharyngeal swabs or saliva alone for SARS-CoV-2 RNA testing in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, very low certainty of evidence).

The rationale for this recommendation is that comparative data showed a much lower sensitivity for oral sampling, compared with nasopharyngeal, mid-turbinate, or nasal sampling.

The average sensitivity of oral swabs is 56%, compared with nasopharyngeal at 97%, mid-turbinate at 100%, and nasal sampling at 95%. Given these test characteristics, there are far less false-negative tests with nasopharyngeal, mid-turbinate, and nasal swabs. Fewer false negatives means fewer instances of incorrectly telling COVID-19–positive patients that they do not have the illness. An exciting new area of testing that is being evaluated is saliva, which appears to have a sensitivity of 85%.

Recommendation 3

The IDSA panel suggests that nasal and mid-turbinate swab specimens may be collected for SARS-CoV-2 RNA testing by either patients or health care providers in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, low certainty of evidence).

This recommendation is particularly exciting because patient self-collection provides the potential for health care personnel to avoid exposure to infection, as can occur when health care personnel are swabbing a patient; this is ow testing has been done at most testing centers.

While the data are limited, it appears that patient self-collection of nasal or mid-turbinate swabs results in similar detection rates as occurs with health care personnel–collected nasopharyngeal swabs.

Recommendation 6

The IDSA panel suggests repeating viral RNA testing when the initial test is negative (versus performing a single test) in symptomatic individuals with an intermediate or high clinical suspicion of COVID-19 (conditional recommendation, low certainty of evidence).

Since none of the tests are perfect and any can have false negatives, the panel places a high value on detecting infection when present. If there is a low clinical likelihood of disease, the panel recommends not retesting. When the clinical likelihood of COVID-19 is moderate to high, in the event that the initial test is negative, the panel recommends retesting for COVID-19 1-2 days after the initial test.

Recommendation 8

The IDSA panel suggests SARS-CoV-2 RNA testing in asymptomatic individuals who are either known or suspected to have been exposed to COVID-19 (conditional recommendation, very low certainty of evidence).

For this recommendation, a known contact is defined as someone who has had direct contact with a confirmed case.

A suspected exposure occurs when someone is working or living in a congregate setting such as long-term care, a correctional facility, or a cruise ship in which there is an outbreak. The time frame during which to do post-exposure testing is five to seven days after the exposure.

Recommendation 10

The IDSA panel recommends direct SARS-CoV-2 RNA testing in asymptomatic individuals with no known contact with COVID-19 who are being hospitalized in areas with a high prevalence of COVID-19 in the community (conditional recommendation, very low certainty of evidence).

The idea is to do rapid testing to identify individuals entering the hospital either for other illnesses or for procedures, in order to be able to institute appropriate precautions and decrease the likelihood of nosocomial transmission and/or transmission to health care personnel. It is worth noting that the recommendations do not address testing in areas with a low or intermediate prevalence of COVID-19. In the absence of an official guideline-based-recommendation, the decision about testing needs to made by the local hospital system.

Recommendations 11, 12, and 13

The IDSA panel recommends SARS-CoV-2 RNA testing in immunocompromised asymptomatic individuals who are being admitted to the hospital and in asymptomatic individuals prior to receiving immunosuppressive therapy regardless of exposure to COVID-19. It is also recommended to test asymptomatic individuals planning to undergo major surgery.

The rationale for this recommendation is that patients who are to receive chemotherapy, other immunosuppressive procedures, or surgery are at high risk if they have COVID-19 and may be better off delaying the procedure.

Some additional issues were addressed, though not in the form of additional recommendations. It was clarified that some individuals remain nucleic acid positive after their symptoms resolve, and sometimes even after seroconversion. It is not clear if those individuals remain infectious to others. The recommendations did not address serologic testing for public health surveillance.
 

Dr. Skolnik is professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.

SOURCE: Hanson KE et al. Infectious Diseases Society of America guidelines on the diagnosis of COVID-19.




 

The COVID-19 pandemic is fraught with unexpected twists, among them a dramatic plunge in emergency department patient volumes, according to an expert panel on unanticipated consequences of pandemic care hosted by the presidents of the Society of Critical Care Medicine and the American College of Emergency Physicians.*

“At the peak of exposure to COVID-19 illness or infection, ED volumes in my system, which are really not much different from others across the country, were cut in half, if not more. And those changes happened across virtually every form of ED presentation, from the highest acuity to the lowest. We’re now beyond our highest level of exposure to COVID-19 clinically symptomatic patients in western Pennsylvania, but that recovery in volume hasn’t occurred yet, although there are some embers,” explained Donald M. Yealy, MD, professor and chair of the department of emergency medicine at the University of Pittsburgh.

He and other panelists also addressed some of the other unanticipated developments in the COVID-19 pandemic, including a recently recognized childhood manifestation called for now COVID-associated pediatric multisystem inflammatory syndrome, an anticipated massive second wave of non-COVID patients expected to present late to EDs and primary care clinics after having avoided needed medical care out of fear of infection, and the pandemic’s negative impact upon medical education.
 

Who’s not showing up in the ED

Dr. Yealy said that across the country, the number of patients arriving in EDs with acute ST-elevation MI, stroke, trauma, and other highest-acuity presentations is down substantially. But the volume of patients with more routine, bread-and-butter conditions typically seen in EDs is down even more.

“You might say, if I was designing from the insurance side, this is exactly what I’d hope for. I’ve heard that some people on the insurance-only side of the business really are experiencing a pretty good deal right now: They’re collecting premiums and not having to pay out on the ED or hospital side,” he said.
 

Tweaking the public health message on seeking medical care

“One of the unanticipated casualties of the pandemic are the patients who don’t have it. It will take a whole lot of work and coordinated effort to re-engage with those patients,” predicted SCCM President Lewis J. Kaplan, MD, professor of surgery at the University of Pennsylvania, Philadelphia.

Evie G. Marcolini, MD, described what she believes is necessary now: “We need to have a big focus on getting the word out to the public that acute MI, stroke, and other acute injuries are still a time-sensitive problem and they warrant at least a call to their physician or consideration of coming in to the ED.

“I think when we started out, we were telling people, ‘Don’t come in.’ Now we’re trying to dial it back a little bit and say, ‘Listen, there are things you really do need to come in for. And we will keep you safe,’” said Dr. Marcolini, an emergency medicine and neurocritical care specialist at Dartmouth-Hitchcock Medical Center, Hanover, N.H.

“It is safe,” Dr. Yealy agreed. “The safest place in the world to be right now is the ED. Everybody’s cordoned off. There’s way more PPE [personal protective equipment]. There’s a level of precision now that should have existed but never did in our previous influenza seasons. So we have something very unique to offer, and we can put people’s minds at rest.”

He spoke of a coming “tsunami of untreated illness.”

“My concern is there is a significant subset of people who are not only eschewing ED care but staying away from their primary care provider. My fear is that we’re not as well aware of this,” he said. “Together with our primary care partners, we have to figure out ways to reach the people who are ignoring illnesses and injuries that they’re making long-term decisions about without realizing it. We have to find a way to reach those people and say it’s okay to reach for care.”

SCCM Immediate Past President Heatherlee Bailey, MD, also sees a problematic looming wave.

“I’m quite concerned about the coming second wave of non-COVID patients who’ve sat home with their worsening renal failure that’s gone from 2 to 5 because they’ve been taking a lot of NSAIDs, or the individual who’s had several TIAs that self-resolved, and we’ve missed an opportunity to prevent some significant disease. At some point they’re going to come back, and we need to figure out how to get these individuals hooked up with care, either through the ED or with their primary care provider, to prevent these potential bad outcomes,” said Dr. Bailey of the Durham (N.C.) Veterans Affairs Medical Center.
 

Interim guidance for pediatricians on an alarming new syndrome

Edward E. Conway Jr., MD, recalled that early in the U.S. pandemic, pediatricians felt a sense of relief that children appeared to be spared from severe COVID-19 disease. But, in just the past few weeks, a new syndrome has emerged. New York City has recorded more than 100 cases of what’s provisionally being called COVID-associated pediatric multisystem inflammatory syndrome. Dr. Conway and others are working with the Centers for Disease Control and Prevention to develop a case definition for the syndrome, first reported by pediatricians in Italy and the United Kingdom.

“We’re trying to get the word out to general pediatricians as to the common signs and symptoms that should prompt parents to bring their children in for medical care,” according to Dr. Conway, chief of pediatric critical care medicine and vice-chair of pediatrics at Jacobi Medical Center in New York.

Ninety percent of affected children have abdominal symptoms early on, including abdominal pain, diarrhea, emesis, or enteritis upon imaging. A nondescript rash, headache, conjunctivitis, and irritability are common, cough much less so – under 25%.

“The thought is that if any one of these is associated with a fever lasting more than 4 days, we suggest these children be brought in and seen by a pediatrician. We don’t have a formal guideline – we’re working on that – but basically the current recommendation is to screen them initially with a CBC with differential, a chem 10, and liver function tests, but also to look for inflammatory markers that we see in our COVID patients. We’ve been quite surprised: These patients have C-reactive proteins of about 240 mg/L on average, ferritin is quite high at around 1,200 ng/mL, and d-dimers of 2,300 ng/mL. We’ve also found very high brain natriuretic peptides and troponins in these patients,” according to Dr. Conway.

Analogies have been made between this COVID-19 pediatric syndrome and Kawasaki disease. Dr. Conway is unconvinced.

“This is quite different from Kawasaki in that these children are usually thrombocytopenic and usually present with DIC [disseminated intravascular coagulation], and the d-dimers are extraordinarily high, compared to what we’re used to seeing in pediatric patients,” he said.

Symptomatic children with laboratory red flags should be hospitalized. Most of the affected New York City children have recovered after 5 or 6 days in the pediatric ICU with empiric treatment using intravenous immunoglobulin (IVIG), corticosteroids, and/or interleukin-6 inhibitors. However, five recent deaths are now under study.

Dr. Yealy commented that this new pediatric syndrome is “really interesting,” but to date, it affects only a very small percentage of children, and children overall have been much less affected by the pandemic than are adults.

“The populations being disproportionately impacted are the elderly, the elderly, the elderly, and then other vulnerable populations, particularly congregants and the poor,” he said. “At my site, three-quarters of the patients coming in are either patients at assisted-living facilities or work at one of those congregant facilities.”
 

The pandemic’s impact on medical education

In many hospitals, grand rounds are being done virtually via videoconferencing, often with attendant challenges in asking and answering questions. Hospital patient volumes are diminished. Medical students aren’t coming in to do clinical rotations. Medical students and residents can’t travel to interview for future residencies or jobs.

“It’s affecting education across all of the components of medicine. It’s hard to say how long this pandemic is going to last. We’re all trying to be innovative in using online tools, but I believe it’s going to have a long-lasting effect on our education system,” Dr. Marcolini predicted.

Remote interface while working from home has become frustrating, especially during peak Internet use hours.

“It’s staggering how slow my home system has become in comparison to what’s wired at work. Now many times when you try to get into your work system from home, you time out while you’re waiting for the next piece of information to come across,” Dr. Kaplan commented.

All panel participants reported having no financial conflicts of interest.

[email protected]

*Correction, 5/15/20: An earlier version of this article misstated the name of the American College of Emergency Physicians.)

 

The COVID-19 pandemic is fraught with unexpected twists, among them a dramatic plunge in emergency department patient volumes, according to an expert panel on unanticipated consequences of pandemic care hosted by the presidents of the Society of Critical Care Medicine and the American College of Emergency Physicians.*

“At the peak of exposure to COVID-19 illness or infection, ED volumes in my system, which are really not much different from others across the country, were cut in half, if not more. And those changes happened across virtually every form of ED presentation, from the highest acuity to the lowest. We’re now beyond our highest level of exposure to COVID-19 clinically symptomatic patients in western Pennsylvania, but that recovery in volume hasn’t occurred yet, although there are some embers,” explained Donald M. Yealy, MD, professor and chair of the department of emergency medicine at the University of Pittsburgh.

He and other panelists also addressed some of the other unanticipated developments in the COVID-19 pandemic, including a recently recognized childhood manifestation called for now COVID-associated pediatric multisystem inflammatory syndrome, an anticipated massive second wave of non-COVID patients expected to present late to EDs and primary care clinics after having avoided needed medical care out of fear of infection, and the pandemic’s negative impact upon medical education.
 

Who’s not showing up in the ED

Dr. Yealy said that across the country, the number of patients arriving in EDs with acute ST-elevation MI, stroke, trauma, and other highest-acuity presentations is down substantially. But the volume of patients with more routine, bread-and-butter conditions typically seen in EDs is down even more.

“You might say, if I was designing from the insurance side, this is exactly what I’d hope for. I’ve heard that some people on the insurance-only side of the business really are experiencing a pretty good deal right now: They’re collecting premiums and not having to pay out on the ED or hospital side,” he said.
 

Tweaking the public health message on seeking medical care

“One of the unanticipated casualties of the pandemic are the patients who don’t have it. It will take a whole lot of work and coordinated effort to re-engage with those patients,” predicted SCCM President Lewis J. Kaplan, MD, professor of surgery at the University of Pennsylvania, Philadelphia.

Evie G. Marcolini, MD, described what she believes is necessary now: “We need to have a big focus on getting the word out to the public that acute MI, stroke, and other acute injuries are still a time-sensitive problem and they warrant at least a call to their physician or consideration of coming in to the ED.

“I think when we started out, we were telling people, ‘Don’t come in.’ Now we’re trying to dial it back a little bit and say, ‘Listen, there are things you really do need to come in for. And we will keep you safe,’” said Dr. Marcolini, an emergency medicine and neurocritical care specialist at Dartmouth-Hitchcock Medical Center, Hanover, N.H.

“It is safe,” Dr. Yealy agreed. “The safest place in the world to be right now is the ED. Everybody’s cordoned off. There’s way more PPE [personal protective equipment]. There’s a level of precision now that should have existed but never did in our previous influenza seasons. So we have something very unique to offer, and we can put people’s minds at rest.”

He spoke of a coming “tsunami of untreated illness.”

“My concern is there is a significant subset of people who are not only eschewing ED care but staying away from their primary care provider. My fear is that we’re not as well aware of this,” he said. “Together with our primary care partners, we have to figure out ways to reach the people who are ignoring illnesses and injuries that they’re making long-term decisions about without realizing it. We have to find a way to reach those people and say it’s okay to reach for care.”

SCCM Immediate Past President Heatherlee Bailey, MD, also sees a problematic looming wave.

“I’m quite concerned about the coming second wave of non-COVID patients who’ve sat home with their worsening renal failure that’s gone from 2 to 5 because they’ve been taking a lot of NSAIDs, or the individual who’s had several TIAs that self-resolved, and we’ve missed an opportunity to prevent some significant disease. At some point they’re going to come back, and we need to figure out how to get these individuals hooked up with care, either through the ED or with their primary care provider, to prevent these potential bad outcomes,” said Dr. Bailey of the Durham (N.C.) Veterans Affairs Medical Center.
 

Interim guidance for pediatricians on an alarming new syndrome

Edward E. Conway Jr., MD, recalled that early in the U.S. pandemic, pediatricians felt a sense of relief that children appeared to be spared from severe COVID-19 disease. But, in just the past few weeks, a new syndrome has emerged. New York City has recorded more than 100 cases of what’s provisionally being called COVID-associated pediatric multisystem inflammatory syndrome. Dr. Conway and others are working with the Centers for Disease Control and Prevention to develop a case definition for the syndrome, first reported by pediatricians in Italy and the United Kingdom.

“We’re trying to get the word out to general pediatricians as to the common signs and symptoms that should prompt parents to bring their children in for medical care,” according to Dr. Conway, chief of pediatric critical care medicine and vice-chair of pediatrics at Jacobi Medical Center in New York.

Ninety percent of affected children have abdominal symptoms early on, including abdominal pain, diarrhea, emesis, or enteritis upon imaging. A nondescript rash, headache, conjunctivitis, and irritability are common, cough much less so – under 25%.

“The thought is that if any one of these is associated with a fever lasting more than 4 days, we suggest these children be brought in and seen by a pediatrician. We don’t have a formal guideline – we’re working on that – but basically the current recommendation is to screen them initially with a CBC with differential, a chem 10, and liver function tests, but also to look for inflammatory markers that we see in our COVID patients. We’ve been quite surprised: These patients have C-reactive proteins of about 240 mg/L on average, ferritin is quite high at around 1,200 ng/mL, and d-dimers of 2,300 ng/mL. We’ve also found very high brain natriuretic peptides and troponins in these patients,” according to Dr. Conway.

Analogies have been made between this COVID-19 pediatric syndrome and Kawasaki disease. Dr. Conway is unconvinced.

“This is quite different from Kawasaki in that these children are usually thrombocytopenic and usually present with DIC [disseminated intravascular coagulation], and the d-dimers are extraordinarily high, compared to what we’re used to seeing in pediatric patients,” he said.

Symptomatic children with laboratory red flags should be hospitalized. Most of the affected New York City children have recovered after 5 or 6 days in the pediatric ICU with empiric treatment using intravenous immunoglobulin (IVIG), corticosteroids, and/or interleukin-6 inhibitors. However, five recent deaths are now under study.

Dr. Yealy commented that this new pediatric syndrome is “really interesting,” but to date, it affects only a very small percentage of children, and children overall have been much less affected by the pandemic than are adults.

“The populations being disproportionately impacted are the elderly, the elderly, the elderly, and then other vulnerable populations, particularly congregants and the poor,” he said. “At my site, three-quarters of the patients coming in are either patients at assisted-living facilities or work at one of those congregant facilities.”
 

The pandemic’s impact on medical education

In many hospitals, grand rounds are being done virtually via videoconferencing, often with attendant challenges in asking and answering questions. Hospital patient volumes are diminished. Medical students aren’t coming in to do clinical rotations. Medical students and residents can’t travel to interview for future residencies or jobs.

“It’s affecting education across all of the components of medicine. It’s hard to say how long this pandemic is going to last. We’re all trying to be innovative in using online tools, but I believe it’s going to have a long-lasting effect on our education system,” Dr. Marcolini predicted.

Remote interface while working from home has become frustrating, especially during peak Internet use hours.

“It’s staggering how slow my home system has become in comparison to what’s wired at work. Now many times when you try to get into your work system from home, you time out while you’re waiting for the next piece of information to come across,” Dr. Kaplan commented.

All panel participants reported having no financial conflicts of interest.

[email protected]

*Correction, 5/15/20: An earlier version of this article misstated the name of the American College of Emergency Physicians.)

 

The COVID-19 pandemic is fraught with unexpected twists, among them a dramatic plunge in emergency department patient volumes, according to an expert panel on unanticipated consequences of pandemic care hosted by the presidents of the Society of Critical Care Medicine and the American College of Emergency Physicians.*

“At the peak of exposure to COVID-19 illness or infection, ED volumes in my system, which are really not much different from others across the country, were cut in half, if not more. And those changes happened across virtually every form of ED presentation, from the highest acuity to the lowest. We’re now beyond our highest level of exposure to COVID-19 clinically symptomatic patients in western Pennsylvania, but that recovery in volume hasn’t occurred yet, although there are some embers,” explained Donald M. Yealy, MD, professor and chair of the department of emergency medicine at the University of Pittsburgh.

He and other panelists also addressed some of the other unanticipated developments in the COVID-19 pandemic, including a recently recognized childhood manifestation called for now COVID-associated pediatric multisystem inflammatory syndrome, an anticipated massive second wave of non-COVID patients expected to present late to EDs and primary care clinics after having avoided needed medical care out of fear of infection, and the pandemic’s negative impact upon medical education.
 

Who’s not showing up in the ED

Dr. Yealy said that across the country, the number of patients arriving in EDs with acute ST-elevation MI, stroke, trauma, and other highest-acuity presentations is down substantially. But the volume of patients with more routine, bread-and-butter conditions typically seen in EDs is down even more.

“You might say, if I was designing from the insurance side, this is exactly what I’d hope for. I’ve heard that some people on the insurance-only side of the business really are experiencing a pretty good deal right now: They’re collecting premiums and not having to pay out on the ED or hospital side,” he said.
 

Tweaking the public health message on seeking medical care

“One of the unanticipated casualties of the pandemic are the patients who don’t have it. It will take a whole lot of work and coordinated effort to re-engage with those patients,” predicted SCCM President Lewis J. Kaplan, MD, professor of surgery at the University of Pennsylvania, Philadelphia.

Evie G. Marcolini, MD, described what she believes is necessary now: “We need to have a big focus on getting the word out to the public that acute MI, stroke, and other acute injuries are still a time-sensitive problem and they warrant at least a call to their physician or consideration of coming in to the ED.

“I think when we started out, we were telling people, ‘Don’t come in.’ Now we’re trying to dial it back a little bit and say, ‘Listen, there are things you really do need to come in for. And we will keep you safe,’” said Dr. Marcolini, an emergency medicine and neurocritical care specialist at Dartmouth-Hitchcock Medical Center, Hanover, N.H.

“It is safe,” Dr. Yealy agreed. “The safest place in the world to be right now is the ED. Everybody’s cordoned off. There’s way more PPE [personal protective equipment]. There’s a level of precision now that should have existed but never did in our previous influenza seasons. So we have something very unique to offer, and we can put people’s minds at rest.”

He spoke of a coming “tsunami of untreated illness.”

“My concern is there is a significant subset of people who are not only eschewing ED care but staying away from their primary care provider. My fear is that we’re not as well aware of this,” he said. “Together with our primary care partners, we have to figure out ways to reach the people who are ignoring illnesses and injuries that they’re making long-term decisions about without realizing it. We have to find a way to reach those people and say it’s okay to reach for care.”

SCCM Immediate Past President Heatherlee Bailey, MD, also sees a problematic looming wave.

“I’m quite concerned about the coming second wave of non-COVID patients who’ve sat home with their worsening renal failure that’s gone from 2 to 5 because they’ve been taking a lot of NSAIDs, or the individual who’s had several TIAs that self-resolved, and we’ve missed an opportunity to prevent some significant disease. At some point they’re going to come back, and we need to figure out how to get these individuals hooked up with care, either through the ED or with their primary care provider, to prevent these potential bad outcomes,” said Dr. Bailey of the Durham (N.C.) Veterans Affairs Medical Center.
 

Interim guidance for pediatricians on an alarming new syndrome

Edward E. Conway Jr., MD, recalled that early in the U.S. pandemic, pediatricians felt a sense of relief that children appeared to be spared from severe COVID-19 disease. But, in just the past few weeks, a new syndrome has emerged. New York City has recorded more than 100 cases of what’s provisionally being called COVID-associated pediatric multisystem inflammatory syndrome. Dr. Conway and others are working with the Centers for Disease Control and Prevention to develop a case definition for the syndrome, first reported by pediatricians in Italy and the United Kingdom.

“We’re trying to get the word out to general pediatricians as to the common signs and symptoms that should prompt parents to bring their children in for medical care,” according to Dr. Conway, chief of pediatric critical care medicine and vice-chair of pediatrics at Jacobi Medical Center in New York.

Ninety percent of affected children have abdominal symptoms early on, including abdominal pain, diarrhea, emesis, or enteritis upon imaging. A nondescript rash, headache, conjunctivitis, and irritability are common, cough much less so – under 25%.

“The thought is that if any one of these is associated with a fever lasting more than 4 days, we suggest these children be brought in and seen by a pediatrician. We don’t have a formal guideline – we’re working on that – but basically the current recommendation is to screen them initially with a CBC with differential, a chem 10, and liver function tests, but also to look for inflammatory markers that we see in our COVID patients. We’ve been quite surprised: These patients have C-reactive proteins of about 240 mg/L on average, ferritin is quite high at around 1,200 ng/mL, and d-dimers of 2,300 ng/mL. We’ve also found very high brain natriuretic peptides and troponins in these patients,” according to Dr. Conway.

Analogies have been made between this COVID-19 pediatric syndrome and Kawasaki disease. Dr. Conway is unconvinced.

“This is quite different from Kawasaki in that these children are usually thrombocytopenic and usually present with DIC [disseminated intravascular coagulation], and the d-dimers are extraordinarily high, compared to what we’re used to seeing in pediatric patients,” he said.

Symptomatic children with laboratory red flags should be hospitalized. Most of the affected New York City children have recovered after 5 or 6 days in the pediatric ICU with empiric treatment using intravenous immunoglobulin (IVIG), corticosteroids, and/or interleukin-6 inhibitors. However, five recent deaths are now under study.

Dr. Yealy commented that this new pediatric syndrome is “really interesting,” but to date, it affects only a very small percentage of children, and children overall have been much less affected by the pandemic than are adults.

“The populations being disproportionately impacted are the elderly, the elderly, the elderly, and then other vulnerable populations, particularly congregants and the poor,” he said. “At my site, three-quarters of the patients coming in are either patients at assisted-living facilities or work at one of those congregant facilities.”
 

The pandemic’s impact on medical education

In many hospitals, grand rounds are being done virtually via videoconferencing, often with attendant challenges in asking and answering questions. Hospital patient volumes are diminished. Medical students aren’t coming in to do clinical rotations. Medical students and residents can’t travel to interview for future residencies or jobs.

“It’s affecting education across all of the components of medicine. It’s hard to say how long this pandemic is going to last. We’re all trying to be innovative in using online tools, but I believe it’s going to have a long-lasting effect on our education system,” Dr. Marcolini predicted.

Remote interface while working from home has become frustrating, especially during peak Internet use hours.

“It’s staggering how slow my home system has become in comparison to what’s wired at work. Now many times when you try to get into your work system from home, you time out while you’re waiting for the next piece of information to come across,” Dr. Kaplan commented.

All panel participants reported having no financial conflicts of interest.

[email protected]

*Correction, 5/15/20: An earlier version of this article misstated the name of the American College of Emergency Physicians.)

 

Potential risks of cardiac injury posed by coronavirus disease 2019 (COVID-19) infection warrant a cautious return-to-play for highly active people and competitive athletes who test positive, according to leading sports cardiologists.

To prevent cardiac injury, athletes should rest for at least 2 weeks after symptoms resolve, then undergo cardiac testing before returning high-level competitive sports, reported lead author Dermot Phelan, MD, PhD, of Atrium Health in Charlotte, N.C., and colleagues.

These recommendations, which were published in JAMA Cardiology, are part of a clinical algorithm that sorts athletes based on coronavirus test status and symptom severity. The algorithm offers a clear timeline for resumption of activity, with management decisions for symptomatic individuals based on additional diagnostics, such as high-sensitivity troponin testing and electrocardiogram.

Despite a scarcity of relevant clinical data, Dr. Phelan said that he and his colleagues wanted to offer their best recommendations to the athletic community, who had been reaching out for help.

“We were getting calls and messages from amateur and professional sporting organizations from around the country asking for guidance about what to do,” Dr. Phelan said. “So a number of us from the American College of Cardiology Sports and Exercise Council decided that we really should provide some guidance even in the absence of good, strong data, for what we feel is a reasonable approach.”

The recommendations were based on what is known of other viral infections, as well as risks posed by COVID-19 that may be worsened by athletic activity.

“We know that, when people have an active infection, vigorous exercise can lower immunity, and that can make the infection worse,” Dr. Phelan said. “That really applies very strongly in people who have had myocarditis. If you exercise when you have myocarditis, it actually increases viral replication and results in increased necrosis of the heart muscle. We really want to avoid exercising during that active infection phase.”

Myocarditis is one of the top causes of sudden cardiac death among young athletes, Dr. Phelan said, “so that’s a major concern for us.”

According to Dr. Phelan, existing data suggest a wide range of incidence of 7%-33% for cardiac injury among patients hospitalized for COVID-19. Even the low end of this range, at 7%, is significantly higher than the incidence rate of 1% found in patients with non–COVID-19 acute viral infections.

“This particular virus appears to cause more cardiac insults than other viruses,” Dr. Phelan said.

The incidence of cardiac injury among nonhospitalized patients remains unknown, leaving a wide knowledge gap that shaped the conservative nature of the present recommendations.

With more information, however, the guidance may “change dramatically,” Dr. Phelan said.

“If the data come back and show that no nonhospitalized patients got cardiac injury, then we would be much more comfortable allowing return to play without the need for cardiac testing,” he said.

Conversely, if cardiac injury is more common than anticipated, then more extensive testing may be needed, he added.

As the algorithm stands, high-sensitivity troponin testing and/or cardiac studies are recommended for all symptomatic athletes; if troponin levels are greater than the 99th percentile or a cardiac study is abnormal, then clinicians should follow return-to-play guidelines for myocarditis. For athletes with normal tests, slow resumption of activity is recommended, including close monitoring for clinical deterioration.

As Dr. Phelan discussed these recommendations in a broader context, he emphasized the need for caution, both preventively, and for cardiologists working with recovering athletes.

“For the early stage of this reentry into normal life while this is still an active pandemic, we need to be cautious,” Dr. Phelan said. “We need to follow the regular CDC guidelines, in terms of social distancing and handwashing, but we also need to consider that those people who have suffered from COVID-19 may have had cardiac injury. We don’t know that yet. But we need to be cautious with these individuals and test them before they return to high-level competitive sports.”

One author disclosed a relationship with the Atlanta Falcons.

SOURCE: Phelan D et al. JAMA Cardiology. 2020 Apr 13. doi: 10.1001/jamacardio.2020.2136.

Potential risks of cardiac injury posed by coronavirus disease 2019 (COVID-19) infection warrant a cautious return-to-play for highly active people and competitive athletes who test positive, according to leading sports cardiologists.

To prevent cardiac injury, athletes should rest for at least 2 weeks after symptoms resolve, then undergo cardiac testing before returning high-level competitive sports, reported lead author Dermot Phelan, MD, PhD, of Atrium Health in Charlotte, N.C., and colleagues.

These recommendations, which were published in JAMA Cardiology, are part of a clinical algorithm that sorts athletes based on coronavirus test status and symptom severity. The algorithm offers a clear timeline for resumption of activity, with management decisions for symptomatic individuals based on additional diagnostics, such as high-sensitivity troponin testing and electrocardiogram.

Despite a scarcity of relevant clinical data, Dr. Phelan said that he and his colleagues wanted to offer their best recommendations to the athletic community, who had been reaching out for help.

“We were getting calls and messages from amateur and professional sporting organizations from around the country asking for guidance about what to do,” Dr. Phelan said. “So a number of us from the American College of Cardiology Sports and Exercise Council decided that we really should provide some guidance even in the absence of good, strong data, for what we feel is a reasonable approach.”

The recommendations were based on what is known of other viral infections, as well as risks posed by COVID-19 that may be worsened by athletic activity.

“We know that, when people have an active infection, vigorous exercise can lower immunity, and that can make the infection worse,” Dr. Phelan said. “That really applies very strongly in people who have had myocarditis. If you exercise when you have myocarditis, it actually increases viral replication and results in increased necrosis of the heart muscle. We really want to avoid exercising during that active infection phase.”

Myocarditis is one of the top causes of sudden cardiac death among young athletes, Dr. Phelan said, “so that’s a major concern for us.”

According to Dr. Phelan, existing data suggest a wide range of incidence of 7%-33% for cardiac injury among patients hospitalized for COVID-19. Even the low end of this range, at 7%, is significantly higher than the incidence rate of 1% found in patients with non–COVID-19 acute viral infections.

“This particular virus appears to cause more cardiac insults than other viruses,” Dr. Phelan said.

The incidence of cardiac injury among nonhospitalized patients remains unknown, leaving a wide knowledge gap that shaped the conservative nature of the present recommendations.

With more information, however, the guidance may “change dramatically,” Dr. Phelan said.

“If the data come back and show that no nonhospitalized patients got cardiac injury, then we would be much more comfortable allowing return to play without the need for cardiac testing,” he said.

Conversely, if cardiac injury is more common than anticipated, then more extensive testing may be needed, he added.

As the algorithm stands, high-sensitivity troponin testing and/or cardiac studies are recommended for all symptomatic athletes; if troponin levels are greater than the 99th percentile or a cardiac study is abnormal, then clinicians should follow return-to-play guidelines for myocarditis. For athletes with normal tests, slow resumption of activity is recommended, including close monitoring for clinical deterioration.

As Dr. Phelan discussed these recommendations in a broader context, he emphasized the need for caution, both preventively, and for cardiologists working with recovering athletes.

“For the early stage of this reentry into normal life while this is still an active pandemic, we need to be cautious,” Dr. Phelan said. “We need to follow the regular CDC guidelines, in terms of social distancing and handwashing, but we also need to consider that those people who have suffered from COVID-19 may have had cardiac injury. We don’t know that yet. But we need to be cautious with these individuals and test them before they return to high-level competitive sports.”

One author disclosed a relationship with the Atlanta Falcons.

SOURCE: Phelan D et al. JAMA Cardiology. 2020 Apr 13. doi: 10.1001/jamacardio.2020.2136.

Potential risks of cardiac injury posed by coronavirus disease 2019 (COVID-19) infection warrant a cautious return-to-play for highly active people and competitive athletes who test positive, according to leading sports cardiologists.

To prevent cardiac injury, athletes should rest for at least 2 weeks after symptoms resolve, then undergo cardiac testing before returning high-level competitive sports, reported lead author Dermot Phelan, MD, PhD, of Atrium Health in Charlotte, N.C., and colleagues.

These recommendations, which were published in JAMA Cardiology, are part of a clinical algorithm that sorts athletes based on coronavirus test status and symptom severity. The algorithm offers a clear timeline for resumption of activity, with management decisions for symptomatic individuals based on additional diagnostics, such as high-sensitivity troponin testing and electrocardiogram.

Despite a scarcity of relevant clinical data, Dr. Phelan said that he and his colleagues wanted to offer their best recommendations to the athletic community, who had been reaching out for help.

“We were getting calls and messages from amateur and professional sporting organizations from around the country asking for guidance about what to do,” Dr. Phelan said. “So a number of us from the American College of Cardiology Sports and Exercise Council decided that we really should provide some guidance even in the absence of good, strong data, for what we feel is a reasonable approach.”

The recommendations were based on what is known of other viral infections, as well as risks posed by COVID-19 that may be worsened by athletic activity.

“We know that, when people have an active infection, vigorous exercise can lower immunity, and that can make the infection worse,” Dr. Phelan said. “That really applies very strongly in people who have had myocarditis. If you exercise when you have myocarditis, it actually increases viral replication and results in increased necrosis of the heart muscle. We really want to avoid exercising during that active infection phase.”

Myocarditis is one of the top causes of sudden cardiac death among young athletes, Dr. Phelan said, “so that’s a major concern for us.”

According to Dr. Phelan, existing data suggest a wide range of incidence of 7%-33% for cardiac injury among patients hospitalized for COVID-19. Even the low end of this range, at 7%, is significantly higher than the incidence rate of 1% found in patients with non–COVID-19 acute viral infections.

“This particular virus appears to cause more cardiac insults than other viruses,” Dr. Phelan said.

The incidence of cardiac injury among nonhospitalized patients remains unknown, leaving a wide knowledge gap that shaped the conservative nature of the present recommendations.

With more information, however, the guidance may “change dramatically,” Dr. Phelan said.

“If the data come back and show that no nonhospitalized patients got cardiac injury, then we would be much more comfortable allowing return to play without the need for cardiac testing,” he said.

Conversely, if cardiac injury is more common than anticipated, then more extensive testing may be needed, he added.

As the algorithm stands, high-sensitivity troponin testing and/or cardiac studies are recommended for all symptomatic athletes; if troponin levels are greater than the 99th percentile or a cardiac study is abnormal, then clinicians should follow return-to-play guidelines for myocarditis. For athletes with normal tests, slow resumption of activity is recommended, including close monitoring for clinical deterioration.

As Dr. Phelan discussed these recommendations in a broader context, he emphasized the need for caution, both preventively, and for cardiologists working with recovering athletes.

“For the early stage of this reentry into normal life while this is still an active pandemic, we need to be cautious,” Dr. Phelan said. “We need to follow the regular CDC guidelines, in terms of social distancing and handwashing, but we also need to consider that those people who have suffered from COVID-19 may have had cardiac injury. We don’t know that yet. But we need to be cautious with these individuals and test them before they return to high-level competitive sports.”

One author disclosed a relationship with the Atlanta Falcons.

SOURCE: Phelan D et al. JAMA Cardiology. 2020 Apr 13. doi: 10.1001/jamacardio.2020.2136.

The number of COVID-19 deaths cannot be directly compared to the number of seasonal influenza deaths because they are calculated differently, researchers say in a report released today.

Whereas COVID-19 death rates are determined from actual counts of people who have died, seasonal influenza death rates are estimated by the Centers for Disease Control and Prevention (CDC) using population modeling algorithms, explains Jeremy Samuel Faust, MD, with Harvard Medical School and Brigham and Women’s Hospital, Division of Health Policy and Public Health in Boston, Massachusetts.

The CDC estimates that between 24,000 and 62,000 people died from influenza during the 2019-2020 season (through April 4). At the time of the analysis (as of April 28), COVID-19 deaths had reached 65,000 in the United States.

Some government officials and others have said the numbers seem similar and have used the comparison as an argument for reopening certain areas.

But making that comparison “is extremely dangerous,” Faust told Medscape Medical News.

“COVID-19 is far more dangerous and is wreaking far more havoc than seasonal influenza ever has,” he said.

Faust coauthored the perspective article, published online in JAMA Internal Medicine, with Carlos del Rio, MD, Division of Infectious Diseases at Emory University School of Medicine in Atlanta, Georgia.

The message and methodology of Faust’s and del Rio’s article are on target, according to Jonathan L. Temte, MD, PhD, who has been working in influenza surveillance for almost 25 years.

Current flu data draw on limited information from primary care practices and hospitals, said Dr. Temte, associate dean for public health and community engagement at the University of Wisconsin School of Medicine and Public Health in Madison. The estimates help bridge the gaps, he said, but the system is inherently vulnerable to error.

“Comparing them – as so many people in this country have done – to try to diminish the impact of SARS-CoV2 is not fair,” he said.
 

Estimated versus actual influenza deaths

The authors illustrate the difference in the way rates of death from influenza are calculated: “Between 2013-2014 and 2018-2019, the reported yearly estimated influenza deaths ranged from 23,000 to 61,000. Over that same time period, however, the number of counted influenza deaths was between 3,448 and 15,620 yearly.”

“It’s apparent [the CDC has] been overestimating,” Faust said. “If you publish a number on the higher end of the estimate, people might take your public health messages more seriously, such as, it’s important to get your yearly flu shot.”

He added that until influenza death rates started to be compared with COVID-19 rates, “there was never really a downside” to reporting estimates.

Dr. Temte said he doesn’t regard overestimating flu deaths as intentional but rather the result of a longstanding “bias against the elderly in this country” that the estimates are meant to account for.

For example, he says, reporting influenza deaths is mandatory when such deaths involve persons younger than 18 years but not when they involve adults.

Also, traditionally, influenza has been seen “as a cause of death in people with multiple comorbidities that was just part and parcel of wintertime,” Dr. Temte said.

“The likelihood of being tested for influenza goes down greatly when you’re older,” he said. “This is slowly changing.”

The CDC acknowledges on its website that it “does not know the exact number of people who have been sick and affected by influenza because influenza is not a reportable disease in most areas of the US.”

It adds that the burden is estimated through the US Influenza Surveillance System, which covers approximately 8.5% of the US population.
 

Comparing recorded deaths

It’s more accurate and meaningful to compare actual numbers of deaths for the diseases, Dr. Faust and Dr. del Rio say in their article.

When the authors made that comparison, they drew a stark contrast.

There were 15,455 recorded COVID-19 deaths in the week that ended April 21. The week before, the number of recorded deaths was 14,478, they found. (Those were the two most recent weeks before they submitted their article for publication.)

In comparison, counted deaths ranged from 351 to 1,626 during the peak week of the seven influenza seasons between 2013-2014 and 2019-2020. The average counted deaths for the peak week of the seven seasons was 752.4 (95% confidence interval, 558.8-946.1).

“These statistics on counted deaths suggest that the number of COVID-19 deaths for the week ending April 21 was 9.5-fold to 44.1-fold greater than the peak week of counted influenza deaths during the past seven influenza seasons in the US, with a 20.5-fold mean increase (95% CI, 16.3-27.7),” the authors write.

However, Natasha Chida, MD, MSPH, an infectious disease physician and assistant professor at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said in an interview that the actual number of deaths doesn’t tell the complete flu story either. That count would miss people who later died from secondary complications associated with influenza, she said.

“There’s just no way to reliably count influenza deaths,” she said. “I think if we required it as a reported illness, that would be the ideal situation, but there’s so much flu every year that that probably would not be practical.”

She said she agrees that rates of influenza deaths and rates of COVID-19 deaths cannot be fairly compared.

What the authors don’t touch on, she said, is that flu season lasts 4 to 6 months a year, and just 3 months into the coronavirus pandemic, US deaths due to COVID-19 are already higher than those for seasonal influenza.

“Even if we look at it in the way that people who think we can compare flu and coronavirus do, it’s still not going to work out in their favor from a numbers standpoint,” she said.

The article clarifies the differences for “people who don’t live in the flu world,” she said.

“It is not accurate to compare the two for the reasons the authors described and also because they are very different diseases,” she added.
 

Real-life validation

Dr. Faust said in an interview that real-life experiences add external validity to their analysis.

Differences in the way deaths are calculated does not reflect frontline clinical conditions during the COVID-19 crisis, with hospitals stretched past their limits, ventilator shortages, and bodies stacking up in some overwhelmed facilities, the authors say.

Dr. Temte said the external validation of the numbers also rings true in light of his own experience.

He said that, in the past 2 months, he has known two people who have had family members who died of COVID-19.

Conversely, “I would have to search long and hard to come up with people I have known or have been one degree of separation from” who have died from influenza, Dr. Temte said.

The authors, Dr. Temte, and Dr. Chida report no relevant financial relationships.

This article first appeared on Medscape.com.

The number of COVID-19 deaths cannot be directly compared to the number of seasonal influenza deaths because they are calculated differently, researchers say in a report released today.

Whereas COVID-19 death rates are determined from actual counts of people who have died, seasonal influenza death rates are estimated by the Centers for Disease Control and Prevention (CDC) using population modeling algorithms, explains Jeremy Samuel Faust, MD, with Harvard Medical School and Brigham and Women’s Hospital, Division of Health Policy and Public Health in Boston, Massachusetts.

The CDC estimates that between 24,000 and 62,000 people died from influenza during the 2019-2020 season (through April 4). At the time of the analysis (as of April 28), COVID-19 deaths had reached 65,000 in the United States.

Some government officials and others have said the numbers seem similar and have used the comparison as an argument for reopening certain areas.

But making that comparison “is extremely dangerous,” Faust told Medscape Medical News.

“COVID-19 is far more dangerous and is wreaking far more havoc than seasonal influenza ever has,” he said.

Faust coauthored the perspective article, published online in JAMA Internal Medicine, with Carlos del Rio, MD, Division of Infectious Diseases at Emory University School of Medicine in Atlanta, Georgia.

The message and methodology of Faust’s and del Rio’s article are on target, according to Jonathan L. Temte, MD, PhD, who has been working in influenza surveillance for almost 25 years.

Current flu data draw on limited information from primary care practices and hospitals, said Dr. Temte, associate dean for public health and community engagement at the University of Wisconsin School of Medicine and Public Health in Madison. The estimates help bridge the gaps, he said, but the system is inherently vulnerable to error.

“Comparing them – as so many people in this country have done – to try to diminish the impact of SARS-CoV2 is not fair,” he said.
 

Estimated versus actual influenza deaths

The authors illustrate the difference in the way rates of death from influenza are calculated: “Between 2013-2014 and 2018-2019, the reported yearly estimated influenza deaths ranged from 23,000 to 61,000. Over that same time period, however, the number of counted influenza deaths was between 3,448 and 15,620 yearly.”

“It’s apparent [the CDC has] been overestimating,” Faust said. “If you publish a number on the higher end of the estimate, people might take your public health messages more seriously, such as, it’s important to get your yearly flu shot.”

He added that until influenza death rates started to be compared with COVID-19 rates, “there was never really a downside” to reporting estimates.

Dr. Temte said he doesn’t regard overestimating flu deaths as intentional but rather the result of a longstanding “bias against the elderly in this country” that the estimates are meant to account for.

For example, he says, reporting influenza deaths is mandatory when such deaths involve persons younger than 18 years but not when they involve adults.

Also, traditionally, influenza has been seen “as a cause of death in people with multiple comorbidities that was just part and parcel of wintertime,” Dr. Temte said.

“The likelihood of being tested for influenza goes down greatly when you’re older,” he said. “This is slowly changing.”

The CDC acknowledges on its website that it “does not know the exact number of people who have been sick and affected by influenza because influenza is not a reportable disease in most areas of the US.”

It adds that the burden is estimated through the US Influenza Surveillance System, which covers approximately 8.5% of the US population.
 

Comparing recorded deaths

It’s more accurate and meaningful to compare actual numbers of deaths for the diseases, Dr. Faust and Dr. del Rio say in their article.

When the authors made that comparison, they drew a stark contrast.

There were 15,455 recorded COVID-19 deaths in the week that ended April 21. The week before, the number of recorded deaths was 14,478, they found. (Those were the two most recent weeks before they submitted their article for publication.)

In comparison, counted deaths ranged from 351 to 1,626 during the peak week of the seven influenza seasons between 2013-2014 and 2019-2020. The average counted deaths for the peak week of the seven seasons was 752.4 (95% confidence interval, 558.8-946.1).

“These statistics on counted deaths suggest that the number of COVID-19 deaths for the week ending April 21 was 9.5-fold to 44.1-fold greater than the peak week of counted influenza deaths during the past seven influenza seasons in the US, with a 20.5-fold mean increase (95% CI, 16.3-27.7),” the authors write.

However, Natasha Chida, MD, MSPH, an infectious disease physician and assistant professor at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said in an interview that the actual number of deaths doesn’t tell the complete flu story either. That count would miss people who later died from secondary complications associated with influenza, she said.

“There’s just no way to reliably count influenza deaths,” she said. “I think if we required it as a reported illness, that would be the ideal situation, but there’s so much flu every year that that probably would not be practical.”

She said she agrees that rates of influenza deaths and rates of COVID-19 deaths cannot be fairly compared.

What the authors don’t touch on, she said, is that flu season lasts 4 to 6 months a year, and just 3 months into the coronavirus pandemic, US deaths due to COVID-19 are already higher than those for seasonal influenza.

“Even if we look at it in the way that people who think we can compare flu and coronavirus do, it’s still not going to work out in their favor from a numbers standpoint,” she said.

The article clarifies the differences for “people who don’t live in the flu world,” she said.

“It is not accurate to compare the two for the reasons the authors described and also because they are very different diseases,” she added.
 

Real-life validation

Dr. Faust said in an interview that real-life experiences add external validity to their analysis.

Differences in the way deaths are calculated does not reflect frontline clinical conditions during the COVID-19 crisis, with hospitals stretched past their limits, ventilator shortages, and bodies stacking up in some overwhelmed facilities, the authors say.

Dr. Temte said the external validation of the numbers also rings true in light of his own experience.

He said that, in the past 2 months, he has known two people who have had family members who died of COVID-19.

Conversely, “I would have to search long and hard to come up with people I have known or have been one degree of separation from” who have died from influenza, Dr. Temte said.

The authors, Dr. Temte, and Dr. Chida report no relevant financial relationships.

This article first appeared on Medscape.com.

The number of COVID-19 deaths cannot be directly compared to the number of seasonal influenza deaths because they are calculated differently, researchers say in a report released today.

Whereas COVID-19 death rates are determined from actual counts of people who have died, seasonal influenza death rates are estimated by the Centers for Disease Control and Prevention (CDC) using population modeling algorithms, explains Jeremy Samuel Faust, MD, with Harvard Medical School and Brigham and Women’s Hospital, Division of Health Policy and Public Health in Boston, Massachusetts.

The CDC estimates that between 24,000 and 62,000 people died from influenza during the 2019-2020 season (through April 4). At the time of the analysis (as of April 28), COVID-19 deaths had reached 65,000 in the United States.

Some government officials and others have said the numbers seem similar and have used the comparison as an argument for reopening certain areas.

But making that comparison “is extremely dangerous,” Faust told Medscape Medical News.

“COVID-19 is far more dangerous and is wreaking far more havoc than seasonal influenza ever has,” he said.

Faust coauthored the perspective article, published online in JAMA Internal Medicine, with Carlos del Rio, MD, Division of Infectious Diseases at Emory University School of Medicine in Atlanta, Georgia.

The message and methodology of Faust’s and del Rio’s article are on target, according to Jonathan L. Temte, MD, PhD, who has been working in influenza surveillance for almost 25 years.

Current flu data draw on limited information from primary care practices and hospitals, said Dr. Temte, associate dean for public health and community engagement at the University of Wisconsin School of Medicine and Public Health in Madison. The estimates help bridge the gaps, he said, but the system is inherently vulnerable to error.

“Comparing them – as so many people in this country have done – to try to diminish the impact of SARS-CoV2 is not fair,” he said.
 

Estimated versus actual influenza deaths

The authors illustrate the difference in the way rates of death from influenza are calculated: “Between 2013-2014 and 2018-2019, the reported yearly estimated influenza deaths ranged from 23,000 to 61,000. Over that same time period, however, the number of counted influenza deaths was between 3,448 and 15,620 yearly.”

“It’s apparent [the CDC has] been overestimating,” Faust said. “If you publish a number on the higher end of the estimate, people might take your public health messages more seriously, such as, it’s important to get your yearly flu shot.”

He added that until influenza death rates started to be compared with COVID-19 rates, “there was never really a downside” to reporting estimates.

Dr. Temte said he doesn’t regard overestimating flu deaths as intentional but rather the result of a longstanding “bias against the elderly in this country” that the estimates are meant to account for.

For example, he says, reporting influenza deaths is mandatory when such deaths involve persons younger than 18 years but not when they involve adults.

Also, traditionally, influenza has been seen “as a cause of death in people with multiple comorbidities that was just part and parcel of wintertime,” Dr. Temte said.

“The likelihood of being tested for influenza goes down greatly when you’re older,” he said. “This is slowly changing.”

The CDC acknowledges on its website that it “does not know the exact number of people who have been sick and affected by influenza because influenza is not a reportable disease in most areas of the US.”

It adds that the burden is estimated through the US Influenza Surveillance System, which covers approximately 8.5% of the US population.
 

Comparing recorded deaths

It’s more accurate and meaningful to compare actual numbers of deaths for the diseases, Dr. Faust and Dr. del Rio say in their article.

When the authors made that comparison, they drew a stark contrast.

There were 15,455 recorded COVID-19 deaths in the week that ended April 21. The week before, the number of recorded deaths was 14,478, they found. (Those were the two most recent weeks before they submitted their article for publication.)

In comparison, counted deaths ranged from 351 to 1,626 during the peak week of the seven influenza seasons between 2013-2014 and 2019-2020. The average counted deaths for the peak week of the seven seasons was 752.4 (95% confidence interval, 558.8-946.1).

“These statistics on counted deaths suggest that the number of COVID-19 deaths for the week ending April 21 was 9.5-fold to 44.1-fold greater than the peak week of counted influenza deaths during the past seven influenza seasons in the US, with a 20.5-fold mean increase (95% CI, 16.3-27.7),” the authors write.

However, Natasha Chida, MD, MSPH, an infectious disease physician and assistant professor at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said in an interview that the actual number of deaths doesn’t tell the complete flu story either. That count would miss people who later died from secondary complications associated with influenza, she said.

“There’s just no way to reliably count influenza deaths,” she said. “I think if we required it as a reported illness, that would be the ideal situation, but there’s so much flu every year that that probably would not be practical.”

She said she agrees that rates of influenza deaths and rates of COVID-19 deaths cannot be fairly compared.

What the authors don’t touch on, she said, is that flu season lasts 4 to 6 months a year, and just 3 months into the coronavirus pandemic, US deaths due to COVID-19 are already higher than those for seasonal influenza.

“Even if we look at it in the way that people who think we can compare flu and coronavirus do, it’s still not going to work out in their favor from a numbers standpoint,” she said.

The article clarifies the differences for “people who don’t live in the flu world,” she said.

“It is not accurate to compare the two for the reasons the authors described and also because they are very different diseases,” she added.
 

Real-life validation

Dr. Faust said in an interview that real-life experiences add external validity to their analysis.

Differences in the way deaths are calculated does not reflect frontline clinical conditions during the COVID-19 crisis, with hospitals stretched past their limits, ventilator shortages, and bodies stacking up in some overwhelmed facilities, the authors say.

Dr. Temte said the external validation of the numbers also rings true in light of his own experience.

He said that, in the past 2 months, he has known two people who have had family members who died of COVID-19.

Conversely, “I would have to search long and hard to come up with people I have known or have been one degree of separation from” who have died from influenza, Dr. Temte said.

The authors, Dr. Temte, and Dr. Chida report no relevant financial relationships.

This article first appeared on Medscape.com.

Kawasaki disease

Given the presentation of persistent fever, nonpurulent conjunctivitis, cracked lips, erythematous tongue, desquamating perianal rash, and acral edema and erythema, suspicion was high for Kawasaki disease (KD). An echocardiogram revealed diffuse dilation of the left anterior descending artery without evidence of an aneurysm. The patient was promptly started on 2 g/kg IVIG and high-dose aspirin. She was later transitioned to low-dose aspirin. Long-term follow-up thus far has revealed no cardiac sequelae.

KD, or mucocutaneous lymph node syndrome, is a multisystem vasculitis with predilection for the coronary arteries that most commonly affects children between 6 months and 5 years of age.¹ While the etiology remains unclear, the pathogenesis is thought to be the result of an immune response to an infection in the setting of genetic susceptibility.¹ Approximately 90% of patients have mucocutaneous manifestations, highlighting the important role dermatologists play in the diagnosis and early intervention to prevent cardiovascular morbidity.

The diagnostic criteria include fever for at least 5 days accompanied by at least four of the following:

• Bilateral bulbar conjunctival injection without exudate that is classically limbal sparing.
• Oral mucosal changes with cracked fissured lips, “strawberry tongue,” or erythema of the lips and mucosa.
• Changes in the extremities: erythema, swelling, or periungual peeling.
• Polymorphous exanthem.
• Cervical lymphadenopathy, often unilateral (greater than 1.5 cm).

Courtesy Dr. Elizabeth H. Cusick and Dr. Molly E. Plovanich, department of dermatology at the University of Rochester (N.Y.)

Although nonspecific for diagnosis, laboratory abnormalities are common, including anemia, thrombocytosis, leukocytosis, elevated inflammatory markers, elevated alanine aminotransferase (ALT), hypoalbuminemia, and sterile pyuria on urine analysis.¹

Notably, a classic finding of KD is perineal dermatitis with desquamation occurring in the acute phase of disease in 80%-90% of patients.^2-5 In a retrospective review, up to 67% of patients with KD developed a perineal rash in the first week, most often beginning in the diaper area.² The perineal rash classically desquamates early during the acute phase of the disease.¹

While most individuals with KD follow a benign disease course, it is the most common cause of acquired heart disease in the United States.¹ Treatment is aimed at decreasing the risk of developing coronary abnormalities through the prompt administration of IVIG and high-dose aspirin initiated early in the acute phase.⁶ A second dose of IVIG may be given to patients who remain febrile within 24-48 hours after treatment.⁶ Infliximab has been used safely and effectively in patients with refractory KD.⁷ Long-term cardiac follow-up of KD patients is recommended.

Recently, there has been an emerging association between COVID-19 and pediatric multi-system inflammatory syndrome, which shares features with KD. Patients with pediatric multi-system inflammatory syndrome who meet clinical criteria for KD should be promptly treated with IVIG and aspirin to avoid long-term cardiac sequelae.

This case and the photos were submitted by Dr. Elizabeth H. Cusick and Dr. Molly E. Plovanich, both with the department of dermatology at the University of Rochester (N.Y.). Dr. Donna Bilu Martin edited the case.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1. Bayers S et al. (2013). J Am Acad Dermatol. 2013 Oct;69(4):501.e1-11.

2. Friter BS and Lucky AW. Arch Dermatol. 1988 Dec;124(12):1805-10.

3. Urbach AH et al. Am J Dis Child. 1988 Nov;142(11):1174-6.

4. Fink CW. Pediatr Infect Dis. 1983 Mar-Apr; 2(2):140-1.

5. Aballi A J and Bisken LC. Pediatr Infect Dis. 1984 Mar-Apr;3(2):187.

6. McCrindle BW et al. Circulation. 2017 Apr 25;135(17):e927-e99.

7.Sauvaget E et al. J Pediatr. 2012 May; 160(5),875-6.


 

Kawasaki disease

Given the presentation of persistent fever, nonpurulent conjunctivitis, cracked lips, erythematous tongue, desquamating perianal rash, and acral edema and erythema, suspicion was high for Kawasaki disease (KD). An echocardiogram revealed diffuse dilation of the left anterior descending artery without evidence of an aneurysm. The patient was promptly started on 2 g/kg IVIG and high-dose aspirin. She was later transitioned to low-dose aspirin. Long-term follow-up thus far has revealed no cardiac sequelae.

KD, or mucocutaneous lymph node syndrome, is a multisystem vasculitis with predilection for the coronary arteries that most commonly affects children between 6 months and 5 years of age.¹ While the etiology remains unclear, the pathogenesis is thought to be the result of an immune response to an infection in the setting of genetic susceptibility.¹ Approximately 90% of patients have mucocutaneous manifestations, highlighting the important role dermatologists play in the diagnosis and early intervention to prevent cardiovascular morbidity.

The diagnostic criteria include fever for at least 5 days accompanied by at least four of the following:

• Bilateral bulbar conjunctival injection without exudate that is classically limbal sparing.
• Oral mucosal changes with cracked fissured lips, “strawberry tongue,” or erythema of the lips and mucosa.
• Changes in the extremities: erythema, swelling, or periungual peeling.
• Polymorphous exanthem.
• Cervical lymphadenopathy, often unilateral (greater than 1.5 cm).

Courtesy Dr. Elizabeth H. Cusick and Dr. Molly E. Plovanich, department of dermatology at the University of Rochester (N.Y.)

Although nonspecific for diagnosis, laboratory abnormalities are common, including anemia, thrombocytosis, leukocytosis, elevated inflammatory markers, elevated alanine aminotransferase (ALT), hypoalbuminemia, and sterile pyuria on urine analysis.¹

Notably, a classic finding of KD is perineal dermatitis with desquamation occurring in the acute phase of disease in 80%-90% of patients.^2-5 In a retrospective review, up to 67% of patients with KD developed a perineal rash in the first week, most often beginning in the diaper area.² The perineal rash classically desquamates early during the acute phase of the disease.¹

While most individuals with KD follow a benign disease course, it is the most common cause of acquired heart disease in the United States.¹ Treatment is aimed at decreasing the risk of developing coronary abnormalities through the prompt administration of IVIG and high-dose aspirin initiated early in the acute phase.⁶ A second dose of IVIG may be given to patients who remain febrile within 24-48 hours after treatment.⁶ Infliximab has been used safely and effectively in patients with refractory KD.⁷ Long-term cardiac follow-up of KD patients is recommended.

Recently, there has been an emerging association between COVID-19 and pediatric multi-system inflammatory syndrome, which shares features with KD. Patients with pediatric multi-system inflammatory syndrome who meet clinical criteria for KD should be promptly treated with IVIG and aspirin to avoid long-term cardiac sequelae.

This case and the photos were submitted by Dr. Elizabeth H. Cusick and Dr. Molly E. Plovanich, both with the department of dermatology at the University of Rochester (N.Y.). Dr. Donna Bilu Martin edited the case.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1. Bayers S et al. (2013). J Am Acad Dermatol. 2013 Oct;69(4):501.e1-11.

2. Friter BS and Lucky AW. Arch Dermatol. 1988 Dec;124(12):1805-10.

3. Urbach AH et al. Am J Dis Child. 1988 Nov;142(11):1174-6.

4. Fink CW. Pediatr Infect Dis. 1983 Mar-Apr; 2(2):140-1.

5. Aballi A J and Bisken LC. Pediatr Infect Dis. 1984 Mar-Apr;3(2):187.

6. McCrindle BW et al. Circulation. 2017 Apr 25;135(17):e927-e99.

7.Sauvaget E et al. J Pediatr. 2012 May; 160(5),875-6.


 

Kawasaki disease

Given the presentation of persistent fever, nonpurulent conjunctivitis, cracked lips, erythematous tongue, desquamating perianal rash, and acral edema and erythema, suspicion was high for Kawasaki disease (KD). An echocardiogram revealed diffuse dilation of the left anterior descending artery without evidence of an aneurysm. The patient was promptly started on 2 g/kg IVIG and high-dose aspirin. She was later transitioned to low-dose aspirin. Long-term follow-up thus far has revealed no cardiac sequelae.

KD, or mucocutaneous lymph node syndrome, is a multisystem vasculitis with predilection for the coronary arteries that most commonly affects children between 6 months and 5 years of age.¹ While the etiology remains unclear, the pathogenesis is thought to be the result of an immune response to an infection in the setting of genetic susceptibility.¹ Approximately 90% of patients have mucocutaneous manifestations, highlighting the important role dermatologists play in the diagnosis and early intervention to prevent cardiovascular morbidity.

The diagnostic criteria include fever for at least 5 days accompanied by at least four of the following:

• Bilateral bulbar conjunctival injection without exudate that is classically limbal sparing.
• Oral mucosal changes with cracked fissured lips, “strawberry tongue,” or erythema of the lips and mucosa.
• Changes in the extremities: erythema, swelling, or periungual peeling.
• Polymorphous exanthem.
• Cervical lymphadenopathy, often unilateral (greater than 1.5 cm).

Courtesy Dr. Elizabeth H. Cusick and Dr. Molly E. Plovanich, department of dermatology at the University of Rochester (N.Y.)

Although nonspecific for diagnosis, laboratory abnormalities are common, including anemia, thrombocytosis, leukocytosis, elevated inflammatory markers, elevated alanine aminotransferase (ALT), hypoalbuminemia, and sterile pyuria on urine analysis.¹

Notably, a classic finding of KD is perineal dermatitis with desquamation occurring in the acute phase of disease in 80%-90% of patients.^2-5 In a retrospective review, up to 67% of patients with KD developed a perineal rash in the first week, most often beginning in the diaper area.² The perineal rash classically desquamates early during the acute phase of the disease.¹

While most individuals with KD follow a benign disease course, it is the most common cause of acquired heart disease in the United States.¹ Treatment is aimed at decreasing the risk of developing coronary abnormalities through the prompt administration of IVIG and high-dose aspirin initiated early in the acute phase.⁶ A second dose of IVIG may be given to patients who remain febrile within 24-48 hours after treatment.⁶ Infliximab has been used safely and effectively in patients with refractory KD.⁷ Long-term cardiac follow-up of KD patients is recommended.

Recently, there has been an emerging association between COVID-19 and pediatric multi-system inflammatory syndrome, which shares features with KD. Patients with pediatric multi-system inflammatory syndrome who meet clinical criteria for KD should be promptly treated with IVIG and aspirin to avoid long-term cardiac sequelae.

This case and the photos were submitted by Dr. Elizabeth H. Cusick and Dr. Molly E. Plovanich, both with the department of dermatology at the University of Rochester (N.Y.). Dr. Donna Bilu Martin edited the case.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1. Bayers S et al. (2013). J Am Acad Dermatol. 2013 Oct;69(4):501.e1-11.

2. Friter BS and Lucky AW. Arch Dermatol. 1988 Dec;124(12):1805-10.

3. Urbach AH et al. Am J Dis Child. 1988 Nov;142(11):1174-6.

4. Fink CW. Pediatr Infect Dis. 1983 Mar-Apr; 2(2):140-1.

5. Aballi A J and Bisken LC. Pediatr Infect Dis. 1984 Mar-Apr;3(2):187.

6. McCrindle BW et al. Circulation. 2017 Apr 25;135(17):e927-e99.

7.Sauvaget E et al. J Pediatr. 2012 May; 160(5),875-6.


 

An allergist and a pediatric pulmonologist cautioned colleagues that COVID-19 could be spawning hazardous behavior as patients question whether they should continue using immune-suppressing drugs during the pandemic.

“In fact, there’s no data to support this at this time. Maintaining adequate asthma control is the current CDC recommendation,” said pediatric pulmonologist John Carl, MD, of Cleveland Clinic Children’s Hospital. Patients, he said, should be advised to “follow your asthma action plan as outlined by your primary care or specialty clinician and communicate about evolving symptoms, such as fever rather than just congestion, wheezing, and coughing, etc.”

Dr. Carl spoke in a May 7 webinar about asthma and COVID-19 with Lakiea Wright, M.D., a physician specializing in internal medicine and allergy and immunology at Brigham and Women’s Hospital in Boston and medical director of clinical affairs for Thermo Fisher Scientific’s ImmunoDiagnostics division. The webinar, sponsored by Thermo Fisher Scientific, included discussion of COVID-19 risks, disease management, and distinguishing between the virus and asthma.

In a follow-up interview, Dr. Wright said she’s hearing from patients and parents who are concerned about whether people with asthma face a higher risk of COVID-19 infection. There’s no evidence that they do, she said, but “the CDC states that individuals with moderate to severe asthma may be higher risk for moderate to severe disease from COVID-19 if they were to become infected.”

Indeed, she said, “it is well established that viruses can trigger asthma.” But, as she also noted, early research about the risk in patients with asthma is conflicting.

“Some studies suggest asthma may be a risk factor for hospitalization while other data suggests asthma is not a common risk factor for those hospitalized,” Dr. Wright said.

She highlighted a recent study that suggests people with allergic asthma have “a reduced ACE2 gene expression in airway cells and thus decreased susceptibility to infection” by the novel coronavirus (J Allergy Clin Immunol. 2020 Apr 22. doi: 10.1016/j.jaci.2020.04.009).

Dr. Wright cautioned, however, that “this is a hypothesis and will need to be studied more.”

For now, she said, patients “should follow their asthma action plan and take their inhalers, including inhaled corticosteroids, as prescribed by their health care providers.”

Most patients are reasonable and do comply when their physicians explain why they should take a medication,” she noted.

Dr. Carl agreed, and added that a short course of oral corticosteroids are also recommended to manage minor exacerbations and “prevent patients from having to arrive as inpatients in more acute settings and risk health system–related exposures to the current pandemic.”

He cautioned, however, that metered-dose inhalers are preferable to nebulizers, and side vent ports should be avoided since they can aerosolize infectious agents and put health care providers and family members at risk.

Unfortunately, he said, there’s been a shortage of short-acting beta agonist albuterol inhalers. This has been linked to hospitals trying to avoid the use of nebulizers.

Dr. Wright advised colleagues to focus on unique symptoms first, then address overlapping symptoms and other symptoms to differentiate between COVID-19 and asthma/allergy.

She noted that environmental allergy symptoms alone do not cause fever, a hallmark of COVID-19. Shortness of breath can be a distinguishing symptom for the virus, because this is not a common symptom of environmental allergies unless the patient has asthma, Dr. Wright said.

Cough can be an overlapping symptom because in environmental allergies, postnasal drip from allergic rhinitis can trigger cough, she explained. Nasal congestion and/or runny nose can develop with viral illnesses in general, but these are symptoms not included in the CDC’s list of the most common COVID-19 symptoms. Severe fatigue and body aches aren’t symptoms consistent with environmental allergies, Dr. Wright said.

Both Dr. Carl and Dr. Wright emphasized the importance of continuing routine asthma therapy during the pandemic.

“When discussing the importance of taking their inhaled steroids with patients, I also remind patients that asthma management is comprehensive,” Dr. Wright said. “I want them to take their medications, but I also want them avoid or minimize exposure to triggers. Allergic and nonallergic triggers such as environmental tobacco smoke can exacerbate asthma.”

In addition, she said, “it’s important to take a detailed medical history to identify triggers. And it’s important to conduct allergy testing to common environmental allergens to help identify allergic triggers and tailor environmental allergen control strategies based on the results. All of these strategies help patients keep their asthma well-controlled.”

Dr. Carl and Dr. Wright report having no relevant disclosures.

An allergist and a pediatric pulmonologist cautioned colleagues that COVID-19 could be spawning hazardous behavior as patients question whether they should continue using immune-suppressing drugs during the pandemic.

“In fact, there’s no data to support this at this time. Maintaining adequate asthma control is the current CDC recommendation,” said pediatric pulmonologist John Carl, MD, of Cleveland Clinic Children’s Hospital. Patients, he said, should be advised to “follow your asthma action plan as outlined by your primary care or specialty clinician and communicate about evolving symptoms, such as fever rather than just congestion, wheezing, and coughing, etc.”

Dr. Carl spoke in a May 7 webinar about asthma and COVID-19 with Lakiea Wright, M.D., a physician specializing in internal medicine and allergy and immunology at Brigham and Women’s Hospital in Boston and medical director of clinical affairs for Thermo Fisher Scientific’s ImmunoDiagnostics division. The webinar, sponsored by Thermo Fisher Scientific, included discussion of COVID-19 risks, disease management, and distinguishing between the virus and asthma.

In a follow-up interview, Dr. Wright said she’s hearing from patients and parents who are concerned about whether people with asthma face a higher risk of COVID-19 infection. There’s no evidence that they do, she said, but “the CDC states that individuals with moderate to severe asthma may be higher risk for moderate to severe disease from COVID-19 if they were to become infected.”

Indeed, she said, “it is well established that viruses can trigger asthma.” But, as she also noted, early research about the risk in patients with asthma is conflicting.

“Some studies suggest asthma may be a risk factor for hospitalization while other data suggests asthma is not a common risk factor for those hospitalized,” Dr. Wright said.

She highlighted a recent study that suggests people with allergic asthma have “a reduced ACE2 gene expression in airway cells and thus decreased susceptibility to infection” by the novel coronavirus (J Allergy Clin Immunol. 2020 Apr 22. doi: 10.1016/j.jaci.2020.04.009).

Dr. Wright cautioned, however, that “this is a hypothesis and will need to be studied more.”

For now, she said, patients “should follow their asthma action plan and take their inhalers, including inhaled corticosteroids, as prescribed by their health care providers.”

Most patients are reasonable and do comply when their physicians explain why they should take a medication,” she noted.

Dr. Carl agreed, and added that a short course of oral corticosteroids are also recommended to manage minor exacerbations and “prevent patients from having to arrive as inpatients in more acute settings and risk health system–related exposures to the current pandemic.”

He cautioned, however, that metered-dose inhalers are preferable to nebulizers, and side vent ports should be avoided since they can aerosolize infectious agents and put health care providers and family members at risk.

Unfortunately, he said, there’s been a shortage of short-acting beta agonist albuterol inhalers. This has been linked to hospitals trying to avoid the use of nebulizers.

Dr. Wright advised colleagues to focus on unique symptoms first, then address overlapping symptoms and other symptoms to differentiate between COVID-19 and asthma/allergy.

She noted that environmental allergy symptoms alone do not cause fever, a hallmark of COVID-19. Shortness of breath can be a distinguishing symptom for the virus, because this is not a common symptom of environmental allergies unless the patient has asthma, Dr. Wright said.

Cough can be an overlapping symptom because in environmental allergies, postnasal drip from allergic rhinitis can trigger cough, she explained. Nasal congestion and/or runny nose can develop with viral illnesses in general, but these are symptoms not included in the CDC’s list of the most common COVID-19 symptoms. Severe fatigue and body aches aren’t symptoms consistent with environmental allergies, Dr. Wright said.

Both Dr. Carl and Dr. Wright emphasized the importance of continuing routine asthma therapy during the pandemic.

“When discussing the importance of taking their inhaled steroids with patients, I also remind patients that asthma management is comprehensive,” Dr. Wright said. “I want them to take their medications, but I also want them avoid or minimize exposure to triggers. Allergic and nonallergic triggers such as environmental tobacco smoke can exacerbate asthma.”

In addition, she said, “it’s important to take a detailed medical history to identify triggers. And it’s important to conduct allergy testing to common environmental allergens to help identify allergic triggers and tailor environmental allergen control strategies based on the results. All of these strategies help patients keep their asthma well-controlled.”

Dr. Carl and Dr. Wright report having no relevant disclosures.

An allergist and a pediatric pulmonologist cautioned colleagues that COVID-19 could be spawning hazardous behavior as patients question whether they should continue using immune-suppressing drugs during the pandemic.

“In fact, there’s no data to support this at this time. Maintaining adequate asthma control is the current CDC recommendation,” said pediatric pulmonologist John Carl, MD, of Cleveland Clinic Children’s Hospital. Patients, he said, should be advised to “follow your asthma action plan as outlined by your primary care or specialty clinician and communicate about evolving symptoms, such as fever rather than just congestion, wheezing, and coughing, etc.”

Dr. Carl spoke in a May 7 webinar about asthma and COVID-19 with Lakiea Wright, M.D., a physician specializing in internal medicine and allergy and immunology at Brigham and Women’s Hospital in Boston and medical director of clinical affairs for Thermo Fisher Scientific’s ImmunoDiagnostics division. The webinar, sponsored by Thermo Fisher Scientific, included discussion of COVID-19 risks, disease management, and distinguishing between the virus and asthma.

In a follow-up interview, Dr. Wright said she’s hearing from patients and parents who are concerned about whether people with asthma face a higher risk of COVID-19 infection. There’s no evidence that they do, she said, but “the CDC states that individuals with moderate to severe asthma may be higher risk for moderate to severe disease from COVID-19 if they were to become infected.”

Indeed, she said, “it is well established that viruses can trigger asthma.” But, as she also noted, early research about the risk in patients with asthma is conflicting.

“Some studies suggest asthma may be a risk factor for hospitalization while other data suggests asthma is not a common risk factor for those hospitalized,” Dr. Wright said.

She highlighted a recent study that suggests people with allergic asthma have “a reduced ACE2 gene expression in airway cells and thus decreased susceptibility to infection” by the novel coronavirus (J Allergy Clin Immunol. 2020 Apr 22. doi: 10.1016/j.jaci.2020.04.009).

Dr. Wright cautioned, however, that “this is a hypothesis and will need to be studied more.”

For now, she said, patients “should follow their asthma action plan and take their inhalers, including inhaled corticosteroids, as prescribed by their health care providers.”

Most patients are reasonable and do comply when their physicians explain why they should take a medication,” she noted.

Dr. Carl agreed, and added that a short course of oral corticosteroids are also recommended to manage minor exacerbations and “prevent patients from having to arrive as inpatients in more acute settings and risk health system–related exposures to the current pandemic.”

He cautioned, however, that metered-dose inhalers are preferable to nebulizers, and side vent ports should be avoided since they can aerosolize infectious agents and put health care providers and family members at risk.

Unfortunately, he said, there’s been a shortage of short-acting beta agonist albuterol inhalers. This has been linked to hospitals trying to avoid the use of nebulizers.

Dr. Wright advised colleagues to focus on unique symptoms first, then address overlapping symptoms and other symptoms to differentiate between COVID-19 and asthma/allergy.

She noted that environmental allergy symptoms alone do not cause fever, a hallmark of COVID-19. Shortness of breath can be a distinguishing symptom for the virus, because this is not a common symptom of environmental allergies unless the patient has asthma, Dr. Wright said.

Cough can be an overlapping symptom because in environmental allergies, postnasal drip from allergic rhinitis can trigger cough, she explained. Nasal congestion and/or runny nose can develop with viral illnesses in general, but these are symptoms not included in the CDC’s list of the most common COVID-19 symptoms. Severe fatigue and body aches aren’t symptoms consistent with environmental allergies, Dr. Wright said.

Both Dr. Carl and Dr. Wright emphasized the importance of continuing routine asthma therapy during the pandemic.

“When discussing the importance of taking their inhaled steroids with patients, I also remind patients that asthma management is comprehensive,” Dr. Wright said. “I want them to take their medications, but I also want them avoid or minimize exposure to triggers. Allergic and nonallergic triggers such as environmental tobacco smoke can exacerbate asthma.”

In addition, she said, “it’s important to take a detailed medical history to identify triggers. And it’s important to conduct allergy testing to common environmental allergens to help identify allergic triggers and tailor environmental allergen control strategies based on the results. All of these strategies help patients keep their asthma well-controlled.”

Dr. Carl and Dr. Wright report having no relevant disclosures.

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children’s health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

ArtMarie/E+

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can’t interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents’ attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer’s expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.
 

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don’t get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren’t overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children’s level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don’t shame or punish them. Just invite them again the next night!

What are going to be the consequences of all this screen time?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures. Email them at [email protected].

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children’s health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

ArtMarie/E+

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can’t interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents’ attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer’s expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.
 

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don’t get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren’t overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children’s level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don’t shame or punish them. Just invite them again the next night!

What are going to be the consequences of all this screen time?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures. Email them at [email protected].

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children’s health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

ArtMarie/E+

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can’t interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents’ attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer’s expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.
 

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don’t get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren’t overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children’s level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don’t shame or punish them. Just invite them again the next night!

What are going to be the consequences of all this screen time?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures. Email them at [email protected].

Productivity benchmarks for physicians are likely to be lowered in light of plunging patient numbers from COVID-19, and bonuses are expected to take a hit, according to experts interviewed by Medscape.

“Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., told Medscape Medical News.

“This amounts to salary reductions of 10% to 30%,” he said.

The COVID-19 crisis dramatically reversed the consistent upward trajectory of physician compensation, according to a Medical Group Management Association (MGMA) survey, as reported by Medscape Medical News.

The survey, conducted April 7-8, found that practices have reported an average 55% drop in income. The report also found an average decrease in patient volume of 60%.

Before pandemic, salaries were rising

The pandemic interrupted a steady gain in compensation for this year compared to last, according to the Medscape Physician Compensation Report 2020.

The report reflects data gathered from October 4, 2019, to February 10, 2020, and includes online survey responses from 17,000 physicians in more than 30 specialties.

Before the pandemic, primary care physician (PCP) pay was up 2.5%, to $243,000, from the previous year’s average of $237,000. Specialists saw a 1.5% increase, from $341,000 in 2019 to $346,000 this year.

Reported compensation for employed physicians included salary, bonus, and profit-sharing contributions. For those self-employed, compensation includes earnings after taxes and deductible business expenses before income tax.

This report reflects only full-time salaries. But most physicians work more than full time. The report notes that physicians overall spent 37.8 hours a week seeing patients. Add to that the 15.6 average hours spent on paperwork, and doctors are averaging 53.4 hours a week.

Administrative demands varied widely by specialty. Physicians in critical care, for example, spent the most hours on paperwork (19.1 per week), and ophthalmologists spent the least on those tasks, at 9.8.

Orthopedists top earners again

The top four specialties were the same this year as they were last year and were ranked in the same order: orthopedists made the most, at $511,000, followed by plastic surgeons, at $479,000, otolaryngologists, at $455,000, and cardiologists, at $438,000.

Pediatricians and public health/preventive medicine physicians made the least, at $232,000, followed by family physicians ($234,000) and diabetes/endocrinology specialists ($236,000).

Despite the low ranking, public health/preventive medicine providers had the biggest compensation increase of all physicians, up 11% from last year. Two specialties saw a decrease: otolaryngology salaries dropped 1%, and dermatology pay dropped 2%. Pay in gastroenterology and diabetes/endocrinology was virtually unchanged from last year.

Kentucky has highest pay

Ranked by state, physicians in Kentucky made the most on average ($346,000). Utah, Ohio, and North Carolina were new to the top 10 in physician pay this year, pushing out Connecticut, Arkansas, and Nevada.

More than half of all physicians receive incentive bonuses (58% of PCPs and 55% of specialists).

The average incentive bonus is 13% of salary, but that varies by specialty. Orthopedists got an average $96,000 bonus, whereas family physicians got $24,000.

According to the report, “Among physicians who have an incentive bonus, about a third of both PCPs and specialists say the prospect of an incentive bonus has encouraged them to work longer hours.”

Gender gap similar to previous year

Consistent with Medscape compensation reports over the past decade, this year’s report shows a large gender gap in pay. Among PCPs, men made 25% more than women ($264,000 vs. $212,000); among specialists, they made 31% more than their female colleagues ($375,000 vs. $286,000).

Some specialties report positive changes from growing awareness of the gap.

“Many organizations have been carefully analyzing their culture, transparency, and pay practices to make sure they aren’t unintentionally discriminating against any group of employees,” Halee Fischer-Wright, MD, pediatrician and CEO of MGMA, told Medscape Medical News.

She added that the growing physician shortage has given all physicians more leverage in salary demands and that increased recognition of the gender gap is giving women more confidence and more evidence to use in negotiations.

Three specialties have seen large increases in the past 5 years in the percentage of women physicians. Obstetrics/gynecology and pediatrics both saw increases from 50% in 2015 to 58% in 2020. Additionally, women now account for 54% of rheumatologists, up from 29% in 2015.

Would you choose your specialty again?

Of responding physicians who were asked if they would choose their specialty again, internists were least likely to say yes (66%), followed by nephrologists (69%) and family physicians (70%).

Orthopedists were most likely to say they would choose the same specialty (97%), followed by oncologists (96%) and ophthalmologists and dermatologists (both at 95%).

Most physicians overall (77%) said they would choose medicine again.

Despite aggravations and pressures, in this survey and in previous years, physicians have indicated that the top rewards are “gratitude/relationships with patients,” “being very good at what I do/finding answers, diagnoses,” and “knowing that I make the world a better place.” From 24% to 27% ranked those rewards most important.

“Making good money at a job I like” came in fourth, at 12%.

This article first appeared on Medscape.com.

Productivity benchmarks for physicians are likely to be lowered in light of plunging patient numbers from COVID-19, and bonuses are expected to take a hit, according to experts interviewed by Medscape.

“Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., told Medscape Medical News.

“This amounts to salary reductions of 10% to 30%,” he said.

The COVID-19 crisis dramatically reversed the consistent upward trajectory of physician compensation, according to a Medical Group Management Association (MGMA) survey, as reported by Medscape Medical News.

The survey, conducted April 7-8, found that practices have reported an average 55% drop in income. The report also found an average decrease in patient volume of 60%.

Before pandemic, salaries were rising

The pandemic interrupted a steady gain in compensation for this year compared to last, according to the Medscape Physician Compensation Report 2020.

The report reflects data gathered from October 4, 2019, to February 10, 2020, and includes online survey responses from 17,000 physicians in more than 30 specialties.

Before the pandemic, primary care physician (PCP) pay was up 2.5%, to $243,000, from the previous year’s average of $237,000. Specialists saw a 1.5% increase, from $341,000 in 2019 to $346,000 this year.

Reported compensation for employed physicians included salary, bonus, and profit-sharing contributions. For those self-employed, compensation includes earnings after taxes and deductible business expenses before income tax.

This report reflects only full-time salaries. But most physicians work more than full time. The report notes that physicians overall spent 37.8 hours a week seeing patients. Add to that the 15.6 average hours spent on paperwork, and doctors are averaging 53.4 hours a week.

Administrative demands varied widely by specialty. Physicians in critical care, for example, spent the most hours on paperwork (19.1 per week), and ophthalmologists spent the least on those tasks, at 9.8.

Orthopedists top earners again

The top four specialties were the same this year as they were last year and were ranked in the same order: orthopedists made the most, at $511,000, followed by plastic surgeons, at $479,000, otolaryngologists, at $455,000, and cardiologists, at $438,000.

Pediatricians and public health/preventive medicine physicians made the least, at $232,000, followed by family physicians ($234,000) and diabetes/endocrinology specialists ($236,000).

Despite the low ranking, public health/preventive medicine providers had the biggest compensation increase of all physicians, up 11% from last year. Two specialties saw a decrease: otolaryngology salaries dropped 1%, and dermatology pay dropped 2%. Pay in gastroenterology and diabetes/endocrinology was virtually unchanged from last year.

Kentucky has highest pay

Ranked by state, physicians in Kentucky made the most on average ($346,000). Utah, Ohio, and North Carolina were new to the top 10 in physician pay this year, pushing out Connecticut, Arkansas, and Nevada.

More than half of all physicians receive incentive bonuses (58% of PCPs and 55% of specialists).

The average incentive bonus is 13% of salary, but that varies by specialty. Orthopedists got an average $96,000 bonus, whereas family physicians got $24,000.

According to the report, “Among physicians who have an incentive bonus, about a third of both PCPs and specialists say the prospect of an incentive bonus has encouraged them to work longer hours.”

Gender gap similar to previous year

Consistent with Medscape compensation reports over the past decade, this year’s report shows a large gender gap in pay. Among PCPs, men made 25% more than women ($264,000 vs. $212,000); among specialists, they made 31% more than their female colleagues ($375,000 vs. $286,000).

Some specialties report positive changes from growing awareness of the gap.

“Many organizations have been carefully analyzing their culture, transparency, and pay practices to make sure they aren’t unintentionally discriminating against any group of employees,” Halee Fischer-Wright, MD, pediatrician and CEO of MGMA, told Medscape Medical News.

She added that the growing physician shortage has given all physicians more leverage in salary demands and that increased recognition of the gender gap is giving women more confidence and more evidence to use in negotiations.

Three specialties have seen large increases in the past 5 years in the percentage of women physicians. Obstetrics/gynecology and pediatrics both saw increases from 50% in 2015 to 58% in 2020. Additionally, women now account for 54% of rheumatologists, up from 29% in 2015.

Would you choose your specialty again?

Of responding physicians who were asked if they would choose their specialty again, internists were least likely to say yes (66%), followed by nephrologists (69%) and family physicians (70%).

Orthopedists were most likely to say they would choose the same specialty (97%), followed by oncologists (96%) and ophthalmologists and dermatologists (both at 95%).

Most physicians overall (77%) said they would choose medicine again.

Despite aggravations and pressures, in this survey and in previous years, physicians have indicated that the top rewards are “gratitude/relationships with patients,” “being very good at what I do/finding answers, diagnoses,” and “knowing that I make the world a better place.” From 24% to 27% ranked those rewards most important.

“Making good money at a job I like” came in fourth, at 12%.

This article first appeared on Medscape.com.

Productivity benchmarks for physicians are likely to be lowered in light of plunging patient numbers from COVID-19, and bonuses are expected to take a hit, according to experts interviewed by Medscape.

“Employed physicians are often getting a guaranteed salary for a month or two, but no bonuses or extra distributions,” Joel Greenwald, MD, a financial adviser for physicians in St. Louis Park, Minn., told Medscape Medical News.

“This amounts to salary reductions of 10% to 30%,” he said.

The COVID-19 crisis dramatically reversed the consistent upward trajectory of physician compensation, according to a Medical Group Management Association (MGMA) survey, as reported by Medscape Medical News.

The survey, conducted April 7-8, found that practices have reported an average 55% drop in income. The report also found an average decrease in patient volume of 60%.

Before pandemic, salaries were rising

The pandemic interrupted a steady gain in compensation for this year compared to last, according to the Medscape Physician Compensation Report 2020.

The report reflects data gathered from October 4, 2019, to February 10, 2020, and includes online survey responses from 17,000 physicians in more than 30 specialties.

Before the pandemic, primary care physician (PCP) pay was up 2.5%, to $243,000, from the previous year’s average of $237,000. Specialists saw a 1.5% increase, from $341,000 in 2019 to $346,000 this year.

Reported compensation for employed physicians included salary, bonus, and profit-sharing contributions. For those self-employed, compensation includes earnings after taxes and deductible business expenses before income tax.

This report reflects only full-time salaries. But most physicians work more than full time. The report notes that physicians overall spent 37.8 hours a week seeing patients. Add to that the 15.6 average hours spent on paperwork, and doctors are averaging 53.4 hours a week.

Administrative demands varied widely by specialty. Physicians in critical care, for example, spent the most hours on paperwork (19.1 per week), and ophthalmologists spent the least on those tasks, at 9.8.

Orthopedists top earners again

The top four specialties were the same this year as they were last year and were ranked in the same order: orthopedists made the most, at $511,000, followed by plastic surgeons, at $479,000, otolaryngologists, at $455,000, and cardiologists, at $438,000.

Pediatricians and public health/preventive medicine physicians made the least, at $232,000, followed by family physicians ($234,000) and diabetes/endocrinology specialists ($236,000).

Despite the low ranking, public health/preventive medicine providers had the biggest compensation increase of all physicians, up 11% from last year. Two specialties saw a decrease: otolaryngology salaries dropped 1%, and dermatology pay dropped 2%. Pay in gastroenterology and diabetes/endocrinology was virtually unchanged from last year.

Kentucky has highest pay

Ranked by state, physicians in Kentucky made the most on average ($346,000). Utah, Ohio, and North Carolina were new to the top 10 in physician pay this year, pushing out Connecticut, Arkansas, and Nevada.

More than half of all physicians receive incentive bonuses (58% of PCPs and 55% of specialists).

The average incentive bonus is 13% of salary, but that varies by specialty. Orthopedists got an average $96,000 bonus, whereas family physicians got $24,000.

According to the report, “Among physicians who have an incentive bonus, about a third of both PCPs and specialists say the prospect of an incentive bonus has encouraged them to work longer hours.”

Gender gap similar to previous year

Consistent with Medscape compensation reports over the past decade, this year’s report shows a large gender gap in pay. Among PCPs, men made 25% more than women ($264,000 vs. $212,000); among specialists, they made 31% more than their female colleagues ($375,000 vs. $286,000).

Some specialties report positive changes from growing awareness of the gap.

“Many organizations have been carefully analyzing their culture, transparency, and pay practices to make sure they aren’t unintentionally discriminating against any group of employees,” Halee Fischer-Wright, MD, pediatrician and CEO of MGMA, told Medscape Medical News.

She added that the growing physician shortage has given all physicians more leverage in salary demands and that increased recognition of the gender gap is giving women more confidence and more evidence to use in negotiations.

Three specialties have seen large increases in the past 5 years in the percentage of women physicians. Obstetrics/gynecology and pediatrics both saw increases from 50% in 2015 to 58% in 2020. Additionally, women now account for 54% of rheumatologists, up from 29% in 2015.

Would you choose your specialty again?

Of responding physicians who were asked if they would choose their specialty again, internists were least likely to say yes (66%), followed by nephrologists (69%) and family physicians (70%).

Orthopedists were most likely to say they would choose the same specialty (97%), followed by oncologists (96%) and ophthalmologists and dermatologists (both at 95%).

Most physicians overall (77%) said they would choose medicine again.

Despite aggravations and pressures, in this survey and in previous years, physicians have indicated that the top rewards are “gratitude/relationships with patients,” “being very good at what I do/finding answers, diagnoses,” and “knowing that I make the world a better place.” From 24% to 27% ranked those rewards most important.

“Making good money at a job I like” came in fourth, at 12%.

This article first appeared on Medscape.com.