Audio

As vice principal of Pennsville Middle School in New Jersey, Adam J. Slusher knows he’s not always going to be Mr. Popularity. 

Part of a vice principal’s job includes scheduling, enforcing policy, and discipline, so Dr. Slusher – who holds a doctorate in education from Wilmington University in Delaware – sometimes has to send emails or make phone calls that address unpleasant topics or unpopular new policies.

Or punishments.

But there was a much different reaction this past July, after he sent a message to the homes of Pennsville’s 450 students spanning grades 6 to 8. The email blast announced a new cellphone policy for the school. Starting in September, as he explained in the message – which also went out to the school’s 60 faculty and staff members – the use of cellphones by Pennsville students would be prohibited during school hours for any reason.

Phones, he emphasized, “are to be turned OFF” and stowed away in backpacks or handbags, not carried or tucked into back pockets.

The announcement of the new Away for the Day policy, which was decided upon by Dr. Slusher and Pennsville Principal Carolyn Carels, provoked a response different from those to his announcements on, say, test dates, emergency procedures, or new detention policies. 

“It was one of the most popular emails I’ve ever sent,” chuckled Dr. Slusher, who has been an educator for 17 years. “We’ve gotten so many thanks from teachers for this.”

Ditto with the staff, who in conversations with Dr. Slusher and Ms. Carels, had reported on the rampant use of phones in the cafeteria and hallways – confirming what both of them had seen. 

“They were telling us, ‘You’ve got to do something about the phones’ ” he recalled. “They were delighted that a clear policy was now going to be in place.”

The overwhelming majority of Pennsville parents have also supported the new policy, especially when presented with some of the sobering evidence about the extent of phone use among this population. One study Dr. Slusher cited in his email showed that the average middle school child is spending between 6 and 9 hours a day on screens. 

“That’s like a full-time job,” he said. 

The heavy cellphone use by kids – in school, out of school, anywhere and everywhere – was part of what prompted internal medicine doctor and filmmaker Delaney Ruston, MD, to create the “Away for the Day” initiative, which Pennsville has adopted.

She and collaborator Lisa Tabb were driven to do “Away for the Day” while working on Screenagers, their award-winning 2016 film examining the impact of social media, videos, and screen time on youngsters and their families that also offered tips for better navigating the digital world.

“Over 3 years of making the film, I was visiting schools all over the country,” Dr. Ruston said. “By the end, I was seeing devices all over the place, even in elementary schools. When I’d ask a student in the hall, ‘What’s the policy?’ they would shrug and say ‘I don’t know.’ When I got the same reaction from teachers – who in many cases were left to decide on their own, so that they had to be the bad guys – I realized there was a problem here.”

The result was what Dr. Ruston and Ms. Tabb describe on their website as a “movement,” designed to provide tools to parents, teachers, and administrators to help them make policies that put phones away during the school day. 
 

The age of social centrality 

As even a casual glance in the homeroom of every high school or college lecture hall will confirm, phone use is high in teenagers and young adults. But Dr. Ruston and Ms. Tabb decided to focus on middle schools. 

“That’s the age where we know schools are facing the most challenges,” Dr. Ruston said. “This is also the age when social centrality becomes a major focus for youth. Thus, the pull to be on social media games, where their peers are, is incredibly enticing.” 

A recent study in the journal JAMA Pediatrics found that middle schoolers who compulsively check social networks on their phones appear to have changes in areas of the brain linked to reward and punishment.

It was in middle schools, she concluded, “where effective policies on cellphones are most needed.”

As part of their research into the issue, she and ms. Tabb did a survey using email contacts collected by Dr. Ruston’s company, MyDoc Productions, during the making of the film, along with subscribers to her blog. In all, 1,200 parents – each of whom had at least one child in middle school at the time – were surveyed. The researchers found an interesting disconnect: Eighty-two percent of the parents surveyed did not want their children using phones in school. Yet 55% of middle schools allowed students to carry phones during the school day.

That survey was done in 2017. Since the COVID-19 pandemic, the use of cellphones by children, both in school and at home, has risen dramatically. A literature review of 46 studies, published in JAMA Pediatrics in November, found that average screen time among children and adolescents has increased by 52% – or 84 minutes a day – during the pandemic.

That trend  has given many schools, including Pennsville, the drive to adopt an Away for the Day–type policy. As part of the program, Dr. Ruston’s website provides ammunition against the kinds of pushback they might expect to get. One of the most common is the idea that banning cellphone use among middle school children is a misguided, antitechnology measure.

“We’re not at all antitech,” Dr. Ruston asserts. Away for the Day, she explains, advocates the use of learning technologies in school that are monitored and supervised by teachers. 

“The majority of students have access to learning devices in the school,” she said. “These have different kinds of blockers, making it harder for their kid to respond to their friend on TikTok when they’re supposed to be using technology for learning.”

Dr. Ruston estimates that about 10,000 middle schools are now using various pieces of the Away for the Day campaign, which includes videos, posters, fact sheets, and other materials. Other schools have adopted similar measures in the same spirit. 
 

Predictable and calm? Not so much

When Katherine Holden was named principal of Oregon’s Talent Middle School in 2022, one of the first things she wanted to do was create some structure for the routines of students (and parents) who were frazzled after 2 years of remote learning, staggered schedules, and mask mandates.

“Predictable and calm,” she said, with a laugh. “I use those words every day.”

Achieving both is hard enough in a middle school without a pandemic – not to mention an epidemic of cellphone use. (Talent also endured a massive fire in 2020 that left many families homeless.) 

For this school year, Ms. Holden is using a new and clearly articulated policy: “Devices are put away from the first bell to the last bell,” she said. “We want them to have a focus on other things. We want them to be socializing, interacting with their peers face to face, thinking about getting to class. We want them making eye contact, asking questions. Learning how to make a friend face to face. Those are important developmental social skills they should be practicing.”

Instead of scrolling through photos on Instagram, watching trending videos on TikTok, or texting their friends.

Like Dr. Slusher, she announced the new cellphone policy last summer, in a letter sent home to parents along with the list of school supplies their children would need. 

“Students are welcome to use their cell phones and personal devices before entering the building prior to 8:30 a.m. and after exiting the school building at 3:10 p.m.,” she wrote. “However, during the school day students’ cellphones and personal devices need to be off and out of sight.

“I think parents generally understand the need for this,” Ms. Holden said. “They’ve watched their children getting distracted at home by these devices, so they have a sense of how a cellphone adds a layer of challenge to learning. And parents are aware of the unkind behavior that often happens online.”

As for the kids themselves? Safe to say the excitement that Dr. Slusher’s email got from Pennsville faculty, staff, and parents didn’t extend to students. 

“They don’t like it all, to be honest,” he said. “But they understand it’s for their benefit. When we sold it to them at our beginning-of-the-year meeting, we presented our rationale. From the kids I speak to, I think the majority understand why we’re doing it.”

A version of this article first appeared on WebMD.com.

As vice principal of Pennsville Middle School in New Jersey, Adam J. Slusher knows he’s not always going to be Mr. Popularity. 

Part of a vice principal’s job includes scheduling, enforcing policy, and discipline, so Dr. Slusher – who holds a doctorate in education from Wilmington University in Delaware – sometimes has to send emails or make phone calls that address unpleasant topics or unpopular new policies.

Or punishments.

But there was a much different reaction this past July, after he sent a message to the homes of Pennsville’s 450 students spanning grades 6 to 8. The email blast announced a new cellphone policy for the school. Starting in September, as he explained in the message – which also went out to the school’s 60 faculty and staff members – the use of cellphones by Pennsville students would be prohibited during school hours for any reason.

Phones, he emphasized, “are to be turned OFF” and stowed away in backpacks or handbags, not carried or tucked into back pockets.

The announcement of the new Away for the Day policy, which was decided upon by Dr. Slusher and Pennsville Principal Carolyn Carels, provoked a response different from those to his announcements on, say, test dates, emergency procedures, or new detention policies. 

“It was one of the most popular emails I’ve ever sent,” chuckled Dr. Slusher, who has been an educator for 17 years. “We’ve gotten so many thanks from teachers for this.”

Ditto with the staff, who in conversations with Dr. Slusher and Ms. Carels, had reported on the rampant use of phones in the cafeteria and hallways – confirming what both of them had seen. 

“They were telling us, ‘You’ve got to do something about the phones’ ” he recalled. “They were delighted that a clear policy was now going to be in place.”

The overwhelming majority of Pennsville parents have also supported the new policy, especially when presented with some of the sobering evidence about the extent of phone use among this population. One study Dr. Slusher cited in his email showed that the average middle school child is spending between 6 and 9 hours a day on screens. 

“That’s like a full-time job,” he said. 

The heavy cellphone use by kids – in school, out of school, anywhere and everywhere – was part of what prompted internal medicine doctor and filmmaker Delaney Ruston, MD, to create the “Away for the Day” initiative, which Pennsville has adopted.

She and collaborator Lisa Tabb were driven to do “Away for the Day” while working on Screenagers, their award-winning 2016 film examining the impact of social media, videos, and screen time on youngsters and their families that also offered tips for better navigating the digital world.

“Over 3 years of making the film, I was visiting schools all over the country,” Dr. Ruston said. “By the end, I was seeing devices all over the place, even in elementary schools. When I’d ask a student in the hall, ‘What’s the policy?’ they would shrug and say ‘I don’t know.’ When I got the same reaction from teachers – who in many cases were left to decide on their own, so that they had to be the bad guys – I realized there was a problem here.”

The result was what Dr. Ruston and Ms. Tabb describe on their website as a “movement,” designed to provide tools to parents, teachers, and administrators to help them make policies that put phones away during the school day. 
 

The age of social centrality 

As even a casual glance in the homeroom of every high school or college lecture hall will confirm, phone use is high in teenagers and young adults. But Dr. Ruston and Ms. Tabb decided to focus on middle schools. 

“That’s the age where we know schools are facing the most challenges,” Dr. Ruston said. “This is also the age when social centrality becomes a major focus for youth. Thus, the pull to be on social media games, where their peers are, is incredibly enticing.” 

A recent study in the journal JAMA Pediatrics found that middle schoolers who compulsively check social networks on their phones appear to have changes in areas of the brain linked to reward and punishment.

It was in middle schools, she concluded, “where effective policies on cellphones are most needed.”

As part of their research into the issue, she and ms. Tabb did a survey using email contacts collected by Dr. Ruston’s company, MyDoc Productions, during the making of the film, along with subscribers to her blog. In all, 1,200 parents – each of whom had at least one child in middle school at the time – were surveyed. The researchers found an interesting disconnect: Eighty-two percent of the parents surveyed did not want their children using phones in school. Yet 55% of middle schools allowed students to carry phones during the school day.

That survey was done in 2017. Since the COVID-19 pandemic, the use of cellphones by children, both in school and at home, has risen dramatically. A literature review of 46 studies, published in JAMA Pediatrics in November, found that average screen time among children and adolescents has increased by 52% – or 84 minutes a day – during the pandemic.

That trend  has given many schools, including Pennsville, the drive to adopt an Away for the Day–type policy. As part of the program, Dr. Ruston’s website provides ammunition against the kinds of pushback they might expect to get. One of the most common is the idea that banning cellphone use among middle school children is a misguided, antitechnology measure.

“We’re not at all antitech,” Dr. Ruston asserts. Away for the Day, she explains, advocates the use of learning technologies in school that are monitored and supervised by teachers. 

“The majority of students have access to learning devices in the school,” she said. “These have different kinds of blockers, making it harder for their kid to respond to their friend on TikTok when they’re supposed to be using technology for learning.”

Dr. Ruston estimates that about 10,000 middle schools are now using various pieces of the Away for the Day campaign, which includes videos, posters, fact sheets, and other materials. Other schools have adopted similar measures in the same spirit. 
 

Predictable and calm? Not so much

When Katherine Holden was named principal of Oregon’s Talent Middle School in 2022, one of the first things she wanted to do was create some structure for the routines of students (and parents) who were frazzled after 2 years of remote learning, staggered schedules, and mask mandates.

“Predictable and calm,” she said, with a laugh. “I use those words every day.”

Achieving both is hard enough in a middle school without a pandemic – not to mention an epidemic of cellphone use. (Talent also endured a massive fire in 2020 that left many families homeless.) 

For this school year, Ms. Holden is using a new and clearly articulated policy: “Devices are put away from the first bell to the last bell,” she said. “We want them to have a focus on other things. We want them to be socializing, interacting with their peers face to face, thinking about getting to class. We want them making eye contact, asking questions. Learning how to make a friend face to face. Those are important developmental social skills they should be practicing.”

Instead of scrolling through photos on Instagram, watching trending videos on TikTok, or texting their friends.

Like Dr. Slusher, she announced the new cellphone policy last summer, in a letter sent home to parents along with the list of school supplies their children would need. 

“Students are welcome to use their cell phones and personal devices before entering the building prior to 8:30 a.m. and after exiting the school building at 3:10 p.m.,” she wrote. “However, during the school day students’ cellphones and personal devices need to be off and out of sight.

“I think parents generally understand the need for this,” Ms. Holden said. “They’ve watched their children getting distracted at home by these devices, so they have a sense of how a cellphone adds a layer of challenge to learning. And parents are aware of the unkind behavior that often happens online.”

As for the kids themselves? Safe to say the excitement that Dr. Slusher’s email got from Pennsville faculty, staff, and parents didn’t extend to students. 

“They don’t like it all, to be honest,” he said. “But they understand it’s for their benefit. When we sold it to them at our beginning-of-the-year meeting, we presented our rationale. From the kids I speak to, I think the majority understand why we’re doing it.”

A version of this article first appeared on WebMD.com.

As vice principal of Pennsville Middle School in New Jersey, Adam J. Slusher knows he’s not always going to be Mr. Popularity. 

Part of a vice principal’s job includes scheduling, enforcing policy, and discipline, so Dr. Slusher – who holds a doctorate in education from Wilmington University in Delaware – sometimes has to send emails or make phone calls that address unpleasant topics or unpopular new policies.

Or punishments.

But there was a much different reaction this past July, after he sent a message to the homes of Pennsville’s 450 students spanning grades 6 to 8. The email blast announced a new cellphone policy for the school. Starting in September, as he explained in the message – which also went out to the school’s 60 faculty and staff members – the use of cellphones by Pennsville students would be prohibited during school hours for any reason.

Phones, he emphasized, “are to be turned OFF” and stowed away in backpacks or handbags, not carried or tucked into back pockets.

The announcement of the new Away for the Day policy, which was decided upon by Dr. Slusher and Pennsville Principal Carolyn Carels, provoked a response different from those to his announcements on, say, test dates, emergency procedures, or new detention policies. 

“It was one of the most popular emails I’ve ever sent,” chuckled Dr. Slusher, who has been an educator for 17 years. “We’ve gotten so many thanks from teachers for this.”

Ditto with the staff, who in conversations with Dr. Slusher and Ms. Carels, had reported on the rampant use of phones in the cafeteria and hallways – confirming what both of them had seen. 

“They were telling us, ‘You’ve got to do something about the phones’ ” he recalled. “They were delighted that a clear policy was now going to be in place.”

The overwhelming majority of Pennsville parents have also supported the new policy, especially when presented with some of the sobering evidence about the extent of phone use among this population. One study Dr. Slusher cited in his email showed that the average middle school child is spending between 6 and 9 hours a day on screens. 

“That’s like a full-time job,” he said. 

The heavy cellphone use by kids – in school, out of school, anywhere and everywhere – was part of what prompted internal medicine doctor and filmmaker Delaney Ruston, MD, to create the “Away for the Day” initiative, which Pennsville has adopted.

She and collaborator Lisa Tabb were driven to do “Away for the Day” while working on Screenagers, their award-winning 2016 film examining the impact of social media, videos, and screen time on youngsters and their families that also offered tips for better navigating the digital world.

“Over 3 years of making the film, I was visiting schools all over the country,” Dr. Ruston said. “By the end, I was seeing devices all over the place, even in elementary schools. When I’d ask a student in the hall, ‘What’s the policy?’ they would shrug and say ‘I don’t know.’ When I got the same reaction from teachers – who in many cases were left to decide on their own, so that they had to be the bad guys – I realized there was a problem here.”

The result was what Dr. Ruston and Ms. Tabb describe on their website as a “movement,” designed to provide tools to parents, teachers, and administrators to help them make policies that put phones away during the school day. 
 

The age of social centrality 

As even a casual glance in the homeroom of every high school or college lecture hall will confirm, phone use is high in teenagers and young adults. But Dr. Ruston and Ms. Tabb decided to focus on middle schools. 

“That’s the age where we know schools are facing the most challenges,” Dr. Ruston said. “This is also the age when social centrality becomes a major focus for youth. Thus, the pull to be on social media games, where their peers are, is incredibly enticing.” 

A recent study in the journal JAMA Pediatrics found that middle schoolers who compulsively check social networks on their phones appear to have changes in areas of the brain linked to reward and punishment.

It was in middle schools, she concluded, “where effective policies on cellphones are most needed.”

As part of their research into the issue, she and ms. Tabb did a survey using email contacts collected by Dr. Ruston’s company, MyDoc Productions, during the making of the film, along with subscribers to her blog. In all, 1,200 parents – each of whom had at least one child in middle school at the time – were surveyed. The researchers found an interesting disconnect: Eighty-two percent of the parents surveyed did not want their children using phones in school. Yet 55% of middle schools allowed students to carry phones during the school day.

That survey was done in 2017. Since the COVID-19 pandemic, the use of cellphones by children, both in school and at home, has risen dramatically. A literature review of 46 studies, published in JAMA Pediatrics in November, found that average screen time among children and adolescents has increased by 52% – or 84 minutes a day – during the pandemic.

That trend  has given many schools, including Pennsville, the drive to adopt an Away for the Day–type policy. As part of the program, Dr. Ruston’s website provides ammunition against the kinds of pushback they might expect to get. One of the most common is the idea that banning cellphone use among middle school children is a misguided, antitechnology measure.

“We’re not at all antitech,” Dr. Ruston asserts. Away for the Day, she explains, advocates the use of learning technologies in school that are monitored and supervised by teachers. 

“The majority of students have access to learning devices in the school,” she said. “These have different kinds of blockers, making it harder for their kid to respond to their friend on TikTok when they’re supposed to be using technology for learning.”

Dr. Ruston estimates that about 10,000 middle schools are now using various pieces of the Away for the Day campaign, which includes videos, posters, fact sheets, and other materials. Other schools have adopted similar measures in the same spirit. 
 

Predictable and calm? Not so much

When Katherine Holden was named principal of Oregon’s Talent Middle School in 2022, one of the first things she wanted to do was create some structure for the routines of students (and parents) who were frazzled after 2 years of remote learning, staggered schedules, and mask mandates.

“Predictable and calm,” she said, with a laugh. “I use those words every day.”

Achieving both is hard enough in a middle school without a pandemic – not to mention an epidemic of cellphone use. (Talent also endured a massive fire in 2020 that left many families homeless.) 

For this school year, Ms. Holden is using a new and clearly articulated policy: “Devices are put away from the first bell to the last bell,” she said. “We want them to have a focus on other things. We want them to be socializing, interacting with their peers face to face, thinking about getting to class. We want them making eye contact, asking questions. Learning how to make a friend face to face. Those are important developmental social skills they should be practicing.”

Instead of scrolling through photos on Instagram, watching trending videos on TikTok, or texting their friends.

Like Dr. Slusher, she announced the new cellphone policy last summer, in a letter sent home to parents along with the list of school supplies their children would need. 

“Students are welcome to use their cell phones and personal devices before entering the building prior to 8:30 a.m. and after exiting the school building at 3:10 p.m.,” she wrote. “However, during the school day students’ cellphones and personal devices need to be off and out of sight.

“I think parents generally understand the need for this,” Ms. Holden said. “They’ve watched their children getting distracted at home by these devices, so they have a sense of how a cellphone adds a layer of challenge to learning. And parents are aware of the unkind behavior that often happens online.”

As for the kids themselves? Safe to say the excitement that Dr. Slusher’s email got from Pennsville faculty, staff, and parents didn’t extend to students. 

“They don’t like it all, to be honest,” he said. “But they understand it’s for their benefit. When we sold it to them at our beginning-of-the-year meeting, we presented our rationale. From the kids I speak to, I think the majority understand why we’re doing it.”

A version of this article first appeared on WebMD.com.

In my last column, I discussed blogging as a great way to capture the attention of anyone interested in your practice, especially prospective patients. If you are already blogging – or would like to consider a less crowded and competitive activity – podcasting might be the answer. At this writing (November 2022), more than 600 million blogs are online, compared with about 2 million podcasts, and relatively few of them are run by physicians. With podcasts, you have a better chance of standing out in a crowded online world.

Starting a podcast is not difficult, but there are several steps you need to go through before launching one.

Eastern _Joseph_S_web.jpg

As with blogging, start by outlining a long-range plan. Your general topic will probably be your specialty, but you will need to narrow your focus to a few specific subjects, such as the problems you see most often, or a subspecialty that you concentrate on. You can always expand your topic later, as you get more popular. Choose a name for your podcast, and purchase a domain name that accurately describes it.

You will also need to choose a hosting service. Numerous inexpensive hosting platforms are available, and a simple Google search will find them for you. Many of them provide free learning materials, helpful creative tools, and customer support to get you through the confusing technical aspects. They can also help you choose a music introduction (to add a bit of polish), and help you piece together your audio segments. Buzzsprout, RSS.com, and Podbean get good reviews on many sites. (As always, I have no financial interest in any company or service mentioned herein.)

Hosting services can assist you in creating a template – a framework that you can reuse each time you record an episode – containing your intro and exit music, tracks for your conversations, etc. This will make your podcasts instantly recognizable each time your listeners tune in.

Many podcasting experts recommend recruiting a co-host. This can be an associate within your practice, a friend who practices elsewhere, or perhaps a resident in an academic setting. You will be able to spread the workload of creating, editing, and promoting. Plus, it is much easier to generate interesting content when two people are having a conversation, rather than one person lecturing from a prepared script. You might also consider having multiple co-hosts, either to expand episodes into group discussions, or to take turns working with you in covering different subjects.

[embed:render:related:node:258666]

How long you make your podcast is entirely up to you. Some consultants recommend specific time frames, such as 5 minutes (because that’s an average attention span), or 28 minutes (because that’s the average driving commute time). There are short podcasts and long ones; whatever works for you is fine, as long as you don’t drift off the topic. Furthermore, no one says they must all be the same length; when you are finished talking, you are done. And no one says you must stick with one subject throughout. Combining several short segments might hold more listeners’ interest and will make it easier to share small clips on social media.

Content guidelines are similar to those for blogs. Give people content that will be of interest or benefit to them. Talk about subjects – medical and otherwise – that are relevant to your practice or are prominent in the news.

As with blogs, try to avoid polarizing political discussions, and while it’s fine to discuss treatments and procedures that you offer, aggressive solicitation tends to make viewers look elsewhere. Keep any medical advice in general terms; don’t portray any specific patients as examples.

When your podcast is ready, your hosting platform will show you how to submit it to iTunes, and how to submit your podcast RSS feed to other podcast directories. As you upload new episodes, your host will automatically update your RSS feed, so that any directory you are listed on will receive the new episode.

Once you are uploaded, you can use your host’s social sharing tools to spread the word. As with blogs, use social media, such as your practice’s Facebook page, to push podcast updates into patients’ feeds and track relevant Twitter hashtags to find online communities that might be interested in your subject matter. You should also find your episode embed code (which your host will have) and place it in a prominent place on your website so patients can listen directly from there.

Transcriptions are another excellent promotional tool. Search engines will “read” your podcasts and list them in searches. Some podcast hosts will do transcribing for a fee, but there are independent transcription services as well.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

In my last column, I discussed blogging as a great way to capture the attention of anyone interested in your practice, especially prospective patients. If you are already blogging – or would like to consider a less crowded and competitive activity – podcasting might be the answer. At this writing (November 2022), more than 600 million blogs are online, compared with about 2 million podcasts, and relatively few of them are run by physicians. With podcasts, you have a better chance of standing out in a crowded online world.

Starting a podcast is not difficult, but there are several steps you need to go through before launching one.

Eastern _Joseph_S_web.jpg

As with blogging, start by outlining a long-range plan. Your general topic will probably be your specialty, but you will need to narrow your focus to a few specific subjects, such as the problems you see most often, or a subspecialty that you concentrate on. You can always expand your topic later, as you get more popular. Choose a name for your podcast, and purchase a domain name that accurately describes it.

You will also need to choose a hosting service. Numerous inexpensive hosting platforms are available, and a simple Google search will find them for you. Many of them provide free learning materials, helpful creative tools, and customer support to get you through the confusing technical aspects. They can also help you choose a music introduction (to add a bit of polish), and help you piece together your audio segments. Buzzsprout, RSS.com, and Podbean get good reviews on many sites. (As always, I have no financial interest in any company or service mentioned herein.)

Hosting services can assist you in creating a template – a framework that you can reuse each time you record an episode – containing your intro and exit music, tracks for your conversations, etc. This will make your podcasts instantly recognizable each time your listeners tune in.

Many podcasting experts recommend recruiting a co-host. This can be an associate within your practice, a friend who practices elsewhere, or perhaps a resident in an academic setting. You will be able to spread the workload of creating, editing, and promoting. Plus, it is much easier to generate interesting content when two people are having a conversation, rather than one person lecturing from a prepared script. You might also consider having multiple co-hosts, either to expand episodes into group discussions, or to take turns working with you in covering different subjects.

[embed:render:related:node:258666]

How long you make your podcast is entirely up to you. Some consultants recommend specific time frames, such as 5 minutes (because that’s an average attention span), or 28 minutes (because that’s the average driving commute time). There are short podcasts and long ones; whatever works for you is fine, as long as you don’t drift off the topic. Furthermore, no one says they must all be the same length; when you are finished talking, you are done. And no one says you must stick with one subject throughout. Combining several short segments might hold more listeners’ interest and will make it easier to share small clips on social media.

Content guidelines are similar to those for blogs. Give people content that will be of interest or benefit to them. Talk about subjects – medical and otherwise – that are relevant to your practice or are prominent in the news.

As with blogs, try to avoid polarizing political discussions, and while it’s fine to discuss treatments and procedures that you offer, aggressive solicitation tends to make viewers look elsewhere. Keep any medical advice in general terms; don’t portray any specific patients as examples.

When your podcast is ready, your hosting platform will show you how to submit it to iTunes, and how to submit your podcast RSS feed to other podcast directories. As you upload new episodes, your host will automatically update your RSS feed, so that any directory you are listed on will receive the new episode.

Once you are uploaded, you can use your host’s social sharing tools to spread the word. As with blogs, use social media, such as your practice’s Facebook page, to push podcast updates into patients’ feeds and track relevant Twitter hashtags to find online communities that might be interested in your subject matter. You should also find your episode embed code (which your host will have) and place it in a prominent place on your website so patients can listen directly from there.

Transcriptions are another excellent promotional tool. Search engines will “read” your podcasts and list them in searches. Some podcast hosts will do transcribing for a fee, but there are independent transcription services as well.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

In my last column, I discussed blogging as a great way to capture the attention of anyone interested in your practice, especially prospective patients. If you are already blogging – or would like to consider a less crowded and competitive activity – podcasting might be the answer. At this writing (November 2022), more than 600 million blogs are online, compared with about 2 million podcasts, and relatively few of them are run by physicians. With podcasts, you have a better chance of standing out in a crowded online world.

Starting a podcast is not difficult, but there are several steps you need to go through before launching one.

Eastern _Joseph_S_web.jpg

As with blogging, start by outlining a long-range plan. Your general topic will probably be your specialty, but you will need to narrow your focus to a few specific subjects, such as the problems you see most often, or a subspecialty that you concentrate on. You can always expand your topic later, as you get more popular. Choose a name for your podcast, and purchase a domain name that accurately describes it.

You will also need to choose a hosting service. Numerous inexpensive hosting platforms are available, and a simple Google search will find them for you. Many of them provide free learning materials, helpful creative tools, and customer support to get you through the confusing technical aspects. They can also help you choose a music introduction (to add a bit of polish), and help you piece together your audio segments. Buzzsprout, RSS.com, and Podbean get good reviews on many sites. (As always, I have no financial interest in any company or service mentioned herein.)

Hosting services can assist you in creating a template – a framework that you can reuse each time you record an episode – containing your intro and exit music, tracks for your conversations, etc. This will make your podcasts instantly recognizable each time your listeners tune in.

Many podcasting experts recommend recruiting a co-host. This can be an associate within your practice, a friend who practices elsewhere, or perhaps a resident in an academic setting. You will be able to spread the workload of creating, editing, and promoting. Plus, it is much easier to generate interesting content when two people are having a conversation, rather than one person lecturing from a prepared script. You might also consider having multiple co-hosts, either to expand episodes into group discussions, or to take turns working with you in covering different subjects.

[embed:render:related:node:258666]

How long you make your podcast is entirely up to you. Some consultants recommend specific time frames, such as 5 minutes (because that’s an average attention span), or 28 minutes (because that’s the average driving commute time). There are short podcasts and long ones; whatever works for you is fine, as long as you don’t drift off the topic. Furthermore, no one says they must all be the same length; when you are finished talking, you are done. And no one says you must stick with one subject throughout. Combining several short segments might hold more listeners’ interest and will make it easier to share small clips on social media.

Content guidelines are similar to those for blogs. Give people content that will be of interest or benefit to them. Talk about subjects – medical and otherwise – that are relevant to your practice or are prominent in the news.

As with blogs, try to avoid polarizing political discussions, and while it’s fine to discuss treatments and procedures that you offer, aggressive solicitation tends to make viewers look elsewhere. Keep any medical advice in general terms; don’t portray any specific patients as examples.

When your podcast is ready, your hosting platform will show you how to submit it to iTunes, and how to submit your podcast RSS feed to other podcast directories. As you upload new episodes, your host will automatically update your RSS feed, so that any directory you are listed on will receive the new episode.

Once you are uploaded, you can use your host’s social sharing tools to spread the word. As with blogs, use social media, such as your practice’s Facebook page, to push podcast updates into patients’ feeds and track relevant Twitter hashtags to find online communities that might be interested in your subject matter. You should also find your episode embed code (which your host will have) and place it in a prominent place on your website so patients can listen directly from there.

Transcriptions are another excellent promotional tool. Search engines will “read” your podcasts and list them in searches. Some podcast hosts will do transcribing for a fee, but there are independent transcription services as well.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Scientists have harnessed the power of a woman’s hypersensitive sense of smell to develop a test to determine whether people have Parkinson’s disease.

The test has been years in the making after academics realized that Joy Milne could smell the condition.

The 72-year-old from Perth, Scotland, has a rare condition that gives her a heightened sense of smell.

She noticed that her late husband Les developed a different odor when he was 33 – some 12 years before he was diagnosed with the disease, which leads to parts of the brain become progressively damaged over many years.

Mrs. Milne, dubbed ‘the woman who can smell Parkinson’s, described a “musky” aroma, different from his normal scent.

Her observation piqued the interest of scientists who decided to research what she could smell, and whether this could be harnessed to help identify people with the neurological condition.
 

‘Early phases of research’

Years later, academics at the University of Manchester (England) have made a breakthrough by developing a test that can identify people with Parkinson’s disease using a simple cotton bud run along the back of the neck.

Researchers can examine the sample to identify molecules linked to the disease to help diagnose whether someone has the disease.

While still in the early phases of research, scientists are excited about the prospect of the NHS being able to deploy a simple test for the disease.

There is currently no definitive test for Parkinson’s disease, with diagnosis based on a patient’s symptoms and medical history.

If the new skin swab is successful outside laboratory conditions it could be rolled out to achieve faster diagnosis.

Mrs. Milne told the PA news agency that it was “not acceptable” that people with Parkinson’s had such high degrees of neurologic damage at the time of diagnosis, adding: “I think it has to be detected far earlier – the same as cancer and diabetes, earlier diagnosis means far more efficient treatment and a better lifestyle for people.

“It has been found that exercise and change of diet can make a phenomenal difference.”

She said her husband, a former doctor, was “determined” to find the right researcher to examine the link between odor and Parkinson’s and they sought out Tilo Kunath, PhD, at the University of Edinburgh in 2012.
 

Chemical change in sebum

Dr. Kunath paired up with Perdita Barran, PhD, to examine Mrs. Milne’s sense of smell.

The scientists believed that the scent may be caused by a chemical change in skin oil, known as sebum, that is triggered by the disease.

In their preliminary work they asked Mrs. Milne to smell t-shirts worn by people who have Parkinson’s and those who did not.

Mrs. Milne correctly identified the t-shirts worn by Parkinson’s patients but she also said that one from the group of people without Parkinson’s smelled like the disease – 8 months later the individual who wore the t-shirt was diagnosed with Parkinson’s.

Researchers hoped the finding could lead to a test being developed to detect Parkinson’s, working under the assumption that if they were able to identify a unique chemical signature in the skin linked to Parkinson’s, they may eventually be able to diagnose the condition from simple skin swabs.

In 2019 researchers at the University of Manchester, led by Dr. Barran, announced that they had identified molecules linked to the disease found in skin swabs.

And now the scientists have developed a test using this information.

The tests have been successfully conducted in research labs and now scientists are assessing whether they can be used in hospital settings.

If successful, the test could potentially be used in the NHS so GPs can refer patients for Parkinson’s tests.

The findings, which have been published in the Journal of the American Chemical Society, detail how sebum can be analyzed with mass spectrometry – a method which weighs molecules – to identify the disease.

Some molecules are present only in people who have Parkinson’s disease.

Researchers compared swabs from 79 people with Parkinson’s with a healthy control group of 71 people.

Dr. Barran told the PA news agency: “At the moment, there are no cures for Parkinson’s, but a confirmatory diagnostic would allow them to get the right treatment and get the drugs that will help to alleviate their symptoms.

“There would also be nonpharmaceutical interventions, including movement and also nutritional classes, which can really help.

“And I think most critically, it will allow them to have a confirmed diagnosis to actually know what’s wrong with them.”

She added: “What we are now doing is seeing if [hospital laboratories] can do what we’ve done in a research lab in a hospital lab. Once that’s happened then we want to see if we can make this a confirmatory diagnostic that could be used along with the referral process from a GP to a consultant. At the moment in Greater Manchester there are about 18,000 people waiting for a neurological consult and just to clear that list, without any new people joining it, will take up to 2 years. Of those 10%-15% are suspect Parkinson’s. Our test would be able to tell them whether they did or whether they didn’t [have Parkinson’s] and allow them to be referred to the right specialist. So at the moment, we’re talking about being able to refer people in a timely manner to the right specialism and that will be transformative.”
 

Mrs. Milne may be able to smell other diseases

Mrs. Milne is now working with scientists around the world to see if she can smell other diseases like cancer and tuberculosis.

“I have to go shopping very early or very late because of people’s perfumes, I can’t go into the chemical aisle in the supermarket,” she told the PA news agency. “So yes, a curse sometimes but I have also been out to Tanzania and have done research on TB, and research on cancer in the U.S. – just preliminary work. So it is a curse and a benefit.”

She said that she can sometimes smell people who have Parkinson’s while in the supermarket or walking down the street but has been told by medical ethicists she cannot tell them. “Which GP would accept a man or a woman walking in saying ‘the woman who smells Parkinson’s has told me I have it?’ Maybe in the future but not now.”

Mrs. Milne said that her husband, who died 7 years ago, was like a “changed man” after researchers found the link between Parkinson’s and odor.

A version of this article first appeared on Medscape UK.

Scientists have harnessed the power of a woman’s hypersensitive sense of smell to develop a test to determine whether people have Parkinson’s disease.

The test has been years in the making after academics realized that Joy Milne could smell the condition.

The 72-year-old from Perth, Scotland, has a rare condition that gives her a heightened sense of smell.

She noticed that her late husband Les developed a different odor when he was 33 – some 12 years before he was diagnosed with the disease, which leads to parts of the brain become progressively damaged over many years.

Mrs. Milne, dubbed ‘the woman who can smell Parkinson’s, described a “musky” aroma, different from his normal scent.

Her observation piqued the interest of scientists who decided to research what she could smell, and whether this could be harnessed to help identify people with the neurological condition.
 

‘Early phases of research’

Years later, academics at the University of Manchester (England) have made a breakthrough by developing a test that can identify people with Parkinson’s disease using a simple cotton bud run along the back of the neck.

Researchers can examine the sample to identify molecules linked to the disease to help diagnose whether someone has the disease.

While still in the early phases of research, scientists are excited about the prospect of the NHS being able to deploy a simple test for the disease.

There is currently no definitive test for Parkinson’s disease, with diagnosis based on a patient’s symptoms and medical history.

If the new skin swab is successful outside laboratory conditions it could be rolled out to achieve faster diagnosis.

Mrs. Milne told the PA news agency that it was “not acceptable” that people with Parkinson’s had such high degrees of neurologic damage at the time of diagnosis, adding: “I think it has to be detected far earlier – the same as cancer and diabetes, earlier diagnosis means far more efficient treatment and a better lifestyle for people.

“It has been found that exercise and change of diet can make a phenomenal difference.”

She said her husband, a former doctor, was “determined” to find the right researcher to examine the link between odor and Parkinson’s and they sought out Tilo Kunath, PhD, at the University of Edinburgh in 2012.
 

Chemical change in sebum

Dr. Kunath paired up with Perdita Barran, PhD, to examine Mrs. Milne’s sense of smell.

The scientists believed that the scent may be caused by a chemical change in skin oil, known as sebum, that is triggered by the disease.

In their preliminary work they asked Mrs. Milne to smell t-shirts worn by people who have Parkinson’s and those who did not.

Mrs. Milne correctly identified the t-shirts worn by Parkinson’s patients but she also said that one from the group of people without Parkinson’s smelled like the disease – 8 months later the individual who wore the t-shirt was diagnosed with Parkinson’s.

Researchers hoped the finding could lead to a test being developed to detect Parkinson’s, working under the assumption that if they were able to identify a unique chemical signature in the skin linked to Parkinson’s, they may eventually be able to diagnose the condition from simple skin swabs.

In 2019 researchers at the University of Manchester, led by Dr. Barran, announced that they had identified molecules linked to the disease found in skin swabs.

And now the scientists have developed a test using this information.

The tests have been successfully conducted in research labs and now scientists are assessing whether they can be used in hospital settings.

If successful, the test could potentially be used in the NHS so GPs can refer patients for Parkinson’s tests.

The findings, which have been published in the Journal of the American Chemical Society, detail how sebum can be analyzed with mass spectrometry – a method which weighs molecules – to identify the disease.

Some molecules are present only in people who have Parkinson’s disease.

Researchers compared swabs from 79 people with Parkinson’s with a healthy control group of 71 people.

Dr. Barran told the PA news agency: “At the moment, there are no cures for Parkinson’s, but a confirmatory diagnostic would allow them to get the right treatment and get the drugs that will help to alleviate their symptoms.

“There would also be nonpharmaceutical interventions, including movement and also nutritional classes, which can really help.

“And I think most critically, it will allow them to have a confirmed diagnosis to actually know what’s wrong with them.”

She added: “What we are now doing is seeing if [hospital laboratories] can do what we’ve done in a research lab in a hospital lab. Once that’s happened then we want to see if we can make this a confirmatory diagnostic that could be used along with the referral process from a GP to a consultant. At the moment in Greater Manchester there are about 18,000 people waiting for a neurological consult and just to clear that list, without any new people joining it, will take up to 2 years. Of those 10%-15% are suspect Parkinson’s. Our test would be able to tell them whether they did or whether they didn’t [have Parkinson’s] and allow them to be referred to the right specialist. So at the moment, we’re talking about being able to refer people in a timely manner to the right specialism and that will be transformative.”
 

Mrs. Milne may be able to smell other diseases

Mrs. Milne is now working with scientists around the world to see if she can smell other diseases like cancer and tuberculosis.

“I have to go shopping very early or very late because of people’s perfumes, I can’t go into the chemical aisle in the supermarket,” she told the PA news agency. “So yes, a curse sometimes but I have also been out to Tanzania and have done research on TB, and research on cancer in the U.S. – just preliminary work. So it is a curse and a benefit.”

She said that she can sometimes smell people who have Parkinson’s while in the supermarket or walking down the street but has been told by medical ethicists she cannot tell them. “Which GP would accept a man or a woman walking in saying ‘the woman who smells Parkinson’s has told me I have it?’ Maybe in the future but not now.”

Mrs. Milne said that her husband, who died 7 years ago, was like a “changed man” after researchers found the link between Parkinson’s and odor.

A version of this article first appeared on Medscape UK.

Scientists have harnessed the power of a woman’s hypersensitive sense of smell to develop a test to determine whether people have Parkinson’s disease.

The test has been years in the making after academics realized that Joy Milne could smell the condition.

The 72-year-old from Perth, Scotland, has a rare condition that gives her a heightened sense of smell.

She noticed that her late husband Les developed a different odor when he was 33 – some 12 years before he was diagnosed with the disease, which leads to parts of the brain become progressively damaged over many years.

Mrs. Milne, dubbed ‘the woman who can smell Parkinson’s, described a “musky” aroma, different from his normal scent.

Her observation piqued the interest of scientists who decided to research what she could smell, and whether this could be harnessed to help identify people with the neurological condition.
 

‘Early phases of research’

Years later, academics at the University of Manchester (England) have made a breakthrough by developing a test that can identify people with Parkinson’s disease using a simple cotton bud run along the back of the neck.

Researchers can examine the sample to identify molecules linked to the disease to help diagnose whether someone has the disease.

While still in the early phases of research, scientists are excited about the prospect of the NHS being able to deploy a simple test for the disease.

There is currently no definitive test for Parkinson’s disease, with diagnosis based on a patient’s symptoms and medical history.

If the new skin swab is successful outside laboratory conditions it could be rolled out to achieve faster diagnosis.

Mrs. Milne told the PA news agency that it was “not acceptable” that people with Parkinson’s had such high degrees of neurologic damage at the time of diagnosis, adding: “I think it has to be detected far earlier – the same as cancer and diabetes, earlier diagnosis means far more efficient treatment and a better lifestyle for people.

“It has been found that exercise and change of diet can make a phenomenal difference.”

She said her husband, a former doctor, was “determined” to find the right researcher to examine the link between odor and Parkinson’s and they sought out Tilo Kunath, PhD, at the University of Edinburgh in 2012.
 

Chemical change in sebum

Dr. Kunath paired up with Perdita Barran, PhD, to examine Mrs. Milne’s sense of smell.

The scientists believed that the scent may be caused by a chemical change in skin oil, known as sebum, that is triggered by the disease.

In their preliminary work they asked Mrs. Milne to smell t-shirts worn by people who have Parkinson’s and those who did not.

Mrs. Milne correctly identified the t-shirts worn by Parkinson’s patients but she also said that one from the group of people without Parkinson’s smelled like the disease – 8 months later the individual who wore the t-shirt was diagnosed with Parkinson’s.

Researchers hoped the finding could lead to a test being developed to detect Parkinson’s, working under the assumption that if they were able to identify a unique chemical signature in the skin linked to Parkinson’s, they may eventually be able to diagnose the condition from simple skin swabs.

In 2019 researchers at the University of Manchester, led by Dr. Barran, announced that they had identified molecules linked to the disease found in skin swabs.

And now the scientists have developed a test using this information.

The tests have been successfully conducted in research labs and now scientists are assessing whether they can be used in hospital settings.

If successful, the test could potentially be used in the NHS so GPs can refer patients for Parkinson’s tests.

The findings, which have been published in the Journal of the American Chemical Society, detail how sebum can be analyzed with mass spectrometry – a method which weighs molecules – to identify the disease.

Some molecules are present only in people who have Parkinson’s disease.

Researchers compared swabs from 79 people with Parkinson’s with a healthy control group of 71 people.

Dr. Barran told the PA news agency: “At the moment, there are no cures for Parkinson’s, but a confirmatory diagnostic would allow them to get the right treatment and get the drugs that will help to alleviate their symptoms.

“There would also be nonpharmaceutical interventions, including movement and also nutritional classes, which can really help.

“And I think most critically, it will allow them to have a confirmed diagnosis to actually know what’s wrong with them.”

She added: “What we are now doing is seeing if [hospital laboratories] can do what we’ve done in a research lab in a hospital lab. Once that’s happened then we want to see if we can make this a confirmatory diagnostic that could be used along with the referral process from a GP to a consultant. At the moment in Greater Manchester there are about 18,000 people waiting for a neurological consult and just to clear that list, without any new people joining it, will take up to 2 years. Of those 10%-15% are suspect Parkinson’s. Our test would be able to tell them whether they did or whether they didn’t [have Parkinson’s] and allow them to be referred to the right specialist. So at the moment, we’re talking about being able to refer people in a timely manner to the right specialism and that will be transformative.”
 

Mrs. Milne may be able to smell other diseases

Mrs. Milne is now working with scientists around the world to see if she can smell other diseases like cancer and tuberculosis.

“I have to go shopping very early or very late because of people’s perfumes, I can’t go into the chemical aisle in the supermarket,” she told the PA news agency. “So yes, a curse sometimes but I have also been out to Tanzania and have done research on TB, and research on cancer in the U.S. – just preliminary work. So it is a curse and a benefit.”

She said that she can sometimes smell people who have Parkinson’s while in the supermarket or walking down the street but has been told by medical ethicists she cannot tell them. “Which GP would accept a man or a woman walking in saying ‘the woman who smells Parkinson’s has told me I have it?’ Maybe in the future but not now.”

Mrs. Milne said that her husband, who died 7 years ago, was like a “changed man” after researchers found the link between Parkinson’s and odor.

A version of this article first appeared on Medscape UK.

A family’s decision to vaccinate their child is best made jointly with a trusted medical provider who knows the child and family. The American Academy of Pediatrics created a toolkit with resources for answering questions about the recently authorized SARS-CoV-2 mRNA vaccines (Pfizer and Moderna) for 6-month- to 5-year-olds with science-backed vaccine facts, including links to other useful AAP information websites, talking points, graphics, and videos.¹

Harrison_Christopher_MO_web.jpg

SARS-CoV-2 seasonality

SARS-CoV-2 is now endemic, not a once-a-year seasonal virus. Seasons (aka surges) will occur whenever a new variant arises (twice yearly since 2020, Omicron BA.4/BA.5 currently), or when enough vaccine holdouts, newborns, and/or those with waning of prior immunity (vaccine or infection induced) accrue.

Emergency use authorization submission data for mRNA vaccine responses in young children^2,3

Moderna in 6-month- through 5-year-olds. Two 25-mcg doses given 4-8 weeks apart produced 37.8% (95% confidence interval, 20.9%-51.1%) protection against symptomatic Omicron SARS-CoV-2 infections through 3 months of follow-up. Immunobridging analysis of antibody responses compared to 18- to 25-year-olds (100-mcg doses) showed the children’s responses were noninferior. Thus, the committee inferred that vaccine effectiveness in children should be similar to that in 18- to 25-year-olds. Fever, irritability, or local reaction/pain occurred in two-thirds after the second dose. Grade 3 reactions were noted in less than 5%.

Pfizer in 6-month- through 4-year-olds. Three 3-mcg doses, two doses 3-8 weeks apart and the third dose at least 8 weeks later (median 16 weeks), produced 80.3% (95% CI, 13.9%-96.7%) protection against symptomatic COVID-19 during the 6 weeks after the third dose. Local and systemic reactions occurred in 63.8%; less than 5% had grade 3 reactions (fever in about 3%, irritability in 1.3%, fatigue in 0.8%) mostly after second dose.

Neither duration of follow-up is very long. The Moderna data tell me that a third primary dose would have been better but restarting the trial to evaluate third doses would have delayed Moderna’s EUA another 4-6 months. The three-dose Pfizer data look better but may not have been as good with another 6 weeks of follow-up.

Additional post-EUA data will be collected. Boosters will be needed when immunity from both vaccines wanes (one estimate is about 6 months after the primary series). The Advisory Committee on Immunization Practices noted in their deliberations that vaccine-induced antibody responses are higher and cross-neutralize variants (even Omicron) better than infection-induced immunity.⁴

Are there downsides to the vaccines? Naysayers question vaccinating children less than 5 years old with reasons containing enough “truth” that they catch people’s attention, for example, “young children don’t get very sick with COVID-19,” “most have been infected already,” “RNA for the spike protein stays in the body for months,” or “myocarditis.” Naysayers can quote references in reputable journals but seem to spin selected data out of context or quote unconfirmed data from the Vaccine Adverse Event Reporting System.
 

Reasons to vaccinate

• While children have milder disease than adults, mid-June 2022 surveillance indicated 50 hospitalizations and 1 pediatric death each day from SARS-CoV-2.⁵
• Vaccinating young children endows a foundation of vaccine-induced SARS-CoV-2 immunity that is superior to infection-induced immunity.⁴
• Long-term effects of large numbers of SARS-CoV-2 particles that enter every organ of a developing child have not been determined.
• Viral loads are lowered by prior vaccine; fewer viral replications lessen chances for newer variants to arise.
• Transmission is less in breakthrough infections than infections in the unvaccinated.
• Thirty percent of 5- to 11-year-olds hospitalized for SARS-CoV-2 had no underlying conditions;⁶ hospitalization rates in newborn to 4-year-olds have been the highest in the Omicron surge.⁷
• No myocarditis or pericarditis episodes have been detected in 6-month- to 11-year-old trials.
• The AAP and ACIP recommend the mRNA vaccines.

My thoughts are that SARS-CoV-2 vaccine is just another “routine” childhood vaccine that prepares children for healthier futures, pandemic or not, and the vaccines are as safe as other routine vaccines.

And like other pediatric vaccines, it should be no surprise that boosters will be needed, even if no newer variants than Omicron BA.4/BA.5 arise. But we know newer variants will arise and, similar to influenza vaccine, new formulations, perhaps with multiple SARS-CoV-2 strain antigens, will be needed every year or so. Everyone will get SARS-CoV-2 multiple times in their lives no matter how careful they are. So isn’t it good medical practice to establish early the best available foundation for maintaining lifelong SARS-CoV-2 immunity?

To me it is like pertussis. Most pertussis-infected children are sick enough to be hospitalized; very few die. They are miserable with illnesses that take weeks to months to subside. The worst disease usually occurs in unvaccinated young children or those with underlying conditions. Reactogenicity was reduced with acellular vaccine but resulted in less immunogenicity, so we give boosters at intervals that best match waning immunity. Circulating strains can be different than the vaccine strain, so protection against infection is 80%. Finally, even the safest vaccine may very rarely have sequelae. That is why The National Vaccine Injury Compensation Program was created. Yet the benefit-to-harm ratio for children and society favors universal pertussis vaccine use. And we vaccinate even those who have had pertussis because even infection-based immunity is incomplete and protection wanes. If arguments similar to those by SARS-CoV-2 vaccine naysayers were applied to acellular pertussis vaccine, it seems they would argue against pertussis vaccine for young children.

Another major issue has been “safety concerns” about the vaccines’ small amount of mRNA for the spike protein encased in microscopic lipid bubbles injected in the arm or leg. This mRNA is picked up by human cells, and in the cytoplasm (not the nucleus where our DNA resides) produces a limited supply of spike protein that is then picked up by antigen-presenting cells for short-lived distribution (days to 2 weeks at most) to regional lymph nodes where immune-memory processes are jump-started. Contrast that to even asymptomatic SARS-CoV-2 infection where multibillions of virus particles are produced for up to 14 days with access to every bodily organ that contains ACE-2 receptors (they all do). Each virus particle hijacks a human cell producing thousands of mRNA for spike protein (and multiple other SARS-CoV-2 proteins), eventually releasing multibillions of lipid fragments from the ruptured cell. Comparing the amount of these components in the mRNA vaccines to those from infection is like comparing a campfire to the many-thousand-acre wildfire. So, if one is worried about the effects of spike protein and lipid fragments, the limited localized amounts in mRNA vaccines should make one much less concerned than the enormous amounts circulating throughout the body as a result of a SARS-CoV-2 infection.

My take is that children 6-months to 5-years-old deserve SARS-CoV-2–induced vaccine protection and we can and should strongly recommend it as medical providers and child advocates.
 

*Dr. Harrison is professor, University of Missouri Kansas City School of Medicine, department of medicine, infectious diseases section, Kansas City. Email him at pdnews@mdedge.com.

References

1. AAP. 2022 Jun 21. As COVID-19 vaccines become available for children ages 6 months to 4 years, AAP urges families to reach out to pediatricians to ask questions and access vaccine. www.aap.org.

2. CDC. Grading of recommendations, assessment, development, and evaluation (GRADE): Moderna COVID-19 vaccine for children aged 6 months–5 years. www.cdc.gov.

3. CDC. ACIP evidence to recommendations for use of Moderna COVID-19 vaccine in children ages 6 months–5 years and Pfizer-BioNTech COVID-19 vaccine in children ages 6 months–4 years under an emergency use authorization. www.cdc.gov.

4. Tang J et al. Nat Commun. 2022;13:2979.

5. Children and COVID-19: State Data Report. 2022 Jun 30. www.aap.org.

6. Shi DS et al. MMWR Morb Mortal Wkly Rep. 2022;71:574-81.

7. Marks KJ et al. MMWR Morb Mortal Wkly Rep. 2022;71:429-36.
 

Other good resources for families are https://getvaccineanswers.org/ or www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-in-babies-and-children/art-20484405.

*This story was updated on July 19, 2022.

A family’s decision to vaccinate their child is best made jointly with a trusted medical provider who knows the child and family. The American Academy of Pediatrics created a toolkit with resources for answering questions about the recently authorized SARS-CoV-2 mRNA vaccines (Pfizer and Moderna) for 6-month- to 5-year-olds with science-backed vaccine facts, including links to other useful AAP information websites, talking points, graphics, and videos.¹

Harrison_Christopher_MO_web.jpg

SARS-CoV-2 seasonality

SARS-CoV-2 is now endemic, not a once-a-year seasonal virus. Seasons (aka surges) will occur whenever a new variant arises (twice yearly since 2020, Omicron BA.4/BA.5 currently), or when enough vaccine holdouts, newborns, and/or those with waning of prior immunity (vaccine or infection induced) accrue.

Emergency use authorization submission data for mRNA vaccine responses in young children^2,3

Moderna in 6-month- through 5-year-olds. Two 25-mcg doses given 4-8 weeks apart produced 37.8% (95% confidence interval, 20.9%-51.1%) protection against symptomatic Omicron SARS-CoV-2 infections through 3 months of follow-up. Immunobridging analysis of antibody responses compared to 18- to 25-year-olds (100-mcg doses) showed the children’s responses were noninferior. Thus, the committee inferred that vaccine effectiveness in children should be similar to that in 18- to 25-year-olds. Fever, irritability, or local reaction/pain occurred in two-thirds after the second dose. Grade 3 reactions were noted in less than 5%.

Pfizer in 6-month- through 4-year-olds. Three 3-mcg doses, two doses 3-8 weeks apart and the third dose at least 8 weeks later (median 16 weeks), produced 80.3% (95% CI, 13.9%-96.7%) protection against symptomatic COVID-19 during the 6 weeks after the third dose. Local and systemic reactions occurred in 63.8%; less than 5% had grade 3 reactions (fever in about 3%, irritability in 1.3%, fatigue in 0.8%) mostly after second dose.

Neither duration of follow-up is very long. The Moderna data tell me that a third primary dose would have been better but restarting the trial to evaluate third doses would have delayed Moderna’s EUA another 4-6 months. The three-dose Pfizer data look better but may not have been as good with another 6 weeks of follow-up.

Additional post-EUA data will be collected. Boosters will be needed when immunity from both vaccines wanes (one estimate is about 6 months after the primary series). The Advisory Committee on Immunization Practices noted in their deliberations that vaccine-induced antibody responses are higher and cross-neutralize variants (even Omicron) better than infection-induced immunity.⁴

Are there downsides to the vaccines? Naysayers question vaccinating children less than 5 years old with reasons containing enough “truth” that they catch people’s attention, for example, “young children don’t get very sick with COVID-19,” “most have been infected already,” “RNA for the spike protein stays in the body for months,” or “myocarditis.” Naysayers can quote references in reputable journals but seem to spin selected data out of context or quote unconfirmed data from the Vaccine Adverse Event Reporting System.
 

Reasons to vaccinate

• While children have milder disease than adults, mid-June 2022 surveillance indicated 50 hospitalizations and 1 pediatric death each day from SARS-CoV-2.⁵
• Vaccinating young children endows a foundation of vaccine-induced SARS-CoV-2 immunity that is superior to infection-induced immunity.⁴
• Long-term effects of large numbers of SARS-CoV-2 particles that enter every organ of a developing child have not been determined.
• Viral loads are lowered by prior vaccine; fewer viral replications lessen chances for newer variants to arise.
• Transmission is less in breakthrough infections than infections in the unvaccinated.
• Thirty percent of 5- to 11-year-olds hospitalized for SARS-CoV-2 had no underlying conditions;⁶ hospitalization rates in newborn to 4-year-olds have been the highest in the Omicron surge.⁷
• No myocarditis or pericarditis episodes have been detected in 6-month- to 11-year-old trials.
• The AAP and ACIP recommend the mRNA vaccines.

My thoughts are that SARS-CoV-2 vaccine is just another “routine” childhood vaccine that prepares children for healthier futures, pandemic or not, and the vaccines are as safe as other routine vaccines.

And like other pediatric vaccines, it should be no surprise that boosters will be needed, even if no newer variants than Omicron BA.4/BA.5 arise. But we know newer variants will arise and, similar to influenza vaccine, new formulations, perhaps with multiple SARS-CoV-2 strain antigens, will be needed every year or so. Everyone will get SARS-CoV-2 multiple times in their lives no matter how careful they are. So isn’t it good medical practice to establish early the best available foundation for maintaining lifelong SARS-CoV-2 immunity?

To me it is like pertussis. Most pertussis-infected children are sick enough to be hospitalized; very few die. They are miserable with illnesses that take weeks to months to subside. The worst disease usually occurs in unvaccinated young children or those with underlying conditions. Reactogenicity was reduced with acellular vaccine but resulted in less immunogenicity, so we give boosters at intervals that best match waning immunity. Circulating strains can be different than the vaccine strain, so protection against infection is 80%. Finally, even the safest vaccine may very rarely have sequelae. That is why The National Vaccine Injury Compensation Program was created. Yet the benefit-to-harm ratio for children and society favors universal pertussis vaccine use. And we vaccinate even those who have had pertussis because even infection-based immunity is incomplete and protection wanes. If arguments similar to those by SARS-CoV-2 vaccine naysayers were applied to acellular pertussis vaccine, it seems they would argue against pertussis vaccine for young children.

Another major issue has been “safety concerns” about the vaccines’ small amount of mRNA for the spike protein encased in microscopic lipid bubbles injected in the arm or leg. This mRNA is picked up by human cells, and in the cytoplasm (not the nucleus where our DNA resides) produces a limited supply of spike protein that is then picked up by antigen-presenting cells for short-lived distribution (days to 2 weeks at most) to regional lymph nodes where immune-memory processes are jump-started. Contrast that to even asymptomatic SARS-CoV-2 infection where multibillions of virus particles are produced for up to 14 days with access to every bodily organ that contains ACE-2 receptors (they all do). Each virus particle hijacks a human cell producing thousands of mRNA for spike protein (and multiple other SARS-CoV-2 proteins), eventually releasing multibillions of lipid fragments from the ruptured cell. Comparing the amount of these components in the mRNA vaccines to those from infection is like comparing a campfire to the many-thousand-acre wildfire. So, if one is worried about the effects of spike protein and lipid fragments, the limited localized amounts in mRNA vaccines should make one much less concerned than the enormous amounts circulating throughout the body as a result of a SARS-CoV-2 infection.

My take is that children 6-months to 5-years-old deserve SARS-CoV-2–induced vaccine protection and we can and should strongly recommend it as medical providers and child advocates.
 

*Dr. Harrison is professor, University of Missouri Kansas City School of Medicine, department of medicine, infectious diseases section, Kansas City. Email him at pdnews@mdedge.com.

References

1. AAP. 2022 Jun 21. As COVID-19 vaccines become available for children ages 6 months to 4 years, AAP urges families to reach out to pediatricians to ask questions and access vaccine. www.aap.org.

2. CDC. Grading of recommendations, assessment, development, and evaluation (GRADE): Moderna COVID-19 vaccine for children aged 6 months–5 years. www.cdc.gov.

3. CDC. ACIP evidence to recommendations for use of Moderna COVID-19 vaccine in children ages 6 months–5 years and Pfizer-BioNTech COVID-19 vaccine in children ages 6 months–4 years under an emergency use authorization. www.cdc.gov.

4. Tang J et al. Nat Commun. 2022;13:2979.

5. Children and COVID-19: State Data Report. 2022 Jun 30. www.aap.org.

6. Shi DS et al. MMWR Morb Mortal Wkly Rep. 2022;71:574-81.

7. Marks KJ et al. MMWR Morb Mortal Wkly Rep. 2022;71:429-36.
 

Other good resources for families are https://getvaccineanswers.org/ or www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-in-babies-and-children/art-20484405.

*This story was updated on July 19, 2022.

A family’s decision to vaccinate their child is best made jointly with a trusted medical provider who knows the child and family. The American Academy of Pediatrics created a toolkit with resources for answering questions about the recently authorized SARS-CoV-2 mRNA vaccines (Pfizer and Moderna) for 6-month- to 5-year-olds with science-backed vaccine facts, including links to other useful AAP information websites, talking points, graphics, and videos.¹

Harrison_Christopher_MO_web.jpg

SARS-CoV-2 seasonality

SARS-CoV-2 is now endemic, not a once-a-year seasonal virus. Seasons (aka surges) will occur whenever a new variant arises (twice yearly since 2020, Omicron BA.4/BA.5 currently), or when enough vaccine holdouts, newborns, and/or those with waning of prior immunity (vaccine or infection induced) accrue.

Emergency use authorization submission data for mRNA vaccine responses in young children^2,3

Moderna in 6-month- through 5-year-olds. Two 25-mcg doses given 4-8 weeks apart produced 37.8% (95% confidence interval, 20.9%-51.1%) protection against symptomatic Omicron SARS-CoV-2 infections through 3 months of follow-up. Immunobridging analysis of antibody responses compared to 18- to 25-year-olds (100-mcg doses) showed the children’s responses were noninferior. Thus, the committee inferred that vaccine effectiveness in children should be similar to that in 18- to 25-year-olds. Fever, irritability, or local reaction/pain occurred in two-thirds after the second dose. Grade 3 reactions were noted in less than 5%.

Pfizer in 6-month- through 4-year-olds. Three 3-mcg doses, two doses 3-8 weeks apart and the third dose at least 8 weeks later (median 16 weeks), produced 80.3% (95% CI, 13.9%-96.7%) protection against symptomatic COVID-19 during the 6 weeks after the third dose. Local and systemic reactions occurred in 63.8%; less than 5% had grade 3 reactions (fever in about 3%, irritability in 1.3%, fatigue in 0.8%) mostly after second dose.

Neither duration of follow-up is very long. The Moderna data tell me that a third primary dose would have been better but restarting the trial to evaluate third doses would have delayed Moderna’s EUA another 4-6 months. The three-dose Pfizer data look better but may not have been as good with another 6 weeks of follow-up.

Additional post-EUA data will be collected. Boosters will be needed when immunity from both vaccines wanes (one estimate is about 6 months after the primary series). The Advisory Committee on Immunization Practices noted in their deliberations that vaccine-induced antibody responses are higher and cross-neutralize variants (even Omicron) better than infection-induced immunity.⁴

Are there downsides to the vaccines? Naysayers question vaccinating children less than 5 years old with reasons containing enough “truth” that they catch people’s attention, for example, “young children don’t get very sick with COVID-19,” “most have been infected already,” “RNA for the spike protein stays in the body for months,” or “myocarditis.” Naysayers can quote references in reputable journals but seem to spin selected data out of context or quote unconfirmed data from the Vaccine Adverse Event Reporting System.
 

Reasons to vaccinate

• While children have milder disease than adults, mid-June 2022 surveillance indicated 50 hospitalizations and 1 pediatric death each day from SARS-CoV-2.⁵
• Vaccinating young children endows a foundation of vaccine-induced SARS-CoV-2 immunity that is superior to infection-induced immunity.⁴
• Long-term effects of large numbers of SARS-CoV-2 particles that enter every organ of a developing child have not been determined.
• Viral loads are lowered by prior vaccine; fewer viral replications lessen chances for newer variants to arise.
• Transmission is less in breakthrough infections than infections in the unvaccinated.
• Thirty percent of 5- to 11-year-olds hospitalized for SARS-CoV-2 had no underlying conditions;⁶ hospitalization rates in newborn to 4-year-olds have been the highest in the Omicron surge.⁷
• No myocarditis or pericarditis episodes have been detected in 6-month- to 11-year-old trials.
• The AAP and ACIP recommend the mRNA vaccines.

My thoughts are that SARS-CoV-2 vaccine is just another “routine” childhood vaccine that prepares children for healthier futures, pandemic or not, and the vaccines are as safe as other routine vaccines.

And like other pediatric vaccines, it should be no surprise that boosters will be needed, even if no newer variants than Omicron BA.4/BA.5 arise. But we know newer variants will arise and, similar to influenza vaccine, new formulations, perhaps with multiple SARS-CoV-2 strain antigens, will be needed every year or so. Everyone will get SARS-CoV-2 multiple times in their lives no matter how careful they are. So isn’t it good medical practice to establish early the best available foundation for maintaining lifelong SARS-CoV-2 immunity?

To me it is like pertussis. Most pertussis-infected children are sick enough to be hospitalized; very few die. They are miserable with illnesses that take weeks to months to subside. The worst disease usually occurs in unvaccinated young children or those with underlying conditions. Reactogenicity was reduced with acellular vaccine but resulted in less immunogenicity, so we give boosters at intervals that best match waning immunity. Circulating strains can be different than the vaccine strain, so protection against infection is 80%. Finally, even the safest vaccine may very rarely have sequelae. That is why The National Vaccine Injury Compensation Program was created. Yet the benefit-to-harm ratio for children and society favors universal pertussis vaccine use. And we vaccinate even those who have had pertussis because even infection-based immunity is incomplete and protection wanes. If arguments similar to those by SARS-CoV-2 vaccine naysayers were applied to acellular pertussis vaccine, it seems they would argue against pertussis vaccine for young children.

Another major issue has been “safety concerns” about the vaccines’ small amount of mRNA for the spike protein encased in microscopic lipid bubbles injected in the arm or leg. This mRNA is picked up by human cells, and in the cytoplasm (not the nucleus where our DNA resides) produces a limited supply of spike protein that is then picked up by antigen-presenting cells for short-lived distribution (days to 2 weeks at most) to regional lymph nodes where immune-memory processes are jump-started. Contrast that to even asymptomatic SARS-CoV-2 infection where multibillions of virus particles are produced for up to 14 days with access to every bodily organ that contains ACE-2 receptors (they all do). Each virus particle hijacks a human cell producing thousands of mRNA for spike protein (and multiple other SARS-CoV-2 proteins), eventually releasing multibillions of lipid fragments from the ruptured cell. Comparing the amount of these components in the mRNA vaccines to those from infection is like comparing a campfire to the many-thousand-acre wildfire. So, if one is worried about the effects of spike protein and lipid fragments, the limited localized amounts in mRNA vaccines should make one much less concerned than the enormous amounts circulating throughout the body as a result of a SARS-CoV-2 infection.

My take is that children 6-months to 5-years-old deserve SARS-CoV-2–induced vaccine protection and we can and should strongly recommend it as medical providers and child advocates.
 

*Dr. Harrison is professor, University of Missouri Kansas City School of Medicine, department of medicine, infectious diseases section, Kansas City. Email him at pdnews@mdedge.com.

References

1. AAP. 2022 Jun 21. As COVID-19 vaccines become available for children ages 6 months to 4 years, AAP urges families to reach out to pediatricians to ask questions and access vaccine. www.aap.org.

2. CDC. Grading of recommendations, assessment, development, and evaluation (GRADE): Moderna COVID-19 vaccine for children aged 6 months–5 years. www.cdc.gov.

3. CDC. ACIP evidence to recommendations for use of Moderna COVID-19 vaccine in children ages 6 months–5 years and Pfizer-BioNTech COVID-19 vaccine in children ages 6 months–4 years under an emergency use authorization. www.cdc.gov.

4. Tang J et al. Nat Commun. 2022;13:2979.

5. Children and COVID-19: State Data Report. 2022 Jun 30. www.aap.org.

6. Shi DS et al. MMWR Morb Mortal Wkly Rep. 2022;71:574-81.

7. Marks KJ et al. MMWR Morb Mortal Wkly Rep. 2022;71:429-36.
 

Other good resources for families are https://getvaccineanswers.org/ or www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-in-babies-and-children/art-20484405.

*This story was updated on July 19, 2022.

REFERENCES

1. Weng MK. Universal adult hepatitis B vaccinations: work group considerations. Presented to the Advisory Committee on Immunization Practices on November 3, 2021. Accessed November 17, 2021. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-2-3/02-HepWG-weng-508.pdf
2. Kovayashi M. Considerations for age-based and risk-based use of PCV15 and PCV20 among US adults and proposed policy options. Presented to the Advisory Committee on Immunization Practices on October 20, 2021. Accessed November 17, 2021. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-10-20-21/02-Pneumococcal-Kobayashi-508.pdf
3. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67:1-31.
4. Matanock A, Lee G, Gierke R, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morbid Mortal Wkly Rep. 2019;68:1069-1075.

REFERENCES

1. Weng MK. Universal adult hepatitis B vaccinations: work group considerations. Presented to the Advisory Committee on Immunization Practices on November 3, 2021. Accessed November 17, 2021. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-2-3/02-HepWG-weng-508.pdf
2. Kovayashi M. Considerations for age-based and risk-based use of PCV15 and PCV20 among US adults and proposed policy options. Presented to the Advisory Committee on Immunization Practices on October 20, 2021. Accessed November 17, 2021. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-10-20-21/02-Pneumococcal-Kobayashi-508.pdf
3. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67:1-31.
4. Matanock A, Lee G, Gierke R, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morbid Mortal Wkly Rep. 2019;68:1069-1075.

REFERENCES

1. Weng MK. Universal adult hepatitis B vaccinations: work group considerations. Presented to the Advisory Committee on Immunization Practices on November 3, 2021. Accessed November 17, 2021. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-2-3/02-HepWG-weng-508.pdf
2. Kovayashi M. Considerations for age-based and risk-based use of PCV15 and PCV20 among US adults and proposed policy options. Presented to the Advisory Committee on Immunization Practices on October 20, 2021. Accessed November 17, 2021. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-10-20-21/02-Pneumococcal-Kobayashi-508.pdf
3. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67:1-31.
4. Matanock A, Lee G, Gierke R, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morbid Mortal Wkly Rep. 2019;68:1069-1075.

REFERENCES

1. US Preventive Services Task Force. Aspirin use to prevent cardiovascular disease: preventive medication. Published October 12, 2021. Accessed October 25, 2021. www.uspreventiveservicestaskforce.org/uspstf/document/draft-evidence-review/aspirin-use-to-prevent-cardiovascular-disease-preventive-medication
2. National Center for Health Statistics. Figure 4. Number of deaths, percentage of total deaths, and age-adjusted death rates for the 10 leading causes of death in 2019: United States, 2018 and 2019. In: Data Brief 395: Mortality in the United States 2019. Published December 2020. Accessed October 25, 2021. www.cdc.gov/nchs/data/databriefs/db395-tables-508.pdf
3. American College of Cardiology/American Heart Association. Heart risk calculator. Updated November 12, 2017. Accessed October 25, 2021. www.cvriskcalculator.com/

REFERENCES

1. US Preventive Services Task Force. Aspirin use to prevent cardiovascular disease: preventive medication. Published October 12, 2021. Accessed October 25, 2021. www.uspreventiveservicestaskforce.org/uspstf/document/draft-evidence-review/aspirin-use-to-prevent-cardiovascular-disease-preventive-medication
2. National Center for Health Statistics. Figure 4. Number of deaths, percentage of total deaths, and age-adjusted death rates for the 10 leading causes of death in 2019: United States, 2018 and 2019. In: Data Brief 395: Mortality in the United States 2019. Published December 2020. Accessed October 25, 2021. www.cdc.gov/nchs/data/databriefs/db395-tables-508.pdf
3. American College of Cardiology/American Heart Association. Heart risk calculator. Updated November 12, 2017. Accessed October 25, 2021. www.cvriskcalculator.com/

REFERENCES

1. US Preventive Services Task Force. Aspirin use to prevent cardiovascular disease: preventive medication. Published October 12, 2021. Accessed October 25, 2021. www.uspreventiveservicestaskforce.org/uspstf/document/draft-evidence-review/aspirin-use-to-prevent-cardiovascular-disease-preventive-medication
2. National Center for Health Statistics. Figure 4. Number of deaths, percentage of total deaths, and age-adjusted death rates for the 10 leading causes of death in 2019: United States, 2018 and 2019. In: Data Brief 395: Mortality in the United States 2019. Published December 2020. Accessed October 25, 2021. www.cdc.gov/nchs/data/databriefs/db395-tables-508.pdf
3. American College of Cardiology/American Heart Association. Heart risk calculator. Updated November 12, 2017. Accessed October 25, 2021. www.cvriskcalculator.com/

REFERENCES

1. US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes. JAMA. 2021;326:736-743. doi: 10.1001/jama.2021.12531
2. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021. Diabetes Care. 2021;44(suppl 1):S15-S33. https://doi.org/10.2337/dc21-S002

REFERENCES

1. US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes. JAMA. 2021;326:736-743. doi: 10.1001/jama.2021.12531
2. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021. Diabetes Care. 2021;44(suppl 1):S15-S33. https://doi.org/10.2337/dc21-S002

REFERENCES

1. US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes. JAMA. 2021;326:736-743. doi: 10.1001/jama.2021.12531
2. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021. Diabetes Care. 2021;44(suppl 1):S15-S33. https://doi.org/10.2337/dc21-S002

The attraction of reproductive endocrinology and infertility (REI), personally, is the hormonal interplay of the hypothalamus and pituitary with the end organs that are intimately involved in female reproduction. While the sex hormone–producing organs, such as the ovaries and adrenal glands, are directly related to reproductive function, the thyroid gland is typically overlooked until dysfunction occurs, resulting in ovulation dysfunction and pregnancy complications, namely miscarriage and preterm labor. This month we address thyroid function, given its vital role for fertility and pregnancy health and the fetus’ reliance on maternal thyroid hormone during the first trimester to ensure normal neurologic development.

Trolice_Mark_P_FLA_new_web.jpg

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age; the first being polycystic ovary syndrome (PCOS). Thyroid dysfunction can impair ovulation and, consequently, fertility. Hyperthyroidism is found in approximately 2.3% of women presenting with fertility problems, compared with 1.5% of women in the general population. Hypothyroidism affects 0.5% of women of reproductive age and has been shown to result in impaired reproductive outcomes, including miscarriage, along with adverse obstetric and fetal outcomes. Subclinical hypothyroidism (SCH), defined as an elevated thyroid-stimulating hormone (TSH) level with a normal free T4, has an incidence of 4%-8% in the reproductive-age population. While there is fair evidence SCH increases miscarriage, treatment may result in improved outcomes.

The prevalence of thyroid autoimmunity (TAI) among women of reproductive age is 8%-14% worldwide and it is increased in the infertility population. TAI, defined as the presence of thyroid peroxidase and thyroglobulin antibodies, has been shown to be associated with a reduced live birth rate, increase in preterm birth, and a two- to threefold increase in miscarriage.

The endocrinologic “pendulum” of guidance regarding the effect on and management of thyroid function regarding fertility, pregnancy, and baby has conflicting results. Controlled ovarian hyperstimulation for in vitro fertilization appears to alter TSH levels and levothyroxine requirements increase in the first trimester by approximately 50%. The controversy lies in which population of women should be tested for TAI, which TSH level is acceptable, and how to manage, if at all, euthyroid women with TAI or women with SCH who are trying to conceive. Ultimately, which women would benefit from levothyroxine while trying to conceive and during pregnancy?
 

Summary of salient studies

• In a meta-analysis, untreated women with SCH had a higher prevalence of miscarriage, compared with euthyroid women (RR, 1.90). Miscarriage rates were even higher in SCH with TIA, compared with women with SCH. The authors recommend “early treatments to avoid adverse pregnancy outcomes and complications.”
• A randomized controlled trial from China studied women who were euthyroid with TAI undergoing IVF. The authors demonstrated levothyroxine did not reduce miscarriage rates or increase live birth rates. To dive further into their cohort, the authors addressed whether TSH above 2.5 mIU/L or above 4 mIU/L (per the American Society for Reproductive Medicine cutoff values) impaired reproductive outcome and found no benefit of levothyroxine in any subgroup. This is consistent with other studies that showed no detrimental effect on pregnancy outcome with TSH levels above 2.5 mIU/L in the normal range and no reduction in miscarriage with the addition of levothyroxine.
• An observational cohort study of IVF patients that underwent preimplantation genetic testing for aneuploidy did not demonstrate an association between chromosomally normal embryos that miscarried and maternal antithyroid antibodies in recurrent miscarriage patients.
• A double-blind, placebo-controlled trial on the use of levothyroxine in euthyroid women with TAI did not result in a higher rate of live births, lower rate of pregnancy loss, or preterm birth, compared with placebo.

Consensus statements

• The American Society for Reproductive Medicine considers it reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH less than 2.5 mIU/L and within the normal range. Women who have TAI and TSH greater than 2.5 mIU/L can be considered for treatment with levothyroxine.
• The Endocrine Society recommends levothyroxine in women with SCH who have TAI.
• The American Thyroid Association guideline recommends women with SCH who are undergoing IVF be treated with levothyroxine to achieve a TSH concentration less than 2.5mIU/L.
• The 2011 guidelines of the American Thyroid Association and the 2012 guidelines of the Endocrine Society recommended the specific reference ranges for TSH in the early, middle, and late stages of pregnancy as 0.1-2.5 mIU/L, 0.2-3.0 mIU/L, and 0.3-3.0 mIU/L, respectively.
• The American College of Obstetricians & Gynecologists recommend avoiding universal thyroid screening in pregnancy since “identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”

Conclusion

The 2019 Cochrane Database states there are no clear conclusions regarding treatment with levothyroxine in euthyroid TAI or SCH because of the low quality of evidence reported. While TAI and SCH have been associated with pregnancy complications, there is no apparent benefit of levothyroxine in women with TAI or TSH levels between 2.5 and 4 mIU/L.

So, the conundrum is which preconception women to test and how to manage nonovert thyroid disease. For now, it is reasonable to obtain a serum TSH on all women desiring fertility, to treat SCH with levothyroxine to maintain TSH less than 2.5 mIU/L in the normal range, and to adjust levothyroxine accordingly throughout pregnancy.

Dr. Trolice is director of fertility at CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no disclosures. Email him at obnews@mdedge.com.

The attraction of reproductive endocrinology and infertility (REI), personally, is the hormonal interplay of the hypothalamus and pituitary with the end organs that are intimately involved in female reproduction. While the sex hormone–producing organs, such as the ovaries and adrenal glands, are directly related to reproductive function, the thyroid gland is typically overlooked until dysfunction occurs, resulting in ovulation dysfunction and pregnancy complications, namely miscarriage and preterm labor. This month we address thyroid function, given its vital role for fertility and pregnancy health and the fetus’ reliance on maternal thyroid hormone during the first trimester to ensure normal neurologic development.

Trolice_Mark_P_FLA_new_web.jpg

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age; the first being polycystic ovary syndrome (PCOS). Thyroid dysfunction can impair ovulation and, consequently, fertility. Hyperthyroidism is found in approximately 2.3% of women presenting with fertility problems, compared with 1.5% of women in the general population. Hypothyroidism affects 0.5% of women of reproductive age and has been shown to result in impaired reproductive outcomes, including miscarriage, along with adverse obstetric and fetal outcomes. Subclinical hypothyroidism (SCH), defined as an elevated thyroid-stimulating hormone (TSH) level with a normal free T4, has an incidence of 4%-8% in the reproductive-age population. While there is fair evidence SCH increases miscarriage, treatment may result in improved outcomes.

The prevalence of thyroid autoimmunity (TAI) among women of reproductive age is 8%-14% worldwide and it is increased in the infertility population. TAI, defined as the presence of thyroid peroxidase and thyroglobulin antibodies, has been shown to be associated with a reduced live birth rate, increase in preterm birth, and a two- to threefold increase in miscarriage.

The endocrinologic “pendulum” of guidance regarding the effect on and management of thyroid function regarding fertility, pregnancy, and baby has conflicting results. Controlled ovarian hyperstimulation for in vitro fertilization appears to alter TSH levels and levothyroxine requirements increase in the first trimester by approximately 50%. The controversy lies in which population of women should be tested for TAI, which TSH level is acceptable, and how to manage, if at all, euthyroid women with TAI or women with SCH who are trying to conceive. Ultimately, which women would benefit from levothyroxine while trying to conceive and during pregnancy?
 

Summary of salient studies

• In a meta-analysis, untreated women with SCH had a higher prevalence of miscarriage, compared with euthyroid women (RR, 1.90). Miscarriage rates were even higher in SCH with TIA, compared with women with SCH. The authors recommend “early treatments to avoid adverse pregnancy outcomes and complications.”
• A randomized controlled trial from China studied women who were euthyroid with TAI undergoing IVF. The authors demonstrated levothyroxine did not reduce miscarriage rates or increase live birth rates. To dive further into their cohort, the authors addressed whether TSH above 2.5 mIU/L or above 4 mIU/L (per the American Society for Reproductive Medicine cutoff values) impaired reproductive outcome and found no benefit of levothyroxine in any subgroup. This is consistent with other studies that showed no detrimental effect on pregnancy outcome with TSH levels above 2.5 mIU/L in the normal range and no reduction in miscarriage with the addition of levothyroxine.
• An observational cohort study of IVF patients that underwent preimplantation genetic testing for aneuploidy did not demonstrate an association between chromosomally normal embryos that miscarried and maternal antithyroid antibodies in recurrent miscarriage patients.
• A double-blind, placebo-controlled trial on the use of levothyroxine in euthyroid women with TAI did not result in a higher rate of live births, lower rate of pregnancy loss, or preterm birth, compared with placebo.

Consensus statements

• The American Society for Reproductive Medicine considers it reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH less than 2.5 mIU/L and within the normal range. Women who have TAI and TSH greater than 2.5 mIU/L can be considered for treatment with levothyroxine.
• The Endocrine Society recommends levothyroxine in women with SCH who have TAI.
• The American Thyroid Association guideline recommends women with SCH who are undergoing IVF be treated with levothyroxine to achieve a TSH concentration less than 2.5mIU/L.
• The 2011 guidelines of the American Thyroid Association and the 2012 guidelines of the Endocrine Society recommended the specific reference ranges for TSH in the early, middle, and late stages of pregnancy as 0.1-2.5 mIU/L, 0.2-3.0 mIU/L, and 0.3-3.0 mIU/L, respectively.
• The American College of Obstetricians & Gynecologists recommend avoiding universal thyroid screening in pregnancy since “identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”

Conclusion

The 2019 Cochrane Database states there are no clear conclusions regarding treatment with levothyroxine in euthyroid TAI or SCH because of the low quality of evidence reported. While TAI and SCH have been associated with pregnancy complications, there is no apparent benefit of levothyroxine in women with TAI or TSH levels between 2.5 and 4 mIU/L.

So, the conundrum is which preconception women to test and how to manage nonovert thyroid disease. For now, it is reasonable to obtain a serum TSH on all women desiring fertility, to treat SCH with levothyroxine to maintain TSH less than 2.5 mIU/L in the normal range, and to adjust levothyroxine accordingly throughout pregnancy.

Dr. Trolice is director of fertility at CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no disclosures. Email him at obnews@mdedge.com.

The attraction of reproductive endocrinology and infertility (REI), personally, is the hormonal interplay of the hypothalamus and pituitary with the end organs that are intimately involved in female reproduction. While the sex hormone–producing organs, such as the ovaries and adrenal glands, are directly related to reproductive function, the thyroid gland is typically overlooked until dysfunction occurs, resulting in ovulation dysfunction and pregnancy complications, namely miscarriage and preterm labor. This month we address thyroid function, given its vital role for fertility and pregnancy health and the fetus’ reliance on maternal thyroid hormone during the first trimester to ensure normal neurologic development.

Trolice_Mark_P_FLA_new_web.jpg

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age; the first being polycystic ovary syndrome (PCOS). Thyroid dysfunction can impair ovulation and, consequently, fertility. Hyperthyroidism is found in approximately 2.3% of women presenting with fertility problems, compared with 1.5% of women in the general population. Hypothyroidism affects 0.5% of women of reproductive age and has been shown to result in impaired reproductive outcomes, including miscarriage, along with adverse obstetric and fetal outcomes. Subclinical hypothyroidism (SCH), defined as an elevated thyroid-stimulating hormone (TSH) level with a normal free T4, has an incidence of 4%-8% in the reproductive-age population. While there is fair evidence SCH increases miscarriage, treatment may result in improved outcomes.

The prevalence of thyroid autoimmunity (TAI) among women of reproductive age is 8%-14% worldwide and it is increased in the infertility population. TAI, defined as the presence of thyroid peroxidase and thyroglobulin antibodies, has been shown to be associated with a reduced live birth rate, increase in preterm birth, and a two- to threefold increase in miscarriage.

The endocrinologic “pendulum” of guidance regarding the effect on and management of thyroid function regarding fertility, pregnancy, and baby has conflicting results. Controlled ovarian hyperstimulation for in vitro fertilization appears to alter TSH levels and levothyroxine requirements increase in the first trimester by approximately 50%. The controversy lies in which population of women should be tested for TAI, which TSH level is acceptable, and how to manage, if at all, euthyroid women with TAI or women with SCH who are trying to conceive. Ultimately, which women would benefit from levothyroxine while trying to conceive and during pregnancy?
 

Summary of salient studies

• In a meta-analysis, untreated women with SCH had a higher prevalence of miscarriage, compared with euthyroid women (RR, 1.90). Miscarriage rates were even higher in SCH with TIA, compared with women with SCH. The authors recommend “early treatments to avoid adverse pregnancy outcomes and complications.”
• A randomized controlled trial from China studied women who were euthyroid with TAI undergoing IVF. The authors demonstrated levothyroxine did not reduce miscarriage rates or increase live birth rates. To dive further into their cohort, the authors addressed whether TSH above 2.5 mIU/L or above 4 mIU/L (per the American Society for Reproductive Medicine cutoff values) impaired reproductive outcome and found no benefit of levothyroxine in any subgroup. This is consistent with other studies that showed no detrimental effect on pregnancy outcome with TSH levels above 2.5 mIU/L in the normal range and no reduction in miscarriage with the addition of levothyroxine.
• An observational cohort study of IVF patients that underwent preimplantation genetic testing for aneuploidy did not demonstrate an association between chromosomally normal embryos that miscarried and maternal antithyroid antibodies in recurrent miscarriage patients.
• A double-blind, placebo-controlled trial on the use of levothyroxine in euthyroid women with TAI did not result in a higher rate of live births, lower rate of pregnancy loss, or preterm birth, compared with placebo.

Consensus statements

• The American Society for Reproductive Medicine considers it reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH less than 2.5 mIU/L and within the normal range. Women who have TAI and TSH greater than 2.5 mIU/L can be considered for treatment with levothyroxine.
• The Endocrine Society recommends levothyroxine in women with SCH who have TAI.
• The American Thyroid Association guideline recommends women with SCH who are undergoing IVF be treated with levothyroxine to achieve a TSH concentration less than 2.5mIU/L.
• The 2011 guidelines of the American Thyroid Association and the 2012 guidelines of the Endocrine Society recommended the specific reference ranges for TSH in the early, middle, and late stages of pregnancy as 0.1-2.5 mIU/L, 0.2-3.0 mIU/L, and 0.3-3.0 mIU/L, respectively.
• The American College of Obstetricians & Gynecologists recommend avoiding universal thyroid screening in pregnancy since “identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”

Conclusion

The 2019 Cochrane Database states there are no clear conclusions regarding treatment with levothyroxine in euthyroid TAI or SCH because of the low quality of evidence reported. While TAI and SCH have been associated with pregnancy complications, there is no apparent benefit of levothyroxine in women with TAI or TSH levels between 2.5 and 4 mIU/L.

So, the conundrum is which preconception women to test and how to manage nonovert thyroid disease. For now, it is reasonable to obtain a serum TSH on all women desiring fertility, to treat SCH with levothyroxine to maintain TSH less than 2.5 mIU/L in the normal range, and to adjust levothyroxine accordingly throughout pregnancy.

Dr. Trolice is director of fertility at CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no disclosures. Email him at obnews@mdedge.com.

Jessica Gosnell, MD, 41, from Portland, Oregon, lives daily with the knowledge that her rare disease — a form of hereditary angioedema — could cause a sudden, severe swelling in her throat that could require quick intubation and land her in an intensive care unit (ICU) for days.

“I’ve been hospitalized for throat swells three times in the last year,” she said in an interview.

Dr. Gosnell no longer practices medicine because of a combination of illnesses, but lives with her husband, Andrew, and two young children, and said they are all “terrified” she will have to go to the hospital amid a COVID-19 surge that had shrunk the number of available ICU beds to 152 from 780 in Oregon as of Aug. 30. Thirty percent of the beds are in use for patients with COVID-19.

She said her life depends on being near hospitals that have ICUs and having access to highly specialized medications, one of which can cost up to $50,000 for the rescue dose.

Her fear has her “literally living bedbound.” In addition to hereditary angioedema, she has Ehlers-Danlos syndrome, which weakens connective tissue. She wears a cervical collar 24/7 to keep from tearing tissues, as any tissue injury can trigger a swell.
 

Patients worry there won’t be room

As ICU beds in most states are filling with COVID-19 patients as the Delta variant spreads, fears are rising among people like Dr. Gosnell, who have chronic conditions and diseases with unpredictable emergency visits, who worry that if they need emergency care there won’t be room.

As of Aug. 30, in the United States, 79% of ICU beds nationally were in use, 30% of them for COVID-19 patients, according to the U.S. Department of Health and Human Services.

In individual states, the picture is dire. Alabama has fewer than 10% of its ICU beds open across the entire state. In Florida, 93% of ICU beds are filled, 53% of them with COVID patients. In Louisiana, 87% of beds were already in use, 45% of them with COVID patients, just as category 4 hurricane Ida smashed into the coastline on Aug. 29.

News reports have told of people transported and airlifted as hospitals reach capacity.

In Bellville, Tex., U.S. Army veteran Daniel Wilkinson needed advanced care for gallstone pancreatitis that normally would take 30 minutes to treat, his Bellville doctor, Hasan Kakli, MD, told CBS News.

Mr. Wilkinson’s house was three doors from Bellville Hospital, but the hospital was not equipped to treat the condition. Calls to other hospitals found the same answer: no empty ICU beds. After a 7-hour wait on a stretcher, he was airlifted to a Veterans Affairs hospital in Houston, but it was too late. He died on August 22 at age 46.

Dr. Kakli said, “I’ve never lost a patient with this diagnosis. Ever. I’m scared that the next patient I see is someone that I can’t get to where they need to get to. We are playing musical chairs with 100 people and 10 chairs. When the music stops, what happens?”

Also in Texas in August, Joe Valdez, who was shot six times as an unlucky bystander in a domestic dispute, waited for more than a week for surgery at Ben Taub Hospital in Houston, which was over capacity with COVID patients, the Washington Post reported.

Others with chronic diseases fear needing emergency services or even entering a hospital for regular care with the COVID surge.

Nicole Seefeldt, 44, from Easton, Penn., who had a double-lung transplant in 2016, said that she hasn’t been able to see her lung transplant specialists in Philadelphia — an hour-and-a-half drive — for almost 2 years because of fear of contracting COVID. Before the pandemic, she made the trip almost weekly.

“I protect my lungs like they’re children,” she said. 

She relies on her local hospital for care, but has put off some needed care, such as a colonoscopy, and has relied on telemedicine because she wants to limit her hospital exposure.

Ms. Seefeldt now faces an eventual kidney transplant, as her kidney function has been reduced to 20%. In the meantime, she worries she will need emergency care for either her lungs or kidneys.

“For those of us who are chronically ill or disabled, what if we have an emergency that is not COVID-related? Are we going to be able to get a bed? Are we going to be able to get treatment? It’s not just COVID patients who come to the [emergency room],” she said.
 

A pandemic problem

Paul E. Casey, MD, MBA, chief medical officer at Rush University Medical Center in Chicago, said that high vaccination rates in Chicago have helped Rush continue to accommodate both non-COVID and COVID patients in the emergency department.

Though the hospital treated a large volume of COVID patients, “The vast majority of people we see and did see through the pandemic were non-COVID patents,” he said.

Dr. Casey said that in the first wave the hospital noticed a concerning drop in patients coming in for strokes and heart attacks — “things we knew hadn’t gone away.”

And the data backs it up. Over the course of the pandemic, the Centers for Disease Control and Prevention’s National Health Interview Survey found that the percentage of Americans who reported seeing a doctor or health professional fell from 85% at the end of 2019 to about 80% in the first three months of 2021. The survey did not differentiate between in-person visits and telehealth appointments.

Medical practices and patients themselves postponed elective procedures and delayed routine visits during the early months of the crisis.

Patients also reported staying away from hospitals’ emergency departments throughout the pandemic. At the end of 2019, 22% of respondents reported visiting an emergency department in the past year. That dropped to 17% by the end of 2020, and was at 17.7% in the first 3 months of 2021.

Dr. Casey said that, in his hospital’s case, clear messaging became very important to assure patients it was safe to come back. And the message is still critical.

“We want to be loud and clear that patients should continue to seek care for those conditions,” Dr. Casey said. “Deferring healthcare only comes with the long-term sequelae of disease left untreated so we want people to be as proactive in seeking care as they always would be.”

In some cases, fears of entering emergency rooms because of excess patients and risk for infection are keeping some patients from seeking necessary care for minor injuries.

Jim Rickert, MD, an orthopedic surgeon with Indiana University Health in Bloomington, said that some of his patients have expressed fears of coming into the hospital for fractures.

Some patients, particularly elderly patients, he said, are having falls and fractures and wearing slings or braces at home rather than going into the hospital for injuries that need immediate attention.

Bones start healing incorrectly, Dr. Rickert said, and the correction becomes much more difficult.
 

Plea for vaccinations

Dr. Gosnell made a plea posted on her neighborhood news forum for people to get COVID vaccinations.

“It seems to me it’s easy for other people who are not in bodies like mine to take health for granted,” she said. “But there are a lot of us who live in very fragile bodies and our entire life is at the intersection of us and getting healthcare treatment. Small complications to getting treatment can be life altering.”

Dr. Gosnell, Ms. Seefeldt, Dr. Casey, and Dr. Rickert reported no relevant financial relationships.

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

Jessica Gosnell, MD, 41, from Portland, Oregon, lives daily with the knowledge that her rare disease — a form of hereditary angioedema — could cause a sudden, severe swelling in her throat that could require quick intubation and land her in an intensive care unit (ICU) for days.

“I’ve been hospitalized for throat swells three times in the last year,” she said in an interview.

Dr. Gosnell no longer practices medicine because of a combination of illnesses, but lives with her husband, Andrew, and two young children, and said they are all “terrified” she will have to go to the hospital amid a COVID-19 surge that had shrunk the number of available ICU beds to 152 from 780 in Oregon as of Aug. 30. Thirty percent of the beds are in use for patients with COVID-19.

She said her life depends on being near hospitals that have ICUs and having access to highly specialized medications, one of which can cost up to $50,000 for the rescue dose.

Her fear has her “literally living bedbound.” In addition to hereditary angioedema, she has Ehlers-Danlos syndrome, which weakens connective tissue. She wears a cervical collar 24/7 to keep from tearing tissues, as any tissue injury can trigger a swell.
 

Patients worry there won’t be room

As ICU beds in most states are filling with COVID-19 patients as the Delta variant spreads, fears are rising among people like Dr. Gosnell, who have chronic conditions and diseases with unpredictable emergency visits, who worry that if they need emergency care there won’t be room.

As of Aug. 30, in the United States, 79% of ICU beds nationally were in use, 30% of them for COVID-19 patients, according to the U.S. Department of Health and Human Services.

In individual states, the picture is dire. Alabama has fewer than 10% of its ICU beds open across the entire state. In Florida, 93% of ICU beds are filled, 53% of them with COVID patients. In Louisiana, 87% of beds were already in use, 45% of them with COVID patients, just as category 4 hurricane Ida smashed into the coastline on Aug. 29.

News reports have told of people transported and airlifted as hospitals reach capacity.

In Bellville, Tex., U.S. Army veteran Daniel Wilkinson needed advanced care for gallstone pancreatitis that normally would take 30 minutes to treat, his Bellville doctor, Hasan Kakli, MD, told CBS News.

Mr. Wilkinson’s house was three doors from Bellville Hospital, but the hospital was not equipped to treat the condition. Calls to other hospitals found the same answer: no empty ICU beds. After a 7-hour wait on a stretcher, he was airlifted to a Veterans Affairs hospital in Houston, but it was too late. He died on August 22 at age 46.

Dr. Kakli said, “I’ve never lost a patient with this diagnosis. Ever. I’m scared that the next patient I see is someone that I can’t get to where they need to get to. We are playing musical chairs with 100 people and 10 chairs. When the music stops, what happens?”

Also in Texas in August, Joe Valdez, who was shot six times as an unlucky bystander in a domestic dispute, waited for more than a week for surgery at Ben Taub Hospital in Houston, which was over capacity with COVID patients, the Washington Post reported.

Others with chronic diseases fear needing emergency services or even entering a hospital for regular care with the COVID surge.

Nicole Seefeldt, 44, from Easton, Penn., who had a double-lung transplant in 2016, said that she hasn’t been able to see her lung transplant specialists in Philadelphia — an hour-and-a-half drive — for almost 2 years because of fear of contracting COVID. Before the pandemic, she made the trip almost weekly.

“I protect my lungs like they’re children,” she said. 

She relies on her local hospital for care, but has put off some needed care, such as a colonoscopy, and has relied on telemedicine because she wants to limit her hospital exposure.

Ms. Seefeldt now faces an eventual kidney transplant, as her kidney function has been reduced to 20%. In the meantime, she worries she will need emergency care for either her lungs or kidneys.

“For those of us who are chronically ill or disabled, what if we have an emergency that is not COVID-related? Are we going to be able to get a bed? Are we going to be able to get treatment? It’s not just COVID patients who come to the [emergency room],” she said.
 

A pandemic problem

Paul E. Casey, MD, MBA, chief medical officer at Rush University Medical Center in Chicago, said that high vaccination rates in Chicago have helped Rush continue to accommodate both non-COVID and COVID patients in the emergency department.

Though the hospital treated a large volume of COVID patients, “The vast majority of people we see and did see through the pandemic were non-COVID patents,” he said.

Dr. Casey said that in the first wave the hospital noticed a concerning drop in patients coming in for strokes and heart attacks — “things we knew hadn’t gone away.”

And the data backs it up. Over the course of the pandemic, the Centers for Disease Control and Prevention’s National Health Interview Survey found that the percentage of Americans who reported seeing a doctor or health professional fell from 85% at the end of 2019 to about 80% in the first three months of 2021. The survey did not differentiate between in-person visits and telehealth appointments.

Medical practices and patients themselves postponed elective procedures and delayed routine visits during the early months of the crisis.

Patients also reported staying away from hospitals’ emergency departments throughout the pandemic. At the end of 2019, 22% of respondents reported visiting an emergency department in the past year. That dropped to 17% by the end of 2020, and was at 17.7% in the first 3 months of 2021.

Dr. Casey said that, in his hospital’s case, clear messaging became very important to assure patients it was safe to come back. And the message is still critical.

“We want to be loud and clear that patients should continue to seek care for those conditions,” Dr. Casey said. “Deferring healthcare only comes with the long-term sequelae of disease left untreated so we want people to be as proactive in seeking care as they always would be.”

In some cases, fears of entering emergency rooms because of excess patients and risk for infection are keeping some patients from seeking necessary care for minor injuries.

Jim Rickert, MD, an orthopedic surgeon with Indiana University Health in Bloomington, said that some of his patients have expressed fears of coming into the hospital for fractures.

Some patients, particularly elderly patients, he said, are having falls and fractures and wearing slings or braces at home rather than going into the hospital for injuries that need immediate attention.

Bones start healing incorrectly, Dr. Rickert said, and the correction becomes much more difficult.
 

Plea for vaccinations

Dr. Gosnell made a plea posted on her neighborhood news forum for people to get COVID vaccinations.

“It seems to me it’s easy for other people who are not in bodies like mine to take health for granted,” she said. “But there are a lot of us who live in very fragile bodies and our entire life is at the intersection of us and getting healthcare treatment. Small complications to getting treatment can be life altering.”

Dr. Gosnell, Ms. Seefeldt, Dr. Casey, and Dr. Rickert reported no relevant financial relationships.

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

Jessica Gosnell, MD, 41, from Portland, Oregon, lives daily with the knowledge that her rare disease — a form of hereditary angioedema — could cause a sudden, severe swelling in her throat that could require quick intubation and land her in an intensive care unit (ICU) for days.

“I’ve been hospitalized for throat swells three times in the last year,” she said in an interview.

Dr. Gosnell no longer practices medicine because of a combination of illnesses, but lives with her husband, Andrew, and two young children, and said they are all “terrified” she will have to go to the hospital amid a COVID-19 surge that had shrunk the number of available ICU beds to 152 from 780 in Oregon as of Aug. 30. Thirty percent of the beds are in use for patients with COVID-19.

She said her life depends on being near hospitals that have ICUs and having access to highly specialized medications, one of which can cost up to $50,000 for the rescue dose.

Her fear has her “literally living bedbound.” In addition to hereditary angioedema, she has Ehlers-Danlos syndrome, which weakens connective tissue. She wears a cervical collar 24/7 to keep from tearing tissues, as any tissue injury can trigger a swell.
 

Patients worry there won’t be room

As ICU beds in most states are filling with COVID-19 patients as the Delta variant spreads, fears are rising among people like Dr. Gosnell, who have chronic conditions and diseases with unpredictable emergency visits, who worry that if they need emergency care there won’t be room.

As of Aug. 30, in the United States, 79% of ICU beds nationally were in use, 30% of them for COVID-19 patients, according to the U.S. Department of Health and Human Services.

In individual states, the picture is dire. Alabama has fewer than 10% of its ICU beds open across the entire state. In Florida, 93% of ICU beds are filled, 53% of them with COVID patients. In Louisiana, 87% of beds were already in use, 45% of them with COVID patients, just as category 4 hurricane Ida smashed into the coastline on Aug. 29.

News reports have told of people transported and airlifted as hospitals reach capacity.

In Bellville, Tex., U.S. Army veteran Daniel Wilkinson needed advanced care for gallstone pancreatitis that normally would take 30 minutes to treat, his Bellville doctor, Hasan Kakli, MD, told CBS News.

Mr. Wilkinson’s house was three doors from Bellville Hospital, but the hospital was not equipped to treat the condition. Calls to other hospitals found the same answer: no empty ICU beds. After a 7-hour wait on a stretcher, he was airlifted to a Veterans Affairs hospital in Houston, but it was too late. He died on August 22 at age 46.

Dr. Kakli said, “I’ve never lost a patient with this diagnosis. Ever. I’m scared that the next patient I see is someone that I can’t get to where they need to get to. We are playing musical chairs with 100 people and 10 chairs. When the music stops, what happens?”

Also in Texas in August, Joe Valdez, who was shot six times as an unlucky bystander in a domestic dispute, waited for more than a week for surgery at Ben Taub Hospital in Houston, which was over capacity with COVID patients, the Washington Post reported.

Others with chronic diseases fear needing emergency services or even entering a hospital for regular care with the COVID surge.

Nicole Seefeldt, 44, from Easton, Penn., who had a double-lung transplant in 2016, said that she hasn’t been able to see her lung transplant specialists in Philadelphia — an hour-and-a-half drive — for almost 2 years because of fear of contracting COVID. Before the pandemic, she made the trip almost weekly.

“I protect my lungs like they’re children,” she said. 

She relies on her local hospital for care, but has put off some needed care, such as a colonoscopy, and has relied on telemedicine because she wants to limit her hospital exposure.

Ms. Seefeldt now faces an eventual kidney transplant, as her kidney function has been reduced to 20%. In the meantime, she worries she will need emergency care for either her lungs or kidneys.

“For those of us who are chronically ill or disabled, what if we have an emergency that is not COVID-related? Are we going to be able to get a bed? Are we going to be able to get treatment? It’s not just COVID patients who come to the [emergency room],” she said.
 

A pandemic problem

Paul E. Casey, MD, MBA, chief medical officer at Rush University Medical Center in Chicago, said that high vaccination rates in Chicago have helped Rush continue to accommodate both non-COVID and COVID patients in the emergency department.

Though the hospital treated a large volume of COVID patients, “The vast majority of people we see and did see through the pandemic were non-COVID patents,” he said.

Dr. Casey said that in the first wave the hospital noticed a concerning drop in patients coming in for strokes and heart attacks — “things we knew hadn’t gone away.”

And the data backs it up. Over the course of the pandemic, the Centers for Disease Control and Prevention’s National Health Interview Survey found that the percentage of Americans who reported seeing a doctor or health professional fell from 85% at the end of 2019 to about 80% in the first three months of 2021. The survey did not differentiate between in-person visits and telehealth appointments.

Medical practices and patients themselves postponed elective procedures and delayed routine visits during the early months of the crisis.

Patients also reported staying away from hospitals’ emergency departments throughout the pandemic. At the end of 2019, 22% of respondents reported visiting an emergency department in the past year. That dropped to 17% by the end of 2020, and was at 17.7% in the first 3 months of 2021.

Dr. Casey said that, in his hospital’s case, clear messaging became very important to assure patients it was safe to come back. And the message is still critical.

“We want to be loud and clear that patients should continue to seek care for those conditions,” Dr. Casey said. “Deferring healthcare only comes with the long-term sequelae of disease left untreated so we want people to be as proactive in seeking care as they always would be.”

In some cases, fears of entering emergency rooms because of excess patients and risk for infection are keeping some patients from seeking necessary care for minor injuries.

Jim Rickert, MD, an orthopedic surgeon with Indiana University Health in Bloomington, said that some of his patients have expressed fears of coming into the hospital for fractures.

Some patients, particularly elderly patients, he said, are having falls and fractures and wearing slings or braces at home rather than going into the hospital for injuries that need immediate attention.

Bones start healing incorrectly, Dr. Rickert said, and the correction becomes much more difficult.
 

Plea for vaccinations

Dr. Gosnell made a plea posted on her neighborhood news forum for people to get COVID vaccinations.

“It seems to me it’s easy for other people who are not in bodies like mine to take health for granted,” she said. “But there are a lot of us who live in very fragile bodies and our entire life is at the intersection of us and getting healthcare treatment. Small complications to getting treatment can be life altering.”

Dr. Gosnell, Ms. Seefeldt, Dr. Casey, and Dr. Rickert reported no relevant financial relationships.

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

REFERENCES

1. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 2020;75:1334-1357. doi: 10.1161/HYPERTENSIONAHA.120.15026
2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248.
3. US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325:1650-1656. doi: 10.1001/jama.2021.4987

REFERENCES

1. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 2020;75:1334-1357. doi: 10.1161/HYPERTENSIONAHA.120.15026
2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248.
3. US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325:1650-1656. doi: 10.1001/jama.2021.4987

REFERENCES

1. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 2020;75:1334-1357. doi: 10.1161/HYPERTENSIONAHA.120.15026
2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248.
3. US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325:1650-1656. doi: 10.1001/jama.2021.4987