As I gear up to welcome and onboard new hires to our hospitalist group, I could not help but reflect on my first day as a hospitalist. Fresh out of residency, my orientation was a day and a half long.

The medical director gave me a brief overview of the program. The program administrator handed me a thick folder of policies followed by a quick tour of the hospital and an afternoon training for the computerized order entry system (that was a time before EHRs). The next morning, I was given my full panel of patients, my new lab coat, and sent off into the battlefield.

I can vividly remember feeling anxious, a bit confused, and quite overwhelmed as I went through my day. The days turned into a week and the next. I kept wondering if I was doing everything right. It took me a month to feel a little more comfortable. It all turned out fine. Since nobody told me otherwise, I assumed it did.

Quite a bit has changed since then in hospital medicine. Hospital medicine groups, nowadays, have to tackle the changing landscape of payment reform, take on responsibility for an increasing range of hospital quality metrics and juggle a swath of subspecialty comanagement agreements. Hospital medicine providers function from the inpatient to the post-acute care arena, all while continuing to demonstrate their value to the hospital administration. Simultaneously, they have to ensure their providers are engaged and functioning at their optimal level while battling the ever-increasing threat of burnout.

Thus, for new hires, all the above aspects of my orientation have become critical but alas terribly insufficient. Well into its third decade, the hospital medicine job market continues to boom but remains a revolving door. Hospital medicine groups continue to grow in size and integrate across hospitals in a given health system. The vast majority of the new hires tend to be fresh out of residency. The first year remains the most vulnerable period for a new hospitalist. Hospital medicine groups must design and implement a robust onboarding program for their new hires. It goes beyond welcoming and orientation of new hires to full integration and assimilation in order to transform them into highly efficient and productive team members. Effective onboarding is table stakes for a successful and thriving hospital medicine group.
 

The content

An effective onboarding program should focus on three key dimensions: the organizational, the technical, and the social.¹

1. The organizational or administrative aspect: The most common aspect of onboarding is providing new hires with information on the group’s policies and procedures: what to do and how to do it. Equally essential is giving them the tools and contacts that will help them understand and navigate their first few months. Information on how to contact consultants, signing on and off shifts, and so on can be easily conveyed through documents. However, having peers and the critical administrative staff communicate other aspects such as a detailed tour of the hospital, scheduling, and vacation policies is far more effective. It provides an excellent opportunity to introduce new hires to the key personnel in the group and vice versa as new hires get familiar with the unofficial workplace language. Breaking down all this information into meaningful, absorbable boluses, spread over time, is key to avoiding information overload. Allowing new hires to assimilate and adapt to the group norms requires follow-up and reinforcement. Group leaders should plan to meet with them at predetermined intervals, such as at 30, 60, 90 days, to engage them in conversations about the group’s values, performance measurements, rewards, and the opportunities for growth that exist within the group and institution.

2. The technical or the clinical aspect: The majority of physicians and advanced providers hired to a hospital medicine group have come immediately from training. Transition into the autonomous role of an attending, or a semi-autonomous role for advanced providers, with a larger patient panel can be quite unnerving and stressful. It can be disorientating even for experienced providers transitioning into a new health system. A well-structured onboarding can allow providers to deploy their training and experience at your organization effectively. Many onboarding programs have a clinical ramp-up period. The providers begin with a limited patient panel and gradually acclimatize into a full patient load. Many programs pair a senior hospitalist with the new hire during this period – a ‘buddy.’ Buddies are available to help new hires navigate the health system and familiarize them with the stakeholders. They help new hires by providing context to understand their new role and how they can contribute to the group’s success. In many instances, buddies help outline the unspoken rules of the group.

3. The social aspect – enculturation and networking: This is probably the most important of the three elements. It is quite common for new hires to feel like a stranger in a new land. A well-designed onboarding program provides new hires the space to forge relationships with each other and existing members of the hospital medicine team. Groups can do this in myriad ways – an informal welcome social, a meet and greet breakfast or lunch, in-person orientation when designing the administrative onboarding, and assignment of buddies or mentors during their clinical ramp-up period. It is all about providing a space to establish and nurture lasting relationships between the new hires and the group. When done well, this helps transform a group into a community. It also lays the groundwork to avoid stress and loneliness, some of the culprits that lead to physician burnout. It is through these interpersonal connections that new hires adapt to a hospital medicine group’s prevailing culture.

The personnel

Effective onboarding should be more than mere orientation. Group leaders should make an active attempt at understanding the core values and needs of the group. A good onboarding process assists new hires to internalize and accept the norms of the group. This process is not just a result of what comes from top management but also what they see and hear from the rank and file providers in the group. Hence it is critical to have the right people who understand and embody these values at the planning table. It is equally essential that necessary time and resources are devoted to building a program that meets the needs of the group. The practice management committee at SHM interviewed five different programs across a spectrum of settings. All of them had a designated onboarding program leader with a planning committee that included the administrative staff and senior frontline hospitalists.

The costs

According to one estimate, the cost of physician turnover is $400,000-$600,000 per provider.² Given such staggering costs, it is not difficult to justify the financial resources required to structure an effective onboarding program. Activities such as a detailed facility tour, a welcome breakfast, and a peer buddy system cost virtually nothing. They go a long way in building comradery, make new hires feel like they are part of a team, and reduce burnout and turnover. Costs of an onboarding program are typically related to wages during shadowing and clinical ramp-up. However, all the programs we interviewed acknowledged that the costs associated with onboarding, in the broader context, were small and necessary.

The bottom line

An effective onboarding program that is well planned, well structured, and well executed is inherently valuable. It sends a positive signal to new hires, reassuring them that they made a great decision by joining the group. It also reminds the existing providers why they want to be a part of the group and its culture.

It is not about what is said or done during the onboarding process or how long it lasts. It need not be overly complicated. It is how the process makes everyone feel about the group. At the end of the day, like in all aspects of life, that is what ultimately matters.

The SHM Practice Management Committee has created a document that outlines the guiding principles for effective onboarding with attached case studies. Visit the SHM website for more information: https://www.hospitalmedicine.org.
 

Dr. Irani is a hospitalist affiliated with Baystate Health in Springfield, Mass. He would like to thank Joshua Lapps, Luke Heisenger, and all the members of the SHM Practice Management Committee for their assistance and input in drafting the guiding principles of onboarding and the case studies that have heavily inspired the above article.

References

1. Carucci R. To Retain New Hires, Spend More Time Onboarding Them. Harvard Busines Review. Dec 3, 2018. https://hbr.org/2018/12/to-retain-new-hires-spend-more-time-onboarding-them

2. Franz D. The staggering costs of physician turnover. Today’s Hospitalist. August 2016. https://www.todayshospitalist.com/staggering-costs-physician-turnover/

As I gear up to welcome and onboard new hires to our hospitalist group, I could not help but reflect on my first day as a hospitalist. Fresh out of residency, my orientation was a day and a half long.

The medical director gave me a brief overview of the program. The program administrator handed me a thick folder of policies followed by a quick tour of the hospital and an afternoon training for the computerized order entry system (that was a time before EHRs). The next morning, I was given my full panel of patients, my new lab coat, and sent off into the battlefield.

I can vividly remember feeling anxious, a bit confused, and quite overwhelmed as I went through my day. The days turned into a week and the next. I kept wondering if I was doing everything right. It took me a month to feel a little more comfortable. It all turned out fine. Since nobody told me otherwise, I assumed it did.

Quite a bit has changed since then in hospital medicine. Hospital medicine groups, nowadays, have to tackle the changing landscape of payment reform, take on responsibility for an increasing range of hospital quality metrics and juggle a swath of subspecialty comanagement agreements. Hospital medicine providers function from the inpatient to the post-acute care arena, all while continuing to demonstrate their value to the hospital administration. Simultaneously, they have to ensure their providers are engaged and functioning at their optimal level while battling the ever-increasing threat of burnout.

Thus, for new hires, all the above aspects of my orientation have become critical but alas terribly insufficient. Well into its third decade, the hospital medicine job market continues to boom but remains a revolving door. Hospital medicine groups continue to grow in size and integrate across hospitals in a given health system. The vast majority of the new hires tend to be fresh out of residency. The first year remains the most vulnerable period for a new hospitalist. Hospital medicine groups must design and implement a robust onboarding program for their new hires. It goes beyond welcoming and orientation of new hires to full integration and assimilation in order to transform them into highly efficient and productive team members. Effective onboarding is table stakes for a successful and thriving hospital medicine group.
 

The content

An effective onboarding program should focus on three key dimensions: the organizational, the technical, and the social.¹

1. The organizational or administrative aspect: The most common aspect of onboarding is providing new hires with information on the group’s policies and procedures: what to do and how to do it. Equally essential is giving them the tools and contacts that will help them understand and navigate their first few months. Information on how to contact consultants, signing on and off shifts, and so on can be easily conveyed through documents. However, having peers and the critical administrative staff communicate other aspects such as a detailed tour of the hospital, scheduling, and vacation policies is far more effective. It provides an excellent opportunity to introduce new hires to the key personnel in the group and vice versa as new hires get familiar with the unofficial workplace language. Breaking down all this information into meaningful, absorbable boluses, spread over time, is key to avoiding information overload. Allowing new hires to assimilate and adapt to the group norms requires follow-up and reinforcement. Group leaders should plan to meet with them at predetermined intervals, such as at 30, 60, 90 days, to engage them in conversations about the group’s values, performance measurements, rewards, and the opportunities for growth that exist within the group and institution.

2. The technical or the clinical aspect: The majority of physicians and advanced providers hired to a hospital medicine group have come immediately from training. Transition into the autonomous role of an attending, or a semi-autonomous role for advanced providers, with a larger patient panel can be quite unnerving and stressful. It can be disorientating even for experienced providers transitioning into a new health system. A well-structured onboarding can allow providers to deploy their training and experience at your organization effectively. Many onboarding programs have a clinical ramp-up period. The providers begin with a limited patient panel and gradually acclimatize into a full patient load. Many programs pair a senior hospitalist with the new hire during this period – a ‘buddy.’ Buddies are available to help new hires navigate the health system and familiarize them with the stakeholders. They help new hires by providing context to understand their new role and how they can contribute to the group’s success. In many instances, buddies help outline the unspoken rules of the group.

3. The social aspect – enculturation and networking: This is probably the most important of the three elements. It is quite common for new hires to feel like a stranger in a new land. A well-designed onboarding program provides new hires the space to forge relationships with each other and existing members of the hospital medicine team. Groups can do this in myriad ways – an informal welcome social, a meet and greet breakfast or lunch, in-person orientation when designing the administrative onboarding, and assignment of buddies or mentors during their clinical ramp-up period. It is all about providing a space to establish and nurture lasting relationships between the new hires and the group. When done well, this helps transform a group into a community. It also lays the groundwork to avoid stress and loneliness, some of the culprits that lead to physician burnout. It is through these interpersonal connections that new hires adapt to a hospital medicine group’s prevailing culture.

The personnel

Effective onboarding should be more than mere orientation. Group leaders should make an active attempt at understanding the core values and needs of the group. A good onboarding process assists new hires to internalize and accept the norms of the group. This process is not just a result of what comes from top management but also what they see and hear from the rank and file providers in the group. Hence it is critical to have the right people who understand and embody these values at the planning table. It is equally essential that necessary time and resources are devoted to building a program that meets the needs of the group. The practice management committee at SHM interviewed five different programs across a spectrum of settings. All of them had a designated onboarding program leader with a planning committee that included the administrative staff and senior frontline hospitalists.

The costs

According to one estimate, the cost of physician turnover is $400,000-$600,000 per provider.² Given such staggering costs, it is not difficult to justify the financial resources required to structure an effective onboarding program. Activities such as a detailed facility tour, a welcome breakfast, and a peer buddy system cost virtually nothing. They go a long way in building comradery, make new hires feel like they are part of a team, and reduce burnout and turnover. Costs of an onboarding program are typically related to wages during shadowing and clinical ramp-up. However, all the programs we interviewed acknowledged that the costs associated with onboarding, in the broader context, were small and necessary.

The bottom line

An effective onboarding program that is well planned, well structured, and well executed is inherently valuable. It sends a positive signal to new hires, reassuring them that they made a great decision by joining the group. It also reminds the existing providers why they want to be a part of the group and its culture.

It is not about what is said or done during the onboarding process or how long it lasts. It need not be overly complicated. It is how the process makes everyone feel about the group. At the end of the day, like in all aspects of life, that is what ultimately matters.

The SHM Practice Management Committee has created a document that outlines the guiding principles for effective onboarding with attached case studies. Visit the SHM website for more information: https://www.hospitalmedicine.org.
 

Dr. Irani is a hospitalist affiliated with Baystate Health in Springfield, Mass. He would like to thank Joshua Lapps, Luke Heisenger, and all the members of the SHM Practice Management Committee for their assistance and input in drafting the guiding principles of onboarding and the case studies that have heavily inspired the above article.

References

1. Carucci R. To Retain New Hires, Spend More Time Onboarding Them. Harvard Busines Review. Dec 3, 2018. https://hbr.org/2018/12/to-retain-new-hires-spend-more-time-onboarding-them

2. Franz D. The staggering costs of physician turnover. Today’s Hospitalist. August 2016. https://www.todayshospitalist.com/staggering-costs-physician-turnover/

As I gear up to welcome and onboard new hires to our hospitalist group, I could not help but reflect on my first day as a hospitalist. Fresh out of residency, my orientation was a day and a half long.

The medical director gave me a brief overview of the program. The program administrator handed me a thick folder of policies followed by a quick tour of the hospital and an afternoon training for the computerized order entry system (that was a time before EHRs). The next morning, I was given my full panel of patients, my new lab coat, and sent off into the battlefield.

I can vividly remember feeling anxious, a bit confused, and quite overwhelmed as I went through my day. The days turned into a week and the next. I kept wondering if I was doing everything right. It took me a month to feel a little more comfortable. It all turned out fine. Since nobody told me otherwise, I assumed it did.

Quite a bit has changed since then in hospital medicine. Hospital medicine groups, nowadays, have to tackle the changing landscape of payment reform, take on responsibility for an increasing range of hospital quality metrics and juggle a swath of subspecialty comanagement agreements. Hospital medicine providers function from the inpatient to the post-acute care arena, all while continuing to demonstrate their value to the hospital administration. Simultaneously, they have to ensure their providers are engaged and functioning at their optimal level while battling the ever-increasing threat of burnout.

Thus, for new hires, all the above aspects of my orientation have become critical but alas terribly insufficient. Well into its third decade, the hospital medicine job market continues to boom but remains a revolving door. Hospital medicine groups continue to grow in size and integrate across hospitals in a given health system. The vast majority of the new hires tend to be fresh out of residency. The first year remains the most vulnerable period for a new hospitalist. Hospital medicine groups must design and implement a robust onboarding program for their new hires. It goes beyond welcoming and orientation of new hires to full integration and assimilation in order to transform them into highly efficient and productive team members. Effective onboarding is table stakes for a successful and thriving hospital medicine group.
 

The content

An effective onboarding program should focus on three key dimensions: the organizational, the technical, and the social.¹

1. The organizational or administrative aspect: The most common aspect of onboarding is providing new hires with information on the group’s policies and procedures: what to do and how to do it. Equally essential is giving them the tools and contacts that will help them understand and navigate their first few months. Information on how to contact consultants, signing on and off shifts, and so on can be easily conveyed through documents. However, having peers and the critical administrative staff communicate other aspects such as a detailed tour of the hospital, scheduling, and vacation policies is far more effective. It provides an excellent opportunity to introduce new hires to the key personnel in the group and vice versa as new hires get familiar with the unofficial workplace language. Breaking down all this information into meaningful, absorbable boluses, spread over time, is key to avoiding information overload. Allowing new hires to assimilate and adapt to the group norms requires follow-up and reinforcement. Group leaders should plan to meet with them at predetermined intervals, such as at 30, 60, 90 days, to engage them in conversations about the group’s values, performance measurements, rewards, and the opportunities for growth that exist within the group and institution.

2. The technical or the clinical aspect: The majority of physicians and advanced providers hired to a hospital medicine group have come immediately from training. Transition into the autonomous role of an attending, or a semi-autonomous role for advanced providers, with a larger patient panel can be quite unnerving and stressful. It can be disorientating even for experienced providers transitioning into a new health system. A well-structured onboarding can allow providers to deploy their training and experience at your organization effectively. Many onboarding programs have a clinical ramp-up period. The providers begin with a limited patient panel and gradually acclimatize into a full patient load. Many programs pair a senior hospitalist with the new hire during this period – a ‘buddy.’ Buddies are available to help new hires navigate the health system and familiarize them with the stakeholders. They help new hires by providing context to understand their new role and how they can contribute to the group’s success. In many instances, buddies help outline the unspoken rules of the group.

3. The social aspect – enculturation and networking: This is probably the most important of the three elements. It is quite common for new hires to feel like a stranger in a new land. A well-designed onboarding program provides new hires the space to forge relationships with each other and existing members of the hospital medicine team. Groups can do this in myriad ways – an informal welcome social, a meet and greet breakfast or lunch, in-person orientation when designing the administrative onboarding, and assignment of buddies or mentors during their clinical ramp-up period. It is all about providing a space to establish and nurture lasting relationships between the new hires and the group. When done well, this helps transform a group into a community. It also lays the groundwork to avoid stress and loneliness, some of the culprits that lead to physician burnout. It is through these interpersonal connections that new hires adapt to a hospital medicine group’s prevailing culture.

The personnel

Effective onboarding should be more than mere orientation. Group leaders should make an active attempt at understanding the core values and needs of the group. A good onboarding process assists new hires to internalize and accept the norms of the group. This process is not just a result of what comes from top management but also what they see and hear from the rank and file providers in the group. Hence it is critical to have the right people who understand and embody these values at the planning table. It is equally essential that necessary time and resources are devoted to building a program that meets the needs of the group. The practice management committee at SHM interviewed five different programs across a spectrum of settings. All of them had a designated onboarding program leader with a planning committee that included the administrative staff and senior frontline hospitalists.

The costs

According to one estimate, the cost of physician turnover is $400,000-$600,000 per provider.² Given such staggering costs, it is not difficult to justify the financial resources required to structure an effective onboarding program. Activities such as a detailed facility tour, a welcome breakfast, and a peer buddy system cost virtually nothing. They go a long way in building comradery, make new hires feel like they are part of a team, and reduce burnout and turnover. Costs of an onboarding program are typically related to wages during shadowing and clinical ramp-up. However, all the programs we interviewed acknowledged that the costs associated with onboarding, in the broader context, were small and necessary.

The bottom line

An effective onboarding program that is well planned, well structured, and well executed is inherently valuable. It sends a positive signal to new hires, reassuring them that they made a great decision by joining the group. It also reminds the existing providers why they want to be a part of the group and its culture.

It is not about what is said or done during the onboarding process or how long it lasts. It need not be overly complicated. It is how the process makes everyone feel about the group. At the end of the day, like in all aspects of life, that is what ultimately matters.

The SHM Practice Management Committee has created a document that outlines the guiding principles for effective onboarding with attached case studies. Visit the SHM website for more information: https://www.hospitalmedicine.org.
 

Dr. Irani is a hospitalist affiliated with Baystate Health in Springfield, Mass. He would like to thank Joshua Lapps, Luke Heisenger, and all the members of the SHM Practice Management Committee for their assistance and input in drafting the guiding principles of onboarding and the case studies that have heavily inspired the above article.

References

1. Carucci R. To Retain New Hires, Spend More Time Onboarding Them. Harvard Busines Review. Dec 3, 2018. https://hbr.org/2018/12/to-retain-new-hires-spend-more-time-onboarding-them

2. Franz D. The staggering costs of physician turnover. Today’s Hospitalist. August 2016. https://www.todayshospitalist.com/staggering-costs-physician-turnover/

In a JAMA Live Stream interview, Anthony S. Fauci, MD, a key member of the White House Coronavirus Task Force, urged resolve, rather than panic, as the coronavirus pandemic takes hold in the United States.

Dr. Fauci got into the details of what is known, what is unknown, what is being done in laboratories, and what clinical elements are still not understood about this disease.

The next several weeks, he said, are likely to tell the tale of whether our health care system is up to the challenge of care for the most ill among those who will be affected by COVID-19.

“It shouldn’t panic or frighten us, but we have to know we’re dealing with a very serious problem that we have to address, and we have to deal with it in a very bold way,” said Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health.

Speaking in an interview with JAMA Editor in Chief Howard Bauchner, MD, Dr. Fauci said the situation favors action over fear. “Let’s apply that energy to doing the things that we know can mitigate this.”

He added that he heard the message loud and clear from health care leaders in Italy and France during a World Health Organization coronavirus call earlier in the day. Officials in those countries, he said, were “almost pleading with the rest of the world to please take this very seriously, because it happens all of a sudden – very abruptly. ... The best time to mitigate is before that happens, because if you wait until after it happens you’re playing catch-up.”

Dr. Bauchner, noting that strict social distancing has been underway in many parts of the United States for several days, posited that, by early April, “We’ll really have a sense if we can manage in terms of serious illness.” Seattle, New York, Boston, and the San Francisco Bay Area may experience demand that outstrips ICU capacity at that point, but the rest of the country, he said, “is doing relatively well.”
 

Stress test on the health care system

Dr. Fauci agreed with this statement and added: “We’re going to know – for better or worse – whether we have enough of what it takes to be able to practice the kind of medicine that we optimally would want to practice.

In the matter of a week or 2 ... I think we’ll get a feel for whether or not we really have enough of the supplies that it takes.”

The well-publicized regional shortages in personal protective equipment (PPE) are forcing tough choices in some areas. As expedited – and even drive-through – testing begins, some of the demand for testing-related PPE may abate, especially if protocols include self-administration of nasal swabs, he noted.

Dr. Fauci added that the strategic national stockpile of medical supplies and equipment has not yet been tapped, “but you need to backfill that as quickly as you can once you start drawing from the strategic national stockpile.”
 

Returning to work after COVID-19 infection

Regarding the thorny question of when health care workers should be permitted to return to work after coronavirus infection, “it’s an evolving story,” said Dr. Fauci. Current guidance advises that health care providers stay away from work until two negative tests after resolution of fever and improvement of respiratory symptoms, or 3 fever-free days.

“We are approaching a point where you’re going to get enough people who are getting infected that we aren’t going to be able to do that,” he said. Depending on the stress to the health care system in a given locality, he said that facilities are going to have to “decide with good judgment” when health care workers go back on the job after coronavirus infection.

Asked how soon an individual would reliably test positive for COVID-19 after exposure, Dr. Fauci said, “We don’t know the answer to that. ... We can surmise it ...” He noted that it’s a median of about 5 days with a range of 2 to 14 days, before an infected individual becomes symptomatic. “I can say it’s not going to happen immediately,” he added, noting that he wouldn’t expect to see a positive test until about 2 days after exposure at the earliest. “When you get to the point where you are symptomatic, you’re almost certainly going to be positive then. ... This is just an extrapolation,” rather than conclusions drawn from solid data, he emphasized.
 

Higher risk reported in cardiac patients

Dr. Bauchner, who was relaying questions sent in from physicians during the live-streamed interview, asked about a newly issued joint statement from the American Heart Association, American College of Cardiology, and the Heart Failure Society of America, which on March 17 affirmed that individuals on ACE inhibitors and angiotensin receptor blockers (ARBs) continue that therapy if they should become ill with COVID-19. The European Society of Cardiology issued a similar recommendation a few days prior.

Despite these societies’ statements, Dr. Fauci pointed to population-level data in Italy as suggesting that the case isn’t yet closed. “We really need to get data, and we need to get data fast. There’s a mechanistic rationale for the concern. It’s there, and it’s firm,” he said. The theoretical concern is that ACE inhibitors can upregulate expression of the ACE-2 protein on cell membranes, which is the entry point for SARS-Cov-2 to enter cells.

He added that he remains concerned about the number of coronavirus fatalities of patients in Italy who had hypertension as their only, or primary, underlying health problem.“That to me was a bit of a red flag,” he said. “Patients with hypertension almost certainly had a physician, and the physician almost certainly treated that person with medication. Why should someone who has hypertension that was well controlled have a much greater chance of dying?” he asked, noting that “I look at a person with well-controlled hypertension as a relatively healthy person. I don’t know what the answer is, but somebody has to look very carefully,” ideally by means of a natural history study that identifies medications used by those who died from coronavirus.
 

Potential therapies

Regarding potential therapies for COVID-19, Dr. Fauci acknowledged the social media buzz and flurry of medical letters and case reports about the use of hydroxychloroquine (Plaquenil) to treat active infection. He said that he and other researchers are “in active discussion” about how best to study the efficacy and safety of hydroxychloroquine, but he also acknowledged that many treating clinicians will use hydroxychloroquine empirically in the absence of other treatments with proven efficacy.

Clinical trials underway in China for antiviral medication are facing some enrollment challenges currently “because people want to get the drug,” said Dr. Fauci. “They don’t want to be in the trial; they just want to get the drug.” Though each of two trials has targeted approximately 500 participants as the number needed for sufficient statistical power, Dr. Fauci urged Chinese data safety monitoring boards to “take a close look” at the data already accrued for the several hundred patients who have already enrolled for the studies “to see if there’s any hint of efficacy.”

koakes@mdedge.com

In a JAMA Live Stream interview, Anthony S. Fauci, MD, a key member of the White House Coronavirus Task Force, urged resolve, rather than panic, as the coronavirus pandemic takes hold in the United States.

Dr. Fauci got into the details of what is known, what is unknown, what is being done in laboratories, and what clinical elements are still not understood about this disease.

The next several weeks, he said, are likely to tell the tale of whether our health care system is up to the challenge of care for the most ill among those who will be affected by COVID-19.

“It shouldn’t panic or frighten us, but we have to know we’re dealing with a very serious problem that we have to address, and we have to deal with it in a very bold way,” said Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health.

Speaking in an interview with JAMA Editor in Chief Howard Bauchner, MD, Dr. Fauci said the situation favors action over fear. “Let’s apply that energy to doing the things that we know can mitigate this.”

He added that he heard the message loud and clear from health care leaders in Italy and France during a World Health Organization coronavirus call earlier in the day. Officials in those countries, he said, were “almost pleading with the rest of the world to please take this very seriously, because it happens all of a sudden – very abruptly. ... The best time to mitigate is before that happens, because if you wait until after it happens you’re playing catch-up.”

Dr. Bauchner, noting that strict social distancing has been underway in many parts of the United States for several days, posited that, by early April, “We’ll really have a sense if we can manage in terms of serious illness.” Seattle, New York, Boston, and the San Francisco Bay Area may experience demand that outstrips ICU capacity at that point, but the rest of the country, he said, “is doing relatively well.”
 

Stress test on the health care system

Dr. Fauci agreed with this statement and added: “We’re going to know – for better or worse – whether we have enough of what it takes to be able to practice the kind of medicine that we optimally would want to practice.

In the matter of a week or 2 ... I think we’ll get a feel for whether or not we really have enough of the supplies that it takes.”

The well-publicized regional shortages in personal protective equipment (PPE) are forcing tough choices in some areas. As expedited – and even drive-through – testing begins, some of the demand for testing-related PPE may abate, especially if protocols include self-administration of nasal swabs, he noted.

Dr. Fauci added that the strategic national stockpile of medical supplies and equipment has not yet been tapped, “but you need to backfill that as quickly as you can once you start drawing from the strategic national stockpile.”
 

Returning to work after COVID-19 infection

Regarding the thorny question of when health care workers should be permitted to return to work after coronavirus infection, “it’s an evolving story,” said Dr. Fauci. Current guidance advises that health care providers stay away from work until two negative tests after resolution of fever and improvement of respiratory symptoms, or 3 fever-free days.

“We are approaching a point where you’re going to get enough people who are getting infected that we aren’t going to be able to do that,” he said. Depending on the stress to the health care system in a given locality, he said that facilities are going to have to “decide with good judgment” when health care workers go back on the job after coronavirus infection.

Asked how soon an individual would reliably test positive for COVID-19 after exposure, Dr. Fauci said, “We don’t know the answer to that. ... We can surmise it ...” He noted that it’s a median of about 5 days with a range of 2 to 14 days, before an infected individual becomes symptomatic. “I can say it’s not going to happen immediately,” he added, noting that he wouldn’t expect to see a positive test until about 2 days after exposure at the earliest. “When you get to the point where you are symptomatic, you’re almost certainly going to be positive then. ... This is just an extrapolation,” rather than conclusions drawn from solid data, he emphasized.
 

Higher risk reported in cardiac patients

Dr. Bauchner, who was relaying questions sent in from physicians during the live-streamed interview, asked about a newly issued joint statement from the American Heart Association, American College of Cardiology, and the Heart Failure Society of America, which on March 17 affirmed that individuals on ACE inhibitors and angiotensin receptor blockers (ARBs) continue that therapy if they should become ill with COVID-19. The European Society of Cardiology issued a similar recommendation a few days prior.

Despite these societies’ statements, Dr. Fauci pointed to population-level data in Italy as suggesting that the case isn’t yet closed. “We really need to get data, and we need to get data fast. There’s a mechanistic rationale for the concern. It’s there, and it’s firm,” he said. The theoretical concern is that ACE inhibitors can upregulate expression of the ACE-2 protein on cell membranes, which is the entry point for SARS-Cov-2 to enter cells.

He added that he remains concerned about the number of coronavirus fatalities of patients in Italy who had hypertension as their only, or primary, underlying health problem.“That to me was a bit of a red flag,” he said. “Patients with hypertension almost certainly had a physician, and the physician almost certainly treated that person with medication. Why should someone who has hypertension that was well controlled have a much greater chance of dying?” he asked, noting that “I look at a person with well-controlled hypertension as a relatively healthy person. I don’t know what the answer is, but somebody has to look very carefully,” ideally by means of a natural history study that identifies medications used by those who died from coronavirus.
 

Potential therapies

Regarding potential therapies for COVID-19, Dr. Fauci acknowledged the social media buzz and flurry of medical letters and case reports about the use of hydroxychloroquine (Plaquenil) to treat active infection. He said that he and other researchers are “in active discussion” about how best to study the efficacy and safety of hydroxychloroquine, but he also acknowledged that many treating clinicians will use hydroxychloroquine empirically in the absence of other treatments with proven efficacy.

Clinical trials underway in China for antiviral medication are facing some enrollment challenges currently “because people want to get the drug,” said Dr. Fauci. “They don’t want to be in the trial; they just want to get the drug.” Though each of two trials has targeted approximately 500 participants as the number needed for sufficient statistical power, Dr. Fauci urged Chinese data safety monitoring boards to “take a close look” at the data already accrued for the several hundred patients who have already enrolled for the studies “to see if there’s any hint of efficacy.”

koakes@mdedge.com

In a JAMA Live Stream interview, Anthony S. Fauci, MD, a key member of the White House Coronavirus Task Force, urged resolve, rather than panic, as the coronavirus pandemic takes hold in the United States.

Dr. Fauci got into the details of what is known, what is unknown, what is being done in laboratories, and what clinical elements are still not understood about this disease.

The next several weeks, he said, are likely to tell the tale of whether our health care system is up to the challenge of care for the most ill among those who will be affected by COVID-19.

“It shouldn’t panic or frighten us, but we have to know we’re dealing with a very serious problem that we have to address, and we have to deal with it in a very bold way,” said Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health.

Speaking in an interview with JAMA Editor in Chief Howard Bauchner, MD, Dr. Fauci said the situation favors action over fear. “Let’s apply that energy to doing the things that we know can mitigate this.”

He added that he heard the message loud and clear from health care leaders in Italy and France during a World Health Organization coronavirus call earlier in the day. Officials in those countries, he said, were “almost pleading with the rest of the world to please take this very seriously, because it happens all of a sudden – very abruptly. ... The best time to mitigate is before that happens, because if you wait until after it happens you’re playing catch-up.”

Dr. Bauchner, noting that strict social distancing has been underway in many parts of the United States for several days, posited that, by early April, “We’ll really have a sense if we can manage in terms of serious illness.” Seattle, New York, Boston, and the San Francisco Bay Area may experience demand that outstrips ICU capacity at that point, but the rest of the country, he said, “is doing relatively well.”
 

Stress test on the health care system

Dr. Fauci agreed with this statement and added: “We’re going to know – for better or worse – whether we have enough of what it takes to be able to practice the kind of medicine that we optimally would want to practice.

In the matter of a week or 2 ... I think we’ll get a feel for whether or not we really have enough of the supplies that it takes.”

The well-publicized regional shortages in personal protective equipment (PPE) are forcing tough choices in some areas. As expedited – and even drive-through – testing begins, some of the demand for testing-related PPE may abate, especially if protocols include self-administration of nasal swabs, he noted.

Dr. Fauci added that the strategic national stockpile of medical supplies and equipment has not yet been tapped, “but you need to backfill that as quickly as you can once you start drawing from the strategic national stockpile.”
 

Returning to work after COVID-19 infection

Regarding the thorny question of when health care workers should be permitted to return to work after coronavirus infection, “it’s an evolving story,” said Dr. Fauci. Current guidance advises that health care providers stay away from work until two negative tests after resolution of fever and improvement of respiratory symptoms, or 3 fever-free days.

“We are approaching a point where you’re going to get enough people who are getting infected that we aren’t going to be able to do that,” he said. Depending on the stress to the health care system in a given locality, he said that facilities are going to have to “decide with good judgment” when health care workers go back on the job after coronavirus infection.

Asked how soon an individual would reliably test positive for COVID-19 after exposure, Dr. Fauci said, “We don’t know the answer to that. ... We can surmise it ...” He noted that it’s a median of about 5 days with a range of 2 to 14 days, before an infected individual becomes symptomatic. “I can say it’s not going to happen immediately,” he added, noting that he wouldn’t expect to see a positive test until about 2 days after exposure at the earliest. “When you get to the point where you are symptomatic, you’re almost certainly going to be positive then. ... This is just an extrapolation,” rather than conclusions drawn from solid data, he emphasized.
 

Higher risk reported in cardiac patients

Dr. Bauchner, who was relaying questions sent in from physicians during the live-streamed interview, asked about a newly issued joint statement from the American Heart Association, American College of Cardiology, and the Heart Failure Society of America, which on March 17 affirmed that individuals on ACE inhibitors and angiotensin receptor blockers (ARBs) continue that therapy if they should become ill with COVID-19. The European Society of Cardiology issued a similar recommendation a few days prior.

Despite these societies’ statements, Dr. Fauci pointed to population-level data in Italy as suggesting that the case isn’t yet closed. “We really need to get data, and we need to get data fast. There’s a mechanistic rationale for the concern. It’s there, and it’s firm,” he said. The theoretical concern is that ACE inhibitors can upregulate expression of the ACE-2 protein on cell membranes, which is the entry point for SARS-Cov-2 to enter cells.

He added that he remains concerned about the number of coronavirus fatalities of patients in Italy who had hypertension as their only, or primary, underlying health problem.“That to me was a bit of a red flag,” he said. “Patients with hypertension almost certainly had a physician, and the physician almost certainly treated that person with medication. Why should someone who has hypertension that was well controlled have a much greater chance of dying?” he asked, noting that “I look at a person with well-controlled hypertension as a relatively healthy person. I don’t know what the answer is, but somebody has to look very carefully,” ideally by means of a natural history study that identifies medications used by those who died from coronavirus.
 

Potential therapies

Regarding potential therapies for COVID-19, Dr. Fauci acknowledged the social media buzz and flurry of medical letters and case reports about the use of hydroxychloroquine (Plaquenil) to treat active infection. He said that he and other researchers are “in active discussion” about how best to study the efficacy and safety of hydroxychloroquine, but he also acknowledged that many treating clinicians will use hydroxychloroquine empirically in the absence of other treatments with proven efficacy.

Clinical trials underway in China for antiviral medication are facing some enrollment challenges currently “because people want to get the drug,” said Dr. Fauci. “They don’t want to be in the trial; they just want to get the drug.” Though each of two trials has targeted approximately 500 participants as the number needed for sufficient statistical power, Dr. Fauci urged Chinese data safety monitoring boards to “take a close look” at the data already accrued for the several hundred patients who have already enrolled for the studies “to see if there’s any hint of efficacy.”

koakes@mdedge.com

Clinical manifestations of COVID-19 infection among children in mainland China generally have been less severe than those among adults, but children of all ages – and infants in particular – are vulnerable to infection, according to a review of 2,143 cases.

CDC/ Dr. Fred Murphy; Sylvia Whitfield

Further, infection patterns in the nationwide series of all pediatric patients reported to the Chinese Center for Disease Control and Prevention from Jan. 16 to Feb. 8, 2020, provide strong evidence of human-to-human transmission, Yuanyuan Dong, MPH, a research assistant at Shanghai Children’s Medical Center, Shanghai Jiao Tong University, China, and colleagues reported in Pediatrics.

Of the 2,143 patients included in the review, 57% were boys and the median age was 7 years; 34% had laboratory-confirmed infection and 67% had suspected infection. More than 90% had asymptomatic, mild, or moderate disease (4%, 51%, and 39%, respectively), and 46% were from Hubei Province, where the first cases were reported, the investigators found.

The median time from illness onset to diagnosis was 2 days, and there was a trend of rapid increase of disease at the early stage of the epidemic – with rapid spread from Hubei Province to surrounding provinces – followed by a gradual and steady decrease, they noted.

“The total number of pediatric patients increased remarkably between mid-January and early February, peaked around February 1, and then declined since early February 2020,” they wrote. The proportion of severe and critical cases was 11% for infants under 1 year of age, compared with 7% for those aged 1-5 years; 4% for those aged 6-10 years; 4% for those 11-15 years; and 3% for those 16 years and older.

As of Feb. 8, 2020, only one child in this group of study patients died and most cases of COVID-19 symptoms were mild. There were many fewer severe and critical cases among the children (6%), compared with those reported in adult patients in other studies (19%). “It suggests that, compared with adult patients, clinical manifestations of children’s COVID-19 may be less severe,” the investigators suggested.

“As most of these children were likely to expose themselves to family members and/or other children with COVID-19, it clearly indicates person-to-person transmission ” of novel coronavirus 2019, they said, adding that similar evidence of such transmission also has been reported from studies of adult patients.

The reasons for reduced severity in children versus adults remain unclear, but may be related to both exposure and host factors, Ms. Dong and associates said. “Children were usually well cared for at home and might have relatively [fewer] opportunities to expose themselves to pathogens and/or sick patients.”

The findings demonstrate a pediatric distribution that varied across time and space, with most cases concentrated in the Hubei province and surrounding areas. No significant gender-related difference in infection rates was observed, and although the median patient age was 7 years, the range was 1 day to 18 years, suggesting that “all ages at childhood were susceptible” to the virus, they added.

The declining number of cases over time further suggests that disease control measures implemented by the government were effective, and that cases will “continue to decline, and finally stop in the near future unless sustained human-to-human transmissions occur,” Ms. Dong and associates concluded.

In an accompanying editorial, Andrea T. Cruz, MD, of Baylor College of Medicine, Houston, and Steven L. Zeichner, MD, PhD, of the University of Virginia, Charlottesville, said the findings regarding reduced severity among children versus adults with novel coronavirus 2019 infection are consistent with data on non-COVID-19 coronavirus.

They pointed out that Ms. Dong and associates did find that 13% of virologically-confirmed cases had asymptomatic infection, “a rate that almost certainly understates the true rate of asymptomatic infection, since many asymptomatic children are unlikely to be tested.”

Of the symptomatic children, “5% had dyspnea or hypoxemia (a substantially lower percentage than what has been reported for adults) and 0.6% progressed to acute respiratory distress syndrome (ARDS) or multiorgan system dysfunction”; this also is at a lower rate than seen in adults, they said.

Very young children –infants or children in preschool – were more likely to have severe clinical manifestations than children who were older.

Thus, it appears that certain subpopulations of children are at increased risk for more significant COVID-19 illness: “younger age, underlying pulmonary pathology, and immunocompromising conditions,” Dr. Cruz and Dr. Zeichner suggested.

The two editorialists said the findings suggest children “may play a major role in community-based viral transmission.” Evidence suggests that children may have more upper respiratory tract involvement and that fecal shedding may occur for several weeks after diagnosis; this raises concerns about fecal-oral transmission, particularly for infants and children, and about viral replication in the gastrointestinal tract, they said. This has substantial implications for community spread in day care centers, schools, and in the home.

A great deal has been learned about COVID-19 in a short time, but there still is much to learn about the effect of the virus on children, the impact of children on viral spread, and about possible vertical transmission, they said.

“Widespread availability of testing will allow for us to more accurately describe the spectrum of illness and may result in adjustment of the apparent morbidity and mortality rate as fewer ill individuals are diagnosed,” Dr. Cruz and Dr. Zeichner wrote, adding that “rigorously gauging the impact of COVID-19 on children will be important to accurately model the pandemic and to ensure that appropriate resources are allocated to children requiring care.”

They noted that understanding differences in children versus adults with COVID-19 “can yield important insights into disease pathogenesis, informing management and the development of therapeutics.”

This study was partially supported by the Science and Technology Commission of Shanghai Municipality. The authors reported having no disclosures. Dr. Cruz and Dr. Zeichner are associate editors for Pediatrics. Dr. Cruz reported having no disclosures. Dr. Zeichner is an inventor of new technologies for the rapid production of vaccines, for which the University of Virginia has filed patent applications.

sworcester@mdedge.com

SOURCE: Dong Y et al. Pediatrics. 2020 Mar 16. doi: 10.1542/peds.2020-0702; Cruz A and Zeichner S. Pediatrics. 2020 Mar 16. doi: 10.1542/peds.2020-0834.

Clinical manifestations of COVID-19 infection among children in mainland China generally have been less severe than those among adults, but children of all ages – and infants in particular – are vulnerable to infection, according to a review of 2,143 cases.

CDC/ Dr. Fred Murphy; Sylvia Whitfield

Further, infection patterns in the nationwide series of all pediatric patients reported to the Chinese Center for Disease Control and Prevention from Jan. 16 to Feb. 8, 2020, provide strong evidence of human-to-human transmission, Yuanyuan Dong, MPH, a research assistant at Shanghai Children’s Medical Center, Shanghai Jiao Tong University, China, and colleagues reported in Pediatrics.

Of the 2,143 patients included in the review, 57% were boys and the median age was 7 years; 34% had laboratory-confirmed infection and 67% had suspected infection. More than 90% had asymptomatic, mild, or moderate disease (4%, 51%, and 39%, respectively), and 46% were from Hubei Province, where the first cases were reported, the investigators found.

The median time from illness onset to diagnosis was 2 days, and there was a trend of rapid increase of disease at the early stage of the epidemic – with rapid spread from Hubei Province to surrounding provinces – followed by a gradual and steady decrease, they noted.

“The total number of pediatric patients increased remarkably between mid-January and early February, peaked around February 1, and then declined since early February 2020,” they wrote. The proportion of severe and critical cases was 11% for infants under 1 year of age, compared with 7% for those aged 1-5 years; 4% for those aged 6-10 years; 4% for those 11-15 years; and 3% for those 16 years and older.

As of Feb. 8, 2020, only one child in this group of study patients died and most cases of COVID-19 symptoms were mild. There were many fewer severe and critical cases among the children (6%), compared with those reported in adult patients in other studies (19%). “It suggests that, compared with adult patients, clinical manifestations of children’s COVID-19 may be less severe,” the investigators suggested.

“As most of these children were likely to expose themselves to family members and/or other children with COVID-19, it clearly indicates person-to-person transmission ” of novel coronavirus 2019, they said, adding that similar evidence of such transmission also has been reported from studies of adult patients.

The reasons for reduced severity in children versus adults remain unclear, but may be related to both exposure and host factors, Ms. Dong and associates said. “Children were usually well cared for at home and might have relatively [fewer] opportunities to expose themselves to pathogens and/or sick patients.”

The findings demonstrate a pediatric distribution that varied across time and space, with most cases concentrated in the Hubei province and surrounding areas. No significant gender-related difference in infection rates was observed, and although the median patient age was 7 years, the range was 1 day to 18 years, suggesting that “all ages at childhood were susceptible” to the virus, they added.

The declining number of cases over time further suggests that disease control measures implemented by the government were effective, and that cases will “continue to decline, and finally stop in the near future unless sustained human-to-human transmissions occur,” Ms. Dong and associates concluded.

In an accompanying editorial, Andrea T. Cruz, MD, of Baylor College of Medicine, Houston, and Steven L. Zeichner, MD, PhD, of the University of Virginia, Charlottesville, said the findings regarding reduced severity among children versus adults with novel coronavirus 2019 infection are consistent with data on non-COVID-19 coronavirus.

They pointed out that Ms. Dong and associates did find that 13% of virologically-confirmed cases had asymptomatic infection, “a rate that almost certainly understates the true rate of asymptomatic infection, since many asymptomatic children are unlikely to be tested.”

Of the symptomatic children, “5% had dyspnea or hypoxemia (a substantially lower percentage than what has been reported for adults) and 0.6% progressed to acute respiratory distress syndrome (ARDS) or multiorgan system dysfunction”; this also is at a lower rate than seen in adults, they said.

Very young children –infants or children in preschool – were more likely to have severe clinical manifestations than children who were older.

Thus, it appears that certain subpopulations of children are at increased risk for more significant COVID-19 illness: “younger age, underlying pulmonary pathology, and immunocompromising conditions,” Dr. Cruz and Dr. Zeichner suggested.

The two editorialists said the findings suggest children “may play a major role in community-based viral transmission.” Evidence suggests that children may have more upper respiratory tract involvement and that fecal shedding may occur for several weeks after diagnosis; this raises concerns about fecal-oral transmission, particularly for infants and children, and about viral replication in the gastrointestinal tract, they said. This has substantial implications for community spread in day care centers, schools, and in the home.

A great deal has been learned about COVID-19 in a short time, but there still is much to learn about the effect of the virus on children, the impact of children on viral spread, and about possible vertical transmission, they said.

“Widespread availability of testing will allow for us to more accurately describe the spectrum of illness and may result in adjustment of the apparent morbidity and mortality rate as fewer ill individuals are diagnosed,” Dr. Cruz and Dr. Zeichner wrote, adding that “rigorously gauging the impact of COVID-19 on children will be important to accurately model the pandemic and to ensure that appropriate resources are allocated to children requiring care.”

They noted that understanding differences in children versus adults with COVID-19 “can yield important insights into disease pathogenesis, informing management and the development of therapeutics.”

This study was partially supported by the Science and Technology Commission of Shanghai Municipality. The authors reported having no disclosures. Dr. Cruz and Dr. Zeichner are associate editors for Pediatrics. Dr. Cruz reported having no disclosures. Dr. Zeichner is an inventor of new technologies for the rapid production of vaccines, for which the University of Virginia has filed patent applications.

sworcester@mdedge.com

SOURCE: Dong Y et al. Pediatrics. 2020 Mar 16. doi: 10.1542/peds.2020-0702; Cruz A and Zeichner S. Pediatrics. 2020 Mar 16. doi: 10.1542/peds.2020-0834.

Clinical manifestations of COVID-19 infection among children in mainland China generally have been less severe than those among adults, but children of all ages – and infants in particular – are vulnerable to infection, according to a review of 2,143 cases.

CDC/ Dr. Fred Murphy; Sylvia Whitfield

Further, infection patterns in the nationwide series of all pediatric patients reported to the Chinese Center for Disease Control and Prevention from Jan. 16 to Feb. 8, 2020, provide strong evidence of human-to-human transmission, Yuanyuan Dong, MPH, a research assistant at Shanghai Children’s Medical Center, Shanghai Jiao Tong University, China, and colleagues reported in Pediatrics.

Of the 2,143 patients included in the review, 57% were boys and the median age was 7 years; 34% had laboratory-confirmed infection and 67% had suspected infection. More than 90% had asymptomatic, mild, or moderate disease (4%, 51%, and 39%, respectively), and 46% were from Hubei Province, where the first cases were reported, the investigators found.

The median time from illness onset to diagnosis was 2 days, and there was a trend of rapid increase of disease at the early stage of the epidemic – with rapid spread from Hubei Province to surrounding provinces – followed by a gradual and steady decrease, they noted.

“The total number of pediatric patients increased remarkably between mid-January and early February, peaked around February 1, and then declined since early February 2020,” they wrote. The proportion of severe and critical cases was 11% for infants under 1 year of age, compared with 7% for those aged 1-5 years; 4% for those aged 6-10 years; 4% for those 11-15 years; and 3% for those 16 years and older.

As of Feb. 8, 2020, only one child in this group of study patients died and most cases of COVID-19 symptoms were mild. There were many fewer severe and critical cases among the children (6%), compared with those reported in adult patients in other studies (19%). “It suggests that, compared with adult patients, clinical manifestations of children’s COVID-19 may be less severe,” the investigators suggested.

“As most of these children were likely to expose themselves to family members and/or other children with COVID-19, it clearly indicates person-to-person transmission ” of novel coronavirus 2019, they said, adding that similar evidence of such transmission also has been reported from studies of adult patients.

The reasons for reduced severity in children versus adults remain unclear, but may be related to both exposure and host factors, Ms. Dong and associates said. “Children were usually well cared for at home and might have relatively [fewer] opportunities to expose themselves to pathogens and/or sick patients.”

The findings demonstrate a pediatric distribution that varied across time and space, with most cases concentrated in the Hubei province and surrounding areas. No significant gender-related difference in infection rates was observed, and although the median patient age was 7 years, the range was 1 day to 18 years, suggesting that “all ages at childhood were susceptible” to the virus, they added.

The declining number of cases over time further suggests that disease control measures implemented by the government were effective, and that cases will “continue to decline, and finally stop in the near future unless sustained human-to-human transmissions occur,” Ms. Dong and associates concluded.

In an accompanying editorial, Andrea T. Cruz, MD, of Baylor College of Medicine, Houston, and Steven L. Zeichner, MD, PhD, of the University of Virginia, Charlottesville, said the findings regarding reduced severity among children versus adults with novel coronavirus 2019 infection are consistent with data on non-COVID-19 coronavirus.

They pointed out that Ms. Dong and associates did find that 13% of virologically-confirmed cases had asymptomatic infection, “a rate that almost certainly understates the true rate of asymptomatic infection, since many asymptomatic children are unlikely to be tested.”

Of the symptomatic children, “5% had dyspnea or hypoxemia (a substantially lower percentage than what has been reported for adults) and 0.6% progressed to acute respiratory distress syndrome (ARDS) or multiorgan system dysfunction”; this also is at a lower rate than seen in adults, they said.

Very young children –infants or children in preschool – were more likely to have severe clinical manifestations than children who were older.

Thus, it appears that certain subpopulations of children are at increased risk for more significant COVID-19 illness: “younger age, underlying pulmonary pathology, and immunocompromising conditions,” Dr. Cruz and Dr. Zeichner suggested.

The two editorialists said the findings suggest children “may play a major role in community-based viral transmission.” Evidence suggests that children may have more upper respiratory tract involvement and that fecal shedding may occur for several weeks after diagnosis; this raises concerns about fecal-oral transmission, particularly for infants and children, and about viral replication in the gastrointestinal tract, they said. This has substantial implications for community spread in day care centers, schools, and in the home.

A great deal has been learned about COVID-19 in a short time, but there still is much to learn about the effect of the virus on children, the impact of children on viral spread, and about possible vertical transmission, they said.

“Widespread availability of testing will allow for us to more accurately describe the spectrum of illness and may result in adjustment of the apparent morbidity and mortality rate as fewer ill individuals are diagnosed,” Dr. Cruz and Dr. Zeichner wrote, adding that “rigorously gauging the impact of COVID-19 on children will be important to accurately model the pandemic and to ensure that appropriate resources are allocated to children requiring care.”

They noted that understanding differences in children versus adults with COVID-19 “can yield important insights into disease pathogenesis, informing management and the development of therapeutics.”

This study was partially supported by the Science and Technology Commission of Shanghai Municipality. The authors reported having no disclosures. Dr. Cruz and Dr. Zeichner are associate editors for Pediatrics. Dr. Cruz reported having no disclosures. Dr. Zeichner is an inventor of new technologies for the rapid production of vaccines, for which the University of Virginia has filed patent applications.

sworcester@mdedge.com

SOURCE: Dong Y et al. Pediatrics. 2020 Mar 16. doi: 10.1542/peds.2020-0702; Cruz A and Zeichner S. Pediatrics. 2020 Mar 16. doi: 10.1542/peds.2020-0834.

The American College of Physicians has published tips for medical practices related to billing and coding for telehealth, and for handling clinician and staff absences due to illness or quarantine during the COVID-19 pandemic.

It strongly encourages practices to use telehealth, whenever possible, to mitigate exposure of patients who are sick or at risk because of other underlying conditions and to protect health care workers and the community from the spread of the disease.

The national organization of internists also recommends in the guidance that practices establish protocols and procedures for use by clinicians and all other staff in light of the pandemic.

The billing and coding tips are being offered to help practices deal with the rapidly changing situation surrounding the COVID-19 emergency, according to a statement from the ACP.

The coding-related guidance incorporates changes to a number of telehealth rules for Medicare beneficiaries, announced by the Centers for Medicare and Medicaid Services on March 17.

“Now in a full state of emergency, many Medicare restrictions related to telehealth have been lifted. Patients can be at home, and non-HIPAA compliant technology is allowed. There is no cost sharing for COVID-19 testing. In addition, to encourage use by patients, Medicare is allowing practices to waive cost sharing (copays and deductibles) for all telehealth services,” the organization said in the guidance. It notes, however, that the CMS does not currently reimburse for telephone calls.

The guidance includes details of the new ICD-10 codes, and stresses the importance of using the appropriate codes, given that some service cost-sharing has been waived for COVID-19 testing and treatment.

There is detailed coding guidance for virtual check-in, online evaluation and management, remote monitoring, originating site, and allowed technology and services.

In regard to clinician and staff absence due to illness or quarantine, the ACP says “practices may need to review emergency plans related to telework and to employee and clinician absence.” Among its recommendations are that practices and employers consider temporary adjustments to compensation formulas to accommodate those clinicians who experience a loss of income because they are paid based on production.

The organization emphasizes that, given the rapidly changing availability of testing for COVID-19, practices should contact their local health departments, hospitals, reference labs, or state health authorities to determine the status of their access to testing.

The full list of the ACP’s tips are available here.

Any new guidance for physicians will be posted on the ACP’s COVID-19 resource page.

klennon@mdedge.com

The American College of Physicians has published tips for medical practices related to billing and coding for telehealth, and for handling clinician and staff absences due to illness or quarantine during the COVID-19 pandemic.

It strongly encourages practices to use telehealth, whenever possible, to mitigate exposure of patients who are sick or at risk because of other underlying conditions and to protect health care workers and the community from the spread of the disease.

The national organization of internists also recommends in the guidance that practices establish protocols and procedures for use by clinicians and all other staff in light of the pandemic.

The billing and coding tips are being offered to help practices deal with the rapidly changing situation surrounding the COVID-19 emergency, according to a statement from the ACP.

The coding-related guidance incorporates changes to a number of telehealth rules for Medicare beneficiaries, announced by the Centers for Medicare and Medicaid Services on March 17.

“Now in a full state of emergency, many Medicare restrictions related to telehealth have been lifted. Patients can be at home, and non-HIPAA compliant technology is allowed. There is no cost sharing for COVID-19 testing. In addition, to encourage use by patients, Medicare is allowing practices to waive cost sharing (copays and deductibles) for all telehealth services,” the organization said in the guidance. It notes, however, that the CMS does not currently reimburse for telephone calls.

The guidance includes details of the new ICD-10 codes, and stresses the importance of using the appropriate codes, given that some service cost-sharing has been waived for COVID-19 testing and treatment.

There is detailed coding guidance for virtual check-in, online evaluation and management, remote monitoring, originating site, and allowed technology and services.

In regard to clinician and staff absence due to illness or quarantine, the ACP says “practices may need to review emergency plans related to telework and to employee and clinician absence.” Among its recommendations are that practices and employers consider temporary adjustments to compensation formulas to accommodate those clinicians who experience a loss of income because they are paid based on production.

The organization emphasizes that, given the rapidly changing availability of testing for COVID-19, practices should contact their local health departments, hospitals, reference labs, or state health authorities to determine the status of their access to testing.

The full list of the ACP’s tips are available here.

Any new guidance for physicians will be posted on the ACP’s COVID-19 resource page.

klennon@mdedge.com

The American College of Physicians has published tips for medical practices related to billing and coding for telehealth, and for handling clinician and staff absences due to illness or quarantine during the COVID-19 pandemic.

It strongly encourages practices to use telehealth, whenever possible, to mitigate exposure of patients who are sick or at risk because of other underlying conditions and to protect health care workers and the community from the spread of the disease.

The national organization of internists also recommends in the guidance that practices establish protocols and procedures for use by clinicians and all other staff in light of the pandemic.

The billing and coding tips are being offered to help practices deal with the rapidly changing situation surrounding the COVID-19 emergency, according to a statement from the ACP.

The coding-related guidance incorporates changes to a number of telehealth rules for Medicare beneficiaries, announced by the Centers for Medicare and Medicaid Services on March 17.

“Now in a full state of emergency, many Medicare restrictions related to telehealth have been lifted. Patients can be at home, and non-HIPAA compliant technology is allowed. There is no cost sharing for COVID-19 testing. In addition, to encourage use by patients, Medicare is allowing practices to waive cost sharing (copays and deductibles) for all telehealth services,” the organization said in the guidance. It notes, however, that the CMS does not currently reimburse for telephone calls.

The guidance includes details of the new ICD-10 codes, and stresses the importance of using the appropriate codes, given that some service cost-sharing has been waived for COVID-19 testing and treatment.

There is detailed coding guidance for virtual check-in, online evaluation and management, remote monitoring, originating site, and allowed technology and services.

In regard to clinician and staff absence due to illness or quarantine, the ACP says “practices may need to review emergency plans related to telework and to employee and clinician absence.” Among its recommendations are that practices and employers consider temporary adjustments to compensation formulas to accommodate those clinicians who experience a loss of income because they are paid based on production.

The organization emphasizes that, given the rapidly changing availability of testing for COVID-19, practices should contact their local health departments, hospitals, reference labs, or state health authorities to determine the status of their access to testing.

The full list of the ACP’s tips are available here.

Any new guidance for physicians will be posted on the ACP’s COVID-19 resource page.

klennon@mdedge.com

Digestive Disease Week (DDW) 2020, originally scheduled for May 2-5, 2020, in Chicago, has been canceled because of the coronavirus pandemic.

Organizers are exploring options for virtual presentation of some of the content material.

“While we are disappointed to miss the science, education, and networking that are hallmarks of DDW, we must focus on the health and safety of our community,” said DDW organizers in an email notification on March 18, 2020. “Thank you for your patience as we evaluated the status of DDW in light of the rapidly changing coronavirus pandemic.”

Citing the meeting’s long tradition of improving patient care and the understanding of digestive diseases, the organizers promised more information to come about opportunities for remote presentation of research and educational material.

All events associated with DDW are also canceled, said the email. A page of frequently asked questions is being maintained (https://digestivediseaseweek.freshdesk.com/support/solutions/43000366101), and questions may be asked by submitting a ticket to the DDW help desk (https://digestivediseaseweek.freshdesk.com/support/tickets/new).

koakes@mdedge.com

Digestive Disease Week (DDW) 2020, originally scheduled for May 2-5, 2020, in Chicago, has been canceled because of the coronavirus pandemic.

Organizers are exploring options for virtual presentation of some of the content material.

“While we are disappointed to miss the science, education, and networking that are hallmarks of DDW, we must focus on the health and safety of our community,” said DDW organizers in an email notification on March 18, 2020. “Thank you for your patience as we evaluated the status of DDW in light of the rapidly changing coronavirus pandemic.”

Citing the meeting’s long tradition of improving patient care and the understanding of digestive diseases, the organizers promised more information to come about opportunities for remote presentation of research and educational material.

All events associated with DDW are also canceled, said the email. A page of frequently asked questions is being maintained (https://digestivediseaseweek.freshdesk.com/support/solutions/43000366101), and questions may be asked by submitting a ticket to the DDW help desk (https://digestivediseaseweek.freshdesk.com/support/tickets/new).

koakes@mdedge.com

Digestive Disease Week (DDW) 2020, originally scheduled for May 2-5, 2020, in Chicago, has been canceled because of the coronavirus pandemic.

Organizers are exploring options for virtual presentation of some of the content material.

“While we are disappointed to miss the science, education, and networking that are hallmarks of DDW, we must focus on the health and safety of our community,” said DDW organizers in an email notification on March 18, 2020. “Thank you for your patience as we evaluated the status of DDW in light of the rapidly changing coronavirus pandemic.”

Citing the meeting’s long tradition of improving patient care and the understanding of digestive diseases, the organizers promised more information to come about opportunities for remote presentation of research and educational material.

All events associated with DDW are also canceled, said the email. A page of frequently asked questions is being maintained (https://digestivediseaseweek.freshdesk.com/support/solutions/43000366101), and questions may be asked by submitting a ticket to the DDW help desk (https://digestivediseaseweek.freshdesk.com/support/tickets/new).

koakes@mdedge.com

ANSWER

The correct answer is acrodermatitis of Hallopeau (choice “c”).

DISCUSSION

Acrodermatitis of Hallopeau (ADH), a rare form of pustular psoriasis, affects the distal digits with changes typified by this patient’s case. It is notoriously difficult to treat, although the advent of the “biologic age” appears to offer a quantum leap in terms of effective treatment alternatives.

Prompt referral to dermatology is needed for ADH to be readily diagnosed and treated. Because ADH is both rare and obscure, it’s not surprising that so many patients suffer for years due to an incorrect diagnosis. And even when correctly diagnosed, treatment is far from satisfactory. For example, methotrexate is commonly used for psoriasis vulgaris but rarely improves ADH—nor do topical steroids or vitamin D–derived topicals.

The 3 other items in the differential would not explain the patient’s condition: (1) Except in cases of immunosuppression, we would not expect Candida (choice “a”) or any other yeast infection to manifest in this manner. (2) Atypical mycobacteria (choice “b”)—such as Mycobacterium marinum—can cause skin infections, but not in a chronically relapsing manner. Moreover, this patient was given minocycline, which would have quickly cleared or at least improved his condition. (3) Pityriasis rubra pilaris (choice “d”) is an unusual papulosquamous disease that can affect nails, but its manifestation would not be as limited as this patient’s was.

TREATMENT

Because the patient’s symptoms are sometimes severe enough to interfere with almost all daily activities, he is clearly in need of prompt treatment. In more severe cases, a short course of cyclosporine followed by a biologic can be an option. For this patient, adalimumab was used. Although it is too early to tell, we expect him to be much improved within a few months.

ANSWER

The correct answer is acrodermatitis of Hallopeau (choice “c”).

DISCUSSION

Acrodermatitis of Hallopeau (ADH), a rare form of pustular psoriasis, affects the distal digits with changes typified by this patient’s case. It is notoriously difficult to treat, although the advent of the “biologic age” appears to offer a quantum leap in terms of effective treatment alternatives.

Prompt referral to dermatology is needed for ADH to be readily diagnosed and treated. Because ADH is both rare and obscure, it’s not surprising that so many patients suffer for years due to an incorrect diagnosis. And even when correctly diagnosed, treatment is far from satisfactory. For example, methotrexate is commonly used for psoriasis vulgaris but rarely improves ADH—nor do topical steroids or vitamin D–derived topicals.

The 3 other items in the differential would not explain the patient’s condition: (1) Except in cases of immunosuppression, we would not expect Candida (choice “a”) or any other yeast infection to manifest in this manner. (2) Atypical mycobacteria (choice “b”)—such as Mycobacterium marinum—can cause skin infections, but not in a chronically relapsing manner. Moreover, this patient was given minocycline, which would have quickly cleared or at least improved his condition. (3) Pityriasis rubra pilaris (choice “d”) is an unusual papulosquamous disease that can affect nails, but its manifestation would not be as limited as this patient’s was.

TREATMENT

Because the patient’s symptoms are sometimes severe enough to interfere with almost all daily activities, he is clearly in need of prompt treatment. In more severe cases, a short course of cyclosporine followed by a biologic can be an option. For this patient, adalimumab was used. Although it is too early to tell, we expect him to be much improved within a few months.

ANSWER

The correct answer is acrodermatitis of Hallopeau (choice “c”).

DISCUSSION

Acrodermatitis of Hallopeau (ADH), a rare form of pustular psoriasis, affects the distal digits with changes typified by this patient’s case. It is notoriously difficult to treat, although the advent of the “biologic age” appears to offer a quantum leap in terms of effective treatment alternatives.

Prompt referral to dermatology is needed for ADH to be readily diagnosed and treated. Because ADH is both rare and obscure, it’s not surprising that so many patients suffer for years due to an incorrect diagnosis. And even when correctly diagnosed, treatment is far from satisfactory. For example, methotrexate is commonly used for psoriasis vulgaris but rarely improves ADH—nor do topical steroids or vitamin D–derived topicals.

The 3 other items in the differential would not explain the patient’s condition: (1) Except in cases of immunosuppression, we would not expect Candida (choice “a”) or any other yeast infection to manifest in this manner. (2) Atypical mycobacteria (choice “b”)—such as Mycobacterium marinum—can cause skin infections, but not in a chronically relapsing manner. Moreover, this patient was given minocycline, which would have quickly cleared or at least improved his condition. (3) Pityriasis rubra pilaris (choice “d”) is an unusual papulosquamous disease that can affect nails, but its manifestation would not be as limited as this patient’s was.

TREATMENT

Because the patient’s symptoms are sometimes severe enough to interfere with almost all daily activities, he is clearly in need of prompt treatment. In more severe cases, a short course of cyclosporine followed by a biologic can be an option. For this patient, adalimumab was used. Although it is too early to tell, we expect him to be much improved within a few months.

Upon palpation, the physician noted a strong pulse consistent with a traumatic arteriovenous fistula (in this case involving the superficial temporal artery). This finding, combined with the cyst’s appearance and the patient’s history, led the physician conclude that this was an epidermoid (sebaceous) cyst. (Prior to palpation, the visual differential diagnosis included dermoid cyst, lipoma, trichilemmal or epidermoid cyst, and foreign body granuloma.)

Cystic nodules on the forehead and midline deserve close scrutiny. This author has seen 3 similar cases in 10 years of daily dermatology consultative practice that have involved the superficial temporal artery and a history of head trauma. Each case had been stable for many months before presentation and had been incorrectly identified as a more common benign cyst.

In this particular case, the planned procedure in the outpatient setting was cancelled and the patient was referred to Vascular Surgery, where surgeons were planning to perform a ligation of the superficial temporal artery.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Upon palpation, the physician noted a strong pulse consistent with a traumatic arteriovenous fistula (in this case involving the superficial temporal artery). This finding, combined with the cyst’s appearance and the patient’s history, led the physician conclude that this was an epidermoid (sebaceous) cyst. (Prior to palpation, the visual differential diagnosis included dermoid cyst, lipoma, trichilemmal or epidermoid cyst, and foreign body granuloma.)

Cystic nodules on the forehead and midline deserve close scrutiny. This author has seen 3 similar cases in 10 years of daily dermatology consultative practice that have involved the superficial temporal artery and a history of head trauma. Each case had been stable for many months before presentation and had been incorrectly identified as a more common benign cyst.

In this particular case, the planned procedure in the outpatient setting was cancelled and the patient was referred to Vascular Surgery, where surgeons were planning to perform a ligation of the superficial temporal artery.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Upon palpation, the physician noted a strong pulse consistent with a traumatic arteriovenous fistula (in this case involving the superficial temporal artery). This finding, combined with the cyst’s appearance and the patient’s history, led the physician conclude that this was an epidermoid (sebaceous) cyst. (Prior to palpation, the visual differential diagnosis included dermoid cyst, lipoma, trichilemmal or epidermoid cyst, and foreign body granuloma.)

Cystic nodules on the forehead and midline deserve close scrutiny. This author has seen 3 similar cases in 10 years of daily dermatology consultative practice that have involved the superficial temporal artery and a history of head trauma. Each case had been stable for many months before presentation and had been incorrectly identified as a more common benign cyst.

In this particular case, the planned procedure in the outpatient setting was cancelled and the patient was referred to Vascular Surgery, where surgeons were planning to perform a ligation of the superficial temporal artery.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Use of the inactivated influenza vaccine by adults with autoimmune rheumatic diseases significantly reduced their risk of influenza-like illness, hospitalization for pneumonia and chronic obstructive pulmonary disease, and death from pneumonia, according to findings from an observational study of more than 30,000 patients in the U.K. Clinical Practice Research Datalink.

CAP53/iStockphoto.com

Although the inactivated vaccine has been recommended for patients with autoimmune rheumatic diseases (AIRDs), including rheumatoid arthritis and spondyloarthritis, the vaccine’s impact on patient outcomes including pneumonia, hospitalization, and death has not been well studied, wrote Georgina Nakafero, PhD, of the University of Nottingham, England, and colleagues.

In a study published in Rheumatology, the researchers identified 30,788 adults with AIRDs from the longitudinal Clinical Practice Research Datalink database in the United Kingdom. Of these, 66% were women, 76% had rheumatoid arthritis, and 61% had been prescribed methotrexate. The study included a total of 125,034 flu cycles between 2006 and 2009 and between 2010 and 2015.

Overall, vaccination with the inactivated influenza vaccine (IIV) reduced the risk of primary care consultation for influenza-like illness (adjusted odds ratio, 0.70), hospitalization for pneumonia (aOR, 0.61), exacerbation of chronic obstructive pulmonary disease (aOR, 0.67), and death caused by pneumonia (aOR, 0.48) in the study population. In a propensity score–adjusted analysis, only protection from influenza-like illness lost statistical significance.

In addition, vaccination was associated with a reduction in all-cause mortality among AIRDs patients, but restricting the outcomes to the active influenza periods may have confounded this result, the researchers said.

The study findings were limited by several factors including observational design, the use of a single vaccine efficacy estimate for each outcome, potential missed vaccination cycles, and potential confounding by indication and healthy user bias that could inflate the vaccine effectiveness, the researchers noted. However, the results were strengthened by the large sample size, including a range of AIRDs, and the use of both diagnostic and prescription codes, they said.

“The findings of this study, together with the results of our previous study demonstrating the safety of IIV in people with AIRDs, provides evidence to promote seasonal flu vaccination in this population,” they concluded. They still emphasized that randomized, controlled trials are needed for an assessment of vaccine efficacy.

The study was supported by Versus Arthritis and the National Institute of Health Research. Lead author Dr. Nakafero had no financial conflicts to disclose. Several coauthors disclosed relationships with companies, including AstraZeneca, Roche, and Pfizer.

SOURCE: Nakafero G et al. Rheumatology. 2020 Mar 11. doi: 10.1093/rheumatology/keaa078.

Use of the inactivated influenza vaccine by adults with autoimmune rheumatic diseases significantly reduced their risk of influenza-like illness, hospitalization for pneumonia and chronic obstructive pulmonary disease, and death from pneumonia, according to findings from an observational study of more than 30,000 patients in the U.K. Clinical Practice Research Datalink.

CAP53/iStockphoto.com

Although the inactivated vaccine has been recommended for patients with autoimmune rheumatic diseases (AIRDs), including rheumatoid arthritis and spondyloarthritis, the vaccine’s impact on patient outcomes including pneumonia, hospitalization, and death has not been well studied, wrote Georgina Nakafero, PhD, of the University of Nottingham, England, and colleagues.

In a study published in Rheumatology, the researchers identified 30,788 adults with AIRDs from the longitudinal Clinical Practice Research Datalink database in the United Kingdom. Of these, 66% were women, 76% had rheumatoid arthritis, and 61% had been prescribed methotrexate. The study included a total of 125,034 flu cycles between 2006 and 2009 and between 2010 and 2015.

Overall, vaccination with the inactivated influenza vaccine (IIV) reduced the risk of primary care consultation for influenza-like illness (adjusted odds ratio, 0.70), hospitalization for pneumonia (aOR, 0.61), exacerbation of chronic obstructive pulmonary disease (aOR, 0.67), and death caused by pneumonia (aOR, 0.48) in the study population. In a propensity score–adjusted analysis, only protection from influenza-like illness lost statistical significance.

In addition, vaccination was associated with a reduction in all-cause mortality among AIRDs patients, but restricting the outcomes to the active influenza periods may have confounded this result, the researchers said.

The study findings were limited by several factors including observational design, the use of a single vaccine efficacy estimate for each outcome, potential missed vaccination cycles, and potential confounding by indication and healthy user bias that could inflate the vaccine effectiveness, the researchers noted. However, the results were strengthened by the large sample size, including a range of AIRDs, and the use of both diagnostic and prescription codes, they said.

“The findings of this study, together with the results of our previous study demonstrating the safety of IIV in people with AIRDs, provides evidence to promote seasonal flu vaccination in this population,” they concluded. They still emphasized that randomized, controlled trials are needed for an assessment of vaccine efficacy.

The study was supported by Versus Arthritis and the National Institute of Health Research. Lead author Dr. Nakafero had no financial conflicts to disclose. Several coauthors disclosed relationships with companies, including AstraZeneca, Roche, and Pfizer.

SOURCE: Nakafero G et al. Rheumatology. 2020 Mar 11. doi: 10.1093/rheumatology/keaa078.

Use of the inactivated influenza vaccine by adults with autoimmune rheumatic diseases significantly reduced their risk of influenza-like illness, hospitalization for pneumonia and chronic obstructive pulmonary disease, and death from pneumonia, according to findings from an observational study of more than 30,000 patients in the U.K. Clinical Practice Research Datalink.

CAP53/iStockphoto.com

Although the inactivated vaccine has been recommended for patients with autoimmune rheumatic diseases (AIRDs), including rheumatoid arthritis and spondyloarthritis, the vaccine’s impact on patient outcomes including pneumonia, hospitalization, and death has not been well studied, wrote Georgina Nakafero, PhD, of the University of Nottingham, England, and colleagues.

In a study published in Rheumatology, the researchers identified 30,788 adults with AIRDs from the longitudinal Clinical Practice Research Datalink database in the United Kingdom. Of these, 66% were women, 76% had rheumatoid arthritis, and 61% had been prescribed methotrexate. The study included a total of 125,034 flu cycles between 2006 and 2009 and between 2010 and 2015.

Overall, vaccination with the inactivated influenza vaccine (IIV) reduced the risk of primary care consultation for influenza-like illness (adjusted odds ratio, 0.70), hospitalization for pneumonia (aOR, 0.61), exacerbation of chronic obstructive pulmonary disease (aOR, 0.67), and death caused by pneumonia (aOR, 0.48) in the study population. In a propensity score–adjusted analysis, only protection from influenza-like illness lost statistical significance.

In addition, vaccination was associated with a reduction in all-cause mortality among AIRDs patients, but restricting the outcomes to the active influenza periods may have confounded this result, the researchers said.

The study findings were limited by several factors including observational design, the use of a single vaccine efficacy estimate for each outcome, potential missed vaccination cycles, and potential confounding by indication and healthy user bias that could inflate the vaccine effectiveness, the researchers noted. However, the results were strengthened by the large sample size, including a range of AIRDs, and the use of both diagnostic and prescription codes, they said.

“The findings of this study, together with the results of our previous study demonstrating the safety of IIV in people with AIRDs, provides evidence to promote seasonal flu vaccination in this population,” they concluded. They still emphasized that randomized, controlled trials are needed for an assessment of vaccine efficacy.

The study was supported by Versus Arthritis and the National Institute of Health Research. Lead author Dr. Nakafero had no financial conflicts to disclose. Several coauthors disclosed relationships with companies, including AstraZeneca, Roche, and Pfizer.

SOURCE: Nakafero G et al. Rheumatology. 2020 Mar 11. doi: 10.1093/rheumatology/keaa078.

Clinicians across the United States are petitioning the federal government to follow the lead of South Korea, China, and other nations by imposing an immediate nationwide quarantine to slow the inevitable spread of COVID-19. Without federal action, the creators say, their lives and the lives of their colleagues, patients, and families are being put at increased risk.

In addition to the quarantine, the petition, posted on the website Change.org, calls on U.S. leaders to institute emergency production and distribution of personal protective equipment for healthcare workers and to rapidly increase access to testing.

The petition – which garnered more than 40,000 signatures in just 12 hours and as of this writing was approaching 94,000 – was started by an apolitical Facebook group to focus attention on what members see as the most critical issues for clinicians: slowing the spread of the virus through a coast-to-coast quarantine, protection of medical personnel with adequate supplies of essential equipment, and widespread testing.

“We started this group last Friday out of the realization that clinicians needed information about the outbreak and weren’t getting it,” said coadministrator Jessica McIntyre, MD, a pediatric hospitalist at Elliot Hospital in Manchester, N.H.

“We wanted to get ahead of it and connect with people before we were in the trenches experiencing it and to see what other programs were doing. From a local perspective, it has been really hard to see what people are doing in other states, especially when the protocols in our own states are changing every single day as we collect more information,” she said in an interview.
 

The Horse Has Bolted

A family medicine physician in Illinois helped launch the Facebook group. She asked that her name not be used but said in an interview that earlier actions may have prevented or at least delayed the need for the more draconian measures that her group is recommending.

“Clearly South Korea is one of the superstars as far as response has gone, but the concern we have in the United States is that we’re well beyond that point – we needed to be testing people over a month ago, in the hope of preventing a quarantine,” she said in an interview.

According to National Public Radio, as of March 13, South Korea had conducted 3,600 tests per million population, compared with five per million in the United States.

“I think the most concerning part is to see where Italy is now and where we are in comparison. Our ICUs have not yet overflowed, but I think we’re definitely looking at that in the next few weeks – hopefully longer, but I suspect that it will happen shortly,” she continued.

She cited work by Harvard University biostatistician Xihong Lin, PhD, that shows that when health authorities in Wuhan, China – widely cited as the epicenter of the global pandemic – cordoned off the city, the infection rate dropped from one person infecting 3.8 others to one infecting 1.25, thereby significantly slowing the rate of transmission.

“This is absolutely what we need to be doing,” she said.
 

Real News

Within 3 days of its creation, the online group had accrued more than 80,000 members with advanced medical training, including MDs, DOs, physician assistants, nurse practitioners, and certified registered nurse anesthetists.

“A lot of us were already very busy with our day-to-day work outside of COVID-19, and I think a lot of us felt unsure about where to get the best information,” said coadministrator David Janssen, MD, a family medicine physician in group practice in Sioux Center, Iowa,

“If you turn on the TV, there’s a lot of politicizing of the issue, and there’s a lot of good information, but also a lot of bad information. When health care providers talk to other health care providers, that’s often how we get our information and how we learn,” he said in an interview.

The COVID-19 U.S. Physicians/APP Facebook group includes 20 volunteer moderators who handle hundreds of posts per hour from persons seeking information on the novel coronavirus, what to tell patients, and how to protect themselves.

“It’s been wonderful to see how providers have been helping other providers sort through issues. Teaching hospitals have their hands on the latest research, but a lot of people like myself are at small community hospitals, critical-access hospitals, where we may have a lot of questions but don’t necessarily have the answers readily available to us,” Dr. Janssen said.

Dr. Janssen said that his community of about 8,000 residents initially had only four COVID-19 testing kits, or one for every 2,000 people. The situation has since improved, and more tests are now available, he added.

Dr. McIntyre, Dr. Janssen, and the Illinois family physician have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Clinicians across the United States are petitioning the federal government to follow the lead of South Korea, China, and other nations by imposing an immediate nationwide quarantine to slow the inevitable spread of COVID-19. Without federal action, the creators say, their lives and the lives of their colleagues, patients, and families are being put at increased risk.

In addition to the quarantine, the petition, posted on the website Change.org, calls on U.S. leaders to institute emergency production and distribution of personal protective equipment for healthcare workers and to rapidly increase access to testing.

The petition – which garnered more than 40,000 signatures in just 12 hours and as of this writing was approaching 94,000 – was started by an apolitical Facebook group to focus attention on what members see as the most critical issues for clinicians: slowing the spread of the virus through a coast-to-coast quarantine, protection of medical personnel with adequate supplies of essential equipment, and widespread testing.

“We started this group last Friday out of the realization that clinicians needed information about the outbreak and weren’t getting it,” said coadministrator Jessica McIntyre, MD, a pediatric hospitalist at Elliot Hospital in Manchester, N.H.

“We wanted to get ahead of it and connect with people before we were in the trenches experiencing it and to see what other programs were doing. From a local perspective, it has been really hard to see what people are doing in other states, especially when the protocols in our own states are changing every single day as we collect more information,” she said in an interview.
 

The Horse Has Bolted

A family medicine physician in Illinois helped launch the Facebook group. She asked that her name not be used but said in an interview that earlier actions may have prevented or at least delayed the need for the more draconian measures that her group is recommending.

“Clearly South Korea is one of the superstars as far as response has gone, but the concern we have in the United States is that we’re well beyond that point – we needed to be testing people over a month ago, in the hope of preventing a quarantine,” she said in an interview.

According to National Public Radio, as of March 13, South Korea had conducted 3,600 tests per million population, compared with five per million in the United States.

“I think the most concerning part is to see where Italy is now and where we are in comparison. Our ICUs have not yet overflowed, but I think we’re definitely looking at that in the next few weeks – hopefully longer, but I suspect that it will happen shortly,” she continued.

She cited work by Harvard University biostatistician Xihong Lin, PhD, that shows that when health authorities in Wuhan, China – widely cited as the epicenter of the global pandemic – cordoned off the city, the infection rate dropped from one person infecting 3.8 others to one infecting 1.25, thereby significantly slowing the rate of transmission.

“This is absolutely what we need to be doing,” she said.
 

Real News

Within 3 days of its creation, the online group had accrued more than 80,000 members with advanced medical training, including MDs, DOs, physician assistants, nurse practitioners, and certified registered nurse anesthetists.

“A lot of us were already very busy with our day-to-day work outside of COVID-19, and I think a lot of us felt unsure about where to get the best information,” said coadministrator David Janssen, MD, a family medicine physician in group practice in Sioux Center, Iowa,

“If you turn on the TV, there’s a lot of politicizing of the issue, and there’s a lot of good information, but also a lot of bad information. When health care providers talk to other health care providers, that’s often how we get our information and how we learn,” he said in an interview.

The COVID-19 U.S. Physicians/APP Facebook group includes 20 volunteer moderators who handle hundreds of posts per hour from persons seeking information on the novel coronavirus, what to tell patients, and how to protect themselves.

“It’s been wonderful to see how providers have been helping other providers sort through issues. Teaching hospitals have their hands on the latest research, but a lot of people like myself are at small community hospitals, critical-access hospitals, where we may have a lot of questions but don’t necessarily have the answers readily available to us,” Dr. Janssen said.

Dr. Janssen said that his community of about 8,000 residents initially had only four COVID-19 testing kits, or one for every 2,000 people. The situation has since improved, and more tests are now available, he added.

Dr. McIntyre, Dr. Janssen, and the Illinois family physician have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Clinicians across the United States are petitioning the federal government to follow the lead of South Korea, China, and other nations by imposing an immediate nationwide quarantine to slow the inevitable spread of COVID-19. Without federal action, the creators say, their lives and the lives of their colleagues, patients, and families are being put at increased risk.

In addition to the quarantine, the petition, posted on the website Change.org, calls on U.S. leaders to institute emergency production and distribution of personal protective equipment for healthcare workers and to rapidly increase access to testing.

The petition – which garnered more than 40,000 signatures in just 12 hours and as of this writing was approaching 94,000 – was started by an apolitical Facebook group to focus attention on what members see as the most critical issues for clinicians: slowing the spread of the virus through a coast-to-coast quarantine, protection of medical personnel with adequate supplies of essential equipment, and widespread testing.

“We started this group last Friday out of the realization that clinicians needed information about the outbreak and weren’t getting it,” said coadministrator Jessica McIntyre, MD, a pediatric hospitalist at Elliot Hospital in Manchester, N.H.

“We wanted to get ahead of it and connect with people before we were in the trenches experiencing it and to see what other programs were doing. From a local perspective, it has been really hard to see what people are doing in other states, especially when the protocols in our own states are changing every single day as we collect more information,” she said in an interview.
 

The Horse Has Bolted

A family medicine physician in Illinois helped launch the Facebook group. She asked that her name not be used but said in an interview that earlier actions may have prevented or at least delayed the need for the more draconian measures that her group is recommending.

“Clearly South Korea is one of the superstars as far as response has gone, but the concern we have in the United States is that we’re well beyond that point – we needed to be testing people over a month ago, in the hope of preventing a quarantine,” she said in an interview.

According to National Public Radio, as of March 13, South Korea had conducted 3,600 tests per million population, compared with five per million in the United States.

“I think the most concerning part is to see where Italy is now and where we are in comparison. Our ICUs have not yet overflowed, but I think we’re definitely looking at that in the next few weeks – hopefully longer, but I suspect that it will happen shortly,” she continued.

She cited work by Harvard University biostatistician Xihong Lin, PhD, that shows that when health authorities in Wuhan, China – widely cited as the epicenter of the global pandemic – cordoned off the city, the infection rate dropped from one person infecting 3.8 others to one infecting 1.25, thereby significantly slowing the rate of transmission.

“This is absolutely what we need to be doing,” she said.
 

Real News

Within 3 days of its creation, the online group had accrued more than 80,000 members with advanced medical training, including MDs, DOs, physician assistants, nurse practitioners, and certified registered nurse anesthetists.

“A lot of us were already very busy with our day-to-day work outside of COVID-19, and I think a lot of us felt unsure about where to get the best information,” said coadministrator David Janssen, MD, a family medicine physician in group practice in Sioux Center, Iowa,

“If you turn on the TV, there’s a lot of politicizing of the issue, and there’s a lot of good information, but also a lot of bad information. When health care providers talk to other health care providers, that’s often how we get our information and how we learn,” he said in an interview.

The COVID-19 U.S. Physicians/APP Facebook group includes 20 volunteer moderators who handle hundreds of posts per hour from persons seeking information on the novel coronavirus, what to tell patients, and how to protect themselves.

“It’s been wonderful to see how providers have been helping other providers sort through issues. Teaching hospitals have their hands on the latest research, but a lot of people like myself are at small community hospitals, critical-access hospitals, where we may have a lot of questions but don’t necessarily have the answers readily available to us,” Dr. Janssen said.

Dr. Janssen said that his community of about 8,000 residents initially had only four COVID-19 testing kits, or one for every 2,000 people. The situation has since improved, and more tests are now available, he added.

Dr. McIntyre, Dr. Janssen, and the Illinois family physician have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Microdiscectomy could significantly reduce pain intensity at 6 months in people with chronic sciatica caused by lumbar disc herniation, a randomized controlled trial has found.

Catherine Yeulet/Thinkstock

Researchers reported the outcomes of a single-center trial in the New England Journal of Medicine in which 128 patients with chronic sciatica resulting from lumbar disc herniation were randomized either to microdiscectomy or 6 months of standardized nonoperative care, followed by surgery if required.

Chris S. Bailey, MD, of the Schulich School of Medicine and Dentistry at Western University in Toronto, Ontario, and coauthors wrote that, while the majority of patients with sciatica from acute herniation of the lumbar disc improve with conservative care, there is little study comparing surgery with conservative care in patients whose symptoms have lasted longer than 3 months.

In this study, all patients had experienced unilateral radiculopathy for 4-12 months. Those randomized to surgery were operated on a median of 3.1 weeks after enrollment, while those randomized to nonsurgical treatment received education on exercise, functioning, and the use of oral analgesics, as well as active physiotherapy and epidural glucocorticoid injections if needed.

At 6 months, the surgical group showed significantly lower visual analog scale scores for leg-pain intensity, compared with the nonsurgical group (2.8 vs. 5.2; 95% confidence interval, 1.4-3.4; P < .001) and the difference persisted at 1 year (2.6 vs. 4.7).

In an editorial accompanying the study, Andrew J. Schoenfeld, MD, and James D. Kang, MD, of the department of orthopedic surgery at Brigham and Women’s Hospital and Harvard Medical School, both in Boston, described the results in this group of patients with persistent sciatica as “encouraging,” and suggested the improvement may be because the surgery achieves more rapid decompression of the compressed nerve.

“Patients in the current trial who were assigned to undergo surgery received the intervention relatively quickly, at a median of 3 weeks, and it is reasonable to conclude that expeditious removal of the nerve compression minimized the potential for long-term persistence of pain,” they wrote.

Among the 64 patients who were randomized to nonsurgical treatment, 22 (34%) crossed over to undergo surgery at a median of 11 months after enrollment in the study. These patients tended to be younger at baseline, and less likely to have an asymmetrical decrease in reflexes.

The intention-to-treat analysis found a similar rate of surgical adverse events in the group initially randomized to surgery and the group who crossed over to have surgery (6% vs. 8%). Two patients in the surgical group and one in the crossover group experienced superficial wound infections, while two patients in the crossover group and one in the surgical group experienced new-onset postoperative neuropathic pain. Two patients in the surgical group also had a recurrence of their herniation; one underwent further surgery for it 250 days after the initial procedure, and the other did not.

The secondary outcomes of the study were disability score, physical health, mental health, back pain intensity, satisfaction with treatment, and employment status. All these showed differences that favored the surgical intervention, but “the absence of a prespecified plan for adjustment for multiple comparisons does not allow for clinical inferences from secondary outcomes.”

The authors noted that some previous randomized trials have shown that surgery was better than conservative care among patients with lumbar disc herniation for the first 6 months, but those trials largely focused on patients who had had symptoms for less than 4 months at the time of the intervention. The results of these trials had also been mixed; some trials in patients with shorter duration of symptoms found little or no benefit of surgery over conservative care.

“The decision about whether to recommend discectomy or nonsurgical treatment in this population is controversial because a longer duration of symptoms has been correlated with a poorer outcome associated with lumbar discectomy in some studies,” they wrote. “However, patients may prefer to avoid surgery if they think that nonsurgical treatment could be successful or if they anticipate a risk from surgery.”

There was the risk for selection bias in the study, the authors said, because both surgeons and patients might have been less inclined to go with nonsurgical care in cases of more severe sciatic pain. However they said patients did not have the option of choosing to have surgery at the center outside the trial, which should have minimized that risk.

The authors of the editorial noted that while the study limited itself to patients who had had symptoms for 4-12 months, it didn’t account for other clinical factors that might impact the outcome of discectomy, such as the size of disc herniation or extent of nerve compression.

They also pointed out that questions still remained about which patients were more likely to benefit from immediate surgical intervention and how long nonsurgical care should be trialed before recommending surgery.

The study was supported by a grant from the Physicians’ Services Incorporated Foundation. None of the study authors reported conflicts of interest. Dr. Kang reported grants from Pfizer, personal fees from DePuy (Johnson & Johnson), nonfinancial support from Stryker, owning stock in ALung and Cardiorobotics, and serving on a scientific advisory board for OnPoint Surgical, outside the submitted work. Dr. Schoenfeld reported grants from the National Institute for Arthritis and Musculoskeletal and Skin Diseases, the Orthopaedic Research and Education Foundation, and the U.S. Department of Defense, outside the submitted work.

SOURCE: Bailey C et al. N Engl J Med. 2020;382:1093-102.

Microdiscectomy could significantly reduce pain intensity at 6 months in people with chronic sciatica caused by lumbar disc herniation, a randomized controlled trial has found.

Catherine Yeulet/Thinkstock

Researchers reported the outcomes of a single-center trial in the New England Journal of Medicine in which 128 patients with chronic sciatica resulting from lumbar disc herniation were randomized either to microdiscectomy or 6 months of standardized nonoperative care, followed by surgery if required.

Chris S. Bailey, MD, of the Schulich School of Medicine and Dentistry at Western University in Toronto, Ontario, and coauthors wrote that, while the majority of patients with sciatica from acute herniation of the lumbar disc improve with conservative care, there is little study comparing surgery with conservative care in patients whose symptoms have lasted longer than 3 months.

In this study, all patients had experienced unilateral radiculopathy for 4-12 months. Those randomized to surgery were operated on a median of 3.1 weeks after enrollment, while those randomized to nonsurgical treatment received education on exercise, functioning, and the use of oral analgesics, as well as active physiotherapy and epidural glucocorticoid injections if needed.

At 6 months, the surgical group showed significantly lower visual analog scale scores for leg-pain intensity, compared with the nonsurgical group (2.8 vs. 5.2; 95% confidence interval, 1.4-3.4; P < .001) and the difference persisted at 1 year (2.6 vs. 4.7).

In an editorial accompanying the study, Andrew J. Schoenfeld, MD, and James D. Kang, MD, of the department of orthopedic surgery at Brigham and Women’s Hospital and Harvard Medical School, both in Boston, described the results in this group of patients with persistent sciatica as “encouraging,” and suggested the improvement may be because the surgery achieves more rapid decompression of the compressed nerve.

“Patients in the current trial who were assigned to undergo surgery received the intervention relatively quickly, at a median of 3 weeks, and it is reasonable to conclude that expeditious removal of the nerve compression minimized the potential for long-term persistence of pain,” they wrote.

Among the 64 patients who were randomized to nonsurgical treatment, 22 (34%) crossed over to undergo surgery at a median of 11 months after enrollment in the study. These patients tended to be younger at baseline, and less likely to have an asymmetrical decrease in reflexes.

The intention-to-treat analysis found a similar rate of surgical adverse events in the group initially randomized to surgery and the group who crossed over to have surgery (6% vs. 8%). Two patients in the surgical group and one in the crossover group experienced superficial wound infections, while two patients in the crossover group and one in the surgical group experienced new-onset postoperative neuropathic pain. Two patients in the surgical group also had a recurrence of their herniation; one underwent further surgery for it 250 days after the initial procedure, and the other did not.

The secondary outcomes of the study were disability score, physical health, mental health, back pain intensity, satisfaction with treatment, and employment status. All these showed differences that favored the surgical intervention, but “the absence of a prespecified plan for adjustment for multiple comparisons does not allow for clinical inferences from secondary outcomes.”

The authors noted that some previous randomized trials have shown that surgery was better than conservative care among patients with lumbar disc herniation for the first 6 months, but those trials largely focused on patients who had had symptoms for less than 4 months at the time of the intervention. The results of these trials had also been mixed; some trials in patients with shorter duration of symptoms found little or no benefit of surgery over conservative care.

“The decision about whether to recommend discectomy or nonsurgical treatment in this population is controversial because a longer duration of symptoms has been correlated with a poorer outcome associated with lumbar discectomy in some studies,” they wrote. “However, patients may prefer to avoid surgery if they think that nonsurgical treatment could be successful or if they anticipate a risk from surgery.”

There was the risk for selection bias in the study, the authors said, because both surgeons and patients might have been less inclined to go with nonsurgical care in cases of more severe sciatic pain. However they said patients did not have the option of choosing to have surgery at the center outside the trial, which should have minimized that risk.

The authors of the editorial noted that while the study limited itself to patients who had had symptoms for 4-12 months, it didn’t account for other clinical factors that might impact the outcome of discectomy, such as the size of disc herniation or extent of nerve compression.

They also pointed out that questions still remained about which patients were more likely to benefit from immediate surgical intervention and how long nonsurgical care should be trialed before recommending surgery.

The study was supported by a grant from the Physicians’ Services Incorporated Foundation. None of the study authors reported conflicts of interest. Dr. Kang reported grants from Pfizer, personal fees from DePuy (Johnson & Johnson), nonfinancial support from Stryker, owning stock in ALung and Cardiorobotics, and serving on a scientific advisory board for OnPoint Surgical, outside the submitted work. Dr. Schoenfeld reported grants from the National Institute for Arthritis and Musculoskeletal and Skin Diseases, the Orthopaedic Research and Education Foundation, and the U.S. Department of Defense, outside the submitted work.

SOURCE: Bailey C et al. N Engl J Med. 2020;382:1093-102.

Microdiscectomy could significantly reduce pain intensity at 6 months in people with chronic sciatica caused by lumbar disc herniation, a randomized controlled trial has found.

Catherine Yeulet/Thinkstock

Researchers reported the outcomes of a single-center trial in the New England Journal of Medicine in which 128 patients with chronic sciatica resulting from lumbar disc herniation were randomized either to microdiscectomy or 6 months of standardized nonoperative care, followed by surgery if required.

Chris S. Bailey, MD, of the Schulich School of Medicine and Dentistry at Western University in Toronto, Ontario, and coauthors wrote that, while the majority of patients with sciatica from acute herniation of the lumbar disc improve with conservative care, there is little study comparing surgery with conservative care in patients whose symptoms have lasted longer than 3 months.

In this study, all patients had experienced unilateral radiculopathy for 4-12 months. Those randomized to surgery were operated on a median of 3.1 weeks after enrollment, while those randomized to nonsurgical treatment received education on exercise, functioning, and the use of oral analgesics, as well as active physiotherapy and epidural glucocorticoid injections if needed.

At 6 months, the surgical group showed significantly lower visual analog scale scores for leg-pain intensity, compared with the nonsurgical group (2.8 vs. 5.2; 95% confidence interval, 1.4-3.4; P < .001) and the difference persisted at 1 year (2.6 vs. 4.7).

In an editorial accompanying the study, Andrew J. Schoenfeld, MD, and James D. Kang, MD, of the department of orthopedic surgery at Brigham and Women’s Hospital and Harvard Medical School, both in Boston, described the results in this group of patients with persistent sciatica as “encouraging,” and suggested the improvement may be because the surgery achieves more rapid decompression of the compressed nerve.

“Patients in the current trial who were assigned to undergo surgery received the intervention relatively quickly, at a median of 3 weeks, and it is reasonable to conclude that expeditious removal of the nerve compression minimized the potential for long-term persistence of pain,” they wrote.

Among the 64 patients who were randomized to nonsurgical treatment, 22 (34%) crossed over to undergo surgery at a median of 11 months after enrollment in the study. These patients tended to be younger at baseline, and less likely to have an asymmetrical decrease in reflexes.

The intention-to-treat analysis found a similar rate of surgical adverse events in the group initially randomized to surgery and the group who crossed over to have surgery (6% vs. 8%). Two patients in the surgical group and one in the crossover group experienced superficial wound infections, while two patients in the crossover group and one in the surgical group experienced new-onset postoperative neuropathic pain. Two patients in the surgical group also had a recurrence of their herniation; one underwent further surgery for it 250 days after the initial procedure, and the other did not.

The secondary outcomes of the study were disability score, physical health, mental health, back pain intensity, satisfaction with treatment, and employment status. All these showed differences that favored the surgical intervention, but “the absence of a prespecified plan for adjustment for multiple comparisons does not allow for clinical inferences from secondary outcomes.”

The authors noted that some previous randomized trials have shown that surgery was better than conservative care among patients with lumbar disc herniation for the first 6 months, but those trials largely focused on patients who had had symptoms for less than 4 months at the time of the intervention. The results of these trials had also been mixed; some trials in patients with shorter duration of symptoms found little or no benefit of surgery over conservative care.

“The decision about whether to recommend discectomy or nonsurgical treatment in this population is controversial because a longer duration of symptoms has been correlated with a poorer outcome associated with lumbar discectomy in some studies,” they wrote. “However, patients may prefer to avoid surgery if they think that nonsurgical treatment could be successful or if they anticipate a risk from surgery.”

There was the risk for selection bias in the study, the authors said, because both surgeons and patients might have been less inclined to go with nonsurgical care in cases of more severe sciatic pain. However they said patients did not have the option of choosing to have surgery at the center outside the trial, which should have minimized that risk.

The authors of the editorial noted that while the study limited itself to patients who had had symptoms for 4-12 months, it didn’t account for other clinical factors that might impact the outcome of discectomy, such as the size of disc herniation or extent of nerve compression.

They also pointed out that questions still remained about which patients were more likely to benefit from immediate surgical intervention and how long nonsurgical care should be trialed before recommending surgery.

The study was supported by a grant from the Physicians’ Services Incorporated Foundation. None of the study authors reported conflicts of interest. Dr. Kang reported grants from Pfizer, personal fees from DePuy (Johnson & Johnson), nonfinancial support from Stryker, owning stock in ALung and Cardiorobotics, and serving on a scientific advisory board for OnPoint Surgical, outside the submitted work. Dr. Schoenfeld reported grants from the National Institute for Arthritis and Musculoskeletal and Skin Diseases, the Orthopaedic Research and Education Foundation, and the U.S. Department of Defense, outside the submitted work.

SOURCE: Bailey C et al. N Engl J Med. 2020;382:1093-102.