A 73-year-old man presented to primary care for an annual examination. Four days prior, he noted right-sided sharp jaw pain such that he could not open his mouth nor chew solid food; it radiated from the right mandible to the ipsilateral temple. He also noted bilateral aching hip pain for several years that increased in severity in the prior 2 months. He reported an intentional weight loss of 9 kg over the past year, achieved through dietary modification. He denied fever, chills, and visual disturbance.

Acute onset of unilateral jaw pain that is worsened by chewing is a feature consistent with a temporomandibular disorder (TMD). TMD consists of musculoskeletal and neuromuscular conditions that affect the temporomandibular joints (TMJs), masticatory muscles, and associated tissues. Common symptoms of TMD include facial or ear pain, temporal headache, and TMJ dysfunction or discomfort. In addition to TMD, craniofacial pain has many possible etiologies such as dental pathology, neuralgias, sinus and otologic disorders, headache and migraine disorders, infections, rheumatologic conditions, and neoplasms.

Systemic etiologies for this patient’s symptoms are a consideration given his age and concomitant worsening of chronic hip pain. Rheumatologic conditions such as giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are more common in adults older than 50 years of age and cause headache, jaw claudication, and pelvic girdle pain. Rarely, hematologic malignancies (eg, lymphoma), solid tumor metastases (eg, breast cancer, melanoma), and primary tumors of the head and neck (eg, nasopharyngeal carcinoma) can involve the mandible, TMJ, or parotid gland and result in symptoms of TMD.

Medical history was notable for hypertension and type 2 diabetes mellitus complicated by peripheral neuropathy. He smoked one pack of cigarettes daily for 40 years but quit 15 years prior. He drank 4 ounces of vodka each night.

On examination, temperature was 36.5°C, heart rate 92 beats per minute, blood pressure 127/60 mmHg, respiratory rate 12 breaths per minute, oxygen saturation 98% on ambient air, and weight 118 kg. Extraocular movements were intact, pupils were equal and reactive to light and accommodation, and there were no visual field deficits. Nondilated funduscopic examination revealed normal blood vessels, optic disc, and optic cup-to-disc ratio. Dentition was good with pink gingiva. Bilateral temples were nontender. There was normal range of motion and strength in the shoulders, hips, and lower extremities with no tenderness over the trochanters. Patellar and ankle reflexes were present and symmetric bilaterally. He had no rashes or ecchymoses.

The history of smoking, especially with concomitant alcohol intake, is a risk factor for head and neck cancer, and these malignancies can lead to facial pain. While the normal oral cavity exam argues against localized oral and dental causes of the patient’s symptoms, direct fiberoptic endoscopy should be considered. The neck should be examined for lymphadenopathy. Normal vital signs point away from severe infection. The lack of findings in the head and musculoskeletal regions does not exclude systemic etiologies such as rheumatologic conditions or neoplasm. Complete blood cell count and markers of inflammation including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels should be obtained. Hip and pelvic radiographs should be obtained to evaluate for hip osteoarthritis, fractures, or osseous lesions.

The appointment occurred during evening hours and the patient declined further evaluation until the following morning, at which time laboratory studies revealed normal serum levels of electrolytes, blood urea nitrogen, and creatinine. White blood cell (WBC) count was 6,800/mm³ with an immature granulocyte ratio of 1.8% (normal, 0.0-0.5%), hemoglobin 13.2 g/dL, and platelet count 163,000/mm³. ESR was 118 mm/hr (normal, 0-15 mm/hr) and CRP was 1.5 mg/dL (normal, 0-0.75 mg/dL). Radiographs of the hips and pelvis showed osteoarthritis of the bilateral hip joints and degenerative disc disease of the lower lumbar spine.

Granulocytosis may occur in response to infection, rheumatologic conditions, and hematologic malignancies such as chronic myelogenous leukemia. While infectious etiologies (eg, abscess, osteomyelitis) are the most common cause of an extremely elevated ESR level, this patient does not have other signs or symptoms of infection such as fever or leukocytosis. Therefore, other common causes for an extremely elevated ESR level should be considered, including malignancy (eg, multiple myeloma, lymphoma, metastatic solid tumor) and autoimmune conditions (eg, rheumatoid arthritis, vasculitis). While multiple myeloma is the most common malignant etiology for extremely elevated ESR, the patient lacks signs of this condition such as anemia, elevated creatinine, or osteolytic lesions on radiographic imaging. Osteoarthritis identified on the radiographs may contribute to the patient’s hip pain but would not explain the patient’s jaw pain, weight loss, granulocytosis, and elevated ESR. These findings, taken together with the patient’s age, are most suggestive of GCA with possible coexisting PMR. Temporal artery biopsy should be obtained as it is the gold standard test for diagnosing GCA.

The patient was contacted by telephone that same day with laboratory test results. During the call, he endorsed increased jaw and temple pain. He was advised to proceed to the emergency department (ED) for timely evaluation and treatment.

Because GCA was being considered, ophthalmology performed an ocular examination in the ED, which demonstrated no signs of optic nerve or retinal ischemia. Computed tomography (CT) scan of the head and neck with intravenous contrast revealed no abscess or soft tissue abnormalities. Right temporal artery biopsy was performed.

The normal ocular examination does not exclude GCA, and temporal artery biopsy is appropriate. The mainstay of treatment for GCA is high-dose systemic glucocorticoids, which should not be withheld while awaiting biopsy results since ophthalmic artery inflammation may occur and threaten vision.

While GCA remains the leading diagnosis, malignant etiologies warrant further consideration because they are a common cause of extreme ESR elevation, particularly among older patients. The patient’s cancer screening history should be reviewed. The normal CT scan of the head and neck reduces the likelihood of localized solid tumor etiologies; however, additional CT imaging of the chest, abdomen, and pelvis is warranted to evaluate for metastatic solid tumors or lymphoma.

A 10-day course of prednisone 60 mg daily was prescribed for empiric treatment of GCA. The patient was discharged home with follow-up scheduled in rheumatology and primary care clinics. Pain in the jaw and temple resolved within several days.

Two weeks later, he presented to the rheumatology clinic. He noted 1 week of lower right back pain described as dull, aching, radiating to the lateral right hip, and occurring when transitioning from sitting to standing. He had no leg numbness, weakness, or change in bowel habits. Bladder habits were also unchanged, although he reported chronic urinary frequency and occasional incontinence. He reported further weight loss, this time an unintentional loss of 9 kg. He noted frequent sweating but no fever.

He reported a normal colonoscopy within the prior 5 years. Because these records were not available for review, a fecal immunochemical test was obtained and negative for hemoglobin. He had previously declined prostate cancer screening.

The resolution of jaw and temple pain with prednisone supports the presumed diagnosis of GCA. Up to half of patients with GCA may also have PMR, which can cause aching and stiffness in the arms, hips, and lumbar region, and pain may be abrupt in onset. However, PMR-related pain would be expected to improve rather than develop or worsen in the setting of high-dose glucocorticoid use. Therefore, other causes of acute-onset back pain must be considered.

While localized musculoskeletal etiologies such as lumbar muscle strain, radiculopathy, and vertebral compression fracture are possible, co-occurrence of unintentional weight loss and diaphoresis with elevated inflammatory markers suggests a systemic etiology. A neoplastic process with bony metastasis is possible. The reportedly normal colonoscopy and the negative fecal immunochemical test make colorectal cancer less likely. Inflammatory conditions such as ankylosing spondylitis and rheumatoid arthritis are also possible. Ankylosing spondylitis usually presents at a much younger age, however, and axial skeletal involvement in rheumatoid arthritis often involves the cervical spine and is usually seen after longstanding disease. Additionally, the hallmark of inflammatory back pain is morning stiffness which the patient does not endorse. Nonetheless, additional laboratory testing should include antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibody. Vertebral osteomyelitis remains on the differential diagnosis, and repeat WBC count and inflammatory markers should be assessed. Lumbosacral radiographs should be obtained to rule out fracture.

Physical examination in the rheumatology clinic revealed a temperature of 37.0°C, heart rate 100 beats per minute, blood pressure 146/72 mmHg, respiratory rate 12 breaths per minute, and oxygen saturation 98% on ambient air. Weight was 109 kg. He was pale and diaphoretic. There was diffuse tenderness to palpation of the right-sided lumbar paraspinal muscles. Straight leg raise was negative bilaterally. Patellar reflexes and gait were normal.

Blood chemistries, renal function, and aminotransferase levels were normal. WBC count was 7,100/mm³, hemoglobin 8.0 g/dL, mean corpuscular volume 88.9 fL, platelet count 128,000/mm³, ESR 66 mm/hr, CRP 0.57 mg/dL, alkaline phosphatase 438 IU/L (normal, 30-130 IU/L), and thyroid-stimulating hormone 0.925 mU/L (normal, 0.34-5.60 mU/L). Testing for antinuclear antibodies, rheumatoid factor, and anti-CCP antibody was unremarkable. Prostate-specific antigen (PSA) level was 2.2 ng/mL (normal, 0-4 ng/mL). Urinalysis was unremarkable. Antibodies to hepatitis C and Treponema pallidum were negative. Interferon gamma release assay was negative.

Findings of new onset anemia and thrombocytopenia, in combination with elevated ESR and alkaline phosphatase level, are concerning for disseminated intravascular coagulation (DIC) and microangiopathic hemolytic anemia (MAHA), bone marrow infiltration of a metastatic neoplasm, or ineffective hematopoiesis caused by myelodysplastic syndromes or myelofibrosis.

Laboratory evaluation should include iron studies, lactate dehydrogenase (LDH), haptoglobin, fibrinogen, D-dimer, reticulocyte count, and peripheral blood smear to assess for hemolysis and erythrocyte morphology. Advanced imaging with lumbosacral magnetic resonance imaging (MRI) should be obtained to evaluate for focal etiologies of back pain such as disc herniation, abscess, marrow infiltration, and infarction.

Additional laboratory studies revealed a gamma-glutamyl transferase level of 49 IU/L (normal, 8-56 IU/L), LDH 288 IU/L (normal, 98-192 IU/L), haptoglobin 495 mg/dL (normal, 32-240 mg/dL), fibrinogen >700 mg/dL (normal, 225-550 mg/dL), D-dimer 693 ng/mL (normal, 200-250 ng/mL), serum iron 57 mcg/dL (normal, 33-150 mcg/dL), total iron binding capacity 286 mcg/dL (normal, 250-450 mcg/dL), ferritin 1,012 ng/mL (normal, 17.9-464 ng/mL), and reticulocyte count 2.9% (normal, 0.5-2.5%). Coagulation studies and serum protein electrophoresis were normal. Erythropoietin level was 109 mIU/mL (normal, 4.0-20.0 mIU/mL). Peripheral blood smear demonstrated moderate anemia with 8% nucleated erythrocytes per white blood cell (normal, 0%) and no circulating blasts.

MRI of the thoracolumbar spine and pelvis revealed diffusely abnormal bone marrow signal with multiple superimposed focal and poorly defined enhancing lesions along the lumbar spine marrow, sacrum, and bilateral iliac bones (Figure 1). Positron emission tomography/computed tomography (PET/CT) scan showed no scintigraphic evidence of metabolically active neoplastic, paraneoplastic, or inflammatory disorder.

The elevated haptoglobin, normal coagulation studies, and absence of fragmented erythrocytes on peripheral smear exclude an intravascular hemolytic process. The patient’s lower than expected reticulocyte count for the degree of anemia, elevated erythropoietin, and nucleated erythrocytes constitute a pattern that can be seen with bone marrow infiltration. There are no circulating blasts, making leukemia less likely. A solid organ tumor with bone metastases may cause enhancing lesions on MRI since this form of imaging is more sensitive than radiography for detecting skeletal malignancies. The negative PET/CT, however, does not reveal a primary tumor. Myelofibrosis is an infiltrative myeloproliferative disorder associated with nonspecific laboratory abnormalities, bone pain, weight loss, and night sweats that could cause diffuse MRI bone marrow signal alterations with normal PET/CT findings. However, myelofibrosis would not typically cause a significantly elevated ESR, and thus would be an unlikely cause for this patient’s presentation.

Given the constellation of symptoms, hematologic abnormalities, and bone marrow infiltration on imaging, hematology should be consulted to perform a bone marrow biopsy to assist with definitive diagnosis.

Bone marrow biopsy demonstrated metastatic adenocarcinoma consistent with prostatic origin (Figure 2). Bone scan demonstrated widespread osteoblastic metastases, which included the skull and temporal regions. These lesions were thought to be the cause of the patient’s original presenting symptom of jaw pain.

The patient was started on androgen deprivation therapy, initially with degarelix and subsequently leuprolide shots and abiraterone with prednisone. PSA was 0.08 ng/mL after 3 months of androgen deprivation therapy. His back and hip pain slowly improved.

Prostate cancer is the most common cancer in men with one out of every nine men diagnosed in his lifetime.¹ While most men initially present with localized, curable disease,¹ 4% present with metastatic disease, an incidence that has been increasing since 2004.² Despite available treatments, metastatic prostate cancer has a poor prognosis, with an average overall survival of approximately 5 years.³

Prostate cancer can be challenging to diagnose. Men with prostate cancer are commonly asymptomatic. Rarely, patients may present with hematuria, bony pain caused by metastasis, or obstructive urinary symptoms like hesitancy or incomplete bladder emptying. Our patient presented with jaw pain, which was ultimately attributed to osteoblastic lesions of the skull. Additionally, his history of urinary frequency and incontinence may have been clues to his underlying diagnosis of prostate cancer.

Prostate cancer screening remains highly nuanced and relies on shared decision-making between patients and healthcare providers. Clinical practice guidelines for early detection of prostate cancer recommend individualized PSA-based serologic screening.^4,5 Specifically, the United States Preventive Services Task Force recommends screening men aged 55 to 69 years who desire screening and understand the potential harms associated with a positive test result. These harms may include psychological distress and complications from prostate biopsy (eg, pain or infection) or prostate cancer treatment (eg, erectile, urinary, and/or bowel dysfunction).^4-6 The decision to screen can be guided by individuals’ risk factors including African American race, family history, and older age.

While our patient elected not to undergo routine prostate cancer screening, a PSA level was obtained during his diagnostic evaluation and highlights the limitations of PSA-based screening. A PSA level ≤4.0 ng/mL has 21% sensitivity and 91% specificity for detecting prostate cancer.⁷ PSA levels above 4.0 ng/mL warrant repeat testing and, if persistently elevated, referral to urology for possible prostate biopsy. PSA levels often correlate with burden of disease, and patients with PSA levels >20 ng/mL are referred for CT imaging to evaluate for metastatic disease.⁸ PSA’s poor sensitivity was underscored in a study by Thompson et al who evaluated the incidence of prostate cancer in men participating in the Prostate Cancer Prevention Trial with PSA levels of <4 ng/mL.⁹ In this study, 15% of men diagnosed with prostate cancer never had a PSA level >4 ng/mL.⁹ While most of the cancers in this study were low grade and may have been clinically insignificant, 15% demonstrated histologic signs of at least intermediate-risk disease. Our patient’s PSA level of 2.2 ng/mL was below the threshold that triggers additional evaluation even though he had widely metastatic prostate cancer.

Our patient’s severe jaw and temple pain, weight loss, and progressive hip pain were concerning for GCA. This vasculitis of large- and medium-sized arteries predominantly affects older adults with greatest incidence among those 70 years of age and older.¹⁰ Symptoms occur because of cranial artery inflammation and may include headache, visual disturbance, erythema or tenderness of the temporal artery, and jaw claudication. Extracranial inflammation may affect the thoracic aorta and its branches and rarely the abdominal aorta and lower limb arteries. Pelvic girdle pain more typically results from associated PMR. Patients may also note systemic symptoms such as fever, weight loss, and fatigue.

Prompt diagnostic testing is important when considering GCA. Most patients with GCA have ESR levels greater than 40 mm/hr.¹¹ ESR is a laboratory test that measures the vertical distance erythrocytes travel in a column of blood over 1 hour; in the setting of inflammation, cells form clumps and travel more quickly than individual cells, resulting in a higher value. While moderate elevations in ESR may occur without an identifiable cause, extreme ESR levels—those above 100 mm/hr, as observed in our patient—are highly suggestive of certain serious conditions, including infection, malignancy, and autoimmune disease such as GCA.^12,13 Temporal artery biopsy is the gold standard test to diagnose GCA. However, because of noncontiguous inflammation of the temporal artery, biopsies may be falsely negative. Thus, sampling of the contralateral temporal artery may be warranted if suspicion remains high.

As was the case for our patient, PET/CT is not reliable for diagnosing prostate cancer. In contrast to other malignancies (eg, lymphoma, lung cancer), prostate cancer typically does not display increased glucose metabolism. Moreover, the close proximity of the bladder and prostate can interfere with imaging interpretation because the fluorodeoxyglucose (FDG) tracer is excreted in the urine.¹⁴ The reported sensitivity of PET/CT for the diagnosis of prostate cancer ranges from 17%-65%.^15,16 In a small study of men with metastatic prostate cancer, only 18% of bony metastases were FDG avid, and there was no correlation between FDG avidity and PSA level.¹⁵ Notably, although PET/CT includes CT imaging, this CT is used to map anatomic landmarks and is not separately interpreted by the radiologist. Thus, even if evidence of prostate cancer was apparent on traditional CT, it may be overlooked on PET/CT.

Several important points regarding diagnostic testing are raised by this case. First, PSA-based screening for prostate cancer may be falsely negative, even in the setting of widely metastatic disease. Second, extreme ESR elevation is a marker for serious underlying disease and warrants a thorough diagnostic evaluation. Finally, PET/CT has limited diagnostic utility in evaluating metastatic prostate cancer because of the normal rates of glucose metabolism. Our patient initially presented with jaw pain, yet his progressive physical symptoms and laboratory abnormalities prompted an evaluation which ultimately revealed the jaw-dropping diagnosis of PSA-negative, metastatic prostate cancer.

• ESR levels greater than 100 mm/hr are highly suggestive of certain serious conditions including infection, autoimmune disease, and malignancy.
• PSA-based screening for prostate cancer can result in false negative test results. In one study, 15% of men diagnosed with prostate cancer never had a PSA level greater than 4 ng/mL (ie, the level at which repeat laboratory testing and/or referral to urology for possible prostate biopsy is advisable).
• PET/CT has limited diagnostic utility in evaluating metastatic prostate cancer, because prostate cancer cells typically demonstrate normal glucose metabolism.

Drs Griauzde, Northway, Yentz, and Houchens have nothing to disclose. Dr Saint reports personal fees from ISMIE Mutual Insurance Company during the conduct of the study, as well as personal fees from Jvion and Doximity outside the submitted work.

A 73-year-old man presented to primary care for an annual examination. Four days prior, he noted right-sided sharp jaw pain such that he could not open his mouth nor chew solid food; it radiated from the right mandible to the ipsilateral temple. He also noted bilateral aching hip pain for several years that increased in severity in the prior 2 months. He reported an intentional weight loss of 9 kg over the past year, achieved through dietary modification. He denied fever, chills, and visual disturbance.

Acute onset of unilateral jaw pain that is worsened by chewing is a feature consistent with a temporomandibular disorder (TMD). TMD consists of musculoskeletal and neuromuscular conditions that affect the temporomandibular joints (TMJs), masticatory muscles, and associated tissues. Common symptoms of TMD include facial or ear pain, temporal headache, and TMJ dysfunction or discomfort. In addition to TMD, craniofacial pain has many possible etiologies such as dental pathology, neuralgias, sinus and otologic disorders, headache and migraine disorders, infections, rheumatologic conditions, and neoplasms.

Systemic etiologies for this patient’s symptoms are a consideration given his age and concomitant worsening of chronic hip pain. Rheumatologic conditions such as giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are more common in adults older than 50 years of age and cause headache, jaw claudication, and pelvic girdle pain. Rarely, hematologic malignancies (eg, lymphoma), solid tumor metastases (eg, breast cancer, melanoma), and primary tumors of the head and neck (eg, nasopharyngeal carcinoma) can involve the mandible, TMJ, or parotid gland and result in symptoms of TMD.

Medical history was notable for hypertension and type 2 diabetes mellitus complicated by peripheral neuropathy. He smoked one pack of cigarettes daily for 40 years but quit 15 years prior. He drank 4 ounces of vodka each night.

On examination, temperature was 36.5°C, heart rate 92 beats per minute, blood pressure 127/60 mmHg, respiratory rate 12 breaths per minute, oxygen saturation 98% on ambient air, and weight 118 kg. Extraocular movements were intact, pupils were equal and reactive to light and accommodation, and there were no visual field deficits. Nondilated funduscopic examination revealed normal blood vessels, optic disc, and optic cup-to-disc ratio. Dentition was good with pink gingiva. Bilateral temples were nontender. There was normal range of motion and strength in the shoulders, hips, and lower extremities with no tenderness over the trochanters. Patellar and ankle reflexes were present and symmetric bilaterally. He had no rashes or ecchymoses.

The history of smoking, especially with concomitant alcohol intake, is a risk factor for head and neck cancer, and these malignancies can lead to facial pain. While the normal oral cavity exam argues against localized oral and dental causes of the patient’s symptoms, direct fiberoptic endoscopy should be considered. The neck should be examined for lymphadenopathy. Normal vital signs point away from severe infection. The lack of findings in the head and musculoskeletal regions does not exclude systemic etiologies such as rheumatologic conditions or neoplasm. Complete blood cell count and markers of inflammation including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels should be obtained. Hip and pelvic radiographs should be obtained to evaluate for hip osteoarthritis, fractures, or osseous lesions.

The appointment occurred during evening hours and the patient declined further evaluation until the following morning, at which time laboratory studies revealed normal serum levels of electrolytes, blood urea nitrogen, and creatinine. White blood cell (WBC) count was 6,800/mm³ with an immature granulocyte ratio of 1.8% (normal, 0.0-0.5%), hemoglobin 13.2 g/dL, and platelet count 163,000/mm³. ESR was 118 mm/hr (normal, 0-15 mm/hr) and CRP was 1.5 mg/dL (normal, 0-0.75 mg/dL). Radiographs of the hips and pelvis showed osteoarthritis of the bilateral hip joints and degenerative disc disease of the lower lumbar spine.

Granulocytosis may occur in response to infection, rheumatologic conditions, and hematologic malignancies such as chronic myelogenous leukemia. While infectious etiologies (eg, abscess, osteomyelitis) are the most common cause of an extremely elevated ESR level, this patient does not have other signs or symptoms of infection such as fever or leukocytosis. Therefore, other common causes for an extremely elevated ESR level should be considered, including malignancy (eg, multiple myeloma, lymphoma, metastatic solid tumor) and autoimmune conditions (eg, rheumatoid arthritis, vasculitis). While multiple myeloma is the most common malignant etiology for extremely elevated ESR, the patient lacks signs of this condition such as anemia, elevated creatinine, or osteolytic lesions on radiographic imaging. Osteoarthritis identified on the radiographs may contribute to the patient’s hip pain but would not explain the patient’s jaw pain, weight loss, granulocytosis, and elevated ESR. These findings, taken together with the patient’s age, are most suggestive of GCA with possible coexisting PMR. Temporal artery biopsy should be obtained as it is the gold standard test for diagnosing GCA.

The patient was contacted by telephone that same day with laboratory test results. During the call, he endorsed increased jaw and temple pain. He was advised to proceed to the emergency department (ED) for timely evaluation and treatment.

Because GCA was being considered, ophthalmology performed an ocular examination in the ED, which demonstrated no signs of optic nerve or retinal ischemia. Computed tomography (CT) scan of the head and neck with intravenous contrast revealed no abscess or soft tissue abnormalities. Right temporal artery biopsy was performed.

The normal ocular examination does not exclude GCA, and temporal artery biopsy is appropriate. The mainstay of treatment for GCA is high-dose systemic glucocorticoids, which should not be withheld while awaiting biopsy results since ophthalmic artery inflammation may occur and threaten vision.

While GCA remains the leading diagnosis, malignant etiologies warrant further consideration because they are a common cause of extreme ESR elevation, particularly among older patients. The patient’s cancer screening history should be reviewed. The normal CT scan of the head and neck reduces the likelihood of localized solid tumor etiologies; however, additional CT imaging of the chest, abdomen, and pelvis is warranted to evaluate for metastatic solid tumors or lymphoma.

A 10-day course of prednisone 60 mg daily was prescribed for empiric treatment of GCA. The patient was discharged home with follow-up scheduled in rheumatology and primary care clinics. Pain in the jaw and temple resolved within several days.

Two weeks later, he presented to the rheumatology clinic. He noted 1 week of lower right back pain described as dull, aching, radiating to the lateral right hip, and occurring when transitioning from sitting to standing. He had no leg numbness, weakness, or change in bowel habits. Bladder habits were also unchanged, although he reported chronic urinary frequency and occasional incontinence. He reported further weight loss, this time an unintentional loss of 9 kg. He noted frequent sweating but no fever.

He reported a normal colonoscopy within the prior 5 years. Because these records were not available for review, a fecal immunochemical test was obtained and negative for hemoglobin. He had previously declined prostate cancer screening.

The resolution of jaw and temple pain with prednisone supports the presumed diagnosis of GCA. Up to half of patients with GCA may also have PMR, which can cause aching and stiffness in the arms, hips, and lumbar region, and pain may be abrupt in onset. However, PMR-related pain would be expected to improve rather than develop or worsen in the setting of high-dose glucocorticoid use. Therefore, other causes of acute-onset back pain must be considered.

While localized musculoskeletal etiologies such as lumbar muscle strain, radiculopathy, and vertebral compression fracture are possible, co-occurrence of unintentional weight loss and diaphoresis with elevated inflammatory markers suggests a systemic etiology. A neoplastic process with bony metastasis is possible. The reportedly normal colonoscopy and the negative fecal immunochemical test make colorectal cancer less likely. Inflammatory conditions such as ankylosing spondylitis and rheumatoid arthritis are also possible. Ankylosing spondylitis usually presents at a much younger age, however, and axial skeletal involvement in rheumatoid arthritis often involves the cervical spine and is usually seen after longstanding disease. Additionally, the hallmark of inflammatory back pain is morning stiffness which the patient does not endorse. Nonetheless, additional laboratory testing should include antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibody. Vertebral osteomyelitis remains on the differential diagnosis, and repeat WBC count and inflammatory markers should be assessed. Lumbosacral radiographs should be obtained to rule out fracture.

Physical examination in the rheumatology clinic revealed a temperature of 37.0°C, heart rate 100 beats per minute, blood pressure 146/72 mmHg, respiratory rate 12 breaths per minute, and oxygen saturation 98% on ambient air. Weight was 109 kg. He was pale and diaphoretic. There was diffuse tenderness to palpation of the right-sided lumbar paraspinal muscles. Straight leg raise was negative bilaterally. Patellar reflexes and gait were normal.

Blood chemistries, renal function, and aminotransferase levels were normal. WBC count was 7,100/mm³, hemoglobin 8.0 g/dL, mean corpuscular volume 88.9 fL, platelet count 128,000/mm³, ESR 66 mm/hr, CRP 0.57 mg/dL, alkaline phosphatase 438 IU/L (normal, 30-130 IU/L), and thyroid-stimulating hormone 0.925 mU/L (normal, 0.34-5.60 mU/L). Testing for antinuclear antibodies, rheumatoid factor, and anti-CCP antibody was unremarkable. Prostate-specific antigen (PSA) level was 2.2 ng/mL (normal, 0-4 ng/mL). Urinalysis was unremarkable. Antibodies to hepatitis C and Treponema pallidum were negative. Interferon gamma release assay was negative.

Findings of new onset anemia and thrombocytopenia, in combination with elevated ESR and alkaline phosphatase level, are concerning for disseminated intravascular coagulation (DIC) and microangiopathic hemolytic anemia (MAHA), bone marrow infiltration of a metastatic neoplasm, or ineffective hematopoiesis caused by myelodysplastic syndromes or myelofibrosis.

Laboratory evaluation should include iron studies, lactate dehydrogenase (LDH), haptoglobin, fibrinogen, D-dimer, reticulocyte count, and peripheral blood smear to assess for hemolysis and erythrocyte morphology. Advanced imaging with lumbosacral magnetic resonance imaging (MRI) should be obtained to evaluate for focal etiologies of back pain such as disc herniation, abscess, marrow infiltration, and infarction.

Additional laboratory studies revealed a gamma-glutamyl transferase level of 49 IU/L (normal, 8-56 IU/L), LDH 288 IU/L (normal, 98-192 IU/L), haptoglobin 495 mg/dL (normal, 32-240 mg/dL), fibrinogen >700 mg/dL (normal, 225-550 mg/dL), D-dimer 693 ng/mL (normal, 200-250 ng/mL), serum iron 57 mcg/dL (normal, 33-150 mcg/dL), total iron binding capacity 286 mcg/dL (normal, 250-450 mcg/dL), ferritin 1,012 ng/mL (normal, 17.9-464 ng/mL), and reticulocyte count 2.9% (normal, 0.5-2.5%). Coagulation studies and serum protein electrophoresis were normal. Erythropoietin level was 109 mIU/mL (normal, 4.0-20.0 mIU/mL). Peripheral blood smear demonstrated moderate anemia with 8% nucleated erythrocytes per white blood cell (normal, 0%) and no circulating blasts.

MRI of the thoracolumbar spine and pelvis revealed diffusely abnormal bone marrow signal with multiple superimposed focal and poorly defined enhancing lesions along the lumbar spine marrow, sacrum, and bilateral iliac bones (Figure 1). Positron emission tomography/computed tomography (PET/CT) scan showed no scintigraphic evidence of metabolically active neoplastic, paraneoplastic, or inflammatory disorder.

The elevated haptoglobin, normal coagulation studies, and absence of fragmented erythrocytes on peripheral smear exclude an intravascular hemolytic process. The patient’s lower than expected reticulocyte count for the degree of anemia, elevated erythropoietin, and nucleated erythrocytes constitute a pattern that can be seen with bone marrow infiltration. There are no circulating blasts, making leukemia less likely. A solid organ tumor with bone metastases may cause enhancing lesions on MRI since this form of imaging is more sensitive than radiography for detecting skeletal malignancies. The negative PET/CT, however, does not reveal a primary tumor. Myelofibrosis is an infiltrative myeloproliferative disorder associated with nonspecific laboratory abnormalities, bone pain, weight loss, and night sweats that could cause diffuse MRI bone marrow signal alterations with normal PET/CT findings. However, myelofibrosis would not typically cause a significantly elevated ESR, and thus would be an unlikely cause for this patient’s presentation.

Given the constellation of symptoms, hematologic abnormalities, and bone marrow infiltration on imaging, hematology should be consulted to perform a bone marrow biopsy to assist with definitive diagnosis.

Bone marrow biopsy demonstrated metastatic adenocarcinoma consistent with prostatic origin (Figure 2). Bone scan demonstrated widespread osteoblastic metastases, which included the skull and temporal regions. These lesions were thought to be the cause of the patient’s original presenting symptom of jaw pain.

The patient was started on androgen deprivation therapy, initially with degarelix and subsequently leuprolide shots and abiraterone with prednisone. PSA was 0.08 ng/mL after 3 months of androgen deprivation therapy. His back and hip pain slowly improved.

Prostate cancer is the most common cancer in men with one out of every nine men diagnosed in his lifetime.¹ While most men initially present with localized, curable disease,¹ 4% present with metastatic disease, an incidence that has been increasing since 2004.² Despite available treatments, metastatic prostate cancer has a poor prognosis, with an average overall survival of approximately 5 years.³

Prostate cancer can be challenging to diagnose. Men with prostate cancer are commonly asymptomatic. Rarely, patients may present with hematuria, bony pain caused by metastasis, or obstructive urinary symptoms like hesitancy or incomplete bladder emptying. Our patient presented with jaw pain, which was ultimately attributed to osteoblastic lesions of the skull. Additionally, his history of urinary frequency and incontinence may have been clues to his underlying diagnosis of prostate cancer.

Prostate cancer screening remains highly nuanced and relies on shared decision-making between patients and healthcare providers. Clinical practice guidelines for early detection of prostate cancer recommend individualized PSA-based serologic screening.^4,5 Specifically, the United States Preventive Services Task Force recommends screening men aged 55 to 69 years who desire screening and understand the potential harms associated with a positive test result. These harms may include psychological distress and complications from prostate biopsy (eg, pain or infection) or prostate cancer treatment (eg, erectile, urinary, and/or bowel dysfunction).^4-6 The decision to screen can be guided by individuals’ risk factors including African American race, family history, and older age.

While our patient elected not to undergo routine prostate cancer screening, a PSA level was obtained during his diagnostic evaluation and highlights the limitations of PSA-based screening. A PSA level ≤4.0 ng/mL has 21% sensitivity and 91% specificity for detecting prostate cancer.⁷ PSA levels above 4.0 ng/mL warrant repeat testing and, if persistently elevated, referral to urology for possible prostate biopsy. PSA levels often correlate with burden of disease, and patients with PSA levels >20 ng/mL are referred for CT imaging to evaluate for metastatic disease.⁸ PSA’s poor sensitivity was underscored in a study by Thompson et al who evaluated the incidence of prostate cancer in men participating in the Prostate Cancer Prevention Trial with PSA levels of <4 ng/mL.⁹ In this study, 15% of men diagnosed with prostate cancer never had a PSA level >4 ng/mL.⁹ While most of the cancers in this study were low grade and may have been clinically insignificant, 15% demonstrated histologic signs of at least intermediate-risk disease. Our patient’s PSA level of 2.2 ng/mL was below the threshold that triggers additional evaluation even though he had widely metastatic prostate cancer.

Our patient’s severe jaw and temple pain, weight loss, and progressive hip pain were concerning for GCA. This vasculitis of large- and medium-sized arteries predominantly affects older adults with greatest incidence among those 70 years of age and older.¹⁰ Symptoms occur because of cranial artery inflammation and may include headache, visual disturbance, erythema or tenderness of the temporal artery, and jaw claudication. Extracranial inflammation may affect the thoracic aorta and its branches and rarely the abdominal aorta and lower limb arteries. Pelvic girdle pain more typically results from associated PMR. Patients may also note systemic symptoms such as fever, weight loss, and fatigue.

Prompt diagnostic testing is important when considering GCA. Most patients with GCA have ESR levels greater than 40 mm/hr.¹¹ ESR is a laboratory test that measures the vertical distance erythrocytes travel in a column of blood over 1 hour; in the setting of inflammation, cells form clumps and travel more quickly than individual cells, resulting in a higher value. While moderate elevations in ESR may occur without an identifiable cause, extreme ESR levels—those above 100 mm/hr, as observed in our patient—are highly suggestive of certain serious conditions, including infection, malignancy, and autoimmune disease such as GCA.^12,13 Temporal artery biopsy is the gold standard test to diagnose GCA. However, because of noncontiguous inflammation of the temporal artery, biopsies may be falsely negative. Thus, sampling of the contralateral temporal artery may be warranted if suspicion remains high.

As was the case for our patient, PET/CT is not reliable for diagnosing prostate cancer. In contrast to other malignancies (eg, lymphoma, lung cancer), prostate cancer typically does not display increased glucose metabolism. Moreover, the close proximity of the bladder and prostate can interfere with imaging interpretation because the fluorodeoxyglucose (FDG) tracer is excreted in the urine.¹⁴ The reported sensitivity of PET/CT for the diagnosis of prostate cancer ranges from 17%-65%.^15,16 In a small study of men with metastatic prostate cancer, only 18% of bony metastases were FDG avid, and there was no correlation between FDG avidity and PSA level.¹⁵ Notably, although PET/CT includes CT imaging, this CT is used to map anatomic landmarks and is not separately interpreted by the radiologist. Thus, even if evidence of prostate cancer was apparent on traditional CT, it may be overlooked on PET/CT.

Several important points regarding diagnostic testing are raised by this case. First, PSA-based screening for prostate cancer may be falsely negative, even in the setting of widely metastatic disease. Second, extreme ESR elevation is a marker for serious underlying disease and warrants a thorough diagnostic evaluation. Finally, PET/CT has limited diagnostic utility in evaluating metastatic prostate cancer because of the normal rates of glucose metabolism. Our patient initially presented with jaw pain, yet his progressive physical symptoms and laboratory abnormalities prompted an evaluation which ultimately revealed the jaw-dropping diagnosis of PSA-negative, metastatic prostate cancer.

• ESR levels greater than 100 mm/hr are highly suggestive of certain serious conditions including infection, autoimmune disease, and malignancy.
• PSA-based screening for prostate cancer can result in false negative test results. In one study, 15% of men diagnosed with prostate cancer never had a PSA level greater than 4 ng/mL (ie, the level at which repeat laboratory testing and/or referral to urology for possible prostate biopsy is advisable).
• PET/CT has limited diagnostic utility in evaluating metastatic prostate cancer, because prostate cancer cells typically demonstrate normal glucose metabolism.

Drs Griauzde, Northway, Yentz, and Houchens have nothing to disclose. Dr Saint reports personal fees from ISMIE Mutual Insurance Company during the conduct of the study, as well as personal fees from Jvion and Doximity outside the submitted work.

A 73-year-old man presented to primary care for an annual examination. Four days prior, he noted right-sided sharp jaw pain such that he could not open his mouth nor chew solid food; it radiated from the right mandible to the ipsilateral temple. He also noted bilateral aching hip pain for several years that increased in severity in the prior 2 months. He reported an intentional weight loss of 9 kg over the past year, achieved through dietary modification. He denied fever, chills, and visual disturbance.

Acute onset of unilateral jaw pain that is worsened by chewing is a feature consistent with a temporomandibular disorder (TMD). TMD consists of musculoskeletal and neuromuscular conditions that affect the temporomandibular joints (TMJs), masticatory muscles, and associated tissues. Common symptoms of TMD include facial or ear pain, temporal headache, and TMJ dysfunction or discomfort. In addition to TMD, craniofacial pain has many possible etiologies such as dental pathology, neuralgias, sinus and otologic disorders, headache and migraine disorders, infections, rheumatologic conditions, and neoplasms.

Systemic etiologies for this patient’s symptoms are a consideration given his age and concomitant worsening of chronic hip pain. Rheumatologic conditions such as giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are more common in adults older than 50 years of age and cause headache, jaw claudication, and pelvic girdle pain. Rarely, hematologic malignancies (eg, lymphoma), solid tumor metastases (eg, breast cancer, melanoma), and primary tumors of the head and neck (eg, nasopharyngeal carcinoma) can involve the mandible, TMJ, or parotid gland and result in symptoms of TMD.

Medical history was notable for hypertension and type 2 diabetes mellitus complicated by peripheral neuropathy. He smoked one pack of cigarettes daily for 40 years but quit 15 years prior. He drank 4 ounces of vodka each night.

On examination, temperature was 36.5°C, heart rate 92 beats per minute, blood pressure 127/60 mmHg, respiratory rate 12 breaths per minute, oxygen saturation 98% on ambient air, and weight 118 kg. Extraocular movements were intact, pupils were equal and reactive to light and accommodation, and there were no visual field deficits. Nondilated funduscopic examination revealed normal blood vessels, optic disc, and optic cup-to-disc ratio. Dentition was good with pink gingiva. Bilateral temples were nontender. There was normal range of motion and strength in the shoulders, hips, and lower extremities with no tenderness over the trochanters. Patellar and ankle reflexes were present and symmetric bilaterally. He had no rashes or ecchymoses.

The history of smoking, especially with concomitant alcohol intake, is a risk factor for head and neck cancer, and these malignancies can lead to facial pain. While the normal oral cavity exam argues against localized oral and dental causes of the patient’s symptoms, direct fiberoptic endoscopy should be considered. The neck should be examined for lymphadenopathy. Normal vital signs point away from severe infection. The lack of findings in the head and musculoskeletal regions does not exclude systemic etiologies such as rheumatologic conditions or neoplasm. Complete blood cell count and markers of inflammation including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels should be obtained. Hip and pelvic radiographs should be obtained to evaluate for hip osteoarthritis, fractures, or osseous lesions.

The appointment occurred during evening hours and the patient declined further evaluation until the following morning, at which time laboratory studies revealed normal serum levels of electrolytes, blood urea nitrogen, and creatinine. White blood cell (WBC) count was 6,800/mm³ with an immature granulocyte ratio of 1.8% (normal, 0.0-0.5%), hemoglobin 13.2 g/dL, and platelet count 163,000/mm³. ESR was 118 mm/hr (normal, 0-15 mm/hr) and CRP was 1.5 mg/dL (normal, 0-0.75 mg/dL). Radiographs of the hips and pelvis showed osteoarthritis of the bilateral hip joints and degenerative disc disease of the lower lumbar spine.

Granulocytosis may occur in response to infection, rheumatologic conditions, and hematologic malignancies such as chronic myelogenous leukemia. While infectious etiologies (eg, abscess, osteomyelitis) are the most common cause of an extremely elevated ESR level, this patient does not have other signs or symptoms of infection such as fever or leukocytosis. Therefore, other common causes for an extremely elevated ESR level should be considered, including malignancy (eg, multiple myeloma, lymphoma, metastatic solid tumor) and autoimmune conditions (eg, rheumatoid arthritis, vasculitis). While multiple myeloma is the most common malignant etiology for extremely elevated ESR, the patient lacks signs of this condition such as anemia, elevated creatinine, or osteolytic lesions on radiographic imaging. Osteoarthritis identified on the radiographs may contribute to the patient’s hip pain but would not explain the patient’s jaw pain, weight loss, granulocytosis, and elevated ESR. These findings, taken together with the patient’s age, are most suggestive of GCA with possible coexisting PMR. Temporal artery biopsy should be obtained as it is the gold standard test for diagnosing GCA.

The patient was contacted by telephone that same day with laboratory test results. During the call, he endorsed increased jaw and temple pain. He was advised to proceed to the emergency department (ED) for timely evaluation and treatment.

Because GCA was being considered, ophthalmology performed an ocular examination in the ED, which demonstrated no signs of optic nerve or retinal ischemia. Computed tomography (CT) scan of the head and neck with intravenous contrast revealed no abscess or soft tissue abnormalities. Right temporal artery biopsy was performed.

The normal ocular examination does not exclude GCA, and temporal artery biopsy is appropriate. The mainstay of treatment for GCA is high-dose systemic glucocorticoids, which should not be withheld while awaiting biopsy results since ophthalmic artery inflammation may occur and threaten vision.

While GCA remains the leading diagnosis, malignant etiologies warrant further consideration because they are a common cause of extreme ESR elevation, particularly among older patients. The patient’s cancer screening history should be reviewed. The normal CT scan of the head and neck reduces the likelihood of localized solid tumor etiologies; however, additional CT imaging of the chest, abdomen, and pelvis is warranted to evaluate for metastatic solid tumors or lymphoma.

A 10-day course of prednisone 60 mg daily was prescribed for empiric treatment of GCA. The patient was discharged home with follow-up scheduled in rheumatology and primary care clinics. Pain in the jaw and temple resolved within several days.

Two weeks later, he presented to the rheumatology clinic. He noted 1 week of lower right back pain described as dull, aching, radiating to the lateral right hip, and occurring when transitioning from sitting to standing. He had no leg numbness, weakness, or change in bowel habits. Bladder habits were also unchanged, although he reported chronic urinary frequency and occasional incontinence. He reported further weight loss, this time an unintentional loss of 9 kg. He noted frequent sweating but no fever.

He reported a normal colonoscopy within the prior 5 years. Because these records were not available for review, a fecal immunochemical test was obtained and negative for hemoglobin. He had previously declined prostate cancer screening.

The resolution of jaw and temple pain with prednisone supports the presumed diagnosis of GCA. Up to half of patients with GCA may also have PMR, which can cause aching and stiffness in the arms, hips, and lumbar region, and pain may be abrupt in onset. However, PMR-related pain would be expected to improve rather than develop or worsen in the setting of high-dose glucocorticoid use. Therefore, other causes of acute-onset back pain must be considered.

While localized musculoskeletal etiologies such as lumbar muscle strain, radiculopathy, and vertebral compression fracture are possible, co-occurrence of unintentional weight loss and diaphoresis with elevated inflammatory markers suggests a systemic etiology. A neoplastic process with bony metastasis is possible. The reportedly normal colonoscopy and the negative fecal immunochemical test make colorectal cancer less likely. Inflammatory conditions such as ankylosing spondylitis and rheumatoid arthritis are also possible. Ankylosing spondylitis usually presents at a much younger age, however, and axial skeletal involvement in rheumatoid arthritis often involves the cervical spine and is usually seen after longstanding disease. Additionally, the hallmark of inflammatory back pain is morning stiffness which the patient does not endorse. Nonetheless, additional laboratory testing should include antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibody. Vertebral osteomyelitis remains on the differential diagnosis, and repeat WBC count and inflammatory markers should be assessed. Lumbosacral radiographs should be obtained to rule out fracture.

Physical examination in the rheumatology clinic revealed a temperature of 37.0°C, heart rate 100 beats per minute, blood pressure 146/72 mmHg, respiratory rate 12 breaths per minute, and oxygen saturation 98% on ambient air. Weight was 109 kg. He was pale and diaphoretic. There was diffuse tenderness to palpation of the right-sided lumbar paraspinal muscles. Straight leg raise was negative bilaterally. Patellar reflexes and gait were normal.

Blood chemistries, renal function, and aminotransferase levels were normal. WBC count was 7,100/mm³, hemoglobin 8.0 g/dL, mean corpuscular volume 88.9 fL, platelet count 128,000/mm³, ESR 66 mm/hr, CRP 0.57 mg/dL, alkaline phosphatase 438 IU/L (normal, 30-130 IU/L), and thyroid-stimulating hormone 0.925 mU/L (normal, 0.34-5.60 mU/L). Testing for antinuclear antibodies, rheumatoid factor, and anti-CCP antibody was unremarkable. Prostate-specific antigen (PSA) level was 2.2 ng/mL (normal, 0-4 ng/mL). Urinalysis was unremarkable. Antibodies to hepatitis C and Treponema pallidum were negative. Interferon gamma release assay was negative.

Findings of new onset anemia and thrombocytopenia, in combination with elevated ESR and alkaline phosphatase level, are concerning for disseminated intravascular coagulation (DIC) and microangiopathic hemolytic anemia (MAHA), bone marrow infiltration of a metastatic neoplasm, or ineffective hematopoiesis caused by myelodysplastic syndromes or myelofibrosis.

Laboratory evaluation should include iron studies, lactate dehydrogenase (LDH), haptoglobin, fibrinogen, D-dimer, reticulocyte count, and peripheral blood smear to assess for hemolysis and erythrocyte morphology. Advanced imaging with lumbosacral magnetic resonance imaging (MRI) should be obtained to evaluate for focal etiologies of back pain such as disc herniation, abscess, marrow infiltration, and infarction.

Additional laboratory studies revealed a gamma-glutamyl transferase level of 49 IU/L (normal, 8-56 IU/L), LDH 288 IU/L (normal, 98-192 IU/L), haptoglobin 495 mg/dL (normal, 32-240 mg/dL), fibrinogen >700 mg/dL (normal, 225-550 mg/dL), D-dimer 693 ng/mL (normal, 200-250 ng/mL), serum iron 57 mcg/dL (normal, 33-150 mcg/dL), total iron binding capacity 286 mcg/dL (normal, 250-450 mcg/dL), ferritin 1,012 ng/mL (normal, 17.9-464 ng/mL), and reticulocyte count 2.9% (normal, 0.5-2.5%). Coagulation studies and serum protein electrophoresis were normal. Erythropoietin level was 109 mIU/mL (normal, 4.0-20.0 mIU/mL). Peripheral blood smear demonstrated moderate anemia with 8% nucleated erythrocytes per white blood cell (normal, 0%) and no circulating blasts.

MRI of the thoracolumbar spine and pelvis revealed diffusely abnormal bone marrow signal with multiple superimposed focal and poorly defined enhancing lesions along the lumbar spine marrow, sacrum, and bilateral iliac bones (Figure 1). Positron emission tomography/computed tomography (PET/CT) scan showed no scintigraphic evidence of metabolically active neoplastic, paraneoplastic, or inflammatory disorder.

The elevated haptoglobin, normal coagulation studies, and absence of fragmented erythrocytes on peripheral smear exclude an intravascular hemolytic process. The patient’s lower than expected reticulocyte count for the degree of anemia, elevated erythropoietin, and nucleated erythrocytes constitute a pattern that can be seen with bone marrow infiltration. There are no circulating blasts, making leukemia less likely. A solid organ tumor with bone metastases may cause enhancing lesions on MRI since this form of imaging is more sensitive than radiography for detecting skeletal malignancies. The negative PET/CT, however, does not reveal a primary tumor. Myelofibrosis is an infiltrative myeloproliferative disorder associated with nonspecific laboratory abnormalities, bone pain, weight loss, and night sweats that could cause diffuse MRI bone marrow signal alterations with normal PET/CT findings. However, myelofibrosis would not typically cause a significantly elevated ESR, and thus would be an unlikely cause for this patient’s presentation.

Given the constellation of symptoms, hematologic abnormalities, and bone marrow infiltration on imaging, hematology should be consulted to perform a bone marrow biopsy to assist with definitive diagnosis.

Bone marrow biopsy demonstrated metastatic adenocarcinoma consistent with prostatic origin (Figure 2). Bone scan demonstrated widespread osteoblastic metastases, which included the skull and temporal regions. These lesions were thought to be the cause of the patient’s original presenting symptom of jaw pain.

The patient was started on androgen deprivation therapy, initially with degarelix and subsequently leuprolide shots and abiraterone with prednisone. PSA was 0.08 ng/mL after 3 months of androgen deprivation therapy. His back and hip pain slowly improved.

Prostate cancer is the most common cancer in men with one out of every nine men diagnosed in his lifetime.¹ While most men initially present with localized, curable disease,¹ 4% present with metastatic disease, an incidence that has been increasing since 2004.² Despite available treatments, metastatic prostate cancer has a poor prognosis, with an average overall survival of approximately 5 years.³

Prostate cancer can be challenging to diagnose. Men with prostate cancer are commonly asymptomatic. Rarely, patients may present with hematuria, bony pain caused by metastasis, or obstructive urinary symptoms like hesitancy or incomplete bladder emptying. Our patient presented with jaw pain, which was ultimately attributed to osteoblastic lesions of the skull. Additionally, his history of urinary frequency and incontinence may have been clues to his underlying diagnosis of prostate cancer.

Prostate cancer screening remains highly nuanced and relies on shared decision-making between patients and healthcare providers. Clinical practice guidelines for early detection of prostate cancer recommend individualized PSA-based serologic screening.^4,5 Specifically, the United States Preventive Services Task Force recommends screening men aged 55 to 69 years who desire screening and understand the potential harms associated with a positive test result. These harms may include psychological distress and complications from prostate biopsy (eg, pain or infection) or prostate cancer treatment (eg, erectile, urinary, and/or bowel dysfunction).^4-6 The decision to screen can be guided by individuals’ risk factors including African American race, family history, and older age.

While our patient elected not to undergo routine prostate cancer screening, a PSA level was obtained during his diagnostic evaluation and highlights the limitations of PSA-based screening. A PSA level ≤4.0 ng/mL has 21% sensitivity and 91% specificity for detecting prostate cancer.⁷ PSA levels above 4.0 ng/mL warrant repeat testing and, if persistently elevated, referral to urology for possible prostate biopsy. PSA levels often correlate with burden of disease, and patients with PSA levels >20 ng/mL are referred for CT imaging to evaluate for metastatic disease.⁸ PSA’s poor sensitivity was underscored in a study by Thompson et al who evaluated the incidence of prostate cancer in men participating in the Prostate Cancer Prevention Trial with PSA levels of <4 ng/mL.⁹ In this study, 15% of men diagnosed with prostate cancer never had a PSA level >4 ng/mL.⁹ While most of the cancers in this study were low grade and may have been clinically insignificant, 15% demonstrated histologic signs of at least intermediate-risk disease. Our patient’s PSA level of 2.2 ng/mL was below the threshold that triggers additional evaluation even though he had widely metastatic prostate cancer.

Our patient’s severe jaw and temple pain, weight loss, and progressive hip pain were concerning for GCA. This vasculitis of large- and medium-sized arteries predominantly affects older adults with greatest incidence among those 70 years of age and older.¹⁰ Symptoms occur because of cranial artery inflammation and may include headache, visual disturbance, erythema or tenderness of the temporal artery, and jaw claudication. Extracranial inflammation may affect the thoracic aorta and its branches and rarely the abdominal aorta and lower limb arteries. Pelvic girdle pain more typically results from associated PMR. Patients may also note systemic symptoms such as fever, weight loss, and fatigue.

Prompt diagnostic testing is important when considering GCA. Most patients with GCA have ESR levels greater than 40 mm/hr.¹¹ ESR is a laboratory test that measures the vertical distance erythrocytes travel in a column of blood over 1 hour; in the setting of inflammation, cells form clumps and travel more quickly than individual cells, resulting in a higher value. While moderate elevations in ESR may occur without an identifiable cause, extreme ESR levels—those above 100 mm/hr, as observed in our patient—are highly suggestive of certain serious conditions, including infection, malignancy, and autoimmune disease such as GCA.^12,13 Temporal artery biopsy is the gold standard test to diagnose GCA. However, because of noncontiguous inflammation of the temporal artery, biopsies may be falsely negative. Thus, sampling of the contralateral temporal artery may be warranted if suspicion remains high.

As was the case for our patient, PET/CT is not reliable for diagnosing prostate cancer. In contrast to other malignancies (eg, lymphoma, lung cancer), prostate cancer typically does not display increased glucose metabolism. Moreover, the close proximity of the bladder and prostate can interfere with imaging interpretation because the fluorodeoxyglucose (FDG) tracer is excreted in the urine.¹⁴ The reported sensitivity of PET/CT for the diagnosis of prostate cancer ranges from 17%-65%.^15,16 In a small study of men with metastatic prostate cancer, only 18% of bony metastases were FDG avid, and there was no correlation between FDG avidity and PSA level.¹⁵ Notably, although PET/CT includes CT imaging, this CT is used to map anatomic landmarks and is not separately interpreted by the radiologist. Thus, even if evidence of prostate cancer was apparent on traditional CT, it may be overlooked on PET/CT.

Several important points regarding diagnostic testing are raised by this case. First, PSA-based screening for prostate cancer may be falsely negative, even in the setting of widely metastatic disease. Second, extreme ESR elevation is a marker for serious underlying disease and warrants a thorough diagnostic evaluation. Finally, PET/CT has limited diagnostic utility in evaluating metastatic prostate cancer because of the normal rates of glucose metabolism. Our patient initially presented with jaw pain, yet his progressive physical symptoms and laboratory abnormalities prompted an evaluation which ultimately revealed the jaw-dropping diagnosis of PSA-negative, metastatic prostate cancer.

• ESR levels greater than 100 mm/hr are highly suggestive of certain serious conditions including infection, autoimmune disease, and malignancy.
• PSA-based screening for prostate cancer can result in false negative test results. In one study, 15% of men diagnosed with prostate cancer never had a PSA level greater than 4 ng/mL (ie, the level at which repeat laboratory testing and/or referral to urology for possible prostate biopsy is advisable).
• PET/CT has limited diagnostic utility in evaluating metastatic prostate cancer, because prostate cancer cells typically demonstrate normal glucose metabolism.

Drs Griauzde, Northway, Yentz, and Houchens have nothing to disclose. Dr Saint reports personal fees from ISMIE Mutual Insurance Company during the conduct of the study, as well as personal fees from Jvion and Doximity outside the submitted work.

A school curriculum–based intervention aimed at reducing the stigma of mental illness was associated with a nearly fourfold increase in the likelihood of youth with significant symptoms seeking treatment.

Ridofranz/Getty Images

Writing in Pediatrics, researchers reported the outcome of a 2-year, longitudinal, cluster-randomized trial involving 416 students in sixth-grade classes in 14 schools across Texas.

The intervention was a school-based curriculum program called Eliminating the Stigma of Differences (ESD); a 3-hour, three-module curriculum program delivered over 1 week, which contained a mix of teaching, group discussion, and homework exercises.

One module explored the idea of difference; the definition, causes and consequences of stigma; ways to end stigma; and the description, causes and treatments of mental illness as well as the barriers to seeking help. The other two modules explored specific mental illnesses in more detail but with content designed to stimulate empathy.

The study compared this with two other interventions – in-class presentations and discussions led by two young adults with a history of mental illness; or exposure to anti-stigma printed materials – and a no-intervention control.

The study found that involvement with the curriculum program was associated with a significant and sustained increase in knowledge of and attitudes to mental illness compared with the control and other interventions, and with significant decreases in social distance, which measures the extent to which children are unwilling to interact with someone who is identified as having a mental illness. This association was seen even after the researchers controlled for other factors such as a participants’ knowledge of or attitudes toward mental illness before the intervention, their age, sex, race or ethnicity, or their parents’ educational level.

“Our study, in combination with other studies, suggests strongly that youth can be positively influenced at a relatively young age, fostering changes in mental health attitudes and behaviors that last, as our study has shown, for at least 2 years,” wrote Bruce G. Link, PhD, of the School of Public Policy at the University of California, Riverside, and coauthors.

The study also found that among youth who were experiencing a high level of symptoms of mental illness, the curriculum-based intervention was associated with nearly fourfold higher odds of seeking treatment (odd ratio 3.9, P < .05), after adjustment for similar covariates.

The authors looked separately at whether this self-reported treatment-seeking was the first time that students had sought treatment, a continuation of treatment seeking, or a return to it. All three showed similar odds ratios but small sample sizes meant they did not reach statistical significance.

“We do know that negative attitudes toward mental illnesses and the exceptionally large percentage of people who experience but do not receive treatment for such illnesses are problems that have been with us for a long time,” Dr. Link and associates said. “Interventions such as ESD represent a partial but positive response to this public mental health challenge.”

The intervention didn’t lead to a significant increase in treatment-seeking behavior among students with low levels of mental illness symptoms.

There were no significant differences in the effectiveness of the intervention across race or ethnicity, sex, education level of caregivers, or the baseline attitudes toward mental illness. The only exception was seen with Latino youth, where the intervention was not associated with a decrease in social distancing.

Contact intervention, in which two young people with a history of mental illness came to talk to classes and participate in discussions, was not associated with any significant changes in attitudes.

“A potential explanation is that contact is not as effective in youth, a possibility that is supported by a meta-analysis showing diminished effects of contact compared with educational interventions in adolescents,” Dr. Link and associates said.

In an accompanying editorial, Nathaniel Beers, MD, of Children’s National Hospital in Washington, and Dr. Shashank V. Joshi, MD, of Stanford (Calif.) University, wrote that more than one-fifth of children and youth in the United States are diagnosed with behavioral health needs before they reach the age of 18, but the perception of stigma can make families reluctant to access treatment.

“Previous research has highlighted the importance of stigma reduction in school-based settings as a crucial component in changing the social norms about seeking help among diverse youth populations,” they said. Reducing stigma also can reduce detrimental outcomes from social isolation and bullying.

Dr. Beers and Dr. Joshi noted that school-based interventions can have a substantial and lasting effect, with the benefit of influencing parents and staff in addition to students.

“Combined with screening and improved access to school-based mental health services, this curriculum could add a critical component to addressing the mental health needs of children and youth in the United States,” they concluded.

The study was supported by the National Institute of Mental Health and National Institutes of Health. The authors said they had no relevant financial disclosures. Dr. Beers and Dr. Joshi received no external funding, and they said they had no relevant financial disclosures.

SOURCES: Link B. et al. Pediatrics 2020, May 20. doi: 10.1542/peds.2019-0780; Beers N and Joshi SV. Pediatrics. 2020, May 20. doi: 10.1542/peds.2020-0127.

A school curriculum–based intervention aimed at reducing the stigma of mental illness was associated with a nearly fourfold increase in the likelihood of youth with significant symptoms seeking treatment.

Ridofranz/Getty Images

Writing in Pediatrics, researchers reported the outcome of a 2-year, longitudinal, cluster-randomized trial involving 416 students in sixth-grade classes in 14 schools across Texas.

The intervention was a school-based curriculum program called Eliminating the Stigma of Differences (ESD); a 3-hour, three-module curriculum program delivered over 1 week, which contained a mix of teaching, group discussion, and homework exercises.

One module explored the idea of difference; the definition, causes and consequences of stigma; ways to end stigma; and the description, causes and treatments of mental illness as well as the barriers to seeking help. The other two modules explored specific mental illnesses in more detail but with content designed to stimulate empathy.

The study compared this with two other interventions – in-class presentations and discussions led by two young adults with a history of mental illness; or exposure to anti-stigma printed materials – and a no-intervention control.

The study found that involvement with the curriculum program was associated with a significant and sustained increase in knowledge of and attitudes to mental illness compared with the control and other interventions, and with significant decreases in social distance, which measures the extent to which children are unwilling to interact with someone who is identified as having a mental illness. This association was seen even after the researchers controlled for other factors such as a participants’ knowledge of or attitudes toward mental illness before the intervention, their age, sex, race or ethnicity, or their parents’ educational level.

“Our study, in combination with other studies, suggests strongly that youth can be positively influenced at a relatively young age, fostering changes in mental health attitudes and behaviors that last, as our study has shown, for at least 2 years,” wrote Bruce G. Link, PhD, of the School of Public Policy at the University of California, Riverside, and coauthors.

The study also found that among youth who were experiencing a high level of symptoms of mental illness, the curriculum-based intervention was associated with nearly fourfold higher odds of seeking treatment (odd ratio 3.9, P < .05), after adjustment for similar covariates.

The authors looked separately at whether this self-reported treatment-seeking was the first time that students had sought treatment, a continuation of treatment seeking, or a return to it. All three showed similar odds ratios but small sample sizes meant they did not reach statistical significance.

“We do know that negative attitudes toward mental illnesses and the exceptionally large percentage of people who experience but do not receive treatment for such illnesses are problems that have been with us for a long time,” Dr. Link and associates said. “Interventions such as ESD represent a partial but positive response to this public mental health challenge.”

The intervention didn’t lead to a significant increase in treatment-seeking behavior among students with low levels of mental illness symptoms.

There were no significant differences in the effectiveness of the intervention across race or ethnicity, sex, education level of caregivers, or the baseline attitudes toward mental illness. The only exception was seen with Latino youth, where the intervention was not associated with a decrease in social distancing.

Contact intervention, in which two young people with a history of mental illness came to talk to classes and participate in discussions, was not associated with any significant changes in attitudes.

“A potential explanation is that contact is not as effective in youth, a possibility that is supported by a meta-analysis showing diminished effects of contact compared with educational interventions in adolescents,” Dr. Link and associates said.

In an accompanying editorial, Nathaniel Beers, MD, of Children’s National Hospital in Washington, and Dr. Shashank V. Joshi, MD, of Stanford (Calif.) University, wrote that more than one-fifth of children and youth in the United States are diagnosed with behavioral health needs before they reach the age of 18, but the perception of stigma can make families reluctant to access treatment.

“Previous research has highlighted the importance of stigma reduction in school-based settings as a crucial component in changing the social norms about seeking help among diverse youth populations,” they said. Reducing stigma also can reduce detrimental outcomes from social isolation and bullying.

Dr. Beers and Dr. Joshi noted that school-based interventions can have a substantial and lasting effect, with the benefit of influencing parents and staff in addition to students.

“Combined with screening and improved access to school-based mental health services, this curriculum could add a critical component to addressing the mental health needs of children and youth in the United States,” they concluded.

The study was supported by the National Institute of Mental Health and National Institutes of Health. The authors said they had no relevant financial disclosures. Dr. Beers and Dr. Joshi received no external funding, and they said they had no relevant financial disclosures.

SOURCES: Link B. et al. Pediatrics 2020, May 20. doi: 10.1542/peds.2019-0780; Beers N and Joshi SV. Pediatrics. 2020, May 20. doi: 10.1542/peds.2020-0127.

A school curriculum–based intervention aimed at reducing the stigma of mental illness was associated with a nearly fourfold increase in the likelihood of youth with significant symptoms seeking treatment.

Ridofranz/Getty Images

Writing in Pediatrics, researchers reported the outcome of a 2-year, longitudinal, cluster-randomized trial involving 416 students in sixth-grade classes in 14 schools across Texas.

The intervention was a school-based curriculum program called Eliminating the Stigma of Differences (ESD); a 3-hour, three-module curriculum program delivered over 1 week, which contained a mix of teaching, group discussion, and homework exercises.

One module explored the idea of difference; the definition, causes and consequences of stigma; ways to end stigma; and the description, causes and treatments of mental illness as well as the barriers to seeking help. The other two modules explored specific mental illnesses in more detail but with content designed to stimulate empathy.

The study compared this with two other interventions – in-class presentations and discussions led by two young adults with a history of mental illness; or exposure to anti-stigma printed materials – and a no-intervention control.

The study found that involvement with the curriculum program was associated with a significant and sustained increase in knowledge of and attitudes to mental illness compared with the control and other interventions, and with significant decreases in social distance, which measures the extent to which children are unwilling to interact with someone who is identified as having a mental illness. This association was seen even after the researchers controlled for other factors such as a participants’ knowledge of or attitudes toward mental illness before the intervention, their age, sex, race or ethnicity, or their parents’ educational level.

“Our study, in combination with other studies, suggests strongly that youth can be positively influenced at a relatively young age, fostering changes in mental health attitudes and behaviors that last, as our study has shown, for at least 2 years,” wrote Bruce G. Link, PhD, of the School of Public Policy at the University of California, Riverside, and coauthors.

The study also found that among youth who were experiencing a high level of symptoms of mental illness, the curriculum-based intervention was associated with nearly fourfold higher odds of seeking treatment (odd ratio 3.9, P < .05), after adjustment for similar covariates.

The authors looked separately at whether this self-reported treatment-seeking was the first time that students had sought treatment, a continuation of treatment seeking, or a return to it. All three showed similar odds ratios but small sample sizes meant they did not reach statistical significance.

“We do know that negative attitudes toward mental illnesses and the exceptionally large percentage of people who experience but do not receive treatment for such illnesses are problems that have been with us for a long time,” Dr. Link and associates said. “Interventions such as ESD represent a partial but positive response to this public mental health challenge.”

The intervention didn’t lead to a significant increase in treatment-seeking behavior among students with low levels of mental illness symptoms.

There were no significant differences in the effectiveness of the intervention across race or ethnicity, sex, education level of caregivers, or the baseline attitudes toward mental illness. The only exception was seen with Latino youth, where the intervention was not associated with a decrease in social distancing.

Contact intervention, in which two young people with a history of mental illness came to talk to classes and participate in discussions, was not associated with any significant changes in attitudes.

“A potential explanation is that contact is not as effective in youth, a possibility that is supported by a meta-analysis showing diminished effects of contact compared with educational interventions in adolescents,” Dr. Link and associates said.

In an accompanying editorial, Nathaniel Beers, MD, of Children’s National Hospital in Washington, and Dr. Shashank V. Joshi, MD, of Stanford (Calif.) University, wrote that more than one-fifth of children and youth in the United States are diagnosed with behavioral health needs before they reach the age of 18, but the perception of stigma can make families reluctant to access treatment.

“Previous research has highlighted the importance of stigma reduction in school-based settings as a crucial component in changing the social norms about seeking help among diverse youth populations,” they said. Reducing stigma also can reduce detrimental outcomes from social isolation and bullying.

Dr. Beers and Dr. Joshi noted that school-based interventions can have a substantial and lasting effect, with the benefit of influencing parents and staff in addition to students.

“Combined with screening and improved access to school-based mental health services, this curriculum could add a critical component to addressing the mental health needs of children and youth in the United States,” they concluded.

The study was supported by the National Institute of Mental Health and National Institutes of Health. The authors said they had no relevant financial disclosures. Dr. Beers and Dr. Joshi received no external funding, and they said they had no relevant financial disclosures.

SOURCES: Link B. et al. Pediatrics 2020, May 20. doi: 10.1542/peds.2019-0780; Beers N and Joshi SV. Pediatrics. 2020, May 20. doi: 10.1542/peds.2020-0127.

On April 3, the Centers for Disease Control and Prevention issued an advisory that the general public wear cloth face masks when outside, particularly those residing in areas with significant severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) community transmission.¹ Recent research reveals several factors related to the nature of the virus as well as the epidemiologic spread of the illness that may have led to this decision.

However, controversy still prevails whether this recommendation will alleviate or aggravate disease progression. With many hospitals across America lacking sufficient personal protective equipment (PPE) and scrambling for supplies, universal masking may create more chaos, especially with certain states imposing monetary fines on individuals spotted outdoors without a mask. With new information being discovered each day about COVID-19, it is more imperative than ever to update existing strategies and formulate more effective methods to flatten the curve.
 

Airborne vs. droplet transmission

According to a scientific brief released by the World Health Organization, there have been studies with mixed evidence and opinions regarding the presence of COVID-19 ribonucleic acid (RNA) in air samples.² In medRxiv, Santarpia et al., from the University of Nebraska Medical Center, Omaha, detected viral RNA in samples taken from beneath a patient’s bed and from a window ledge, both areas in which neither the patient nor health care personnel had any direct contact. They also found that 66.7% of air samples taken from a hospital hallway carried virus-containing particles.³ It is worth noting that certain aerosol-generating procedures (AGP) may increase the likelihood of airborne dissemination. Whether airborne transmission is a major mode of COVID-19 spread in the community and routine clinical settings (with no aerosol-generating procedures) is still a debatable question without a definitive answer.

We should consider the epidemiology of COVID-19 thus far in the pandemic to determine if transmission patterns are more consistent with that of other common respiratory viral pathogens or more consistent with that of the agents we classically consider to be transmitted by the airborne route (measles, varicella zoster virus, and Mycobacterium tuberculosis). The attack rates in various settings (household, health care, and the public) as well as the expected number of secondary cases from a single infected individual in a susceptible population (R0) are more consistent with those of a droplet spread pathogen.

For measles, the R0 is 12-18, and the secondary household attack rates are ≥ 90%. In case of the varicella zoster virus, the R0 is ~10, and the secondary household attack rate is 85%. The R0 for pulmonary tuberculosis is up to 10 (per year) and the secondary household attack rate has been reported to be >50%. With COVID-19, the R0 appears to be around 2.5-3 and secondary household attack rates are ~ 10% from data available so far, similar to that of influenza viruses. This discrepancy suggests that droplet transmission may be more likely. The dichotomy of airborne versus droplet mode of spread may be better described as a continuum, as pointed out in a recent article in the JAMA. Infectious droplets form turbulent gas clouds allowing the virus particles to travel further and remain in the air longer.⁴ The necessary precautions for an airborne illness should be chosen over droplet precautions, especially when there is concern for an AGP.
 

Universal masking: Risks and benefits

The idea of universal masking has been debated extensively since the initial stages of the COVID-19 pandemic. According to public health authorities, significant exposure is defined as “face-to-face contact within 6 feet with a patient with symptomatic COVID-19” in the range of a few minutes up to 30 minutes.⁵ The researchers wrote in the New England Journal of Medicine that the chance of catching COVID-19 from a passing interaction in a public space is therefore minimal, and it may seem unnecessary to wear a mask at all times in public.

As reported in Science, randomized clinical studies performed on other viruses in the past have shown no added protection conferred by wearing a mask, though small sample sizes and noncompliance are limiting factors to their validity.⁶ On the contrary, mask wearing has been enforced in many parts of Asia, including Hong Kong and Singapore with promising results.⁵ Leung et al. stated in The Lancet that the lack of proof that masks are effective should not rule them as ineffective. Also, universal masking would reduce the stigma around symptomatic individuals covering their faces. It has become a cultural phenomenon in many southeast Asian countries and has been cited as one of the reasons for relatively successful containment in Singapore, South Korea, and Taiwan. The most important benefit of universal masking is protection attained by preventing spread from asymptomatic, mildly symptomatic, and presymptomatic carriers.⁷

In a study in the New England Journal of Medicine that estimated viral loads during various stages of COVID-19, researchers found that asymptomatic patients had similar viral loads to symptomatic patients, thereby suggesting high potential for transmission.⁸ Furthermore, numerous cases are being reported concerning the spread of illness from asymptomatic carriers.^9-12 In an outbreak at a skilled nursing facility in Washington outlined in MMWR, 13 of 23 residents with positive test results were asymptomatic at the time of testing, and of those, 3 never developed any symptoms.¹²

Many hospitals are now embracing the policy of universal masking. A mask is a critical component of the personal protective equipment (PPE) clinicians need when caring for symptomatic patients with respiratory viral infections, in conjunction with a gown, gloves, and eye protection. Masking in this context is already part of routine operations in most hospitals. There are two scenarios in which there may be possible benefits. One scenario is the lower likelihood of transmission from asymptomatic and minimally symptomatic health care workers with COVID-19 to other providers and patients. The other less plausible benefit of universal masking among health care workers is that it may provide some protection in the possibility of caring for an unrecognized COVID-19 patient. However, universal masking should be coupled with other favorable practices like temperature checks and symptom screening on a daily basis to avail the maximum benefit from masking. Despite varied opinions on the outcomes of universal masking, this measure helps improve health care workers’ safety, psychological well-being, trust in their hospital, and decreases anxiety of acquiring the illness.
 

Efficacy of various types of masks

With the possibility of airborne transmission of the virus, are cloth masks as recommended by the CDC truly helpful in preventing infection? A study in the Journal of Medical Virology demonstrates 99.98%, 97.14%, and 95.15% efficacy for N95, surgical, and homemade masks, respectively, in blocking the avian influenza virus (comparable to coronavirus in size and physical characteristics). The homemade mask was created using one layer of polyester cloth and a four-layered kitchen filter paper.¹³

N95 masks (equivalent to FFP/P2 in European countries) are made of electrostatically charged polypropylene microfibers designed to filter particles measuring 100-300nm in diameter with 95% efficacy. A single SARS-CoV-2 molecule measures 125 nm approximately. N99 (FFP3) and N100 (P3) masks are also available, though not as widely used, with 99% and 99.7% efficacy respectively for the same size range. Though cloth masks are the clear-cut last resort for medical professionals, a few studies state no clinically proven difference in protection between surgical masks and N95 respirators.^14,15 Even aerosolized droplets (< 5 mcm) were found to be blocked by surgical masks in a Nature Medicine study in which 4/10 subjects tested positive for coronavirus in exhaled breath samples without masks and 0/10 subjects with masks.¹⁶

On the contrary, an Annals of Internal Medicine study of four COVID-19 positive subjects that “neither surgical masks nor cloth masks effectively filtered SARS-CoV-2 during coughs of infected patients.” In fact, more contamination was found on the outer surface of the masks when compared to the inner surface, probably owing to the masks’ aerodynamic properties.¹⁷ Because of limitations present in the above-mentioned studies, further research is necessary to conclusively determine which types of masks are efficacious in preventing infection by the virus. In a scarcity of surgical masks and respirators for health care personnel, suboptimal masks can be of some use provided there is adherent use, minimal donning and doffing, and it is to be accompanied by adequate hand washing practices.¹⁴

In case of severe infections with high viral loads or patients undergoing aerosol-generating procedures, powered air-purifying respirators (PAPRs) also are advisable as they confer greater protection than N95 respirators, according to a study in the Annals of Work Exposures and Health. Despite being more comfortable for long-term use and accommodative of facial hair, their use is limited because of high cost and difficult maintenance.¹⁸ 3-D printing also is being used to combat the current shortage of masks worldwide. However, a study from the International Journal of Oral & Maxillofacial Surgery reported that virologic testing for leakage between the two reusable components and contamination of the components themselves after one or multiple disinfection cycles is essential before application in real-life situations.¹⁹

Ongoing issues

WHO estimates a monthly requirement of nearly 90 million masks exclusively for health care workers to protect themselves against COVID-19.²⁰ In spite of increasing the production rate by 40%, if the general public hoards masks and respirators, the results could be disastrous. Personal protective equipment is currently at 100 times the usual demand and 20 times the usual cost, with stocks backlogged by 4-6 months. The appropriate order of priority in distribution to health care professionals first, followed by those caring for infected patients is critical.²⁰ In a survey conducted by the Association for Professionals in Infection Control and Epidemiology, results revealed that 48% of the U.S. health care facilities that responded were either out or nearly out of respirators as of March 25. ²¹

The gravest risk behind the universal masking policy is the likely depletion of medical resources.²² A possible solution to this issue could be to modify the policy to stagger the requirement based on the severity of community transmission in that area of residence. In the article appropriately titled “Rational use of face masks in the COVID-19 pandemic” published in The Lancet Respiratory Medicine, researchers described how the Chinese population was classified into moderate, low, and very-low risk of infection categories and advised to wear a surgical or disposable mask, disposable mask, and no mask respectively.²³ This curbs widespread panic and eagerness by the general public to stock up on essential medical equipment when it may not even be necessary.
 

Reuse, extended use, and sterilization

Several studies have been conducted to identify the viability of the COVID-19 on various surfaces.^24-25 The CDC and National Institute for Occupational Safety and Health (NIOSH) guidelines state that an N95 respirator can be used up to 8 hours with intermittent or continuous use, though this number is not fixed and heavily depends upon the extent of exposure, risk of contamination, and frequency of donning and doffing^26,27. Though traditionally meant for single-time usage, after 8 hours, the mask can be decontaminated and reused. The CDC defines extended use as the “practice of wearing the same N95 respirator for repeated close-contact encounters with several patients, without removing the respirator between patient encounters.” Reuse is defined as “using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient.”

It has been established that extended use is more advisable than reuse given the lower risk of self-inoculation. Furthermore, health care professionals are urged to wear a cleanable face shield or disposable mask over the respirator to minimize contamination and practice diligent hand hygiene before and after handling the respirator. N95 respirators are to be discarded following aerosol-generating procedures or if they come in contact with blood, respiratory secretions, or bodily fluids. They should also be discarded in case of close contact with an infected patient or if they cause breathing difficulties to the wearer.²⁷ This may not always be possible given the unprecedented shortage of PPE, hence decontamination techniques and repurposing are the need of the hour.

In Anesthesia & Analgesia, Naveen Nathan, MD, of Northwestern University, Chicago, recommends recycling four masks in a series, using one per day, keeping the mask in a dry, clean environment, and then repeating use of the first mask on the 5th day, the second on the 6th day, and so forth. This ensures clearance of the virus particles by the next use. Alternatively, respirators can be sterilized between uses by heating to 70º C (158º F) for 30 minutes. Liquid disinfectants such as alcohol and bleach as well as ultraviolet rays in sunlight tend to damage masks.²⁸ Steam sterilization is the most commonly utilized technique in hospitals. Other methods, described by the N95/PPE Working Group, report include gamma irradiation at 20kGy (2MRad) for large-scale sterilization (though the facilities may not be widely available), vaporized hydrogen peroxide, ozone decontamination, ultraviolet germicidal irradiation, and ethylene oxide.²⁹ Though a discussion on various considerations of decontamination techniques is out of the scope of this article, detailed guidelines have been published by the CDC30 and the COVID-19 Healthcare Coalition.³⁰

Conclusion

A recent startling discovery reported on in Emerging Infectious Diseases suggests that the basic COVID-19 reproductive number (R0) is actually much higher than previously thought. Using expanded data, updated epidemiologic parameters, and the current outbreak dynamics in Wuhan, the team came to the conclusion that the R0 for the novel coronavirus is actually 5.7 (95% CI 3.8-8.9), compared with an initial estimate of 2.2-2.7.³¹ Concern for transmissibility demands heightened prevention strategies until more data evolves. The latest recommendation by the CDC regarding cloth masking in the public may help slow the progression of the pandemic. However, it is of paramount importance to keep in mind that masks alone are not enough to control the disease and must be coupled with other nonpharmacologic interventions such as social distancing, quarantining/isolation, and diligent hand hygiene.

Dr. Tirupathi is the medical director of Keystone Infectious Diseases/HIV in Chambersburg, Pa., and currently chair of infection prevention at Wellspan Chambersburg and Waynesboro (Pa.) Hospitals. He also is the lead physician for antibiotic stewardship at these hospitals. Dr. Bharathidasan is a recent medical graduate from India with an interest in public health and community research; she plans to pursue residency training in the United States. Ms. Freshman is currently the regional director of infection prevention for WellSpan Health and has 35 years of experience in nursing. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Centers for Disease Control and Prevention. Recommendation regarding the use of cloth face coverings.

2. World Health Organization. Modes of transmission of virus causing COVID-19 : implications for IPC precaution recommendations. Sci Br. 2020 Mar 29:1-3.

3. Santarpia JL et al. Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. 2020 Mar 26. medRxiv. 2020;2020.03.23.20039446.

4. Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: Potential implications for reducing transmission of COVID-19. JAMA. 2020 Mar 26. doi: 10.1001/jama.2020.4756.

5. Klompas M et al. Universal masking in hospitals in the Covid-19 era. N Engl J Med. 2020 Apr 1. doi: 10.1056/NEJMp2006372.

6. Servick K. Would everyone wearing face masks help us slow the pandemic? Science 2020 Mar 28. doi: 10.1126/science.abb9371.

7. Leung CC et al. Mass masking in the COVID-19 epidemic: People need guidance. Lancet 2020 Mar 21;395(10228):945. doi: 10.1016/S0140-6736(20)30520-1.

8. Zou L et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020 Mar 19;382(12):1177-9.

9. Pan X et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. Lancet Infect Dis. 2020 Apr;20(4):410-1.

10. Bai Y et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA. 2020 Feb 21;323(14):1406-7.

11. Wei WE et al. Presymptomatic transmission of SARS-CoV-2 – Singapore, Jan. 23–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411-5.

12. Kimball A et al. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility – King County, Washington, March 2020. 2020 Apr 3. MMWR Morb Mortal Wkly Rep 2020;69:377-81.

13. Ma Q-X et al. Potential utilities of mask wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020 Mar 31;10.1002/jmv.25805. doi: 10.1002/jmv.25805.

14. Abd-Elsayed A et al. Utility of substandard face mask options for health care workers during the COVID-19 pandemic. Anesth Analg. 2020 Mar 31;10.1213/ANE.0000000000004841. doi: 10.1213/ANE.0000000000004841.

15. Long Y et al. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. J Evid Based Med. 2020 Mar 13;10.1111/jebm.12381. doi: 10.1111/jebm.12381.

16. Leung NHL et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020 May;26(5):676-80.

17. Bae S et al. Effectiveness of surgical and cotton masks in blocking SARS-CoV-2: A controlled comparison in 4 patients. Ann Intern Med. 2020 Apr 6;M20-1342. doi: 10.7326/M20-1342.

18. Brosseau LM. Are powered air purifying respirators a solution for protecting healthcare workers from emerging aerosol-transmissible diseases? Ann Work Expo Health. 2020 Apr 30;64(4):339-41.

19. Swennen GRJ et al. Custom-made 3D-printed face masks in case of pandemic crisis situations with a lack of commercially available FFP2/3 masks. Int J Oral Maxillofac Surg. 2020 May;49(5):673-7.

20. Mahase E. Coronavirus: Global stocks of protective gear are depleted, with demand at “100 times” normal level, WHO warns. BMJ. 2020 Feb 10;368:m543. doi: 10.1136/bmj.m543.

21. National survey shows dire shortages of PPE, hand sanitizer across the U.S. 2020 Mar 27. Association for Professionals in Infection Control and Epidemiology (APIC) press briefing.

22. Wu HL et al. Facemask shortage and the novel coronavirus disease (COVID-19) outbreak: Reflections on public health measures. EClinicalMedicine. 2020 Apr 3:100329. doi: 10.1016/j.eclinm.2020.100329.

23. Feng S et al. Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med. 2020 May;8(5):434-6.

24. Chin AWH et al. Stability of SARS-CoV-2 in different environmental. The Lancet Microbe. 2020 May 1;5247(20):2004973. doi. org/10.1016/S2666-5247(20)30003-3.

25. van Doremalen N et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Apr 16;382(16):1564-7.

26. NIOSH – Workplace Safety and Health Topics: Recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings.

27. Centers for Disease Control and Prevention. COVID-19 decontamination and reuse of filtering facepiece respirators. 2020 Apr 15.

28. Nathan N. Waste not, want not: The re-usability of N95 masks. Anesth Analg. 2020 Mar 31.doi: 10.1213/ane.0000000000004843.

29. European Centre for Disease Prevention and Control technical report. Cloth masks and mask sterilisation as options in case of shortage of surgical masks and respirators. 2020 Mar. 

30. N95/PPE Working Group report. Evaluation of decontamination techniques for the reuse of N95 respirators. 2020 Apr 3;2:1-7.

31. Sanche Set al. High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis. 2020 Jul. doi. org/10.3201/eid2607.200282.

On April 3, the Centers for Disease Control and Prevention issued an advisory that the general public wear cloth face masks when outside, particularly those residing in areas with significant severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) community transmission.¹ Recent research reveals several factors related to the nature of the virus as well as the epidemiologic spread of the illness that may have led to this decision.

However, controversy still prevails whether this recommendation will alleviate or aggravate disease progression. With many hospitals across America lacking sufficient personal protective equipment (PPE) and scrambling for supplies, universal masking may create more chaos, especially with certain states imposing monetary fines on individuals spotted outdoors without a mask. With new information being discovered each day about COVID-19, it is more imperative than ever to update existing strategies and formulate more effective methods to flatten the curve.
 

Airborne vs. droplet transmission

According to a scientific brief released by the World Health Organization, there have been studies with mixed evidence and opinions regarding the presence of COVID-19 ribonucleic acid (RNA) in air samples.² In medRxiv, Santarpia et al., from the University of Nebraska Medical Center, Omaha, detected viral RNA in samples taken from beneath a patient’s bed and from a window ledge, both areas in which neither the patient nor health care personnel had any direct contact. They also found that 66.7% of air samples taken from a hospital hallway carried virus-containing particles.³ It is worth noting that certain aerosol-generating procedures (AGP) may increase the likelihood of airborne dissemination. Whether airborne transmission is a major mode of COVID-19 spread in the community and routine clinical settings (with no aerosol-generating procedures) is still a debatable question without a definitive answer.

We should consider the epidemiology of COVID-19 thus far in the pandemic to determine if transmission patterns are more consistent with that of other common respiratory viral pathogens or more consistent with that of the agents we classically consider to be transmitted by the airborne route (measles, varicella zoster virus, and Mycobacterium tuberculosis). The attack rates in various settings (household, health care, and the public) as well as the expected number of secondary cases from a single infected individual in a susceptible population (R0) are more consistent with those of a droplet spread pathogen.

For measles, the R0 is 12-18, and the secondary household attack rates are ≥ 90%. In case of the varicella zoster virus, the R0 is ~10, and the secondary household attack rate is 85%. The R0 for pulmonary tuberculosis is up to 10 (per year) and the secondary household attack rate has been reported to be >50%. With COVID-19, the R0 appears to be around 2.5-3 and secondary household attack rates are ~ 10% from data available so far, similar to that of influenza viruses. This discrepancy suggests that droplet transmission may be more likely. The dichotomy of airborne versus droplet mode of spread may be better described as a continuum, as pointed out in a recent article in the JAMA. Infectious droplets form turbulent gas clouds allowing the virus particles to travel further and remain in the air longer.⁴ The necessary precautions for an airborne illness should be chosen over droplet precautions, especially when there is concern for an AGP.
 

Universal masking: Risks and benefits

The idea of universal masking has been debated extensively since the initial stages of the COVID-19 pandemic. According to public health authorities, significant exposure is defined as “face-to-face contact within 6 feet with a patient with symptomatic COVID-19” in the range of a few minutes up to 30 minutes.⁵ The researchers wrote in the New England Journal of Medicine that the chance of catching COVID-19 from a passing interaction in a public space is therefore minimal, and it may seem unnecessary to wear a mask at all times in public.

As reported in Science, randomized clinical studies performed on other viruses in the past have shown no added protection conferred by wearing a mask, though small sample sizes and noncompliance are limiting factors to their validity.⁶ On the contrary, mask wearing has been enforced in many parts of Asia, including Hong Kong and Singapore with promising results.⁵ Leung et al. stated in The Lancet that the lack of proof that masks are effective should not rule them as ineffective. Also, universal masking would reduce the stigma around symptomatic individuals covering their faces. It has become a cultural phenomenon in many southeast Asian countries and has been cited as one of the reasons for relatively successful containment in Singapore, South Korea, and Taiwan. The most important benefit of universal masking is protection attained by preventing spread from asymptomatic, mildly symptomatic, and presymptomatic carriers.⁷

In a study in the New England Journal of Medicine that estimated viral loads during various stages of COVID-19, researchers found that asymptomatic patients had similar viral loads to symptomatic patients, thereby suggesting high potential for transmission.⁸ Furthermore, numerous cases are being reported concerning the spread of illness from asymptomatic carriers.^9-12 In an outbreak at a skilled nursing facility in Washington outlined in MMWR, 13 of 23 residents with positive test results were asymptomatic at the time of testing, and of those, 3 never developed any symptoms.¹²

Many hospitals are now embracing the policy of universal masking. A mask is a critical component of the personal protective equipment (PPE) clinicians need when caring for symptomatic patients with respiratory viral infections, in conjunction with a gown, gloves, and eye protection. Masking in this context is already part of routine operations in most hospitals. There are two scenarios in which there may be possible benefits. One scenario is the lower likelihood of transmission from asymptomatic and minimally symptomatic health care workers with COVID-19 to other providers and patients. The other less plausible benefit of universal masking among health care workers is that it may provide some protection in the possibility of caring for an unrecognized COVID-19 patient. However, universal masking should be coupled with other favorable practices like temperature checks and symptom screening on a daily basis to avail the maximum benefit from masking. Despite varied opinions on the outcomes of universal masking, this measure helps improve health care workers’ safety, psychological well-being, trust in their hospital, and decreases anxiety of acquiring the illness.
 

Efficacy of various types of masks

With the possibility of airborne transmission of the virus, are cloth masks as recommended by the CDC truly helpful in preventing infection? A study in the Journal of Medical Virology demonstrates 99.98%, 97.14%, and 95.15% efficacy for N95, surgical, and homemade masks, respectively, in blocking the avian influenza virus (comparable to coronavirus in size and physical characteristics). The homemade mask was created using one layer of polyester cloth and a four-layered kitchen filter paper.¹³

N95 masks (equivalent to FFP/P2 in European countries) are made of electrostatically charged polypropylene microfibers designed to filter particles measuring 100-300nm in diameter with 95% efficacy. A single SARS-CoV-2 molecule measures 125 nm approximately. N99 (FFP3) and N100 (P3) masks are also available, though not as widely used, with 99% and 99.7% efficacy respectively for the same size range. Though cloth masks are the clear-cut last resort for medical professionals, a few studies state no clinically proven difference in protection between surgical masks and N95 respirators.^14,15 Even aerosolized droplets (< 5 mcm) were found to be blocked by surgical masks in a Nature Medicine study in which 4/10 subjects tested positive for coronavirus in exhaled breath samples without masks and 0/10 subjects with masks.¹⁶

On the contrary, an Annals of Internal Medicine study of four COVID-19 positive subjects that “neither surgical masks nor cloth masks effectively filtered SARS-CoV-2 during coughs of infected patients.” In fact, more contamination was found on the outer surface of the masks when compared to the inner surface, probably owing to the masks’ aerodynamic properties.¹⁷ Because of limitations present in the above-mentioned studies, further research is necessary to conclusively determine which types of masks are efficacious in preventing infection by the virus. In a scarcity of surgical masks and respirators for health care personnel, suboptimal masks can be of some use provided there is adherent use, minimal donning and doffing, and it is to be accompanied by adequate hand washing practices.¹⁴

In case of severe infections with high viral loads or patients undergoing aerosol-generating procedures, powered air-purifying respirators (PAPRs) also are advisable as they confer greater protection than N95 respirators, according to a study in the Annals of Work Exposures and Health. Despite being more comfortable for long-term use and accommodative of facial hair, their use is limited because of high cost and difficult maintenance.¹⁸ 3-D printing also is being used to combat the current shortage of masks worldwide. However, a study from the International Journal of Oral & Maxillofacial Surgery reported that virologic testing for leakage between the two reusable components and contamination of the components themselves after one or multiple disinfection cycles is essential before application in real-life situations.¹⁹

Ongoing issues

WHO estimates a monthly requirement of nearly 90 million masks exclusively for health care workers to protect themselves against COVID-19.²⁰ In spite of increasing the production rate by 40%, if the general public hoards masks and respirators, the results could be disastrous. Personal protective equipment is currently at 100 times the usual demand and 20 times the usual cost, with stocks backlogged by 4-6 months. The appropriate order of priority in distribution to health care professionals first, followed by those caring for infected patients is critical.²⁰ In a survey conducted by the Association for Professionals in Infection Control and Epidemiology, results revealed that 48% of the U.S. health care facilities that responded were either out or nearly out of respirators as of March 25. ²¹

The gravest risk behind the universal masking policy is the likely depletion of medical resources.²² A possible solution to this issue could be to modify the policy to stagger the requirement based on the severity of community transmission in that area of residence. In the article appropriately titled “Rational use of face masks in the COVID-19 pandemic” published in The Lancet Respiratory Medicine, researchers described how the Chinese population was classified into moderate, low, and very-low risk of infection categories and advised to wear a surgical or disposable mask, disposable mask, and no mask respectively.²³ This curbs widespread panic and eagerness by the general public to stock up on essential medical equipment when it may not even be necessary.
 

Reuse, extended use, and sterilization

Several studies have been conducted to identify the viability of the COVID-19 on various surfaces.^24-25 The CDC and National Institute for Occupational Safety and Health (NIOSH) guidelines state that an N95 respirator can be used up to 8 hours with intermittent or continuous use, though this number is not fixed and heavily depends upon the extent of exposure, risk of contamination, and frequency of donning and doffing^26,27. Though traditionally meant for single-time usage, after 8 hours, the mask can be decontaminated and reused. The CDC defines extended use as the “practice of wearing the same N95 respirator for repeated close-contact encounters with several patients, without removing the respirator between patient encounters.” Reuse is defined as “using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient.”

It has been established that extended use is more advisable than reuse given the lower risk of self-inoculation. Furthermore, health care professionals are urged to wear a cleanable face shield or disposable mask over the respirator to minimize contamination and practice diligent hand hygiene before and after handling the respirator. N95 respirators are to be discarded following aerosol-generating procedures or if they come in contact with blood, respiratory secretions, or bodily fluids. They should also be discarded in case of close contact with an infected patient or if they cause breathing difficulties to the wearer.²⁷ This may not always be possible given the unprecedented shortage of PPE, hence decontamination techniques and repurposing are the need of the hour.

In Anesthesia & Analgesia, Naveen Nathan, MD, of Northwestern University, Chicago, recommends recycling four masks in a series, using one per day, keeping the mask in a dry, clean environment, and then repeating use of the first mask on the 5th day, the second on the 6th day, and so forth. This ensures clearance of the virus particles by the next use. Alternatively, respirators can be sterilized between uses by heating to 70º C (158º F) for 30 minutes. Liquid disinfectants such as alcohol and bleach as well as ultraviolet rays in sunlight tend to damage masks.²⁸ Steam sterilization is the most commonly utilized technique in hospitals. Other methods, described by the N95/PPE Working Group, report include gamma irradiation at 20kGy (2MRad) for large-scale sterilization (though the facilities may not be widely available), vaporized hydrogen peroxide, ozone decontamination, ultraviolet germicidal irradiation, and ethylene oxide.²⁹ Though a discussion on various considerations of decontamination techniques is out of the scope of this article, detailed guidelines have been published by the CDC30 and the COVID-19 Healthcare Coalition.³⁰

Conclusion

A recent startling discovery reported on in Emerging Infectious Diseases suggests that the basic COVID-19 reproductive number (R0) is actually much higher than previously thought. Using expanded data, updated epidemiologic parameters, and the current outbreak dynamics in Wuhan, the team came to the conclusion that the R0 for the novel coronavirus is actually 5.7 (95% CI 3.8-8.9), compared with an initial estimate of 2.2-2.7.³¹ Concern for transmissibility demands heightened prevention strategies until more data evolves. The latest recommendation by the CDC regarding cloth masking in the public may help slow the progression of the pandemic. However, it is of paramount importance to keep in mind that masks alone are not enough to control the disease and must be coupled with other nonpharmacologic interventions such as social distancing, quarantining/isolation, and diligent hand hygiene.

Dr. Tirupathi is the medical director of Keystone Infectious Diseases/HIV in Chambersburg, Pa., and currently chair of infection prevention at Wellspan Chambersburg and Waynesboro (Pa.) Hospitals. He also is the lead physician for antibiotic stewardship at these hospitals. Dr. Bharathidasan is a recent medical graduate from India with an interest in public health and community research; she plans to pursue residency training in the United States. Ms. Freshman is currently the regional director of infection prevention for WellSpan Health and has 35 years of experience in nursing. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Centers for Disease Control and Prevention. Recommendation regarding the use of cloth face coverings.

2. World Health Organization. Modes of transmission of virus causing COVID-19 : implications for IPC precaution recommendations. Sci Br. 2020 Mar 29:1-3.

3. Santarpia JL et al. Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. 2020 Mar 26. medRxiv. 2020;2020.03.23.20039446.

4. Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: Potential implications for reducing transmission of COVID-19. JAMA. 2020 Mar 26. doi: 10.1001/jama.2020.4756.

5. Klompas M et al. Universal masking in hospitals in the Covid-19 era. N Engl J Med. 2020 Apr 1. doi: 10.1056/NEJMp2006372.

6. Servick K. Would everyone wearing face masks help us slow the pandemic? Science 2020 Mar 28. doi: 10.1126/science.abb9371.

7. Leung CC et al. Mass masking in the COVID-19 epidemic: People need guidance. Lancet 2020 Mar 21;395(10228):945. doi: 10.1016/S0140-6736(20)30520-1.

8. Zou L et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020 Mar 19;382(12):1177-9.

9. Pan X et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. Lancet Infect Dis. 2020 Apr;20(4):410-1.

10. Bai Y et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA. 2020 Feb 21;323(14):1406-7.

11. Wei WE et al. Presymptomatic transmission of SARS-CoV-2 – Singapore, Jan. 23–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411-5.

12. Kimball A et al. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility – King County, Washington, March 2020. 2020 Apr 3. MMWR Morb Mortal Wkly Rep 2020;69:377-81.

13. Ma Q-X et al. Potential utilities of mask wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020 Mar 31;10.1002/jmv.25805. doi: 10.1002/jmv.25805.

14. Abd-Elsayed A et al. Utility of substandard face mask options for health care workers during the COVID-19 pandemic. Anesth Analg. 2020 Mar 31;10.1213/ANE.0000000000004841. doi: 10.1213/ANE.0000000000004841.

15. Long Y et al. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. J Evid Based Med. 2020 Mar 13;10.1111/jebm.12381. doi: 10.1111/jebm.12381.

16. Leung NHL et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020 May;26(5):676-80.

17. Bae S et al. Effectiveness of surgical and cotton masks in blocking SARS-CoV-2: A controlled comparison in 4 patients. Ann Intern Med. 2020 Apr 6;M20-1342. doi: 10.7326/M20-1342.

18. Brosseau LM. Are powered air purifying respirators a solution for protecting healthcare workers from emerging aerosol-transmissible diseases? Ann Work Expo Health. 2020 Apr 30;64(4):339-41.

19. Swennen GRJ et al. Custom-made 3D-printed face masks in case of pandemic crisis situations with a lack of commercially available FFP2/3 masks. Int J Oral Maxillofac Surg. 2020 May;49(5):673-7.

20. Mahase E. Coronavirus: Global stocks of protective gear are depleted, with demand at “100 times” normal level, WHO warns. BMJ. 2020 Feb 10;368:m543. doi: 10.1136/bmj.m543.

21. National survey shows dire shortages of PPE, hand sanitizer across the U.S. 2020 Mar 27. Association for Professionals in Infection Control and Epidemiology (APIC) press briefing.

22. Wu HL et al. Facemask shortage and the novel coronavirus disease (COVID-19) outbreak: Reflections on public health measures. EClinicalMedicine. 2020 Apr 3:100329. doi: 10.1016/j.eclinm.2020.100329.

23. Feng S et al. Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med. 2020 May;8(5):434-6.

24. Chin AWH et al. Stability of SARS-CoV-2 in different environmental. The Lancet Microbe. 2020 May 1;5247(20):2004973. doi. org/10.1016/S2666-5247(20)30003-3.

25. van Doremalen N et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Apr 16;382(16):1564-7.

26. NIOSH – Workplace Safety and Health Topics: Recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings.

27. Centers for Disease Control and Prevention. COVID-19 decontamination and reuse of filtering facepiece respirators. 2020 Apr 15.

28. Nathan N. Waste not, want not: The re-usability of N95 masks. Anesth Analg. 2020 Mar 31.doi: 10.1213/ane.0000000000004843.

29. European Centre for Disease Prevention and Control technical report. Cloth masks and mask sterilisation as options in case of shortage of surgical masks and respirators. 2020 Mar. 

30. N95/PPE Working Group report. Evaluation of decontamination techniques for the reuse of N95 respirators. 2020 Apr 3;2:1-7.

31. Sanche Set al. High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis. 2020 Jul. doi. org/10.3201/eid2607.200282.

On April 3, the Centers for Disease Control and Prevention issued an advisory that the general public wear cloth face masks when outside, particularly those residing in areas with significant severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) community transmission.¹ Recent research reveals several factors related to the nature of the virus as well as the epidemiologic spread of the illness that may have led to this decision.

However, controversy still prevails whether this recommendation will alleviate or aggravate disease progression. With many hospitals across America lacking sufficient personal protective equipment (PPE) and scrambling for supplies, universal masking may create more chaos, especially with certain states imposing monetary fines on individuals spotted outdoors without a mask. With new information being discovered each day about COVID-19, it is more imperative than ever to update existing strategies and formulate more effective methods to flatten the curve.
 

Airborne vs. droplet transmission

According to a scientific brief released by the World Health Organization, there have been studies with mixed evidence and opinions regarding the presence of COVID-19 ribonucleic acid (RNA) in air samples.² In medRxiv, Santarpia et al., from the University of Nebraska Medical Center, Omaha, detected viral RNA in samples taken from beneath a patient’s bed and from a window ledge, both areas in which neither the patient nor health care personnel had any direct contact. They also found that 66.7% of air samples taken from a hospital hallway carried virus-containing particles.³ It is worth noting that certain aerosol-generating procedures (AGP) may increase the likelihood of airborne dissemination. Whether airborne transmission is a major mode of COVID-19 spread in the community and routine clinical settings (with no aerosol-generating procedures) is still a debatable question without a definitive answer.

We should consider the epidemiology of COVID-19 thus far in the pandemic to determine if transmission patterns are more consistent with that of other common respiratory viral pathogens or more consistent with that of the agents we classically consider to be transmitted by the airborne route (measles, varicella zoster virus, and Mycobacterium tuberculosis). The attack rates in various settings (household, health care, and the public) as well as the expected number of secondary cases from a single infected individual in a susceptible population (R0) are more consistent with those of a droplet spread pathogen.

For measles, the R0 is 12-18, and the secondary household attack rates are ≥ 90%. In case of the varicella zoster virus, the R0 is ~10, and the secondary household attack rate is 85%. The R0 for pulmonary tuberculosis is up to 10 (per year) and the secondary household attack rate has been reported to be >50%. With COVID-19, the R0 appears to be around 2.5-3 and secondary household attack rates are ~ 10% from data available so far, similar to that of influenza viruses. This discrepancy suggests that droplet transmission may be more likely. The dichotomy of airborne versus droplet mode of spread may be better described as a continuum, as pointed out in a recent article in the JAMA. Infectious droplets form turbulent gas clouds allowing the virus particles to travel further and remain in the air longer.⁴ The necessary precautions for an airborne illness should be chosen over droplet precautions, especially when there is concern for an AGP.
 

Universal masking: Risks and benefits

The idea of universal masking has been debated extensively since the initial stages of the COVID-19 pandemic. According to public health authorities, significant exposure is defined as “face-to-face contact within 6 feet with a patient with symptomatic COVID-19” in the range of a few minutes up to 30 minutes.⁵ The researchers wrote in the New England Journal of Medicine that the chance of catching COVID-19 from a passing interaction in a public space is therefore minimal, and it may seem unnecessary to wear a mask at all times in public.

As reported in Science, randomized clinical studies performed on other viruses in the past have shown no added protection conferred by wearing a mask, though small sample sizes and noncompliance are limiting factors to their validity.⁶ On the contrary, mask wearing has been enforced in many parts of Asia, including Hong Kong and Singapore with promising results.⁵ Leung et al. stated in The Lancet that the lack of proof that masks are effective should not rule them as ineffective. Also, universal masking would reduce the stigma around symptomatic individuals covering their faces. It has become a cultural phenomenon in many southeast Asian countries and has been cited as one of the reasons for relatively successful containment in Singapore, South Korea, and Taiwan. The most important benefit of universal masking is protection attained by preventing spread from asymptomatic, mildly symptomatic, and presymptomatic carriers.⁷

In a study in the New England Journal of Medicine that estimated viral loads during various stages of COVID-19, researchers found that asymptomatic patients had similar viral loads to symptomatic patients, thereby suggesting high potential for transmission.⁸ Furthermore, numerous cases are being reported concerning the spread of illness from asymptomatic carriers.^9-12 In an outbreak at a skilled nursing facility in Washington outlined in MMWR, 13 of 23 residents with positive test results were asymptomatic at the time of testing, and of those, 3 never developed any symptoms.¹²

Many hospitals are now embracing the policy of universal masking. A mask is a critical component of the personal protective equipment (PPE) clinicians need when caring for symptomatic patients with respiratory viral infections, in conjunction with a gown, gloves, and eye protection. Masking in this context is already part of routine operations in most hospitals. There are two scenarios in which there may be possible benefits. One scenario is the lower likelihood of transmission from asymptomatic and minimally symptomatic health care workers with COVID-19 to other providers and patients. The other less plausible benefit of universal masking among health care workers is that it may provide some protection in the possibility of caring for an unrecognized COVID-19 patient. However, universal masking should be coupled with other favorable practices like temperature checks and symptom screening on a daily basis to avail the maximum benefit from masking. Despite varied opinions on the outcomes of universal masking, this measure helps improve health care workers’ safety, psychological well-being, trust in their hospital, and decreases anxiety of acquiring the illness.
 

Efficacy of various types of masks

With the possibility of airborne transmission of the virus, are cloth masks as recommended by the CDC truly helpful in preventing infection? A study in the Journal of Medical Virology demonstrates 99.98%, 97.14%, and 95.15% efficacy for N95, surgical, and homemade masks, respectively, in blocking the avian influenza virus (comparable to coronavirus in size and physical characteristics). The homemade mask was created using one layer of polyester cloth and a four-layered kitchen filter paper.¹³

N95 masks (equivalent to FFP/P2 in European countries) are made of electrostatically charged polypropylene microfibers designed to filter particles measuring 100-300nm in diameter with 95% efficacy. A single SARS-CoV-2 molecule measures 125 nm approximately. N99 (FFP3) and N100 (P3) masks are also available, though not as widely used, with 99% and 99.7% efficacy respectively for the same size range. Though cloth masks are the clear-cut last resort for medical professionals, a few studies state no clinically proven difference in protection between surgical masks and N95 respirators.^14,15 Even aerosolized droplets (< 5 mcm) were found to be blocked by surgical masks in a Nature Medicine study in which 4/10 subjects tested positive for coronavirus in exhaled breath samples without masks and 0/10 subjects with masks.¹⁶

On the contrary, an Annals of Internal Medicine study of four COVID-19 positive subjects that “neither surgical masks nor cloth masks effectively filtered SARS-CoV-2 during coughs of infected patients.” In fact, more contamination was found on the outer surface of the masks when compared to the inner surface, probably owing to the masks’ aerodynamic properties.¹⁷ Because of limitations present in the above-mentioned studies, further research is necessary to conclusively determine which types of masks are efficacious in preventing infection by the virus. In a scarcity of surgical masks and respirators for health care personnel, suboptimal masks can be of some use provided there is adherent use, minimal donning and doffing, and it is to be accompanied by adequate hand washing practices.¹⁴

In case of severe infections with high viral loads or patients undergoing aerosol-generating procedures, powered air-purifying respirators (PAPRs) also are advisable as they confer greater protection than N95 respirators, according to a study in the Annals of Work Exposures and Health. Despite being more comfortable for long-term use and accommodative of facial hair, their use is limited because of high cost and difficult maintenance.¹⁸ 3-D printing also is being used to combat the current shortage of masks worldwide. However, a study from the International Journal of Oral & Maxillofacial Surgery reported that virologic testing for leakage between the two reusable components and contamination of the components themselves after one or multiple disinfection cycles is essential before application in real-life situations.¹⁹

Ongoing issues

WHO estimates a monthly requirement of nearly 90 million masks exclusively for health care workers to protect themselves against COVID-19.²⁰ In spite of increasing the production rate by 40%, if the general public hoards masks and respirators, the results could be disastrous. Personal protective equipment is currently at 100 times the usual demand and 20 times the usual cost, with stocks backlogged by 4-6 months. The appropriate order of priority in distribution to health care professionals first, followed by those caring for infected patients is critical.²⁰ In a survey conducted by the Association for Professionals in Infection Control and Epidemiology, results revealed that 48% of the U.S. health care facilities that responded were either out or nearly out of respirators as of March 25. ²¹

The gravest risk behind the universal masking policy is the likely depletion of medical resources.²² A possible solution to this issue could be to modify the policy to stagger the requirement based on the severity of community transmission in that area of residence. In the article appropriately titled “Rational use of face masks in the COVID-19 pandemic” published in The Lancet Respiratory Medicine, researchers described how the Chinese population was classified into moderate, low, and very-low risk of infection categories and advised to wear a surgical or disposable mask, disposable mask, and no mask respectively.²³ This curbs widespread panic and eagerness by the general public to stock up on essential medical equipment when it may not even be necessary.
 

Reuse, extended use, and sterilization

Several studies have been conducted to identify the viability of the COVID-19 on various surfaces.^24-25 The CDC and National Institute for Occupational Safety and Health (NIOSH) guidelines state that an N95 respirator can be used up to 8 hours with intermittent or continuous use, though this number is not fixed and heavily depends upon the extent of exposure, risk of contamination, and frequency of donning and doffing^26,27. Though traditionally meant for single-time usage, after 8 hours, the mask can be decontaminated and reused. The CDC defines extended use as the “practice of wearing the same N95 respirator for repeated close-contact encounters with several patients, without removing the respirator between patient encounters.” Reuse is defined as “using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient.”

It has been established that extended use is more advisable than reuse given the lower risk of self-inoculation. Furthermore, health care professionals are urged to wear a cleanable face shield or disposable mask over the respirator to minimize contamination and practice diligent hand hygiene before and after handling the respirator. N95 respirators are to be discarded following aerosol-generating procedures or if they come in contact with blood, respiratory secretions, or bodily fluids. They should also be discarded in case of close contact with an infected patient or if they cause breathing difficulties to the wearer.²⁷ This may not always be possible given the unprecedented shortage of PPE, hence decontamination techniques and repurposing are the need of the hour.

In Anesthesia & Analgesia, Naveen Nathan, MD, of Northwestern University, Chicago, recommends recycling four masks in a series, using one per day, keeping the mask in a dry, clean environment, and then repeating use of the first mask on the 5th day, the second on the 6th day, and so forth. This ensures clearance of the virus particles by the next use. Alternatively, respirators can be sterilized between uses by heating to 70º C (158º F) for 30 minutes. Liquid disinfectants such as alcohol and bleach as well as ultraviolet rays in sunlight tend to damage masks.²⁸ Steam sterilization is the most commonly utilized technique in hospitals. Other methods, described by the N95/PPE Working Group, report include gamma irradiation at 20kGy (2MRad) for large-scale sterilization (though the facilities may not be widely available), vaporized hydrogen peroxide, ozone decontamination, ultraviolet germicidal irradiation, and ethylene oxide.²⁹ Though a discussion on various considerations of decontamination techniques is out of the scope of this article, detailed guidelines have been published by the CDC30 and the COVID-19 Healthcare Coalition.³⁰

Conclusion

A recent startling discovery reported on in Emerging Infectious Diseases suggests that the basic COVID-19 reproductive number (R0) is actually much higher than previously thought. Using expanded data, updated epidemiologic parameters, and the current outbreak dynamics in Wuhan, the team came to the conclusion that the R0 for the novel coronavirus is actually 5.7 (95% CI 3.8-8.9), compared with an initial estimate of 2.2-2.7.³¹ Concern for transmissibility demands heightened prevention strategies until more data evolves. The latest recommendation by the CDC regarding cloth masking in the public may help slow the progression of the pandemic. However, it is of paramount importance to keep in mind that masks alone are not enough to control the disease and must be coupled with other nonpharmacologic interventions such as social distancing, quarantining/isolation, and diligent hand hygiene.

Dr. Tirupathi is the medical director of Keystone Infectious Diseases/HIV in Chambersburg, Pa., and currently chair of infection prevention at Wellspan Chambersburg and Waynesboro (Pa.) Hospitals. He also is the lead physician for antibiotic stewardship at these hospitals. Dr. Bharathidasan is a recent medical graduate from India with an interest in public health and community research; she plans to pursue residency training in the United States. Ms. Freshman is currently the regional director of infection prevention for WellSpan Health and has 35 years of experience in nursing. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Centers for Disease Control and Prevention. Recommendation regarding the use of cloth face coverings.

2. World Health Organization. Modes of transmission of virus causing COVID-19 : implications for IPC precaution recommendations. Sci Br. 2020 Mar 29:1-3.

3. Santarpia JL et al. Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. 2020 Mar 26. medRxiv. 2020;2020.03.23.20039446.

4. Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: Potential implications for reducing transmission of COVID-19. JAMA. 2020 Mar 26. doi: 10.1001/jama.2020.4756.

5. Klompas M et al. Universal masking in hospitals in the Covid-19 era. N Engl J Med. 2020 Apr 1. doi: 10.1056/NEJMp2006372.

6. Servick K. Would everyone wearing face masks help us slow the pandemic? Science 2020 Mar 28. doi: 10.1126/science.abb9371.

7. Leung CC et al. Mass masking in the COVID-19 epidemic: People need guidance. Lancet 2020 Mar 21;395(10228):945. doi: 10.1016/S0140-6736(20)30520-1.

8. Zou L et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020 Mar 19;382(12):1177-9.

9. Pan X et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. Lancet Infect Dis. 2020 Apr;20(4):410-1.

10. Bai Y et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA. 2020 Feb 21;323(14):1406-7.

11. Wei WE et al. Presymptomatic transmission of SARS-CoV-2 – Singapore, Jan. 23–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411-5.

12. Kimball A et al. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility – King County, Washington, March 2020. 2020 Apr 3. MMWR Morb Mortal Wkly Rep 2020;69:377-81.

13. Ma Q-X et al. Potential utilities of mask wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020 Mar 31;10.1002/jmv.25805. doi: 10.1002/jmv.25805.

14. Abd-Elsayed A et al. Utility of substandard face mask options for health care workers during the COVID-19 pandemic. Anesth Analg. 2020 Mar 31;10.1213/ANE.0000000000004841. doi: 10.1213/ANE.0000000000004841.

15. Long Y et al. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. J Evid Based Med. 2020 Mar 13;10.1111/jebm.12381. doi: 10.1111/jebm.12381.

16. Leung NHL et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020 May;26(5):676-80.

17. Bae S et al. Effectiveness of surgical and cotton masks in blocking SARS-CoV-2: A controlled comparison in 4 patients. Ann Intern Med. 2020 Apr 6;M20-1342. doi: 10.7326/M20-1342.

18. Brosseau LM. Are powered air purifying respirators a solution for protecting healthcare workers from emerging aerosol-transmissible diseases? Ann Work Expo Health. 2020 Apr 30;64(4):339-41.

19. Swennen GRJ et al. Custom-made 3D-printed face masks in case of pandemic crisis situations with a lack of commercially available FFP2/3 masks. Int J Oral Maxillofac Surg. 2020 May;49(5):673-7.

20. Mahase E. Coronavirus: Global stocks of protective gear are depleted, with demand at “100 times” normal level, WHO warns. BMJ. 2020 Feb 10;368:m543. doi: 10.1136/bmj.m543.

21. National survey shows dire shortages of PPE, hand sanitizer across the U.S. 2020 Mar 27. Association for Professionals in Infection Control and Epidemiology (APIC) press briefing.

22. Wu HL et al. Facemask shortage and the novel coronavirus disease (COVID-19) outbreak: Reflections on public health measures. EClinicalMedicine. 2020 Apr 3:100329. doi: 10.1016/j.eclinm.2020.100329.

23. Feng S et al. Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med. 2020 May;8(5):434-6.

24. Chin AWH et al. Stability of SARS-CoV-2 in different environmental. The Lancet Microbe. 2020 May 1;5247(20):2004973. doi. org/10.1016/S2666-5247(20)30003-3.

25. van Doremalen N et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Apr 16;382(16):1564-7.

26. NIOSH – Workplace Safety and Health Topics: Recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings.

27. Centers for Disease Control and Prevention. COVID-19 decontamination and reuse of filtering facepiece respirators. 2020 Apr 15.

28. Nathan N. Waste not, want not: The re-usability of N95 masks. Anesth Analg. 2020 Mar 31.doi: 10.1213/ane.0000000000004843.

29. European Centre for Disease Prevention and Control technical report. Cloth masks and mask sterilisation as options in case of shortage of surgical masks and respirators. 2020 Mar. 

30. N95/PPE Working Group report. Evaluation of decontamination techniques for the reuse of N95 respirators. 2020 Apr 3;2:1-7.

31. Sanche Set al. High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis. 2020 Jul. doi. org/10.3201/eid2607.200282.

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For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:


COVID-19 in kids
Children and young adults in all age groups can develop severe illess after SARS-CoV-2 infection, but infants and teens are most likely to be hospitalized, according to retrospective data from 177 children and young adults at a single center. “One patient had features consistent with the recently emerged Kawasaki disease–like presentation with hyperinflammatory state, hypotension, and profound myocardial depression,” Roberta L. DeBiasi, MD, of Children’s National Hospital, Washington, and colleagues reported in the Journal of Pediatrics. READ MORE

Avoiding ageism in COVID resource allocation
The American Geriatrics Society has issued new policy recommendations for resource allocation during the COVID-19 pandemic that are aimed at protecting seniors for ageism. When allocating scarce resources in an emergency, officials should equally weigh in-hospital survival and severe comorbidities contributing to short-term mortality, the group wrote. “Age per se should never be used as a means for a categorical exclusion from therapeutic interventions that represent the standard of care. ... Likewise, specific age-based cutoffs should not be used in resource allocation strategies,” AGS officials wrote in the statement. READ MORE

Preventing addiction-related suicide
Individuals with substance use disorders are at a significant risk for suicide, but there have been few evidence-based options for their treatment. Now a single intervention is showing promise for this high-risk group. In a large, multicenter randomized effectiveness study, a single 3-hour-long group psychosocial intervention resulted in significantly improved knowledge and attitudes regarding suicide that persisted at 6 months of follow-up. The intervention to prevent future suicide was designed specifically for patients who were in intensive outpatient programs for addiction treatment. “We’ve shown that suicide prevention in intensive outpatient program addiction groups is feasible, easy to train, and highly rated by counselors, and I’d say it’s very adaptable, easy to go national in almost any addiction treatment program, right out of the box,” said Richard K. Ries, MD, director of outpatient psychiatry as well as the psychiatry addiction division at Harborview Medical Center. READ MORE

TNF inhibitors may hamper COVID-19 severity
Early evidence from the COVID-19 Global Rheumatology Alliance Registry has produced an intriguing result: Patients on tumor necrosis factor inhibitors for their rheumatic disease are less likely to require hospitalization when infected with COVID-19. The registry data also show that taking hydroxychloroquine or other antimalarials at the time of COVID-19 infection had no impact on hospitalization. “A strength of the global registry has been that it provides timely data that’s been very helpful for rheumatologists to rapidly dispel misinformation that has been spread about hydroxychloroquine, especially statements about lupus patients not getting COVID-19. We know from these data that’s not true,” said Jinoos Yazdany, MD, professor of medicine at the University of California, San Francisco, and chief of rheumatology at San Francisco General Hospital. READ MORE

Audrey Hepburn’s lessons in pandemic grace
There are a lot of new skills required for praticing medicine during the COVID-19 pandemic. In his latest MDedge column, Jeffrey Benabio, MD, explains that grace is one of them. Dr. Benabio, director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego, looks to Audrey Hepburn for inspiration. “Effort is also required for telephone and video visits,” he writes. “In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.” READ MORE

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:


COVID-19 in kids
Children and young adults in all age groups can develop severe illess after SARS-CoV-2 infection, but infants and teens are most likely to be hospitalized, according to retrospective data from 177 children and young adults at a single center. “One patient had features consistent with the recently emerged Kawasaki disease–like presentation with hyperinflammatory state, hypotension, and profound myocardial depression,” Roberta L. DeBiasi, MD, of Children’s National Hospital, Washington, and colleagues reported in the Journal of Pediatrics. READ MORE

Avoiding ageism in COVID resource allocation
The American Geriatrics Society has issued new policy recommendations for resource allocation during the COVID-19 pandemic that are aimed at protecting seniors for ageism. When allocating scarce resources in an emergency, officials should equally weigh in-hospital survival and severe comorbidities contributing to short-term mortality, the group wrote. “Age per se should never be used as a means for a categorical exclusion from therapeutic interventions that represent the standard of care. ... Likewise, specific age-based cutoffs should not be used in resource allocation strategies,” AGS officials wrote in the statement. READ MORE

Preventing addiction-related suicide
Individuals with substance use disorders are at a significant risk for suicide, but there have been few evidence-based options for their treatment. Now a single intervention is showing promise for this high-risk group. In a large, multicenter randomized effectiveness study, a single 3-hour-long group psychosocial intervention resulted in significantly improved knowledge and attitudes regarding suicide that persisted at 6 months of follow-up. The intervention to prevent future suicide was designed specifically for patients who were in intensive outpatient programs for addiction treatment. “We’ve shown that suicide prevention in intensive outpatient program addiction groups is feasible, easy to train, and highly rated by counselors, and I’d say it’s very adaptable, easy to go national in almost any addiction treatment program, right out of the box,” said Richard K. Ries, MD, director of outpatient psychiatry as well as the psychiatry addiction division at Harborview Medical Center. READ MORE

TNF inhibitors may hamper COVID-19 severity
Early evidence from the COVID-19 Global Rheumatology Alliance Registry has produced an intriguing result: Patients on tumor necrosis factor inhibitors for their rheumatic disease are less likely to require hospitalization when infected with COVID-19. The registry data also show that taking hydroxychloroquine or other antimalarials at the time of COVID-19 infection had no impact on hospitalization. “A strength of the global registry has been that it provides timely data that’s been very helpful for rheumatologists to rapidly dispel misinformation that has been spread about hydroxychloroquine, especially statements about lupus patients not getting COVID-19. We know from these data that’s not true,” said Jinoos Yazdany, MD, professor of medicine at the University of California, San Francisco, and chief of rheumatology at San Francisco General Hospital. READ MORE

Audrey Hepburn’s lessons in pandemic grace
There are a lot of new skills required for praticing medicine during the COVID-19 pandemic. In his latest MDedge column, Jeffrey Benabio, MD, explains that grace is one of them. Dr. Benabio, director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego, looks to Audrey Hepburn for inspiration. “Effort is also required for telephone and video visits,” he writes. “In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.” READ MORE

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

A universal chimeric antigen receptor (CAR) T-cell therapy produced responses in adults with relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL), according to initial findings from an ongoing study.

The first five patients enrolled in this first-in-human study received conditioning and an infusion of the premanufactured CD7-targeted CAR T-cell therapy, TruUCAR GC027.

All five patients achieved a complete remission (CR) or CR with incomplete count recovery (CRi), although one patient had a morphological relapse at 1 month.

Xinxin Wang, PhD, reported these results at the AACR Virtual Meeting I. Dr. Wang is employed by Gracell Biotechnologies in Shanghai, China, which is the company developing TruUCAR GC027.

The CAR T-cell therapy is manufactured using lentivirus and leukopaks from HLA-mismatched healthy donors, according to Dr. Wang. TruUCAR GC027 contains second-generation CAR T cells with genomic disruption of TCR-alpha and CD7 to help prevent graft-versus-host disease and fratricide.

TruUCAR GC027 was previously shown to expand and have antileukemic activity in a murine model, Dr. Wang noted.
 

Patients and treatment

The five patients in the phase 1 study had a median age of 24 years (range, 19 to 38 years). They had heavily pretreated T-ALL, with a median of 5 prior lines of therapy (range, 1-9). Baseline bone marrow tumor burden ranged from 4% to 80.2% (median, 38.2%).

None of the patients received prior allogeneic hematopoietic stem cell transplant.

All patients received a preconditioning chemotherapy regimen. One patient received TruUCAR GC027 at dose level 1 (6 x 10⁶ cells/kg), three patients received dose level 2 (1 x 10⁷ cells/kg), and one patient received dose level 3 (1.5 x 10⁷ cells/kg) – each as a single infusion.
 

Expansion, response, and safety

“GC027 expansion, analyzed by flow [cytometry] was observed in most of the patients treated,” Dr. Wang said. “We started to see GC027 in the peripheral blood as early as day 5, with peaks around day 7-14.”

All five patients had a CR or CRi at the first postinfusion evaluation, which occurred at day 14 in four of the five patients. Four patients also achieved minimum residual disease (MRD) negativity by 1 month of follow-up and remained in MRD-negative CR at the February 6, 2020, data cutoff.

One patient achieved MRD-positive CR at day 14 but experienced morphological relapse at 1 month.

In the four patients with MRD-negative CR at 1 month, cellular expansion was observed as early as day 5 and continued for 2 weeks, but the patient who relapsed at day 29 showed no cellular expansion on flow cytometry, Dr. Wang said.

However, by a more sensitive quantitative polymerase chain reaction analysis, cellular expansion was observed in all five patients starting as early as day 1 after infusion, although the patient who relapsed had the shortest duration of expansion.

All patients developed cytokine release syndrome (CRS). Four patients experienced grade 3 CRS, and one experienced grade 4 CRS.

“The CRS was manageable and reversible,” Dr. Wang said, adding that none of the patients experienced neurotoxicity or graft-versus-host disease.

Prolonged cytopenia occurred in four patients, including one grade 1 case, two grade 3 cases, and one grade 4 case. Grade 3 pulmonary infections occurred in three patients, and grade 3 neutropenia occurred in all five patients.
 

‘Very impressive’ early results

Dr. Wang said the responses observed in this trial are notable because T-ALL constitutes 20%-25% of all adult ALL and 12%-15% of all pediatric ALL. T-ALL is highly aggressive, with event-free and overall survival of less than 25% in the relapsed setting. Dr. Wang noted that, despite the high unmet medical need and lack of treatment options for T-ALL, the development of novel immunotherapies has lagged.

One challenge is that T-ALL and normal T cells share common surface antigens, so targeted therapies for T-ALL will also target normal T cells. Another challenge is the potential contamination by malignant cells in autologous T-cell products, Dr. Wang said, noting that this can be avoided with universal CAR T cells.

Further, CD7 is a good target for T-ALL because it is expressed in more than 95% of T-ALL patients, she added.

“[TruUCAR GC027] demonstrated a very promising early response rate ... and showed a manageable toxicity profile at all three dose levels,” Dr. Wang said in closing, noting that further evaluation is warranted.

Indeed, the results of this next-generation CAR T-cell trial are “very impressive,” said invited discussant Yvonne Y. Chen, PhD, of the University of California, Los Angeles.

There have been concerns that “off-the-shelf” CAR T-cell products like TruUCAR GC027 might be limited by factors such as a reduced level of CAR T-cell persistence and therefore reduced efficacy leading to a need for repeat dosing, Dr. Chen noted. However, Dr. Wang and her colleagues showed a 100% CR/CRi rate with a single dose of CAR T cells and without graft-versus-host disease or neurotoxicity, Dr. Chen emphasized.

“I think it’s also important to note, however, that there’s quite a high incidence rate of grade 3 or higher toxicities, including CRS,” Dr. Chen said. “I suspect this may have something to do with the fairly high dosing levels used in this trial.”

The “big question,” however, is durability of the response, Dr. Chen said. “And this is something that the field will really watch as this trial progresses beyond the 7-month monitoring period ... reported today.”

Dr. Wang is an employee of Gracell Biotechnologies. Dr. Chen is cofounder of Kalthera Therapeutics and a scientific adviser for Gritstone Oncology and Notch Therapeutics.

sworcester@mdedge.com

SOURCE: Wang X et al. AACR 2020, Abstract CT052.

A universal chimeric antigen receptor (CAR) T-cell therapy produced responses in adults with relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL), according to initial findings from an ongoing study.

The first five patients enrolled in this first-in-human study received conditioning and an infusion of the premanufactured CD7-targeted CAR T-cell therapy, TruUCAR GC027.

All five patients achieved a complete remission (CR) or CR with incomplete count recovery (CRi), although one patient had a morphological relapse at 1 month.

Xinxin Wang, PhD, reported these results at the AACR Virtual Meeting I. Dr. Wang is employed by Gracell Biotechnologies in Shanghai, China, which is the company developing TruUCAR GC027.

The CAR T-cell therapy is manufactured using lentivirus and leukopaks from HLA-mismatched healthy donors, according to Dr. Wang. TruUCAR GC027 contains second-generation CAR T cells with genomic disruption of TCR-alpha and CD7 to help prevent graft-versus-host disease and fratricide.

TruUCAR GC027 was previously shown to expand and have antileukemic activity in a murine model, Dr. Wang noted.
 

Patients and treatment

The five patients in the phase 1 study had a median age of 24 years (range, 19 to 38 years). They had heavily pretreated T-ALL, with a median of 5 prior lines of therapy (range, 1-9). Baseline bone marrow tumor burden ranged from 4% to 80.2% (median, 38.2%).

None of the patients received prior allogeneic hematopoietic stem cell transplant.

All patients received a preconditioning chemotherapy regimen. One patient received TruUCAR GC027 at dose level 1 (6 x 10⁶ cells/kg), three patients received dose level 2 (1 x 10⁷ cells/kg), and one patient received dose level 3 (1.5 x 10⁷ cells/kg) – each as a single infusion.
 

Expansion, response, and safety

“GC027 expansion, analyzed by flow [cytometry] was observed in most of the patients treated,” Dr. Wang said. “We started to see GC027 in the peripheral blood as early as day 5, with peaks around day 7-14.”

All five patients had a CR or CRi at the first postinfusion evaluation, which occurred at day 14 in four of the five patients. Four patients also achieved minimum residual disease (MRD) negativity by 1 month of follow-up and remained in MRD-negative CR at the February 6, 2020, data cutoff.

One patient achieved MRD-positive CR at day 14 but experienced morphological relapse at 1 month.

In the four patients with MRD-negative CR at 1 month, cellular expansion was observed as early as day 5 and continued for 2 weeks, but the patient who relapsed at day 29 showed no cellular expansion on flow cytometry, Dr. Wang said.

However, by a more sensitive quantitative polymerase chain reaction analysis, cellular expansion was observed in all five patients starting as early as day 1 after infusion, although the patient who relapsed had the shortest duration of expansion.

All patients developed cytokine release syndrome (CRS). Four patients experienced grade 3 CRS, and one experienced grade 4 CRS.

“The CRS was manageable and reversible,” Dr. Wang said, adding that none of the patients experienced neurotoxicity or graft-versus-host disease.

Prolonged cytopenia occurred in four patients, including one grade 1 case, two grade 3 cases, and one grade 4 case. Grade 3 pulmonary infections occurred in three patients, and grade 3 neutropenia occurred in all five patients.
 

‘Very impressive’ early results

Dr. Wang said the responses observed in this trial are notable because T-ALL constitutes 20%-25% of all adult ALL and 12%-15% of all pediatric ALL. T-ALL is highly aggressive, with event-free and overall survival of less than 25% in the relapsed setting. Dr. Wang noted that, despite the high unmet medical need and lack of treatment options for T-ALL, the development of novel immunotherapies has lagged.

One challenge is that T-ALL and normal T cells share common surface antigens, so targeted therapies for T-ALL will also target normal T cells. Another challenge is the potential contamination by malignant cells in autologous T-cell products, Dr. Wang said, noting that this can be avoided with universal CAR T cells.

Further, CD7 is a good target for T-ALL because it is expressed in more than 95% of T-ALL patients, she added.

“[TruUCAR GC027] demonstrated a very promising early response rate ... and showed a manageable toxicity profile at all three dose levels,” Dr. Wang said in closing, noting that further evaluation is warranted.

Indeed, the results of this next-generation CAR T-cell trial are “very impressive,” said invited discussant Yvonne Y. Chen, PhD, of the University of California, Los Angeles.

There have been concerns that “off-the-shelf” CAR T-cell products like TruUCAR GC027 might be limited by factors such as a reduced level of CAR T-cell persistence and therefore reduced efficacy leading to a need for repeat dosing, Dr. Chen noted. However, Dr. Wang and her colleagues showed a 100% CR/CRi rate with a single dose of CAR T cells and without graft-versus-host disease or neurotoxicity, Dr. Chen emphasized.

“I think it’s also important to note, however, that there’s quite a high incidence rate of grade 3 or higher toxicities, including CRS,” Dr. Chen said. “I suspect this may have something to do with the fairly high dosing levels used in this trial.”

The “big question,” however, is durability of the response, Dr. Chen said. “And this is something that the field will really watch as this trial progresses beyond the 7-month monitoring period ... reported today.”

Dr. Wang is an employee of Gracell Biotechnologies. Dr. Chen is cofounder of Kalthera Therapeutics and a scientific adviser for Gritstone Oncology and Notch Therapeutics.

sworcester@mdedge.com

SOURCE: Wang X et al. AACR 2020, Abstract CT052.

A universal chimeric antigen receptor (CAR) T-cell therapy produced responses in adults with relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL), according to initial findings from an ongoing study.

The first five patients enrolled in this first-in-human study received conditioning and an infusion of the premanufactured CD7-targeted CAR T-cell therapy, TruUCAR GC027.

All five patients achieved a complete remission (CR) or CR with incomplete count recovery (CRi), although one patient had a morphological relapse at 1 month.

Xinxin Wang, PhD, reported these results at the AACR Virtual Meeting I. Dr. Wang is employed by Gracell Biotechnologies in Shanghai, China, which is the company developing TruUCAR GC027.

The CAR T-cell therapy is manufactured using lentivirus and leukopaks from HLA-mismatched healthy donors, according to Dr. Wang. TruUCAR GC027 contains second-generation CAR T cells with genomic disruption of TCR-alpha and CD7 to help prevent graft-versus-host disease and fratricide.

TruUCAR GC027 was previously shown to expand and have antileukemic activity in a murine model, Dr. Wang noted.
 

Patients and treatment

The five patients in the phase 1 study had a median age of 24 years (range, 19 to 38 years). They had heavily pretreated T-ALL, with a median of 5 prior lines of therapy (range, 1-9). Baseline bone marrow tumor burden ranged from 4% to 80.2% (median, 38.2%).

None of the patients received prior allogeneic hematopoietic stem cell transplant.

All patients received a preconditioning chemotherapy regimen. One patient received TruUCAR GC027 at dose level 1 (6 x 10⁶ cells/kg), three patients received dose level 2 (1 x 10⁷ cells/kg), and one patient received dose level 3 (1.5 x 10⁷ cells/kg) – each as a single infusion.
 

Expansion, response, and safety

“GC027 expansion, analyzed by flow [cytometry] was observed in most of the patients treated,” Dr. Wang said. “We started to see GC027 in the peripheral blood as early as day 5, with peaks around day 7-14.”

All five patients had a CR or CRi at the first postinfusion evaluation, which occurred at day 14 in four of the five patients. Four patients also achieved minimum residual disease (MRD) negativity by 1 month of follow-up and remained in MRD-negative CR at the February 6, 2020, data cutoff.

One patient achieved MRD-positive CR at day 14 but experienced morphological relapse at 1 month.

In the four patients with MRD-negative CR at 1 month, cellular expansion was observed as early as day 5 and continued for 2 weeks, but the patient who relapsed at day 29 showed no cellular expansion on flow cytometry, Dr. Wang said.

However, by a more sensitive quantitative polymerase chain reaction analysis, cellular expansion was observed in all five patients starting as early as day 1 after infusion, although the patient who relapsed had the shortest duration of expansion.

All patients developed cytokine release syndrome (CRS). Four patients experienced grade 3 CRS, and one experienced grade 4 CRS.

“The CRS was manageable and reversible,” Dr. Wang said, adding that none of the patients experienced neurotoxicity or graft-versus-host disease.

Prolonged cytopenia occurred in four patients, including one grade 1 case, two grade 3 cases, and one grade 4 case. Grade 3 pulmonary infections occurred in three patients, and grade 3 neutropenia occurred in all five patients.
 

‘Very impressive’ early results

Dr. Wang said the responses observed in this trial are notable because T-ALL constitutes 20%-25% of all adult ALL and 12%-15% of all pediatric ALL. T-ALL is highly aggressive, with event-free and overall survival of less than 25% in the relapsed setting. Dr. Wang noted that, despite the high unmet medical need and lack of treatment options for T-ALL, the development of novel immunotherapies has lagged.

One challenge is that T-ALL and normal T cells share common surface antigens, so targeted therapies for T-ALL will also target normal T cells. Another challenge is the potential contamination by malignant cells in autologous T-cell products, Dr. Wang said, noting that this can be avoided with universal CAR T cells.

Further, CD7 is a good target for T-ALL because it is expressed in more than 95% of T-ALL patients, she added.

“[TruUCAR GC027] demonstrated a very promising early response rate ... and showed a manageable toxicity profile at all three dose levels,” Dr. Wang said in closing, noting that further evaluation is warranted.

Indeed, the results of this next-generation CAR T-cell trial are “very impressive,” said invited discussant Yvonne Y. Chen, PhD, of the University of California, Los Angeles.

There have been concerns that “off-the-shelf” CAR T-cell products like TruUCAR GC027 might be limited by factors such as a reduced level of CAR T-cell persistence and therefore reduced efficacy leading to a need for repeat dosing, Dr. Chen noted. However, Dr. Wang and her colleagues showed a 100% CR/CRi rate with a single dose of CAR T cells and without graft-versus-host disease or neurotoxicity, Dr. Chen emphasized.

“I think it’s also important to note, however, that there’s quite a high incidence rate of grade 3 or higher toxicities, including CRS,” Dr. Chen said. “I suspect this may have something to do with the fairly high dosing levels used in this trial.”

The “big question,” however, is durability of the response, Dr. Chen said. “And this is something that the field will really watch as this trial progresses beyond the 7-month monitoring period ... reported today.”

Dr. Wang is an employee of Gracell Biotechnologies. Dr. Chen is cofounder of Kalthera Therapeutics and a scientific adviser for Gritstone Oncology and Notch Therapeutics.

sworcester@mdedge.com

SOURCE: Wang X et al. AACR 2020, Abstract CT052.

Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.

Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”

Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.

Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.

Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.

Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.

When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.

Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.

Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.

Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.

Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”

Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.

Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.

Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.

Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.

When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.

Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.

Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.

Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.

Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”

Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.

Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.

Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.

Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.

When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.

Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.

Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.

When a mass trauma or disaster hit, mental health clinicians often focus on encouraging resilience. In the middle of the COVID-19 pandemic, however, interventions that maintain calm, build community, and sustain hope may take priority, according to a working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Research Network of the European College of Neuropsychopharmacology.

While the COVID-19 pandemic has tested everyone, “[p]erhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD),” say the group members, who include clinicians from Stanford University, University of California, and VAHCS in Palo Alto. “Paradoxically, they are ‘experts by experience’ in attempting to avert dangers through enacting compulsive behaviors.”

Consequently, coronavirus may become all these patients think about. Some who have contamination-related OCD may express doubts about the rationality of their therapies, while other  patients have told their clinicians they were “right all along.” Moreover, people with OCD can be inflexible at “unlearning” danger responses and are thus conditioned to prolonged virus-induced distress and anxiety.

In response to the emerging crisis and growing calls from patients and clinicians, the working group produced a consensus statement with the aim of delivering “pragmatic guidance” for the treatment of OCD under COVID-19 conditions. Their report covers the issues they judged currently most relevant for clinicians.

Stipulating that the best available treatments for most patients are likely to include evidence-based pharmacotherapy and modifying or pausing cognitive behavioral therapy (CBT) in conjunction with enhanced supportive therapies, the panel also recommends:

• Using telemedicine, including telephone or video calls, but be aware of the patient’s circumstances: For some, poverty makes it hard to stay home. Regularly check on patients who are likely to engage in particularly harmful decontamination rituals or behaviors. The added benefit of video calling is that it helps the therapist perform a visual risk evaluation—which is especially valuable for patients living alone—to determine the condition of the patient's hands, presence of food in the fridge or cupboard, etc.
• Taking a careful history, clarifying the extent to which the symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of the OCD. Don’t assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19.
• Assessing suicide risk. Factors such as a recent increase in OCD severity, experiencing a family member found positive for COVID-19, or finding the effects of quarantine or isolation distressing have anecdotally been shown to raise suicide risk.
• Providing balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Patients need to understand that this health crisis may persist for some time, and they will need to manage their stress levels over that time (eg, by putting into play long-term routines of mindfulness techniques, exercise and structure).
• Inquiring about Internet usage and news consumption. Some patients spend hours a day watching television and online media sources, which may significantly exacerbate OCD and anxiety symptoms. Offer a balanced approach (eg, individuals should not spend more than a half-hour in the morning and at night to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest trusted sources to avoid myths, rumors and misinformation.
• Identifying and discouraging high-risk obsessive-compulsive behaviors, such as washing in water that is too hot or bleach, or total fasting. Some patients, as a result of doubt or uncertainty about whether food in the house is contaminated, respond by throwing everything away and consequently have little or nothing to eat. Encourage eating and drinking to maintain health.

Keeping people calm and reducing the risk of depression using supportive techniques are an essential element of care. Nevertheless, the group says, clinicians should still try to find ways to help patients foster resilience towards obsessional thinking and compulsive acts.

“We are aware this guidance marks a change in practice for many clinicians treating OCD,” they note. “Temporarily modifying or pausing in vivo CBT with ERP [exposure response prevention] for contamination-related OCD, … is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed.”

Understanding the impact of a pandemic like COVID-19 on patients with mental health disorders can provide important insights into the environmental determinants, the panel says. They urge research-active groups to investigate the effects of such changes on health outcomes—as well as exploring ways to address the expected rise in incidence of OCD once the pandemic is over.

When a mass trauma or disaster hit, mental health clinicians often focus on encouraging resilience. In the middle of the COVID-19 pandemic, however, interventions that maintain calm, build community, and sustain hope may take priority, according to a working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Research Network of the European College of Neuropsychopharmacology.

While the COVID-19 pandemic has tested everyone, “[p]erhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD),” say the group members, who include clinicians from Stanford University, University of California, and VAHCS in Palo Alto. “Paradoxically, they are ‘experts by experience’ in attempting to avert dangers through enacting compulsive behaviors.”

Consequently, coronavirus may become all these patients think about. Some who have contamination-related OCD may express doubts about the rationality of their therapies, while other  patients have told their clinicians they were “right all along.” Moreover, people with OCD can be inflexible at “unlearning” danger responses and are thus conditioned to prolonged virus-induced distress and anxiety.

In response to the emerging crisis and growing calls from patients and clinicians, the working group produced a consensus statement with the aim of delivering “pragmatic guidance” for the treatment of OCD under COVID-19 conditions. Their report covers the issues they judged currently most relevant for clinicians.

Stipulating that the best available treatments for most patients are likely to include evidence-based pharmacotherapy and modifying or pausing cognitive behavioral therapy (CBT) in conjunction with enhanced supportive therapies, the panel also recommends:

• Using telemedicine, including telephone or video calls, but be aware of the patient’s circumstances: For some, poverty makes it hard to stay home. Regularly check on patients who are likely to engage in particularly harmful decontamination rituals or behaviors. The added benefit of video calling is that it helps the therapist perform a visual risk evaluation—which is especially valuable for patients living alone—to determine the condition of the patient's hands, presence of food in the fridge or cupboard, etc.
• Taking a careful history, clarifying the extent to which the symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of the OCD. Don’t assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19.
• Assessing suicide risk. Factors such as a recent increase in OCD severity, experiencing a family member found positive for COVID-19, or finding the effects of quarantine or isolation distressing have anecdotally been shown to raise suicide risk.
• Providing balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Patients need to understand that this health crisis may persist for some time, and they will need to manage their stress levels over that time (eg, by putting into play long-term routines of mindfulness techniques, exercise and structure).
• Inquiring about Internet usage and news consumption. Some patients spend hours a day watching television and online media sources, which may significantly exacerbate OCD and anxiety symptoms. Offer a balanced approach (eg, individuals should not spend more than a half-hour in the morning and at night to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest trusted sources to avoid myths, rumors and misinformation.
• Identifying and discouraging high-risk obsessive-compulsive behaviors, such as washing in water that is too hot or bleach, or total fasting. Some patients, as a result of doubt or uncertainty about whether food in the house is contaminated, respond by throwing everything away and consequently have little or nothing to eat. Encourage eating and drinking to maintain health.

Keeping people calm and reducing the risk of depression using supportive techniques are an essential element of care. Nevertheless, the group says, clinicians should still try to find ways to help patients foster resilience towards obsessional thinking and compulsive acts.

“We are aware this guidance marks a change in practice for many clinicians treating OCD,” they note. “Temporarily modifying or pausing in vivo CBT with ERP [exposure response prevention] for contamination-related OCD, … is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed.”

Understanding the impact of a pandemic like COVID-19 on patients with mental health disorders can provide important insights into the environmental determinants, the panel says. They urge research-active groups to investigate the effects of such changes on health outcomes—as well as exploring ways to address the expected rise in incidence of OCD once the pandemic is over.

When a mass trauma or disaster hit, mental health clinicians often focus on encouraging resilience. In the middle of the COVID-19 pandemic, however, interventions that maintain calm, build community, and sustain hope may take priority, according to a working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Research Network of the European College of Neuropsychopharmacology.

While the COVID-19 pandemic has tested everyone, “[p]erhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD),” say the group members, who include clinicians from Stanford University, University of California, and VAHCS in Palo Alto. “Paradoxically, they are ‘experts by experience’ in attempting to avert dangers through enacting compulsive behaviors.”

Consequently, coronavirus may become all these patients think about. Some who have contamination-related OCD may express doubts about the rationality of their therapies, while other  patients have told their clinicians they were “right all along.” Moreover, people with OCD can be inflexible at “unlearning” danger responses and are thus conditioned to prolonged virus-induced distress and anxiety.

In response to the emerging crisis and growing calls from patients and clinicians, the working group produced a consensus statement with the aim of delivering “pragmatic guidance” for the treatment of OCD under COVID-19 conditions. Their report covers the issues they judged currently most relevant for clinicians.

Stipulating that the best available treatments for most patients are likely to include evidence-based pharmacotherapy and modifying or pausing cognitive behavioral therapy (CBT) in conjunction with enhanced supportive therapies, the panel also recommends:

• Using telemedicine, including telephone or video calls, but be aware of the patient’s circumstances: For some, poverty makes it hard to stay home. Regularly check on patients who are likely to engage in particularly harmful decontamination rituals or behaviors. The added benefit of video calling is that it helps the therapist perform a visual risk evaluation—which is especially valuable for patients living alone—to determine the condition of the patient's hands, presence of food in the fridge or cupboard, etc.
• Taking a careful history, clarifying the extent to which the symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of the OCD. Don’t assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19.
• Assessing suicide risk. Factors such as a recent increase in OCD severity, experiencing a family member found positive for COVID-19, or finding the effects of quarantine or isolation distressing have anecdotally been shown to raise suicide risk.
• Providing balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Patients need to understand that this health crisis may persist for some time, and they will need to manage their stress levels over that time (eg, by putting into play long-term routines of mindfulness techniques, exercise and structure).
• Inquiring about Internet usage and news consumption. Some patients spend hours a day watching television and online media sources, which may significantly exacerbate OCD and anxiety symptoms. Offer a balanced approach (eg, individuals should not spend more than a half-hour in the morning and at night to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest trusted sources to avoid myths, rumors and misinformation.
• Identifying and discouraging high-risk obsessive-compulsive behaviors, such as washing in water that is too hot or bleach, or total fasting. Some patients, as a result of doubt or uncertainty about whether food in the house is contaminated, respond by throwing everything away and consequently have little or nothing to eat. Encourage eating and drinking to maintain health.

Keeping people calm and reducing the risk of depression using supportive techniques are an essential element of care. Nevertheless, the group says, clinicians should still try to find ways to help patients foster resilience towards obsessional thinking and compulsive acts.

“We are aware this guidance marks a change in practice for many clinicians treating OCD,” they note. “Temporarily modifying or pausing in vivo CBT with ERP [exposure response prevention] for contamination-related OCD, … is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed.”

Understanding the impact of a pandemic like COVID-19 on patients with mental health disorders can provide important insights into the environmental determinants, the panel says. They urge research-active groups to investigate the effects of such changes on health outcomes—as well as exploring ways to address the expected rise in incidence of OCD once the pandemic is over.

The American Geriatrics Society has issued policy recommendations aimed at protecting seniors from ageism when it comes to resource allocation in the current context of treating patients infected with COVID-19.

“The AGS is deeply concerned about potentially negative long-term consequences of COVID-19 emergency rationing strategies that disfavor older adults,” Timothy W. Farrell, MD, University of Utah, Salt Lake City, and colleagues wrote in an AGS position statement published online in the Journal of the American Geriatrics Society.

“In particular, rationing strategies that are solely, or predominantly, based on age cutoffs could lead to persistent beliefs that older adults’ lives are less valuable than others or are even expendable, and contribute to already rampant ageism,” the authors continued. “Unless the injustice in these strategies is corrected, this will be a persistent issue if there is a resurgence of COVID-19 cases, a pandemic caused by a different virus in the future, or a different type of disaster where resources are scarce.”

To counter a potential bias against the elderly population should scarce resources force rationing decisions, AGS has made recommendations and strategies that health care systems should incorporate into a policy framework.

One principle in the AGS statement is clear: “Age per se should never be used as a means for a categorical exclusion from therapeutic interventions that represent the standard of care. ... Likewise, specific age-based cutoffs should not be used in resource allocation strategies.”

Peter Angelos, MD, chief of endocrine surgery at the University of Chicago, applauded the position statement.

“It is a well-written statement and I do think that it appropriately suggests that age in and of itself is not a good predictor of who is at greatest risk if infected with coronavirus,” Dr. Angelos, who also serves as the associate director of the MacLean Center for Clinical Medical Ethics, said in an interview.

He suggested a scenario in which a younger person could have multiple comorbidities that could put that individual at a higher risk of death because of complications from COVID-19 (or another pandemic in the future), compared with an older patient who is otherwise a healthy individual with a lower risk of death.

“For that reason, I agree with the authors that there should not be an arbitrary cutoff of age for which we don’t treat people or we limit treatment.”

Rather, the authors state that the primary allocation method in emergency circumstances that require rationing because of lack of resources should “equally weigh in-hospital survival and severe comorbidities contributing to short-term (<6 months) mortality.”

When assessing comorbidities, “the disparate impact of social determinants of health including culture, ethnicity, socioeconomic status, and other factors should be considered.”

AGS’s position statement adds that criteria such as “life-years saved” and “long-term predicted life expectancy” should not be used as they tend to disadvantage older adults.

The organization noted that institutions “should develop resource allocation strategies that are transparent, applied uniformly, and developed with forethought and input from multiple disciplines including ethics, medicine, law, and nursing. These strategies should be used consistently when making emergency decisions.” The AGS called for institutions to frequently review these strategies to ensure they are updated with the most recent evidence and to identify any issues of bias that may emerge.

Dr. Angelos stressed that these guidelines should be developed in a transparent and open fashion. He also highlighted the AGS recommendation of the use of triage officers or triage committees to make the determination about resource allocation should those decisions need to be made.

“We don’t want caregivers who are at the bedside taking care of patients to have the responsibility to say ‘We are going to treat one person as opposed to another person,’ ” he said. “You want to have those decisions made by a team that is separate from the bedside caregivers.”

He agreed with the statement authors that the goal of the triage committee decisions should be to maximize lives saved as opposed to life-years saved. Dr. Angelos noted that his institution’s plan focuses on lives saved should the need for resource rationing come to pass.

In addition to institutional strategies, AGS also emphasized in the position statement that older adults should develop individual care plans that include lists of medical conditions, medications, health care providers, and advance directives. The statement also noted that about only 50% of adults over age 60 years have complete advance directives, a rate Dr. Farrell and colleagues state is “unacceptably low.”

“Advance care planning should not be limited to the purview of only the primary care, geriatrics, or palliative care health professional, and urgent efforts should be made to discuss patient preferences before an emergent need arises,” the paper states, noting that specialists need to be a part of the conversation.

However, the position statement is clear that, while AGS is encouraging providers to talk about advance care planning with their patients, “providers should not pressure, even subtly, patients to engage in advance care planning or change to Do Not Resuscitate/Do Not Intubate (DNR/DNI) status with the intent to conserve health resources.”

Dr. Angelos reiterated this point and suggested that advance directive conversations need to be happening and happening more often.

“This current pandemic has forced us all to realize that, even in well-resourced societies like the United States, we may be faced with situations of absolute scarcity, so we ought to have these conversations up front so that we are not put in a position where we have to make decisions, and those decisions may not be well thought out and may not be ethically justifiable,” he said.

gtwachtman@mdedge.com

SOURCE: Farrell TW et al. J Am Geriat Soc. 2020 May 6; doi: 10.1111/jgs.16537.

The American Geriatrics Society has issued policy recommendations aimed at protecting seniors from ageism when it comes to resource allocation in the current context of treating patients infected with COVID-19.

“The AGS is deeply concerned about potentially negative long-term consequences of COVID-19 emergency rationing strategies that disfavor older adults,” Timothy W. Farrell, MD, University of Utah, Salt Lake City, and colleagues wrote in an AGS position statement published online in the Journal of the American Geriatrics Society.

“In particular, rationing strategies that are solely, or predominantly, based on age cutoffs could lead to persistent beliefs that older adults’ lives are less valuable than others or are even expendable, and contribute to already rampant ageism,” the authors continued. “Unless the injustice in these strategies is corrected, this will be a persistent issue if there is a resurgence of COVID-19 cases, a pandemic caused by a different virus in the future, or a different type of disaster where resources are scarce.”

To counter a potential bias against the elderly population should scarce resources force rationing decisions, AGS has made recommendations and strategies that health care systems should incorporate into a policy framework.

One principle in the AGS statement is clear: “Age per se should never be used as a means for a categorical exclusion from therapeutic interventions that represent the standard of care. ... Likewise, specific age-based cutoffs should not be used in resource allocation strategies.”

Peter Angelos, MD, chief of endocrine surgery at the University of Chicago, applauded the position statement.

“It is a well-written statement and I do think that it appropriately suggests that age in and of itself is not a good predictor of who is at greatest risk if infected with coronavirus,” Dr. Angelos, who also serves as the associate director of the MacLean Center for Clinical Medical Ethics, said in an interview.

He suggested a scenario in which a younger person could have multiple comorbidities that could put that individual at a higher risk of death because of complications from COVID-19 (or another pandemic in the future), compared with an older patient who is otherwise a healthy individual with a lower risk of death.

“For that reason, I agree with the authors that there should not be an arbitrary cutoff of age for which we don’t treat people or we limit treatment.”

Rather, the authors state that the primary allocation method in emergency circumstances that require rationing because of lack of resources should “equally weigh in-hospital survival and severe comorbidities contributing to short-term (<6 months) mortality.”

When assessing comorbidities, “the disparate impact of social determinants of health including culture, ethnicity, socioeconomic status, and other factors should be considered.”

AGS’s position statement adds that criteria such as “life-years saved” and “long-term predicted life expectancy” should not be used as they tend to disadvantage older adults.

The organization noted that institutions “should develop resource allocation strategies that are transparent, applied uniformly, and developed with forethought and input from multiple disciplines including ethics, medicine, law, and nursing. These strategies should be used consistently when making emergency decisions.” The AGS called for institutions to frequently review these strategies to ensure they are updated with the most recent evidence and to identify any issues of bias that may emerge.

Dr. Angelos stressed that these guidelines should be developed in a transparent and open fashion. He also highlighted the AGS recommendation of the use of triage officers or triage committees to make the determination about resource allocation should those decisions need to be made.

“We don’t want caregivers who are at the bedside taking care of patients to have the responsibility to say ‘We are going to treat one person as opposed to another person,’ ” he said. “You want to have those decisions made by a team that is separate from the bedside caregivers.”

He agreed with the statement authors that the goal of the triage committee decisions should be to maximize lives saved as opposed to life-years saved. Dr. Angelos noted that his institution’s plan focuses on lives saved should the need for resource rationing come to pass.

In addition to institutional strategies, AGS also emphasized in the position statement that older adults should develop individual care plans that include lists of medical conditions, medications, health care providers, and advance directives. The statement also noted that about only 50% of adults over age 60 years have complete advance directives, a rate Dr. Farrell and colleagues state is “unacceptably low.”

“Advance care planning should not be limited to the purview of only the primary care, geriatrics, or palliative care health professional, and urgent efforts should be made to discuss patient preferences before an emergent need arises,” the paper states, noting that specialists need to be a part of the conversation.

However, the position statement is clear that, while AGS is encouraging providers to talk about advance care planning with their patients, “providers should not pressure, even subtly, patients to engage in advance care planning or change to Do Not Resuscitate/Do Not Intubate (DNR/DNI) status with the intent to conserve health resources.”

Dr. Angelos reiterated this point and suggested that advance directive conversations need to be happening and happening more often.

“This current pandemic has forced us all to realize that, even in well-resourced societies like the United States, we may be faced with situations of absolute scarcity, so we ought to have these conversations up front so that we are not put in a position where we have to make decisions, and those decisions may not be well thought out and may not be ethically justifiable,” he said.

gtwachtman@mdedge.com

SOURCE: Farrell TW et al. J Am Geriat Soc. 2020 May 6; doi: 10.1111/jgs.16537.

The American Geriatrics Society has issued policy recommendations aimed at protecting seniors from ageism when it comes to resource allocation in the current context of treating patients infected with COVID-19.

“The AGS is deeply concerned about potentially negative long-term consequences of COVID-19 emergency rationing strategies that disfavor older adults,” Timothy W. Farrell, MD, University of Utah, Salt Lake City, and colleagues wrote in an AGS position statement published online in the Journal of the American Geriatrics Society.

“In particular, rationing strategies that are solely, or predominantly, based on age cutoffs could lead to persistent beliefs that older adults’ lives are less valuable than others or are even expendable, and contribute to already rampant ageism,” the authors continued. “Unless the injustice in these strategies is corrected, this will be a persistent issue if there is a resurgence of COVID-19 cases, a pandemic caused by a different virus in the future, or a different type of disaster where resources are scarce.”

To counter a potential bias against the elderly population should scarce resources force rationing decisions, AGS has made recommendations and strategies that health care systems should incorporate into a policy framework.

One principle in the AGS statement is clear: “Age per se should never be used as a means for a categorical exclusion from therapeutic interventions that represent the standard of care. ... Likewise, specific age-based cutoffs should not be used in resource allocation strategies.”

Peter Angelos, MD, chief of endocrine surgery at the University of Chicago, applauded the position statement.

“It is a well-written statement and I do think that it appropriately suggests that age in and of itself is not a good predictor of who is at greatest risk if infected with coronavirus,” Dr. Angelos, who also serves as the associate director of the MacLean Center for Clinical Medical Ethics, said in an interview.

He suggested a scenario in which a younger person could have multiple comorbidities that could put that individual at a higher risk of death because of complications from COVID-19 (or another pandemic in the future), compared with an older patient who is otherwise a healthy individual with a lower risk of death.

“For that reason, I agree with the authors that there should not be an arbitrary cutoff of age for which we don’t treat people or we limit treatment.”

Rather, the authors state that the primary allocation method in emergency circumstances that require rationing because of lack of resources should “equally weigh in-hospital survival and severe comorbidities contributing to short-term (<6 months) mortality.”

When assessing comorbidities, “the disparate impact of social determinants of health including culture, ethnicity, socioeconomic status, and other factors should be considered.”

AGS’s position statement adds that criteria such as “life-years saved” and “long-term predicted life expectancy” should not be used as they tend to disadvantage older adults.

The organization noted that institutions “should develop resource allocation strategies that are transparent, applied uniformly, and developed with forethought and input from multiple disciplines including ethics, medicine, law, and nursing. These strategies should be used consistently when making emergency decisions.” The AGS called for institutions to frequently review these strategies to ensure they are updated with the most recent evidence and to identify any issues of bias that may emerge.

Dr. Angelos stressed that these guidelines should be developed in a transparent and open fashion. He also highlighted the AGS recommendation of the use of triage officers or triage committees to make the determination about resource allocation should those decisions need to be made.

“We don’t want caregivers who are at the bedside taking care of patients to have the responsibility to say ‘We are going to treat one person as opposed to another person,’ ” he said. “You want to have those decisions made by a team that is separate from the bedside caregivers.”

He agreed with the statement authors that the goal of the triage committee decisions should be to maximize lives saved as opposed to life-years saved. Dr. Angelos noted that his institution’s plan focuses on lives saved should the need for resource rationing come to pass.

In addition to institutional strategies, AGS also emphasized in the position statement that older adults should develop individual care plans that include lists of medical conditions, medications, health care providers, and advance directives. The statement also noted that about only 50% of adults over age 60 years have complete advance directives, a rate Dr. Farrell and colleagues state is “unacceptably low.”

“Advance care planning should not be limited to the purview of only the primary care, geriatrics, or palliative care health professional, and urgent efforts should be made to discuss patient preferences before an emergent need arises,” the paper states, noting that specialists need to be a part of the conversation.

However, the position statement is clear that, while AGS is encouraging providers to talk about advance care planning with their patients, “providers should not pressure, even subtly, patients to engage in advance care planning or change to Do Not Resuscitate/Do Not Intubate (DNR/DNI) status with the intent to conserve health resources.”

Dr. Angelos reiterated this point and suggested that advance directive conversations need to be happening and happening more often.

“This current pandemic has forced us all to realize that, even in well-resourced societies like the United States, we may be faced with situations of absolute scarcity, so we ought to have these conversations up front so that we are not put in a position where we have to make decisions, and those decisions may not be well thought out and may not be ethically justifiable,” he said.

gtwachtman@mdedge.com

SOURCE: Farrell TW et al. J Am Geriat Soc. 2020 May 6; doi: 10.1111/jgs.16537.

From the ash of our post “coron-apocalyptic” world, we emerge. It’s back to work, to life in a new normal. Patients are still scarce and scared, as are some doctors. Queues of patients wait to clear security and enter the sterile area at every medical office. Water bottles are allowed, fevers and visitors are not. Those who fail clearance or who are afraid to be seen in person must be treated virtually. In this context, virtually means by telephone or video, yet, aptly, it also means “nearly or almost,” as in we can nearly or almost treat them these ways. We’ve emerged safely, but we’ve lost sensibility. Because of this, what’s important in the doctor-patient relationships will drift a bit. Clinical acumen and technical skill won’t be enough. Successful practices will also have grace.

Hans Gerber/CC BY-SA 4.0

If your image of grace is Audrey Hepburn gliding along Fifth Avenue in a long black dress and elbow-length gloves, you’re in the right place. Ms. Hepburn embodied elegance and decorum and there are lessons to be drawn from her. Piling your hair high and donning oversized sunglasses along with your face mask would be to miss the point here though. Ms. Hepburn dressed exquisitely, yes, but her grace came from what wearing a difficult-to-walk-in dress meant to us, not to her. Appearance, self-control, and warmth are what made her charismatic.

To appear urbane requires effort; it’s the effort that we appreciate in someone who is graceful. When you’re thoughtful about how you look, you plan ahead, you work to look polished. In effect, you’re saying: “As my patient, you’re important enough for me to be well dressed.” It is a visible signal of all the unobservable work you’ve done to care for them. This is more critical now that our faces are covered and concern for infection means wearing shabby hospital scrubs rather than shirt and tie.

Effort is also required for telephone and video visits. In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.

Whether in person or by phone, grace, as Ms. Hepburn demonstrated, is physical awareness and body control. She would often be completely still when someone is speaking, showing a countenance of warmth. She’d pause after the other person completed a thought and before replying. In doing so, she conveyed that she was present and engaged in what was being said. It is that confidence and ease of manner we perceived as grace.

I thought about this the other day during a mixed clinic of telephone and face-to-face visits. I had on my wrinkle-free scrubs (I could do better). I was listening to a patient describe all possible triggers for her hand dermatitis. My urge to interrupt grew with each paragraph of her storytelling. “Be patient,” I thought, “be at ease with her rambling. ... When she stops, thank her as if you were looking her in the eye acknowledging how interesting her observations were.” This is not just good manners, it’s the essence of grace: The art of showing how important others are to you.

Our world needs grace more than ever and what better place to start but with us. In pleasing, assisting, and honoring them, our patients can be reassured that we can and will care for them. Make Ms. Hepburn proud.

“For beautiful eyes, look for the good in others; for beautiful lips, speak only words of kindness; and for poise, walk with the knowledge that you are never alone.” – Audrey Hepburn

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He has no disclosures related to this column. Write to him at dermnews@mdedge.com .

From the ash of our post “coron-apocalyptic” world, we emerge. It’s back to work, to life in a new normal. Patients are still scarce and scared, as are some doctors. Queues of patients wait to clear security and enter the sterile area at every medical office. Water bottles are allowed, fevers and visitors are not. Those who fail clearance or who are afraid to be seen in person must be treated virtually. In this context, virtually means by telephone or video, yet, aptly, it also means “nearly or almost,” as in we can nearly or almost treat them these ways. We’ve emerged safely, but we’ve lost sensibility. Because of this, what’s important in the doctor-patient relationships will drift a bit. Clinical acumen and technical skill won’t be enough. Successful practices will also have grace.

Hans Gerber/CC BY-SA 4.0

If your image of grace is Audrey Hepburn gliding along Fifth Avenue in a long black dress and elbow-length gloves, you’re in the right place. Ms. Hepburn embodied elegance and decorum and there are lessons to be drawn from her. Piling your hair high and donning oversized sunglasses along with your face mask would be to miss the point here though. Ms. Hepburn dressed exquisitely, yes, but her grace came from what wearing a difficult-to-walk-in dress meant to us, not to her. Appearance, self-control, and warmth are what made her charismatic.

To appear urbane requires effort; it’s the effort that we appreciate in someone who is graceful. When you’re thoughtful about how you look, you plan ahead, you work to look polished. In effect, you’re saying: “As my patient, you’re important enough for me to be well dressed.” It is a visible signal of all the unobservable work you’ve done to care for them. This is more critical now that our faces are covered and concern for infection means wearing shabby hospital scrubs rather than shirt and tie.

Effort is also required for telephone and video visits. In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.

Whether in person or by phone, grace, as Ms. Hepburn demonstrated, is physical awareness and body control. She would often be completely still when someone is speaking, showing a countenance of warmth. She’d pause after the other person completed a thought and before replying. In doing so, she conveyed that she was present and engaged in what was being said. It is that confidence and ease of manner we perceived as grace.

I thought about this the other day during a mixed clinic of telephone and face-to-face visits. I had on my wrinkle-free scrubs (I could do better). I was listening to a patient describe all possible triggers for her hand dermatitis. My urge to interrupt grew with each paragraph of her storytelling. “Be patient,” I thought, “be at ease with her rambling. ... When she stops, thank her as if you were looking her in the eye acknowledging how interesting her observations were.” This is not just good manners, it’s the essence of grace: The art of showing how important others are to you.

Our world needs grace more than ever and what better place to start but with us. In pleasing, assisting, and honoring them, our patients can be reassured that we can and will care for them. Make Ms. Hepburn proud.

“For beautiful eyes, look for the good in others; for beautiful lips, speak only words of kindness; and for poise, walk with the knowledge that you are never alone.” – Audrey Hepburn

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He has no disclosures related to this column. Write to him at dermnews@mdedge.com .

From the ash of our post “coron-apocalyptic” world, we emerge. It’s back to work, to life in a new normal. Patients are still scarce and scared, as are some doctors. Queues of patients wait to clear security and enter the sterile area at every medical office. Water bottles are allowed, fevers and visitors are not. Those who fail clearance or who are afraid to be seen in person must be treated virtually. In this context, virtually means by telephone or video, yet, aptly, it also means “nearly or almost,” as in we can nearly or almost treat them these ways. We’ve emerged safely, but we’ve lost sensibility. Because of this, what’s important in the doctor-patient relationships will drift a bit. Clinical acumen and technical skill won’t be enough. Successful practices will also have grace.

Hans Gerber/CC BY-SA 4.0

If your image of grace is Audrey Hepburn gliding along Fifth Avenue in a long black dress and elbow-length gloves, you’re in the right place. Ms. Hepburn embodied elegance and decorum and there are lessons to be drawn from her. Piling your hair high and donning oversized sunglasses along with your face mask would be to miss the point here though. Ms. Hepburn dressed exquisitely, yes, but her grace came from what wearing a difficult-to-walk-in dress meant to us, not to her. Appearance, self-control, and warmth are what made her charismatic.

To appear urbane requires effort; it’s the effort that we appreciate in someone who is graceful. When you’re thoughtful about how you look, you plan ahead, you work to look polished. In effect, you’re saying: “As my patient, you’re important enough for me to be well dressed.” It is a visible signal of all the unobservable work you’ve done to care for them. This is more critical now that our faces are covered and concern for infection means wearing shabby hospital scrubs rather than shirt and tie.

Effort is also required for telephone and video visits. In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.

Whether in person or by phone, grace, as Ms. Hepburn demonstrated, is physical awareness and body control. She would often be completely still when someone is speaking, showing a countenance of warmth. She’d pause after the other person completed a thought and before replying. In doing so, she conveyed that she was present and engaged in what was being said. It is that confidence and ease of manner we perceived as grace.

I thought about this the other day during a mixed clinic of telephone and face-to-face visits. I had on my wrinkle-free scrubs (I could do better). I was listening to a patient describe all possible triggers for her hand dermatitis. My urge to interrupt grew with each paragraph of her storytelling. “Be patient,” I thought, “be at ease with her rambling. ... When she stops, thank her as if you were looking her in the eye acknowledging how interesting her observations were.” This is not just good manners, it’s the essence of grace: The art of showing how important others are to you.

Our world needs grace more than ever and what better place to start but with us. In pleasing, assisting, and honoring them, our patients can be reassured that we can and will care for them. Make Ms. Hepburn proud.

“For beautiful eyes, look for the good in others; for beautiful lips, speak only words of kindness; and for poise, walk with the knowledge that you are never alone.” – Audrey Hepburn

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He has no disclosures related to this column. Write to him at dermnews@mdedge.com .

References

1. Sterling TR, Njie G, Zenner D, et al. Guidelines for the treatment of latent tubercular infection: recommendations from the National Tuberculosis Controllers Association and the CDC, 2020. MMWR Recomm Rep. 2020;69:1-11.
2. USPSTF. Latent tuberculosis screening [final recommendation statement]. Published September 6, 2016. www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening. Accessed May 19, 2020.
3. CDC. Tuberculosis (TB): data and statistics. Updated September 6, 2019. www.cdc.gov/tb/statistics/default.htm. Accessed May 19, 2020.

References

1. Sterling TR, Njie G, Zenner D, et al. Guidelines for the treatment of latent tubercular infection: recommendations from the National Tuberculosis Controllers Association and the CDC, 2020. MMWR Recomm Rep. 2020;69:1-11.
2. USPSTF. Latent tuberculosis screening [final recommendation statement]. Published September 6, 2016. www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening. Accessed May 19, 2020.
3. CDC. Tuberculosis (TB): data and statistics. Updated September 6, 2019. www.cdc.gov/tb/statistics/default.htm. Accessed May 19, 2020.

References

1. Sterling TR, Njie G, Zenner D, et al. Guidelines for the treatment of latent tubercular infection: recommendations from the National Tuberculosis Controllers Association and the CDC, 2020. MMWR Recomm Rep. 2020;69:1-11.
2. USPSTF. Latent tuberculosis screening [final recommendation statement]. Published September 6, 2016. www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening. Accessed May 19, 2020.
3. CDC. Tuberculosis (TB): data and statistics. Updated September 6, 2019. www.cdc.gov/tb/statistics/default.htm. Accessed May 19, 2020.