2021 session titled COVID-19 and Athletes, Later Effects and Lessons Learned. We have a great session planned for you today to build off of a similar session that we did last year at AUPMNR's conference to discuss any updates and experiences that have been developed in this last year. The format will be similar to last year where we'll have you as the audience vote on the top three topics you would like to hear the panelists discuss. And then we can certainly get into the other topics if we have time. This will be a very interactive discussion and we'd like to answer all of your questions as well. So make sure you please send your questions through the chat function below and we'll try to address as many of them as we can. We have a power health panel with us today to help discuss this topic. For time's sake, I'm not gonna do them all justice and go through all their many accomplishments but wanted to briefly introduce them. So first we have Dr. Sherry Blauwet who's an associate professor in PMNR at Harvard Medical School and serves in multiple leadership roles throughout the Olympic and Paralympic movement who give the Olympic and Paralympic perspective. Next we have Dr. Carly Day who's an adjunct associate professor at Purdue University and serves as head team physician of Purdue University Athletics who will help give the collegiate and athletic perspective. Next we have Dr. Ken Mautner who is an associate professor at Emory University and serves as head team physician for the Atlanta Hawks and team physician for the Atlanta Braves who will help give professional sports perspective. And then finally, we're honored to have Dr. Sumita Katri who's a professor of medicine at Cleveland Clinic and Keith Western Reserve University School of Medicine who's trained in adult pulmonary and critical care medicine to help discuss her experiences with COVID-19 effects among COVID. And then for me, my name is Jennifer Suhu. I'm an assistant professor and sports medicine physiatrist at Weill Cornell and will be today's session moderator. So now we'll move over to the polling question. So if everyone can take the next 30 seconds here to vote on the top three topics they would like to hear our panelists discuss. There's a whole wide variety as you see here ranging from vaccination issues with athletes, COVID-19 testing updates, cardiac screening updates, experience with long COVID and athletes, any differences in experience with COVID-19 and athletes that may be higher risk, et cetera. So I will let this run for another, I think 15 seconds or so and then we'll see what our topic will be. I think it should be finishing up here shortly. All right, so let me take a look here. So it looks like by a far margin experience with COVID-19 in athletes and how it's managed. Then next, let's see, experiencing COVID-19 in athletes that may be higher risk. And then current cardiac screening recommendations. All right, so let me stop sharing my screen so we can get back to the panel. All right, all right, so let's start off with that first topic, talking about experience with COVID-19 and long COVID in athletes. So why don't we start with Dr. Day? Do you want to get us started in kind of your experience with that? Sure, hello everybody. So like Dr. Suhu said, I'm Dr. Day, I work in the collegiate athletes with collegiate athletes. I've also been part of the NCA COVID-19 medical advisory group, which has put out, you know, a bunch of those documents looking at resocialization guidelines. Long COVID has been a really interesting experience for us because I can tell you I have probably two legitimate cases of long COVID within my student athlete population. But then to me, and those are very obvious, I mean, people really just can't get back to activity and I'm sure you guys have seen some of those in the news. But I think that the really interesting part is more of this hazy, like maybe lack of return to optimal performance, which is a big issue in our athletes more so than the general population. So we might have people who can function totally fine with daily activities, but I could probably list off 10 to 15 of my student athletes who just, you know, once they were cleared and they did your graduated return to play, like, and their heart was fine, like just weren't quite there, whether it was endurance or fatigue or that kind of stuff. And there's a good amount of those. You know, I think people discuss some of our, like larger athletes, like offensive linemen. And I did have a few of those that I can think of, but also some, you know, random sports, you know, softball, baseball, you know, really cheer like any sport that there's people who just sort of come in a month later and they're like, I know I'm clear and I'm fine. Like, I'm just exhausted and my classes are draining me. And to me, that's more of the issue that we are dealing with as team physicians, right? Because the one or two people that are really bad, a lot of times they're seeing someone like Dr. Khatri, who's a pulmonologist or seeing the cardiologist, but that in between we're like, they're not super sick, but it's a problem for performance. That's what I've been seeing a lot of. And again, most of those people I have seen get better, but it takes a while, a lot longer than they would like for sure. Great, thank you. Dr. Mautner. Yeah, thanks. Thanks for having me again this year. And it's fun to be here and be a part of AAP Menorah and talk about this topic. And it's great to be on this panel of such great folks as well. So, you know, fortunately in professional athletes with the teams I worked with, we have had very little long COVID experiences and it's hard to know why that is. I mean, even what Carly talks about, we've not had a lot of those folks. We have had folks kind of in that, you know, once they recover phase for a little bit, kind of get some myalgias and fatigue and take a little bit of time to kind of get back to optimal performance. Some of y'all may have seen, you know, all the professional teams published a paper about six months ago, looking at, you know, over 700 athletes who had had COVID and they were doing cardiovascular screening on all these athletes. And of the, I think it was 760 athletes of 250 to 300 were asymptomatic or minimally symptomatic. I think they found five cases of cardiac abnormalities when they did their full cardiac testing, which at the time, you know, the recommendation was for a high sensitivity troponin, EKG, as well as a echocardiogram. And there were, I think, two or three myocarditis and then two pericarditis. So that means 700 plus, you know, other than those five from a cardiac point of view were just fine. And it actually helped shape the recommendation, which I'm sure we'll talk about later. So I'm not sure what it is about the professional athletes. I do think there is a lot of, you know, psychosocial aspects, which I'd love for other people to give their opinions on, on long COVID with anxiety and other things that I've seen in some of my younger athletes who may have it, but that's been my experience. Great, thank you. Dr. Obawa, do you want to share any experiences you may have had? Yeah. And first off, again, to the other panelists, it's great to be here today. So thanks, Dr. Sugu, for the invitation. And I am learning just as much as any points I'm making. So it's just a pleasure. No, I, in general, would agree with the observations from Dr. Dey and Dr. Mautner. The one thing that I'd say is unique in our para-athlete population is really getting at the distinction between preexisting symptoms versus anything that then may be attributable to long COVID. And that can be tricky, particularly in any athletes who has, who's competing in para-sport because of underlying, you know, traumatic brain injury or stroke or other neurologic involvement that may involve any type of preexisting cognitive symptoms as well as those who may have reduced pulmonary reserve because of their underlying disability. And whether or not the symptoms of long COVID really represent a status change versus, you know, the fact that maybe they weren't able to access training environments as much over the prior year, and maybe they're just deconditioned because of training changes versus true long COVID. So I think that's the nuance that I would add is just the importance of understanding athletes' baselines to then be able to understand if there's been a true status change or if it's really, or if the changes that we're seeing are due to, you know, more straightforward deconditioning from not being able to access training more readily because of COVID restrictions. We always say that in a para-athlete population, the whole concept of PPEs or PHEs is more important than ever because of issues like this. Same thing applies for, you know, potential prolonged concussive symptoms, for example, or other sports med conditions, which the athlete may have some underlying symptoms because of their disability at baseline. And so we need that PPE data to best understand then whether there truly has been a status change or we're just seeing a presentation of their baseline symptoms. Great, thank you. And then to round us out, Dr. Kachri, I know you've had a lot of experience with long COVID, but you want to share any experiences you may have had with any athletes with it or any other tidbits that you might want to share? Yeah, sure, of course. Dr. Day and I knew each other when we were at the same institution and we had a good stream of patients between us in general. And now she's in the big leagues and was at the NCAA tournament when we were actually sharing a patient together. So it's interesting, Dr. Mautner, your experience with the professional athletes. Like for me in Cleveland, we helped the basketball team. And it's interesting, every year, usually somebody from the draft ends up coming to see me because of some asthma, but since COVID, I haven't seen anybody. So it's quite interesting now that you mentioned it. Something about the professional athletes might be a little bit different, and I'm not sure what it is. And it is quite remarkable, even though they're a little older, that you didn't see the myocarditis. But there's something unique about the collegiate athlete population. And I'm sure anybody who does that knows it. They have not only the pressure of being a great athlete, they have the pressure of grades. They have the pressure of keeping up so that they don't lose their scholarship. They're like the star of the family. And I know you see this, but I do too in pulmonary where the helicopter parents show up, and there's just a lot of skin in the game. So when you think about, when I remember the patients I've seen now, and mostly there's women athletes now, and some men too in the collegiate realm here, and there's a lot of soccer, volleyball, some track, some cross country. Those are the people I'm seeing now. And they'll come and they may have some exercise induced bronchospasm to begin with, but they show up, they have fatigue, they feel the stress of it. They wonder if people think they're crazy. And they just, even when they're returning to play in a graded fashion, they just keep hitting the wall over and over again. So that's what I've seen. And everybody worries that they're not gonna get back to normal, but it just takes a very, very long time. And I do know when you look at all of the effects of COVID, which starts at week one, it starts with the nasopharyngeal, and then it goes all the way to week 12, where even people then are having fatigue, dyspnea, anxiety, palpitations, even then some clotting diathesis. These are not always athletes, but they're having these issues. And you add that to the stressors, I think becomes an issue. And that's what I've been seeing, an impatience. They're worried they're gonna lose their scholarship. And then lastly, I just wanted to mention someone that Dr. Day and I took care of together, who, like I said, very rarely do I have to see these patients because the PM&R and physiatry community do know how to take care of them. But this gentleman came over, he's an immigrant. He got a scholarship for his sport, and then was actually hospitalized. So this is before the vaccination. He was actually hospitalized for a few days, fatigued when discharged. He had a plateau and improvement. He was on an inhaled steroid. Then he was cleared by cardiology after echo and cardiac MRI. But in the end of December, he'd have chest tightness, difficulty getting a breath in, get dizzy and have low saturations. And the PFTs were done. And I saw that the inspiratory limb was flattened. And I was like, oh, Eureka, because why would you lose your sats when actually his CT scan was getting better? So it's interesting that all of the things that our athletes are predisposed for, which is all this functional as well as physical issues, just become enhanced. It was fun to see him, I think, getting better. Last I heard, I'd love to hear the follow-up. But honestly, imagine somebody coming from Africa and the burden of that stress, and then the guilt about getting COVID. I think there's just so much in there on top of that true, true physiologic abnormalities and pathophysiological abnormality. So I just have a lot of empathy for these patients. And I just, having patience as the quality for our patients is very difficult. So we're still learning. That's my experience. Great, thank you. Sounds like you all have had some great experiences. And then kind of pulling off of the question that we have here in the chat in terms of how you guys have managed, if you've had experience with anyone, any athletes with long COVID, how have you managed it and what protocols or different things have you put in place to try to get them back to where they were functioning previously? Dr. Dyck, why don't you start us off here? Yeah, so as Dr. Kachi mentioned, I have one person who basically struggled for at least a year, more or less. I mean, and it was involved a week-long ICU stay, did not require intubation, thankfully, but very low SATS before he was hospitalized. And again, like things got better, got worse. And as Dr. Kachi said, we did deal with some of the exercise-induced laryngeal obstruction, but that wasn't the whole thing. So addressing that helped, but there continued to be a lot going on that, again, was not all mental health related. He had some pulmonary, I mean, there's a lot going on there. So I have someone who struggled a long time. I have someone right now who's two months out who had actually gotten COVID last November and was symptomatic at the time, tested positive. It wasn't like a false positive or anything. Fully vaccinated with an mRNA vaccine in May and got COVID again in September and is still having symptoms two months out. And hers is mostly fatigue. She's not dealing with some of the, what my other athlete dealt with, which was chest tightness and shortness of breath, but pretty dense, prolonged fatigue, which is very scary that someone who's had it before and is vaccinated was able to get it again and have prolonged symptoms. So again, still dealing with that, but she is getting better. So some of these are a really long time. And then, like I said, I do think there are some where it's just a month and it's just a little longer than they want. But every once in a while, a couple of my athletes will make a comment like that they're not seeing me for it. And they'll, let's say they see me for a knee injury and I say, like, how's it, like, oh, good. Like, man, I haven't been the same since COVID. Like, oh, you know, and it's not bad enough that they seek treatment for it, but they still just have a little something lingering. The other thing I wanted to mention with mental health is I can think of five of my student athletes specifically who had very severe anxiety after COVID who had no preexisting anxiety disorder and not like an undiagnosed. You know, one person said, maybe I was a little anxious before, but like four of them legitimately, like were scared of the anxiety because they've almost never felt anxiety before. Like they were very non-anxious people prior, you know, again, asking a ton of questions of if this was just preexisting, got flared up getting COVID and couldn't pull anything out of them. And all four of them were getting panic attacks, like really problematic. A couple of them had chest tightness with their disease. So then I wonder, well, maybe that triggers anxiety because you get that experience of shortness of breath or chest pain. And, but a couple didn't, a couple had more of like a mild illness and then really dense anxiety afterwards that again, I've been able to manage all of those, but I just haven't seen that in other disorders, you know, or other viruses. So I don't know the pathophysiology with it, but it's very stark to me as not like, yeah, yeah, they got sick and they felt a little worried afterwards because it took them all to come back, but just really severe anxiety. So I don't know if other people are seeing that, but it's been really noticeable on my end for those people who have it. Great, thank you. Dr. Mautner, I don't know if you've had any professional athletes who have had long COVID or any who have struggled coming back, but if you do, if you want to comment or anything that you want to say about how before you clear athletes back to full play. Yeah, a couple of comments. One, you know, to Carly's point, you know, I think there is some recent literature suggesting that some folks who get it the second time are actually having more severe COVID the second time, which is a little bit counterintuitive. You'd think you'd have some protection, but there is some evidence that people are getting more severe COVID and, you know, I'm sure anything's possible, but I've read that recently. As far as our return to play, you know, the title of this was kind of lesson learned that I think that we have seen an evolution over the year in terms of getting athletes back, especially at the high level where, you know, still at a professional level in professional basketball, I should say, where, you know, cardiac testing is kind of, you know, a yearly endeavor. We're still doing some cardiac testing on anybody who has COVID before returning them to play, but, you know, unlike prior, you know, folks who are minimally symptomatic or asymptomatic, we're not really restricting activity. We're getting them right back into activity, and that's something we've certainly learned over time. You know, I think if you look at a lot of the recommendations from AAP and youth athletes, it's a lot more, you know, looking at kind of a gradual slow return to activity and monitoring for symptoms and seeing if any symptoms that are concerning, you know, chest pain, shortness of breath that are unusual kind of develop. But in our professional athletes, for those who just missed, you know, the seven to 10 days time, once they clear cardiac testing, we're getting them back, you know, pretty quickly unless they had moderate or severe illness, and then we're doing a little bit more of a gradual return. Great. Thank you. And then, Dr. Blauwit, any experiences with your para-athletes in terms of managing long COVID and any protocols to getting them back? Yeah. So, you know, the touchpoint that I've had with the para-athlete population this year has primarily been in the lead up to Tokyo and more from a logistics and planning perspective because a lot of our athletes, you know, if you look at the care they're receiving on a more year-round basis and the folks that are managing those symptoms, a lot of them are working with the national governing bodies or, you know, with the medical staff within the USOPC. So, you know, what I can comment on is that we definitely saw, I wanted to bring back this concept regarding this sort of intersection between mental health and long COVID because we certainly saw a lot of complexities in that space, particularly with our athletes who are preparing for the Olympic and Paralympic Games. And it was just this incredible confluence of factors related to, you know, both for those who hadn't been exposed or didn't have COVID, the concerns about getting it and the extreme anxiety around, you know, being able or needing to train and preparing for, you know, something that was for most of them the most important competition of their life while also having to worry about being in environments where they could contract COVID as well as traveling to an international sporting event where even if they were vaccinated, they had, you know, very little assurance that the person they were walking by in the athlete village was or where they were from in the world or what their exposure may have been. And so that was, even if they hadn't had COVID, there was a lot of anxiety around that. And then if they did, you know, layer that on top of, you know, any persistent symptoms that they might be trying to manage. And so, you know, there was a lot of effort within the USOPC to really shore up and really broadly expand mental health services and immediate access to counselors and psychologists who could support athletes and really be on the ground to provide, you know, direct care as well as the use of hotlines and 24-hour services where people could call at any point in time. And we did use the tools that had been published recently by the IOC in terms of the sports mental health assessment tool, you know, to better understand what types of symptoms athletes were experiencing. We did see higher prevalence within a para-athlete population of symptoms related to depression and anxiety. And I do think that there was a significant confluence between both the stressors of preparing for the Olympic and Paralympic Games as well as layered on top of that, the really intense stressors of having to do that in the time of a global pandemic. So, you know, just wanted to add in that point regarding this unique athlete population that only competes regularly, but has that pinnacle event once every four years, which creates a very unique environment. Dr. Khatri, anything else you want to say about, you know, managing long COVID, any protocols in your experience to getting people back to their activity or back to play? Well, I would just say that a multidisciplinary approach is needed, where you have physiatrists, you have physical therapists, and for instance, for the patients I see, often they have a lingering cough. If it's not asthma, it's just a lingering cough and some chest tightness, and I'm seeing in the chat, there was a question about the mechanism by which they do their PFTs, and they seem like very interesting patterns of respirations. And I would say some of that may be due to the stretch fibers in the lungs. Obviously there's not only the cough sensitivity from the inflammation and the hypersensitivity, but then there's also some upper airway cough sensitivity that happens. People perceive some tightness in their chest, even though the lung function might be okay, and then just the cough, the chronic cough that happens can become a hypersensitivity cough. So sometimes not just inhaled steroids, you'll have to use some sort of like gabapent and some neuromodulators to manage those, and that can help that as well. So that's something we've seen quite a bit. Thank you for addressing that question. And just so we can hit a couple of these questions before we move on, through the questions here, for the ones who initially had mild symptoms and didn't warrant further workup, but then complain of longer duration symptoms, lingering fatigue, et cetera, does that push you in direction of then evaluating with echo, EKG, or MRI, and then Dr. Day? Yeah, most of the updated protocols will say that if there's issues with return to play, then you're going to then go ahead and send them for a full eval. So we've had a few people where that happened. Last year, as part of the big 10, every single person tested positive got what I call the full Monty. So they got a troponin, echo, EKG, and a cardiac MRI, so 200 people get cardiac MRIs. This year, and there's pros and cons to that, this year, we're all allowed to make sort of our own protocols within reason, but following some of the NCA, AMSSM, NFHS, ACC, all those recommendations sort of combined. And almost all of those will say that if your asymptomatic or mild population is going to be cleared through just a physician visit, that if there are either cardiopulmonary symptoms with return to play, or really, you know, any issues with that, that they are going to then trigger, you know, a cardiopulmonary workup at your discretion based on what the symptoms are. So I would think most of us are doing that. It's always hard. I think Dr. Blout mentioned this, someone mentioned, you know, the hard part is the out of shape, right? So what is an issue with return to play versus a deconditioning in someone who never takes a day off in the whole year, and then they, they're, you know, either off or modified for 10 plus days that, you know, as they return to play and they feel a little short of breath, is that a symptom or is that just anyone who took a week off is going to have it? So there's a little nuance to that. And sometimes that's more just maybe saying, okay, if it was just one day, maybe it's okay the next day, just back down a little bit and then move up a little slower. And if they do find great, if they're continuing to have problems, or if they have symptoms with daily activities, for sure, I would then definitely pull the trigger and do a more advanced workup. Great. Thank you. And then, Dr. Mautner, there's one question here for you. Someone was curious about your experience with vaccine hesitancy in the professional athlete population, how you've navigated that and what advice you would give in discussing vaccination in the athletic community. Yeah, that's a great question. And you know, I've had two experiences with, you know, professional basketball team and a professional baseball team, and it's been different experiences, I would say. And so our basketball team, we got to be 100% vaccinated last year, and we're 100% vaccinated again this year. And honestly, if you look at the data, all the five NBA players are vaccinated. So we're well over 95, 98% vaccinated right now. And honestly, it was a lot of, you know, carrots that had to be put out there. And that's what got people to get vaccinated. There were definitely those who wanted to get vaccinated, but I would say half the team really did not have a desire to be vaccinated. And you know, it was either the social rewards, meaning that people who were vaccinated... Sorry, someone's talking. People who were vaccinated were allowed to go out more on the road. There were testing rewards where when you were vaccinated, you know, now this year, if you're not vaccinated, you're still being tested every day and twice on game days. If you're vaccinated, there's no surveillance testing in the NBA this year, unless there is some, you know, outbreak on your team or some close contact that you need to then test for. There are contact tracing rewards, right? Vaccinated players are not contact traced. They won't have to quarantine or isolate just because they were around someone who had COVID. When the Hawks were making their playoff run last year, our GM, I mean, for one of our best players who was originally hesitant, was like, you know, you could be at a store if someone has COVID, you're contact traced, you're out five days, you're out seven days, and that could cost us a series. And so there was that that helped kind of convince some people to do it. And masking rewards. I mean, there were masking rules that were different for people who are vaccinated and not vaccinated. Interestingly, in baseball, where our team had less, we were about 90% vaccinated. I found that a lot of it was there a lot of cultural differences. You know, a lot of our Latin American players, for whatever reason, or not a lot, a few of them seem a lot more hesitant to get the vaccine. But these are also players who, you know, we stayed in the hotel where there were some rumors of a ghost that was in that hotel, and they literally would not stay at the hotel. And so I think there are cultural factors for a lot of what these athletes do. And some just didn't want to, you know, put something in their body and, you know, all the typical reasons that you kind of hear. And so, you know, education, just like with, I think, all of our athletes, education, the professional athletes will only go so far. But honestly, you have to give them some carrots that they need to kind of, you know, get vaccinated for a reason with some of those hesitant ones. Great, thank you. Before we get to the other questions, I just want to make sure we we talk a little bit about your guys's experience with, you know, any different testing or protocols and athletes that may be higher risk. So those who may have really bad asthma, those who may have a disability or otherwise, you know, immunosuppressed in any way. So Dr. Blowett, why don't we start with you? Yeah, absolutely. So, you know, I think that the concept of risk, obviously, is pretty complex. And, you know, when the when the pandemic first was really ramping up in the spring of 2020, you know, we got a lot of questions within the Paralympic athlete population and concerns about the Paralympic athlete population. And interestingly, you know, through that initial time, one of the key messages that I felt like we had to be somewhat of a broken record about was the fact that the Paralympic athlete population is very diverse and heterogeneous, and one athlete is not the same as the other. So we can't make speaking statements about everyone being high risk, because that's certainly not likely to be the case. That said, there are certainly some who are, you know, classically, we think about, you know, athletes with spinal cord injury, particularly at the cervical level, who may have, you know, reduced pulmonary reserve and also some differences in their autonomic function. Athletes with fairly small cerebral palsy may also have differences in pulmonary reserve. We do have a fair amount of athletes who are amputees for non-traumatic reasons, for example, for a history of cancer, who may be on ongoing, you know, modulating or immunosuppression for their cancer treatment. So certainly there are pockets within the Paralympic athlete population where risk is somewhat higher. And in those cases, of course, we really have to put on the full court press about prevention for these athletes and mitigation strategies, ensuring that we do everything possible to, you know, prevent an infection, certainly strongly promoting the vaccine as well as the booster, because we know if they have any underlying immunosuppression that the booster is even more important to provide them full protection from the vaccine. There's a lot of logistical considerations that come into mind around training and travel and competition, you know, thinking about factors relating to, you know, training and facilities when potentially it's a little bit less busy, there are fewer people around, it's possible to maintain greater social distance, not messing with small potatoes competitions and really saving, you know, the need for travel for competitions that are really important. And then when you do travel, trying to make it as safe as possible with regards to social distancing, extra space in athlete villages, enabling them to room on their own rather than having to room with a roommate. So all these factors come into play, but it is very, the point I want to make is that it's very individualized and based on the athlete's underlying disability and the pathophysiology of that disability, rather than assuming that it needs to be the same considerations for everyone. And then I, you know, wanted to bring back in the consideration around these events where you do have, that are global in nature, where you have athletes from all different corners of the world coming to compete. And we've seen an evolution regarding standards. So coming into Tokyo, you know, vaccines were not required, they were certainly encouraged. And if you were vaccinated, then that as an athlete, that would be helpful to you if you were to test positive and have to quarantine. It may mean that there was a, that it was a bit easier to reduce the time in quarantine, you know, before you could return to the village or return to play. And obviously every day counts in an Olympic and Paralympic Games environment. As we look to Beijing, it is looking more and more like vaccines will be required with except, you know, with very few exceptions. Team by team, teams are starting to implement a vaccine requirement. We in the U.S. now have one for athletes who are going to Beijing. And again, there are some exceptions that will be reviewed and potentially granted. But the expectation is that people are vaccinated. And it is looking like Beijing will probably be making a similar requirement. And now we have more time for the IOC and IPC to be able to work with the WHO to get more vaccines applied to some countries and some athletes where they may not have had access in the lead up to Tokyo. So things continue to evolve that I think will also help to make the whole Games environment safer, you know, moving forward. And certainly as we look to Beijing, the Winter Games coming up in Beijing in February and March of next year. Awesome. Yes. Very excited for the Winter Games coming up. Dr. Day, any experience with, you know, any athletes who are higher risk that have gotten COVID-19 and or are you doing anything differently for those people who maybe have really bad asthma on the team or anything like that? Yeah, you know, our small population, obviously within our, you know, one college athletics program, we don't have a ton of people who, you know, have high risk issues. So we have a few with rheumatologic issues. We have, you know, a fair amount with asthma, but really only a couple with like even moderate asthma, you know, and the ones that do are pretty well controlled to get to this level. Now, the high school level, there may be a lot of people with poorly controlled asthma, but at this point, it's pretty tightly controlled. And again, a few people's hypertension, but at this point, it's treated and under control. So most of our people who have pre-existing conditions have them under control to some extent, you know, unless they're on immunosuppressants. So I have not had a lot of people like, you know, we've had plenty of people with asthma get COVID and it has not really been triggering a ton of asthma problems for us, but it's a small population. So I defer to Dr. Khatri on anything that has to do with asthma on that. So our folks have been lucky. We did have one student athlete with an RA diagnosis who actually got monoclonal antibodies. She wasn't super sick, but it was, she was through our school management basically of an ill person. Cause they sort of take over with some stuff and they just had a protocol that if you, you know, met, tick certain criteria, they'd get it to you. So she got it. I don't know if it helped at all, but it was, it was interesting when that happened. Great. And Dr. Mautner, any experiences you may not, but if you have any experiences, same question. No, I don't have a lot of experiences, but, but since Carly brought up the monoclonal antibodies, I'll bring up a little anecdote that in the NBA, especially going towards the you know, the NBA finals last year they, they found that monoclonal antibodies may, you know, shorten the, actually the duration of your, your symptoms, which we know and may actually reduce your viral load quicker. So turn you negative. And so they were actually trying to have us line up monoclonal antibodies. If we had a player turn positive with the hopes that they might then, you know, miss less time. But of course, you know, at Emory, we have very strict guidelines for who can get monoclonal antibodies and, and, you know, they basically told the, not that we ever had the situation come up, but they basically told the NBA, you know, we're going to follow our guidelines. And so if you don't meet these criterias, you know, you know, you're not going to get monoclonal antibodies. But it's interesting that some professional sports have turned to those sorts of things because, you know, the interesting thing about professional sports is that, you know, illness is not our end game with COVID, it's a positive test, whether you're ill or not. So, you know, we can't have people with positive COVID running through our locker room, playing on the athletic field. So unlike, you know, real life, when we're trying to prevent death and dying in sports, especially professional sports with all the money involved, we're really just trying to get our end of cases as minimal as possible. So it's a very unique situation, I'm sure, you know, similar to obviously what Sherry went through and what Carly's been going through. Thank you. And then, Dr. Khachri, interesting to hear your experience with, especially, I'm sure you see a lot of people with asthma and your experience with those who have, you know, bad asthma or higher risk and COVID-19. I just have to react to the irony of the hierarchy, right? When you've got a global pandemic and money matters still, it still bothers me, right? Like where the vaccines are and where they're not. So just had to put that out there as a public health person. Anyway, let's just call that out for a second. But more importantly, I would say you're right, if asthma is well controlled, less likely that they were going to get sick. I thought at the beginning of the pandemic that things were going to be really bad. We were so much preventive management, making sure they had three months worth of medicines that there would be no lapse in therapy. What we did see, though, is as long as their asthma was well controlled, they did relatively well. And having a little bit of type two inflammation might have been slightly protective, oddly enough. Because of the whole ACE receptor mechanism. But I would just say that for people who got really sick, there were just a couple or three that were on ventilators of my own patients. And yes, the dyspnea lasted longer. And so I had to use prolonged efforts with anti-inflammatory, sometimes using like a macrolide antibiotic just to get them through from an anti-inflammatory standpoint. But luckily, they did pretty well. Thank you. Thank you. All right. So let's just hit a couple of these questions. So have there been many athletes using homeopathic remedies? If you guys, I don't know if any of you guys have any experience with that, Dr. Blowett? No, I haven't. Thankfully, I haven't run into that directly. Where there was an individual athlete needing counseling and education regarding other remedies. I would say that when we think about things like appropriate treatment, vaccine hesitancy, one of the mechanisms that we found most helpful is athlete-to-athlete education. So trying to recruit athlete leaders to themselves, do focus groups, or talk to other athletes who do forums or social media to talk about the importance of vaccines and when to seek care. And that tends to be fairly well-received by other athletes because that's where they have the relationship and the trust. But thankfully, I have not been directly having to counsel in this regard. Curious about the experience of the others. Yeah. Dr. Day, Dr. Moutner, have you guys had experience with this? Yeah. Again, not much here. But I think in the collegiate setting, which is not very different from the pros and from Olympics, but probably different from high school, is our folks are so well-conditioned about drug testing and not putting anything in your body that isn't certified that anything you take, even supplement-wise, should be reviewed by our dietician. So I've gotten the regular vitamin C and zinc questions, which are pretty harmless. And even then, we still, for those supplements, have people talk to the dietician to make sure it's a certified brand. So again, there could be people doing it and not talking to us. But it's just been hammered home to them every year from a drug testing standpoint that maybe that has discouraged them from going too far outside the box. I've had a couple ivermectin failures in my ICU. And it's not pretty. And then people feel badly that they tried it. So there's regret. We had the first wave of people unvaccinated because we didn't have one. And now we're having the residual of people trying their own thing. And so that's been very, I would say, disheartening. And I would just say, at the bedside standpoint, it's very difficult to sort of... I used to get angry. And now I'm just sad when I see this because this is a lost chance for them to get better. And I did. There was a rush of people asking, would you give me a prescription for ivermectin just in case? I'm like, no. And they said, well, what are you going to do if I get sick? I said, I'll take care of you with the proper medications. So back to the whole empathetic way of dealing with... People are trying their best not to harm themselves, but they often don't know better. So it's gone from desperation in my mind to get people vaccinated to some frustration. Now I'm just talking about the trajectory of where a caregiver feels. I'm just sharing that with you to now just kind of sadness and empathy. Because you can't force people to change their minds. You can just leave them. And I think the lack of mandatory testing if they're... And the quarantining. And that's what's getting people vaccinated now because they're otherwise missing too much of life. So no homeopathics. Great. Thank you. Just so we can hit that third topic that people voted on, current cardiac screening recommendations. So I know this has evolved a lot since when, you know, we talked about this last year and I know Dr. Mautner, you started to talk about this a little bit, but do you want to just kind of give us a sense of what your guys' protocol is and where things are currently? Yeah. I mean, I mentioned this, you know, briefly and it's still probably an evolving algorithm. And as I said, you know, it used to be in professional sports, especially that everybody would get a high sensitivity troponin, the EKG and echocardiogram. We didn't do cardiac MRIs routinely only if there was some abnormality that we thought we needed to follow up on. And now a lot of the recommendation, you know, the American Heart Association, AAP, you know, everyone's coming out with their recommendation and most have suggested that, you know, asymptomatic and mildly symptomatic, you know, probably, you know, we're not seeing a lot of cardiac issues with them with pericarditis and myocarditis and certainly in a high school population and probably collegiate as well. We don't need to screen everybody with those tests. And those on the far end who have severe illness and hospitalization, you know, still do need to be screened. And those with kind of moderate illness, there's probably some interpretation of whether to screen them or not, or at least, as I mentioned, to bring them along a little more slowly with close observation of any, you know, exercise intolerance that seems out of the ordinary. But, you know, once again, professional sports is obviously treated a little bit differently. And especially in our MBA, we already have a high risk of cardiac abnormalities and, you know, morphinoid type of athletes who we screen regularly with cardiac testing. We have been very diligent about it, although now we're starting to kind of come off as some of those, you know, harsher or more stringent recommendations. Well, thank you, Dr. Day. Any differences from last year or the protocols that you guys are implementing? Yeah, I think one of the more interesting things, and at least, you know, these Power Five school recommendations for cardiac testing is it went from very prescriptive to very vague. And again, describe the pros and cons of each. Prescriptive, some people get upset, like, well, either this is overkill, or I'm a doctor, and I should get to make my decisions. But then when you get to these vague recommendations, and as Ken mentioned, with moderate symptoms, there's 18 different, every single, you know, place has a different definition of moderate. Is it any fever? Is it fever greater than 24 hours or 48 hours? Is it any body aches or it's prolonged? Like there's a lot of up to interpretation in that moderate category. So I think that's where I've seen people trying to figure out what's best. And there's probably no right. I think, you know, a lot of people maybe that I work with in the collegiate setting lean towards, okay, if it was like a decent enough illness, and they had a fever and didn't feel good, we have all this cardiac testing set up so well, because we had to do it so much last year, that we have the systems in place to do it quickly. So I think I see people erring on calling something moderate. But again, it's pretty variable at each institution, depending on what resources they have. Okay. And then Dr. Blowett, can you give us your perspective on cardiac freeing? Yeah, my perspective is aligned with what Dr. Mountain and Day have outlined. I don't have a lot to add. The only thing I'd add that's unique to our population in parasport is that we're still learning a lot about some of those, you know, underlying baseline differences about prevalence of underlying cardiac abnormalities, cardiac involvement. And so, because of that, I think I tend to have a lower threshold, slightly lower threshold towards, you know, going that extra mile and doing more testing in anyone who, again, may have moderate to severe symptoms, or any sense that they're off their baseline for a prolonged period of time. There was one study from 2016 published in BJSM, which did show a higher prevalence of structural cardiac changes in para-athletes. But it's all very preliminary. It's just a very active area of research. And there's still so many unknown, unanswered questions, that it makes me err a little bit more on the side of caution. And then, of course, for anyone, again, with, you know, an underlying or background disability that we know they may have a higher risk of cardiac involvement. So, just a few extra nuances on top of what's been said. Great. Thank you. And then there's a question asking, what is your guys' I guess assessment or opinion on the vaccine adverse effect reporting system data? Dr. Kachri, do you want to start? Sure. I'm glad we're collecting it. There needs to be information gathered. And I had a chance to look at the dashboard. They don't readily provide data without you understanding how to interpret it. So, it's not a quickie. However, you know, the CDC website does keep up with what's going on. And, you know, still, you know, we know that, you know, anaphylaxis is rare. That would be the most common. But that's two to five out of a million people getting anaphylaxis. And if there are reactions, my colleagues in the allergy area, we're very comfortable testing them so that, you know, after the first shot, is the second shot safe or not? Or is it a peg allergy, polyethylene glycol? Meanwhile, clots also was so rare in 50 million people, you know, 0.002%. Only 50 in 16 million people, you may remember from the J and J data had thrombosis. And then deaths are so rare, 9,000 out of 432 million doses. And we don't even know if those deaths could have been for anything. It wasn't tracked, whether it was from COVID or related to the vaccine. So, you know, far and away, chances of death from COVID are much higher than chances of anything severe with the vaccination. And it's just something that we need to keep consistent in our brains and consistent in our mindset as we're having those conversations. So thanks for asking. And again, anything can be reported, and then it'll be filtered and appropriately evaluated. Great, thank you. I just wanted to get a sense from your guys's experience on the commonality of any breakthrough infections and what the rate of that, if you've seen a lot of that in your experiences. Dr. Day, why don't you start? Yeah, this is obviously very timely for anyone who's seen the, you know, Cal football team data. And I don't have any insider knowledge, but just what's been, you know, in the news is that they were 99% vaccinated. They have 44 cases, right? So you have to presume just about all of those are in vaccinated folks. So it's hard, you know, because we know based on large trials that the vaccine is very protective, right? So you're less likely to get it, you're less likely to get severe illness. And that's way bigger data than one college athletics department. So yes, we've seen breakthrough cases. We've had a couple that are more random or sporadic with a known exposure. And then we've had one cluster of vaccinated folks who, you know, were all symptomatic and tested positive this whole year with a very high, you know, we're at 95 plus percent vaccinated in my department. So it happens, right? But it's always one of those hard things because we know that the vaccine is very protective, but when it happens in your department and you're the team physician, it's a big problem, right? And you get a lot of pushback from the people who were vaccine hesitant. I mean, there's a lot to unpack there. So again, I have to go more from what larger trials are showing when I'm counseling my athletes on this, because they do, I do hear when we talk about vaccine hesitancy, I definitely get the, well, so-and-so was vaccinated and they got COVID. I said, well, that's accurate, you know, and sometimes I'll use like musculoskeletal references to help people understand, like maybe a strength coach who's questioning this to say, you know, we have ACL prevention programs, but people still tear their ACL. So like, it's not like one person tears their ACL and we say, we're never doing this prevention program because it didn't work. We say, even though someone did tear their ACL, we probably prevented other people from tearing it. So sometimes those references hit a little better, you know, and stick a little better, but that's what I've been trying to go with are some of those nuances there to try to help people understand. But yeah, we've had breakthrough cases, but that's going to happen. Sorry, I was muted. Dr. Mautner. Yeah, a couple of things. So, you know, I mean, there's certainly been clusters within professional athletes as well. If you look at the data and some of the inside information you may hear about or is reported, it seems as though, you know, the J&J vaccine may be a little bit more responsible for some of the breakthrough clusters that have happened, especially with some of the major league baseball teams this year. You know, the NBA has, is interesting at this point because most teams are just passing that six to seven month mark post, you know, vaccination for the majority of NBA players. It happened in like April. And when everyone reported at the end of September, we have, we took an antibody, a blood antibody test on every NBA player in the league. And it's not data I can share, but it's very interesting data looking at the different levels of antibodies that are being produced. And we, the antibody test we did is different than some of the other commercial ones out there. And it's actually the largest application of that test so far. And so they're still actually testing different strains of the virus in the lab against these antibodies to figure out what all the numbers mean. And we know antibodies numbers do not correlate necessarily with vaccination. I don't want that message to get or with immunization. I don't want that message to get out there, but it is very interesting that, you know, certain vaccines and I've seen at least with my team have produced folks on the lower edge of the antibody titers, higher vaccines are, some are still have really high, you know, antibody levels with vaccines and no COVID exposure that we know of since then. And so it is kind of all over the place and we're, you know, in the boat of trying to figure out at what point, you know, do we recommend boosters? Because if you look at the definition, if you work in an environment where you have a lot of exposure and certainly athletes on a court in close proximity to each other defines a lot of exposure, you know, I think a lot of our athletes and the conversation, the education around boosters is now coming up amongst the NBA players. And hopefully we're going to get some guidance soon about, you know, how to correlate some of the antibody levels to whether, you know, backs where the boosters should be more recommended or not. Great, thank you. Dr. Blauwit, an experience with breakthrough infections in your population of athletes? Yeah. No, you know, I think, I think what will be interesting will be the experience in Beijing. And I think we'll learn a lot from that because we will have athletes in close proximity. And obviously all athletes being tested on a daily basis. So I think in itself, it's going to provide some really fascinating data. But, you know, I think from my perspective, the counseling doesn't, in our Olympic and Paralympic athlete population, the counseling doesn't change around the importance of prevention and mitigation and trying to do everything possible to prevent that positive test in a game's time environment. In Tokyo, the testing, the criteria that would require someone to actually go into quarantine was very high and robust because of, you know, the significant impact that that could have on an athlete's career and them potentially having to miss a prelim or even a final that, you know, could have just be devastating. And so athletes were tested, everyone there was tested daily with a saliva sample for qualitative antigen. And then if that came back positive immediately, that same sample would be tested for PC, but with via PCR. And if that came back positive, then the athlete would be asked to give a nasopharyngeal swab and that would be tested via PCR. So it was like this three-step process before you'd actually remove anyone from training and competition. And that was extremely important. I'm sure it will be the same in Beijing, but the big difference will be that we will have more people vaccinated. So it'd be really interesting to see whether that changes the overall number of positive tests. With the restrictions that were put in place in Tokyo, the overall number of positive tests were very, extremely low. And most of those that we did see were actually from the saliva test that was done at the airport. So something that was picked up on the way that then required an initial period of quarantine, but a lot of those athletes, thankfully, could get back in time in order to compete. Although, to some of our earlier points, it was extremely stressful to them. Once they were in the village environment, then the rates of positive tests were exceedingly low. So the overall system worked. Kudos to the Tokyo Organizing Committee that was working 24-7 to implement this type of process. And I know that Beijing will be just as rigorous, if not actually more. And it'll be very interesting to see whether that prevalence of positive tests changes on a per-athlete basis between the two games. Great, thank you. And then Dr. Kachi, anything you want to add about breakthrough infections and your experiences? Well, right. And I'm, first of all, just so enthralled by all of the different, basically, laboratories you work in and how you're having to look at this differently, which shows how elusive this messaging is. So just my, I guess, my take-home message is that this is a hard one-liner. You can't explain it away in a one-liner. And so we have to share with people that, yes, breakthroughs are occurring, likelihood that you're going to be less ill, and also likelihood from a public health perspective that you're going to make fewer people sick around you because the carriage of it will be less. So I think we'll have to start not just talking about yourself, but your obligation to society and the people around you, if people are willing to think that way. So that's my message. And thank you, again, very much. I feel so privileged to have been among you all. Great, thank you. So it looks like there's one more question in here. Do you hear complaints of COVID fog memory, attention issues in the long COVID athletes, or does it stay related to more physical and mental effects? Dr. Day? Yeah, I do have one person where when fatigue is the predominant symptom, some of it is, I don't know if it's true, COVID fog versus they're so fatigued, it's like hard to make it through a whole day of classes and practice. One of our student athletes, all we did is just take out her morning lift. It was not necessarily the most important thing for her sport. And to get up at 5.30 for a 6 a.m. lift was really like making that whole day much harder to get through. So by the time she got to her classes, she had already been up a while, exerted herself, and that actually helped significantly. So again, but she did say it feels like it's harder to focus a little bit in some of that too. So whether it was the fatigue or brain fog or the similarity between the two, sometimes it's just modifying that training regimen. And as you all know, in sports medicine, some people lifting is very important, some people it's not as important, even if coaches always think it's important. So some of that is navigating that and trying to figure out, you know, how can this person function in school, function in their sport, function in daily life, and finding the best path to do so is that there's not always one right answer. Great, thank you. I think we have one minute left here. Any kind of words of wisdom, pearls for things that you guys have learned in this last year that might help prepare for future pandemics? Hopefully not, but any last words here? Dr. Mautner, do you want to start? Yeah, no, thanks for organizing this, Jennifer. I thought it was great again, and very different perspectives are helpful, and I've learned some things as well. You know, I think that, I think a lot of us will say that, you know, being proactive is definitely the way to be here, and I think we learned a lot, you know, from the early days of reacting to everything that was going on and things we didn't know, and I think we could have been a little bit more proactive, you know, early on with things in a society as well as, you know, with our professional sports. You know, the NBA, you know, was probably front and center in the fact that, you know, things, you know, shut down mid-season, kind of mid-game even when we first heard about the pandemic and, you know, no one really knew what was what, but I think in the future we now have kind of a blueprint to hopefully get ahead of this thing, you know, and not have it become like it has, I guess, and then hopefully we are, you know, on the downslope of this pandemic, so thank you. Thank you. Dr. Blauwet, any last words here? All right, I know we're at the top of the hour, so I'll be really brief. Couldn't agree more with Dr. Mautner, and I'd also just say that maybe my last word of reminder to everyone is to don't forget, you know, the most important stakeholder in all of this, you know, the athlete, and thinking about how we get to athletes to provide that education and, you know, bring them these key messages from an evidence-based standpoint. You know, it's so easy to talk at conferences, talk to colleagues, be in these peer environments, and then forget about the importance of ensuring that the message gets back to them and really thinking about what resonates. Again, how do we provide those messages regarding, you know, trying to educate about things like vaccine hesitancy, who's delivering the message, who do they trust, you know, how can we do it in a way that it'll be best received and really absorbed and hopefully help to empower that athlete to make the right decisions for their health. Okay, thank you. Just really quickly, Dr. O'Day. Yeah, I just want to thank all the physicians attending this talk. You know, I know it was a very stressful year for a lot of us. Some of these folks who are PGY2s might have been interns and on a COVID unit, you know, Dr. Khatri's doing some of the hard work in the ICUs, but I know all of us had our own stresses, and I know what got me through it honestly was my colleagues, was having other college team physicians, other friends that you could bounce ideas off them, ask them how it's going. So if anything that I've learned through this is really the appreciation of a network of colleagues who know what you're going through and you can vent to, and they can vent to you, and I just appreciate everyone on this call for everything you guys have done because it was not an easy year, but I think, you know, I've gotten a few very meaningful thank yous from people, and that that's what got me through this. Great, and then Dr. Khatri, any last words? I did my piece at the last answer, and I just wanted to thank you Dr. Suhu for putting us all together. No problem. Well, thank you everyone for attending. Sorry, I know we went a couple minutes over, but we appreciate you all attending, and hopefully we can see you all in person next year. Have a great rest of your conference.

COVID-19

athletes

later effects

lessons learned

updates

experiences

managing COVID-19

long COVID

higher risk

cardiac screening