Hi, everyone. Welcome to our 2020 AAP UNR Virtual Annual Assembly's live session called Update on Return to Sports and the Role of the Sports Medicine Physician During COVID-19. We know that this has been a real hot topic of late, and we have a real powerhouse panel today to hopefully address all your questions. Before we get started with all the introductions, I'm just going to run through a couple of housekeeping items that they want me to talk about. So first here to post questions to the faculty, please type questions in the Q&A or chat field to the left of your screen. I will monitor that box and field the questions to our panel. And then just an update on CME claiming for AAP UNR 20. We are aware that due to the high volume of CME and high participation, there is a lag in transferring your participation data to the online learning portal for certain sessions. Rest assured that your participation in all sessions is recorded. We are currently working on the backend to speed up the data transfer. We will send a notification to all registrants once the process is updated and all data has been transferred. All right, so onto our session here. So we understand that return to sports looks very different in the different levels of sport, and we hope to address how different topics such as testing, cardiac clearance, et cetera, are handled at all these different levels. I will now briefly introduce our esteemed panelists. And for time's sake, I want to introduce them briefly and not cover all their many, many accomplishments. All right, I have no financial disclosures. Intro to panel. So we'll have Dr. Jonathan Finoff, who will be giving us the Olympic Paralympic perspective. He's our chief medical officer for the United States Olympic and Paralympic Committee and is also a professor in the Department of PM&R at Mayo Clinic. To talk about the professional sports perspective, we have Dr. Kenneth Motner, who is associate professor in the Department of PM&R and Department of Orthopedic Surgery at Emory University. He is also the director of primary care sports medicine and serves as the fellowship director for their primary care sports medicine fellowship. He's also the head team physician for the Atlanta Hawks and a team physician for the Atlanta Braves. To talk about the collegiate sports perspective, we have Dr. Carly Day, who's the associate professor at Purdue University. She also serves as the head team physician for Purdue Athletics and serves on the board of directors of MSSM and is also a team physician for the U.S. Soccer U-20 Women's National Team. And then to discuss the high school and community sports perspective, we have Dr. Jason Zarensky, who's associate professor in the divisions of PM&R and Department of Orthopedics and Rehabilitation at the University of Florida College of Medicine. He also serves on the board of directors of MSSM and is the co-chair of the MSSM Fellowship Committee. He is also the co-medical director of the Adolescent and High School Sports Medicine Outreach Program. And then I'm Jen Suhu. I'll be your moderator for today. And I am an assistant professor in the Department of Clinical Rehabilitation Medicine at Weill Cornell and your Presbyterian. And I also serve as the Associate Sports Fellowship Director. And I do some traveling with the U.S. Soccer Youth National Team and the U.S. Paralympic Team. All right. So next here, before we start the panel discussion, we wanted to make sure we address the topics that you guys would like to hear most. Hopefully we'll be able to address all of these topics. But just in case we run out of time, we just want you to vote for the top three topics you'd like to hear our panel discuss most. So I think it's transitioning to the polling questions now. So we'll have this maybe run for about 15, 20 seconds before we get the results and move on to the poll. All right. Maybe 10 more seconds here. Seems like everyone really wants to hear about everything. Can you pull those polling results back up? Great, thank you. So it sounds like top three look like return to activity considerations, best practice recommendations, and then COVID-19 testing. Seems like it's the top three. So we'll make sure we hit that. All right, so now before we delve into those topics, I just wanted to give the opportunity for our panelists to introduce themselves a bit further and give an update on their current involvement in these levels of sports to set the background. And we'll start with Dr. Jason Zaremski. Hey everybody, my name is Jason Zaremski. As Jen said, I'm at the University of Florida and my primary role from a sports medicine perspective is I'm the co-director of our high school program here in the Greater Gainesville, North Central Florida area. As all of us will undoubtedly state in the next hour, and a lot of us who put on the call, there's a lot of evolving changes. I actually literally just found out two minutes ago where my high school football game just got canceled two minutes ago because of positives on team. So it's stuff that we're all adjusting to and there's commonalities that we all have at different levels and there's obviously some differences based on resources and some other issues, including politics. So that's me. Next, Carly, do you wanna say a few words? Sure, hey everybody, Carly Day. As you guys can imagine, college sports right now is a little crazy. So happy to give any insight I can. It's ever evolving as our nation's COVID prevalence is evolving as well, but happy to answer any questions and give you this perspective from the college level. Ken. Yeah, hey, Ken Mountner. I'm down here in Emory in Atlanta. So my involvement, I'm the head team position of the Hawks, as Jen mentioned. And so I was actually at the game when the NBA season got postponed. And that was not a story I'll tell now, but a very unique experience being there when they're literally were, was, you know, teams were getting cases and they stopped the play and it was kind of crazy. Unfortunately, the Hawks were not part of the bubble, but I've been really involved in the COVID protocol with the Hawks as well as with the NBA over the last several months. I also work with the Atlanta Braves and, you know, I covered half of their home, their truncated home games this year and some of their playoff games. And so I was very involved in their COVID protocols as well. I'm peripherally involved with the Falcons. I can talk a little bit about the NFL, but not as much. So hopefully, you know, our experience can help you all out there too. And then John. So this has been a crazy ride for me. I started at the US Olympic and Paralympic Committee on March 2nd. And within a week, yeah, within a week, we had to close our training centers. The Olympics and Paralympics had not been delayed or postponed. And the whole, I tell you, my whole job has been related to COVID so far. Reopening the training centers, helping to guide return to sport across the country and around the world, and then preparing for the games next year. So it's been really interesting. I've learned a ton and I'm looking forward to sharing it with you and hearing the perspectives of all of these esteemed colleagues. Great, thank you guys. So we'll get started going over kind of the different topics that people voted on. I think, why don't we start with COVID-19 testing? Because, you know, that's definitely been something that's been very hotly discussed. And it'd be interesting to kind of hear all of your different perspectives and how you're managing that at all the different levels and any challenges that you guys might've encountered. John, why don't we start with you hearing kind of what things are like in the Olympic Paralympic side of things, and then we'll kind of go down the panel. Yeah, so I'll talk about the training center and then I'll talk a little bit about the national governing bodies, which are essentially the small businesses of sport. And they are all separate from the USOPC, but each of the different NGBs does look to us for direction. So we have two primary training centers, one in Lake Placid, one in Colorado Springs, and then another one that's operated by a separate nonprofit entity out in Chula Vista, California. So it's not run by the USOPC, but we have a lot of different athletes that are there and we have a sports medicine center there. So we do essentially help them develop their policies for COVID-19. So after we had shut down the training centers because of public health mandates, and then they were allowing facilities to reopen, we thought about how can we do this safely? And the way that we did it is we started off with the least risky sports. So ones that can have significant physical distancing and smaller numbers, and those that didn't have high-risk athletes associated with them. So nobody with immunodeficiency, diabetes, and so on. And we had people come on to the site. We have them in a single room. We set them up with a training program in that room and we give them an hour a day outside independently where they're not around any other athletes. And we have a strength and conditioning coach write them a program. So while they're doing this quarantine process and we're monitoring for signs or symptoms, we allow them to do some exercise. So they're not just sitting in their room for this timeframe. We also provide them with mental health resources because it's tough. You come into a place, you're sitting in a room, you don't have a lot to do. And so we provide them with mental health resources and group sessions and so on, all virtual. And then on days four and five of their quarantine, we do a PCR test. So we're monitoring their signs and symptoms and then we do the PCR tests. And on day five, we also do an antibody test. And so if the PCRs are negative and they're asymptomatic, then the following day, we allow them to exit quarantine and start with their normal exercise. If they either have a positive PCR or they have evidence of prior infection based on antibodies, if they have prior infection, we allow them to come out of quarantine, but we do a ECG, troponin and cardiac echo. We also are doing PFTs on all the athletes as just part of our routine pre-participation physical. If they have a positive PCR, so they have an active infection, they're symptomatic, then we treat them according to the CDC guidelines. And after they're no longer contagious, then they come out and we go through that cardiopulmonary screening. And so that's what we've done so far. We've had, at this point, around 400 athletes go through that process and we've had very, we have had few that actually came in and had active COVID. We had about 11 who had prior COVID. We've had, we originally had no athletes that developed any symptoms or pathology afterwards, but just recently, because we've had this skyrocket in cases, we've ended up with two cases in our bubble, essentially, where people have gotten sick, but no spread from there. And nobody has had any cardiopulmonary complications associated with it. So that's our testing and our process. Awesome, thank you, John. Ken, how do you guys, how are you guys handling that on a professional level? If there's any differences there. Yeah, so, yeah, I'll talk a little bit about both basketball and baseball then. And it's been kind of an evolution, like a lot of people will talk about here. Initially, when the season shut down and they were trying to decide if they were gonna restart it, were they gonna finish the season or go into a bubble, there was a point in time when, so we have been pretty much sticking with PCR testing in our sports, right? So there's a rapid point of care testing, we know that's available, which can give you 15 or 20 minute results, but we have not felt that they were probably accurate enough or widespread available enough that we wanted to take the resources to use those tests in. So I'll say this, both Major League Baseball and the NBA have been very aware not to take away resources that people in the public could be using. So they never wanted to be acting like we're jumping to the front of the line or we're getting a test that everyone else can't have. And so, the good and bad, as we know, the PCR testing is a delay in getting the results back, which can be at best 12 hours, at worst, well, at worst with our professional outfit, 24 to 36 hours. We know some people in the community wait a week to get it back. What Major League Baseball did though, is they took one of their sites that was doing like drug testing for baseball out in Utah, and they converted it into their PCR testing laboratory. So baseball did saliva testing. They did it every other day throughout the season. If you were a tier one athlete or a tier one doctor, as I was, and it was sent to the lab. And so you wouldn't get that result for about 36 hours. So you would test one day, you wouldn't really find out till the next evening. So there's obviously a risk of possible exposure and people playing during that time period. And as you saw early in the Major League Baseball season, a lot of people did get in, certain teams had some spreading and events that occurred. Once Major League Baseball got to the playoffs, as many of you all know, they instituted a bubble down in Texas and California. If you got to go into the bubble, which was a very small group of people, then they were doing PCR testing every day in the bubble, and they were quarantining, they quarantined everybody before they kind of left and went to the bubble. Real quick with the NBA, when they first started letting us back or letting our athletes back on the court, they were really cautious with things, right? So they were doing the PCR testing. We had 12 feet apart, not just six feet, 12 feet apart, one ball, one basket, one coach, right? So our practice facility has four courts on it. And we had basically, or I guess we have two courts on it, four baskets. And so we never had more than four people in a building. And it was, like I said, one basket, one ball, one court. There was no practices or anything intermingling going on there. Initially, we weren't even doing any therapy or training on our athletes that needed hands-on stuff. Eventually, obviously, we know the bubble got started down in Orlando, and those folks obviously went through the regular quarantine kind of like John described, very strict quarantine before they went in the bubble. They were getting daily PCR testing in the bubble. And as you saw, people violated any of the protocols down there. There were fairly harsh penalties. And it gets tricky, and I don't want to get into all the nuances, but what do you do when someone needs to go see a doctor or go out of the bubble? And so what our professional league did was try to create these kind of clean corridors, they would call it, where our athletes would be able to safely go from point A to point B outside of the bubble and not interact with people who could potentially make them exposed so that they wouldn't have to have this extended time out when they kind of came back into the bubble. And it didn't work perfectly all the time, but it was a really good concept, including sometimes if you knew you were going to go see a doctor, that doctor would get tested the day before to make sure they weren't positive. And then you could go see them the next day and obviously maintain social distancing as much as possible and mask wear and all those other things. So, and there's a lot of other stuff I can get into. We'll probably talk about cardiovascular testing, but just to follow up on John's point, because I think it's important when we get to it, in the NBA, we've had well over 100 positive cases. They've all undergone ECG, troponin and echocardiogram before they've been allowed back to play, major league baseball as well. But in the NBA, we haven't had one case, we have not had a case of myocarditis. I think the WNBA had one case of pericarditis and major league baseball, there've been a couple of them, which have been well publicized, but overall extremely low risk for cardiovascular complications. Thank you, Ken. Carly, how does COVID-19 testing look in the collegiate world? Yeah, it's very evolving. So today, the second edition of the re-socialization guidelines came out from the NCAA. So if you look at that, that will give the most up-to-date current testing guidelines but really, it's been so much work setting up testing and every time we have it figured out, the recommendations change or we change our thoughts. So it's been, when we first started this summer, we figured out through our department of pharmacy and our department of nursing and we have a veterinary lab that got CLIA certified and we... Switched to antigen testing when we were returning to play in September. So now we have daily antigen testing with confirmatory PCR. It's just changed so much and based on schools, conferences, divisions, it's very variable. So I have a general idea, there are certain schools doing three times a week and doing two antigen, one PCR for their football teams. There are some doing PCRs daily, there are some doing daily antigen, three times a week antigen. So even within the power five conferences, it is extremely variable. And some of the interesting things we've found is that with football, most people are sticking to conference only, but with basketball, people are starting to talk about playing teams from other conferences and you're basically trying to meet each other's standards. And if they're different, sometimes you're like adding additional testing to your testing already, cause you have to meet, if they want a certain number of PCRs and we want a certain number of antigens. So the contracts between the schools that are playing basketball has been interesting to look at. So it's super variable. Again, I can tell you at our school, we're doing daily antigen testing. I am included in our tier one. So I get COVID swabbed every day. And every day when I get home before my kids hug me, they say, do you have COVID mom? I said, not today. And then they give me a hug and we wait and see what happens the next day. Thanks Carly. And then Jason, you know, you take care of a lot of high school, you know, community sport athletes that may not have quite the amount of resources that some of these professional collegiate teams have. What do you kind of recommend or, you know, talk about COVID-19 testing about those types of sports? So it's very interesting at high school levels or community sports because each state has their own high school state athletic association. And there are 50 plus different guidelines currently at this time. So because there's not a one particular algorithm that everyone is following, it's really, it's in some respects more difficult at the high school level. So as an example here in our county, we recommend certain things, but we cannot mandate anything. And furthermore, our athletic association in Florida, so the FHSAA has basically deferred to the governor's office and Florida, whatever your opinion is, it's basically said we're open for business, which is very different than other states. And this is before the last couple of weeks. And I'm trying to say this very carefully. That said, we give the best advice we can. If there are symptoms, we recommend go get tested. I know through the University of Florida Health, as well as a few other hospital systems in our region, the testing is really quite accessible. And we get results back quickly. However, I actually wanna give a lot of credit to a lot of our high school coaches, because if anyone has possibly been positive, the coaches and subsequently our athletic directors are actually just canceling the games and putting teams in isolation, whether that is the most appropriate thing to do or not, and fully recognizing that CDC guidelines have changed in the last couple of months as our other guidelines. So it's been quite difficult, but we don't really have a lot of say other than what we would recommend. So the example I give is if you have a concussion, I can take your son or daughter off the field and I have the final say. But if you have an ankle sprain and don't agree with me that I should hold you out, you can go to another physician and get cleared. And that's okay. Even if I might disagree with that or my athletic trainer disagrees with that. So in some respects, the high school and the adolescent sports is quite difficult. This has been well-publicized back in late summer. One of our sports medicine colleagues who's not a physiatrist who works in the St. Louis area was quite concerned about the number of baseball tournaments going on in greater St. Louis. And there was a significant outbreak, even a super spreader event because of that, even if the high schools weren't allowing it, the private leagues were. So it's been quite challenging, I should say. And right now we're just making the best efforts we can to at a grassroots level, recommend follow your social distancing guidelines and guidance from the CDC, WHO, and local government. Thanks, Jason. I was gonna add when Ken was mentioning about the PCR turnaround. So we have like a four hour turnaround at our lab that we do locally, and obviously we don't have transit time. And when we say things evolve literally weekly, I'm scrambling for new recommendations for my conference. So when the Big Ten first started playing, which was three weeks ago, we were told that any positive on Friday or Saturday, so all our antigen tests are on a Friday or Saturday. It doesn't matter if you can turn it around, they are not allowed to play, period. So even if they have a negative PCR, like they're out, and it was just to make sure there was parity. If there were schools that couldn't get a PCR that quickly, then they changed the rules and said, okay, you can flip a Friday test. So if you have a positive antigen Friday, negative PCR, and then a negative antigen Saturday, you can play. So we had to work all of that out. And then this past week, they now said you can flip a Saturday test if you have enough time. And then to state cancel their game, they moved our game time to 5 p.m. So that created an additional step to try to get this done. So it's interesting to me that some of the professional leagues had that long turnaround, and we're essentially expected to turn around a 10 a.m. antigen test for a 5 p.m. game and see if we can get a negative result back. So it's a game of minutes right now, it feels like, with testing. It's crazy. Thanks, Carly. Go ahead, John. Just to have a quick comment on testing, because we've got the Olympic trials, national championships, and a lot of big competitions coming up. And as we talk about testing, one of the things that happens is we're trying to make the events safe. And so people are planning how to test in advance of events, and particularly people flying in only there for a short period of time doing their event and then going home. And for the Olympics or Paralympics, you know, this is a once every four-year event. And so what happens if you fly in and it's the day before your event and you have a positive test? Is it a real positive or is it a false positive? Is there time to get a backup test? How many backup tests do you use? What's your original screening test? What if somebody contact traces, so they're asymptomatic, they have a negative test, but they were close to somebody who tests positive that morning, do they get pulled from the competition? Because this is your time to qualify for the Olympic or Paralympic Games. And so there's a lot of ethical discussions and testing discussions on the process and the arbitration panel, and who should be on an arbitration panel if an athlete contests the test results, and or when should an athlete who technically is contact traced be allowed to compete? You know, so these are really tough questions, and there's a very strong wording within the Olympic movement on the right for athletes to compete. And so it's something that we're facing right now, and we don't have the answers. We're working with the IOC and IPC to come up with solutions, but interesting questions. Yes, definitely. Always evolving. Jason, before we move on from COVID-19 testing, Jason, there were just a couple of questions, and anyone else if they want to comment. So one said, particularly with regards to high school and younger athletes, what role do you think improved testing will play looking forward? Is there potential for rapid antigen testing to take on a significant role where athletes are tested shortly before playing, allowing for competition to occur even when one slash a few athletes are positive? Would this allow more fans to attend, make indoor competition easier to do in good faith? Lots of questions here. So I will say in general, and this will obviously vary based on socioeconomic factors based on the part of the country or county or private versus colloquial versus public institutions at the secondary level. So that's my big caveat for everything. That said, it's going to be very difficult. Basically, it's resources. Resources obviously are more available to higher levels of sport. So ethically, to kind of bounce off Dr. Finoth, what if you have a private school playing an underserved school, and one school has access to tests and finances are not an issue, and another school really doesn't, and they may just have access to a nurse practitioner once a week? So the question, I don't know if I'm actually answering the question, but if we have access to tests on Fridays or Friday night high school football games, and they're negative, well, then it goes back to the basic science of, well, were you exposed within the last day or two, or was it five days ago? Because we know the viral load is between five to seven. Additionally, and while we may not want to truly say this, I will say it's true at the collegiate levels and above, there is a financial aspect to things. There's a lot of places where folks are losing jobs. There's folks who are being furloughed, and it's affecting towns. I'm in a college town. Dr. Day is in a college town. So that, you can truly see how it affects the entire town when businesses close down because nothing is going on. Our job is to simply care for the athlete and make sure that he or she either isn't sick or doesn't pass it on necessarily to the next person, but they're all ethical questions as I mentioned Dr. Finoff brought up and the rest of the panel will as well. So the short answer is, I don't know. I don't know if we had more testing at the high school level just for high school athletes. Now the question is, what about for the non-high school athletes in the school? Thank you, Jason. Go ahead. Go ahead. Yeah, I was just going to add on that. People may have seen, I mean, obviously that's the goal, right? That we're going to have some kind of rapid test that is widely available, cheap and accessible. And you've been hearing for a few months about these tests that are in development and may be things you can pick up at the grocery store, like a home pregnancy test and do yourself. If you just saw this morning, just a little different spin on this, but one of the NBA teams, we're starting to figure out how we're going to do our next season at the NBA, not just for our team, but also for our fans. And if you saw, they were talking about one of the golden state, I think it was, was talking about how they wanted to do rapid testing on fans so that maybe they could have 50% attendance. And if you could test you before they entered the stadium. And so I think ultimately that's going to be the goal is that we can have rapid tests and that we can be doing before practice, before something important. So we can have an answer right there, right then, but it's only as good as the test quality is. And so in the past, a lot of these rapid testing were not accurate enough that we felt comfortable with them. There are a couple of companies out there, I won't mention their names, that have really good rapid tests that are available. But once again, resource wise, I mean, these products are on back order in places, they're only in hospitals and they're obviously the community is using them at large. And so that's a significant strain on our resources. And so to trickle down to the high school level, you know, unless you have those at-home tests, you know, I think it's going to be really hard. John, but do you have some more to say? Yeah. You know, I think one of the biggest issues we've got is the test that's rapid, cheap, and more readily available is not a very good test. And what it does is it gives people a false sense of security and it allows them to say, we can do 50%, you know, attendance at this area. But the fact of the matter is, is the issue with antigen compared to PCR, as probably people are very familiar, is PCRs do amplification of the viral RNA. And so if you amplify it, then you have a much higher sensitivity. And so you have a much lower likelihood of a false negative. And so if you have an antigen, you have to have a large enough antigen load that with no amplification, you actually detect that antigen, the protein that your particular test is looking at. And so now you have a lower sensitivity test that increases your likelihood that you're going to have false negatives and result in a super spreader event, like has happened at, you know, major settings that we can all read about daily in the paper. And, you know, ones that are continuing to go on now. So I'm, if you can do it, you know, the PCR is more expensive. It's a way better test though. And the antigen test right now, I think just gives people a false sense of security and they start doing things that are foolish. Go ahead, Jason. And again, I would, I would just kind of add on when, when do you use that test that you feel like you can take it to the bank, so to speak, should it be, you know, we've heard a lot of stories about if the collegiate professional level, someone took a test on Thursday or Friday and he or she is ready to go, but then Monday or Tuesday, they're positive though. Is it better to say the day five test is the quote unquote most sensitive test because that is when you will likely going to have your viral load potentially at its peak. I'm not saying that is the right answer, but does a negative test in day two equal a negative test on day five? And I think most of us know, based on the data, it doesn't, it's, it's more, I guess, sensitive and specific once you get into day five to seven or so. That's why we do a six day quarantine. You know, that's the difficulty. That is absolutely the difficulty of trying to do testing the day of the event. You do your tests and you know, your results take several hours. And in that time, somebody may have a viral load that makes them contagious. And so, you know, you really do need to have this quarantine timeframe and the testing if you want to have the cleanest environment. That's why the NBA was so successful. And that's why most other professional and collegiate and recreational sports have not been as successful. You know, our bubble is pretty dang good, but it's not as good as the NBA's bubble, but they also spent, I mean, it's just an astronomical amount on it. And so the difference between that type of support and resource versus community level sports is really different. And when you're looking at community level sport, I think you really have to look at the prevalence in the community, decide whether it needs to be regional and by regional, like your own community versus multiple towns, you know, and spreading from there to larger regions, states, and then country. Right now, obviously that's really tough, but there are ways of doing sports, even with high prevalences, but really narrowing it down, keeping your cohort small, doing sports that don't have close sustained contact and so on. And I'd like to throw out, you know, we were discussing antigen testing versus PCR. So right now the two conferences that are doing daily antigen testing are the PAC-12 and the Big 10. And some of the thoughts behind that was that you trade your sensitivity and specificity for a rapid turnaround and a frequency of testing. So you have more frequent testing and a faster turnaround that makes up for the fact that the test isn't as good. And so that's the thought, right? So maybe if you miss it on day one, but you catch it on day two, you know, because you're testing them every day, that was a pretty minimal exposure versus if you're only doing PCR twice a week and it takes 24 to 36 hours to get the PCR back, then you're really, you know, that's the trade-off. And Michael Mina, I don't know what his specialty is, if he's infectious disease or what he is, but he has some YouTube videos that explain this more eloquently than I can, where you look at, again, the test turnaround and the frequency. And it basically shows how quick, how much you can catch the infectivity, right? So someone might have it that would be positive on PCR, but negative on antigen. But if their viral load is that low, are they really infectious? And if you catch them with the antigen and pull them out immediately, as in they are positive that morning, they did not participate in anything after a positive test. And the day before they were negative, are you pulling the infectivity out, even if you're not catching every positive as soon as they turn positive? And that's the thought behind it. It scientifically and theoretically works, but practically nothing's perfect as we know. And that's why we're still seeing probably some positives in teams, even if they follow the scientific concept to a T, it's just, there's going to be a flaw in everything. But again, just trade-offs really with testing. Thanks, Carly. So I know we have a lot of questions coming in, and I know that this is a huge topic to cover, and only an hour, and we only have 20 minutes left. So I just want to make sure we cover the topic of return to activity considerations after COVID-19, because that was the number one thing that people voted on. And then I will try to get to a lot of these questions after we cover that topic, but I just want to make sure we hit that. So kind of going through the panel here, what are you guys' guidelines in terms of return to activity, both for maybe mild versus severe COVID-19 infection, and maybe add a little bit of cardiac clearance in there, just so we can hit a little bit of that in this topic. John, do you want to get started with this? Yeah. So it is very interesting. The majority of studies that have looked at cardiac involvement that really found a fairly high cardiac involvement, such as the German study on patients that came through a COVID clinic. And so it was people who were hospitalized and people in the community, but they did cardiac MRIs. And cardiac MRIs, we still don't really understand that much about how to interpret it. We haven't done cardiac MRIs on everybody who had the flu. We haven't done cardiac MRIs on everybody who has Coxsackievirus or just athletes in general. And so the interpretation of cardiac MRIs are very difficult, whereas we have really good data on ECGs and echoes and troponins. So I would say it's not that you shouldn't use cardiac MRIs, but be very careful about using cardiac MRI as your primary tool to diagnose this and how you interpret that test. But in general, if somebody is asymptomatic, they are caught on a screening test and they never develop symptoms, they never felt bad. Then typically after that, based on the available data, if you look at cardiac MRIs, some, a small percentage of them likely will have some cardiac abnormalities on MRI, but there does not appear to be clinically significant abnormalities. And so the American College of Cardiology is not recommending that those people have further cardiac workup. Now, if you have mild symptoms, then they are recommending that you consider, you should certainly see a physician. And they recommend that certainly if somebody is having any shortness of breath, chest pain, and so on, you absolutely need to have a cardiac workup. But there are variances between different groups on whether you get an ECG, troponin, and echo. And that's sort of the minimum workup that most people would recommend if you're going to do it. I would say if somebody at this point has mild symptoms, they are not having cardiac symptoms afterwards, if they have the resources, I would get those tests right now because we still are learning about this and there is a risk of sudden cardiac death. Certainly with moderate and severe, I would go troponin, ECG, and echocardiogram. But it's that mild symptom one that I think you have a debate. And I worry about excluding people who had mild COVID from participation in sports based on resources and data that we don't know yet. Thanks, John. Any thoughts on that for the professional sports, Ken? Yeah. So John alluded to this, but this whole idea of the myocarditis was out of some studies where people who are hospitalized with severe infection, the rate of myocarditis in those folks were I think it was 20 times higher than you see with influenza. And so this is what caused a lot of the concern. And what they never really have found or have shown is that our people who are mildly symptomatic or asymptomatic, you know, what is the risk in that athlete? And we don't know the answer to that. And so, you know, obviously in the NBA, cardiovascular screening is a big deal anyway because, you know, we see more hypertrophic cardiomyopathy, we see more sudden cardiac death. And so honestly, EKG and Rest and Echo, we get every year on every NBA player. Resources aren't a question here. The troponin is the one thing we've thrown in now differently to look at folks who have either been antibody positive, you know, they never had symptoms, or if they were coming off a positive PCR, we don't, you know, we wait the two weeks, as John mentioned, and then we do the testing before we allow them to do any significant exertion. Major League Baseball, exact same test in troponin, EKG, and an echocardiogram. And, you know, our cardiologists who work with the NBA, and one of which is one of my partners here, just like John said, the cardiac MRI is maybe too sensitive. We don't really know enough about it. And so even in those professional sports, we're using cardiac MRI on some questionable, you know, hypertrophic cardiomyopathy and some other things. It's kind of our fallback if we get something on the other test that lead us to need a cardiac MRI. So when you have all the resources in the world, we're seeing that as kind of the test to do when maybe there's some questionable abnormalities to give you. I'll let Jason answer about how it transfers down to the high school level, but that's really where the question is. And I take care of high school teams as well. And I think even at a more private high school, to think that every mildly asymptomatic kid should go down this route of cardiovascular testing when you may be able to do some kind of, you know, where you slowly increase their activity over a couple of weeks and you look for symptoms is a pretty effective tool, but I'm sure Jason will talk about it as well. Before we get to Jason, Carly, you want to talk about in the collegiate athletes return to activity considerations and any players that you might have had mild versus severe COVID-19. Yeah, ironically, again, I feel like at the college level, we could have eight people on a panel with the different conferences and different divisions and all the different testing that they're doing because it really is so variable. So again, the Big Ten is doing the most testing. Every single positive for us gets a troponin, echo EKG, and a cardiac MRI. We are the tightest conference regarding testing. There are some, again, smaller divisions who don't have anything required and probably have the equivalent of a high school, you know, as far as their... Folks through AMSSM who have put together like a registry and then there's also going to be a Big Ten registry. So we hope to have, the big question is, does chest tightness correlate with myocarditis? Because like, you know, when we're talking, what symptoms, because when you say severity, there's even a debate within college sports of what's mild versus moderate, does a fever automatically put you in moderate or you had one day where you're 100.6 and felt good the rest of the time compared to someone else who just had two weeks of cold symptoms? What's the difference? So that's what they're trying to look at and see what symptoms correlate with, you know, myocarditis or more severe illness. I will tell you just, I do know of quite a number of cases of myocarditis at the collegiate level. Not all of them have been publicized. And when you talk to those team physicians who have been around a lot longer than me, this clearly is at a rate that is higher than they have had in the past when people were getting flu, other viruses, what have you. And this is, some of these are symptomatic where you could say, oh, but we're screening everybody now, but no, people have had people with a more significant illness that clearly would have triggered some weirdness after a flu that like, why are they still in symptoms a month after the flu? So my comments about the cardiac involvement is we know in sick people in hospitals that there's a higher rate of cardiac involvement compared to the flu and COVID. There's no doubt about that. You can talk to cardiologists, there's data on that. So there's something about this virus that is preferential to whether it's the vasculature and that's the issue or the heart itself or the myocardium, I don't know what it is, but there's something about this that's worse than the flu with hearts, but we don't know how much worse, especially in young people, right? So in old people, I think almost everyone would agree, it seems like it's worse than the flu and cardiac issues. In young people, is it 5% worse? And if that's the case, is that, you know, is that really worth all the testing? We don't know. So I think the Big Ten's thought was like, well, let's collect as much data as we can and hope that we can back down if we find that it's not as severe as we think. But I can tell you, like I said, I do know of multiple cases at the collegiate level. And what people are also seeing is prolonged respiratory illness. Just want to throw that out, that that is also an issue that people are having after a more moderate illness. That's nothing to shake your head at either. How are you canceling return to sport and those athletes that you're catching those more severe cases? Yeah, so most of the cardio, you know, every school, at least in the Big Ten, has a sports cardiologist and they tend to handle return to play. It's been variable. I know some schools will do a six-week follow-up cardiac MRI. Some go with the more three to six-month rigid response. It's just variable based on the cardiology recommendations. Got it. And at this point, both cardiologists, and if you look at the guidelines, they would say that with myocarditis, it would typically be a three-month timeframe before you go back to sport. But that was a consensus. It was not based necessarily on science. It was a bunch of people in a room that said, yeah, probably it'll take about three months to get better. So it is reasonable to look at it earlier. The other thing is, so if somebody has no symptoms, typically you can return them to play essentially after they're no longer contagious. If they had mild symptoms, then usually after their symptoms resolve, about a week of gradual increasing activity is reasonable. And if they have moderate to severe symptoms, it's going to take longer. They have to pass the cardiopulmonary testing and you're going to anticipate that this, you know, if they don't have myocarditis, it's still probably going to take a few weeks for them to come back from a more significant illness. And then Jason, do you want to say a few words about this in the high school community sport level? Well, I think, you know, John actually just kind of summarized it best, would apply at the community level. The only thing I actually might add on are two things. One is something that Carly alluded to, and this would be a great research study if anyone on the panel or anyone who's listening in, is I have had patients in the community who are not athletes when they were older, who suddenly see all their muscles and their joints and their body had been sore for four to six weeks after they had COVID, even though they're seeing me for their right shoulder, left knee, right ankle, wherever the case may be. So I would be actually very curious if anyone is actually looking at muscle levels of muscle enzyme levels and or have any muscle biopsies, because there have been anecdotal reports of athletes who returned to play at the high school and collegiate level and at my area who feel like, I just feel like I just can't get my wind, but their breathing is fine and they just feel sore all over. It's not the typical DOMS, delayed onset muscle soreness symptoms. So I'm wondering hypothetically, if yes, the heart is being affected, but that's a muscle. So is that not necessarily unique to just that muscle, but other muscles in our body? I have not seen research on that yet. To take it back to the high school level, unfortunately, you're going to have to go based on some of the more simple algorithms that John summarized them perfectly well. Positive test, isolated with no symptoms, you can basically return to play as your condition allows you to. If you're positive with minimal symptoms, maybe a low-grade fever, you had a sore throat, you can probably return to play. I might recommend getting a basic cardiac workup, but I cannot mandate that and it's up to the parents if they want to do that or not. If anyone was hospitalized, I strongly encourage getting a full cardiac workup and meet with the cardiologist. So that's my very simple algorithm. And like I said, I don't think that's unique. I think everyone on this panel, as well as everyone listening, that's probably the approach we are currently taking, unless there's certain areas or certain states or even counties that have certain mandates that can be enforced. But otherwise, that's basically the approach right now. In terms of return to play, let's say you were in the most common thing is you return to play with mild symptoms, with a negative cardiac workup, you know, whether it's a week or two weeks, I kind of want the athlete to see how they feel before I let them back into competition. So it's almost like you're developing your own concussion protocol. Are you able to do 50% for two or three consecutive days? Okay, let's move it up to 75. So it may take, I think John said it, two weeks, it may take four weeks, I don't know. Just the challenging thing is, is you're sort of trusting a 14 to 18 year old to be very honest with you, which for those of us that care for those type of athletes is sometimes difficult. So, but I think the simple algorithm of asymptomatic positive, don't necessarily need the workup unless you want to get it, minimal symptoms, non-hospitalized, I would recommend the workup. It's not mandatory. And if you're hospitalized, I strongly encourage you to get a cardiac workup. And just real quick, I mean, the Federation of High School with AMSSM. Oh, this is a good resource for folks out there. So I was just going to throw a little bit from Eve's side of the coin that sort of do a lot of testing and they don't do a lot of testing just to muddy the waters even more. So the newest version that came out in JAMA was basically saying mild symptoms do not require a cardiac workup. It says CV testing is unnecessary, but individualized decisions can be made. And they put the moderate, and again, you can ask to define what moderate is, but the new recommendation basically said mild, no CV testing, and then moderate, you would consider cardiovascular testing, and they do troponin, EKG, echo, they leave out cardiac MRI. Okay? So that's the like, maybe you're good letting mild people just go once they feel better. The other side of the coin is the paper that came out of Ohio State with their four significant myocarditis, and it's, you know, maybe you're picking up on some clinically unimportant findings on the cardiac MRI, but there was something on these asymptomatic people's MRI. Something was there. So again, it just makes it more confusing instead of less confusing when you really look at the data where we're saying it's really bad, it's not really bad, and the hope is over time that, you know, we figure it out. But I wouldn't be surprised if the pendulum keeps swinging back and forth as more information comes out, and eventually we'll hopefully settle somewhere that's evidence-based. All right. So we have about five minutes left of our session here, and I know, unfortunately, we won't be able to get to a lot of the questions here, but clearly, you know, this is definitely a hot topic and something that we need to talk about, you know, further, maybe have a different forum so we can have some more time to talk about this. But just wanted to get to some questions. I think there were a couple questions related to how is testing and management may be done differently in, like, the Paralympic or adaptive athletes, and, John, I don't know if you want to start us off with that. Yeah, really quick, I mean, there's more athletes in our Paralympic population that have higher risks for complications and a bad outcome associated with COVID-19, whether it's because they have a neurologic disease that causes a restrictive lung disease at baseline or immunodeficiency, you know, so there's a lot of issues. So number one, we are much carefuler about keeping them physically distanced. You know, if they do not have to have close, sustained contact in training or participation in their sport, they do not have close, sustained contact. We absolutely are testing those athletes on a more regular basis, and I think that it's you just have to consider them a high-risk population and treat them from a public health standpoint accordingly. Great, thanks, John. All right, and then any comments? Someone asked a question about impact of the vaccine and how that may affect, you know, sports moving forward, maybe in the spring, who knows when this vaccine is going to come out, but what thoughts are, I know no one knows, but thoughts about what that, how that may affect things. Anyway, John, go ahead. Yeah, I'll say that, yeah, the vaccine, if all goes well, I mean, the preliminary data on the Pfizer is obviously really exciting. They only had 96 cases of positive COVID-19, so they're basing it on those 96 positive cases, those who had placebo versus those who did not have placebo. So, you know, I think it's really important for us to make sure that we have the right data for those 96 positive cases, those who had placebo versus those who did not have placebo, but the preliminary results do look promising. If they get an emergency use exemption rapidly, at best, they would start distributing the drug in January, and they would go, that would go to high-risk populations, including healthcare workers and those in, that are elderly in nursing homes and so on. So it's probably not until March or April that it would actually be available for the regular population, and so in my opinion, sport is not going to be put, they shouldn't be put in front of those populations that are high-risk. It's going to take a while for it to permeate even into the professional and collegiate sports and certainly down into the community. And so by the time we actually have significant immunization within our community, it's probably going to be summer to fall, then it is going to be kind of going in this phase. So I would say we are going to be planning for quite a while to be in the same sort of situation that we're in right now. And even after we've got the vaccine, we don't know how long it lasts. And so, and there's going to be a lot of people who aren't going to take it. And so we're still going to have to be, I think a lot of the things we're doing now are going to carry forward. Great. Yeah, I don't have much. Go ahead. No, I was going to say John summed it up really well. Our NBA and even next season, Major League Baseball season, the planning is going on as if we are going to be status quo. They were hoping that we would, they were more worried about probably a vaccine from a fan's perspective and from the player's perspective and who you could get into the stadium, obviously the economic impact of it. But I agree with John. I mean, that's the stuff I read in a very similar timeline. Thank you. There are a lot of questions here about testing. One person asked, thoughts about pooled tests? Pooled tests are nice because they are cheap and it's pretty quick. The bad part is, is that if you pool 10 people or 20 people into a pool and there's a positive, then all of those people have to get quarantined until you repeat tests on all of them. And so if everything's going smoothly and there are no positive tests, great. If you get a positive test, boom, a whole bunch of people are taken out immediately. So that's the pro and con of pooled tests. Yeah, our lab recently asked us about that and their plan would be for surveillance testing to do pooled but for diagnostic testing not to, to get a result faster. And again, literally it's a matter of hours for us. If you have a pool that turns positive, I don't know if we would, I mean, we get it so fast. If we get it in four hours and they can run another test in four hours, we wouldn't isolate and quarantine everyone. But for us, a four-hour result versus an eight-hour result is the difference between being able to play and not play on a game day test. So that was our thought is like, ah, maybe for the collegiate population, we do surveillance at the whole college, maybe they would do it. But for us, that extra four hours. Thanks, Carly. All right, someone has a question. When can the player return to play after testing positive with a PCR RNA test? Would they have to retest with the antigen test until they are negative? Actually, it's a big deal. Go ahead, Ken. Yeah. I mean, I think we're going to say the same thing. You know, early on, the CDC recommended, you know, a negative test before you return people to play. And in fact, there was one NBA player who was, took him I think 44 days until he returned a negative test. And then we realized that, you know, we know based on symptomatology that after, you know, seven days, you're not going to be able to play. After seven days, you're not going to be symptomatic anymore. And you may still be shed and dead virus for weeks or even months. And so everyone's recommendation at this point is to not to retest for 90 days after a positive test. And we are not requiring a negative test to go back. Now, if somebody wants to go back earlier, sometimes in the professional sports scene, we can potentially test them to see if there are negative tests to go back earlier. But we don't do it routinely. The only time, the interesting thing is on the no testing for 90 days after somebody's a positive, which we follow also, the exception to that is somebody is symptomatic. So if somebody comes in and they're symptomatic, you would run a respiratory syndromic panel on them and look and see if you have another reason. But if you don't have another reason and they test positive for COVID, then they may be that low, you know, very infrequent. But some people do get reinfected within that 90 day time frame. Great. Thanks, guys. I'm getting told that we have to wrap up here. We went over a little bit. Big topic. And I know we didn't get to cover everything or answer everybody's questions. But I wanted to give a huge thanks to our panel for joining us today. Really, you know, great things to, you know, hear about kind of everything that you're doing and hearing recommendations. And I definitely learned a lot. So thank you all for joining us. And hopefully we can have another one of these soon because it sounds like there's a lot of questions out there from especially our specialty about return to sports and I know things are changing all the time. Thank you, guys, so much. Thank you. It was a pleasure. Thanks.

return to sports

sports medicine physician

COVID-19

guidelines

considerations

cardiac clearance

PCR tests

antigen tests

vaccine impact