Athletes and Complications of COVID-19

Steve Stites, MD: Hey, good morning. This is Steve Stites, chief medical officer here at The University of Kansas Health System. We're back, broadcasting live from the Dolph Simons Family Studio here at the KU Hospital. Today is a really special program. I think I say that about all of our programs. But this one is special because first of all, we've got a great team of people here with us today and I think you're going to really enjoy hearing about them. Hearing from them, and about them I hope. You know, we have spoken on many different occasions about youth sports, and we have tried to take a pretty fine line and just be as honest as we could about the information and the data that was out there.

Steve Stites, MD: One of the things we've learned about this pandemic, you've heard us say it before, you build an airplane while you fly it, good luck. And today, is no different than that basic theme. As new information arises, we feel that we have to offer you our healthcare and medical insights about that information. We're not going to take on a lot of policy stuff. We've tried to not do that. We try to stick to our lane and tell you, "This is the best we know as far as medical science can deliver." And today, we're going to talk it to you about the medical science of COVID, and sports, and recovery, because there's information that is changing.

Steve Stites, MD: To help us address that of course, is my right-hand man [Doc Hawk 00:04:23] here on the stage of course, with us every day. Bruce Toby, Bruce Toby is the ... I say to people, he's the father of sports medicine here at The University of Kansas Health System. Some days I call him the godfather of sports medicine here too, just to mess with him a little bit. Bruce is an outstanding orthopedic surgeon. He's the chair of ortho for approximately, a very long time.

Bruce Toby, MD: [inaudible 00:04:48].

Steve Stites, MD: It may have been a couple. After the pandemic, it will be 5 or 6. Michael Rippee. Michael Rippee is a sports medicine concussion physician here at KU and he does an outstanding job. And some of the information that's emerging is neurocognitive function, and so we want to take that on. Then to my left is Tim Beaver. Tim is a sports medicine cardiologist, so he's a heart doc who specializes in taking care of athletes and the complications that sports can bring to athletes. We've asked Tim to be here because he is the head of our sports medicine cardiology rogram. He has done a great job working with us not only with our professional teams, but also our college teams and our youth teams. So, we need to answer these new and talk about this new information. But first Doc Hawk, let's talk about our numbers because there is good news here.

Dana Hawkinson, MD: Yeah, we are very happy. The last 2 days we have been after again, reaching that peak of 39 recently. We are down to 24 patients in the hospital, 9 of those in the ICU and 6 of those on the ventilator. So, that is good. We have had discharges. We have had admissions as well during that time. But overall, the numbers are much lower than they were pretty recently, so that's a very good thing.

Steve Stites, MD: We do like that.

Dana Hawkinson, MD: Yes.

Steve Stites, MD: Bruce Toby, again, you started the sports medicine program here at KU. You've seen it through some early years, and to the place where now we're the team physicians for the Chiefs and Royals, and a number of school districts. We work with Lawrence Memorial over at KU and we're a part of the partners that are at Kansas Team Health. So, lots of sports medicine. Talk to us about what you see as being so challenging in a pandemic, to make sure that athletes are safe.

Bruce Toby, MD: Well, I think that what we do and what we've done so well in our institution, is to give the best scientific information and present that. But then there's the other issue, and that is the implementation and that's where I want to give some credit to a lot of different people. Because when we start talking about testing, somebody has to implement that and somebody has to get that done, and that includes our team doctors and also the trainers that are associated with it. So, it is a big team deal.

Bruce Toby, MD: I was talking to Dr. Vincent Key who's taken care of the Royals for us as the head team doctor for many years. What's going to be difficult for us is to implement these types of studies that need to be done, all the right things, while the team is playing and actually engaging into a season. So there'll be challenges, but fortunately we have great partners. For the Royals, for example, we have Nick Kenny and his people. They work very closely with Vince and Joe Nolan and his colleagues to get these things done. But, it is extremely difficult and time consuming.

Steve Stites, MD: It is, and you're going to hear about what some of those things are that we're talking about in just a few minutes. As they do that Dana, talk to us a moment just some of the extensive testing that's being done for example, on KU athletes as they go forward.

Dana Hawkinson, MD: Yeah. We have had a very good health partnership with the Lawrence campus, again, led by Chris Wilson, and then boots on the ground there. Dr. [Scrimshire 00:07:57] at Lawrence as well. So, there is an extensive amount of testing going on. There has been since the athletes arrived on campus. Since that time now, there is going to be a ramping up of the testing as well. This testing is mostly going to be PCR testing, but we are also doing antibody testing as well.

Dana Hawkinson, MD: From there, there's other algorithms that we're looking at if you are positive. Certainly isolation, quarantine, contact tracing has been very important. Further testing is going to involve things of specific organs such as the heart that are going to be evaluated there in Lawrence as well. So, there will be further evolution of this but right now, we have been testing. We have continued to test and as we move forward, we are evaluating and actually increasing our testing as we move forward.

Steve Stites, MD: And what we've noticed so far in our testing is that yes, we've had positive tests as athletes returned to campus and as the Royals return to practice, the Chiefs. But what we've seen is that once people got here, for example, the Jayhawks got to their sports program when they came back this summer, really the number of positives has been very, very small out of all the athletes we've tested, so that's impressive. I think the same thing has happened with the Royals and the Chiefs. But Mike, one of our concerns is in those people who have been positive, that there are some indications of some neurocognitive, that's a big word. You'll have to help us on what that means, some neurocognitive changes that do raise a few alarm bells. Can you address that for us?

Michael Rippee, MD: Sure. I would say, we're still learning a lot about this from the neurology side of things, but we do have some experience in previous epidemics. The SARS and MERS from a few years ago were similar viruses where we would see these long-term neurocognitive or really a very basic level, issues with things like attention, focus and these mirror, actually very closely symptoms that you might see after a concussion. We're still learning about that. The neurology community has really been talking a lot about this and trying to make sure we're watching very closely for these types of symptoms after a player has been tested positive.

Steve Stites, MD: Yeah. Was one of the concerns then that, can you tell a player that it's safe to return if they haven't been followed from a neurocognitive standpoint or redone testing?

Michael Rippee, MD: I think the really short answer is we don't know if it's safe to return. In talking with colleagues, there's been a really mixed response about this. I've talked with a couple of colleagues who said, "We're not testing at all. We're not doing any cognitive testing when they're recovered and they're cleared by all the other team physicians. We may not even be involved." And, I've talked to other people who have a very regimented, you know, "We have our ImPACT test, or our C3 Logix," whatever their computerized neurocognitive testing is, and they're doing it at very specified times. They recover, and then 2 weeks, and then 3 weeks, and then 6 weeks, and so on and so forth.

Michael Rippee, MD: I would advocate somewhere probably closer to that end of the spectrum, maybe somewhere in the middle, but that we need to be monitoring for these cognitive deficits. It's a really simple thing to do. In the athletic world, it's already built in that we have these cognitive tests. And while we don't know how sensitive those cognitive tests are in this particular setting because they've never been tested for postinfectious cognitive disorders, we'd like to think we would see some of these effects on those tests.

Steve Stites, MD: And I think the key is to our listening audience, that this is a relatively new finding and one of the problems in a pandemic is that as you fly that plane trying to build it, you learn new things. And just as in the first days of the coronavirus, we were in this room with a lot of crowds, with an old telephone right here. We were all huddled over it. There was a bank of reporters right here. We probably had 15 people in the room or 20 people in the room. Things we would never do today because we've learned so much about the coronavirus, we've totally inverted. Oh, there we are, there I go. I looked so good back there 21 weeks ago. I had more hair 21 weeks ago. Look at that.

Steve Stites, MD: He's got hair, he looks younger, he looks like he's been sleeping. What is that? But today, we know that we can't do those things, and so the story changes as we learn. So Tim, we've been learning a little bit more about inflammation of the heart muscle, what we call myocarditis, and we know that it can occur in people ... The study out of Germany looked at 100 different patients and found that 70% of them had inflammation of the heart muscle. And there appears to be emerging evidence that that can be true in athletes as well, which begs the question, how safe is it to be back in a high-intensity or high-impact sports after you've had COVID? I think that's the thing and I'm just concerned we don't really know the answer.

Tim Beaver, MD: Yeah, we don't know what we don't know. It's the million dollar question and I think to put it in context just to give the general audience a context, I think we've known for a long time that viruses affect the heart. Whether it be acutely from the infection, or an inflammatory phase of the virus that occurs afterwards. So as sports medicine physicians and cardiologists, we follow patients and screen them for symptoms, and also have testing to confirm if they have symptoms that they have suggestion to myocarditis. What was unique about this study is the asymptomatic population had significant changes, which they weren't expecting. That's where that's hard to put in context, although the age group was older than our average athletes. I'm an adult cardiologist so I usually take care of people 18 to 35 that are participating in high level sports.

Steve Stites, MD: So 6 zeros, you're saying we don't don't really have high-level sports at 60?

Tim Beaver, MD: No, I take care of masters athletes too, [crosstalk 00:13:54]. I think that the context is we don't know, and I think there's emerging evidence that are coming out of some of the testing that's occurring with some of the bigger programs that people are finding asymptomatic myocarditis. That's really what the hullabaloo is about and all the concern, and that's the context in which people are concerned about the new studies. The one study was an autopsy study. I don't think it was really that significant to the population. It just showed the virus can be in the heart.

Tim Beaver, MD: The other study was important based on the fact that they found asymptomatic people having post-inflammatory changes time out from the virus infection. The MRI is a unique tool as well. We don't in the course of looking at athletes and diagnosing them unless they have a suggestion of myocarditis. They don't usually go to that study. A cardiac MRI is not an uncommon study for us to order on an athlete, but not a routine study to order.

Steve Stites, MD: Does echocardiogram find it, or does it take an MRI to do it?

Tim Beaver, MD: It depends on the extent of the heart involved. If the heart has significant fluid from the inflammatory process around it or it has a significant area of damage, you can see it on ultrasound. When you start getting more microscopic levels and evidence of inflammation, that's something that's very specific to see on an MRI. That's why that was used in that study as a tool, because it can pick up scar and that can pick up inflammation.

Steve Stites, MD: This is new and evolving news, right? I mean, what are you hearing from colleagues in your field around the country?

Tim Beaver, MD: You know, I think as everybody is seeing in the meeting, there are some mixed emotions. It's been a little bit of a polarizing topic in the respect that some people ... I think we're dealing with a population of young people that are healthy and the majority of them are going to be safe. But the problem is that with the propensity of this virus to affect the heart more and emerging data showing asymptomatic people having evidence of inflammation, that concern about that baseline rate of sudden death with myocarditis being around 8% that, that could be higher because you have an asymptomatic population that's going to be active. So, that inflammatory phase or even the post-inflammatory phase when you develop a little scar could put you at higher risk.

Steve Stites, MD: Lots of inflammation in the heart muscle, but we are really beginning to know how ... We knew that was true acutely. We're seeing it for months and several, through the three months afterwards. We don't know when that inflammation begins to go away. We don't know what it means to the heart muscle, raises our concern. So as you said, you got to know what you don't know. Do you feel like it's okay to tell an athlete that it is safe to go back?

Tim Beaver, MD: I mean, my job is when I have an athlete with a problem, I sit down with them and we go through and it's a shared decision-making discussion. This is the particular problem that you have, this is the risks and at this point, I really can't other than the emerging data, give them information about the risks. So, I don't feel like I know that it's safe to go back necessarily without a lot of testing that is outside the norm.

Steve Stites, MD: Yeah, you know it's interesting, we all have this in our respective fields. I'm a cystic fibrosis doctor. I treat people with ... My patients all died when I started, when Bruce and I were very young. My patients only lived to be 19, and now they're living to be 40 and 50 years of age, and many of them want to go to college. How do you say to a young person, "Okay, you're going to go to college with cystic fibrosis. Hey, that's an amazing accomplishment." But then, a lot of them have role models that are respiratory therapists and nurses. So they come to me and they say, "Doctor, I want to be a respiratory therapist."

Steve Stites, MD: I've known these patients for 10 or 15 years sometimes and they'll, "I want to be a respiratory therapist," and I'm going to say, "You know, I just can't tell you that that's safe. I can't tell you that it's safe." I think that's the struggle because you don't want to put a patient who's susceptible to severe lung infections to be a restaurant therapist, when that could be a profession that gets you in front of a lot of people with bad lung infections. So we don't tell you not to do it, we just have to have an honest conversation and say, "I don't know if it's safe." So Mike, if an athlete comes to you and feels a little bit in a fog or something, maybe they've had COVID, what do you think? Can you tell them that it's safe?

Michael Rippee, MD: Well, luckily I have this conversation a lot both around return-to-play from concussion and those long term concussion effects, and whether they should keep playing or not. Like Tim, it's a conversation that isn't necessarily new, it's just a different framing of it maybe, and I think it's the same thing where I would say if you had these foggy symptoms or you're confused, even if it may not be more neurologic risk, what are the other risks that we have to think about? Are you at higher risk for other musculoskeletal injuries or those types of things? Because, those have been shown after concussion.

Michael Rippee, MD: So, I would sit down and I think it's the same thing as with Tim. I would say, "We need to talk about this together. What are your risks?" And in most cases right now, I would say with this we don't know. But, what are some of the things we want to think about as potential risk and using other knowledge that we have about other issues similar to this? What do we think ... I would personally like to see them back to their normal cognitive function before we return them to a high level athletic event but again, we would have to share that conversation and decide where things fall.

Steve Stites, MD: Yeah, and Bruce I think you've done this for ... Okay, I'm not trying to say you're old, but you and I have done this for a long time. It feels like that is a conversation that we have with patients. Is that a risk? Is it not a risk? I mean, that's just something we have to talk to patients about and the family have to weigh that risk to decide what they want to do.

Bruce Toby, MD: Yeah. I think it's in the approach though. What you want to do is to show that you care about them and care about their opinion, but we as healthcare providers who have a better knowledge base, we need to be able to put that fairly clearly to these individuals that there are risks, and the risks sometimes can be very significant.

Steve Stites, MD: And sometimes we don't know what all the risks are, which is where I think the problem is right here. Well Jill, that was a opening prologue. We wanted to make sure we hit the key scientific points. I wonder if there's questions out there now from our media friends.

Jill Chadwick: I'll ask one after that conversation. If I'm a parent and my child or somebody in our family had COVID a couple months ago, and are getting ready to go back to school and they play a sport, just again, what would you say to that parent about whether or not their kiddo should be playing?

Steve Stites, MD: I think I know what I would say, but I'm going to turn to our sports experts. I mean, my sense is like I told my patients who wanted to be a respiratory therapists. I don't know if it's safe. And that's not saying it's not safe, it's just saying I can't tell you that it is, because some of this stuff occurs fairly late in the disease Tim.

Tim Beaver, MD: Yeah, and I think there's a lot of unknown. We don't know if it's safe, and that's part of the reason why everybody's having all these conversations, and I think it's tough. The data we have mostly that's published is in an older age group. I also don't take care of pediatric patients, but I think it's important as we have this. I think that's what some of the people that have decided to postpone their seasons realize, is that having the tincture of time to have more information about these athletes may benefit them all.

Steve Stites, MD: And in fact, isn't that why the Big 10 stopped fall football, because they didn't feel like they knew enough and they'd had some myocarditis in some of their athletes?

Tim Beaver, MD: That's my understanding.

Steve Stites, MD: That's ESPN reporting.

Tim Beaver, MD: Right, right.

Steve Stites, MD: That's my source for medical facts, ESPN. Michael, how do you feel about that as far as the neurocognitive effects? What would you say if a parent asked you, is this safe?

Michael Rippee, MD: Well, I think I would echo. I don't know if it's safe. I think what I would talk to them about is if you're going to go back to play if you make that decision after we have this conversation, that we have a good plan in place to monitor that, whether it's formalized computerized cognitive testing, or ... Making sure that not only the parents are involved in that, that if they have an athletic trainer, the coaches, the staff at school, the school nurse, making sure there's a lot of people watching them in this situation and monitoring for these issues and if they come up, that they can react quickly to them. I think that's an important piece to this.

Steve Stites, MD: Bruce, what are your thoughts? Again, you and I've been here for a long time and I'm a little nervous. I don't feel comfortable saying it's safe. How about you?

Bruce Toby, MD: If my son or daughter was asking about participation and has not been ill, it would depend on what they're doing and maybe what their goals are and where they're playing. But if they have had COVID, I would tell them not to resume playing for an extended period of time. I would think almost it would be the end of the ... It would be an another season before I would encourage them. Or if I has the power to tell them not to do it, I would tell them not to do it until at least several months. I just think that there are risks that are unknown at this point, and life is precious and health is precious. Life doesn't end when you finish your high school career or your college career, it goes on. Some people want to participate in sports in their 50s and even in their 60s or so, and so it's important to keep your health.

Steve Stites, MD: If we're not just talking about college sports or high school, let's even hit people our age. If we've had COVID, I think we'd even have to say you have to be very careful going back to exercise right now.

Bruce Toby, MD: Yeah, I would say three months, and that's just from comments that you've made and others have made.

Steve Stites, MD: Yeah, that's what I'm saying. It's got to be a 3 to 6 month thing. That's the thing that concerns me and Dana again, we're talking to people who are positive for COVID.

Dana Hawkinson, MD: Correct, yeah.

Steve Stites, MD: But those who are negative for COVID?

Dana Hawkinson, MD: You know, I think that is a very good question, and you brought it up and Bruce brought it up, the delineation of, have you had the disease? That is one thing. That is one risk you have to evaluate, and certainly we know the spread of the disease is more and more. I think if you haven't had COVID that you know, of, it's probably safe. But again, we know that a lot of people are asymptomatic so that's a whole other conversation as well. If you're pretty definitive and you know you haven't had it, it's probably safe. Now, what is your risk of getting COVID in being in those sports and being in those groups? That's one thing. But afterward, I think if you know you've had it, I think the smart thing, and of course the numbers that are being thrown is maybe 3 to 6 months and waiting for that next season to start so you have time to recover.

Steve Stites, MD: Well, and waiting for us to have a few more parts on that airplane so we know what we're talking. I mean, that's the other ... We just don't know what we don't know and I think that's what's guiding our fear. You don't want to watch people sacrifice their lives or their cognitive function, their ability to do the things they want to do down the line for a short term gain. Other questions? Okay Jill, maybe we hear what our listening audience has to say. I bet there's a few questions out there.

Jill Chadwick: I do have one more reporter.

Steve Stites, MD: Please.

Jill Chadwick: Matt Flener with Channel 9 texted me and he wants to know, what do you see in patients that are discharged? Are you seeing the myocarditis? Are you seeing brain fog? Could you list the things that you're seeing, and what their path after discharge is?

Steve Stites, MD: You bet. That's a great question. And I think Dana, one of our challenges is first of all, let's say ... You don't even have to be discharged from the hospital. Remember, this could be somebody who had COVID at home and may have been even asymptomatic initially. Some of these symptoms are emerging weeks and months later. It's not that you have ... The German study that looked at myocarditis was testing about 10 weeks after and still finding inflammation. So it's not what you have right when you're discharged or after two weeks, it's what could develop thereafter.

Dana Hawkinson, MD: Yeah, absolutely. We don't do cardiac MRIs frequently here on regular basis, especially for people who have had COVID, but we do understand that just talking to the patients about their symptoms. So, obviously a lot of the symptoms that are going to be persistent afterward are going to be malaise, which is just feeling bad fatigue, tiredness. Cough and shortness of breath certainly are very important and very prevalent in a lot of patients who are discharged. But also other things such as the brain fog, just not thinking correctly. Maybe it's sleep disturbance. There are a lot of symptoms. I can't really again, speak to the myocarditis in particular, just because we aren't doing that study on a regular basis for discharge patients. But we understand in other people who have critical illness who are in the hospital, we get echoes on them echocardiograms frequently and a lot of them do show, certainly evidence at that time of acute illness, some heart dysfunction as well.

Jill Chadwick: He also asked about rehab. How common is rehab among these patients?

Steve Stites, MD: Yeah, we haven't really put a lot of people through rehab from that standpoint. I'll turn to Tim and to Michael, but I don't know of a real rehabbing around COVID. Again, this stuff is kind of breaking news, so it's not something we really come back to.

Tim Beaver, MD: I think it would be more about if you have an organ that's affected. If you actually developed myocarditis and myocardial dysfunction during an acute illness, you may end up in some rehab situation. But beyond that, or if you had a heart attack as a consequence because you're elderly and had other risk factors, you may end up in a rehab situation. But as far as commonly post-COVID patients being discharged, I don't think from a heart standpoint.

Steve Stites, MD: Tim, we know that myocarditis, or inflammation of the heart can occur with other viruses as well. What's the natural history of that and how would you treat them if it was influenza, or H1N1, or whatever?

Tim Beaver, MD: The natural history of it is from those people that recover, and that's the average virus. But, we do have patients acutely obviously, and it's the minority of them that end up coming in acutely needing heart transplants or people that develop long-term sequelae, where they will have heart dysfunction, cardiomyopathy, or evidence of scar in their heart. With average virus, I think because we've been doing this for so long and that this is a novel virus we're dealing with now, we have a good handle on that. And especially with sports, we're used to this return-to-play algorithm where we monitor for symptoms and all this stuff, and I think we're a little bit more in tune to that. But the problem is, having asymptomatic inflammation is [crosstalk 00:28:36].

Dana Hawkinson, MD: And I think to your point, we don't really necessarily understand the mechanism of the myocarditis in this, the inflammation. We know that this virus does cause significant immune dysregulation that is not like any other virus that we've seen like influenza, so we are keeping that distinction there.

Steve Stites, MD: Yeah, and I think that's one of the key points is that this virus causes inflammation in a lot of places. It's not limited to the heart and brain, it can happen in the lung and we know that about 20% of patients with this do end up with some significant lung disease. An inflammation of the lung, and even some scarring in the lung. This is just another manifestation of what we see, and we also know that many people who die have had the cytokine, which is an inflammatory storm in their body. This inflammation is a big story.

Steve Stites, MD: In pediatrics we're seeing it as well, and it emerges sometimes weeks and weeks after you've had the virus and you get the inflammation. It's just a tough story and the problem is, we just don't know what we don't know. So when people say to us, "Is it safe?" We have to say, "I don't know." We as physicians, we hate to say I don't know because it leaves people hanging, but what we don't want to do is not tell you the truth. You see, that's where the real problem starts.

Jill Chadwick: Okay, Sally wants to know if you can speak to high school sports because they don't have access to testing and monitoring capabilities. Are there symptoms for myocarditis? I know with brain fog it's [inaudible 00:30:08].

Tim Beaver, MD: Yeah. That's what we were speaking of. With other viruses in the past, you would be able to identify an athlete or anyone with myocarditis or pericarditis, which is the inflammation of a sack around the heart by them having coming in with symptoms. They would have chest pain, shortness of breath, other things, and then they would start to get active studies and then get referred on to a cardiologist from the sports medicine physicians. That's the tough thing with COVID, is that we're finding it in asymptomatic people and we're not sure what to do with that, because we also haven't MRIed everybody, every year that gets the flu. There's a lot of unknowns and that's why when we're being asked do we know if it's safe, we don't know because we don't have a lot of information. And unfortunately, it's just going to be the tincture of time to get more information and to understand better.

Jill Chadwick: You've kind of spoken to this, but Simone was wondering, do you ever recover from myocarditis?

Tim Beaver, MD: Yeah. There's a significant number of people that recover from myocarditis. Again, some people develop long term heart dysfunction, but the majority of people recover that we see from the standpoint that have small abnormalities. But, most people recover from viruses in general and don't have long-term sequelae, so the people that develop significant heart dysfunction from myocarditis from the average virus is not a large group.

Steve Stites, MD: And Tim, just to say, with this one because you're asymptomatic often when we see a myocarditis, the risk is that you could by playing high-intensity or high-impact sports, get worse by doing that, is that right?

Tim Beaver, MD: Yeah. People that push and train heavily to play team or the other types of sports, push their adrenaline levels really high and when you have either inflammation of your heart or a scar in your heart, that can be negative to have bad heart rhythms. And that's their originator of sudden death in athletes, even though it's not a high risk for the average virus up to all the sudden deaths that happen across the United States in a year. It's about 8%, somewhere around there. That's the concern with this virus, those people we know more about, but we don't know with this increased documentation of the asymptomatic population what exactly that means.

Steve Stites, MD: And Michael, I don't want us to forget this neurocognitive thing because my fear is that somebody could have some mild inflammation, not have a fog, go into a high impact sport post-COVID, and actually give themselves a worse concussion or essentially a concussion and develop some long term sequelae. Do you have that concern? Thoughts about that?

Michael Rippee, MD: Yeah. I mean, we don't know how this is going to affect concussions in general. Are they going to be more susceptible? Are they going to be more susceptible to a worse injury or a longer term recovery? We don't know that. I just tell my athletes, the concussion is based to some degree on how you go into it, what you carry into it. Do you carry a history of migraines or some other chronic illness? Those settings tend to prolong recovery from concussion and I think if they're going in with some really subtle postinfectious cognitive issues, and then sustain a concussion, you have the chicken or the egg question, which caused it? But, you have the risk that they may have a longer recovery.

Steve Stites, MD: Bruce, you're a marathon athlete. We've run a number of those, and I saw you had stress fracture not so long ago. It was a long ... How long did it take you to recover from that?

Bruce Toby, MD: Well, it took about six months but probably because I ran a marathon in the middle of that six months, but it took a long time.

Steve Stites, MD: And I think one of the points is that sometimes it just takes time. That was one of my rules in the ICU back when I did that a lot. The longer it takes somebody to get sick, the longer it takes them to recover. A stress fracture just takes a while to recover and I think what we're really saying is, we need to take our time recovering from COVID.

Bruce Toby, MD: I agree. One of the problems though with this, is that we can have these people who are minimally symptomatic or not symptomatic at all, and we don't have the ability to say, "Okay, you need to stay off your activities for three months or six months." That's what's difficult. For our professional and collegiate athletes we have the ability to do periodic testing, but that's much, much more difficult in high schools and then small colleges.

Steve Stites, MD: Yes, and we've seen a lot of colleges, especially the small colleges cancel their sports seasons as well. Wyandotte County, or the Wyandotte School District just put a halt to their fall sports seasons as well.

Jill Chadwick: Tina is joining us from Texas. She says, "I'm an athletic trainer at a high school, and we are trying to figure out the best return-to-play protocol. Besides the cardiac and cognitive component, what other things should we consider to return-to-play?

Steve Stites, MD: Well, I'd tell you just a good history and making sure people don't have underlying lung disease. I think that's going to be a big part of it as well. I'm just speaking as a pulmonologist. We do know that there are pulmonary changes after COVID that can sometimes persistent in 10 to 20% of people. So, I think a history for how short of breath. If there's any sense of shortness of breath, and that person needs to be evaluated by a pulmonary and a heart doc, because that should not be a symptom post-COVID in somebody who's a high-intensity athlete already. If you've got any sense of shortness of breath, trouble on the horizon to me.

Tim Beaver, MD: I would agree. I think the history and physical is still the best we can do as far as screening the average high school athlete to understand to make sure they're not having symptoms that we feel like they're at risk and then monitoring people as much as we can. And I think every athletic trainer should be heightened if they have a post-COVID athlete to being sensitive to make sure they're communicating with the athlete sometimes, especially with high school and college. With teen-aged people that don't necessarily always like to share everything, it's hard but I think you have to go to that extra step to be vigilant about talking to your athletes.

Steve Stites, MD: Michael, there's a room for graded exercise in post concussion. Is there any room for graded exercise return in this do you think? And I know we're speculating entirely, so this is a wild leap on my part?

Michael Rippee, MD: No, absolutely. I was trying to raise my hand here to make sure you would call on me. Yeah, I think we would absolutely use a graded return here. And I think what Tim said, the perk the athletic trainers have is, you have a trainer in your school. They tend to know these athletes very well. So, absolutely you want to take a good history and you want to know how they're feeling. And you put them through a a graded exercise program, and you monitor them to the point where they don't like you very much. You're in their business checking on them frequently, and and you just gradually, gradually increase that exertion activity and watch for symptoms. Even if you're not, again, doing any formalized testing, just watching for their symptoms, their reaction. Again, knowing that athlete and how they're reacting to that.

Steve Stites, MD: You bet. Bruce, other thoughts?

Bruce Toby, MD: I think you guys have summarized it very well, thank you.

Jill Chadwick: Holly wants to know, "Should you be getting athletes antibody testing or some other kind of testing, especially if they're asymptomatic before they return-to-play?"

Steve Stites, MD: That's an interesting question. Should an athlete Dana, have an antibody test regardless of they've had a history of COVID disease to see if they might have had it, and been asymptomatic?

Dana Hawkinson, MD: Yeah, that's a really good question. I think a lot of that would depend on the infection dynamics in your community. I think it depends on testing capacity. I think antibody tests are easier to get. Ultimately, and I know for KU we have done the antibody testing, that would probably be a smart thing to do. Now, the caveat to that being is, are we sure that the antibody testing that you're getting is accurate? That's the other issue here. We know here with the Health System, our antibody testing is accurate. It's been validated by [Rachel Eastman 00:38:21]. We know that it's a very good antibody test. It's very sensitive and specific. So, I think that is one ... If we're talking about the optimal practice, that is certainly one of the measurements you could use to start doing to athletes to see if they have had it in the past.

Steve Stites, MD: Just to make sure. It's a screening in case you're asymptomatic because we said, asymptomatic patients can have some of these other problems.

Jill Chadwick: Dr. Beaver, Robin wants to know, would a child who has COVID asymptomatic, and also has a heart murmur be more susceptible to myocarditis?

Tim Beaver, MD: Again, I'm not a pediatric cardiologist. I will put that out there, but I think it's hard to know whether the ... If the child has been proven not to have an underlying heart condition, I'm not sure that they would be in adverse risk. But if there's an unknown there, then they probably should see a pediatrician or a pediatric cardiologist to put it into context.

Steve Stites, MD: Yeah, there is so much about this we don't know and again, I turn to that wonderful pictures that Logan and Anthony were able to bring up us huddling over the phone without masks on back when this COVID thing started.

Dana Hawkinson, MD: We were close together.

Steve Stites, MD: Yeah, we were all close together. We looked just great, violating every principle of infection control we now hold dear around this. There we go, look at that. [inaudible 00:39:32] trying to like me up, and I'm sitting there yapping. Yeah, I still looked younger then. Okay, next question.

Jill Chadwick: Yeah, they're wanting to know if age matters of the athlete when it comes to myocarditis and brain fog.

Steve Stites, MD: Yeah, I think age always matters but let's figure that ... Let's take it on.

Tim Beaver, MD: We don't know. We don't have the studies and that's the thing, we don't know what we don't know. We don't have the information, and that's the thing about COVID I think, that we're all learning a lot of this stuff in real time. It take time to get perspective and wisdom, and we just don't quite have it yet.

Steve Stites, MD: What do you think, Michael?

Michael Rippee, MD: I think age matters a little bit, but I guess I would caution. I personally don't view this as kids are less susceptible. Well, I guess I shouldn't say. I don't think kids are not susceptible to some of these issues. Could it be that if you're older and sicker, you're more likely to get some of these issues? Yes, but I guess my caution would be not to discount age on the younger side as someone, "Well, they're healthy and they're not going to get the issues that come after this."

Steve Stites, MD: Yeah, I think we have to be really careful in the whole thing. And I think I would caution that youth is not a protection here because we know that the post-inflammatory syndrome in pediatrics occurs, and we know that the cytokine storm tends to be worse when you're younger. It can occur across all age groups, but it ... So inflammation, that's a tricky deal. And we think we use these words as if they're a diagnosis like myocarditis, and inflammation and post-concussion but the reality is, those are all syndromes. They're not an exact diagnosis. And that's part of our struggle, is we are using descriptive words about a process we don't totally understand. And because we don't understand it but we're seeing it in pretty good prevalence, it's making us as Bruce has pointed out, it's making us real nervous.

Bruce Toby: You know, during the Spanish Flu of 1918, 1919, one of the reasons that maybe the young people were so susceptible is that they had such a potent immune system. So, this is one time when maybe us old guy Steve, have an advantage. Maybe our immune systems won't overwhelm our bodies and we may be better off than some of the younger folks.

Steve Stites, MD: Take that to the bank, Bruce Toby.

Jill Chadwick: We have several people that are asking, rank the sports. Which ones are more dangerous? Indoor versus outdoor soccer, baseball, track?

Steve Stites, MD: All right, well infection control standpoint.

Dana Hawkinson, MD: I think we really have landed on certainly indoor sports are definitely more dangerous, more risky for spread of the disease than outdoor sports. Outdoor sports, at least you are outdoor, you do have turbulent flow. Any virus that is expressed into the environment should dissipate pretty quickly, so I think certainly we've landed on indoors is definitely more risky than outdoors.

Steve Stites, MD: Yeah, and I think there are some sports ... You know, I'm going to tell you that bowling, golf and fly fishing, some of those things aren't as endurance heavy or may not challenge you as much. It may more just be like a walk but other sports, I think they're going to be more dangerous Tim. I don't know about you, and I want our sports medicine guys. That's Steve Stite's, funny looking pulmonologist answer. Let's see what you all think.

Tim Beaver, MD: Yeah, I think the intensities are different. If you look at our guidelines, we rank sports based on their intensity of aerobic versus isometric activity, which is muscle strength and ones that fall on that, football and basketball tend to be very heavy and then obviously other big endurance sports, but those are the two team sports I think that are considered overall. That's not in the era of COVID, that's just in general really. Those are the ones that for we worry about athletes having events, those are the higher risks.

Steve Stites, MD: Long distance running.

Tim Beaver, MD: I don't know necessarily long distance running, but as far as team sports, high-intensity football for sure I think is if you look where the events occurred.

Steve Stites, MD: Michael, thoughts?

Michael Rippee, MD: Yeah, in the neurology role, we tend to rank them more about risk for impact. So I think this is a little bit different, and I would agree with Tim. I think you're looking in this case more for those either high-exertion, or more prolonged high-exertion. Again, football, potentially soccer, those things where they're running much more and doing more prolonged activity.

Steve Stites, MD: Okay. And Bruce, what do you think?

Bruce Toby, MD: I think again, the risk is whether it's before you get it, or after you get it? I think after you get it, you'd want to be careful about doing high-intensity type of sports.

Steve Stites, MD: Time for one more question I think. There's probably a lot.

Jill Chadwick: Lots of questions. I guess I'll do this one because more than one person is asking about the mask wearing and the risk of hypoxia. And if athletes are wearing a mask, is it putting them at greater risk for these ailments that you were discussing today?

Steve Stites, MD: Okay, well that's interesting. Should an athlete wear a mask that they've had COVID, or will then actually put them at a higher risk for these events? I'm just going to take the first leap at this as a lung doctor and tell you, masks really don't cause hypoxia in a healthy population. What we see athletes doing is that when they're on the sidelines, they should wear a mask. When they're actively in the sport and they're out in the field, I don't see a lot of masks then, but what are your thoughts?

Tim Beaver, MD: Yeah, no. I don't see a lot of masks then. If you put a mask on someone it's going to be aerobically harder to perform, but there again are ... You can go to some marathon runners that have severe allergies where you'll see them run a marathon in a mask to try to prevent getting their pulmonary symptoms. I don't think we have a great-

Steve Stites, MD: Great knowledge.

Tim Beaver, MD: Great knowledge base of that because we don't have a history of a lot of people wearing masks. Doing that otherwise, I don't think it's going to make someone worse, but we don't have any evidence of that, that I know of.

Steve Stites, MD: I don't know of it either. I don't know if you guys do Bruce. Do you have any thought about that?

Bruce Toby, MD: I think it's perfectly fine to wear a mask. I think most endurance athletes would say that it gets in their way, but I don't think it would cause any harm.

Steve Stites, MD: I don't think it's going to cause harm either. Well, as we wrap up the program today, I want to first of all thank each of you for being here. It's always hard to go into a place where there's a lot of unknown and to try and talk about it, and to try and make people feel comfortable who are listening to our program. On the other hand, part of what we've always tried to do on this program is to be honest, to tell the truth and let you know where it is, and then each individual has to make their own decision. How many times have you heard us say, it's a risk-benefit analysis and each individual has to weigh the risks and their benefits?

Steve Stites, MD: An athlete who can't play sports may have more issues around depression or isolation, but you have to think about it in the terms not only of what the next few months are, but really for the rest of your life. What does that really mean? So, let's think about that, and let me ask our guests to give us their final comments today. Bruce, let's start with you.

Bruce Toby, MD: Well, I think that these are unsettled times. I would recommend that everybody take stock of what's important. Be careful, do the right thing.

Steve Stites, MD: Final thoughts.

Michael Rippee, MD: Yeah, I think I'd echo Dr. Toby's response and to say a cautious approach is not a bad approach. Thinking through all of your options and making an educated decision with as much knowledge as you absolutely can is probably the important piece here.

Tim Beaver, MD: I think the only thing I would have to add to that is young people are very resilient and I think although this has been a tough time for them, I think that they're going to be resilient and do great.

Steve Stites, MD: Yeah. And are your kids playing fall sports or football this fall?

Tim Beaver, MD: Yeah, my son has decided after the shared decision-making discussion with me and my wife, that he's not going to play football this fall.

Steve Stites, MD: Yeah, it's hard. Dana?

Dana Hawkinson, MD: You know, these are tough decisions. As we get more and more information and knowledge about this, we'll certainly relay that to you. We always come from the standpoint of the most up-to-date medical information and what we have. We've seen this evolve from the first days we were doing this and we'll continue to give you again, the most accurate and up-to-date information.

Steve Stites, MD: Yeah, we didn't like huddling around that phone. We wouldn't do that now would we? We learned a little bit. And isn't that the really the story? The story is that the more we get learn, the more we know. Sometimes, the more we learn, the more we don't know, and that's what's happening right now. We've learned things over the last few weeks about a high incidence of myocarditis and neurocognitive dysfunction after COVID-19. We knew it was out there beforehand, we may not have realized its reach. That has implications for all of us. It has implications for our children's, for our parents, for ourselves.

Steve Stites, MD: Sometimes, as we said, you got to know what you don't know, and then you just have to do the right thing. The next right thing, and that's something that each person has to help define on their own. Our job is to stay in our medical lane. We're not going to tell you what to do, but we're going to tell you, "This is the information you have and try to make the best possible decision, the most informed decision that you can." And the one that we keep coming back to is, can we tell you that it's safe? As young people who want to become respiratory therapists at CF, I can tell them, I don't think it's safe. I had one still try and stop later.

Steve Stites, MD: But what you do try to find when you say to somebody, "I don't think you should do that," is you try to find hope. And I think the hope here is, there are emerging therapies, there are new things, there are all sorts of things coming out and as it is right now, we don't think this is a permanent state. We don't think this is going to be long term. We believe you are going to recover. The human body is a magnificent thing and it has amazing recuperative powers. Sometimes you just have to give it enough chance that [inaudible 00:49:41] fully recuperated and you totally come back, and sometimes that just takes time. Hey tomorrow, Roy Jensen, Greg Gan, and Deepika Polineni are here to talk about a new COVID-19 study that we're launching using an old cancer drug that may have important powers for defeating COVID-19. You might want to join us. I think that'll be fun too.

Steve Stites, MD: And we normally answer questions Friday, but actually we did this sports thing today, which pushed that conversation into tomorrow. We wanted to make sure we had that sports conversation because so much of that is going on out there. Got a couple of cool masking pictures again. High school baseball coach. I'm not going to say this right, [Martis 00:50:21], hoping that I got that close. Gardener shows off his university academy mask, and his first real estate commission check accomplished during a pandemic. He shows us how to be out and about safely. Thank you, sir. And the Turner family says, "Two girls and two boys can be a handful, but they love shopping with their masks." Great job on the role modeling. Hey, we're back here tomorrow. We hope you're with us. And remember, there's still no place like home. Let's all stay safe.