COVID-19 in Children from Italy

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NEJM: Children with Covid-19 in Pediatric Emergency Departments in Italy

Key points:

  • Children younger than 18 years of age who had Covid-19 composed only 1% of the total number of patients; 11% of these children were hospitalized, and none died
  • The Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) study involved a cohort of 100 Italian children younger than 18 years of age with Covid-19 (median age 3.3 years)
    • .Common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%) (especially if <2 years)
    •  Fever, cough, or shortness of breath occurred in 28 of 54 of febrile patients (52%)
    •  Of the 9 patients who received respiratory support, 6 had coexisting conditions

My take: This study provides additional data indicating that severe outcomes are rare in children with Covid-19.

Related article from NY Times: How Coronavirus Mutates and Spreads

An excerpt:

Researchers have found that the coronavirus is mutating relatively slowly compared to some other RNA viruses, in part because virus proteins acting as proofreaders are able to fix some mistakes. Each month, a lineage of coronaviruses might acquire only two single-letter mutations.

In the future, the coronavirus may pick up some mutations that help it evade our immune systems. But the slow mutation rate of the coronavirus means that these changes will emerge over the course of years.

That bodes well for vaccines currently in development for Covid-19. If people get vaccinated in 2021 against the new coronavirus, they may well enjoy a protection that lasts for years.

Related blog posts:

Why Surprise Billing Still Exists

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A piece of good news: —Doubletree Reveals Cookie Recipe

This blog does not receive any sponsorships.  That being said, my wife made a batch of these cookies and they are delicious!  My advice is to freeze half the batch and cook some later to avoid overconsumption.

A recent commentary (ECF Brown. NEJM 2020; 382: 1189-91) helps explain why surprise billing still exists despite bipartisan contempt.

Key points:

  • “An estimated 20% of U.S. emergency-department visits, 9% of inpatient admissions, and more than half of ambulance or air-ambulance transports involve an out-of-network provider.”
  • “Surprise medical billing…is more prevalent …in groups owned by certain private-equity investment companies.”
  • There are generally two approaches to solving the problem of surprise medical billing, either arbitration or using a payment benchmark, the former generally favors providers and the latter generally favors payers.
  • “Deep-pocketed private equity firms continue to oppose any legislation that cuts into their profits, as they increase their investments in physician practices…Nearly everyone else agrees that patients should be protected from surprise medical bills.”

My take (borrowed from the author): The outcome of the surprise medical billing issue “raises questions about both the role of private equity in health care and the ability of Congress to pass meaningful health care legislation.”

Related blog posts:

Blood Mountain Trail

 

AGA Guidelines: Moderate to Severe Ulcerative Colitis

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Full Text: JD Feuerstein et al. Gastroenterol 2020; 158: 1450-61. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis

Full Tex PDF: AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis

 

Associated articles included the following:

  • Clinical decision support tool (1462-63)
  • PDF: Spotlight (summary -images above) (1464)
  • Technical Review (1465-96)

Key recommendations:

  • 2a. In adult outpatients with moderate to severe UC who are naïve to biologic agents, the AGA suggests using infliximab or vedolizumab rather than adalimumab, for induction of remission. Comment: Patients, particularly those with less severe disease, who place higher value on the convenience of self-administered subcutaneous injection, and a lower value on the relative efficacy of medications, may reasonably chose adalimumab as an alternative
  • 2c. In adult outpatients with moderate to severe UC who have previously been exposed to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission.
  • 6. In adult outpatients with moderate to severe UC, the AGA suggests early use of biologic agents with or without immunomodulator therapy rather than gradual step up after failure of 5-ASA. Comment: Patients, particularly those with less severe disease, who place higher value on the safety of 5-ASA therapy and lower value on the efficacy of biologic agents or tofacitinib may reasonably chose gradual step therapy with 5-ASA therapy.
  • 10. In hospitalized adult patients with ASUC refractory to intravenous corticosteroids, the AGA suggests using infliximab or cyclosporine

Summary of recommendations:

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Costly Free COVID-19 Testing and Timely Tweets

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From NPR: COVID-19 Tests That Are Supposed To Be Free Can Ring Up Surprising Charge

An excerpt:

This reality means some medical providers… must rule out other respiratory diseases before ordering a COVID-19 test, leaving some patients with a difficult choice. Do they seek medical attention and risk a high medical bill? Or do they forgo care altogether?

A second hole in these federal protections may leave patients holding the bill for their COVID-19 test. The law prohibits insurers from charging patients for testing, but it does not block medical providers from doing so. If an insurer does not cover the total amount charged by a provider, the patient may get balance-billed, or slapped with a surprise charge.

From USAToday:

Related blog post:‘Quietly’ Testing Famotidine for COVID-19

From NY Times:

Elevated Bilirubin in Newborns with Down Syndrome

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Elevated bilirubin in newborns with Down syndrome has been previously reported but the frequency has not been well-described.  A recent retrospective report (TM Bahr J Pediatr 2020; 219; 140-5) compared 357 neonates with Down syndrome to 377,368 controls.

Key findings:

  • Compared with control subjects, neonates with Down syndrome had 4.7 times the risk of having an initial total serum bilirubin exceeding the 95th percentile (23.5% vs 5.0%), 8.9 times the need for phototherapy (62.2% vs 7.0%) and 3.6 times the readmission rate for jaundice (17.4 vs 4.8 per 1000 live births).

The authors note that the basis for the increased risk of hyperbilirubinemia may be early hemolysis related to “neocytolysis” which is due to destruction of RBCs following a change from low to high oxygen exposure. Other factors could include slower bilirubin conjugation/elimination and poor feeding.

My take: This study indicates that infants with Down syndrome have a substantial risk of hyperbilirubinemia.  And, while you are checking a bilirubin, it is worthwhile to obtain a direct bilirubin as cholestasis is increased in infants with Down syndrome too; the latter is often transient and/or associated with other organ involvement.

Related blog post: Neonatal cholestasis and Down syndrome

Island Ford Nat’l Recreation Area/Chattahoochee River, Sandy Springs

COVID Toes

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USA Today (4/27/20): Doctors find more cases of ‘COVID toes’ in dermatological registry. Here’s what they learned

An excerpt:

Dr. Esther Freeman, director of Massachusetts General Hospital Global Health Dermatology and member of the AAD task force on COVID-19, said COVID toes are pinkish-reddish “pernio-like lesions” that can turn purple over time…

While experts can’t confirm why COVID toes appear, they have some educated guesses. One could be inflammation in the toes’ tissue… Another hypothesis is inflammation of the blood vessel wall, medically known as vasculitis. And finally, … it is possible COVID toes could be caused by small blood clots that form inside the blood vessel…

COVID toes have appeared in some cases of asymptomatic patients. The majority of the toe cases manifested simultaneously or after more common COVID-19 symptoms, rather than before.  

My take: During this pandemic, I need to look at my patient’s feet.

Measles Outbreak, 2018-2019 & More on Coronavirus in Georgia

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A recent report (JR Zucker et al. NEJM 2020; 382: 1009-17) highlights an outbreak of a vaccine-preventable disease, measles.  Measles is much more contagious than the recent coronavirus; this is one reason why a vaccine is so crucial.

In total, there were 649 cases confirmed –most of the cases were in a close-knit community in Brooklyn, NY.  86% of the cases with a known vaccination history occurred in those who were unvaccinated. 49 required hospitalization.  The cost to the Department of Health was $8.4 million.

My take:  The health consequences and cost of not preventing measles is staggering -though being eclipsed by the coronavirus pandemic.  The toll in Europe has been much higher.  Worldwide more than 140,000 died from measles in 2018.

Related blog posts:

From Georgia Department of Health: COVID-19 Status Report

It is important to understand that some data, particularly in the last 2 weeks, may not be reported yet.

Related blog post (April 24): Why Georgia Isn’t Ready to Reopen

“Quietly” Testing Famotidine for COVID-19

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Yesterday, I received two emails (first from Steven Liu) about an article in Science and today I’ve already seen this article is referenced in a CNN report:

New York Clinical Trial Quietly Tests Heartburn Remedy Against Coronavirus

Key points:

  • In China, a review of ~6000 patients suggested lower mortality in those taking famotidine (not statistically significant)
  • Famotidine may interfere with viral replication protease in the coronavirus based on computer modeling
  • A randomized trial with IV famotidine (large quantities are not available) is underway in New York using 9 times the dose used for heartburn.
  • The article notes that increased heart problems are common in those with reduced renal function
  • “We still don’t know if it will work or not”

My take: Famotidine may be a hot commodity –at least until studies are completed.  Based on experience with hydroxychloroquine, some of our patients may need to look for alternative acid blockers.

Related blog posts:

 

 

New and Improved Biomarker Blood Test for Crohn’s Disease?

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A recent study (G D’Haens, O Kelly, R Battat et al. Gastroenterol 2020; 158: 515-26,editorial 463) describes the development and validation of a blood test panel to assess Crohn’s disease (CD) endoscopic activity level.  The authors evaluated a blood test which measured 13 proteins in the blood using samples from 278 patients.  Then there were two validation cohorts:

  • 116 biologic-naive CD patients -cohort 1
  • 195 biologic-exposed CD patients -cohort 2

The blood tests were used to develop an endoscopic healing index (EHI) score (0-100). Higher scores indicate greater disease activity.

Key findings:

  • EHI values below 20 identified remission with a sensitivity of 97.1%  and 83.2% in cohorts 1 & 2 respectively; specificity was 69% and 37% respectively.
  • EHI values below 50 points identified patients with highest specificity of 100% and 88% in cohorts 1 and 2 respectively.
  • EHI AUROC (area under the receiver operating characteristic curve) did not differ significantly from that of fecal calprotectin and were higher than measurement of serum CRP (in cohort 1 but not cohort 2).

The editorial notes that the EHI performed much better in younger, biologically-naive patients and that the EHI could potentially be incorporated into a treat-to-target strategy which would potentially entail followup endoscopy in those with EHI >50.

My take: While the stool calprotectin has some logistical barriers in many patients, the EHI is likely a much more expensive test and needs further validation.  For now, the combination of CRP and calprotectin are the best noninvasive biomarkers to assess CD activity.

Briefly noted: Vedolizumab-Induced Pulmonary Toxicity -Case report of a patient with ulcerative colitis who developed interstitial lung disease (Gastroenterol 2020; 158: 478-9).

Related blog posts:

 

Efficacy of Anti-TNF Agents for Internal Fistulas and Study of Antibiotics and Development of IBD

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G Bougen et al. Clin Gastroenterol Hepatol 2020; 18: 628-36.  This retrospective study (n=156, median age 32 years) found that anti-TNF therapy delays or prevents surgery for almost half of patients with Crohn’s disease who had luminal fistulas.  Key findings:

  • With a median followup of 3.5 years, “68 patients (43.6%) underwent a major abdominal surgery.”
  • Fistula healing occurred on average 1 year after the introduction of anti-TNF treatment
  • The presence of a stricture or abscess increased the likelihood of surgery.
  • Three patients died from intestinal adenocarcinomas, one patient died from melanoma (6 months after initiation of anti-TNF therapy), one patient died from sepsis (3 months after initiation of anti-TNF therapy, and 32 patients (20.5%) developed an intestinal abscess.

My take: Therapy with anti-TNF agent, in the setting of a luminal fistula, is a reasonable option, especially in the absence of a concurrent stricture.

FS Troelsen, S Jick. Inflamm Bowel Dis 2020; 26: 440-7, editorial 448-9. Using a UK database, the authors identified 461 cases of ulcerative colitis (UC) and 863 cases of Crohn’s disease (CD) and then matched each case to 4 controls. Key findings:

  • There was no association between ever use of antibiotics and UC, OR 1.02 or CD, OR 1.01 compared to never use of antibiotics
  • CD was associated with antibiotic exposure before age 5 (OR 2.2) in analysis restricted to individuals followed from birth
  • A slight increase was seen for CD in ever users of quinolones (OR 1.76, CI 1.00-3.11) and metronidazole (OR 1.43, CI 0.87-2.34)

In the editorial, Charles Bernstein notes that “it may be that specific types of antibiotics…at specific times in a person’s life have differential risks for IBD development. Also, it may be that what triggers IBD in children is different than what triggers IBD later in life.”

Duke University -late Fall 2019