Some nonsleepy patients with coronary artery disease and obstructive sleep apnea (OSA) may receive cardiovascular benefit from continuous positive airway pressure (CPAP) therapy, according to a post hoc analysis of the RICCADSA clinical trial. That study found no benefit among patients overall, but the new analysis found that patients whose heart rate increases (delta heart rate, or dHR) more than average during apnea or hypopnea experienced fewer cardiovascular or cerebrovascular events during apnea or hypopnea when treated with CPAP.

Although RICCADSA showed no benefit, an analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) and the Sleep Heart Health Study (SHHS) cohorts found that elevated pulse rate response to respiratory events was associated with greater risk of cardiovascular disease (CVD) morbidity and mortality. But the effect was seen only in nonsleepy patients. “We hypothesized that pulse rate response to apneas would predict which patients with OSA may most benefit from CPAP treatment. Now, our study suggests that there is, in fact, a subgroup of nonsleepy patients with OSA for whom CPAP could provide a reduction in risk, specifically those with a higher pulse rate response to their respiratory events,” Ali Azarbarzin, PhD, said in an interview.

Dr. Azarbarzin presented the study at the American Thoracic Society’s virtual international conference (Abstract A1103). He is in the division of sleep and circadian disorders at Brigham and Women’s Hospital, and is assistant professor of medicine at Harvard Medical School, both in Boston.

The study is in line with recent efforts to subgroup OSA patients to determine which are at higher risk of cardiovascular events and other complications, and which are most likely to respond to treatment, according to Esra Tasali, MD, of the University of Chicago, who moderated the session where the study was presented. “The field is really urgently in need of coming up with new methods, and I think this study is getting a handle on that,” said Dr. Tasali in an interview.

“I think that this is really pointing toward a new area that the whole (sleep field) is moving toward, which is better phenotyping of sleep apnea so that we can come up with more personalized treatments,” said Dr. Tasali.

The patients who appeared to gain a cardiovascular benefit from CPAP represented about 16% of trial participants. Dr. Azarbarzin refrained from making clinical recommendations, citing the need for more data. The team next plans to reproduce the findings in additional, larger trials such as the SAVE and ISAACC trials. “Ultimately, our goal is to confirm our findings in a future randomized controlled trial of CPAP by enrolling participants based on their pulse rate response,” said Dr. Azarbarzin.

The RICCADSA study was a single center randomized, controlled trial with 226 patients with coronary artery disease and OSA who were randomized to CPAP or no CPAP treatment. In the overall population, CPAP treatment was not associated with a statistically significant change in repeat revascularization, myocardial infarction, stroke, or cardiovascular mortality (hazard ratio [HR], 0.79; P = .435). That study assumed that the effect of OSA on CVD is similar across all subgroups of dHR.

The mean increase in heart rate was 7.1 beats per minute (BPM; standard deviation, 3.7). Each standard deviation increase in dHR was linked to greater CVD risk (HR, 1.45; P = .029). For each standard deviation decrease in dHR, treatment with CPAP decreased the CVD risk (HR, 0.54; P = .043).

For patients with a low dHR of 4 BPM, the hazard ratio for CVD was 0.8 with no CPAP treatment and 1.2 for CPAP treatment. For those at the mean value of 7 BPM, the HRs were 1.1 and 0.9 respectively. For those with a high dHR, (10 BPM), the hazard ratio was 1.6 without treatment and 0.7 with CPAP.

“We modeled delta heart rate interaction with CPAP, which was significant. What this means is that for someone with a mean delta heart rate of 7 beats per minute, the risk reduction (with CPAP) is similar to what RICCADSA reported. But if you look at those with high delta heart rate, the risk reduction was significantly larger. It was actually a more than 50% reduction of risk with CPAP treatment,” said Dr. Azarbarzin.

Dr. Azarbarzin has consulted for Somnifix and Apnimed and has received grants from Somnifix. Dr. Tasali has no relevant financial disclosures.

Some nonsleepy patients with coronary artery disease and obstructive sleep apnea (OSA) may receive cardiovascular benefit from continuous positive airway pressure (CPAP) therapy, according to a post hoc analysis of the RICCADSA clinical trial. That study found no benefit among patients overall, but the new analysis found that patients whose heart rate increases (delta heart rate, or dHR) more than average during apnea or hypopnea experienced fewer cardiovascular or cerebrovascular events during apnea or hypopnea when treated with CPAP.

Although RICCADSA showed no benefit, an analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) and the Sleep Heart Health Study (SHHS) cohorts found that elevated pulse rate response to respiratory events was associated with greater risk of cardiovascular disease (CVD) morbidity and mortality. But the effect was seen only in nonsleepy patients. “We hypothesized that pulse rate response to apneas would predict which patients with OSA may most benefit from CPAP treatment. Now, our study suggests that there is, in fact, a subgroup of nonsleepy patients with OSA for whom CPAP could provide a reduction in risk, specifically those with a higher pulse rate response to their respiratory events,” Ali Azarbarzin, PhD, said in an interview.

Dr. Azarbarzin presented the study at the American Thoracic Society’s virtual international conference (Abstract A1103). He is in the division of sleep and circadian disorders at Brigham and Women’s Hospital, and is assistant professor of medicine at Harvard Medical School, both in Boston.

The study is in line with recent efforts to subgroup OSA patients to determine which are at higher risk of cardiovascular events and other complications, and which are most likely to respond to treatment, according to Esra Tasali, MD, of the University of Chicago, who moderated the session where the study was presented. “The field is really urgently in need of coming up with new methods, and I think this study is getting a handle on that,” said Dr. Tasali in an interview.

“I think that this is really pointing toward a new area that the whole (sleep field) is moving toward, which is better phenotyping of sleep apnea so that we can come up with more personalized treatments,” said Dr. Tasali.

The patients who appeared to gain a cardiovascular benefit from CPAP represented about 16% of trial participants. Dr. Azarbarzin refrained from making clinical recommendations, citing the need for more data. The team next plans to reproduce the findings in additional, larger trials such as the SAVE and ISAACC trials. “Ultimately, our goal is to confirm our findings in a future randomized controlled trial of CPAP by enrolling participants based on their pulse rate response,” said Dr. Azarbarzin.

The RICCADSA study was a single center randomized, controlled trial with 226 patients with coronary artery disease and OSA who were randomized to CPAP or no CPAP treatment. In the overall population, CPAP treatment was not associated with a statistically significant change in repeat revascularization, myocardial infarction, stroke, or cardiovascular mortality (hazard ratio [HR], 0.79; P = .435). That study assumed that the effect of OSA on CVD is similar across all subgroups of dHR.

The mean increase in heart rate was 7.1 beats per minute (BPM; standard deviation, 3.7). Each standard deviation increase in dHR was linked to greater CVD risk (HR, 1.45; P = .029). For each standard deviation decrease in dHR, treatment with CPAP decreased the CVD risk (HR, 0.54; P = .043).

For patients with a low dHR of 4 BPM, the hazard ratio for CVD was 0.8 with no CPAP treatment and 1.2 for CPAP treatment. For those at the mean value of 7 BPM, the HRs were 1.1 and 0.9 respectively. For those with a high dHR, (10 BPM), the hazard ratio was 1.6 without treatment and 0.7 with CPAP.

“We modeled delta heart rate interaction with CPAP, which was significant. What this means is that for someone with a mean delta heart rate of 7 beats per minute, the risk reduction (with CPAP) is similar to what RICCADSA reported. But if you look at those with high delta heart rate, the risk reduction was significantly larger. It was actually a more than 50% reduction of risk with CPAP treatment,” said Dr. Azarbarzin.

Dr. Azarbarzin has consulted for Somnifix and Apnimed and has received grants from Somnifix. Dr. Tasali has no relevant financial disclosures.

Some nonsleepy patients with coronary artery disease and obstructive sleep apnea (OSA) may receive cardiovascular benefit from continuous positive airway pressure (CPAP) therapy, according to a post hoc analysis of the RICCADSA clinical trial. That study found no benefit among patients overall, but the new analysis found that patients whose heart rate increases (delta heart rate, or dHR) more than average during apnea or hypopnea experienced fewer cardiovascular or cerebrovascular events during apnea or hypopnea when treated with CPAP.

Although RICCADSA showed no benefit, an analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) and the Sleep Heart Health Study (SHHS) cohorts found that elevated pulse rate response to respiratory events was associated with greater risk of cardiovascular disease (CVD) morbidity and mortality. But the effect was seen only in nonsleepy patients. “We hypothesized that pulse rate response to apneas would predict which patients with OSA may most benefit from CPAP treatment. Now, our study suggests that there is, in fact, a subgroup of nonsleepy patients with OSA for whom CPAP could provide a reduction in risk, specifically those with a higher pulse rate response to their respiratory events,” Ali Azarbarzin, PhD, said in an interview.

Dr. Azarbarzin presented the study at the American Thoracic Society’s virtual international conference (Abstract A1103). He is in the division of sleep and circadian disorders at Brigham and Women’s Hospital, and is assistant professor of medicine at Harvard Medical School, both in Boston.

The study is in line with recent efforts to subgroup OSA patients to determine which are at higher risk of cardiovascular events and other complications, and which are most likely to respond to treatment, according to Esra Tasali, MD, of the University of Chicago, who moderated the session where the study was presented. “The field is really urgently in need of coming up with new methods, and I think this study is getting a handle on that,” said Dr. Tasali in an interview.

“I think that this is really pointing toward a new area that the whole (sleep field) is moving toward, which is better phenotyping of sleep apnea so that we can come up with more personalized treatments,” said Dr. Tasali.

The patients who appeared to gain a cardiovascular benefit from CPAP represented about 16% of trial participants. Dr. Azarbarzin refrained from making clinical recommendations, citing the need for more data. The team next plans to reproduce the findings in additional, larger trials such as the SAVE and ISAACC trials. “Ultimately, our goal is to confirm our findings in a future randomized controlled trial of CPAP by enrolling participants based on their pulse rate response,” said Dr. Azarbarzin.

The RICCADSA study was a single center randomized, controlled trial with 226 patients with coronary artery disease and OSA who were randomized to CPAP or no CPAP treatment. In the overall population, CPAP treatment was not associated with a statistically significant change in repeat revascularization, myocardial infarction, stroke, or cardiovascular mortality (hazard ratio [HR], 0.79; P = .435). That study assumed that the effect of OSA on CVD is similar across all subgroups of dHR.

The mean increase in heart rate was 7.1 beats per minute (BPM; standard deviation, 3.7). Each standard deviation increase in dHR was linked to greater CVD risk (HR, 1.45; P = .029). For each standard deviation decrease in dHR, treatment with CPAP decreased the CVD risk (HR, 0.54; P = .043).

For patients with a low dHR of 4 BPM, the hazard ratio for CVD was 0.8 with no CPAP treatment and 1.2 for CPAP treatment. For those at the mean value of 7 BPM, the HRs were 1.1 and 0.9 respectively. For those with a high dHR, (10 BPM), the hazard ratio was 1.6 without treatment and 0.7 with CPAP.

“We modeled delta heart rate interaction with CPAP, which was significant. What this means is that for someone with a mean delta heart rate of 7 beats per minute, the risk reduction (with CPAP) is similar to what RICCADSA reported. But if you look at those with high delta heart rate, the risk reduction was significantly larger. It was actually a more than 50% reduction of risk with CPAP treatment,” said Dr. Azarbarzin.

Dr. Azarbarzin has consulted for Somnifix and Apnimed and has received grants from Somnifix. Dr. Tasali has no relevant financial disclosures.

While colorectal cancer may be the most common and deadly gastrointestinal malignancy, liver and gastric cancers account for some of the most consistent racial and ethnic disparities, a recent retrospective, cross-sectional analysis of U.S. data suggested.

Liver and gastric cancer incidence and mortality were significantly higher for all racial and ethnic minority groups in the study, compared with non-Hispanic Whites, according to the analysis. Notably, however, non-Hispanic Blacks represented the only group to also have elevated incidence and mortality for pancreatic and colorectal, compared with non-Hispanic Whites, according to investigator Aileen Bui, MD, with the University of California, Los Angeles Health.

These study results highlights the need to address modifiable cancer risk factors and overcome barriers to cancer prevention and care in medically underserved minority populations, Dr. Bui said in a virtual presentation of the results at the annual Digestive Disease Week® (DDW).

“While we cannot infer causation or determine risk factors for certain malignancies from the results of our study, there’s little data to support a strong role of biological or genetic differences between racial and ethnic groups to account for the observed disparities in incidence and mortality for GI cancers,” she said in her presentation.
 

Setting out to explore disparities

Gastrointestinal cancer incidence and mortality remain on the rise, despite significant progress in some areas, including colorectal cancer screening and the introduction of effective treatments for hepatitis C virus, Dr. Bui said.

Incidence and mortality from gastrointestinal cancers are set to increase by 34% and 43%, respectively, by the year 2040, and will remain a significant contributor to cancer incidence and mortality in the United States, according to the researcher.

Gastrointestinal cancer incidence and mortality are known to vary by race and ethnicity, so Dr. Bui and colleagues sought to assess the extent of racial and ethnic disparities for individual gastrointestinal cancer types. They identified more than 140,000 incident cases of colorectal, pancreatic, liver, esophageal, and gastric cancers in the Surveillance, Epidemiology, and End Results database from 2013 to 2017. They also incorporated nearly 185,000 mortality cases for those same types of malignancy from National Center for Health Statistics data from the years 2014 to 2018.
 

Breaking down the numbers

Overall, the incidence of colorectal cancer was highest, at 36.9 (cases per 100,000), followed by pancreatic cancer at 11.0, gastric cancer at 7.1, esophageal cancer at 4.1, and liver cancer at 3.0, Dr. Bui’s data show. The mortality rate was again highest for colorectal cancer, followed by pancreatic, liver, esophageal and gastric cancer.

When compared with non-Hispanic Whites, all racial ethnic minority groups had significantly higher incidence of both liver and gastric cancers, according to Dr. Bui.

The researchers calculated rate ratios for gastrointestinal cancer incidence and mortality, with ratios above 1 indicating a higher incidence relative to non-Hispanic Whites.

Among Hispanics, the incidence rate ratios were 1.83 for both liver and gastric cancers, according to the analysis. Similarly, non-Hispanic Asian Pacific Islanders had IRRs of 2.00 for liver cancer and 1.9 for gastric cancer. Non-Hispanic American Indians and Alaska Natives had IRRs of 2.09 for liver cancer and 1.51 for gastric cancer.

By contrast, non-Hispanic Blacks had significantly higher IRRs not only for liver and gastric cancers, at 1.64 and 1.8, respectively, but also for pancreatic cancer, at 1.18, and colorectal cancer at 1.17, Dr. Bui said.

Similar trends were seen in mortality in the presented data, with all racial and ethnic groups exhibiting significantly increased mortality RRs for liver and gastric cancer, compared with non-Hispanic Whites, but with non-Hispanic Blacks showing significantly increases in RRs for liver (1.66), gastric (2.36), pancreatic (1.22), and colorectal (1.36) cancers.

Esophageal cancer rates of incidence and mortality were both lower in racial and ethnic minority groups, compared with non-Hispanic whites, according to Dr. Bui.
 

Increasing screening and surveillance

While the esophageal cancer data is encouraging, these data otherwise clearly highlight the need to step up efforts to help level gastrointestinal cancer disparities, according to Byron Cryer, MD, professor of internal medicine and associate dean for the office of faculty diversity and development at the University of Texas Southwestern Medical Center, Dallas.

AGA Institute

“Clearly more work needs to be done for the other four cancers,” Dr. Cryer said in an interview.

Screening and surveillance may be key to addressing those disparities, not only for colorectal cancer, but for the liver and gastric cancers for which disparities were seen throughout racial and ethnic groups in this study.

“We know that if we get rid of hepatitis C virus early, you can prevent those downstream complications such as cancer,” Dr. Cryer said. “It’s same thing with the gastric cancer – if we get rid of Helicobacter pylori early on in the infection, we decrease the burden of cancer down downstream years later.”

Dr. Bui provided no financial disclosures related to the research. Dr. Cryer has nothing to disclose.

While colorectal cancer may be the most common and deadly gastrointestinal malignancy, liver and gastric cancers account for some of the most consistent racial and ethnic disparities, a recent retrospective, cross-sectional analysis of U.S. data suggested.

Liver and gastric cancer incidence and mortality were significantly higher for all racial and ethnic minority groups in the study, compared with non-Hispanic Whites, according to the analysis. Notably, however, non-Hispanic Blacks represented the only group to also have elevated incidence and mortality for pancreatic and colorectal, compared with non-Hispanic Whites, according to investigator Aileen Bui, MD, with the University of California, Los Angeles Health.

These study results highlights the need to address modifiable cancer risk factors and overcome barriers to cancer prevention and care in medically underserved minority populations, Dr. Bui said in a virtual presentation of the results at the annual Digestive Disease Week® (DDW).

“While we cannot infer causation or determine risk factors for certain malignancies from the results of our study, there’s little data to support a strong role of biological or genetic differences between racial and ethnic groups to account for the observed disparities in incidence and mortality for GI cancers,” she said in her presentation.
 

Setting out to explore disparities

Gastrointestinal cancer incidence and mortality remain on the rise, despite significant progress in some areas, including colorectal cancer screening and the introduction of effective treatments for hepatitis C virus, Dr. Bui said.

Incidence and mortality from gastrointestinal cancers are set to increase by 34% and 43%, respectively, by the year 2040, and will remain a significant contributor to cancer incidence and mortality in the United States, according to the researcher.

Gastrointestinal cancer incidence and mortality are known to vary by race and ethnicity, so Dr. Bui and colleagues sought to assess the extent of racial and ethnic disparities for individual gastrointestinal cancer types. They identified more than 140,000 incident cases of colorectal, pancreatic, liver, esophageal, and gastric cancers in the Surveillance, Epidemiology, and End Results database from 2013 to 2017. They also incorporated nearly 185,000 mortality cases for those same types of malignancy from National Center for Health Statistics data from the years 2014 to 2018.
 

Breaking down the numbers

Overall, the incidence of colorectal cancer was highest, at 36.9 (cases per 100,000), followed by pancreatic cancer at 11.0, gastric cancer at 7.1, esophageal cancer at 4.1, and liver cancer at 3.0, Dr. Bui’s data show. The mortality rate was again highest for colorectal cancer, followed by pancreatic, liver, esophageal and gastric cancer.

When compared with non-Hispanic Whites, all racial ethnic minority groups had significantly higher incidence of both liver and gastric cancers, according to Dr. Bui.

The researchers calculated rate ratios for gastrointestinal cancer incidence and mortality, with ratios above 1 indicating a higher incidence relative to non-Hispanic Whites.

Among Hispanics, the incidence rate ratios were 1.83 for both liver and gastric cancers, according to the analysis. Similarly, non-Hispanic Asian Pacific Islanders had IRRs of 2.00 for liver cancer and 1.9 for gastric cancer. Non-Hispanic American Indians and Alaska Natives had IRRs of 2.09 for liver cancer and 1.51 for gastric cancer.

By contrast, non-Hispanic Blacks had significantly higher IRRs not only for liver and gastric cancers, at 1.64 and 1.8, respectively, but also for pancreatic cancer, at 1.18, and colorectal cancer at 1.17, Dr. Bui said.

Similar trends were seen in mortality in the presented data, with all racial and ethnic groups exhibiting significantly increased mortality RRs for liver and gastric cancer, compared with non-Hispanic Whites, but with non-Hispanic Blacks showing significantly increases in RRs for liver (1.66), gastric (2.36), pancreatic (1.22), and colorectal (1.36) cancers.

Esophageal cancer rates of incidence and mortality were both lower in racial and ethnic minority groups, compared with non-Hispanic whites, according to Dr. Bui.
 

Increasing screening and surveillance

While the esophageal cancer data is encouraging, these data otherwise clearly highlight the need to step up efforts to help level gastrointestinal cancer disparities, according to Byron Cryer, MD, professor of internal medicine and associate dean for the office of faculty diversity and development at the University of Texas Southwestern Medical Center, Dallas.

AGA Institute

“Clearly more work needs to be done for the other four cancers,” Dr. Cryer said in an interview.

Screening and surveillance may be key to addressing those disparities, not only for colorectal cancer, but for the liver and gastric cancers for which disparities were seen throughout racial and ethnic groups in this study.

“We know that if we get rid of hepatitis C virus early, you can prevent those downstream complications such as cancer,” Dr. Cryer said. “It’s same thing with the gastric cancer – if we get rid of Helicobacter pylori early on in the infection, we decrease the burden of cancer down downstream years later.”

Dr. Bui provided no financial disclosures related to the research. Dr. Cryer has nothing to disclose.

While colorectal cancer may be the most common and deadly gastrointestinal malignancy, liver and gastric cancers account for some of the most consistent racial and ethnic disparities, a recent retrospective, cross-sectional analysis of U.S. data suggested.

Liver and gastric cancer incidence and mortality were significantly higher for all racial and ethnic minority groups in the study, compared with non-Hispanic Whites, according to the analysis. Notably, however, non-Hispanic Blacks represented the only group to also have elevated incidence and mortality for pancreatic and colorectal, compared with non-Hispanic Whites, according to investigator Aileen Bui, MD, with the University of California, Los Angeles Health.

These study results highlights the need to address modifiable cancer risk factors and overcome barriers to cancer prevention and care in medically underserved minority populations, Dr. Bui said in a virtual presentation of the results at the annual Digestive Disease Week® (DDW).

“While we cannot infer causation or determine risk factors for certain malignancies from the results of our study, there’s little data to support a strong role of biological or genetic differences between racial and ethnic groups to account for the observed disparities in incidence and mortality for GI cancers,” she said in her presentation.
 

Setting out to explore disparities

Gastrointestinal cancer incidence and mortality remain on the rise, despite significant progress in some areas, including colorectal cancer screening and the introduction of effective treatments for hepatitis C virus, Dr. Bui said.

Incidence and mortality from gastrointestinal cancers are set to increase by 34% and 43%, respectively, by the year 2040, and will remain a significant contributor to cancer incidence and mortality in the United States, according to the researcher.

Gastrointestinal cancer incidence and mortality are known to vary by race and ethnicity, so Dr. Bui and colleagues sought to assess the extent of racial and ethnic disparities for individual gastrointestinal cancer types. They identified more than 140,000 incident cases of colorectal, pancreatic, liver, esophageal, and gastric cancers in the Surveillance, Epidemiology, and End Results database from 2013 to 2017. They also incorporated nearly 185,000 mortality cases for those same types of malignancy from National Center for Health Statistics data from the years 2014 to 2018.
 

Breaking down the numbers

Overall, the incidence of colorectal cancer was highest, at 36.9 (cases per 100,000), followed by pancreatic cancer at 11.0, gastric cancer at 7.1, esophageal cancer at 4.1, and liver cancer at 3.0, Dr. Bui’s data show. The mortality rate was again highest for colorectal cancer, followed by pancreatic, liver, esophageal and gastric cancer.

When compared with non-Hispanic Whites, all racial ethnic minority groups had significantly higher incidence of both liver and gastric cancers, according to Dr. Bui.

The researchers calculated rate ratios for gastrointestinal cancer incidence and mortality, with ratios above 1 indicating a higher incidence relative to non-Hispanic Whites.

Among Hispanics, the incidence rate ratios were 1.83 for both liver and gastric cancers, according to the analysis. Similarly, non-Hispanic Asian Pacific Islanders had IRRs of 2.00 for liver cancer and 1.9 for gastric cancer. Non-Hispanic American Indians and Alaska Natives had IRRs of 2.09 for liver cancer and 1.51 for gastric cancer.

By contrast, non-Hispanic Blacks had significantly higher IRRs not only for liver and gastric cancers, at 1.64 and 1.8, respectively, but also for pancreatic cancer, at 1.18, and colorectal cancer at 1.17, Dr. Bui said.

Similar trends were seen in mortality in the presented data, with all racial and ethnic groups exhibiting significantly increased mortality RRs for liver and gastric cancer, compared with non-Hispanic Whites, but with non-Hispanic Blacks showing significantly increases in RRs for liver (1.66), gastric (2.36), pancreatic (1.22), and colorectal (1.36) cancers.

Esophageal cancer rates of incidence and mortality were both lower in racial and ethnic minority groups, compared with non-Hispanic whites, according to Dr. Bui.
 

Increasing screening and surveillance

While the esophageal cancer data is encouraging, these data otherwise clearly highlight the need to step up efforts to help level gastrointestinal cancer disparities, according to Byron Cryer, MD, professor of internal medicine and associate dean for the office of faculty diversity and development at the University of Texas Southwestern Medical Center, Dallas.

AGA Institute

“Clearly more work needs to be done for the other four cancers,” Dr. Cryer said in an interview.

Screening and surveillance may be key to addressing those disparities, not only for colorectal cancer, but for the liver and gastric cancers for which disparities were seen throughout racial and ethnic groups in this study.

“We know that if we get rid of hepatitis C virus early, you can prevent those downstream complications such as cancer,” Dr. Cryer said. “It’s same thing with the gastric cancer – if we get rid of Helicobacter pylori early on in the infection, we decrease the burden of cancer down downstream years later.”

Dr. Bui provided no financial disclosures related to the research. Dr. Cryer has nothing to disclose.

A potassium hydroxide (KOH) mount of skin scrapings from the patient’s feet and hand confirmed a diagnosis of unilateral tinea manuum and bilateral tinea pedis—the so-called 2-foot, 1-hand syndrome. Additionally, nail clippings from the patient’s right hand confirmed onychomycosis.

Tinea is common and caused by various dermatophytes that are ubiquitous in soil. Often there is a history of atopic dermatitis or xerosis leading to skin barrier dysfunction. Immunosuppression and diabetes mellitus are also predisposing factors. Trichophyton rubrum is a commonly isolated cause.

On the hands, tinea may be challenging to distinguish from irritant dermatitis, atopic dermatitis, and contact dermatitis. A KOH prep test should be considered for any red, scaly rash, especially on the hands and feet. Curiously, the incidence of unilateral tinea manuum and bilateral tinea pedis occurs relatively frequently and can affect either the dominant or nondominant hand. The cause of this asymmetry is speculative.

Topical therapy with various antifungals—terbinafine, clotrimazole, ketoconazole, ciclopirox—can be effective, but challenging to apply to affected areas. For the treatment of nail disease, oral therapy with terbinafine or itraconazole is usually indicated (6 weeks for fingernails and 12 weeks for toenails). Terbinafine is generally tolerated very well for both 6- and 12-week courses. Some clinicians consider lab monitoring unnecessary because the risk of hepatic injury from terbinafine is uncertain; others consider it worthwhile to check liver function test results prior to initiation of terbinafine and after 6 weeks of therapy, with either a 6- or 12-week course.¹

Since the patient in this case had skin and nail disease, oral therapy with terbinafine 250 mg/d for 6 weeks was prescribed. His skin cleared within 3 weeks and his nails cleared after 6 months. It is important to counsel patients with nail disease that treatment will end before they see a clinical improvement. Fingernails typically require 6 months to see clearance and toenails require 18 months.

‌

Text and photos courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. (Photo copyright retained.)

A potassium hydroxide (KOH) mount of skin scrapings from the patient’s feet and hand confirmed a diagnosis of unilateral tinea manuum and bilateral tinea pedis—the so-called 2-foot, 1-hand syndrome. Additionally, nail clippings from the patient’s right hand confirmed onychomycosis.

Tinea is common and caused by various dermatophytes that are ubiquitous in soil. Often there is a history of atopic dermatitis or xerosis leading to skin barrier dysfunction. Immunosuppression and diabetes mellitus are also predisposing factors. Trichophyton rubrum is a commonly isolated cause.

On the hands, tinea may be challenging to distinguish from irritant dermatitis, atopic dermatitis, and contact dermatitis. A KOH prep test should be considered for any red, scaly rash, especially on the hands and feet. Curiously, the incidence of unilateral tinea manuum and bilateral tinea pedis occurs relatively frequently and can affect either the dominant or nondominant hand. The cause of this asymmetry is speculative.

Topical therapy with various antifungals—terbinafine, clotrimazole, ketoconazole, ciclopirox—can be effective, but challenging to apply to affected areas. For the treatment of nail disease, oral therapy with terbinafine or itraconazole is usually indicated (6 weeks for fingernails and 12 weeks for toenails). Terbinafine is generally tolerated very well for both 6- and 12-week courses. Some clinicians consider lab monitoring unnecessary because the risk of hepatic injury from terbinafine is uncertain; others consider it worthwhile to check liver function test results prior to initiation of terbinafine and after 6 weeks of therapy, with either a 6- or 12-week course.¹

Since the patient in this case had skin and nail disease, oral therapy with terbinafine 250 mg/d for 6 weeks was prescribed. His skin cleared within 3 weeks and his nails cleared after 6 months. It is important to counsel patients with nail disease that treatment will end before they see a clinical improvement. Fingernails typically require 6 months to see clearance and toenails require 18 months.

‌

Text and photos courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. (Photo copyright retained.)

A potassium hydroxide (KOH) mount of skin scrapings from the patient’s feet and hand confirmed a diagnosis of unilateral tinea manuum and bilateral tinea pedis—the so-called 2-foot, 1-hand syndrome. Additionally, nail clippings from the patient’s right hand confirmed onychomycosis.

Tinea is common and caused by various dermatophytes that are ubiquitous in soil. Often there is a history of atopic dermatitis or xerosis leading to skin barrier dysfunction. Immunosuppression and diabetes mellitus are also predisposing factors. Trichophyton rubrum is a commonly isolated cause.

On the hands, tinea may be challenging to distinguish from irritant dermatitis, atopic dermatitis, and contact dermatitis. A KOH prep test should be considered for any red, scaly rash, especially on the hands and feet. Curiously, the incidence of unilateral tinea manuum and bilateral tinea pedis occurs relatively frequently and can affect either the dominant or nondominant hand. The cause of this asymmetry is speculative.

Topical therapy with various antifungals—terbinafine, clotrimazole, ketoconazole, ciclopirox—can be effective, but challenging to apply to affected areas. For the treatment of nail disease, oral therapy with terbinafine or itraconazole is usually indicated (6 weeks for fingernails and 12 weeks for toenails). Terbinafine is generally tolerated very well for both 6- and 12-week courses. Some clinicians consider lab monitoring unnecessary because the risk of hepatic injury from terbinafine is uncertain; others consider it worthwhile to check liver function test results prior to initiation of terbinafine and after 6 weeks of therapy, with either a 6- or 12-week course.¹

Since the patient in this case had skin and nail disease, oral therapy with terbinafine 250 mg/d for 6 weeks was prescribed. His skin cleared within 3 weeks and his nails cleared after 6 months. It is important to counsel patients with nail disease that treatment will end before they see a clinical improvement. Fingernails typically require 6 months to see clearance and toenails require 18 months.

‌

Text and photos courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. (Photo copyright retained.)

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

Targeting “discharge before noon” (DBN) for hospitalized patients has been proposed as a way to improve hospital throughput and patient safety by reducing emergency department (ED) boarding and crowding. In this issue, Kirubarajan et al¹ report no association between morning discharge and length of stay (LOS) for either the ED or hospitalization.¹ This large (189,781 patients) 7-year study from seven quite different Canadian hospitals adds important data to a literature that remains divided about whether DBN helps or hurts hospital LOS and ED boarding.

Unlike trials reporting interventions to encourage DBN, this observational study was unique in that it took each day as the unit of observation. This method cleverly allowed the authors to examine whether days with more discharges before noon conferred a lower mean ED and inpatient LOS among patients admitted on those days. Their approach appropriately reframes the central issue as one of patient flow.

Kirubarajan et al’s most notable, and perhaps surprising, finding is the lack of association between morning discharge and ED LOS. Computer modeling supports the hypothesis that ED throughput will improve on days with earlier inpatient bed availability.² Several studies have also noted earlier ED departure times and decreased ED wait times after implementing interventions to promote DBN.³ Why might the authors’ findings contradict previous studies? Their outcomes may in part be due to high ED LOS (>14 hours), exceeding Canadian published targets and reports from the United States.^4,5 Problems relating to ED resources, practice, and hospital census may have overwhelmed DBN as factors in boarding. The interpretation of their findings is limited by the authors’ decision to report only ED LOS, rather than including the time between a decision to admit and ED departure (boarding time).

While early studies that focused on interventions to promote DBN noted decreased inpatient LOS after their implementation, later studies found no effect or even an increase in LOS for general internal medicine patients. Concerns have been raised about the confounding effect of concurrent initiatives aimed at improving LOS as well as misaligned incentives to delay discharge to the following morning. As the number of conflicting studies mounts, and with the current report in hand, it is tempting to conclude that for the DBN evidence base as a whole, we are observing random variation around no effect.

With growing doubt about benefits of morning discharge, perhaps we should turn our attention away from the question of how to increase DBN and consider instead why and at what cost. Hospitals are delicate organisms; a singular focus on one metric will undoubtedly impact others. Does the effort to discharge before noon consume valuable morning hours and detract from the care of other patients? Are patients held overnight unnecessarily to comply with DBN? Are there consequences in patient, nursing, or trainee satisfaction? Is bedside teaching affected?

And as concepts of patient-centered care are increasingly valued, we may ask whether DBN is such a concept, or is it rather an increasingly dubious strategy aimed at regularizing hospital operations? The need for a more holistic assessment of “discharge quality” is apparent. Instead of focusing on a particular hour, initiatives should determine the “best, earliest discharge time” for each patient and align multidisciplinary efforts toward this patient-centered goal. Such efforts are already underway in pediatric hospitals, where fixed discharge times are being replaced by discharge milestones embedded into the electronic medical record.⁶ An instrument to track “discharge readiness” such as this one, paired with ongoing analysis of the barriers to timely discharge, might better facilitate throughput by targeting the entire admission, rather than concentrating pressure on its final hours.

Targeting “discharge before noon” (DBN) for hospitalized patients has been proposed as a way to improve hospital throughput and patient safety by reducing emergency department (ED) boarding and crowding. In this issue, Kirubarajan et al¹ report no association between morning discharge and length of stay (LOS) for either the ED or hospitalization.¹ This large (189,781 patients) 7-year study from seven quite different Canadian hospitals adds important data to a literature that remains divided about whether DBN helps or hurts hospital LOS and ED boarding.

Unlike trials reporting interventions to encourage DBN, this observational study was unique in that it took each day as the unit of observation. This method cleverly allowed the authors to examine whether days with more discharges before noon conferred a lower mean ED and inpatient LOS among patients admitted on those days. Their approach appropriately reframes the central issue as one of patient flow.

Kirubarajan et al’s most notable, and perhaps surprising, finding is the lack of association between morning discharge and ED LOS. Computer modeling supports the hypothesis that ED throughput will improve on days with earlier inpatient bed availability.² Several studies have also noted earlier ED departure times and decreased ED wait times after implementing interventions to promote DBN.³ Why might the authors’ findings contradict previous studies? Their outcomes may in part be due to high ED LOS (>14 hours), exceeding Canadian published targets and reports from the United States.^4,5 Problems relating to ED resources, practice, and hospital census may have overwhelmed DBN as factors in boarding. The interpretation of their findings is limited by the authors’ decision to report only ED LOS, rather than including the time between a decision to admit and ED departure (boarding time).

While early studies that focused on interventions to promote DBN noted decreased inpatient LOS after their implementation, later studies found no effect or even an increase in LOS for general internal medicine patients. Concerns have been raised about the confounding effect of concurrent initiatives aimed at improving LOS as well as misaligned incentives to delay discharge to the following morning. As the number of conflicting studies mounts, and with the current report in hand, it is tempting to conclude that for the DBN evidence base as a whole, we are observing random variation around no effect.

With growing doubt about benefits of morning discharge, perhaps we should turn our attention away from the question of how to increase DBN and consider instead why and at what cost. Hospitals are delicate organisms; a singular focus on one metric will undoubtedly impact others. Does the effort to discharge before noon consume valuable morning hours and detract from the care of other patients? Are patients held overnight unnecessarily to comply with DBN? Are there consequences in patient, nursing, or trainee satisfaction? Is bedside teaching affected?

And as concepts of patient-centered care are increasingly valued, we may ask whether DBN is such a concept, or is it rather an increasingly dubious strategy aimed at regularizing hospital operations? The need for a more holistic assessment of “discharge quality” is apparent. Instead of focusing on a particular hour, initiatives should determine the “best, earliest discharge time” for each patient and align multidisciplinary efforts toward this patient-centered goal. Such efforts are already underway in pediatric hospitals, where fixed discharge times are being replaced by discharge milestones embedded into the electronic medical record.⁶ An instrument to track “discharge readiness” such as this one, paired with ongoing analysis of the barriers to timely discharge, might better facilitate throughput by targeting the entire admission, rather than concentrating pressure on its final hours.

Targeting “discharge before noon” (DBN) for hospitalized patients has been proposed as a way to improve hospital throughput and patient safety by reducing emergency department (ED) boarding and crowding. In this issue, Kirubarajan et al¹ report no association between morning discharge and length of stay (LOS) for either the ED or hospitalization.¹ This large (189,781 patients) 7-year study from seven quite different Canadian hospitals adds important data to a literature that remains divided about whether DBN helps or hurts hospital LOS and ED boarding.

Unlike trials reporting interventions to encourage DBN, this observational study was unique in that it took each day as the unit of observation. This method cleverly allowed the authors to examine whether days with more discharges before noon conferred a lower mean ED and inpatient LOS among patients admitted on those days. Their approach appropriately reframes the central issue as one of patient flow.

Kirubarajan et al’s most notable, and perhaps surprising, finding is the lack of association between morning discharge and ED LOS. Computer modeling supports the hypothesis that ED throughput will improve on days with earlier inpatient bed availability.² Several studies have also noted earlier ED departure times and decreased ED wait times after implementing interventions to promote DBN.³ Why might the authors’ findings contradict previous studies? Their outcomes may in part be due to high ED LOS (>14 hours), exceeding Canadian published targets and reports from the United States.^4,5 Problems relating to ED resources, practice, and hospital census may have overwhelmed DBN as factors in boarding. The interpretation of their findings is limited by the authors’ decision to report only ED LOS, rather than including the time between a decision to admit and ED departure (boarding time).

While early studies that focused on interventions to promote DBN noted decreased inpatient LOS after their implementation, later studies found no effect or even an increase in LOS for general internal medicine patients. Concerns have been raised about the confounding effect of concurrent initiatives aimed at improving LOS as well as misaligned incentives to delay discharge to the following morning. As the number of conflicting studies mounts, and with the current report in hand, it is tempting to conclude that for the DBN evidence base as a whole, we are observing random variation around no effect.

With growing doubt about benefits of morning discharge, perhaps we should turn our attention away from the question of how to increase DBN and consider instead why and at what cost. Hospitals are delicate organisms; a singular focus on one metric will undoubtedly impact others. Does the effort to discharge before noon consume valuable morning hours and detract from the care of other patients? Are patients held overnight unnecessarily to comply with DBN? Are there consequences in patient, nursing, or trainee satisfaction? Is bedside teaching affected?

And as concepts of patient-centered care are increasingly valued, we may ask whether DBN is such a concept, or is it rather an increasingly dubious strategy aimed at regularizing hospital operations? The need for a more holistic assessment of “discharge quality” is apparent. Instead of focusing on a particular hour, initiatives should determine the “best, earliest discharge time” for each patient and align multidisciplinary efforts toward this patient-centered goal. Such efforts are already underway in pediatric hospitals, where fixed discharge times are being replaced by discharge milestones embedded into the electronic medical record.⁶ An instrument to track “discharge readiness” such as this one, paired with ongoing analysis of the barriers to timely discharge, might better facilitate throughput by targeting the entire admission, rather than concentrating pressure on its final hours.

Hospital discharge is a complex, multi-stakeholder event, and evidence suggests that the quality of that transition directly relates to mortality, readmissions, and postdischarge quality of life and functional status.¹ The Centers for Medicare & Medicaid Services call for team-based and patient-centered discharge planning,² yet the process for achieving this is poorly defined.

In this issue of the Journal of Hospital Medicine, Manges et al³ use shared mental models (SMM) as a conceptual framework to describe differences in how care team members and patients perceive hospital discharge readiness. While our understanding of factors associated with safe and patient-centered hospital discharges is still growing, the authors focus on one critical component: lack of agreement between patients and interprofessional teams regarding discharge readiness.

Manges et al³ measured whether interprofessional team members agree, or converge, on their assessment of a patient’s discharge readiness (team-SMM convergence) and whether that assessment converges with the patient’s self-assessment (team-patient SMM convergence). They found good team-SMM convergence regarding the patient’s discharge readiness, yet teams overestimated readiness compared with the patient’s self-assessment nearly half (48.4%) of the time. A clinical trial found that clinician assessments of discharge readiness were poorly predictive of readmissions unless they were combined with a patient’s self-assessment.⁴ Manges et al’s study findings, while of limited generalizability, enhance our understanding of a potential gap in achieving patient-centered care as outlined in the Institute of Medicine’s Crossing the Quality Chasm,⁵ which urges clinicians to see patients and families as partners in improving care.

The authors also found that higher team-patient convergence was associated with teams that reported high-quality teamwork and those having more baccalaureate degree−educated nurses (BSN). While Manges et al³ did not elucidate the mechanism by which this occurs, their findings align with existing literature showing that patients receiving care from a higher proportion of BSN-prepared nurses experience an 18.7% reduction in odds of readmission.⁶ Further research investigating the link between team communication, registered nurse education, and discharge outcomes may reveal additional opportunities for interventions to improve discharge quality.

The lack of patient outcomes and the limited diversity of the patient population are substantial limitations of the study. The authors did not assess the relationship between SMMs and important outcomes like readmission or adverse events. Furthermore, most of the patients were White and English-speaking, precluding assessment of factors that disproportionately impact patient populations that already experience disparities in a multitude of health outcomes.

In summary, Manges et al³ highlight challenges and opportunities in optimizing clinician communication and ensuring that the team’s and the patient’s self-assessments align and inform discharge planning. Their findings suggest the theoretical framework of SMM holds promise in identifying and evaluating some of the complex determinants involved in high-quality, patient-centered hospital discharges.

Hospital discharge is a complex, multi-stakeholder event, and evidence suggests that the quality of that transition directly relates to mortality, readmissions, and postdischarge quality of life and functional status.¹ The Centers for Medicare & Medicaid Services call for team-based and patient-centered discharge planning,² yet the process for achieving this is poorly defined.

In this issue of the Journal of Hospital Medicine, Manges et al³ use shared mental models (SMM) as a conceptual framework to describe differences in how care team members and patients perceive hospital discharge readiness. While our understanding of factors associated with safe and patient-centered hospital discharges is still growing, the authors focus on one critical component: lack of agreement between patients and interprofessional teams regarding discharge readiness.

Manges et al³ measured whether interprofessional team members agree, or converge, on their assessment of a patient’s discharge readiness (team-SMM convergence) and whether that assessment converges with the patient’s self-assessment (team-patient SMM convergence). They found good team-SMM convergence regarding the patient’s discharge readiness, yet teams overestimated readiness compared with the patient’s self-assessment nearly half (48.4%) of the time. A clinical trial found that clinician assessments of discharge readiness were poorly predictive of readmissions unless they were combined with a patient’s self-assessment.⁴ Manges et al’s study findings, while of limited generalizability, enhance our understanding of a potential gap in achieving patient-centered care as outlined in the Institute of Medicine’s Crossing the Quality Chasm,⁵ which urges clinicians to see patients and families as partners in improving care.

The authors also found that higher team-patient convergence was associated with teams that reported high-quality teamwork and those having more baccalaureate degree−educated nurses (BSN). While Manges et al³ did not elucidate the mechanism by which this occurs, their findings align with existing literature showing that patients receiving care from a higher proportion of BSN-prepared nurses experience an 18.7% reduction in odds of readmission.⁶ Further research investigating the link between team communication, registered nurse education, and discharge outcomes may reveal additional opportunities for interventions to improve discharge quality.

The lack of patient outcomes and the limited diversity of the patient population are substantial limitations of the study. The authors did not assess the relationship between SMMs and important outcomes like readmission or adverse events. Furthermore, most of the patients were White and English-speaking, precluding assessment of factors that disproportionately impact patient populations that already experience disparities in a multitude of health outcomes.

In summary, Manges et al³ highlight challenges and opportunities in optimizing clinician communication and ensuring that the team’s and the patient’s self-assessments align and inform discharge planning. Their findings suggest the theoretical framework of SMM holds promise in identifying and evaluating some of the complex determinants involved in high-quality, patient-centered hospital discharges.

Hospital discharge is a complex, multi-stakeholder event, and evidence suggests that the quality of that transition directly relates to mortality, readmissions, and postdischarge quality of life and functional status.¹ The Centers for Medicare & Medicaid Services call for team-based and patient-centered discharge planning,² yet the process for achieving this is poorly defined.

In this issue of the Journal of Hospital Medicine, Manges et al³ use shared mental models (SMM) as a conceptual framework to describe differences in how care team members and patients perceive hospital discharge readiness. While our understanding of factors associated with safe and patient-centered hospital discharges is still growing, the authors focus on one critical component: lack of agreement between patients and interprofessional teams regarding discharge readiness.

Manges et al³ measured whether interprofessional team members agree, or converge, on their assessment of a patient’s discharge readiness (team-SMM convergence) and whether that assessment converges with the patient’s self-assessment (team-patient SMM convergence). They found good team-SMM convergence regarding the patient’s discharge readiness, yet teams overestimated readiness compared with the patient’s self-assessment nearly half (48.4%) of the time. A clinical trial found that clinician assessments of discharge readiness were poorly predictive of readmissions unless they were combined with a patient’s self-assessment.⁴ Manges et al’s study findings, while of limited generalizability, enhance our understanding of a potential gap in achieving patient-centered care as outlined in the Institute of Medicine’s Crossing the Quality Chasm,⁵ which urges clinicians to see patients and families as partners in improving care.

The authors also found that higher team-patient convergence was associated with teams that reported high-quality teamwork and those having more baccalaureate degree−educated nurses (BSN). While Manges et al³ did not elucidate the mechanism by which this occurs, their findings align with existing literature showing that patients receiving care from a higher proportion of BSN-prepared nurses experience an 18.7% reduction in odds of readmission.⁶ Further research investigating the link between team communication, registered nurse education, and discharge outcomes may reveal additional opportunities for interventions to improve discharge quality.

The lack of patient outcomes and the limited diversity of the patient population are substantial limitations of the study. The authors did not assess the relationship between SMMs and important outcomes like readmission or adverse events. Furthermore, most of the patients were White and English-speaking, precluding assessment of factors that disproportionately impact patient populations that already experience disparities in a multitude of health outcomes.

In summary, Manges et al³ highlight challenges and opportunities in optimizing clinician communication and ensuring that the team’s and the patient’s self-assessments align and inform discharge planning. Their findings suggest the theoretical framework of SMM holds promise in identifying and evaluating some of the complex determinants involved in high-quality, patient-centered hospital discharges.

Ten percent of patients with immune-mediated inflammatory diseases (IMIDs) fail to respond properly to COVID-19 vaccinations regardless of medication, researchers report, and small new studies suggest those on methotrexate and rituximab may be especially vulnerable to vaccine failure.

Even so, it’s still crucially vital for patients with IMIDs to get vaccinated and for clinicians to follow recommendations to temporarily withhold certain medications around the time of vaccination, rheumatologist Anne R. Bass, MD, of Weill Cornell Medicine and the Hospital for Special Surgery, New York, said in an interview. “We’re not making any significant adjustments,” added Dr. Bass, a coauthor of the American College of Rheumatology’s COVID-19 vaccination guidelines for patients with rheumatic and musculoskeletal diseases.

The findings appear in a trio of studies in Annals of the Rheumatic Diseases. The most recent study, which appeared May 25, 2021, found that more than one-third of patients with IMIDs who took methotrexate didn’t produce adequate antibody levels after vaccination versus 10% of those in other groups. (P < .001) A May 11 study found that 20 of 30 patients with rheumatic diseases on rituximab failed to respond to vaccination. And a May 6 study reported that immune responses against SARS-CoV-2 are “somewhat delayed and reduced” in patients with IMID, with 99.5% of a control group developing neutralizing antibody activity after vaccination versus 90% of those with IMID (P = .0008).


 

Development of neutralizing antibodies somewhat delayed and reduced

Team members were surprised by the high number of vaccine nonresponders in the May 6 IMID study, coauthor Georg Schett, MD, of Germany’s Friedrich-Alexander University Erlangen-Nuremberg and University Hospital Erlangen, said in an interview.

The researchers compared two groups of patients who had no history of COVID-19 and received COVID-19 vaccinations, mostly two shots of the Pfizer-BioNTech vaccine (96%): 84 with IMID (mean age, 53.1 years; 65.5% females) and 182 healthy controls (mean age, 40.8 years; 57.1% females).

The patients with IMID most commonly had spondyloarthritis (32.1%), RA (29.8%), inflammatory bowel disease (9.5%), and psoriasis (9.5%). Nearly 43% of the patients were treated with biologic and targeted synthetic disease-modifying antirheumatic drugs and 23.9% with conventional synthetic DMARDSs. Another 29% were not treated.

All of the controls developed anti–SARS-CoV-2 IgG, but 6% of the patients with IMID did not (P = .003). The gap in development of neutralizing antibodies was even higher: 99.5% of the controls developed neutralizing antibody activity versus 90% of the IMID group. “Neutralizing antibodies are more relevant because the test shows how much the antibodies interfere with the binding of SARS-CoV-2 proteins to the receptor,” Dr. Schett said.

The study authors concluded that “our study provides evidence that, while vaccination against SARS-CoV-2 is well tolerated and even associated with lower incidence of side effects in patients with IMID, its efficacy is somewhat delayed and reduced. Nonetheless, the data also show that, in principle, patients with IMID respond to SARS-CoV-2 vaccination, supporting an aggressive vaccination strategy.”
 

Lowered antibody response to vaccination for some methotrexate users

In the newer study, led by Rebecca H. Haberman, MD, of New York University Langone Health, researchers examined COVID-19 vaccine response in cohorts in New York City and Erlangen, Germany.

The New York cohort included 25 patients with IMID who were taking methotrexate by itself or with other immunomodulatory medications (mean age, 63.2 years), 26 with IMID who were on anticytokine therapy and/or other oral immunomodulators (mean age, 49.1 years) and 26 healthy controls (mean age, 49.2 years). Most patients with IMID had psoriasis/psoriatic arthritis or RA.

The German validation cohort included 182 healthy subjects (mean age, 45.0 years), 11 subjects with IMID who received TNF inhibitor monotherapy (mean age, 40.8 years), and 20 subjects with IMID on methotrexate monotherapy (mean age, 54.5 years).

In the New York cohort, 96.1% of healthy controls showed “adequate humoral immune response,” along with 92.3% of patients with IMID who weren’t taking methotrexate. However, those on methotrexate had a lower rate of adequate response (72.0%), and the gap persisted even after researchers removed those who showed signs of previous COVID-19 infection (P = .045).

In the German cohort, 98.3% of healthy cohorts and 90.9% of patients with IMID who didn’t receive methotrexate reached an “adequate” humoral response versus just half (50.0%) of those who were taking methotrexate.

When both cohorts are combined, over 90% of the healthy subjects and the patients with IMID on biologic treatments (mainly TNF blockers, n = 37) showed “robust” antibody response. However, only 62% of patients with IMID who took methotrexate (n = 45) reached an “adequate” level of response. The methotrexate gap remained after researchers accounted for differences in age among the cohorts.

What’s going on? “We think that the underlying chronic immune stimulation in autoimmune patients may cause T-cell exhaustion and thus blunts the immune response,” said Dr. Schett, who’s also a coauthor of this study. “In addition, specific drugs such as methotrexate could additionally impair the immune response.”

Still, the findings “reiterate that vaccinations are safe and effective, which is what the recommendations state,” he said, adding that more testing of vaccination immune response is wise.
 

Insights into vaccine response while on rituximab

Two more reports, also published in Annals of the Rheumatic Diseases, offer insight into vaccine response in patients with IMID who take rituximab.

Ridofranz/Getty Images

In one report, published May 11, U.S. researchers retrospectively tracked 89 rheumatic disease patients (76% female; mean age, 61) at a single clinic who’d received at least one dose of a COVID-19 vaccine. Of those, 21 patients showed no sign of vaccine antibody response, and 20 of them were in the group taking rituximab. (The other patient was taking belimumab.) Another 10 patients taking rituximab did show a response.

“Longer duration from most recent rituximab exposure was associated with a greater likelihood of response,” the report’s authors wrote. “The results suggest that time from last rituximab exposure is an important consideration in maximizing the likelihood of a serological response, but this likely is related to the substantial variation in the period of B-cell depletion following rituximab.”

Finally, an Austrian report published May 6 examined COVID-19 vaccine immune response in five patients who were taking rituximab (four with other drugs such as methotrexate and prednisone). Researchers compared them with eight healthy controls, half who’d been vaccinated.

The researchers found evidence that rituximab “may not have to preclude SARS-CoV-2 vaccination, since a cellular immune response will be mounted even in the absence of circulating B cells. Alternatively, in patients with stable disease, delaying [rituximab] treatment until after the second vaccination may be warranted and, therefore, vaccines with a short interval between first and second vaccination or those showing full protection after a single vaccination may be preferable. Importantly, in the presence of circulating B cells also a humoral immune response may be expected despite prior [rituximab] therapy.”

Dr. Bass said the findings reflect growing awareness that “patients with autoimmune disease, especially when they’re on immunosuppressant medications, don’t quite have as optimal responses to the vaccinations.” However, she said, the vaccines are so potent that they’re likely to still have significant efficacy in these patients even if there’s a reduction in response.

What’s next? Dr. Schett said “testing immune response to vaccination is important for patients with autoimmune disease. Some of them may need a third vaccination.”

The American College of Rheumatology’s COVID-19 vaccination guidelines do not recommend third vaccinations or postvaccination immune testing at this time. However, Dr. Bass, one of the coauthors of the recommendations, said it’s likely that postvaccination immune testing and booster shots will become routine.

Dr. Bass reported no relevant disclosures. Dr. Schett reported receiving consulting fees from AbbVie. The May 6 German vaccine study was funded by Deutsche Forschungsgemeinschaft, Bundesministerium für Bildung und Forschung, the ERC Synergy grant 4D Nanoscope, the IMI funded project RTCure, the Emerging Fields Initiative MIRACLE of the Friedrich-Alexander-Universität Erlangen-Nürnberg, the Schreiber Stiftung, and the Else Kröner-Memorial Scholarship. The study authors reported no disclosures. The May 25 study of German and American cohorts was funded by the National Institute of Arthritis and Musculoskletal and Skin Diseases, National Institute of Allergy and Infectious Diseases, Rheumatology Research Foundation, Bloomberg Philanthropies COVID-19 Initiative, Pfizer COVID-19 Competitive Grant Program, Beatrice Snyder Foundation, Riley Family Foundation, National Psoriasis Foundation, and Deutsche Forschungsgemeinschaft. The authors reported a range of financial relationships with pharmaceutical companies. No specific funding was reported for the other two studies mentioned.

Ten percent of patients with immune-mediated inflammatory diseases (IMIDs) fail to respond properly to COVID-19 vaccinations regardless of medication, researchers report, and small new studies suggest those on methotrexate and rituximab may be especially vulnerable to vaccine failure.

Even so, it’s still crucially vital for patients with IMIDs to get vaccinated and for clinicians to follow recommendations to temporarily withhold certain medications around the time of vaccination, rheumatologist Anne R. Bass, MD, of Weill Cornell Medicine and the Hospital for Special Surgery, New York, said in an interview. “We’re not making any significant adjustments,” added Dr. Bass, a coauthor of the American College of Rheumatology’s COVID-19 vaccination guidelines for patients with rheumatic and musculoskeletal diseases.

The findings appear in a trio of studies in Annals of the Rheumatic Diseases. The most recent study, which appeared May 25, 2021, found that more than one-third of patients with IMIDs who took methotrexate didn’t produce adequate antibody levels after vaccination versus 10% of those in other groups. (P < .001) A May 11 study found that 20 of 30 patients with rheumatic diseases on rituximab failed to respond to vaccination. And a May 6 study reported that immune responses against SARS-CoV-2 are “somewhat delayed and reduced” in patients with IMID, with 99.5% of a control group developing neutralizing antibody activity after vaccination versus 90% of those with IMID (P = .0008).


 

Development of neutralizing antibodies somewhat delayed and reduced

Team members were surprised by the high number of vaccine nonresponders in the May 6 IMID study, coauthor Georg Schett, MD, of Germany’s Friedrich-Alexander University Erlangen-Nuremberg and University Hospital Erlangen, said in an interview.

The researchers compared two groups of patients who had no history of COVID-19 and received COVID-19 vaccinations, mostly two shots of the Pfizer-BioNTech vaccine (96%): 84 with IMID (mean age, 53.1 years; 65.5% females) and 182 healthy controls (mean age, 40.8 years; 57.1% females).

The patients with IMID most commonly had spondyloarthritis (32.1%), RA (29.8%), inflammatory bowel disease (9.5%), and psoriasis (9.5%). Nearly 43% of the patients were treated with biologic and targeted synthetic disease-modifying antirheumatic drugs and 23.9% with conventional synthetic DMARDSs. Another 29% were not treated.

All of the controls developed anti–SARS-CoV-2 IgG, but 6% of the patients with IMID did not (P = .003). The gap in development of neutralizing antibodies was even higher: 99.5% of the controls developed neutralizing antibody activity versus 90% of the IMID group. “Neutralizing antibodies are more relevant because the test shows how much the antibodies interfere with the binding of SARS-CoV-2 proteins to the receptor,” Dr. Schett said.

The study authors concluded that “our study provides evidence that, while vaccination against SARS-CoV-2 is well tolerated and even associated with lower incidence of side effects in patients with IMID, its efficacy is somewhat delayed and reduced. Nonetheless, the data also show that, in principle, patients with IMID respond to SARS-CoV-2 vaccination, supporting an aggressive vaccination strategy.”
 

Lowered antibody response to vaccination for some methotrexate users

In the newer study, led by Rebecca H. Haberman, MD, of New York University Langone Health, researchers examined COVID-19 vaccine response in cohorts in New York City and Erlangen, Germany.

The New York cohort included 25 patients with IMID who were taking methotrexate by itself or with other immunomodulatory medications (mean age, 63.2 years), 26 with IMID who were on anticytokine therapy and/or other oral immunomodulators (mean age, 49.1 years) and 26 healthy controls (mean age, 49.2 years). Most patients with IMID had psoriasis/psoriatic arthritis or RA.

The German validation cohort included 182 healthy subjects (mean age, 45.0 years), 11 subjects with IMID who received TNF inhibitor monotherapy (mean age, 40.8 years), and 20 subjects with IMID on methotrexate monotherapy (mean age, 54.5 years).

In the New York cohort, 96.1% of healthy controls showed “adequate humoral immune response,” along with 92.3% of patients with IMID who weren’t taking methotrexate. However, those on methotrexate had a lower rate of adequate response (72.0%), and the gap persisted even after researchers removed those who showed signs of previous COVID-19 infection (P = .045).

In the German cohort, 98.3% of healthy cohorts and 90.9% of patients with IMID who didn’t receive methotrexate reached an “adequate” humoral response versus just half (50.0%) of those who were taking methotrexate.

When both cohorts are combined, over 90% of the healthy subjects and the patients with IMID on biologic treatments (mainly TNF blockers, n = 37) showed “robust” antibody response. However, only 62% of patients with IMID who took methotrexate (n = 45) reached an “adequate” level of response. The methotrexate gap remained after researchers accounted for differences in age among the cohorts.

What’s going on? “We think that the underlying chronic immune stimulation in autoimmune patients may cause T-cell exhaustion and thus blunts the immune response,” said Dr. Schett, who’s also a coauthor of this study. “In addition, specific drugs such as methotrexate could additionally impair the immune response.”

Still, the findings “reiterate that vaccinations are safe and effective, which is what the recommendations state,” he said, adding that more testing of vaccination immune response is wise.
 

Insights into vaccine response while on rituximab

Two more reports, also published in Annals of the Rheumatic Diseases, offer insight into vaccine response in patients with IMID who take rituximab.

Ridofranz/Getty Images

In one report, published May 11, U.S. researchers retrospectively tracked 89 rheumatic disease patients (76% female; mean age, 61) at a single clinic who’d received at least one dose of a COVID-19 vaccine. Of those, 21 patients showed no sign of vaccine antibody response, and 20 of them were in the group taking rituximab. (The other patient was taking belimumab.) Another 10 patients taking rituximab did show a response.

“Longer duration from most recent rituximab exposure was associated with a greater likelihood of response,” the report’s authors wrote. “The results suggest that time from last rituximab exposure is an important consideration in maximizing the likelihood of a serological response, but this likely is related to the substantial variation in the period of B-cell depletion following rituximab.”

Finally, an Austrian report published May 6 examined COVID-19 vaccine immune response in five patients who were taking rituximab (four with other drugs such as methotrexate and prednisone). Researchers compared them with eight healthy controls, half who’d been vaccinated.

The researchers found evidence that rituximab “may not have to preclude SARS-CoV-2 vaccination, since a cellular immune response will be mounted even in the absence of circulating B cells. Alternatively, in patients with stable disease, delaying [rituximab] treatment until after the second vaccination may be warranted and, therefore, vaccines with a short interval between first and second vaccination or those showing full protection after a single vaccination may be preferable. Importantly, in the presence of circulating B cells also a humoral immune response may be expected despite prior [rituximab] therapy.”

Dr. Bass said the findings reflect growing awareness that “patients with autoimmune disease, especially when they’re on immunosuppressant medications, don’t quite have as optimal responses to the vaccinations.” However, she said, the vaccines are so potent that they’re likely to still have significant efficacy in these patients even if there’s a reduction in response.

What’s next? Dr. Schett said “testing immune response to vaccination is important for patients with autoimmune disease. Some of them may need a third vaccination.”

The American College of Rheumatology’s COVID-19 vaccination guidelines do not recommend third vaccinations or postvaccination immune testing at this time. However, Dr. Bass, one of the coauthors of the recommendations, said it’s likely that postvaccination immune testing and booster shots will become routine.

Dr. Bass reported no relevant disclosures. Dr. Schett reported receiving consulting fees from AbbVie. The May 6 German vaccine study was funded by Deutsche Forschungsgemeinschaft, Bundesministerium für Bildung und Forschung, the ERC Synergy grant 4D Nanoscope, the IMI funded project RTCure, the Emerging Fields Initiative MIRACLE of the Friedrich-Alexander-Universität Erlangen-Nürnberg, the Schreiber Stiftung, and the Else Kröner-Memorial Scholarship. The study authors reported no disclosures. The May 25 study of German and American cohorts was funded by the National Institute of Arthritis and Musculoskletal and Skin Diseases, National Institute of Allergy and Infectious Diseases, Rheumatology Research Foundation, Bloomberg Philanthropies COVID-19 Initiative, Pfizer COVID-19 Competitive Grant Program, Beatrice Snyder Foundation, Riley Family Foundation, National Psoriasis Foundation, and Deutsche Forschungsgemeinschaft. The authors reported a range of financial relationships with pharmaceutical companies. No specific funding was reported for the other two studies mentioned.

Ten percent of patients with immune-mediated inflammatory diseases (IMIDs) fail to respond properly to COVID-19 vaccinations regardless of medication, researchers report, and small new studies suggest those on methotrexate and rituximab may be especially vulnerable to vaccine failure.

Even so, it’s still crucially vital for patients with IMIDs to get vaccinated and for clinicians to follow recommendations to temporarily withhold certain medications around the time of vaccination, rheumatologist Anne R. Bass, MD, of Weill Cornell Medicine and the Hospital for Special Surgery, New York, said in an interview. “We’re not making any significant adjustments,” added Dr. Bass, a coauthor of the American College of Rheumatology’s COVID-19 vaccination guidelines for patients with rheumatic and musculoskeletal diseases.

The findings appear in a trio of studies in Annals of the Rheumatic Diseases. The most recent study, which appeared May 25, 2021, found that more than one-third of patients with IMIDs who took methotrexate didn’t produce adequate antibody levels after vaccination versus 10% of those in other groups. (P < .001) A May 11 study found that 20 of 30 patients with rheumatic diseases on rituximab failed to respond to vaccination. And a May 6 study reported that immune responses against SARS-CoV-2 are “somewhat delayed and reduced” in patients with IMID, with 99.5% of a control group developing neutralizing antibody activity after vaccination versus 90% of those with IMID (P = .0008).


 

Development of neutralizing antibodies somewhat delayed and reduced

Team members were surprised by the high number of vaccine nonresponders in the May 6 IMID study, coauthor Georg Schett, MD, of Germany’s Friedrich-Alexander University Erlangen-Nuremberg and University Hospital Erlangen, said in an interview.

The researchers compared two groups of patients who had no history of COVID-19 and received COVID-19 vaccinations, mostly two shots of the Pfizer-BioNTech vaccine (96%): 84 with IMID (mean age, 53.1 years; 65.5% females) and 182 healthy controls (mean age, 40.8 years; 57.1% females).

The patients with IMID most commonly had spondyloarthritis (32.1%), RA (29.8%), inflammatory bowel disease (9.5%), and psoriasis (9.5%). Nearly 43% of the patients were treated with biologic and targeted synthetic disease-modifying antirheumatic drugs and 23.9% with conventional synthetic DMARDSs. Another 29% were not treated.

All of the controls developed anti–SARS-CoV-2 IgG, but 6% of the patients with IMID did not (P = .003). The gap in development of neutralizing antibodies was even higher: 99.5% of the controls developed neutralizing antibody activity versus 90% of the IMID group. “Neutralizing antibodies are more relevant because the test shows how much the antibodies interfere with the binding of SARS-CoV-2 proteins to the receptor,” Dr. Schett said.

The study authors concluded that “our study provides evidence that, while vaccination against SARS-CoV-2 is well tolerated and even associated with lower incidence of side effects in patients with IMID, its efficacy is somewhat delayed and reduced. Nonetheless, the data also show that, in principle, patients with IMID respond to SARS-CoV-2 vaccination, supporting an aggressive vaccination strategy.”
 

Lowered antibody response to vaccination for some methotrexate users

In the newer study, led by Rebecca H. Haberman, MD, of New York University Langone Health, researchers examined COVID-19 vaccine response in cohorts in New York City and Erlangen, Germany.

The New York cohort included 25 patients with IMID who were taking methotrexate by itself or with other immunomodulatory medications (mean age, 63.2 years), 26 with IMID who were on anticytokine therapy and/or other oral immunomodulators (mean age, 49.1 years) and 26 healthy controls (mean age, 49.2 years). Most patients with IMID had psoriasis/psoriatic arthritis or RA.

The German validation cohort included 182 healthy subjects (mean age, 45.0 years), 11 subjects with IMID who received TNF inhibitor monotherapy (mean age, 40.8 years), and 20 subjects with IMID on methotrexate monotherapy (mean age, 54.5 years).

In the New York cohort, 96.1% of healthy controls showed “adequate humoral immune response,” along with 92.3% of patients with IMID who weren’t taking methotrexate. However, those on methotrexate had a lower rate of adequate response (72.0%), and the gap persisted even after researchers removed those who showed signs of previous COVID-19 infection (P = .045).

In the German cohort, 98.3% of healthy cohorts and 90.9% of patients with IMID who didn’t receive methotrexate reached an “adequate” humoral response versus just half (50.0%) of those who were taking methotrexate.

When both cohorts are combined, over 90% of the healthy subjects and the patients with IMID on biologic treatments (mainly TNF blockers, n = 37) showed “robust” antibody response. However, only 62% of patients with IMID who took methotrexate (n = 45) reached an “adequate” level of response. The methotrexate gap remained after researchers accounted for differences in age among the cohorts.

What’s going on? “We think that the underlying chronic immune stimulation in autoimmune patients may cause T-cell exhaustion and thus blunts the immune response,” said Dr. Schett, who’s also a coauthor of this study. “In addition, specific drugs such as methotrexate could additionally impair the immune response.”

Still, the findings “reiterate that vaccinations are safe and effective, which is what the recommendations state,” he said, adding that more testing of vaccination immune response is wise.
 

Insights into vaccine response while on rituximab

Two more reports, also published in Annals of the Rheumatic Diseases, offer insight into vaccine response in patients with IMID who take rituximab.

Ridofranz/Getty Images

In one report, published May 11, U.S. researchers retrospectively tracked 89 rheumatic disease patients (76% female; mean age, 61) at a single clinic who’d received at least one dose of a COVID-19 vaccine. Of those, 21 patients showed no sign of vaccine antibody response, and 20 of them were in the group taking rituximab. (The other patient was taking belimumab.) Another 10 patients taking rituximab did show a response.

“Longer duration from most recent rituximab exposure was associated with a greater likelihood of response,” the report’s authors wrote. “The results suggest that time from last rituximab exposure is an important consideration in maximizing the likelihood of a serological response, but this likely is related to the substantial variation in the period of B-cell depletion following rituximab.”

Finally, an Austrian report published May 6 examined COVID-19 vaccine immune response in five patients who were taking rituximab (four with other drugs such as methotrexate and prednisone). Researchers compared them with eight healthy controls, half who’d been vaccinated.

The researchers found evidence that rituximab “may not have to preclude SARS-CoV-2 vaccination, since a cellular immune response will be mounted even in the absence of circulating B cells. Alternatively, in patients with stable disease, delaying [rituximab] treatment until after the second vaccination may be warranted and, therefore, vaccines with a short interval between first and second vaccination or those showing full protection after a single vaccination may be preferable. Importantly, in the presence of circulating B cells also a humoral immune response may be expected despite prior [rituximab] therapy.”

Dr. Bass said the findings reflect growing awareness that “patients with autoimmune disease, especially when they’re on immunosuppressant medications, don’t quite have as optimal responses to the vaccinations.” However, she said, the vaccines are so potent that they’re likely to still have significant efficacy in these patients even if there’s a reduction in response.

What’s next? Dr. Schett said “testing immune response to vaccination is important for patients with autoimmune disease. Some of them may need a third vaccination.”

The American College of Rheumatology’s COVID-19 vaccination guidelines do not recommend third vaccinations or postvaccination immune testing at this time. However, Dr. Bass, one of the coauthors of the recommendations, said it’s likely that postvaccination immune testing and booster shots will become routine.

Dr. Bass reported no relevant disclosures. Dr. Schett reported receiving consulting fees from AbbVie. The May 6 German vaccine study was funded by Deutsche Forschungsgemeinschaft, Bundesministerium für Bildung und Forschung, the ERC Synergy grant 4D Nanoscope, the IMI funded project RTCure, the Emerging Fields Initiative MIRACLE of the Friedrich-Alexander-Universität Erlangen-Nürnberg, the Schreiber Stiftung, and the Else Kröner-Memorial Scholarship. The study authors reported no disclosures. The May 25 study of German and American cohorts was funded by the National Institute of Arthritis and Musculoskletal and Skin Diseases, National Institute of Allergy and Infectious Diseases, Rheumatology Research Foundation, Bloomberg Philanthropies COVID-19 Initiative, Pfizer COVID-19 Competitive Grant Program, Beatrice Snyder Foundation, Riley Family Foundation, National Psoriasis Foundation, and Deutsche Forschungsgemeinschaft. The authors reported a range of financial relationships with pharmaceutical companies. No specific funding was reported for the other two studies mentioned.

Children with food allergies often require diligent monitoring and a restricted diet to reduce allergic attacks, but there is little evidence available to support so-called “food bans” at schools and childcare centers.

Instead, a new practice guideline published earlier this month in the Journal of Allergy and Clinical Immunology calls for better allergy management training for staff, as well as increased epinephrine availability in educational environments. The guidelines were developed by an international panel of clinicians, school personnel, and parents.
 

The guidance at a glance

Rather than creating site-wide food prohibitions on nuts, dairy, and other allergenic foods, the practice guidance recommends centers and schools use “common-sense approaches” to reduce allergic reaction risk among school-aged children. According to the guideline authors, these strategies could include promoting handwashing, providing adult supervision during snacks and meals, and cleaning surfaces where food is either eaten or prepared.

Additionally, the new evidence-based guidance calls for schools and childcare centers to teach school personnel to recognize, prevent, and respond appropriately to food-related allergic reactions when they do occur.

The guidance also recommends that educational institutions require an up-to-date allergy ‘action plan’ from parents, designed for their children with allergies. These action plans can be integrated into the training of teachers and nurses to help manage potential allergic reactions.

Moreover, the guidance suggests schools should keep unassigned epinephrine autoinjectors in stock, both on site and even when traveling, where laws permit, rather than requiring students with allergies to bring in their own autoinjectors. Ultimately, this represents a more proactive approach to treating anaphylaxis, particularly in settings where treatment is urgently needed, such as when students are away from campus and participating in a school-designated trip or event.
 

Expert perspectives

Jennifer A. Dantzer, MD, MHS, allergist-immunologist and assistant professor of pediatrics at Johns Hopkins University, Baltimore, told this news organization via email that the practice guidelines offer an important starting point for ensuring quality of life of students, parents, and other school personnel.

While the Centers for Disease Control and Prevention published voluntary guidance for managing food allergies in schools back in 2013, there has since “been a lack of universal policies and procedures to manage the risk of allergic reactions in schools,” explained Dr. Dantzer. “The new guidelines are a good first step of using available evidence and all the key stakeholders, clinicians, school personnel, and families to figure out the best way to keep children with food allergies safe at school.”

Dr. Dantzer wasn’t involved in the creation of the new practice guidelines, but she shared how her clinical experience reinforces the need for the evidence-based recommendations. “Every single week we talk with families, both in clinic and in our research studies, about living with food allergies, and we recognize that every child is different,” she said. “We constantly work to advocate for each individual child with food allergies.”

Pediatric allergist Malika Gupta, MBBS, MD, said in an interview via email that the guidelines could assist in the creation of new nationwide policies for food allergy management at schools. “Also, the guidelines are labeled ‘conditional,’ which gives policymakers the ability to adapt to their specific circumstances and individuals, as well as make modifications according to regional trends,” she added.

Dr. Gupta, a clinical assistant professor in the Division of Allergy and Clinical Immunology at the University of Michigan, Ann Arbor, echoed the guideline panel’s sentiments regarding food bans, explaining that prohibiting certain foods could lend a “false sense of security” and could also “promote bullying and a sense of isolation for the food-allergic child.” In spite of the lack of evidence supporting food bans, Dr. Gupta noted that these bans can give families a sense of control and security. Ideally, more research should be performed to determine whether food bans actually work, she added.

In addition to promoting the new guidelines, allergists and pediatricians can also implement proactive allergy reaction mitigation strategies that work with school systems, according to Dr. Gupta. “In-clinic, we ensure all families have food allergy action plans for school and current epinephrine auto-injectors,” she said. “We also often have our food allergy nurses educate schools when food allergy awareness is a concern.”

Many of the 25 authors of the food allergy guidelines disclosed relevant financial relationships. The full list is with the original article. According to a footnote within the guidelines, “Panel members who were deemed to have a real, perceived, or potential conflict of interest were asked to abstain from voting on recommendations related to that interest.”  

A version of this article first appeared on Medscape.com.

Children with food allergies often require diligent monitoring and a restricted diet to reduce allergic attacks, but there is little evidence available to support so-called “food bans” at schools and childcare centers.

Instead, a new practice guideline published earlier this month in the Journal of Allergy and Clinical Immunology calls for better allergy management training for staff, as well as increased epinephrine availability in educational environments. The guidelines were developed by an international panel of clinicians, school personnel, and parents.
 

The guidance at a glance

Rather than creating site-wide food prohibitions on nuts, dairy, and other allergenic foods, the practice guidance recommends centers and schools use “common-sense approaches” to reduce allergic reaction risk among school-aged children. According to the guideline authors, these strategies could include promoting handwashing, providing adult supervision during snacks and meals, and cleaning surfaces where food is either eaten or prepared.

Additionally, the new evidence-based guidance calls for schools and childcare centers to teach school personnel to recognize, prevent, and respond appropriately to food-related allergic reactions when they do occur.

The guidance also recommends that educational institutions require an up-to-date allergy ‘action plan’ from parents, designed for their children with allergies. These action plans can be integrated into the training of teachers and nurses to help manage potential allergic reactions.

Moreover, the guidance suggests schools should keep unassigned epinephrine autoinjectors in stock, both on site and even when traveling, where laws permit, rather than requiring students with allergies to bring in their own autoinjectors. Ultimately, this represents a more proactive approach to treating anaphylaxis, particularly in settings where treatment is urgently needed, such as when students are away from campus and participating in a school-designated trip or event.
 

Expert perspectives

Jennifer A. Dantzer, MD, MHS, allergist-immunologist and assistant professor of pediatrics at Johns Hopkins University, Baltimore, told this news organization via email that the practice guidelines offer an important starting point for ensuring quality of life of students, parents, and other school personnel.

While the Centers for Disease Control and Prevention published voluntary guidance for managing food allergies in schools back in 2013, there has since “been a lack of universal policies and procedures to manage the risk of allergic reactions in schools,” explained Dr. Dantzer. “The new guidelines are a good first step of using available evidence and all the key stakeholders, clinicians, school personnel, and families to figure out the best way to keep children with food allergies safe at school.”

Dr. Dantzer wasn’t involved in the creation of the new practice guidelines, but she shared how her clinical experience reinforces the need for the evidence-based recommendations. “Every single week we talk with families, both in clinic and in our research studies, about living with food allergies, and we recognize that every child is different,” she said. “We constantly work to advocate for each individual child with food allergies.”

Pediatric allergist Malika Gupta, MBBS, MD, said in an interview via email that the guidelines could assist in the creation of new nationwide policies for food allergy management at schools. “Also, the guidelines are labeled ‘conditional,’ which gives policymakers the ability to adapt to their specific circumstances and individuals, as well as make modifications according to regional trends,” she added.

Dr. Gupta, a clinical assistant professor in the Division of Allergy and Clinical Immunology at the University of Michigan, Ann Arbor, echoed the guideline panel’s sentiments regarding food bans, explaining that prohibiting certain foods could lend a “false sense of security” and could also “promote bullying and a sense of isolation for the food-allergic child.” In spite of the lack of evidence supporting food bans, Dr. Gupta noted that these bans can give families a sense of control and security. Ideally, more research should be performed to determine whether food bans actually work, she added.

In addition to promoting the new guidelines, allergists and pediatricians can also implement proactive allergy reaction mitigation strategies that work with school systems, according to Dr. Gupta. “In-clinic, we ensure all families have food allergy action plans for school and current epinephrine auto-injectors,” she said. “We also often have our food allergy nurses educate schools when food allergy awareness is a concern.”

Many of the 25 authors of the food allergy guidelines disclosed relevant financial relationships. The full list is with the original article. According to a footnote within the guidelines, “Panel members who were deemed to have a real, perceived, or potential conflict of interest were asked to abstain from voting on recommendations related to that interest.”  

A version of this article first appeared on Medscape.com.

Children with food allergies often require diligent monitoring and a restricted diet to reduce allergic attacks, but there is little evidence available to support so-called “food bans” at schools and childcare centers.

Instead, a new practice guideline published earlier this month in the Journal of Allergy and Clinical Immunology calls for better allergy management training for staff, as well as increased epinephrine availability in educational environments. The guidelines were developed by an international panel of clinicians, school personnel, and parents.
 

The guidance at a glance

Rather than creating site-wide food prohibitions on nuts, dairy, and other allergenic foods, the practice guidance recommends centers and schools use “common-sense approaches” to reduce allergic reaction risk among school-aged children. According to the guideline authors, these strategies could include promoting handwashing, providing adult supervision during snacks and meals, and cleaning surfaces where food is either eaten or prepared.

Additionally, the new evidence-based guidance calls for schools and childcare centers to teach school personnel to recognize, prevent, and respond appropriately to food-related allergic reactions when they do occur.

The guidance also recommends that educational institutions require an up-to-date allergy ‘action plan’ from parents, designed for their children with allergies. These action plans can be integrated into the training of teachers and nurses to help manage potential allergic reactions.

Moreover, the guidance suggests schools should keep unassigned epinephrine autoinjectors in stock, both on site and even when traveling, where laws permit, rather than requiring students with allergies to bring in their own autoinjectors. Ultimately, this represents a more proactive approach to treating anaphylaxis, particularly in settings where treatment is urgently needed, such as when students are away from campus and participating in a school-designated trip or event.
 

Expert perspectives

Jennifer A. Dantzer, MD, MHS, allergist-immunologist and assistant professor of pediatrics at Johns Hopkins University, Baltimore, told this news organization via email that the practice guidelines offer an important starting point for ensuring quality of life of students, parents, and other school personnel.

While the Centers for Disease Control and Prevention published voluntary guidance for managing food allergies in schools back in 2013, there has since “been a lack of universal policies and procedures to manage the risk of allergic reactions in schools,” explained Dr. Dantzer. “The new guidelines are a good first step of using available evidence and all the key stakeholders, clinicians, school personnel, and families to figure out the best way to keep children with food allergies safe at school.”

Dr. Dantzer wasn’t involved in the creation of the new practice guidelines, but she shared how her clinical experience reinforces the need for the evidence-based recommendations. “Every single week we talk with families, both in clinic and in our research studies, about living with food allergies, and we recognize that every child is different,” she said. “We constantly work to advocate for each individual child with food allergies.”

Pediatric allergist Malika Gupta, MBBS, MD, said in an interview via email that the guidelines could assist in the creation of new nationwide policies for food allergy management at schools. “Also, the guidelines are labeled ‘conditional,’ which gives policymakers the ability to adapt to their specific circumstances and individuals, as well as make modifications according to regional trends,” she added.

Dr. Gupta, a clinical assistant professor in the Division of Allergy and Clinical Immunology at the University of Michigan, Ann Arbor, echoed the guideline panel’s sentiments regarding food bans, explaining that prohibiting certain foods could lend a “false sense of security” and could also “promote bullying and a sense of isolation for the food-allergic child.” In spite of the lack of evidence supporting food bans, Dr. Gupta noted that these bans can give families a sense of control and security. Ideally, more research should be performed to determine whether food bans actually work, she added.

In addition to promoting the new guidelines, allergists and pediatricians can also implement proactive allergy reaction mitigation strategies that work with school systems, according to Dr. Gupta. “In-clinic, we ensure all families have food allergy action plans for school and current epinephrine auto-injectors,” she said. “We also often have our food allergy nurses educate schools when food allergy awareness is a concern.”

Many of the 25 authors of the food allergy guidelines disclosed relevant financial relationships. The full list is with the original article. According to a footnote within the guidelines, “Panel members who were deemed to have a real, perceived, or potential conflict of interest were asked to abstain from voting on recommendations related to that interest.”  

A version of this article first appeared on Medscape.com.

With nearly half of all Americans having received at least one dose of a COVID-19 vaccine, the youngest eligible group is beginning to overcome its late start, according to data from the Centers for Disease Control and Prevention.

As of May 24, 49.4% of the U.S. population – that’s almost 164 million people – has received at least one dose of vaccine. The corresponding figure for children aged 12-15 years is 14.4%, but that’s up from only 0.6% just 3 weeks before. Among children aged 16-17, who’ve been getting vaccinated since early April in some states, the proportion receiving at least one dose went from 24.9% to 33.9% over those same 3 weeks, the CDC said on its COVID Data Tracker site.

The comparatively rapid increase among the younger group of eligible children can be seen over the last 14 days. The 12- to 15-year-old group represents 21.3% of all the vaccines initiated in the 2-week period ending May 24, compared with 4.2% for those aged 16-17, the CDC data show. To put that into perspective, only those aged 25-39 years were higher at 21.9%, while 18-24 (12.1%), 40-49 (13.4%), 50-64 (18.2%), 65-74 (5.3%), and ≥75 (2.9%) were all lower.

The 12- to 15-year-olds are further behind when it comes to full vaccination status, however, with just 0.6% having received both doses of a two-dose vaccine or one dose of the single-shot variety, compared with 21.6% for those aged 16-17 years. Children aged 12-15 make up 5% of the total U.S. population but just 0.1% of all those who have been fully vaccinated versus 2.5% and 1.4%, respectively, for those aged 16-17, the CDC reported.

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With nearly half of all Americans having received at least one dose of a COVID-19 vaccine, the youngest eligible group is beginning to overcome its late start, according to data from the Centers for Disease Control and Prevention.

As of May 24, 49.4% of the U.S. population – that’s almost 164 million people – has received at least one dose of vaccine. The corresponding figure for children aged 12-15 years is 14.4%, but that’s up from only 0.6% just 3 weeks before. Among children aged 16-17, who’ve been getting vaccinated since early April in some states, the proportion receiving at least one dose went from 24.9% to 33.9% over those same 3 weeks, the CDC said on its COVID Data Tracker site.

The comparatively rapid increase among the younger group of eligible children can be seen over the last 14 days. The 12- to 15-year-old group represents 21.3% of all the vaccines initiated in the 2-week period ending May 24, compared with 4.2% for those aged 16-17, the CDC data show. To put that into perspective, only those aged 25-39 years were higher at 21.9%, while 18-24 (12.1%), 40-49 (13.4%), 50-64 (18.2%), 65-74 (5.3%), and ≥75 (2.9%) were all lower.

The 12- to 15-year-olds are further behind when it comes to full vaccination status, however, with just 0.6% having received both doses of a two-dose vaccine or one dose of the single-shot variety, compared with 21.6% for those aged 16-17 years. Children aged 12-15 make up 5% of the total U.S. population but just 0.1% of all those who have been fully vaccinated versus 2.5% and 1.4%, respectively, for those aged 16-17, the CDC reported.

[email protected]

With nearly half of all Americans having received at least one dose of a COVID-19 vaccine, the youngest eligible group is beginning to overcome its late start, according to data from the Centers for Disease Control and Prevention.

As of May 24, 49.4% of the U.S. population – that’s almost 164 million people – has received at least one dose of vaccine. The corresponding figure for children aged 12-15 years is 14.4%, but that’s up from only 0.6% just 3 weeks before. Among children aged 16-17, who’ve been getting vaccinated since early April in some states, the proportion receiving at least one dose went from 24.9% to 33.9% over those same 3 weeks, the CDC said on its COVID Data Tracker site.

The comparatively rapid increase among the younger group of eligible children can be seen over the last 14 days. The 12- to 15-year-old group represents 21.3% of all the vaccines initiated in the 2-week period ending May 24, compared with 4.2% for those aged 16-17, the CDC data show. To put that into perspective, only those aged 25-39 years were higher at 21.9%, while 18-24 (12.1%), 40-49 (13.4%), 50-64 (18.2%), 65-74 (5.3%), and ≥75 (2.9%) were all lower.

The 12- to 15-year-olds are further behind when it comes to full vaccination status, however, with just 0.6% having received both doses of a two-dose vaccine or one dose of the single-shot variety, compared with 21.6% for those aged 16-17 years. Children aged 12-15 make up 5% of the total U.S. population but just 0.1% of all those who have been fully vaccinated versus 2.5% and 1.4%, respectively, for those aged 16-17, the CDC reported.

[email protected]