A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

Chronic pain is a common condition among people with hemophilia and is associated with joint deterioration because of repeated joint bleeds. This systematic review and meta-analysis aimed to determine the prevalence of chronic pain because of hemophilia and to analyze its interference in the lives of patients, according to Ana Cristina Paredes, a PhD student at the University of Minho, Braga, Portugal, and colleagues.

Crystal/Wikimedia Commons/Creative Commons Attribution 2.0

The manuscripts included in the study, which was published online in the Journal of Pain, were mostly observational, cross-sectional studies and one prospective investigation, published between 2009 and 2019.

The issue of pain is particularly important among people with hemophilia, as many adult patients suffer from distinct degrees of arthropathy and associated chronic pain, due to the lifelong occurrence of hemarthrosis, the authors noted. In an important distinction, according to the authors, people with hemophilia may therefore experience both acute pain during bleeds and chronic pain caused by joint deterioration. Acute pain ceases with the resolution of the bleeding episode, but the chronic pain is significantly more challenging, since it persists in time and may trigger changes in the nervous system, leading to peripheral or central sensitization.

Data in the assessed studies were collected from a variety of sources: hemophilia centers, online surveys, by mail, or through a national database, with return rates ranging from 29.2% to 98%. Overall, these studies comprised 4,772 adults, with individual sample sizes ranging from 21 to 2,253 patients, the authors added.
 

Conflicting results

Overall, there was a widely varying prevalence of hemophilia-related chronic pain reported across studies. Additionally, methodologies and sample characteristics varied widely. The meta-analyses revealed high heterogeneity between studies, and, therefore, pooled prevalence estimates values must be interpreted with caution, the authors stated.

All of the 11 selected studies included for meta-analysis and review reported on the prevalence of chronic pain caused by hemophilia. Chronic pain was assessed using direct questions developed by the authors in eight studies and using the European Haemophilia Therapy Standardization Board definition in three studies. The prevalence for global samples ranged widely from 17% to 84%.

Although there was high heterogeneity, the random-effects meta-analysis including all studies demonstrated a pooled prevalence of 46% of patients reporting chronic pain. Subgroup analyses of studies including all disease severities (mild, moderate, and severe; seven studies) revealed a pooled prevalence of 48%, but also with high heterogeneity. Looking at severe patients only (six studies), the chronic pain prevalence ranged from 33% to 86.4%, with a pooled prevalence of 53% and high heterogeneity, the authors added.

The wide disparity of the chronic pain prevalence seen across the studies is likely because of the fact that some investigations inquired about pain without distinguishing between acute (hemarthrosis-related) or chronic (arthropathy-related) pain, and without clarifying if the only focus is pain caused by hemophilia, or including all causes of pain complaints, according to the researchers.

“Concerning hemophilia-related chronic pain interference, it is striking that the existing literature does not distinguish between the impact of acute or chronic pain. Such a distinction is needed and should be made in future studies to ensure accurate accounts of hemophilia-related pain and to fully understand its interference according to the type of pain (acute vs. chronic). This information is relevant to promote targeted and effective treatment approaches,” the researchers concluded.

The research was supported by a Novo Nordisk HERO Research Grant 2015, the Portuguese Foundation for Science and Technology, and the Foundation for Science and Technology in Portugal. The authors declared they had no conflicts of interest.

[email protected]

Chronic pain is a common condition among people with hemophilia and is associated with joint deterioration because of repeated joint bleeds. This systematic review and meta-analysis aimed to determine the prevalence of chronic pain because of hemophilia and to analyze its interference in the lives of patients, according to Ana Cristina Paredes, a PhD student at the University of Minho, Braga, Portugal, and colleagues.

Crystal/Wikimedia Commons/Creative Commons Attribution 2.0

The manuscripts included in the study, which was published online in the Journal of Pain, were mostly observational, cross-sectional studies and one prospective investigation, published between 2009 and 2019.

The issue of pain is particularly important among people with hemophilia, as many adult patients suffer from distinct degrees of arthropathy and associated chronic pain, due to the lifelong occurrence of hemarthrosis, the authors noted. In an important distinction, according to the authors, people with hemophilia may therefore experience both acute pain during bleeds and chronic pain caused by joint deterioration. Acute pain ceases with the resolution of the bleeding episode, but the chronic pain is significantly more challenging, since it persists in time and may trigger changes in the nervous system, leading to peripheral or central sensitization.

Data in the assessed studies were collected from a variety of sources: hemophilia centers, online surveys, by mail, or through a national database, with return rates ranging from 29.2% to 98%. Overall, these studies comprised 4,772 adults, with individual sample sizes ranging from 21 to 2,253 patients, the authors added.
 

Conflicting results

Overall, there was a widely varying prevalence of hemophilia-related chronic pain reported across studies. Additionally, methodologies and sample characteristics varied widely. The meta-analyses revealed high heterogeneity between studies, and, therefore, pooled prevalence estimates values must be interpreted with caution, the authors stated.

All of the 11 selected studies included for meta-analysis and review reported on the prevalence of chronic pain caused by hemophilia. Chronic pain was assessed using direct questions developed by the authors in eight studies and using the European Haemophilia Therapy Standardization Board definition in three studies. The prevalence for global samples ranged widely from 17% to 84%.

Although there was high heterogeneity, the random-effects meta-analysis including all studies demonstrated a pooled prevalence of 46% of patients reporting chronic pain. Subgroup analyses of studies including all disease severities (mild, moderate, and severe; seven studies) revealed a pooled prevalence of 48%, but also with high heterogeneity. Looking at severe patients only (six studies), the chronic pain prevalence ranged from 33% to 86.4%, with a pooled prevalence of 53% and high heterogeneity, the authors added.

The wide disparity of the chronic pain prevalence seen across the studies is likely because of the fact that some investigations inquired about pain without distinguishing between acute (hemarthrosis-related) or chronic (arthropathy-related) pain, and without clarifying if the only focus is pain caused by hemophilia, or including all causes of pain complaints, according to the researchers.

“Concerning hemophilia-related chronic pain interference, it is striking that the existing literature does not distinguish between the impact of acute or chronic pain. Such a distinction is needed and should be made in future studies to ensure accurate accounts of hemophilia-related pain and to fully understand its interference according to the type of pain (acute vs. chronic). This information is relevant to promote targeted and effective treatment approaches,” the researchers concluded.

The research was supported by a Novo Nordisk HERO Research Grant 2015, the Portuguese Foundation for Science and Technology, and the Foundation for Science and Technology in Portugal. The authors declared they had no conflicts of interest.

[email protected]

Chronic pain is a common condition among people with hemophilia and is associated with joint deterioration because of repeated joint bleeds. This systematic review and meta-analysis aimed to determine the prevalence of chronic pain because of hemophilia and to analyze its interference in the lives of patients, according to Ana Cristina Paredes, a PhD student at the University of Minho, Braga, Portugal, and colleagues.

Crystal/Wikimedia Commons/Creative Commons Attribution 2.0

The manuscripts included in the study, which was published online in the Journal of Pain, were mostly observational, cross-sectional studies and one prospective investigation, published between 2009 and 2019.

The issue of pain is particularly important among people with hemophilia, as many adult patients suffer from distinct degrees of arthropathy and associated chronic pain, due to the lifelong occurrence of hemarthrosis, the authors noted. In an important distinction, according to the authors, people with hemophilia may therefore experience both acute pain during bleeds and chronic pain caused by joint deterioration. Acute pain ceases with the resolution of the bleeding episode, but the chronic pain is significantly more challenging, since it persists in time and may trigger changes in the nervous system, leading to peripheral or central sensitization.

Data in the assessed studies were collected from a variety of sources: hemophilia centers, online surveys, by mail, or through a national database, with return rates ranging from 29.2% to 98%. Overall, these studies comprised 4,772 adults, with individual sample sizes ranging from 21 to 2,253 patients, the authors added.
 

Conflicting results

Overall, there was a widely varying prevalence of hemophilia-related chronic pain reported across studies. Additionally, methodologies and sample characteristics varied widely. The meta-analyses revealed high heterogeneity between studies, and, therefore, pooled prevalence estimates values must be interpreted with caution, the authors stated.

All of the 11 selected studies included for meta-analysis and review reported on the prevalence of chronic pain caused by hemophilia. Chronic pain was assessed using direct questions developed by the authors in eight studies and using the European Haemophilia Therapy Standardization Board definition in three studies. The prevalence for global samples ranged widely from 17% to 84%.

Although there was high heterogeneity, the random-effects meta-analysis including all studies demonstrated a pooled prevalence of 46% of patients reporting chronic pain. Subgroup analyses of studies including all disease severities (mild, moderate, and severe; seven studies) revealed a pooled prevalence of 48%, but also with high heterogeneity. Looking at severe patients only (six studies), the chronic pain prevalence ranged from 33% to 86.4%, with a pooled prevalence of 53% and high heterogeneity, the authors added.

The wide disparity of the chronic pain prevalence seen across the studies is likely because of the fact that some investigations inquired about pain without distinguishing between acute (hemarthrosis-related) or chronic (arthropathy-related) pain, and without clarifying if the only focus is pain caused by hemophilia, or including all causes of pain complaints, according to the researchers.

“Concerning hemophilia-related chronic pain interference, it is striking that the existing literature does not distinguish between the impact of acute or chronic pain. Such a distinction is needed and should be made in future studies to ensure accurate accounts of hemophilia-related pain and to fully understand its interference according to the type of pain (acute vs. chronic). This information is relevant to promote targeted and effective treatment approaches,” the researchers concluded.

The research was supported by a Novo Nordisk HERO Research Grant 2015, the Portuguese Foundation for Science and Technology, and the Foundation for Science and Technology in Portugal. The authors declared they had no conflicts of interest.

[email protected]

One of the top stories in the local newspaper recently described an unfortunate incident in which a previously healthy 19-month-old baby was found unresponsive and apneic in a crib at her day-care center. She was successfully resuscitated by the daycare provider but is now blind, has seizures, and no longer walks or talks. According to the day care owner, the child had not settled down during rest time and her talking was preventing the other children from sleeping. This apparently had happened before and the day-care provider had successfully resorted to triple wrapping the child in a blanket and placing her in a crib in a separate room. The day-care provider had checked on the child once and noted she was snoring. When the child failed to wake after the expected interval of time she was found face down with her head partially covered by a pillow.

An investigation of the day-care center is ongoing and no reports or prior violations, warnings, or license suspensions have surfaced at this point. The day-care provider has been charged with aggravated assault and endangering the welfare of a child. The charges could carry a prison sentence of 30 years.

As I reread this very sad story I began wondering how this tragedy is going to unfold in the next months and years. We can assume one young life has already been permanently damaged. Her family will have to deal with the consequences of this event for decades or longer. What about the day-care provider? I hope we can assume that she intended no harm to the child nor had she ignored prior warnings or training about swaddling. Nor does this lapse in judgment fit a previous pattern of behavior. Regardless of what the courts decide she will carry some degree of guilt for the foreseeable future. The day-care center has been closed voluntarily and given that Maine is a small state where word travels fast it is unlikely that it will ever reopen.

Can we imagine any good coming out of this tragedy? It may be that with luck and diligent therapies that the little girl will be able to lead a life she finds rewarding and gives others some pleasure. It is possible that some individuals involved in her life – her parents or therapists – will find the devotion to her care brings new meaning to their lives.

Will the day-care provider find a new career or a cause that can help her restore some of the self worth she may have lost in the wake of the event? Or, will a protracted course through the legal system take its devastating toll on her life and marriage? It is unlikely that she will spend anywhere near 30 years in prison, if any at all. Will the child’s family sue this small family day-care center? It is hard to imagine they will recover anything more than a tiny fraction of the lifetime costs of this child’s care.

It is also unlikely that the message that swaddling children old enough to turn over carries a significant risk will go beyond one or two more stories in the local Maine newspapers. If this child’s father had been a professional football player or her mother had been an actress or U.S. Senator this tragic turn of events could possibly have stirred enough waters to grab national attention, spawn a foundation, or even result in legislation. But, she appears to come from a family with modest means without claims to notoriety. There is no flawed product to ban. She is a victim of ignorance and our failure to educate. As a result, her tragedy and those of thousands of other children will do little more than accumulate as unfortunate statistics.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

One of the top stories in the local newspaper recently described an unfortunate incident in which a previously healthy 19-month-old baby was found unresponsive and apneic in a crib at her day-care center. She was successfully resuscitated by the daycare provider but is now blind, has seizures, and no longer walks or talks. According to the day care owner, the child had not settled down during rest time and her talking was preventing the other children from sleeping. This apparently had happened before and the day-care provider had successfully resorted to triple wrapping the child in a blanket and placing her in a crib in a separate room. The day-care provider had checked on the child once and noted she was snoring. When the child failed to wake after the expected interval of time she was found face down with her head partially covered by a pillow.

An investigation of the day-care center is ongoing and no reports or prior violations, warnings, or license suspensions have surfaced at this point. The day-care provider has been charged with aggravated assault and endangering the welfare of a child. The charges could carry a prison sentence of 30 years.

As I reread this very sad story I began wondering how this tragedy is going to unfold in the next months and years. We can assume one young life has already been permanently damaged. Her family will have to deal with the consequences of this event for decades or longer. What about the day-care provider? I hope we can assume that she intended no harm to the child nor had she ignored prior warnings or training about swaddling. Nor does this lapse in judgment fit a previous pattern of behavior. Regardless of what the courts decide she will carry some degree of guilt for the foreseeable future. The day-care center has been closed voluntarily and given that Maine is a small state where word travels fast it is unlikely that it will ever reopen.

Can we imagine any good coming out of this tragedy? It may be that with luck and diligent therapies that the little girl will be able to lead a life she finds rewarding and gives others some pleasure. It is possible that some individuals involved in her life – her parents or therapists – will find the devotion to her care brings new meaning to their lives.

Will the day-care provider find a new career or a cause that can help her restore some of the self worth she may have lost in the wake of the event? Or, will a protracted course through the legal system take its devastating toll on her life and marriage? It is unlikely that she will spend anywhere near 30 years in prison, if any at all. Will the child’s family sue this small family day-care center? It is hard to imagine they will recover anything more than a tiny fraction of the lifetime costs of this child’s care.

It is also unlikely that the message that swaddling children old enough to turn over carries a significant risk will go beyond one or two more stories in the local Maine newspapers. If this child’s father had been a professional football player or her mother had been an actress or U.S. Senator this tragic turn of events could possibly have stirred enough waters to grab national attention, spawn a foundation, or even result in legislation. But, she appears to come from a family with modest means without claims to notoriety. There is no flawed product to ban. She is a victim of ignorance and our failure to educate. As a result, her tragedy and those of thousands of other children will do little more than accumulate as unfortunate statistics.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

One of the top stories in the local newspaper recently described an unfortunate incident in which a previously healthy 19-month-old baby was found unresponsive and apneic in a crib at her day-care center. She was successfully resuscitated by the daycare provider but is now blind, has seizures, and no longer walks or talks. According to the day care owner, the child had not settled down during rest time and her talking was preventing the other children from sleeping. This apparently had happened before and the day-care provider had successfully resorted to triple wrapping the child in a blanket and placing her in a crib in a separate room. The day-care provider had checked on the child once and noted she was snoring. When the child failed to wake after the expected interval of time she was found face down with her head partially covered by a pillow.

An investigation of the day-care center is ongoing and no reports or prior violations, warnings, or license suspensions have surfaced at this point. The day-care provider has been charged with aggravated assault and endangering the welfare of a child. The charges could carry a prison sentence of 30 years.

As I reread this very sad story I began wondering how this tragedy is going to unfold in the next months and years. We can assume one young life has already been permanently damaged. Her family will have to deal with the consequences of this event for decades or longer. What about the day-care provider? I hope we can assume that she intended no harm to the child nor had she ignored prior warnings or training about swaddling. Nor does this lapse in judgment fit a previous pattern of behavior. Regardless of what the courts decide she will carry some degree of guilt for the foreseeable future. The day-care center has been closed voluntarily and given that Maine is a small state where word travels fast it is unlikely that it will ever reopen.

Can we imagine any good coming out of this tragedy? It may be that with luck and diligent therapies that the little girl will be able to lead a life she finds rewarding and gives others some pleasure. It is possible that some individuals involved in her life – her parents or therapists – will find the devotion to her care brings new meaning to their lives.

Will the day-care provider find a new career or a cause that can help her restore some of the self worth she may have lost in the wake of the event? Or, will a protracted course through the legal system take its devastating toll on her life and marriage? It is unlikely that she will spend anywhere near 30 years in prison, if any at all. Will the child’s family sue this small family day-care center? It is hard to imagine they will recover anything more than a tiny fraction of the lifetime costs of this child’s care.

It is also unlikely that the message that swaddling children old enough to turn over carries a significant risk will go beyond one or two more stories in the local Maine newspapers. If this child’s father had been a professional football player or her mother had been an actress or U.S. Senator this tragic turn of events could possibly have stirred enough waters to grab national attention, spawn a foundation, or even result in legislation. But, she appears to come from a family with modest means without claims to notoriety. There is no flawed product to ban. She is a victim of ignorance and our failure to educate. As a result, her tragedy and those of thousands of other children will do little more than accumulate as unfortunate statistics.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Whether they realize it or not, hospitalists treating patients during the COVID-19 pandemic have been in a combat-like situation, with challenges and stresses similar to those faced by soldiers in a war zone.

And now, as the pandemic shows signs of subsiding, they’re about to emerge from this fight, which poses a whole new set of challenges, according a retired U.S. Army general who spoke May 4 at SHM Converge, the annual conference of the Society of Hospital Medicine.

Lt. Gen. (Ret.) Mark Hertling, DBA, said during his keynote speech that clinicians and soldiers – the only two professions that routinely have to navigate through life and death situations – must lead during all phases of combat.

“This is a period where you’re going to experience some things that you may or may not be ready for,” he said. “These are the same kind of issues soldiers face when redeploying from a combat zone.”

To help draw the comparison between hospitalists during the COVID-19 era and troops during a war, Lt. Gen. Hertling showed a photo of a U.S. paratrooper who’d just dropped into northern Iraq, carrying a backpack engorged with gear. He was on one knee with his face downcast as he seemed to be taking a moment to reflect on the enormity, complexity, and danger of the crisis into which he was about to plunge. He was, Lt. Gen. Hertling said, likely pondering the mission, his family he left behind, and concerns about making mistakes in front of his comrades.

Then he showed a picture of a health care worker in a hospital corridor slumped on the floor with his or her back against the wall, knees up, and hands loosely clasped, looking exhausted and dazed. Health care workers also have carried a load that has seemed unbearable.

“You can certainly see that they are experiencing an emotional trauma at the very start of the pandemic,” he said. “The things you have carried over the last year-plus as the pandemic has raged will be with you in good and sometimes bad ways, and you need to address those things.”

Lt. Gen. Hertling described several issues – mirroring those seen in combat – that clinicians will take away from the COVID-19 experience and must grapple with as the closing chapters of the pandemic play out:
 

A sense of teamwork in a crisis

While it’s not unusual, he said, for physicians not to get along well with administrators, and for nurses sometimes not to trust doctors, the COVID-19 crisis created a sense of effective teamwork.

“They have built trust because they see a common mission and a common requirement,” he said.
 

A sense of loss

“You have lost patients, you probably have lost comrades, and some of you are having this associated survivor’s guilt – why did you survive and so many of your patients, perhaps a lot of your friends, did not?”

At memorial services for fallen soldiers, Lt. Gen. Hertling would bring a laminated card with the soldier’s picture and put it in a box with the words “Make It Matter” on it.

“That was our code for ensuring that every one of these individual soldiers who sacrificed their lives for the organization, we would carry on their legacy and make their sacrifice matter,” he said. “That’s one of the few ways you can overcome survivor’s guilt.”
 

Sense of accomplishment

Lt. Gen. Hertling said hospitalists, pushed to the extreme, were able to do things they never thought they were capable of.

“You have to relish in that, and you have to write those things down so you can go back and think about the things you did in a crisis environment to help,” he said.

In the post-pandemic era, health care workers should reflect on what they have seen, learned, and experienced, to help set a new standard and to establish ways to eliminate “bureaucratic morasses,” which seemed more possible than ever because the urgency of the moment demanded it.

Lt. Gen. Hertling also said hospitalists should take time to make a plan to handle personal, professional, team, and organizational requirements. For instance, health care workers should get a physical to take stock of how their bodies reacted to the stress of the pandemic. He said they should also recognize the difference between posttraumatic stress, which is to be expected, and posttraumatic stress disorder (PTSD), which is less common.

“It’s only at the extreme that it becomes a dysfunction and you have to address it with the help of others,” he said. Hospitalists should examine the state of their emotional and spiritual relationships – with family and friends as well as with God or other figures important to them spiritually.

Professionally, hospitalists should review professional accomplishments and shortcomings and make changes based on those assessments, he said. It’s also a good time to assess leadership issues – recall who the contributors were and who could have done more. Hospitalists should also consider contributing post-pandemic articles to the Journal of Hospital Medicine, he said.

Lt. Gen. Hertling concluded by suggesting that hospitalists seek feedback on themselves and their own leadership qualities, from their team members.

“Really press the issue,” he said, “and get a good critique on how you can improve personally and professionally in terms of your leadership approach.”

Whether they realize it or not, hospitalists treating patients during the COVID-19 pandemic have been in a combat-like situation, with challenges and stresses similar to those faced by soldiers in a war zone.

And now, as the pandemic shows signs of subsiding, they’re about to emerge from this fight, which poses a whole new set of challenges, according a retired U.S. Army general who spoke May 4 at SHM Converge, the annual conference of the Society of Hospital Medicine.

Lt. Gen. (Ret.) Mark Hertling, DBA, said during his keynote speech that clinicians and soldiers – the only two professions that routinely have to navigate through life and death situations – must lead during all phases of combat.

“This is a period where you’re going to experience some things that you may or may not be ready for,” he said. “These are the same kind of issues soldiers face when redeploying from a combat zone.”

To help draw the comparison between hospitalists during the COVID-19 era and troops during a war, Lt. Gen. Hertling showed a photo of a U.S. paratrooper who’d just dropped into northern Iraq, carrying a backpack engorged with gear. He was on one knee with his face downcast as he seemed to be taking a moment to reflect on the enormity, complexity, and danger of the crisis into which he was about to plunge. He was, Lt. Gen. Hertling said, likely pondering the mission, his family he left behind, and concerns about making mistakes in front of his comrades.

Then he showed a picture of a health care worker in a hospital corridor slumped on the floor with his or her back against the wall, knees up, and hands loosely clasped, looking exhausted and dazed. Health care workers also have carried a load that has seemed unbearable.

“You can certainly see that they are experiencing an emotional trauma at the very start of the pandemic,” he said. “The things you have carried over the last year-plus as the pandemic has raged will be with you in good and sometimes bad ways, and you need to address those things.”

Lt. Gen. Hertling described several issues – mirroring those seen in combat – that clinicians will take away from the COVID-19 experience and must grapple with as the closing chapters of the pandemic play out:
 

A sense of teamwork in a crisis

While it’s not unusual, he said, for physicians not to get along well with administrators, and for nurses sometimes not to trust doctors, the COVID-19 crisis created a sense of effective teamwork.

“They have built trust because they see a common mission and a common requirement,” he said.
 

A sense of loss

“You have lost patients, you probably have lost comrades, and some of you are having this associated survivor’s guilt – why did you survive and so many of your patients, perhaps a lot of your friends, did not?”

At memorial services for fallen soldiers, Lt. Gen. Hertling would bring a laminated card with the soldier’s picture and put it in a box with the words “Make It Matter” on it.

“That was our code for ensuring that every one of these individual soldiers who sacrificed their lives for the organization, we would carry on their legacy and make their sacrifice matter,” he said. “That’s one of the few ways you can overcome survivor’s guilt.”
 

Sense of accomplishment

Lt. Gen. Hertling said hospitalists, pushed to the extreme, were able to do things they never thought they were capable of.

“You have to relish in that, and you have to write those things down so you can go back and think about the things you did in a crisis environment to help,” he said.

In the post-pandemic era, health care workers should reflect on what they have seen, learned, and experienced, to help set a new standard and to establish ways to eliminate “bureaucratic morasses,” which seemed more possible than ever because the urgency of the moment demanded it.

Lt. Gen. Hertling also said hospitalists should take time to make a plan to handle personal, professional, team, and organizational requirements. For instance, health care workers should get a physical to take stock of how their bodies reacted to the stress of the pandemic. He said they should also recognize the difference between posttraumatic stress, which is to be expected, and posttraumatic stress disorder (PTSD), which is less common.

“It’s only at the extreme that it becomes a dysfunction and you have to address it with the help of others,” he said. Hospitalists should examine the state of their emotional and spiritual relationships – with family and friends as well as with God or other figures important to them spiritually.

Professionally, hospitalists should review professional accomplishments and shortcomings and make changes based on those assessments, he said. It’s also a good time to assess leadership issues – recall who the contributors were and who could have done more. Hospitalists should also consider contributing post-pandemic articles to the Journal of Hospital Medicine, he said.

Lt. Gen. Hertling concluded by suggesting that hospitalists seek feedback on themselves and their own leadership qualities, from their team members.

“Really press the issue,” he said, “and get a good critique on how you can improve personally and professionally in terms of your leadership approach.”

Whether they realize it or not, hospitalists treating patients during the COVID-19 pandemic have been in a combat-like situation, with challenges and stresses similar to those faced by soldiers in a war zone.

And now, as the pandemic shows signs of subsiding, they’re about to emerge from this fight, which poses a whole new set of challenges, according a retired U.S. Army general who spoke May 4 at SHM Converge, the annual conference of the Society of Hospital Medicine.

Lt. Gen. (Ret.) Mark Hertling, DBA, said during his keynote speech that clinicians and soldiers – the only two professions that routinely have to navigate through life and death situations – must lead during all phases of combat.

“This is a period where you’re going to experience some things that you may or may not be ready for,” he said. “These are the same kind of issues soldiers face when redeploying from a combat zone.”

To help draw the comparison between hospitalists during the COVID-19 era and troops during a war, Lt. Gen. Hertling showed a photo of a U.S. paratrooper who’d just dropped into northern Iraq, carrying a backpack engorged with gear. He was on one knee with his face downcast as he seemed to be taking a moment to reflect on the enormity, complexity, and danger of the crisis into which he was about to plunge. He was, Lt. Gen. Hertling said, likely pondering the mission, his family he left behind, and concerns about making mistakes in front of his comrades.

Then he showed a picture of a health care worker in a hospital corridor slumped on the floor with his or her back against the wall, knees up, and hands loosely clasped, looking exhausted and dazed. Health care workers also have carried a load that has seemed unbearable.

“You can certainly see that they are experiencing an emotional trauma at the very start of the pandemic,” he said. “The things you have carried over the last year-plus as the pandemic has raged will be with you in good and sometimes bad ways, and you need to address those things.”

Lt. Gen. Hertling described several issues – mirroring those seen in combat – that clinicians will take away from the COVID-19 experience and must grapple with as the closing chapters of the pandemic play out:
 

A sense of teamwork in a crisis

While it’s not unusual, he said, for physicians not to get along well with administrators, and for nurses sometimes not to trust doctors, the COVID-19 crisis created a sense of effective teamwork.

“They have built trust because they see a common mission and a common requirement,” he said.
 

A sense of loss

“You have lost patients, you probably have lost comrades, and some of you are having this associated survivor’s guilt – why did you survive and so many of your patients, perhaps a lot of your friends, did not?”

At memorial services for fallen soldiers, Lt. Gen. Hertling would bring a laminated card with the soldier’s picture and put it in a box with the words “Make It Matter” on it.

“That was our code for ensuring that every one of these individual soldiers who sacrificed their lives for the organization, we would carry on their legacy and make their sacrifice matter,” he said. “That’s one of the few ways you can overcome survivor’s guilt.”
 

Sense of accomplishment

Lt. Gen. Hertling said hospitalists, pushed to the extreme, were able to do things they never thought they were capable of.

“You have to relish in that, and you have to write those things down so you can go back and think about the things you did in a crisis environment to help,” he said.

In the post-pandemic era, health care workers should reflect on what they have seen, learned, and experienced, to help set a new standard and to establish ways to eliminate “bureaucratic morasses,” which seemed more possible than ever because the urgency of the moment demanded it.

Lt. Gen. Hertling also said hospitalists should take time to make a plan to handle personal, professional, team, and organizational requirements. For instance, health care workers should get a physical to take stock of how their bodies reacted to the stress of the pandemic. He said they should also recognize the difference between posttraumatic stress, which is to be expected, and posttraumatic stress disorder (PTSD), which is less common.

“It’s only at the extreme that it becomes a dysfunction and you have to address it with the help of others,” he said. Hospitalists should examine the state of their emotional and spiritual relationships – with family and friends as well as with God or other figures important to them spiritually.

Professionally, hospitalists should review professional accomplishments and shortcomings and make changes based on those assessments, he said. It’s also a good time to assess leadership issues – recall who the contributors were and who could have done more. Hospitalists should also consider contributing post-pandemic articles to the Journal of Hospital Medicine, he said.

Lt. Gen. Hertling concluded by suggesting that hospitalists seek feedback on themselves and their own leadership qualities, from their team members.

“Really press the issue,” he said, “and get a good critique on how you can improve personally and professionally in terms of your leadership approach.”

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61.