MDedge Infectious Disease

Further details from multiple cases of myocarditis linked to the Pfizer and Moderna mRNA COVID vaccines have been described in recent papers in the medical literature.

The cases appear to occur almost exclusively in males and most often in younger age groups. While symptoms and signs of myocarditis mostly resolved with a few days of supportive care, long-term effects are unknown at present.

The authors of all the reports and of two accompanying editorials in JAMA Cardiology are unanimous in their opinion that the benefits of vaccination still outweigh the risks.  

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices met June 23 to discuss this issue. At that meeting, it was reported that 323 cases of myocarditis or pericarditis in individuals aged 29 years and younger have been confirmed, but committee members delivered a strong endorsement for continuing to vaccinate young people with the mRNA vaccines.

The current case reports are published in two papers in JAMA Cardiology and in three in Circulation.
 

U.S. military reports 23 cases

In one report in JAMA Cardiology, authors led by Jay Montgomery, MD, from Walter Reed National Military Medical Center in Bethesda, Md., described 23 cases from the U.S. Military Health System of individuals with acute myocarditis who presented within 4 days after mRNA-based COVID-19 vaccination (7 Pfizer and 16 Moderna).

All patients were male, 22 of 23 were on active duty, and the median age was 25 years (range, 20-51); 20 of the 23 cases occurred after receipt of a second dose of an mRNA COVID-19 vaccine.

The patients all presented with acute onset of marked chest pain. All patients had significantly elevated cardiac troponin levels. Among eight patients who underwent cardiac MRI (cMRI), all had findings consistent with the clinical diagnosis of myocarditis.

Additional testing did not identify other possible causes of myocarditis. All patients received brief supportive care and were recovered or recovering.

The authors reported that the military administered more than 2.8 million doses of mRNA COVID-19 vaccine in this period, and while the observed number of myocarditis cases was small, the number was “substantially higher” than expected among male military members after a second vaccine dose.

They noted that, based on historical data, among the 544,000 second doses to military members there may have been 0-10 expected myocarditis cases, but they observed 19 cases.  

“All patients in this series reflect substantial similarities in demographic characteristics, proximate vaccine dose, onset interval, and character of vaccine-associated myocarditis. The consistent pattern of clinical presentation, rapid recovery, and absence of evidence of other causes support the diagnosis of hypersensitivity myocarditis,” they stated.

They added that presentation after a second vaccine dose or, in three patients, when vaccination followed SARS-CoV-2 infection, suggests that prior exposure was relevant in the hypersensitivity response.

“The spectrum of clinical presentation and reliance on patients seeking health care and on health care professionals recognizing a rare vaccine-associated adverse event limits determination of the true incidence of this condition,” the authors wrote.

They stressed that recognition of vaccine-associated myocarditis is clinically important because diagnosis impacts management, recommendations for exercise, and monitoring for cardiomyopathy.

But the authors also acknowledged that it is important to frame concerns about potential vaccine-associated myocarditis within the context of the current pandemic.

“Infection with SARS-CoV-2 is a clear cause of serious cardiac injury in many patients. ... Prevalence of cardiac injury may be as high as 60% in seriously ill patients. Notably, nearly 1% of highly fit athletes with mild COVID-19 infection have evidence of myocarditis on cMRI,” they wrote.

“Given that COVID-19 vaccines are remarkably effective at preventing infection, any risk of rare adverse events following immunization must be carefully weighed against the very substantial benefit of vaccination,” they concluded.
 

Four cases at Duke

In the second paper in JAMA Cardiology, a group led by Han W. Kim, MD, reported four patients with acute myocarditis occurring within days of mRNA COVID-19 vaccination (two Pfizer and two Moderna) in patients treated at Duke University Medical Center, Durham, N.C. The hospital courses of the four patients with myocarditis following COVID-19 vaccination were uneventful, and they were discharged within 2-4 days.

The authors said that, although a causal relationship cannot be established, none of the patients had a viral prodrome or had coincident testing that revealed an alternative explanation.

They stated that these four patients represent the majority of patients with acute myocarditis identified in the past 3 months at their institution, and this led to the highest total number of patients with acute myocarditis, compared with the same 3-month period for the past 5 years. 

“Additionally, we identified only those patients with severe unremitting chest pain who sought medical attention. Those with mild or moderate chest pain might not seek medical attention, and it is possible that subclinical myocarditis may occur and could be detected by active surveillance, as has been described with smallpox vaccination,” they wrote.
 

Further case reports

In one of the papers in Circulation, a group led by Kathryn F. Larson, MD, from the Mayo Clinic in Rochester, Minn., described eight patients hospitalized with chest pain who were diagnosed with myocarditis within 2-4 days of receiving either the Pfizer or Moderna vaccine.

Two of the patients had previously been infected by SARS-CoV-2 without need for hospitalization. All individuals were otherwise healthy males between the ages of 21 and 56 years. All but one patient developed symptoms after their second dose, and the one patient who developed myocarditis after the first vaccine dose had previously been infected with SARS-CoV-2.  

Systemic symptoms began within 24 hours after vaccine administration in five of eight patients, with chest pain presenting between 48 and 96 hours later. Troponin values were elevated in all individuals and appeared to peak the day after admission, whereas none had eosinophilia.

Cardiac MRI revealed findings consistent with myocarditis in all patients. All patients had resolution of their chest pain and were discharged from the hospital in stable condition.

“The patients presented here demonstrated typical signs, symptoms, and diagnostic features of acute myocarditis. The temporal association between receiving an mRNA-based COVID-19 vaccine and the development of myocarditis is notable,” the authors said.  

They added that they would consider the use of corticosteroids in these patients but cautioned that this could reduce the specific immune response against SARS-COV-2 triggered by the vaccine. “Thus, the duration of corticosteroid administration should be limited to the resolution of the symptoms or ventricular arrhythmias or the recovery of the left ventricular ejection fraction.”

Pending publication of long-term outcome data after SARS-CoV-2 vaccine–related myocarditis, they suggest adherence to the current consensus recommendation to abstain from competitive sports for a period of 3-6 months with reevaluation prior to sports participation. 

In another of the Circulation papers, a group led by Carolyn M. Rosner, MSN,  presented a case series of seven patients hospitalized for acute myocarditis-like illness following COVID-19 vaccination, from two U.S. medical centers, in Falls Church, Va., and Dallas. All patients were males below the age of 40 years and of White or Hispanic race/ethnicity. Only one patient reported prior history of COVID-19 infection. Six patients received mRNA (Moderna or Pfizer) and one received the adenovirus (Johnson & Johnson) vaccine. All patients presented 3-7 days post vaccination with acute onset chest pain and biochemical evidence of myocardial injury.

Hospital length of stay was 3 days, and all patients’ symptoms resolved by hospital discharge.

And finally, the third paper in Circulation reported a detailed description of one patient – a 52-year-old, previously healthy male who presented with acute myocarditis 3 days after the administration of the second dose of Moderna’s COVID-19 vaccine. The symptoms resolved, and there was a gradual improvement in cMRI findings. Ischemic injury and other potential causes of acute myocardial injury were excluded, as were other potential infectious causes of myocarditis, and there was no evidence of systemic autoimmune disease.

“Clinicians should be aware that myocarditis may be present in patients exhibiting cardiac signs and symptoms 2-4 days after COVID-19 vaccination,” the authors said.

They added that additional surveillance of such adverse events post–COVID-19 vaccination will help identify subgroups at higher risk for this vaccine-related effect, and whether additional precautions are necessary.
 

‘Benefits outweigh risk’

In an accompanying editorial in JAMA Cardiology, three doctors from the CDC cite several other reports of myocarditis after mRNA COVID vaccination. These include a case report published in Pediatrics of seven male adolescents aged 14-19 years who presented with myocarditis or myopericarditis within 4 days after receipt of a second dose of the Pfizer vaccine.

But the editorialists noted that the most comprehensive data about the risk for myocarditis following immunization with mRNA vaccines comes from Israel.

The Israeli Ministry of Health recently posted data describing 121 myocarditis cases occurring within 30 days of a second dose of mRNA vaccine among 5,049,424 persons, suggesting a crude incidence rate of approximately 24 cases per million.

On the current case reports, the CDC doctors wrote: “The striking clinical similarities in the presentations of these patients, their recent vaccination with an mRNA-based COVID-19 vaccine, and the lack of any alternative etiologies for acute myocarditis suggest an association with immunization.”

They said that acute onset of chest pain 3-5 days after vaccine administration, usually after a second dose, is a typical feature of reported cases and suggests an immune-mediated mechanism.

But SARS-CoV-2 infection also causes cardiac injury which may result in severe outcomes, and based on currently available data, myocarditis following immunization with current mRNA-based vaccines is rare.

“At present, the benefits of immunization in preventing severe morbidity favors continued COVID-19 vaccination, particularly considering the increasing COVID-19 hospitalization rates among adolescents reported during spring 2021,” the editorialists stated.

But they added that many questions remain. These include whether modifications are needed to the vaccine schedule among persons with a history of possible or confirmed myocarditis after COVID vaccine, how should postvaccine myocarditis be managed, how often should follow-up assessments be performed, how might follow-up assessments affect recommendations to avoid vigorous physical activity following the diagnosis of myocarditis, and do all likely cases of acute myocarditis that appear to be uncomplicated require cardiac MRI for more definitive diagnosis?

“While the data needed to answer such questions are being collected, there is an opportunity for researchers with expertise in myocarditis to develop a comprehensive, national assessment of the natural history, pathogenesis, and treatment of acute myocarditis associated with receipt of mRNA-based COVID-19 vaccines,” they concluded.

In a second editorial in JAMA Cardiology, a group of editors from the journal acknowledged that publication of the current case reports may contribute to additional public concern regarding immunization. But they added that clinicians discussing immunization with patients should recognize that these case series suggest that the symptomatic events consistent with myocarditis are still very rare and appear to be self-limiting.

“Given the risks of COVID-19, including the risk of myocarditis from COVID-19 infection, the editors do not believe these case reports are sufficient to interrupt the march toward maximal vaccination against SARS-CoV-2 as expeditiously as possible,” they said.

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

Further details from multiple cases of myocarditis linked to the Pfizer and Moderna mRNA COVID vaccines have been described in recent papers in the medical literature.

The cases appear to occur almost exclusively in males and most often in younger age groups. While symptoms and signs of myocarditis mostly resolved with a few days of supportive care, long-term effects are unknown at present.

The authors of all the reports and of two accompanying editorials in JAMA Cardiology are unanimous in their opinion that the benefits of vaccination still outweigh the risks.  

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices met June 23 to discuss this issue. At that meeting, it was reported that 323 cases of myocarditis or pericarditis in individuals aged 29 years and younger have been confirmed, but committee members delivered a strong endorsement for continuing to vaccinate young people with the mRNA vaccines.

The current case reports are published in two papers in JAMA Cardiology and in three in Circulation.
 

U.S. military reports 23 cases

In one report in JAMA Cardiology, authors led by Jay Montgomery, MD, from Walter Reed National Military Medical Center in Bethesda, Md., described 23 cases from the U.S. Military Health System of individuals with acute myocarditis who presented within 4 days after mRNA-based COVID-19 vaccination (7 Pfizer and 16 Moderna).

All patients were male, 22 of 23 were on active duty, and the median age was 25 years (range, 20-51); 20 of the 23 cases occurred after receipt of a second dose of an mRNA COVID-19 vaccine.

The patients all presented with acute onset of marked chest pain. All patients had significantly elevated cardiac troponin levels. Among eight patients who underwent cardiac MRI (cMRI), all had findings consistent with the clinical diagnosis of myocarditis.

Additional testing did not identify other possible causes of myocarditis. All patients received brief supportive care and were recovered or recovering.

The authors reported that the military administered more than 2.8 million doses of mRNA COVID-19 vaccine in this period, and while the observed number of myocarditis cases was small, the number was “substantially higher” than expected among male military members after a second vaccine dose.

They noted that, based on historical data, among the 544,000 second doses to military members there may have been 0-10 expected myocarditis cases, but they observed 19 cases.  

“All patients in this series reflect substantial similarities in demographic characteristics, proximate vaccine dose, onset interval, and character of vaccine-associated myocarditis. The consistent pattern of clinical presentation, rapid recovery, and absence of evidence of other causes support the diagnosis of hypersensitivity myocarditis,” they stated.

They added that presentation after a second vaccine dose or, in three patients, when vaccination followed SARS-CoV-2 infection, suggests that prior exposure was relevant in the hypersensitivity response.

“The spectrum of clinical presentation and reliance on patients seeking health care and on health care professionals recognizing a rare vaccine-associated adverse event limits determination of the true incidence of this condition,” the authors wrote.

They stressed that recognition of vaccine-associated myocarditis is clinically important because diagnosis impacts management, recommendations for exercise, and monitoring for cardiomyopathy.

But the authors also acknowledged that it is important to frame concerns about potential vaccine-associated myocarditis within the context of the current pandemic.

“Infection with SARS-CoV-2 is a clear cause of serious cardiac injury in many patients. ... Prevalence of cardiac injury may be as high as 60% in seriously ill patients. Notably, nearly 1% of highly fit athletes with mild COVID-19 infection have evidence of myocarditis on cMRI,” they wrote.

“Given that COVID-19 vaccines are remarkably effective at preventing infection, any risk of rare adverse events following immunization must be carefully weighed against the very substantial benefit of vaccination,” they concluded.
 

Four cases at Duke

In the second paper in JAMA Cardiology, a group led by Han W. Kim, MD, reported four patients with acute myocarditis occurring within days of mRNA COVID-19 vaccination (two Pfizer and two Moderna) in patients treated at Duke University Medical Center, Durham, N.C. The hospital courses of the four patients with myocarditis following COVID-19 vaccination were uneventful, and they were discharged within 2-4 days.

The authors said that, although a causal relationship cannot be established, none of the patients had a viral prodrome or had coincident testing that revealed an alternative explanation.

They stated that these four patients represent the majority of patients with acute myocarditis identified in the past 3 months at their institution, and this led to the highest total number of patients with acute myocarditis, compared with the same 3-month period for the past 5 years. 

“Additionally, we identified only those patients with severe unremitting chest pain who sought medical attention. Those with mild or moderate chest pain might not seek medical attention, and it is possible that subclinical myocarditis may occur and could be detected by active surveillance, as has been described with smallpox vaccination,” they wrote.
 

Further case reports

In one of the papers in Circulation, a group led by Kathryn F. Larson, MD, from the Mayo Clinic in Rochester, Minn., described eight patients hospitalized with chest pain who were diagnosed with myocarditis within 2-4 days of receiving either the Pfizer or Moderna vaccine.

Two of the patients had previously been infected by SARS-CoV-2 without need for hospitalization. All individuals were otherwise healthy males between the ages of 21 and 56 years. All but one patient developed symptoms after their second dose, and the one patient who developed myocarditis after the first vaccine dose had previously been infected with SARS-CoV-2.  

Systemic symptoms began within 24 hours after vaccine administration in five of eight patients, with chest pain presenting between 48 and 96 hours later. Troponin values were elevated in all individuals and appeared to peak the day after admission, whereas none had eosinophilia.

Cardiac MRI revealed findings consistent with myocarditis in all patients. All patients had resolution of their chest pain and were discharged from the hospital in stable condition.

“The patients presented here demonstrated typical signs, symptoms, and diagnostic features of acute myocarditis. The temporal association between receiving an mRNA-based COVID-19 vaccine and the development of myocarditis is notable,” the authors said.  

They added that they would consider the use of corticosteroids in these patients but cautioned that this could reduce the specific immune response against SARS-COV-2 triggered by the vaccine. “Thus, the duration of corticosteroid administration should be limited to the resolution of the symptoms or ventricular arrhythmias or the recovery of the left ventricular ejection fraction.”

Pending publication of long-term outcome data after SARS-CoV-2 vaccine–related myocarditis, they suggest adherence to the current consensus recommendation to abstain from competitive sports for a period of 3-6 months with reevaluation prior to sports participation. 

In another of the Circulation papers, a group led by Carolyn M. Rosner, MSN,  presented a case series of seven patients hospitalized for acute myocarditis-like illness following COVID-19 vaccination, from two U.S. medical centers, in Falls Church, Va., and Dallas. All patients were males below the age of 40 years and of White or Hispanic race/ethnicity. Only one patient reported prior history of COVID-19 infection. Six patients received mRNA (Moderna or Pfizer) and one received the adenovirus (Johnson & Johnson) vaccine. All patients presented 3-7 days post vaccination with acute onset chest pain and biochemical evidence of myocardial injury.

Hospital length of stay was 3 days, and all patients’ symptoms resolved by hospital discharge.

And finally, the third paper in Circulation reported a detailed description of one patient – a 52-year-old, previously healthy male who presented with acute myocarditis 3 days after the administration of the second dose of Moderna’s COVID-19 vaccine. The symptoms resolved, and there was a gradual improvement in cMRI findings. Ischemic injury and other potential causes of acute myocardial injury were excluded, as were other potential infectious causes of myocarditis, and there was no evidence of systemic autoimmune disease.

“Clinicians should be aware that myocarditis may be present in patients exhibiting cardiac signs and symptoms 2-4 days after COVID-19 vaccination,” the authors said.

They added that additional surveillance of such adverse events post–COVID-19 vaccination will help identify subgroups at higher risk for this vaccine-related effect, and whether additional precautions are necessary.
 

‘Benefits outweigh risk’

In an accompanying editorial in JAMA Cardiology, three doctors from the CDC cite several other reports of myocarditis after mRNA COVID vaccination. These include a case report published in Pediatrics of seven male adolescents aged 14-19 years who presented with myocarditis or myopericarditis within 4 days after receipt of a second dose of the Pfizer vaccine.

But the editorialists noted that the most comprehensive data about the risk for myocarditis following immunization with mRNA vaccines comes from Israel.

The Israeli Ministry of Health recently posted data describing 121 myocarditis cases occurring within 30 days of a second dose of mRNA vaccine among 5,049,424 persons, suggesting a crude incidence rate of approximately 24 cases per million.

On the current case reports, the CDC doctors wrote: “The striking clinical similarities in the presentations of these patients, their recent vaccination with an mRNA-based COVID-19 vaccine, and the lack of any alternative etiologies for acute myocarditis suggest an association with immunization.”

They said that acute onset of chest pain 3-5 days after vaccine administration, usually after a second dose, is a typical feature of reported cases and suggests an immune-mediated mechanism.

But SARS-CoV-2 infection also causes cardiac injury which may result in severe outcomes, and based on currently available data, myocarditis following immunization with current mRNA-based vaccines is rare.

“At present, the benefits of immunization in preventing severe morbidity favors continued COVID-19 vaccination, particularly considering the increasing COVID-19 hospitalization rates among adolescents reported during spring 2021,” the editorialists stated.

But they added that many questions remain. These include whether modifications are needed to the vaccine schedule among persons with a history of possible or confirmed myocarditis after COVID vaccine, how should postvaccine myocarditis be managed, how often should follow-up assessments be performed, how might follow-up assessments affect recommendations to avoid vigorous physical activity following the diagnosis of myocarditis, and do all likely cases of acute myocarditis that appear to be uncomplicated require cardiac MRI for more definitive diagnosis?

“While the data needed to answer such questions are being collected, there is an opportunity for researchers with expertise in myocarditis to develop a comprehensive, national assessment of the natural history, pathogenesis, and treatment of acute myocarditis associated with receipt of mRNA-based COVID-19 vaccines,” they concluded.

In a second editorial in JAMA Cardiology, a group of editors from the journal acknowledged that publication of the current case reports may contribute to additional public concern regarding immunization. But they added that clinicians discussing immunization with patients should recognize that these case series suggest that the symptomatic events consistent with myocarditis are still very rare and appear to be self-limiting.

“Given the risks of COVID-19, including the risk of myocarditis from COVID-19 infection, the editors do not believe these case reports are sufficient to interrupt the march toward maximal vaccination against SARS-CoV-2 as expeditiously as possible,” they said.

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

Further details from multiple cases of myocarditis linked to the Pfizer and Moderna mRNA COVID vaccines have been described in recent papers in the medical literature.

The cases appear to occur almost exclusively in males and most often in younger age groups. While symptoms and signs of myocarditis mostly resolved with a few days of supportive care, long-term effects are unknown at present.

The authors of all the reports and of two accompanying editorials in JAMA Cardiology are unanimous in their opinion that the benefits of vaccination still outweigh the risks.  

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices met June 23 to discuss this issue. At that meeting, it was reported that 323 cases of myocarditis or pericarditis in individuals aged 29 years and younger have been confirmed, but committee members delivered a strong endorsement for continuing to vaccinate young people with the mRNA vaccines.

The current case reports are published in two papers in JAMA Cardiology and in three in Circulation.
 

U.S. military reports 23 cases

In one report in JAMA Cardiology, authors led by Jay Montgomery, MD, from Walter Reed National Military Medical Center in Bethesda, Md., described 23 cases from the U.S. Military Health System of individuals with acute myocarditis who presented within 4 days after mRNA-based COVID-19 vaccination (7 Pfizer and 16 Moderna).

All patients were male, 22 of 23 were on active duty, and the median age was 25 years (range, 20-51); 20 of the 23 cases occurred after receipt of a second dose of an mRNA COVID-19 vaccine.

The patients all presented with acute onset of marked chest pain. All patients had significantly elevated cardiac troponin levels. Among eight patients who underwent cardiac MRI (cMRI), all had findings consistent with the clinical diagnosis of myocarditis.

Additional testing did not identify other possible causes of myocarditis. All patients received brief supportive care and were recovered or recovering.

The authors reported that the military administered more than 2.8 million doses of mRNA COVID-19 vaccine in this period, and while the observed number of myocarditis cases was small, the number was “substantially higher” than expected among male military members after a second vaccine dose.

They noted that, based on historical data, among the 544,000 second doses to military members there may have been 0-10 expected myocarditis cases, but they observed 19 cases.  

“All patients in this series reflect substantial similarities in demographic characteristics, proximate vaccine dose, onset interval, and character of vaccine-associated myocarditis. The consistent pattern of clinical presentation, rapid recovery, and absence of evidence of other causes support the diagnosis of hypersensitivity myocarditis,” they stated.

They added that presentation after a second vaccine dose or, in three patients, when vaccination followed SARS-CoV-2 infection, suggests that prior exposure was relevant in the hypersensitivity response.

“The spectrum of clinical presentation and reliance on patients seeking health care and on health care professionals recognizing a rare vaccine-associated adverse event limits determination of the true incidence of this condition,” the authors wrote.

They stressed that recognition of vaccine-associated myocarditis is clinically important because diagnosis impacts management, recommendations for exercise, and monitoring for cardiomyopathy.

But the authors also acknowledged that it is important to frame concerns about potential vaccine-associated myocarditis within the context of the current pandemic.

“Infection with SARS-CoV-2 is a clear cause of serious cardiac injury in many patients. ... Prevalence of cardiac injury may be as high as 60% in seriously ill patients. Notably, nearly 1% of highly fit athletes with mild COVID-19 infection have evidence of myocarditis on cMRI,” they wrote.

“Given that COVID-19 vaccines are remarkably effective at preventing infection, any risk of rare adverse events following immunization must be carefully weighed against the very substantial benefit of vaccination,” they concluded.
 

Four cases at Duke

In the second paper in JAMA Cardiology, a group led by Han W. Kim, MD, reported four patients with acute myocarditis occurring within days of mRNA COVID-19 vaccination (two Pfizer and two Moderna) in patients treated at Duke University Medical Center, Durham, N.C. The hospital courses of the four patients with myocarditis following COVID-19 vaccination were uneventful, and they were discharged within 2-4 days.

The authors said that, although a causal relationship cannot be established, none of the patients had a viral prodrome or had coincident testing that revealed an alternative explanation.

They stated that these four patients represent the majority of patients with acute myocarditis identified in the past 3 months at their institution, and this led to the highest total number of patients with acute myocarditis, compared with the same 3-month period for the past 5 years. 

“Additionally, we identified only those patients with severe unremitting chest pain who sought medical attention. Those with mild or moderate chest pain might not seek medical attention, and it is possible that subclinical myocarditis may occur and could be detected by active surveillance, as has been described with smallpox vaccination,” they wrote.
 

Further case reports

In one of the papers in Circulation, a group led by Kathryn F. Larson, MD, from the Mayo Clinic in Rochester, Minn., described eight patients hospitalized with chest pain who were diagnosed with myocarditis within 2-4 days of receiving either the Pfizer or Moderna vaccine.

Two of the patients had previously been infected by SARS-CoV-2 without need for hospitalization. All individuals were otherwise healthy males between the ages of 21 and 56 years. All but one patient developed symptoms after their second dose, and the one patient who developed myocarditis after the first vaccine dose had previously been infected with SARS-CoV-2.  

Systemic symptoms began within 24 hours after vaccine administration in five of eight patients, with chest pain presenting between 48 and 96 hours later. Troponin values were elevated in all individuals and appeared to peak the day after admission, whereas none had eosinophilia.

Cardiac MRI revealed findings consistent with myocarditis in all patients. All patients had resolution of their chest pain and were discharged from the hospital in stable condition.

“The patients presented here demonstrated typical signs, symptoms, and diagnostic features of acute myocarditis. The temporal association between receiving an mRNA-based COVID-19 vaccine and the development of myocarditis is notable,” the authors said.  

They added that they would consider the use of corticosteroids in these patients but cautioned that this could reduce the specific immune response against SARS-COV-2 triggered by the vaccine. “Thus, the duration of corticosteroid administration should be limited to the resolution of the symptoms or ventricular arrhythmias or the recovery of the left ventricular ejection fraction.”

Pending publication of long-term outcome data after SARS-CoV-2 vaccine–related myocarditis, they suggest adherence to the current consensus recommendation to abstain from competitive sports for a period of 3-6 months with reevaluation prior to sports participation. 

In another of the Circulation papers, a group led by Carolyn M. Rosner, MSN,  presented a case series of seven patients hospitalized for acute myocarditis-like illness following COVID-19 vaccination, from two U.S. medical centers, in Falls Church, Va., and Dallas. All patients were males below the age of 40 years and of White or Hispanic race/ethnicity. Only one patient reported prior history of COVID-19 infection. Six patients received mRNA (Moderna or Pfizer) and one received the adenovirus (Johnson & Johnson) vaccine. All patients presented 3-7 days post vaccination with acute onset chest pain and biochemical evidence of myocardial injury.

Hospital length of stay was 3 days, and all patients’ symptoms resolved by hospital discharge.

And finally, the third paper in Circulation reported a detailed description of one patient – a 52-year-old, previously healthy male who presented with acute myocarditis 3 days after the administration of the second dose of Moderna’s COVID-19 vaccine. The symptoms resolved, and there was a gradual improvement in cMRI findings. Ischemic injury and other potential causes of acute myocardial injury were excluded, as were other potential infectious causes of myocarditis, and there was no evidence of systemic autoimmune disease.

“Clinicians should be aware that myocarditis may be present in patients exhibiting cardiac signs and symptoms 2-4 days after COVID-19 vaccination,” the authors said.

They added that additional surveillance of such adverse events post–COVID-19 vaccination will help identify subgroups at higher risk for this vaccine-related effect, and whether additional precautions are necessary.
 

‘Benefits outweigh risk’

In an accompanying editorial in JAMA Cardiology, three doctors from the CDC cite several other reports of myocarditis after mRNA COVID vaccination. These include a case report published in Pediatrics of seven male adolescents aged 14-19 years who presented with myocarditis or myopericarditis within 4 days after receipt of a second dose of the Pfizer vaccine.

But the editorialists noted that the most comprehensive data about the risk for myocarditis following immunization with mRNA vaccines comes from Israel.

The Israeli Ministry of Health recently posted data describing 121 myocarditis cases occurring within 30 days of a second dose of mRNA vaccine among 5,049,424 persons, suggesting a crude incidence rate of approximately 24 cases per million.

On the current case reports, the CDC doctors wrote: “The striking clinical similarities in the presentations of these patients, their recent vaccination with an mRNA-based COVID-19 vaccine, and the lack of any alternative etiologies for acute myocarditis suggest an association with immunization.”

They said that acute onset of chest pain 3-5 days after vaccine administration, usually after a second dose, is a typical feature of reported cases and suggests an immune-mediated mechanism.

But SARS-CoV-2 infection also causes cardiac injury which may result in severe outcomes, and based on currently available data, myocarditis following immunization with current mRNA-based vaccines is rare.

“At present, the benefits of immunization in preventing severe morbidity favors continued COVID-19 vaccination, particularly considering the increasing COVID-19 hospitalization rates among adolescents reported during spring 2021,” the editorialists stated.

But they added that many questions remain. These include whether modifications are needed to the vaccine schedule among persons with a history of possible or confirmed myocarditis after COVID vaccine, how should postvaccine myocarditis be managed, how often should follow-up assessments be performed, how might follow-up assessments affect recommendations to avoid vigorous physical activity following the diagnosis of myocarditis, and do all likely cases of acute myocarditis that appear to be uncomplicated require cardiac MRI for more definitive diagnosis?

“While the data needed to answer such questions are being collected, there is an opportunity for researchers with expertise in myocarditis to develop a comprehensive, national assessment of the natural history, pathogenesis, and treatment of acute myocarditis associated with receipt of mRNA-based COVID-19 vaccines,” they concluded.

In a second editorial in JAMA Cardiology, a group of editors from the journal acknowledged that publication of the current case reports may contribute to additional public concern regarding immunization. But they added that clinicians discussing immunization with patients should recognize that these case series suggest that the symptomatic events consistent with myocarditis are still very rare and appear to be self-limiting.

“Given the risks of COVID-19, including the risk of myocarditis from COVID-19 infection, the editors do not believe these case reports are sufficient to interrupt the march toward maximal vaccination against SARS-CoV-2 as expeditiously as possible,” they said.

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

With vaccination rates increasing and new infections declining, we all hope the worst of the COVID-19 pandemic is over (fingers crossed really tight). Regardless, the post–COVID-19 syndrome pandemic has already begun. What is post–COVID-19 syndrome (or long-haulers or long-COVID)? Is it standard postviral fatigue? Prolonged deconditioning following debilitating illness? Permanent lung or vascular injury? Common sense and past experience say it’s all of these.

In theory, the burden of actual lung injury post COVID-19 should be the easiest to quantify, so let’s discuss what we think we know. I’ve heard experts break post–COVID-19 lung injury into three broad categories:

• Preexisting lung disease that is exacerbated by acute COVID-19 infection.
• Acute COVID-19 infection that causes acute respiratory distress syndrome (ARDS) or other acute lung injury (ALI).
• Non–critically ill acute COVID-19 with residual lung damage and abnormal repair.

These categories are necessarily imprecise, making it challenging to fit some patients neatly into a single definition.

For patients in the first category, management will be dictated largely by the nature of the preexisting lung disease. For those in category two, we already know a lot about what their recovery from ARDS will look like. There’s no longer reason to believe that COVID-19–related ARDS is particularly unique, and all things being equal, lung recovery should mimic that seen with non–COVID-19 ARDS.

It’s going to take patience and time, and beyond targeted rehabilitation it’s not clear that we have anything available to expedite the process.

The third category of patients is the most intriguing. Is there a group of patients who have residual lung injury but didn’t have evident ARDS/ALI during their acute COVID-19 infection? Anecdotally we think so, but we know little about prevalence and less about management. A recent study published in Annals of the American Thoracic Society addresses both issues. In an observational report on patients recovering after being hospitalized with COVID-19 infection, the authors found that 3.6% of patients had residual lung injury that improved with 3 weeks of corticosteroid treatment.

The report is timely and helpful but hardly definitive. It’s observational, and patients required extensive screening and identification by a multidisciplinary committee of experts in interstitial lung disease. Patients were diagnosed as having organizing pneumonia (OP) as their “lung injury” if certain radiographic criteria were met. There were no biopsies. Last, there was no control group. Still, this report is critically important. It tells us that at 6 weeks post discharge, about 3.6% of patients who were hospitalized for COVID-19 will have persistent symptoms, radiographic abnormalities, and a plateau in their recovery.

Beyond that, it tells us little. Did these patients really have OP? It’s impossible to know. The CT findings used to establish the diagnosis are nonspecific. Response to steroids is consistent with OP, but the treatment course was quite short. If truly OP, one would expect a high relapse rate after steroid withdrawal. Patients weren’t followed long enough to monitor recurrence rates. Also, as appropriately discussed in the accompanying editorial, there’s no control group so we can’t know whether the patients treated with steroids would have recovered without treatment. There was objective improvement in lung function for the two to three patients they followed who did not receive steroids. However, it was of lesser magnitude than in the steroid group.

Post–COVID-19 symptoms will remain a challenge for the foreseeable future. More than 30 million patients have been diagnosed with COVID-19 in the United States and close to half will experience persistent dyspnea. Putting the numbers together, I conclude that the vast majority will not have identifiable lung injury that will benefit from steroids. I wish I could prescribe patience to both physicians and patients.

Dr. Holley is associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.
 

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

With vaccination rates increasing and new infections declining, we all hope the worst of the COVID-19 pandemic is over (fingers crossed really tight). Regardless, the post–COVID-19 syndrome pandemic has already begun. What is post–COVID-19 syndrome (or long-haulers or long-COVID)? Is it standard postviral fatigue? Prolonged deconditioning following debilitating illness? Permanent lung or vascular injury? Common sense and past experience say it’s all of these.

In theory, the burden of actual lung injury post COVID-19 should be the easiest to quantify, so let’s discuss what we think we know. I’ve heard experts break post–COVID-19 lung injury into three broad categories:

• Preexisting lung disease that is exacerbated by acute COVID-19 infection.
• Acute COVID-19 infection that causes acute respiratory distress syndrome (ARDS) or other acute lung injury (ALI).
• Non–critically ill acute COVID-19 with residual lung damage and abnormal repair.

These categories are necessarily imprecise, making it challenging to fit some patients neatly into a single definition.

For patients in the first category, management will be dictated largely by the nature of the preexisting lung disease. For those in category two, we already know a lot about what their recovery from ARDS will look like. There’s no longer reason to believe that COVID-19–related ARDS is particularly unique, and all things being equal, lung recovery should mimic that seen with non–COVID-19 ARDS.

It’s going to take patience and time, and beyond targeted rehabilitation it’s not clear that we have anything available to expedite the process.

The third category of patients is the most intriguing. Is there a group of patients who have residual lung injury but didn’t have evident ARDS/ALI during their acute COVID-19 infection? Anecdotally we think so, but we know little about prevalence and less about management. A recent study published in Annals of the American Thoracic Society addresses both issues. In an observational report on patients recovering after being hospitalized with COVID-19 infection, the authors found that 3.6% of patients had residual lung injury that improved with 3 weeks of corticosteroid treatment.

The report is timely and helpful but hardly definitive. It’s observational, and patients required extensive screening and identification by a multidisciplinary committee of experts in interstitial lung disease. Patients were diagnosed as having organizing pneumonia (OP) as their “lung injury” if certain radiographic criteria were met. There were no biopsies. Last, there was no control group. Still, this report is critically important. It tells us that at 6 weeks post discharge, about 3.6% of patients who were hospitalized for COVID-19 will have persistent symptoms, radiographic abnormalities, and a plateau in their recovery.

Beyond that, it tells us little. Did these patients really have OP? It’s impossible to know. The CT findings used to establish the diagnosis are nonspecific. Response to steroids is consistent with OP, but the treatment course was quite short. If truly OP, one would expect a high relapse rate after steroid withdrawal. Patients weren’t followed long enough to monitor recurrence rates. Also, as appropriately discussed in the accompanying editorial, there’s no control group so we can’t know whether the patients treated with steroids would have recovered without treatment. There was objective improvement in lung function for the two to three patients they followed who did not receive steroids. However, it was of lesser magnitude than in the steroid group.

Post–COVID-19 symptoms will remain a challenge for the foreseeable future. More than 30 million patients have been diagnosed with COVID-19 in the United States and close to half will experience persistent dyspnea. Putting the numbers together, I conclude that the vast majority will not have identifiable lung injury that will benefit from steroids. I wish I could prescribe patience to both physicians and patients.

Dr. Holley is associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.
 

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

With vaccination rates increasing and new infections declining, we all hope the worst of the COVID-19 pandemic is over (fingers crossed really tight). Regardless, the post–COVID-19 syndrome pandemic has already begun. What is post–COVID-19 syndrome (or long-haulers or long-COVID)? Is it standard postviral fatigue? Prolonged deconditioning following debilitating illness? Permanent lung or vascular injury? Common sense and past experience say it’s all of these.

In theory, the burden of actual lung injury post COVID-19 should be the easiest to quantify, so let’s discuss what we think we know. I’ve heard experts break post–COVID-19 lung injury into three broad categories:

• Preexisting lung disease that is exacerbated by acute COVID-19 infection.
• Acute COVID-19 infection that causes acute respiratory distress syndrome (ARDS) or other acute lung injury (ALI).
• Non–critically ill acute COVID-19 with residual lung damage and abnormal repair.

These categories are necessarily imprecise, making it challenging to fit some patients neatly into a single definition.

For patients in the first category, management will be dictated largely by the nature of the preexisting lung disease. For those in category two, we already know a lot about what their recovery from ARDS will look like. There’s no longer reason to believe that COVID-19–related ARDS is particularly unique, and all things being equal, lung recovery should mimic that seen with non–COVID-19 ARDS.

It’s going to take patience and time, and beyond targeted rehabilitation it’s not clear that we have anything available to expedite the process.

The third category of patients is the most intriguing. Is there a group of patients who have residual lung injury but didn’t have evident ARDS/ALI during their acute COVID-19 infection? Anecdotally we think so, but we know little about prevalence and less about management. A recent study published in Annals of the American Thoracic Society addresses both issues. In an observational report on patients recovering after being hospitalized with COVID-19 infection, the authors found that 3.6% of patients had residual lung injury that improved with 3 weeks of corticosteroid treatment.

The report is timely and helpful but hardly definitive. It’s observational, and patients required extensive screening and identification by a multidisciplinary committee of experts in interstitial lung disease. Patients were diagnosed as having organizing pneumonia (OP) as their “lung injury” if certain radiographic criteria were met. There were no biopsies. Last, there was no control group. Still, this report is critically important. It tells us that at 6 weeks post discharge, about 3.6% of patients who were hospitalized for COVID-19 will have persistent symptoms, radiographic abnormalities, and a plateau in their recovery.

Beyond that, it tells us little. Did these patients really have OP? It’s impossible to know. The CT findings used to establish the diagnosis are nonspecific. Response to steroids is consistent with OP, but the treatment course was quite short. If truly OP, one would expect a high relapse rate after steroid withdrawal. Patients weren’t followed long enough to monitor recurrence rates. Also, as appropriately discussed in the accompanying editorial, there’s no control group so we can’t know whether the patients treated with steroids would have recovered without treatment. There was objective improvement in lung function for the two to three patients they followed who did not receive steroids. However, it was of lesser magnitude than in the steroid group.

Post–COVID-19 symptoms will remain a challenge for the foreseeable future. More than 30 million patients have been diagnosed with COVID-19 in the United States and close to half will experience persistent dyspnea. Putting the numbers together, I conclude that the vast majority will not have identifiable lung injury that will benefit from steroids. I wish I could prescribe patience to both physicians and patients.

Dr. Holley is associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.
 

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

Ignore this pacemaker and it will go away

At some point – and now seems to be that point – we have to say enough is enough. The throwaway culture that produces phones, TVs, and computers that get tossed in the trash because they can’t be repaired has gone too far. That’s right, we’re looking at you, medical science!

This time, it’s a pacemaker that just disappears when it’s no longer needed. Some lazy heart surgeon decided that it was way too much trouble to do another surgery to remove the leads when a temporary pacemaker was no longer needed. You know the type: “It sure would be nice if the pacemaker components were biocompatible and were naturally absorbed by the body over the course of a few weeks and wouldn’t need to be surgically extracted.” Slacker.

Well, get a load of this. Researchers at Northwestern and George Washington universities say that they have come up with a transient pacemaker that “harvests energy from an external, remote antenna using near-field communication protocols – the same technology used in smartphones for electronic payments and in RFID tags.”

Northwestern University/George Washington University

It’s a mask! No, it’s a COVID-19 test!

Mask wearing has gotten more lax as people get vaccinated for COVID-19, but as wearing masks for virus prevention is becoming more normalized in western society, some saw an opportunity to make them work for diagnosis.

Researchers from the Massachusetts Institute of Technology and the Wyss Institute for Biologically Inspired Engineering at Harvard University have found a way to do just that with their wearable freeze-dried cell-free (wFDCF) technology. A single push of a button releases water from a reservoir in the mask that sequentially activates three different freeze-dried biological reactions, which detect the SARS-CoV-2 virus in the wearer’s breath.

Initially meant as a tool for the Zika outbreak in 2015, the team made a quick pivot in May 2020. But this isn’t just some run-of-the-mill, at-home test. The data prove that the wFDCF mask is comparable to polymerase chain reactions tests, the standard in COVID-19 detection. Plus there aren’t any extra factors to deal with, like room or instrument temperature to ensure accuracy. In just 90 minutes, the mask gives results on a readout in a way similar to that of a pregnancy test. Voilà! To have COVID-19 or not to have COVID-19 is an easily answered question.

UerDomwet/PxHere

Finally, an excuse for the all-beer diet

Weight loss is hard work. Extremely hard work, and, as evidenced by the constant inundation and advertisement of quick fixes, crash diets, and expensive gym memberships, there’s not really a solid, 100% solution to the issue. Until now, thanks to a team of doctors from New Zealand, who’ve decided that the best way to combat obesity is to leave you in constant agony.

The DentalSlim Diet Control device is certainly a radical yet comically logical attempt to combat obesity. The creators say that the biggest problem with dieting is compliance, and, well, it’s difficult to eat too much if you can’t actually open your mouth. The metal contraption is mounted onto your teeth and uses magnetic locks to prevent the user from opening their mouths more than 2 mm. That’s less than a tenth of an inch. Which is not a lot. So not a lot that essentially all you can consume is liquid.

University of Otago

Ignore this pacemaker and it will go away

At some point – and now seems to be that point – we have to say enough is enough. The throwaway culture that produces phones, TVs, and computers that get tossed in the trash because they can’t be repaired has gone too far. That’s right, we’re looking at you, medical science!

This time, it’s a pacemaker that just disappears when it’s no longer needed. Some lazy heart surgeon decided that it was way too much trouble to do another surgery to remove the leads when a temporary pacemaker was no longer needed. You know the type: “It sure would be nice if the pacemaker components were biocompatible and were naturally absorbed by the body over the course of a few weeks and wouldn’t need to be surgically extracted.” Slacker.

Well, get a load of this. Researchers at Northwestern and George Washington universities say that they have come up with a transient pacemaker that “harvests energy from an external, remote antenna using near-field communication protocols – the same technology used in smartphones for electronic payments and in RFID tags.”

Northwestern University/George Washington University

It’s a mask! No, it’s a COVID-19 test!

Mask wearing has gotten more lax as people get vaccinated for COVID-19, but as wearing masks for virus prevention is becoming more normalized in western society, some saw an opportunity to make them work for diagnosis.

Researchers from the Massachusetts Institute of Technology and the Wyss Institute for Biologically Inspired Engineering at Harvard University have found a way to do just that with their wearable freeze-dried cell-free (wFDCF) technology. A single push of a button releases water from a reservoir in the mask that sequentially activates three different freeze-dried biological reactions, which detect the SARS-CoV-2 virus in the wearer’s breath.

Initially meant as a tool for the Zika outbreak in 2015, the team made a quick pivot in May 2020. But this isn’t just some run-of-the-mill, at-home test. The data prove that the wFDCF mask is comparable to polymerase chain reactions tests, the standard in COVID-19 detection. Plus there aren’t any extra factors to deal with, like room or instrument temperature to ensure accuracy. In just 90 minutes, the mask gives results on a readout in a way similar to that of a pregnancy test. Voilà! To have COVID-19 or not to have COVID-19 is an easily answered question.

UerDomwet/PxHere

Finally, an excuse for the all-beer diet

Weight loss is hard work. Extremely hard work, and, as evidenced by the constant inundation and advertisement of quick fixes, crash diets, and expensive gym memberships, there’s not really a solid, 100% solution to the issue. Until now, thanks to a team of doctors from New Zealand, who’ve decided that the best way to combat obesity is to leave you in constant agony.

The DentalSlim Diet Control device is certainly a radical yet comically logical attempt to combat obesity. The creators say that the biggest problem with dieting is compliance, and, well, it’s difficult to eat too much if you can’t actually open your mouth. The metal contraption is mounted onto your teeth and uses magnetic locks to prevent the user from opening their mouths more than 2 mm. That’s less than a tenth of an inch. Which is not a lot. So not a lot that essentially all you can consume is liquid.

University of Otago

Ignore this pacemaker and it will go away

At some point – and now seems to be that point – we have to say enough is enough. The throwaway culture that produces phones, TVs, and computers that get tossed in the trash because they can’t be repaired has gone too far. That’s right, we’re looking at you, medical science!

This time, it’s a pacemaker that just disappears when it’s no longer needed. Some lazy heart surgeon decided that it was way too much trouble to do another surgery to remove the leads when a temporary pacemaker was no longer needed. You know the type: “It sure would be nice if the pacemaker components were biocompatible and were naturally absorbed by the body over the course of a few weeks and wouldn’t need to be surgically extracted.” Slacker.

Well, get a load of this. Researchers at Northwestern and George Washington universities say that they have come up with a transient pacemaker that “harvests energy from an external, remote antenna using near-field communication protocols – the same technology used in smartphones for electronic payments and in RFID tags.”

Northwestern University/George Washington University

It’s a mask! No, it’s a COVID-19 test!

Mask wearing has gotten more lax as people get vaccinated for COVID-19, but as wearing masks for virus prevention is becoming more normalized in western society, some saw an opportunity to make them work for diagnosis.

Researchers from the Massachusetts Institute of Technology and the Wyss Institute for Biologically Inspired Engineering at Harvard University have found a way to do just that with their wearable freeze-dried cell-free (wFDCF) technology. A single push of a button releases water from a reservoir in the mask that sequentially activates three different freeze-dried biological reactions, which detect the SARS-CoV-2 virus in the wearer’s breath.

Initially meant as a tool for the Zika outbreak in 2015, the team made a quick pivot in May 2020. But this isn’t just some run-of-the-mill, at-home test. The data prove that the wFDCF mask is comparable to polymerase chain reactions tests, the standard in COVID-19 detection. Plus there aren’t any extra factors to deal with, like room or instrument temperature to ensure accuracy. In just 90 minutes, the mask gives results on a readout in a way similar to that of a pregnancy test. Voilà! To have COVID-19 or not to have COVID-19 is an easily answered question.

UerDomwet/PxHere

Finally, an excuse for the all-beer diet

Weight loss is hard work. Extremely hard work, and, as evidenced by the constant inundation and advertisement of quick fixes, crash diets, and expensive gym memberships, there’s not really a solid, 100% solution to the issue. Until now, thanks to a team of doctors from New Zealand, who’ve decided that the best way to combat obesity is to leave you in constant agony.

The DentalSlim Diet Control device is certainly a radical yet comically logical attempt to combat obesity. The creators say that the biggest problem with dieting is compliance, and, well, it’s difficult to eat too much if you can’t actually open your mouth. The metal contraption is mounted onto your teeth and uses magnetic locks to prevent the user from opening their mouths more than 2 mm. That’s less than a tenth of an inch. Which is not a lot. So not a lot that essentially all you can consume is liquid.

University of Otago

Guillain-Barré syndrome, a rare peripheral nerve disorder that can occur after certain types of viral and bacterial infections, has not to date been definitively linked to infection by SARS-CoV-2 or with vaccination against the virus, despite surveillance searching for such associations.

Spikes in Guillain-Barré syndrome incidence have previously, but rarely, been associated with outbreaks of other viral diseases, including Zika, but not with vaccination, except for a 1976-1977 swine influenza vaccine campaign in the United States that was seen associated with a slight elevation in risk, and was halted when that risk became known. Since then, all sorts of vaccines in the European Union and United States have come with warnings about Guillain-Barré syndrome in their package inserts – a fact that some Guillain-Barré syndrome experts lament as perpetuating the notion that vaccines cause Guillain-Barré syndrome.

Epidemiologic studies in the United Kingdom and Singapore did not detect increases in Guillain-Barré syndrome incidence during the COVID-19 pandemic. And as mass vaccination against COVID-19 got underway early this year, experts cautioned against the temptation to attribute incident Guillain-Barré syndrome cases following vaccination to SARS-CoV-2 without careful statistical and epidemiological analysis. Until now reports of Guillain-Barré syndrome have been scant: clinical trials of a viral vector vaccine developed by Johnson & Johnson saw one in the placebo arm and another in the intervention arm, while another case was reported following administration of a Pfizer mRNA SARS-Cov-2 vaccine.
 

Recent case reports

Two reports published this month in the Annals of Neurology – one from India and one from the United Kingdom – describe multiple cases of Guillain-Barré syndrome following a first dose of the ChAdOx1-S/nCoV-19, (Covishield, AstraZeneca) vector vaccine. None of the patients had evidence of current SARS-CoV-2 infection.

From India, Boby V. Maramattom, MD, of Aster Medcity in Kochi, India, and colleagues reported on seven severe cases of Guillain-Barré syndrome occurring between 10 and 14 days after a first dose of the AstraZeneca vaccine. All but one of the patients were women, all had bilateral facial paresis, all progressed to areflexic quadriplegia, and six required respiratory support. Patients’ ages ranged from 43 to 70. Four developed other cranial neuropathies, including abducens palsy and trigeminal sensory nerve involvement, which are rare in reports of Guillain-Barré syndrome from India, Dr. Maramattom and colleagues noted.

The authors argued that their findings “should prompt all physicians to be vigilant in recognizing Guillain-Barré syndrome in patients who have received the AstraZeneca vaccine. While the risk per patient (5.8 per million) may be relatively low, our observations suggest that this clinically distinct [Guillain-Barré syndrome] variant is more severe than usual and may require mechanical ventilation.”

The U.K. cases, reported by Christopher Martin Allen, MD, and colleagues at Nottingham (England) University Hospitals NHS Trust, describe bifacial weakness and normal facial sensation in four men between 11 and 22 days after their first doses of the Astra-Zeneca vaccine. This type of facial palsy, the authors wrote, was unusual Guillain-Barré syndrome variant that one rapid review found in 3 of 42 European patients diagnosed with Guillain-Barré syndrome following SARS-CoV-2 infection.

Dr. Allen and colleagues acknowledged that causality could not be assumed from the temporal relationship of immunization to onset of bifacial weakness in their report, but argued that their findings argued for “robust postvaccination surveillance” and that “the report of a similar syndrome in the setting of SARS-CoV-2 infection suggests an immunologic response to the spike protein.” If the link is casual, they wrote, “it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system.”
 

‘The jury is still out’

Asked for comment, neurologist Anthony Amato, MD, of Brigham and Women’s Hospital, Boston, said that he did not see what the two new studies add to what is already known. “Guillain-Barré syndrome has already been reported temporally following COVID-19 along with accompanying editorials that such temporal occurrences do not imply causation and there is a need for surveillance and epidemiological studies.”

Robert Lisak, MD, of Wayne State University, Detroit, and a longtime adviser to the GBS-CIDP Foundation International, commented that “the relationship between vaccines and association with Guillain-Barré syndrome continues to be controversial in part because Guillain-Barré syndrome, a rare disorder, has many reported associated illnesses including infections. Many vaccines have been implicated but with the probable exception of the ‘swine flu’ vaccine in the 1970s, most have not stood up to scrutiny.”

With SARS-Cov-2 infection and vaccines, “the jury is still out,” Dr. Lisak said. “The report from the U.K. is intriguing since they report several cases of an uncommon variant, but the cases from India seem to be more of the usual forms of Guillain-Barré syndrome.”

Dr. Lisak noted that, even if an association turns out to be valid, “we are talking about a very low incidence of Guillain-Barré syndrome associated with COVID-19 vaccines,” one that would not justify avoiding them because of a possible association with Guillain-Barré syndrome.

The GBS-CIDP Foundation, which supports research into Guillain-Barré syndrome and related diseases, has likewise stressed the low risk presented by SARS-CoV-2 vaccines, noting on its website that “the risk of death or long-term complications from COVID in adults still far exceeds the risk of any possible risk of Guillain-Barré syndrome by several orders of magnitude.”

None of the study authors reported financial conflicts of interest related to their research. Dr. Amato is an adviser to the pharmaceutical firms Alexion and Argenx, while Dr. Lisak has received research support or honoraria from Alexion, Novartis, Hoffmann–La Roche, and others.

Guillain-Barré syndrome, a rare peripheral nerve disorder that can occur after certain types of viral and bacterial infections, has not to date been definitively linked to infection by SARS-CoV-2 or with vaccination against the virus, despite surveillance searching for such associations.

Spikes in Guillain-Barré syndrome incidence have previously, but rarely, been associated with outbreaks of other viral diseases, including Zika, but not with vaccination, except for a 1976-1977 swine influenza vaccine campaign in the United States that was seen associated with a slight elevation in risk, and was halted when that risk became known. Since then, all sorts of vaccines in the European Union and United States have come with warnings about Guillain-Barré syndrome in their package inserts – a fact that some Guillain-Barré syndrome experts lament as perpetuating the notion that vaccines cause Guillain-Barré syndrome.

Epidemiologic studies in the United Kingdom and Singapore did not detect increases in Guillain-Barré syndrome incidence during the COVID-19 pandemic. And as mass vaccination against COVID-19 got underway early this year, experts cautioned against the temptation to attribute incident Guillain-Barré syndrome cases following vaccination to SARS-CoV-2 without careful statistical and epidemiological analysis. Until now reports of Guillain-Barré syndrome have been scant: clinical trials of a viral vector vaccine developed by Johnson & Johnson saw one in the placebo arm and another in the intervention arm, while another case was reported following administration of a Pfizer mRNA SARS-Cov-2 vaccine.
 

Recent case reports

Two reports published this month in the Annals of Neurology – one from India and one from the United Kingdom – describe multiple cases of Guillain-Barré syndrome following a first dose of the ChAdOx1-S/nCoV-19, (Covishield, AstraZeneca) vector vaccine. None of the patients had evidence of current SARS-CoV-2 infection.

From India, Boby V. Maramattom, MD, of Aster Medcity in Kochi, India, and colleagues reported on seven severe cases of Guillain-Barré syndrome occurring between 10 and 14 days after a first dose of the AstraZeneca vaccine. All but one of the patients were women, all had bilateral facial paresis, all progressed to areflexic quadriplegia, and six required respiratory support. Patients’ ages ranged from 43 to 70. Four developed other cranial neuropathies, including abducens palsy and trigeminal sensory nerve involvement, which are rare in reports of Guillain-Barré syndrome from India, Dr. Maramattom and colleagues noted.

The authors argued that their findings “should prompt all physicians to be vigilant in recognizing Guillain-Barré syndrome in patients who have received the AstraZeneca vaccine. While the risk per patient (5.8 per million) may be relatively low, our observations suggest that this clinically distinct [Guillain-Barré syndrome] variant is more severe than usual and may require mechanical ventilation.”

The U.K. cases, reported by Christopher Martin Allen, MD, and colleagues at Nottingham (England) University Hospitals NHS Trust, describe bifacial weakness and normal facial sensation in four men between 11 and 22 days after their first doses of the Astra-Zeneca vaccine. This type of facial palsy, the authors wrote, was unusual Guillain-Barré syndrome variant that one rapid review found in 3 of 42 European patients diagnosed with Guillain-Barré syndrome following SARS-CoV-2 infection.

Dr. Allen and colleagues acknowledged that causality could not be assumed from the temporal relationship of immunization to onset of bifacial weakness in their report, but argued that their findings argued for “robust postvaccination surveillance” and that “the report of a similar syndrome in the setting of SARS-CoV-2 infection suggests an immunologic response to the spike protein.” If the link is casual, they wrote, “it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system.”
 

‘The jury is still out’

Asked for comment, neurologist Anthony Amato, MD, of Brigham and Women’s Hospital, Boston, said that he did not see what the two new studies add to what is already known. “Guillain-Barré syndrome has already been reported temporally following COVID-19 along with accompanying editorials that such temporal occurrences do not imply causation and there is a need for surveillance and epidemiological studies.”

Robert Lisak, MD, of Wayne State University, Detroit, and a longtime adviser to the GBS-CIDP Foundation International, commented that “the relationship between vaccines and association with Guillain-Barré syndrome continues to be controversial in part because Guillain-Barré syndrome, a rare disorder, has many reported associated illnesses including infections. Many vaccines have been implicated but with the probable exception of the ‘swine flu’ vaccine in the 1970s, most have not stood up to scrutiny.”

With SARS-Cov-2 infection and vaccines, “the jury is still out,” Dr. Lisak said. “The report from the U.K. is intriguing since they report several cases of an uncommon variant, but the cases from India seem to be more of the usual forms of Guillain-Barré syndrome.”

Dr. Lisak noted that, even if an association turns out to be valid, “we are talking about a very low incidence of Guillain-Barré syndrome associated with COVID-19 vaccines,” one that would not justify avoiding them because of a possible association with Guillain-Barré syndrome.

The GBS-CIDP Foundation, which supports research into Guillain-Barré syndrome and related diseases, has likewise stressed the low risk presented by SARS-CoV-2 vaccines, noting on its website that “the risk of death or long-term complications from COVID in adults still far exceeds the risk of any possible risk of Guillain-Barré syndrome by several orders of magnitude.”

None of the study authors reported financial conflicts of interest related to their research. Dr. Amato is an adviser to the pharmaceutical firms Alexion and Argenx, while Dr. Lisak has received research support or honoraria from Alexion, Novartis, Hoffmann–La Roche, and others.

Guillain-Barré syndrome, a rare peripheral nerve disorder that can occur after certain types of viral and bacterial infections, has not to date been definitively linked to infection by SARS-CoV-2 or with vaccination against the virus, despite surveillance searching for such associations.

Spikes in Guillain-Barré syndrome incidence have previously, but rarely, been associated with outbreaks of other viral diseases, including Zika, but not with vaccination, except for a 1976-1977 swine influenza vaccine campaign in the United States that was seen associated with a slight elevation in risk, and was halted when that risk became known. Since then, all sorts of vaccines in the European Union and United States have come with warnings about Guillain-Barré syndrome in their package inserts – a fact that some Guillain-Barré syndrome experts lament as perpetuating the notion that vaccines cause Guillain-Barré syndrome.

Epidemiologic studies in the United Kingdom and Singapore did not detect increases in Guillain-Barré syndrome incidence during the COVID-19 pandemic. And as mass vaccination against COVID-19 got underway early this year, experts cautioned against the temptation to attribute incident Guillain-Barré syndrome cases following vaccination to SARS-CoV-2 without careful statistical and epidemiological analysis. Until now reports of Guillain-Barré syndrome have been scant: clinical trials of a viral vector vaccine developed by Johnson & Johnson saw one in the placebo arm and another in the intervention arm, while another case was reported following administration of a Pfizer mRNA SARS-Cov-2 vaccine.
 

Recent case reports

Two reports published this month in the Annals of Neurology – one from India and one from the United Kingdom – describe multiple cases of Guillain-Barré syndrome following a first dose of the ChAdOx1-S/nCoV-19, (Covishield, AstraZeneca) vector vaccine. None of the patients had evidence of current SARS-CoV-2 infection.

From India, Boby V. Maramattom, MD, of Aster Medcity in Kochi, India, and colleagues reported on seven severe cases of Guillain-Barré syndrome occurring between 10 and 14 days after a first dose of the AstraZeneca vaccine. All but one of the patients were women, all had bilateral facial paresis, all progressed to areflexic quadriplegia, and six required respiratory support. Patients’ ages ranged from 43 to 70. Four developed other cranial neuropathies, including abducens palsy and trigeminal sensory nerve involvement, which are rare in reports of Guillain-Barré syndrome from India, Dr. Maramattom and colleagues noted.

The authors argued that their findings “should prompt all physicians to be vigilant in recognizing Guillain-Barré syndrome in patients who have received the AstraZeneca vaccine. While the risk per patient (5.8 per million) may be relatively low, our observations suggest that this clinically distinct [Guillain-Barré syndrome] variant is more severe than usual and may require mechanical ventilation.”

The U.K. cases, reported by Christopher Martin Allen, MD, and colleagues at Nottingham (England) University Hospitals NHS Trust, describe bifacial weakness and normal facial sensation in four men between 11 and 22 days after their first doses of the Astra-Zeneca vaccine. This type of facial palsy, the authors wrote, was unusual Guillain-Barré syndrome variant that one rapid review found in 3 of 42 European patients diagnosed with Guillain-Barré syndrome following SARS-CoV-2 infection.

Dr. Allen and colleagues acknowledged that causality could not be assumed from the temporal relationship of immunization to onset of bifacial weakness in their report, but argued that their findings argued for “robust postvaccination surveillance” and that “the report of a similar syndrome in the setting of SARS-CoV-2 infection suggests an immunologic response to the spike protein.” If the link is casual, they wrote, “it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system.”
 

‘The jury is still out’

Asked for comment, neurologist Anthony Amato, MD, of Brigham and Women’s Hospital, Boston, said that he did not see what the two new studies add to what is already known. “Guillain-Barré syndrome has already been reported temporally following COVID-19 along with accompanying editorials that such temporal occurrences do not imply causation and there is a need for surveillance and epidemiological studies.”

Robert Lisak, MD, of Wayne State University, Detroit, and a longtime adviser to the GBS-CIDP Foundation International, commented that “the relationship between vaccines and association with Guillain-Barré syndrome continues to be controversial in part because Guillain-Barré syndrome, a rare disorder, has many reported associated illnesses including infections. Many vaccines have been implicated but with the probable exception of the ‘swine flu’ vaccine in the 1970s, most have not stood up to scrutiny.”

With SARS-Cov-2 infection and vaccines, “the jury is still out,” Dr. Lisak said. “The report from the U.K. is intriguing since they report several cases of an uncommon variant, but the cases from India seem to be more of the usual forms of Guillain-Barré syndrome.”

Dr. Lisak noted that, even if an association turns out to be valid, “we are talking about a very low incidence of Guillain-Barré syndrome associated with COVID-19 vaccines,” one that would not justify avoiding them because of a possible association with Guillain-Barré syndrome.

The GBS-CIDP Foundation, which supports research into Guillain-Barré syndrome and related diseases, has likewise stressed the low risk presented by SARS-CoV-2 vaccines, noting on its website that “the risk of death or long-term complications from COVID in adults still far exceeds the risk of any possible risk of Guillain-Barré syndrome by several orders of magnitude.”

None of the study authors reported financial conflicts of interest related to their research. Dr. Amato is an adviser to the pharmaceutical firms Alexion and Argenx, while Dr. Lisak has received research support or honoraria from Alexion, Novartis, Hoffmann–La Roche, and others.

The COVID-19 pandemic has worsened the health of patients with liver disease worldwide, researchers say.

Not only does liver disease make people more vulnerable to the virus that causes COVID-19, precautions to prevent its spread have delayed health care and worsened alcohol abuse.

At this year’s virtual International Liver Congress (ILC) 2021, experts from around the world documented this toll on their patients.

Surgeons have seen a surge in patients needing transplants because of alcoholic liver disease, the campaign to snuff out hepatitis C slowed down, and procedures such as endoscopy and ultrasound exams postponed, said Mario Mondelli, MD, PhD, a professor and consultant physician of infectious diseases at the University of Pavia, Italy.

“We were able to ensure only emergency treatments, not routine surveillance,” he said in an interview.

Of 1,994 people with chronic liver disease who responded to a survey through the Global Liver Registry, 11% reported that the pandemic had affected their liver health.

This proportion was not statistically different for the 165 patients (8.2%) who had been diagnosed with COVID-19 compared with those who had not. But many of those who had been diagnosed with COVID-19 reported that it severely affected them. They reported worse overall heath, more mental illness, and greater need for supportive service than those who evaded the virus. Thirty-three respondents (20.8%) were hospitalized.

The global effort to eradicate hepatitis C slowed as a result of the pandemic. Already in 2019, the United States was behind the World Health Organization schedule for eliminating this virus. In 2020, it slipped further, with 25% fewer patients starting treatment for hepatitis C than in 2019, according to researchers at the U.S. Centers for Disease Control and Prevention.

Similar delays in eliminating hepatitis C occurred around the world, Dr. Mondelli said, noting that the majority of countries will not be able to reach the WHO objectives.

One striking result of the pandemic was an uptick of patients needing liver transplants as a result of alcoholic liver disease, said George Cholankeril, MD, a liver transplant surgeon at Baylor College of Medicine, Houston.

Before the pandemic, he and his colleagues had noted an increase in the number of people needing liver transplants because of alcohol abuse. During the pandemic, that trend accelerated.

They defined the pre-COVID era as June 1, 2019, to Feb. 29, 2020, and the COVID era as after April 1, 2020. In the COVID era, alcoholic liver disease accounted for 40% of patients whom the hospital put on its list for liver transplant. Hepatitis C and nonalcoholic fatty liver disease combined accounted for only 36%.

The change has resulted in part from the effectiveness of hepatitis C treatments, which have reduced the number of patients with livers damaged by that virus. But the change also resulted from the increased severity of illness in the patients with alcoholic liver disease, Dr. Cholankeril said in an interview. Overall, Model for End-Stage Liver Disease scores – which are used to predict survival – worsened for patients with alcoholic liver disease but remained the same for patients with nonalcoholic liver disease.

In the pre-COVID era, patients with alcoholic liver disease had a 10% higher chance for undergoing transplant, compared with patients with nonalcoholic liver disease. In the COVID era, they had a 50% higher chance, a statistically significant change (P < .001).

The finding parallels those of other studies that have shown a spike in consults for alcohol-related gastrointestinal and liver diseases, as reported by this news organization.

“We feel that the increase in alcoholic hepatitis is possibly from binge drinking and alcoholic consumption during the pandemic,” said Dr. Cholankeril. “Anecdotally, I can’t tell you how many patients say that the video meetings for Alcoholic Anonymous just don’t work. It’s not the same as in person. They don’t feel that they’re getting the support that they need.”

In Europe, fewer of the people who need liver transplants may be receiving them, said Dr. Mondelli.

“There are several papers indicating, particularly in Italy, in France, and in the United Kingdom, that during the pandemic, the offer for organs significantly declined,” he said.

Other studies have shown increases in mortality from liver disease during the pandemic, Dr. Mondelli said. The same is true of myocardial infarction, cancer, and most other life-threatening illnesses, he pointed out.

“Because of the enormous tsunami that has affected hospital services during the peaks of the pandemic, there has been an increase in deceased patients from a variety of other diseases, not only liver disease,” he said.

But Dr. Mondelli also added that physicians had improved in their ability to safely care for their patients while protecting themselves over the course of the pandemic.

Dr. Mondelli and Dr. Cholankeril have disclosed no relevant financial relationships.

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

The COVID-19 pandemic has worsened the health of patients with liver disease worldwide, researchers say.

Not only does liver disease make people more vulnerable to the virus that causes COVID-19, precautions to prevent its spread have delayed health care and worsened alcohol abuse.

At this year’s virtual International Liver Congress (ILC) 2021, experts from around the world documented this toll on their patients.

Surgeons have seen a surge in patients needing transplants because of alcoholic liver disease, the campaign to snuff out hepatitis C slowed down, and procedures such as endoscopy and ultrasound exams postponed, said Mario Mondelli, MD, PhD, a professor and consultant physician of infectious diseases at the University of Pavia, Italy.

“We were able to ensure only emergency treatments, not routine surveillance,” he said in an interview.

Of 1,994 people with chronic liver disease who responded to a survey through the Global Liver Registry, 11% reported that the pandemic had affected their liver health.

This proportion was not statistically different for the 165 patients (8.2%) who had been diagnosed with COVID-19 compared with those who had not. But many of those who had been diagnosed with COVID-19 reported that it severely affected them. They reported worse overall heath, more mental illness, and greater need for supportive service than those who evaded the virus. Thirty-three respondents (20.8%) were hospitalized.

The global effort to eradicate hepatitis C slowed as a result of the pandemic. Already in 2019, the United States was behind the World Health Organization schedule for eliminating this virus. In 2020, it slipped further, with 25% fewer patients starting treatment for hepatitis C than in 2019, according to researchers at the U.S. Centers for Disease Control and Prevention.

Similar delays in eliminating hepatitis C occurred around the world, Dr. Mondelli said, noting that the majority of countries will not be able to reach the WHO objectives.

One striking result of the pandemic was an uptick of patients needing liver transplants as a result of alcoholic liver disease, said George Cholankeril, MD, a liver transplant surgeon at Baylor College of Medicine, Houston.

Before the pandemic, he and his colleagues had noted an increase in the number of people needing liver transplants because of alcohol abuse. During the pandemic, that trend accelerated.

They defined the pre-COVID era as June 1, 2019, to Feb. 29, 2020, and the COVID era as after April 1, 2020. In the COVID era, alcoholic liver disease accounted for 40% of patients whom the hospital put on its list for liver transplant. Hepatitis C and nonalcoholic fatty liver disease combined accounted for only 36%.

The change has resulted in part from the effectiveness of hepatitis C treatments, which have reduced the number of patients with livers damaged by that virus. But the change also resulted from the increased severity of illness in the patients with alcoholic liver disease, Dr. Cholankeril said in an interview. Overall, Model for End-Stage Liver Disease scores – which are used to predict survival – worsened for patients with alcoholic liver disease but remained the same for patients with nonalcoholic liver disease.

In the pre-COVID era, patients with alcoholic liver disease had a 10% higher chance for undergoing transplant, compared with patients with nonalcoholic liver disease. In the COVID era, they had a 50% higher chance, a statistically significant change (P < .001).

The finding parallels those of other studies that have shown a spike in consults for alcohol-related gastrointestinal and liver diseases, as reported by this news organization.

“We feel that the increase in alcoholic hepatitis is possibly from binge drinking and alcoholic consumption during the pandemic,” said Dr. Cholankeril. “Anecdotally, I can’t tell you how many patients say that the video meetings for Alcoholic Anonymous just don’t work. It’s not the same as in person. They don’t feel that they’re getting the support that they need.”

In Europe, fewer of the people who need liver transplants may be receiving them, said Dr. Mondelli.

“There are several papers indicating, particularly in Italy, in France, and in the United Kingdom, that during the pandemic, the offer for organs significantly declined,” he said.

Other studies have shown increases in mortality from liver disease during the pandemic, Dr. Mondelli said. The same is true of myocardial infarction, cancer, and most other life-threatening illnesses, he pointed out.

“Because of the enormous tsunami that has affected hospital services during the peaks of the pandemic, there has been an increase in deceased patients from a variety of other diseases, not only liver disease,” he said.

But Dr. Mondelli also added that physicians had improved in their ability to safely care for their patients while protecting themselves over the course of the pandemic.

Dr. Mondelli and Dr. Cholankeril have disclosed no relevant financial relationships.

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

The COVID-19 pandemic has worsened the health of patients with liver disease worldwide, researchers say.

Not only does liver disease make people more vulnerable to the virus that causes COVID-19, precautions to prevent its spread have delayed health care and worsened alcohol abuse.

At this year’s virtual International Liver Congress (ILC) 2021, experts from around the world documented this toll on their patients.

Surgeons have seen a surge in patients needing transplants because of alcoholic liver disease, the campaign to snuff out hepatitis C slowed down, and procedures such as endoscopy and ultrasound exams postponed, said Mario Mondelli, MD, PhD, a professor and consultant physician of infectious diseases at the University of Pavia, Italy.

“We were able to ensure only emergency treatments, not routine surveillance,” he said in an interview.

Of 1,994 people with chronic liver disease who responded to a survey through the Global Liver Registry, 11% reported that the pandemic had affected their liver health.

This proportion was not statistically different for the 165 patients (8.2%) who had been diagnosed with COVID-19 compared with those who had not. But many of those who had been diagnosed with COVID-19 reported that it severely affected them. They reported worse overall heath, more mental illness, and greater need for supportive service than those who evaded the virus. Thirty-three respondents (20.8%) were hospitalized.

The global effort to eradicate hepatitis C slowed as a result of the pandemic. Already in 2019, the United States was behind the World Health Organization schedule for eliminating this virus. In 2020, it slipped further, with 25% fewer patients starting treatment for hepatitis C than in 2019, according to researchers at the U.S. Centers for Disease Control and Prevention.

Similar delays in eliminating hepatitis C occurred around the world, Dr. Mondelli said, noting that the majority of countries will not be able to reach the WHO objectives.

One striking result of the pandemic was an uptick of patients needing liver transplants as a result of alcoholic liver disease, said George Cholankeril, MD, a liver transplant surgeon at Baylor College of Medicine, Houston.

Before the pandemic, he and his colleagues had noted an increase in the number of people needing liver transplants because of alcohol abuse. During the pandemic, that trend accelerated.

They defined the pre-COVID era as June 1, 2019, to Feb. 29, 2020, and the COVID era as after April 1, 2020. In the COVID era, alcoholic liver disease accounted for 40% of patients whom the hospital put on its list for liver transplant. Hepatitis C and nonalcoholic fatty liver disease combined accounted for only 36%.

The change has resulted in part from the effectiveness of hepatitis C treatments, which have reduced the number of patients with livers damaged by that virus. But the change also resulted from the increased severity of illness in the patients with alcoholic liver disease, Dr. Cholankeril said in an interview. Overall, Model for End-Stage Liver Disease scores – which are used to predict survival – worsened for patients with alcoholic liver disease but remained the same for patients with nonalcoholic liver disease.

In the pre-COVID era, patients with alcoholic liver disease had a 10% higher chance for undergoing transplant, compared with patients with nonalcoholic liver disease. In the COVID era, they had a 50% higher chance, a statistically significant change (P < .001).

The finding parallels those of other studies that have shown a spike in consults for alcohol-related gastrointestinal and liver diseases, as reported by this news organization.

“We feel that the increase in alcoholic hepatitis is possibly from binge drinking and alcoholic consumption during the pandemic,” said Dr. Cholankeril. “Anecdotally, I can’t tell you how many patients say that the video meetings for Alcoholic Anonymous just don’t work. It’s not the same as in person. They don’t feel that they’re getting the support that they need.”

In Europe, fewer of the people who need liver transplants may be receiving them, said Dr. Mondelli.

“There are several papers indicating, particularly in Italy, in France, and in the United Kingdom, that during the pandemic, the offer for organs significantly declined,” he said.

Other studies have shown increases in mortality from liver disease during the pandemic, Dr. Mondelli said. The same is true of myocardial infarction, cancer, and most other life-threatening illnesses, he pointed out.

“Because of the enormous tsunami that has affected hospital services during the peaks of the pandemic, there has been an increase in deceased patients from a variety of other diseases, not only liver disease,” he said.

But Dr. Mondelli also added that physicians had improved in their ability to safely care for their patients while protecting themselves over the course of the pandemic.

Dr. Mondelli and Dr. Cholankeril have disclosed no relevant financial relationships.

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

A 1-week course of doxycycline is more effective than single-dose azithromycin to treat rectal chlamydia in men who have sex with men (MSM), according to newly published results in the New England Journal of Medicine.

Chlamydia is the most commonly reported bacterial STI in the United States, with 4 million cases reported in 2018, and 127 million globally. Most infections are asymptomatic.

Rates of rectal chlamydia among MSM screened for infection range from 3% to 10.5%.

The most recent Centers for Disease Control and Prevention chlamydia guidelines recommend either a single dose of azithromycin (1 g) or doxycycline 100 mg twice daily for 7 days. These 2015 guidelines were based on a meta-analysis of urogenital chlamydia infections, which showed comparable efficacy of 97% or 98%, respectively.

Study coauthor Jane S. Hocking, PhD, head of the sexual health unit at the University of Melbourne, told this news organization that “observational studies had suggested that azithromycin was about 20% less effective than doxycycline,” prompting this clinical trial.

The study, conducted at five sexual health clinics in Australia, was a double-blind, randomized, controlled trial of doxycycline (100 mg twice daily for 7 days) or azithromycin (1-g single dose).

Because 85% of infected men are asymptomatic, the study’s primary outcome was a negative nucleic acid amplification test at 4 weeks, confirming a microbiologic cure.

Using a modified intention-to-treat population, the study showed a microbiologic cure in 281 of 290 men (96.9%) in the doxycycline group and 227 of 297 (76.4%) in the azithromycin group (P < .001).

Adverse events were more common in the azithromycin group. Nausea, diarrhea, and vomiting occurred in 134 (45.1%) men in that group versus 98 men (33.8%) in those receiving doxycycline (P = .006).

A similar study was reported in Clinical Infectious Diseases in February 2021 by Dombrowski and colleagues. It was also randomized, double blinded, and placebo controlled but was smaller and conducted in Seattle and Boston. A 20% difference was found, with 80/88 (91%) in the doxycycline group and 63/89 (71%) in the azithromycin group having a microbiologic cure at 4 weeks of follow-up.

Jeanne Marrazzo, MD, director of the division of infectious diseases at the University of Alabama at Birmingham, said in an interview that the researchers focused solely on asymptomatic proctitis because “other symptoms might indicate need for broader presumptive antibiotics” for coinfections. Similarly, symptomatic proctitis “could indicate LGV [lymphogranuloma venereum] chlamydia, which ... automatically mandates that 3-weeks of doxycycline be used.” Dr. Marrazzo concluded: “The fact that this was a blinded study obviously strengthens the conclusions/findings, which is great. It’s very reassuring that results overall are so consistent with the CID paper.” Dr. Marrazzo was not involved in either the New England Journal of Medicine investigation or CID study.

Ina Park, MD, associate professor in the department of family and community medicine at the University of California, San Francisco, and author of “Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STDs,” (New York: Flatiron Books, 2021) was not involved in either study but has a long history of working with adolescents in clinics for STDs. Based on that experience, she told this news organization that, while doxycycline now clearly appears to be the drug of choice, “if compliance is an issue and rectal chlamydia is not likely, then I think azithromycin is still something we need to consider, particularly for younger patients, and folks for whom compliance is going to be an issue.” She added: “with adolescent patients, there are issues of parents possibly discovering the antibiotic and asking lots of questions. So, it’s very nice for folks to be able to get therapy, sort of a one and done approach in the clinic.”

The 2020 CDC Guidelines for Gonococcal Infections says: “CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded.”

Hocking concluded – and Dr. Marrazzo and Dr. Park concur – that this study “provides conclusive evidence that doxycycline should be the first-line treatment for rectal chlamydia, but probably for just any chlamydia infection,” with specific exceptions.

The University of Melbourne researchers also noted that the doxycycline course requires more compliant patients, as adherence isn’t assured. The issue of compliance and need for directly observed therapy, allergy to doxycycline, and pregnancy (where doxycycline is contraindicated) will remain the primary indications for continued use of azithromycin.

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

A 1-week course of doxycycline is more effective than single-dose azithromycin to treat rectal chlamydia in men who have sex with men (MSM), according to newly published results in the New England Journal of Medicine.

Chlamydia is the most commonly reported bacterial STI in the United States, with 4 million cases reported in 2018, and 127 million globally. Most infections are asymptomatic.

Rates of rectal chlamydia among MSM screened for infection range from 3% to 10.5%.

The most recent Centers for Disease Control and Prevention chlamydia guidelines recommend either a single dose of azithromycin (1 g) or doxycycline 100 mg twice daily for 7 days. These 2015 guidelines were based on a meta-analysis of urogenital chlamydia infections, which showed comparable efficacy of 97% or 98%, respectively.

Study coauthor Jane S. Hocking, PhD, head of the sexual health unit at the University of Melbourne, told this news organization that “observational studies had suggested that azithromycin was about 20% less effective than doxycycline,” prompting this clinical trial.

The study, conducted at five sexual health clinics in Australia, was a double-blind, randomized, controlled trial of doxycycline (100 mg twice daily for 7 days) or azithromycin (1-g single dose).

Because 85% of infected men are asymptomatic, the study’s primary outcome was a negative nucleic acid amplification test at 4 weeks, confirming a microbiologic cure.

Using a modified intention-to-treat population, the study showed a microbiologic cure in 281 of 290 men (96.9%) in the doxycycline group and 227 of 297 (76.4%) in the azithromycin group (P < .001).

Adverse events were more common in the azithromycin group. Nausea, diarrhea, and vomiting occurred in 134 (45.1%) men in that group versus 98 men (33.8%) in those receiving doxycycline (P = .006).

A similar study was reported in Clinical Infectious Diseases in February 2021 by Dombrowski and colleagues. It was also randomized, double blinded, and placebo controlled but was smaller and conducted in Seattle and Boston. A 20% difference was found, with 80/88 (91%) in the doxycycline group and 63/89 (71%) in the azithromycin group having a microbiologic cure at 4 weeks of follow-up.

Jeanne Marrazzo, MD, director of the division of infectious diseases at the University of Alabama at Birmingham, said in an interview that the researchers focused solely on asymptomatic proctitis because “other symptoms might indicate need for broader presumptive antibiotics” for coinfections. Similarly, symptomatic proctitis “could indicate LGV [lymphogranuloma venereum] chlamydia, which ... automatically mandates that 3-weeks of doxycycline be used.” Dr. Marrazzo concluded: “The fact that this was a blinded study obviously strengthens the conclusions/findings, which is great. It’s very reassuring that results overall are so consistent with the CID paper.” Dr. Marrazzo was not involved in either the New England Journal of Medicine investigation or CID study.

Ina Park, MD, associate professor in the department of family and community medicine at the University of California, San Francisco, and author of “Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STDs,” (New York: Flatiron Books, 2021) was not involved in either study but has a long history of working with adolescents in clinics for STDs. Based on that experience, she told this news organization that, while doxycycline now clearly appears to be the drug of choice, “if compliance is an issue and rectal chlamydia is not likely, then I think azithromycin is still something we need to consider, particularly for younger patients, and folks for whom compliance is going to be an issue.” She added: “with adolescent patients, there are issues of parents possibly discovering the antibiotic and asking lots of questions. So, it’s very nice for folks to be able to get therapy, sort of a one and done approach in the clinic.”

The 2020 CDC Guidelines for Gonococcal Infections says: “CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded.”

Hocking concluded – and Dr. Marrazzo and Dr. Park concur – that this study “provides conclusive evidence that doxycycline should be the first-line treatment for rectal chlamydia, but probably for just any chlamydia infection,” with specific exceptions.

The University of Melbourne researchers also noted that the doxycycline course requires more compliant patients, as adherence isn’t assured. The issue of compliance and need for directly observed therapy, allergy to doxycycline, and pregnancy (where doxycycline is contraindicated) will remain the primary indications for continued use of azithromycin.

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

A 1-week course of doxycycline is more effective than single-dose azithromycin to treat rectal chlamydia in men who have sex with men (MSM), according to newly published results in the New England Journal of Medicine.

Chlamydia is the most commonly reported bacterial STI in the United States, with 4 million cases reported in 2018, and 127 million globally. Most infections are asymptomatic.

Rates of rectal chlamydia among MSM screened for infection range from 3% to 10.5%.

The most recent Centers for Disease Control and Prevention chlamydia guidelines recommend either a single dose of azithromycin (1 g) or doxycycline 100 mg twice daily for 7 days. These 2015 guidelines were based on a meta-analysis of urogenital chlamydia infections, which showed comparable efficacy of 97% or 98%, respectively.

Study coauthor Jane S. Hocking, PhD, head of the sexual health unit at the University of Melbourne, told this news organization that “observational studies had suggested that azithromycin was about 20% less effective than doxycycline,” prompting this clinical trial.

The study, conducted at five sexual health clinics in Australia, was a double-blind, randomized, controlled trial of doxycycline (100 mg twice daily for 7 days) or azithromycin (1-g single dose).

Because 85% of infected men are asymptomatic, the study’s primary outcome was a negative nucleic acid amplification test at 4 weeks, confirming a microbiologic cure.

Using a modified intention-to-treat population, the study showed a microbiologic cure in 281 of 290 men (96.9%) in the doxycycline group and 227 of 297 (76.4%) in the azithromycin group (P < .001).

Adverse events were more common in the azithromycin group. Nausea, diarrhea, and vomiting occurred in 134 (45.1%) men in that group versus 98 men (33.8%) in those receiving doxycycline (P = .006).

A similar study was reported in Clinical Infectious Diseases in February 2021 by Dombrowski and colleagues. It was also randomized, double blinded, and placebo controlled but was smaller and conducted in Seattle and Boston. A 20% difference was found, with 80/88 (91%) in the doxycycline group and 63/89 (71%) in the azithromycin group having a microbiologic cure at 4 weeks of follow-up.

Jeanne Marrazzo, MD, director of the division of infectious diseases at the University of Alabama at Birmingham, said in an interview that the researchers focused solely on asymptomatic proctitis because “other symptoms might indicate need for broader presumptive antibiotics” for coinfections. Similarly, symptomatic proctitis “could indicate LGV [lymphogranuloma venereum] chlamydia, which ... automatically mandates that 3-weeks of doxycycline be used.” Dr. Marrazzo concluded: “The fact that this was a blinded study obviously strengthens the conclusions/findings, which is great. It’s very reassuring that results overall are so consistent with the CID paper.” Dr. Marrazzo was not involved in either the New England Journal of Medicine investigation or CID study.

Ina Park, MD, associate professor in the department of family and community medicine at the University of California, San Francisco, and author of “Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STDs,” (New York: Flatiron Books, 2021) was not involved in either study but has a long history of working with adolescents in clinics for STDs. Based on that experience, she told this news organization that, while doxycycline now clearly appears to be the drug of choice, “if compliance is an issue and rectal chlamydia is not likely, then I think azithromycin is still something we need to consider, particularly for younger patients, and folks for whom compliance is going to be an issue.” She added: “with adolescent patients, there are issues of parents possibly discovering the antibiotic and asking lots of questions. So, it’s very nice for folks to be able to get therapy, sort of a one and done approach in the clinic.”

The 2020 CDC Guidelines for Gonococcal Infections says: “CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded.”

Hocking concluded – and Dr. Marrazzo and Dr. Park concur – that this study “provides conclusive evidence that doxycycline should be the first-line treatment for rectal chlamydia, but probably for just any chlamydia infection,” with specific exceptions.

The University of Melbourne researchers also noted that the doxycycline course requires more compliant patients, as adherence isn’t assured. The issue of compliance and need for directly observed therapy, allergy to doxycycline, and pregnancy (where doxycycline is contraindicated) will remain the primary indications for continued use of azithromycin.

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

If you, a friend, or a loved one remain unvaccinated against COVID-19 at this point – for whatever reason – you are at higher risk of dying if you become infected.

That’s the conclusion of a new report released by the Associated Press looking at COVID-19 deaths during May 2021.

Of more than 18,000 people who died from COVID-19, for example, only about 150 were fully vaccinated. That’s less than 1%.

“Recently, I was working in the emergency room [and] I saw a 21-year-old African American who came in with shortness of breath,” said Vino K. Palli, MD, MPH, a physician specializing in emergency medicine, internal medicine, and urgent care.

The patient rapidly deteriorated and required intubation and ventilation. She was transferred to a specialized hospital for possible extracorporeal membrane oxygenation (ECMO) treatment.

“This patient was unvaccinated, along with her entire family. This would have been easily preventable,” added Dr. Palli, who is also founder and CEO of MiDoctor Urgent Care in New York City.

“Vaccine misinformation, compounded with vaccine inertia and vaccine access, have contributed to this,” he added. “Even though we have a surplus amount of vaccines at this time, we are only seeing 50% to 55% of completely vaccinated patients.”

Authors of the Associated Press report also acknowledge that some people who are fully vaccinated can get a breakthrough infection. These occurred in fewer than 1,200 of more than 853,000 people hospitalized for COVID-19 in May, or about 0.1%.

The Associated Press came up with these numbers using data from the Centers for Disease Control and Prevention. The CDC tracks the numbers of cases, hospitalizations, and deaths but does not breakdown rates by vaccination status.  
 

Stronger argument for vaccination?

“The fact that only 0.8% of COVID-19 deaths are in the fully vaccinated should persuade those people still hesitant about vaccination,” said Hugh Cassiere, MD, medical director of Respiratory Therapy Services at North Shore University Hospital in Manhasset, New York.

Stuart C. Ray, MD, professor of medicine and oncology in the Division of Infectious Diseases at Johns Hopkins University, Baltimore, agreed. “It seems compelling, even for skeptics, that unvaccinated people represent 99% of those now dying from COVID-19 when they represent less than 50% of the adult population in the United States.”

The findings from the study could be more persuasive than previous arguments made in favor of immunization, Dr. Ray said. “These recent findings of striking reductions in risk of death in the vaccinated are more directly attributable and harder to ignore or dismiss.”

Brian Labus, PhD, MPH, of the University of Nevada Las Vegas (UNLV) is less convinced. “While this might change some peoples’ minds, it probably won’t make a major difference. People have many different reasons for not getting vaccinated, and this is only one of the things they consider.”

The study adds information that was not available before, said Dr. Labus, assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health. “We study the vaccine under tightly controlled, ideal conditions. This is the evidence that it works as well in the real world as it did in the trials, and that is what is most important in implementing a vaccination program,” added Dr. Labus.

“The scientific data has honed in on one thing: Vaccines are effective in preventing hospitalizations, ICU admissions, ventilations, and deaths,” agreed Dr. Palli.

“We now know that almost all deaths occurred in patients who were not vaccinated. We also know that all vaccines are effective against various strains that are in circulation right now, including the Delta variant, which is rapidly spreading,” Dr. Palli said.

Dr. Cassiere pointed out that the unvaccinated are not only at higher risk of developing COVID-19 but also of spreading, being hospitalized for, and dying from the infection. Avoiding “long hauler” symptoms is another argument in favor of immunization, he added.

As of June 28, the CDC reports that 63% of Americans 12 years and older have received at least one dose of a COVID-19 vaccine, and 54% are fully vaccinated.
 

Worldwide worry?

Although overall rates of U.S. COVID-19 hospitalizations and deaths are down, the outlook may not remain as encouraging. “I hope I’m wrong about this, but I anticipate that the coming fall and winter will bring increasingly localized versions of similar findings – severe disease and death due to SARS-CoV-2 infection in regions or groups with lower vaccination rates,” Dr. Ray said.

There could be a silver lining, he added: “If this unfortunate surge occurs, the health and economic consequences seem likely to erode much of the remaining hesitancy regarding vaccination.”

The rise of more infectious SARS-CoV-2 variants, such as the Delta variant, could also throw a wrench in controlling COVID-19. “This isn’t just a domestic issue,” Dr. Ray said. “We have learned that the world is a small place in pandemic times.”

The Associated Press investigators state that their findings support the high efficacy of the vaccine. Also, given the current widespread availability of COVID-19 vaccines in the United States, they believe many of the COVID-19 deaths now occurring are preventable.

Public health measures should have continued longer to protect unvaccinated individuals, especially Black Americans, Hispanic Americans, and other minorities, Dr. Palli said. “Only time will tell if re-opening and abandoning all public health measures by the CDC was premature.”

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

If you, a friend, or a loved one remain unvaccinated against COVID-19 at this point – for whatever reason – you are at higher risk of dying if you become infected.

That’s the conclusion of a new report released by the Associated Press looking at COVID-19 deaths during May 2021.

Of more than 18,000 people who died from COVID-19, for example, only about 150 were fully vaccinated. That’s less than 1%.

“Recently, I was working in the emergency room [and] I saw a 21-year-old African American who came in with shortness of breath,” said Vino K. Palli, MD, MPH, a physician specializing in emergency medicine, internal medicine, and urgent care.

The patient rapidly deteriorated and required intubation and ventilation. She was transferred to a specialized hospital for possible extracorporeal membrane oxygenation (ECMO) treatment.

“This patient was unvaccinated, along with her entire family. This would have been easily preventable,” added Dr. Palli, who is also founder and CEO of MiDoctor Urgent Care in New York City.

“Vaccine misinformation, compounded with vaccine inertia and vaccine access, have contributed to this,” he added. “Even though we have a surplus amount of vaccines at this time, we are only seeing 50% to 55% of completely vaccinated patients.”

Authors of the Associated Press report also acknowledge that some people who are fully vaccinated can get a breakthrough infection. These occurred in fewer than 1,200 of more than 853,000 people hospitalized for COVID-19 in May, or about 0.1%.

The Associated Press came up with these numbers using data from the Centers for Disease Control and Prevention. The CDC tracks the numbers of cases, hospitalizations, and deaths but does not breakdown rates by vaccination status.  
 

Stronger argument for vaccination?

“The fact that only 0.8% of COVID-19 deaths are in the fully vaccinated should persuade those people still hesitant about vaccination,” said Hugh Cassiere, MD, medical director of Respiratory Therapy Services at North Shore University Hospital in Manhasset, New York.

Stuart C. Ray, MD, professor of medicine and oncology in the Division of Infectious Diseases at Johns Hopkins University, Baltimore, agreed. “It seems compelling, even for skeptics, that unvaccinated people represent 99% of those now dying from COVID-19 when they represent less than 50% of the adult population in the United States.”

The findings from the study could be more persuasive than previous arguments made in favor of immunization, Dr. Ray said. “These recent findings of striking reductions in risk of death in the vaccinated are more directly attributable and harder to ignore or dismiss.”

Brian Labus, PhD, MPH, of the University of Nevada Las Vegas (UNLV) is less convinced. “While this might change some peoples’ minds, it probably won’t make a major difference. People have many different reasons for not getting vaccinated, and this is only one of the things they consider.”

The study adds information that was not available before, said Dr. Labus, assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health. “We study the vaccine under tightly controlled, ideal conditions. This is the evidence that it works as well in the real world as it did in the trials, and that is what is most important in implementing a vaccination program,” added Dr. Labus.

“The scientific data has honed in on one thing: Vaccines are effective in preventing hospitalizations, ICU admissions, ventilations, and deaths,” agreed Dr. Palli.

“We now know that almost all deaths occurred in patients who were not vaccinated. We also know that all vaccines are effective against various strains that are in circulation right now, including the Delta variant, which is rapidly spreading,” Dr. Palli said.

Dr. Cassiere pointed out that the unvaccinated are not only at higher risk of developing COVID-19 but also of spreading, being hospitalized for, and dying from the infection. Avoiding “long hauler” symptoms is another argument in favor of immunization, he added.

As of June 28, the CDC reports that 63% of Americans 12 years and older have received at least one dose of a COVID-19 vaccine, and 54% are fully vaccinated.
 

Worldwide worry?

Although overall rates of U.S. COVID-19 hospitalizations and deaths are down, the outlook may not remain as encouraging. “I hope I’m wrong about this, but I anticipate that the coming fall and winter will bring increasingly localized versions of similar findings – severe disease and death due to SARS-CoV-2 infection in regions or groups with lower vaccination rates,” Dr. Ray said.

There could be a silver lining, he added: “If this unfortunate surge occurs, the health and economic consequences seem likely to erode much of the remaining hesitancy regarding vaccination.”

The rise of more infectious SARS-CoV-2 variants, such as the Delta variant, could also throw a wrench in controlling COVID-19. “This isn’t just a domestic issue,” Dr. Ray said. “We have learned that the world is a small place in pandemic times.”

The Associated Press investigators state that their findings support the high efficacy of the vaccine. Also, given the current widespread availability of COVID-19 vaccines in the United States, they believe many of the COVID-19 deaths now occurring are preventable.

Public health measures should have continued longer to protect unvaccinated individuals, especially Black Americans, Hispanic Americans, and other minorities, Dr. Palli said. “Only time will tell if re-opening and abandoning all public health measures by the CDC was premature.”

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

If you, a friend, or a loved one remain unvaccinated against COVID-19 at this point – for whatever reason – you are at higher risk of dying if you become infected.

That’s the conclusion of a new report released by the Associated Press looking at COVID-19 deaths during May 2021.

Of more than 18,000 people who died from COVID-19, for example, only about 150 were fully vaccinated. That’s less than 1%.

“Recently, I was working in the emergency room [and] I saw a 21-year-old African American who came in with shortness of breath,” said Vino K. Palli, MD, MPH, a physician specializing in emergency medicine, internal medicine, and urgent care.

The patient rapidly deteriorated and required intubation and ventilation. She was transferred to a specialized hospital for possible extracorporeal membrane oxygenation (ECMO) treatment.

“This patient was unvaccinated, along with her entire family. This would have been easily preventable,” added Dr. Palli, who is also founder and CEO of MiDoctor Urgent Care in New York City.

“Vaccine misinformation, compounded with vaccine inertia and vaccine access, have contributed to this,” he added. “Even though we have a surplus amount of vaccines at this time, we are only seeing 50% to 55% of completely vaccinated patients.”

Authors of the Associated Press report also acknowledge that some people who are fully vaccinated can get a breakthrough infection. These occurred in fewer than 1,200 of more than 853,000 people hospitalized for COVID-19 in May, or about 0.1%.

The Associated Press came up with these numbers using data from the Centers for Disease Control and Prevention. The CDC tracks the numbers of cases, hospitalizations, and deaths but does not breakdown rates by vaccination status.  
 

Stronger argument for vaccination?

“The fact that only 0.8% of COVID-19 deaths are in the fully vaccinated should persuade those people still hesitant about vaccination,” said Hugh Cassiere, MD, medical director of Respiratory Therapy Services at North Shore University Hospital in Manhasset, New York.

Stuart C. Ray, MD, professor of medicine and oncology in the Division of Infectious Diseases at Johns Hopkins University, Baltimore, agreed. “It seems compelling, even for skeptics, that unvaccinated people represent 99% of those now dying from COVID-19 when they represent less than 50% of the adult population in the United States.”

The findings from the study could be more persuasive than previous arguments made in favor of immunization, Dr. Ray said. “These recent findings of striking reductions in risk of death in the vaccinated are more directly attributable and harder to ignore or dismiss.”

Brian Labus, PhD, MPH, of the University of Nevada Las Vegas (UNLV) is less convinced. “While this might change some peoples’ minds, it probably won’t make a major difference. People have many different reasons for not getting vaccinated, and this is only one of the things they consider.”

The study adds information that was not available before, said Dr. Labus, assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health. “We study the vaccine under tightly controlled, ideal conditions. This is the evidence that it works as well in the real world as it did in the trials, and that is what is most important in implementing a vaccination program,” added Dr. Labus.

“The scientific data has honed in on one thing: Vaccines are effective in preventing hospitalizations, ICU admissions, ventilations, and deaths,” agreed Dr. Palli.

“We now know that almost all deaths occurred in patients who were not vaccinated. We also know that all vaccines are effective against various strains that are in circulation right now, including the Delta variant, which is rapidly spreading,” Dr. Palli said.

Dr. Cassiere pointed out that the unvaccinated are not only at higher risk of developing COVID-19 but also of spreading, being hospitalized for, and dying from the infection. Avoiding “long hauler” symptoms is another argument in favor of immunization, he added.

As of June 28, the CDC reports that 63% of Americans 12 years and older have received at least one dose of a COVID-19 vaccine, and 54% are fully vaccinated.
 

Worldwide worry?

Although overall rates of U.S. COVID-19 hospitalizations and deaths are down, the outlook may not remain as encouraging. “I hope I’m wrong about this, but I anticipate that the coming fall and winter will bring increasingly localized versions of similar findings – severe disease and death due to SARS-CoV-2 infection in regions or groups with lower vaccination rates,” Dr. Ray said.

There could be a silver lining, he added: “If this unfortunate surge occurs, the health and economic consequences seem likely to erode much of the remaining hesitancy regarding vaccination.”

The rise of more infectious SARS-CoV-2 variants, such as the Delta variant, could also throw a wrench in controlling COVID-19. “This isn’t just a domestic issue,” Dr. Ray said. “We have learned that the world is a small place in pandemic times.”

The Associated Press investigators state that their findings support the high efficacy of the vaccine. Also, given the current widespread availability of COVID-19 vaccines in the United States, they believe many of the COVID-19 deaths now occurring are preventable.

Public health measures should have continued longer to protect unvaccinated individuals, especially Black Americans, Hispanic Americans, and other minorities, Dr. Palli said. “Only time will tell if re-opening and abandoning all public health measures by the CDC was premature.”

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

Even though less than 21% of all children aged 12-15 years are fully vaccinated against COVID-19, the number seeking first vaccinations continues to decline, according to data from the Centers for Disease Control and Prevention.

Just over 283,000 children aged 12-15 received a first vaccination during the week ending June 28, compared with almost 420,000 for the week ending June 21 and 462,000 during the week ending June 14. Collectively, 30.2% of 12- to 15-year-olds have gotten at least one dose of vaccine so far and 20.7% are now fully vaccinated, the CDC said on its COVID Data Tracker site.

Among children aged 16-17 years, who were able to start the vaccination process earlier, 42.9% have received at least one dose and 34.0% have completed the COVID-19 vaccine regimen. Vaccine initiation – measured as the proportion of all individuals getting a first shot over the previous 2 weeks – has been consistently around 4.8% during the month of June for this age group but has dropped from 17.9% on June 7 to 14.3% on June 28 for those aged 12-15, the CDC data show.

Looking at the same measure for vaccine completion, 16.7% of all those who reached full vaccination status in the 14 days ending June 28 were 12- to 15-years-olds, down from 21.5% on June 21 and 19.6% on June 14. The numbers for those aged 15-16 were, respectively, 4.6%, 4.5%, and 4.2%, the CDC reported.

Fortunately, in the wake of recent vaccination trends, new cases of COVID-19 in children were down to their lowest level – just 8,447 for the week ending June 24 – since May of 2020, according to a new report from the American Academy of Pediatrics and the Children’s Hospital Association.

New cases had been well over 15,000 the previous week (June 17), following weeks of 14,000 (June 10) and 16,000 (June 3) new cases, so the latest drop down to just four digits represents a 1-week decline of over 46% in the 49 states (excluding New York) that are reporting age distribution, along with the District of Columbia, New York City, Puerto Rico, and Guam.

The cumulative number of child COVID-19 cases in those jurisdictions is about 4.03 million since the beginning of the pandemic, which represents 14.2% of all cases in the United States. At the state level, the cumulative rate of cases in children is highest in Vermont (22.7%) and lowest in Florida (8.9%), which uses an age range of 0-14 years for children, compared with 0-17 or 0-19 for most states, the AAP and CHA said.

Severe illness has been rare in children, which is reflected in the proportion of children among all hospitalizations, 2.2% in 24 jurisdictions, and the proportion of deaths, 0.06% in 46 jurisdictions, since the start of the pandemic, the AAP and CHA said, with a total of 336 COVID-19–related deaths reported.

rfranki@mdedge.com

Even though less than 21% of all children aged 12-15 years are fully vaccinated against COVID-19, the number seeking first vaccinations continues to decline, according to data from the Centers for Disease Control and Prevention.

Just over 283,000 children aged 12-15 received a first vaccination during the week ending June 28, compared with almost 420,000 for the week ending June 21 and 462,000 during the week ending June 14. Collectively, 30.2% of 12- to 15-year-olds have gotten at least one dose of vaccine so far and 20.7% are now fully vaccinated, the CDC said on its COVID Data Tracker site.

Among children aged 16-17 years, who were able to start the vaccination process earlier, 42.9% have received at least one dose and 34.0% have completed the COVID-19 vaccine regimen. Vaccine initiation – measured as the proportion of all individuals getting a first shot over the previous 2 weeks – has been consistently around 4.8% during the month of June for this age group but has dropped from 17.9% on June 7 to 14.3% on June 28 for those aged 12-15, the CDC data show.

Looking at the same measure for vaccine completion, 16.7% of all those who reached full vaccination status in the 14 days ending June 28 were 12- to 15-years-olds, down from 21.5% on June 21 and 19.6% on June 14. The numbers for those aged 15-16 were, respectively, 4.6%, 4.5%, and 4.2%, the CDC reported.

Fortunately, in the wake of recent vaccination trends, new cases of COVID-19 in children were down to their lowest level – just 8,447 for the week ending June 24 – since May of 2020, according to a new report from the American Academy of Pediatrics and the Children’s Hospital Association.

New cases had been well over 15,000 the previous week (June 17), following weeks of 14,000 (June 10) and 16,000 (June 3) new cases, so the latest drop down to just four digits represents a 1-week decline of over 46% in the 49 states (excluding New York) that are reporting age distribution, along with the District of Columbia, New York City, Puerto Rico, and Guam.

The cumulative number of child COVID-19 cases in those jurisdictions is about 4.03 million since the beginning of the pandemic, which represents 14.2% of all cases in the United States. At the state level, the cumulative rate of cases in children is highest in Vermont (22.7%) and lowest in Florida (8.9%), which uses an age range of 0-14 years for children, compared with 0-17 or 0-19 for most states, the AAP and CHA said.

Severe illness has been rare in children, which is reflected in the proportion of children among all hospitalizations, 2.2% in 24 jurisdictions, and the proportion of deaths, 0.06% in 46 jurisdictions, since the start of the pandemic, the AAP and CHA said, with a total of 336 COVID-19–related deaths reported.

rfranki@mdedge.com

Even though less than 21% of all children aged 12-15 years are fully vaccinated against COVID-19, the number seeking first vaccinations continues to decline, according to data from the Centers for Disease Control and Prevention.

Just over 283,000 children aged 12-15 received a first vaccination during the week ending June 28, compared with almost 420,000 for the week ending June 21 and 462,000 during the week ending June 14. Collectively, 30.2% of 12- to 15-year-olds have gotten at least one dose of vaccine so far and 20.7% are now fully vaccinated, the CDC said on its COVID Data Tracker site.

Among children aged 16-17 years, who were able to start the vaccination process earlier, 42.9% have received at least one dose and 34.0% have completed the COVID-19 vaccine regimen. Vaccine initiation – measured as the proportion of all individuals getting a first shot over the previous 2 weeks – has been consistently around 4.8% during the month of June for this age group but has dropped from 17.9% on June 7 to 14.3% on June 28 for those aged 12-15, the CDC data show.

Looking at the same measure for vaccine completion, 16.7% of all those who reached full vaccination status in the 14 days ending June 28 were 12- to 15-years-olds, down from 21.5% on June 21 and 19.6% on June 14. The numbers for those aged 15-16 were, respectively, 4.6%, 4.5%, and 4.2%, the CDC reported.

Fortunately, in the wake of recent vaccination trends, new cases of COVID-19 in children were down to their lowest level – just 8,447 for the week ending June 24 – since May of 2020, according to a new report from the American Academy of Pediatrics and the Children’s Hospital Association.

New cases had been well over 15,000 the previous week (June 17), following weeks of 14,000 (June 10) and 16,000 (June 3) new cases, so the latest drop down to just four digits represents a 1-week decline of over 46% in the 49 states (excluding New York) that are reporting age distribution, along with the District of Columbia, New York City, Puerto Rico, and Guam.

The cumulative number of child COVID-19 cases in those jurisdictions is about 4.03 million since the beginning of the pandemic, which represents 14.2% of all cases in the United States. At the state level, the cumulative rate of cases in children is highest in Vermont (22.7%) and lowest in Florida (8.9%), which uses an age range of 0-14 years for children, compared with 0-17 or 0-19 for most states, the AAP and CHA said.

Severe illness has been rare in children, which is reflected in the proportion of children among all hospitalizations, 2.2% in 24 jurisdictions, and the proportion of deaths, 0.06% in 46 jurisdictions, since the start of the pandemic, the AAP and CHA said, with a total of 336 COVID-19–related deaths reported.

rfranki@mdedge.com

Medscape’s Medical Power Couples is a new series highlighting spouses or domestic partners prominent in health care. Both have achieved high-level professional success and have made significant contributions to their respective fields.

When people started dying from lethal anthrax spores sent through the mail in 2001, infectious disease expert Jeannette Guarner, MD, was called to Florida and Connecticut to analyze the bodies. She and her pathology team investigated how the bacteria had entered the victims and examined tissue samples from across the country to discern the scale of the attacks.

In their own words

What was one of your most surprising discoveries?

Jeannette: During the anthrax attacks, we received lots of tissues on live patients, particularly skin biopsies from different parts of the country where pathologists had concerns that there was anthrax. From New York, we received more than 50 skin biopsies and discovered that the necrotic lesions suspected of anthrax had Rickettsia in them. In other words, we discovered that rickettsialpox – a mite-borne infectious disease – was circulating in the city, which was unknown at the time.

Describe a challenge that you overcame:

Carlos: When I was appointed as director of the National AIDS Council of Mexico (CONASIDA), I was quite young, only 32 years old. I had to learn to listen to others who had expertise and institutional memory, to respect their opinions, and at the same time to push for change. A huge challenge was the role of the Catholic Church and conservative groups that were adamantly against condom promotion. Thus, I learned how to advance policies based in science without being confrontational.

Have you ever been famous for anything other than your work?

Jeannette: In 2017, a tree fell on our house during Hurricane Irma. It fell right on my husband’s office a few minutes after he left the room. Fortunately, I have always been small and flexible, and I crawled through the rubble to save our valuables before they were ruined by the rain. Later, a local Atlanta TV news crew was in the neighborhood reporting on the damage, and I told them to come to our house if they wanted to see real damage. That night, we were on the local news.
 

Power couple Paul and Mary Klotman

When Mary Klotman, MD, was offered an opportunity with the National Institutes of Health in 1991, Paul Klotman, MD, didn’t hesitate to resign his post at Duke University, Durham, N.C., and join his wife in Washington. Paul says he wanted to support Mary’s aspirations, even though it meant an uncertain track for his own career.

Fortunately for the Klotmans, the move proved instrumental for both of their careers and spurred one of their proudest scientific breakthroughs.

At NIH, Mary was a member of the Public Health Service and worked in the laboratory of tumor cell biology, and Paul became chief of the institute’s molecular medicine section in the laboratory of developmental biology. Together, their work led to the first animal model of HIV-associated nephropathy using transgenic techniques. The Klotmans and their team demonstrated that HIV resides in and evolves separately in kidney cells, a critical step in HIV-associated kidney disease.

“That’s where our longstanding collaboration around HIV-associated nephropathy started,” Mary says. “Paul and I have a passion for research, and we’ve had the same grant together for 25 years.”

After their successful stint at NIH, the Klotmans next climbed the ranks at the Icahn School of Medicine at Mount Sinai, where Paul started as chief of the nephrology division and became chair of medicine, and Mary became chief of infectious diseases and co-director of Mount Sinai’s Global Health and Emerging Pathogens Institute.

Today, Mary and Paul are the first – and only – married couple in the United States to lead separate medical schools. Mary is dean and vice chancellor for health affairs at Duke, and Paul is president and executive dean of Baylor College of Medicine, Houston.

Despite their 1,100-mile separation, the Klotmans manage their relationship in an unconventional way that some might balk at: Every Friday, one spouse hops on a plane and travels to the other for a date night and weekend.

“When we started this crazy lifestyle, we committed to being together every weekend,” says Mary. “And in 10 years – before COVID – we missed only one weekend together.”

The Klotmans say the scheduled time together places a hard end to each work week and enables them to truly enjoy their quality time.

“Friday at noon, I’m on the plane going to Durham, and I know that in 2 hours I’m going to have a date with my wife,” Paul said. “There are institutions that we’ve run into that think you have to be 7 days a week on site. But Duke and Baylor have been very supportive [of our situation].”

No doubt, the arrangement means a lot of time in the air for the couple. Paul says he travels about 150,000 miles every year by plane.

Having dual leadership positions in academic medicine has kept the Klotmans tightly connected, and the couple says their strong partnership has contributed to their success.

“It’s really been helpful having a deep understanding of our career paths, because we’ve been able to understand when one of us needed to be really focused on work and the other one would step back a bit with the kids and vice versa,” Mary said.

“There’s no question that we wouldn’t be in the positions we are in now if it weren’t for the fact that we’ve had each other,” Paul said.

In their own words

What is a little-known title that you have?

Paul: Purse-carrier for my wife. When she is honored at a national meeting or event, she often stands up and hands me her purse. I now make sure I have on an appropriate outfit that matches the purse.

Tell us about your children.

Mary: We had a very traumatic first pregnancy that we lost. Six years later, we adopted our first child, which was an amazing blessing. Our second son was Duke’s first successful frozen embryo transfer.

Describe a memorable moment in your relationship.

Paul: As we were leaving for our honeymoon, Mary’s dad handed me this booklet. It was the receipts for Mary’s medical school loans for the next 10 years. He said, “Congratulations, she’s all yours!”

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

Medscape’s Medical Power Couples is a new series highlighting spouses or domestic partners prominent in health care. Both have achieved high-level professional success and have made significant contributions to their respective fields.

When people started dying from lethal anthrax spores sent through the mail in 2001, infectious disease expert Jeannette Guarner, MD, was called to Florida and Connecticut to analyze the bodies. She and her pathology team investigated how the bacteria had entered the victims and examined tissue samples from across the country to discern the scale of the attacks.

In their own words

What was one of your most surprising discoveries?

Jeannette: During the anthrax attacks, we received lots of tissues on live patients, particularly skin biopsies from different parts of the country where pathologists had concerns that there was anthrax. From New York, we received more than 50 skin biopsies and discovered that the necrotic lesions suspected of anthrax had Rickettsia in them. In other words, we discovered that rickettsialpox – a mite-borne infectious disease – was circulating in the city, which was unknown at the time.

Describe a challenge that you overcame:

Carlos: When I was appointed as director of the National AIDS Council of Mexico (CONASIDA), I was quite young, only 32 years old. I had to learn to listen to others who had expertise and institutional memory, to respect their opinions, and at the same time to push for change. A huge challenge was the role of the Catholic Church and conservative groups that were adamantly against condom promotion. Thus, I learned how to advance policies based in science without being confrontational.

Have you ever been famous for anything other than your work?

Jeannette: In 2017, a tree fell on our house during Hurricane Irma. It fell right on my husband’s office a few minutes after he left the room. Fortunately, I have always been small and flexible, and I crawled through the rubble to save our valuables before they were ruined by the rain. Later, a local Atlanta TV news crew was in the neighborhood reporting on the damage, and I told them to come to our house if they wanted to see real damage. That night, we were on the local news.
 

Power couple Paul and Mary Klotman

When Mary Klotman, MD, was offered an opportunity with the National Institutes of Health in 1991, Paul Klotman, MD, didn’t hesitate to resign his post at Duke University, Durham, N.C., and join his wife in Washington. Paul says he wanted to support Mary’s aspirations, even though it meant an uncertain track for his own career.

Fortunately for the Klotmans, the move proved instrumental for both of their careers and spurred one of their proudest scientific breakthroughs.

At NIH, Mary was a member of the Public Health Service and worked in the laboratory of tumor cell biology, and Paul became chief of the institute’s molecular medicine section in the laboratory of developmental biology. Together, their work led to the first animal model of HIV-associated nephropathy using transgenic techniques. The Klotmans and their team demonstrated that HIV resides in and evolves separately in kidney cells, a critical step in HIV-associated kidney disease.

“That’s where our longstanding collaboration around HIV-associated nephropathy started,” Mary says. “Paul and I have a passion for research, and we’ve had the same grant together for 25 years.”

After their successful stint at NIH, the Klotmans next climbed the ranks at the Icahn School of Medicine at Mount Sinai, where Paul started as chief of the nephrology division and became chair of medicine, and Mary became chief of infectious diseases and co-director of Mount Sinai’s Global Health and Emerging Pathogens Institute.

Today, Mary and Paul are the first – and only – married couple in the United States to lead separate medical schools. Mary is dean and vice chancellor for health affairs at Duke, and Paul is president and executive dean of Baylor College of Medicine, Houston.

Despite their 1,100-mile separation, the Klotmans manage their relationship in an unconventional way that some might balk at: Every Friday, one spouse hops on a plane and travels to the other for a date night and weekend.

“When we started this crazy lifestyle, we committed to being together every weekend,” says Mary. “And in 10 years – before COVID – we missed only one weekend together.”

The Klotmans say the scheduled time together places a hard end to each work week and enables them to truly enjoy their quality time.

“Friday at noon, I’m on the plane going to Durham, and I know that in 2 hours I’m going to have a date with my wife,” Paul said. “There are institutions that we’ve run into that think you have to be 7 days a week on site. But Duke and Baylor have been very supportive [of our situation].”

No doubt, the arrangement means a lot of time in the air for the couple. Paul says he travels about 150,000 miles every year by plane.

Having dual leadership positions in academic medicine has kept the Klotmans tightly connected, and the couple says their strong partnership has contributed to their success.

“It’s really been helpful having a deep understanding of our career paths, because we’ve been able to understand when one of us needed to be really focused on work and the other one would step back a bit with the kids and vice versa,” Mary said.

“There’s no question that we wouldn’t be in the positions we are in now if it weren’t for the fact that we’ve had each other,” Paul said.

In their own words

What is a little-known title that you have?

Paul: Purse-carrier for my wife. When she is honored at a national meeting or event, she often stands up and hands me her purse. I now make sure I have on an appropriate outfit that matches the purse.

Tell us about your children.

Mary: We had a very traumatic first pregnancy that we lost. Six years later, we adopted our first child, which was an amazing blessing. Our second son was Duke’s first successful frozen embryo transfer.

Describe a memorable moment in your relationship.

Paul: As we were leaving for our honeymoon, Mary’s dad handed me this booklet. It was the receipts for Mary’s medical school loans for the next 10 years. He said, “Congratulations, she’s all yours!”

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

Medscape’s Medical Power Couples is a new series highlighting spouses or domestic partners prominent in health care. Both have achieved high-level professional success and have made significant contributions to their respective fields.

When people started dying from lethal anthrax spores sent through the mail in 2001, infectious disease expert Jeannette Guarner, MD, was called to Florida and Connecticut to analyze the bodies. She and her pathology team investigated how the bacteria had entered the victims and examined tissue samples from across the country to discern the scale of the attacks.

In their own words

What was one of your most surprising discoveries?

Jeannette: During the anthrax attacks, we received lots of tissues on live patients, particularly skin biopsies from different parts of the country where pathologists had concerns that there was anthrax. From New York, we received more than 50 skin biopsies and discovered that the necrotic lesions suspected of anthrax had Rickettsia in them. In other words, we discovered that rickettsialpox – a mite-borne infectious disease – was circulating in the city, which was unknown at the time.

Describe a challenge that you overcame:

Carlos: When I was appointed as director of the National AIDS Council of Mexico (CONASIDA), I was quite young, only 32 years old. I had to learn to listen to others who had expertise and institutional memory, to respect their opinions, and at the same time to push for change. A huge challenge was the role of the Catholic Church and conservative groups that were adamantly against condom promotion. Thus, I learned how to advance policies based in science without being confrontational.

Have you ever been famous for anything other than your work?

Jeannette: In 2017, a tree fell on our house during Hurricane Irma. It fell right on my husband’s office a few minutes after he left the room. Fortunately, I have always been small and flexible, and I crawled through the rubble to save our valuables before they were ruined by the rain. Later, a local Atlanta TV news crew was in the neighborhood reporting on the damage, and I told them to come to our house if they wanted to see real damage. That night, we were on the local news.
 

Power couple Paul and Mary Klotman

When Mary Klotman, MD, was offered an opportunity with the National Institutes of Health in 1991, Paul Klotman, MD, didn’t hesitate to resign his post at Duke University, Durham, N.C., and join his wife in Washington. Paul says he wanted to support Mary’s aspirations, even though it meant an uncertain track for his own career.

Fortunately for the Klotmans, the move proved instrumental for both of their careers and spurred one of their proudest scientific breakthroughs.

At NIH, Mary was a member of the Public Health Service and worked in the laboratory of tumor cell biology, and Paul became chief of the institute’s molecular medicine section in the laboratory of developmental biology. Together, their work led to the first animal model of HIV-associated nephropathy using transgenic techniques. The Klotmans and their team demonstrated that HIV resides in and evolves separately in kidney cells, a critical step in HIV-associated kidney disease.

“That’s where our longstanding collaboration around HIV-associated nephropathy started,” Mary says. “Paul and I have a passion for research, and we’ve had the same grant together for 25 years.”

After their successful stint at NIH, the Klotmans next climbed the ranks at the Icahn School of Medicine at Mount Sinai, where Paul started as chief of the nephrology division and became chair of medicine, and Mary became chief of infectious diseases and co-director of Mount Sinai’s Global Health and Emerging Pathogens Institute.

Today, Mary and Paul are the first – and only – married couple in the United States to lead separate medical schools. Mary is dean and vice chancellor for health affairs at Duke, and Paul is president and executive dean of Baylor College of Medicine, Houston.

Despite their 1,100-mile separation, the Klotmans manage their relationship in an unconventional way that some might balk at: Every Friday, one spouse hops on a plane and travels to the other for a date night and weekend.

“When we started this crazy lifestyle, we committed to being together every weekend,” says Mary. “And in 10 years – before COVID – we missed only one weekend together.”

The Klotmans say the scheduled time together places a hard end to each work week and enables them to truly enjoy their quality time.

“Friday at noon, I’m on the plane going to Durham, and I know that in 2 hours I’m going to have a date with my wife,” Paul said. “There are institutions that we’ve run into that think you have to be 7 days a week on site. But Duke and Baylor have been very supportive [of our situation].”

No doubt, the arrangement means a lot of time in the air for the couple. Paul says he travels about 150,000 miles every year by plane.

Having dual leadership positions in academic medicine has kept the Klotmans tightly connected, and the couple says their strong partnership has contributed to their success.

“It’s really been helpful having a deep understanding of our career paths, because we’ve been able to understand when one of us needed to be really focused on work and the other one would step back a bit with the kids and vice versa,” Mary said.

“There’s no question that we wouldn’t be in the positions we are in now if it weren’t for the fact that we’ve had each other,” Paul said.

In their own words

What is a little-known title that you have?

Paul: Purse-carrier for my wife. When she is honored at a national meeting or event, she often stands up and hands me her purse. I now make sure I have on an appropriate outfit that matches the purse.

Tell us about your children.

Mary: We had a very traumatic first pregnancy that we lost. Six years later, we adopted our first child, which was an amazing blessing. Our second son was Duke’s first successful frozen embryo transfer.

Describe a memorable moment in your relationship.

Paul: As we were leaving for our honeymoon, Mary’s dad handed me this booklet. It was the receipts for Mary’s medical school loans for the next 10 years. He said, “Congratulations, she’s all yours!”

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

The most comprehensive molecular study to date of brain tissue from people who died of COVID-19 provides clear evidence that SARS-CoV-2 causes profound molecular changes in the brain, despite no molecular trace of the virus in brain tissue.

“The signature the virus leaves in the brain speaks of strong inflammation and disrupted brain circuits and resembles signatures the field has observed in Alzheimer’s or other neurodegenerative diseases,” senior author Tony Wyss-Coray, PhD, professor of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.

The study was published online June 21 in Nature.
 

Signs of distress

“We know that up to a third of SARS-CoV-2-infected people show brain symptoms including brain fog, memory problems, and fatigue, and a growing number of people have such symptoms long after they [have] seemingly recovered from virus infection,” said Dr. Wyss-Coray.

“However, we have very little understanding of how the virus causes these symptoms and what its effects are on the brain at a molecular level,” he added.

Using single-cell RNA sequencing, the researchers profiled the transcriptomes of 65,309 nuclei isolated from frontal cortex and choroid plexus samples from eight patients who died of COVID-19 and 14 controls who died of other causes.

There was no molecular evidence of SARS-CoV-2 in brain tissue samples from the patients who died of COVID-19.

Yet, “we were very surprised to learn that no matter which type of cell we studied (different types of nerve cells, immune cells, or different support cells in the brain) there were prominent changes” compared with brain tissue samples from controls who died of other causes, said Dr. Wyss-Coray.

The changes in the COVID-19 brains showed signatures of inflammation, abnormal nerve cell communication, and chronic neurodegeneration.

“Across cell types, COVID-19 perturbations overlap with those in chronic brain disorders and reside in genetic variants associated with cognition, schizophrenia, and depression,” the researchers report.

“Viral infection appears to trigger inflammatory responses throughout the body that may cause inflammatory signaling across the blood–brain barrier, which in turn could ‘trip off’ neuroinflammation in the brain,” Dr. Wyss-Coray said.

The findings may help explain the brain fog, fatigue, and other neurological and psychiatric symptoms of long COVID.

“While we studied only brains from people who died of COVID-19, we believe it is likely that similar, but hopefully weaker, signs of inflammation and chronic neurodegeneration will be found in COVID-19 survivors, especially those with chronic brain symptoms,” Dr. Wyss-Coray said.

This research was funded by the Nomis Foundation, the National Institutes of Health, Nan Fung Life Sciences, the Wu Tsai Neurosciences Institute and the Stanford Alzheimer’s Disease Research Center. The authors have disclosed no relevant financial relationships.

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

The most comprehensive molecular study to date of brain tissue from people who died of COVID-19 provides clear evidence that SARS-CoV-2 causes profound molecular changes in the brain, despite no molecular trace of the virus in brain tissue.

“The signature the virus leaves in the brain speaks of strong inflammation and disrupted brain circuits and resembles signatures the field has observed in Alzheimer’s or other neurodegenerative diseases,” senior author Tony Wyss-Coray, PhD, professor of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.

The study was published online June 21 in Nature.
 

Signs of distress

“We know that up to a third of SARS-CoV-2-infected people show brain symptoms including brain fog, memory problems, and fatigue, and a growing number of people have such symptoms long after they [have] seemingly recovered from virus infection,” said Dr. Wyss-Coray.

“However, we have very little understanding of how the virus causes these symptoms and what its effects are on the brain at a molecular level,” he added.

Using single-cell RNA sequencing, the researchers profiled the transcriptomes of 65,309 nuclei isolated from frontal cortex and choroid plexus samples from eight patients who died of COVID-19 and 14 controls who died of other causes.

There was no molecular evidence of SARS-CoV-2 in brain tissue samples from the patients who died of COVID-19.

Yet, “we were very surprised to learn that no matter which type of cell we studied (different types of nerve cells, immune cells, or different support cells in the brain) there were prominent changes” compared with brain tissue samples from controls who died of other causes, said Dr. Wyss-Coray.

The changes in the COVID-19 brains showed signatures of inflammation, abnormal nerve cell communication, and chronic neurodegeneration.

“Across cell types, COVID-19 perturbations overlap with those in chronic brain disorders and reside in genetic variants associated with cognition, schizophrenia, and depression,” the researchers report.

“Viral infection appears to trigger inflammatory responses throughout the body that may cause inflammatory signaling across the blood–brain barrier, which in turn could ‘trip off’ neuroinflammation in the brain,” Dr. Wyss-Coray said.

The findings may help explain the brain fog, fatigue, and other neurological and psychiatric symptoms of long COVID.

“While we studied only brains from people who died of COVID-19, we believe it is likely that similar, but hopefully weaker, signs of inflammation and chronic neurodegeneration will be found in COVID-19 survivors, especially those with chronic brain symptoms,” Dr. Wyss-Coray said.

This research was funded by the Nomis Foundation, the National Institutes of Health, Nan Fung Life Sciences, the Wu Tsai Neurosciences Institute and the Stanford Alzheimer’s Disease Research Center. The authors have disclosed no relevant financial relationships.

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

The most comprehensive molecular study to date of brain tissue from people who died of COVID-19 provides clear evidence that SARS-CoV-2 causes profound molecular changes in the brain, despite no molecular trace of the virus in brain tissue.

“The signature the virus leaves in the brain speaks of strong inflammation and disrupted brain circuits and resembles signatures the field has observed in Alzheimer’s or other neurodegenerative diseases,” senior author Tony Wyss-Coray, PhD, professor of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.

The study was published online June 21 in Nature.
 

Signs of distress

“We know that up to a third of SARS-CoV-2-infected people show brain symptoms including brain fog, memory problems, and fatigue, and a growing number of people have such symptoms long after they [have] seemingly recovered from virus infection,” said Dr. Wyss-Coray.

“However, we have very little understanding of how the virus causes these symptoms and what its effects are on the brain at a molecular level,” he added.

Using single-cell RNA sequencing, the researchers profiled the transcriptomes of 65,309 nuclei isolated from frontal cortex and choroid plexus samples from eight patients who died of COVID-19 and 14 controls who died of other causes.

There was no molecular evidence of SARS-CoV-2 in brain tissue samples from the patients who died of COVID-19.

Yet, “we were very surprised to learn that no matter which type of cell we studied (different types of nerve cells, immune cells, or different support cells in the brain) there were prominent changes” compared with brain tissue samples from controls who died of other causes, said Dr. Wyss-Coray.

The changes in the COVID-19 brains showed signatures of inflammation, abnormal nerve cell communication, and chronic neurodegeneration.

“Across cell types, COVID-19 perturbations overlap with those in chronic brain disorders and reside in genetic variants associated with cognition, schizophrenia, and depression,” the researchers report.

“Viral infection appears to trigger inflammatory responses throughout the body that may cause inflammatory signaling across the blood–brain barrier, which in turn could ‘trip off’ neuroinflammation in the brain,” Dr. Wyss-Coray said.

The findings may help explain the brain fog, fatigue, and other neurological and psychiatric symptoms of long COVID.

“While we studied only brains from people who died of COVID-19, we believe it is likely that similar, but hopefully weaker, signs of inflammation and chronic neurodegeneration will be found in COVID-19 survivors, especially those with chronic brain symptoms,” Dr. Wyss-Coray said.

This research was funded by the Nomis Foundation, the National Institutes of Health, Nan Fung Life Sciences, the Wu Tsai Neurosciences Institute and the Stanford Alzheimer’s Disease Research Center. The authors have disclosed no relevant financial relationships.

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