Tinea corporis is a superficial fungal infection that affects the trunk and extremities, more often on exposed skin. In the United States, Trichophyton rubrum, T. mentagrophytes, and Microsporum canis are the most common causal organisms. People can become infected from contact with other people, animals, or soil. Variants of tinea corporis include tinea imbricata (caused by T. concentricum), bullous tinea corporis, tinea gladiatorum (seen in wrestlers), tinea incognito (atypical tinea resulting from topical steroid use), and Majocchi’s granuloma. Widespread tinea may be secondary to underlying immunodeficiency such as HIV/AIDS or treatment with topical or oral steroids.

The typical presentation of tinea corporis is scaly erythematous or hypopigmented annular patches with a raised border and central clearing. In tinea imbricata, which is more commonly seen in southeast Asia, India, and Central America, concentric circles and serpiginous plaques are present. Majocchi’s granuloma has a deeper involvement of fungus in the hair follicles, presenting with papules and pustules at the periphery of the patches. Lesions of tinea incognito may lack a scaly border and can be more widespread.

Diagnosis can be confirmed with a skin scraping and potassium hydroxide (KOH) staining, which will reveal septate and branching hyphae. Biopsy is often helpful, especially in tinea incognito. Classically, a “sandwich sign” is seen: hyphae between orthokeratosis and compact hyperkeratosis or parakeratosis. In this patient, a biopsy from the left hip revealed dermatophytosis, with PAS positive for organisms.

Localized lesions respond to topical antifungal creams such as azoles or topical terbinafine. More extensive tinea will often require a systemic antifungal with griseofulvin, terbinafine, itraconazole, or fluconazole. This patient responded to topical ketoconazole cream and oral terbinafine. A workup for underlying immunodeficiency was negative.

Dr. Bilu Martin provided this case and photo.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at MDedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

Tinea corporis is a superficial fungal infection that affects the trunk and extremities, more often on exposed skin. In the United States, Trichophyton rubrum, T. mentagrophytes, and Microsporum canis are the most common causal organisms. People can become infected from contact with other people, animals, or soil. Variants of tinea corporis include tinea imbricata (caused by T. concentricum), bullous tinea corporis, tinea gladiatorum (seen in wrestlers), tinea incognito (atypical tinea resulting from topical steroid use), and Majocchi’s granuloma. Widespread tinea may be secondary to underlying immunodeficiency such as HIV/AIDS or treatment with topical or oral steroids.

The typical presentation of tinea corporis is scaly erythematous or hypopigmented annular patches with a raised border and central clearing. In tinea imbricata, which is more commonly seen in southeast Asia, India, and Central America, concentric circles and serpiginous plaques are present. Majocchi’s granuloma has a deeper involvement of fungus in the hair follicles, presenting with papules and pustules at the periphery of the patches. Lesions of tinea incognito may lack a scaly border and can be more widespread.

Diagnosis can be confirmed with a skin scraping and potassium hydroxide (KOH) staining, which will reveal septate and branching hyphae. Biopsy is often helpful, especially in tinea incognito. Classically, a “sandwich sign” is seen: hyphae between orthokeratosis and compact hyperkeratosis or parakeratosis. In this patient, a biopsy from the left hip revealed dermatophytosis, with PAS positive for organisms.

Localized lesions respond to topical antifungal creams such as azoles or topical terbinafine. More extensive tinea will often require a systemic antifungal with griseofulvin, terbinafine, itraconazole, or fluconazole. This patient responded to topical ketoconazole cream and oral terbinafine. A workup for underlying immunodeficiency was negative.

Dr. Bilu Martin provided this case and photo.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at MDedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

Tinea corporis is a superficial fungal infection that affects the trunk and extremities, more often on exposed skin. In the United States, Trichophyton rubrum, T. mentagrophytes, and Microsporum canis are the most common causal organisms. People can become infected from contact with other people, animals, or soil. Variants of tinea corporis include tinea imbricata (caused by T. concentricum), bullous tinea corporis, tinea gladiatorum (seen in wrestlers), tinea incognito (atypical tinea resulting from topical steroid use), and Majocchi’s granuloma. Widespread tinea may be secondary to underlying immunodeficiency such as HIV/AIDS or treatment with topical or oral steroids.

The typical presentation of tinea corporis is scaly erythematous or hypopigmented annular patches with a raised border and central clearing. In tinea imbricata, which is more commonly seen in southeast Asia, India, and Central America, concentric circles and serpiginous plaques are present. Majocchi’s granuloma has a deeper involvement of fungus in the hair follicles, presenting with papules and pustules at the periphery of the patches. Lesions of tinea incognito may lack a scaly border and can be more widespread.

Diagnosis can be confirmed with a skin scraping and potassium hydroxide (KOH) staining, which will reveal septate and branching hyphae. Biopsy is often helpful, especially in tinea incognito. Classically, a “sandwich sign” is seen: hyphae between orthokeratosis and compact hyperkeratosis or parakeratosis. In this patient, a biopsy from the left hip revealed dermatophytosis, with PAS positive for organisms.

Localized lesions respond to topical antifungal creams such as azoles or topical terbinafine. More extensive tinea will often require a systemic antifungal with griseofulvin, terbinafine, itraconazole, or fluconazole. This patient responded to topical ketoconazole cream and oral terbinafine. A workup for underlying immunodeficiency was negative.

Dr. Bilu Martin provided this case and photo.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at MDedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

On the basis of the patient's presentation and history, this is probably a case of Crohn disease. Considering that the age of onset of Crohn disease has a bimodal distribution, this case is representative of late-onset disease. Among patients diagnosed with Crohn disease, the first peak is seen between 15 and 30 years of age, whereas the second peak, occurring in up to 15% of diagnoses, is observed mainly in women between 60 and 70 years of age. A significant proportion of Crohn disease cases are heritable. Patients of Ashkenazi Jewish descent are at higher risk of developing the condition than any other ethnic group.

According to American Gastroenterological Association guidelines, a diagnosis of inflammatory bowel disease (IBD) should be considered in older patients who present with diarrhea, rectal bleeding, urgency, abdominal pain, or weight loss. Fecal calprotectin or lactoferrin measurement may help identify patients who warrant further endoscopic evaluation. Colonoscopy is indicated for patients presenting with chronic diarrhea or hematochezia due to suspected IBD, microscopic colitis, or colorectal neoplasia.

Upon further workup for IBD, signs that suggest Crohn disease rather than ulcerative colitis (UC) are sparing of the rectum; discontinuous involvement with skip areas, deep, linear, or serpiginous ulcers of the colon; strictures; fistulas; or granulomatous inflammation. Antiglycan antibodies are more prevalent in Crohn disease than in ulcerative colitis, but they are not sensitive. Weight loss, perineal disease, fistulae, and obstruction are common in Crohn disease but uncommon in UC.

In treating Crohn disease among older adults, systemic corticosteroids are not indicated for maintenance therapy, though they may be used for induction therapy. When possible, nonsystemic corticosteroids should be used, or, if the phenotype prevents their use, early biological therapy. The decision to treat a patient with immunosuppressive drugs should be based on age, functional status, and comorbidities. Immunomodulatory treatments with lower risks for infection and cancer may be safer for patients with late-onset disease. For maintenance of remission, thiopurine monotherapy may be used, with consideration given to its risk for nonmelanoma skin cancers and lymphoma in older patients.

Bhupinder S. Anand, MD, Professor, Department of Medicine, Baylor College of Medicine, Houston, TX

Bhupinder S. Anand, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

On the basis of the patient's presentation and history, this is probably a case of Crohn disease. Considering that the age of onset of Crohn disease has a bimodal distribution, this case is representative of late-onset disease. Among patients diagnosed with Crohn disease, the first peak is seen between 15 and 30 years of age, whereas the second peak, occurring in up to 15% of diagnoses, is observed mainly in women between 60 and 70 years of age. A significant proportion of Crohn disease cases are heritable. Patients of Ashkenazi Jewish descent are at higher risk of developing the condition than any other ethnic group.

According to American Gastroenterological Association guidelines, a diagnosis of inflammatory bowel disease (IBD) should be considered in older patients who present with diarrhea, rectal bleeding, urgency, abdominal pain, or weight loss. Fecal calprotectin or lactoferrin measurement may help identify patients who warrant further endoscopic evaluation. Colonoscopy is indicated for patients presenting with chronic diarrhea or hematochezia due to suspected IBD, microscopic colitis, or colorectal neoplasia.

Upon further workup for IBD, signs that suggest Crohn disease rather than ulcerative colitis (UC) are sparing of the rectum; discontinuous involvement with skip areas, deep, linear, or serpiginous ulcers of the colon; strictures; fistulas; or granulomatous inflammation. Antiglycan antibodies are more prevalent in Crohn disease than in ulcerative colitis, but they are not sensitive. Weight loss, perineal disease, fistulae, and obstruction are common in Crohn disease but uncommon in UC.

In treating Crohn disease among older adults, systemic corticosteroids are not indicated for maintenance therapy, though they may be used for induction therapy. When possible, nonsystemic corticosteroids should be used, or, if the phenotype prevents their use, early biological therapy. The decision to treat a patient with immunosuppressive drugs should be based on age, functional status, and comorbidities. Immunomodulatory treatments with lower risks for infection and cancer may be safer for patients with late-onset disease. For maintenance of remission, thiopurine monotherapy may be used, with consideration given to its risk for nonmelanoma skin cancers and lymphoma in older patients.

Bhupinder S. Anand, MD, Professor, Department of Medicine, Baylor College of Medicine, Houston, TX

Bhupinder S. Anand, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

On the basis of the patient's presentation and history, this is probably a case of Crohn disease. Considering that the age of onset of Crohn disease has a bimodal distribution, this case is representative of late-onset disease. Among patients diagnosed with Crohn disease, the first peak is seen between 15 and 30 years of age, whereas the second peak, occurring in up to 15% of diagnoses, is observed mainly in women between 60 and 70 years of age. A significant proportion of Crohn disease cases are heritable. Patients of Ashkenazi Jewish descent are at higher risk of developing the condition than any other ethnic group.

According to American Gastroenterological Association guidelines, a diagnosis of inflammatory bowel disease (IBD) should be considered in older patients who present with diarrhea, rectal bleeding, urgency, abdominal pain, or weight loss. Fecal calprotectin or lactoferrin measurement may help identify patients who warrant further endoscopic evaluation. Colonoscopy is indicated for patients presenting with chronic diarrhea or hematochezia due to suspected IBD, microscopic colitis, or colorectal neoplasia.

Upon further workup for IBD, signs that suggest Crohn disease rather than ulcerative colitis (UC) are sparing of the rectum; discontinuous involvement with skip areas, deep, linear, or serpiginous ulcers of the colon; strictures; fistulas; or granulomatous inflammation. Antiglycan antibodies are more prevalent in Crohn disease than in ulcerative colitis, but they are not sensitive. Weight loss, perineal disease, fistulae, and obstruction are common in Crohn disease but uncommon in UC.

In treating Crohn disease among older adults, systemic corticosteroids are not indicated for maintenance therapy, though they may be used for induction therapy. When possible, nonsystemic corticosteroids should be used, or, if the phenotype prevents their use, early biological therapy. The decision to treat a patient with immunosuppressive drugs should be based on age, functional status, and comorbidities. Immunomodulatory treatments with lower risks for infection and cancer may be safer for patients with late-onset disease. For maintenance of remission, thiopurine monotherapy may be used, with consideration given to its risk for nonmelanoma skin cancers and lymphoma in older patients.

Bhupinder S. Anand, MD, Professor, Department of Medicine, Baylor College of Medicine, Houston, TX

Bhupinder S. Anand, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

It was wonderful to see long-term friends and colleagues again in New Orleans! Warmed me from the bottom of my COVID-scarred heart.

I had trepidation and anxiety about further COVID exposure, as I am sure many of you all did. I have carefully resumed traveling, although the rules on masking continue to change and confuse us all.

But I did it. I went to the American Psychiatric Association meeting in New Orleans and am so glad I did.

There was of course a lot of discussion about the pandemic, which separated us physically for 3 years – too many virtual meetings. And quiet discussions of grief and loss, both before and during the APA.

I just learned that Joe Napoli, MD, died. He was one of the hearts of the APA Disaster Psychiatry Committee. Others were lost as well, and I am processing those losses.

I do not want this column to be just a promotion for the APA, although it has been my home organization for decades. So, let me define further the cons and pros of going to the meeting. (Yes, I am deliberately reversing the order of these words.) I warn all the readers in advance that this is a soapbox.
 

Cons

The convention center in New Orleans is ridiculously long. Our convention was in Hall G down at end of its telescoping length. Only a couple of doors were open – clearly quite a challenge for folks with disabilities, or those aging into possible disability, like myself. I helped a psychiatrist with impaired vision down the endless hall and of course, felt good about it. (My motto: “Perform acts of kindness, and you will feel better yourself.”)

Another con: Too much going on at the same time. That’s a perpetual problem.

And the noise at the parties was way too loud. We could not hear each other.
 

Pros

Seeing people I have known for 40 years – with masks, without masks. Hugs or bows (on my part, I bow I do not yet hug in COVID times).

The receptions. Great networking. Mid-level psychiatrists who I had forgotten I had mentored. The “young ones” – the psychiatry residents. They seem to be a great and ambitious group.

I did several talks, including one on female veterans, and another on clinical management of the homeless population. The audiences were large and engaged. I am wondering how to make these topics an APA priority, especially engagement with strategies to take care of the unhoused/homeless folks.

Let me give you a brief synopsis of both of those talks, as they represent some of my passions. The first on female veterans. We tend to focus on PTSD and military sexual trauma. I am also concerned about reproductive and musculoskeletal concerns. Too many female service members get pregnant, then quit the military as they cannot manage being a Service member and a mother. They think they can make it (go to school, get a job) but they cannot manage it all.

Veterans services usually focus on single older men. There are not enough rooms and services for female veterans with children. In fairness to the Department of Veterans Affairs, they are trying to remedy this lack.

Transitioning to the homeless population in general, this is an incredible problem which is not easily solved. The VA has done an incredible job here, but the whole country should be mobilized.

My focus at the talk was the importance of assessing and treating medical problems. Again, homeless women are at high risk for barriers to contraception, sexual assault, pregnancy, and the corresponding difficulties of finding housing that will accept infants and small children.

Then there are the numerous medical issues in the unhoused population. Diabetes, hypertension, ulcers on the feet leading to cellulitis and amputation. I am advocating that we psychiatrists behave as medical doctors and think of the whole person, not just of the mind.

Another pro of the APA meeting: such desire to share what we know with the world. I found a few more potential authors for book chapters, specifically Dr. Anne Hansen to write a chapter in my capacity volume. And getting recruited myself, by Maria Llorente, MD, for one on centenarians (people who aged over 100.) Not sure if I know very much now, but I will try.

But another con: I am very tired of endless “scope of practice” discussions about what psychologists and nurse practitioners should do. They are all my comrades. We have plenty of business for all, in this never-ending anxiety tide of COVID.

Another con: I tested positive for COVID after my return, as did several of my friends.

I am sure our readers have many more takes on returning to the APA. These are a few of my thoughts.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

It was wonderful to see long-term friends and colleagues again in New Orleans! Warmed me from the bottom of my COVID-scarred heart.

I had trepidation and anxiety about further COVID exposure, as I am sure many of you all did. I have carefully resumed traveling, although the rules on masking continue to change and confuse us all.

But I did it. I went to the American Psychiatric Association meeting in New Orleans and am so glad I did.

There was of course a lot of discussion about the pandemic, which separated us physically for 3 years – too many virtual meetings. And quiet discussions of grief and loss, both before and during the APA.

I just learned that Joe Napoli, MD, died. He was one of the hearts of the APA Disaster Psychiatry Committee. Others were lost as well, and I am processing those losses.

I do not want this column to be just a promotion for the APA, although it has been my home organization for decades. So, let me define further the cons and pros of going to the meeting. (Yes, I am deliberately reversing the order of these words.) I warn all the readers in advance that this is a soapbox.
 

Cons

The convention center in New Orleans is ridiculously long. Our convention was in Hall G down at end of its telescoping length. Only a couple of doors were open – clearly quite a challenge for folks with disabilities, or those aging into possible disability, like myself. I helped a psychiatrist with impaired vision down the endless hall and of course, felt good about it. (My motto: “Perform acts of kindness, and you will feel better yourself.”)

Another con: Too much going on at the same time. That’s a perpetual problem.

And the noise at the parties was way too loud. We could not hear each other.
 

Pros

Seeing people I have known for 40 years – with masks, without masks. Hugs or bows (on my part, I bow I do not yet hug in COVID times).

The receptions. Great networking. Mid-level psychiatrists who I had forgotten I had mentored. The “young ones” – the psychiatry residents. They seem to be a great and ambitious group.

I did several talks, including one on female veterans, and another on clinical management of the homeless population. The audiences were large and engaged. I am wondering how to make these topics an APA priority, especially engagement with strategies to take care of the unhoused/homeless folks.

Let me give you a brief synopsis of both of those talks, as they represent some of my passions. The first on female veterans. We tend to focus on PTSD and military sexual trauma. I am also concerned about reproductive and musculoskeletal concerns. Too many female service members get pregnant, then quit the military as they cannot manage being a Service member and a mother. They think they can make it (go to school, get a job) but they cannot manage it all.

Veterans services usually focus on single older men. There are not enough rooms and services for female veterans with children. In fairness to the Department of Veterans Affairs, they are trying to remedy this lack.

Transitioning to the homeless population in general, this is an incredible problem which is not easily solved. The VA has done an incredible job here, but the whole country should be mobilized.

My focus at the talk was the importance of assessing and treating medical problems. Again, homeless women are at high risk for barriers to contraception, sexual assault, pregnancy, and the corresponding difficulties of finding housing that will accept infants and small children.

Then there are the numerous medical issues in the unhoused population. Diabetes, hypertension, ulcers on the feet leading to cellulitis and amputation. I am advocating that we psychiatrists behave as medical doctors and think of the whole person, not just of the mind.

Another pro of the APA meeting: such desire to share what we know with the world. I found a few more potential authors for book chapters, specifically Dr. Anne Hansen to write a chapter in my capacity volume. And getting recruited myself, by Maria Llorente, MD, for one on centenarians (people who aged over 100.) Not sure if I know very much now, but I will try.

But another con: I am very tired of endless “scope of practice” discussions about what psychologists and nurse practitioners should do. They are all my comrades. We have plenty of business for all, in this never-ending anxiety tide of COVID.

Another con: I tested positive for COVID after my return, as did several of my friends.

I am sure our readers have many more takes on returning to the APA. These are a few of my thoughts.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

It was wonderful to see long-term friends and colleagues again in New Orleans! Warmed me from the bottom of my COVID-scarred heart.

I had trepidation and anxiety about further COVID exposure, as I am sure many of you all did. I have carefully resumed traveling, although the rules on masking continue to change and confuse us all.

But I did it. I went to the American Psychiatric Association meeting in New Orleans and am so glad I did.

There was of course a lot of discussion about the pandemic, which separated us physically for 3 years – too many virtual meetings. And quiet discussions of grief and loss, both before and during the APA.

I just learned that Joe Napoli, MD, died. He was one of the hearts of the APA Disaster Psychiatry Committee. Others were lost as well, and I am processing those losses.

I do not want this column to be just a promotion for the APA, although it has been my home organization for decades. So, let me define further the cons and pros of going to the meeting. (Yes, I am deliberately reversing the order of these words.) I warn all the readers in advance that this is a soapbox.
 

Cons

The convention center in New Orleans is ridiculously long. Our convention was in Hall G down at end of its telescoping length. Only a couple of doors were open – clearly quite a challenge for folks with disabilities, or those aging into possible disability, like myself. I helped a psychiatrist with impaired vision down the endless hall and of course, felt good about it. (My motto: “Perform acts of kindness, and you will feel better yourself.”)

Another con: Too much going on at the same time. That’s a perpetual problem.

And the noise at the parties was way too loud. We could not hear each other.
 

Pros

Seeing people I have known for 40 years – with masks, without masks. Hugs or bows (on my part, I bow I do not yet hug in COVID times).

The receptions. Great networking. Mid-level psychiatrists who I had forgotten I had mentored. The “young ones” – the psychiatry residents. They seem to be a great and ambitious group.

I did several talks, including one on female veterans, and another on clinical management of the homeless population. The audiences were large and engaged. I am wondering how to make these topics an APA priority, especially engagement with strategies to take care of the unhoused/homeless folks.

Let me give you a brief synopsis of both of those talks, as they represent some of my passions. The first on female veterans. We tend to focus on PTSD and military sexual trauma. I am also concerned about reproductive and musculoskeletal concerns. Too many female service members get pregnant, then quit the military as they cannot manage being a Service member and a mother. They think they can make it (go to school, get a job) but they cannot manage it all.

Veterans services usually focus on single older men. There are not enough rooms and services for female veterans with children. In fairness to the Department of Veterans Affairs, they are trying to remedy this lack.

Transitioning to the homeless population in general, this is an incredible problem which is not easily solved. The VA has done an incredible job here, but the whole country should be mobilized.

My focus at the talk was the importance of assessing and treating medical problems. Again, homeless women are at high risk for barriers to contraception, sexual assault, pregnancy, and the corresponding difficulties of finding housing that will accept infants and small children.

Then there are the numerous medical issues in the unhoused population. Diabetes, hypertension, ulcers on the feet leading to cellulitis and amputation. I am advocating that we psychiatrists behave as medical doctors and think of the whole person, not just of the mind.

Another pro of the APA meeting: such desire to share what we know with the world. I found a few more potential authors for book chapters, specifically Dr. Anne Hansen to write a chapter in my capacity volume. And getting recruited myself, by Maria Llorente, MD, for one on centenarians (people who aged over 100.) Not sure if I know very much now, but I will try.

But another con: I am very tired of endless “scope of practice” discussions about what psychologists and nurse practitioners should do. They are all my comrades. We have plenty of business for all, in this never-ending anxiety tide of COVID.

Another con: I tested positive for COVID after my return, as did several of my friends.

I am sure our readers have many more takes on returning to the APA. These are a few of my thoughts.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Dermoscopy revealed multiple small white structures around a central pore and tortuous, but not arborizing, blood vessels around the periphery (frequently called a crown pattern). These features pointed to the diagnosis of sebaceous gland hyperplasia (SGH).

SGH is a common benign condition seen predominantly in middle- to older-age people and patients on immunosuppressant drugs (especially ciclosporin). SGH tends to manifest as multiple lesions on the face and forehead, although the lesions can appear elsewhere.¹

As the name implies, SGH is hyperplasia of the sebocytes of the hair follicle, which results in white-to-yellow clusters around the dilated opening of the follicle.¹ In contrast to BCCs, which have arborizing blood vessels that can occur throughout the lesion, the vessels in SGH have a lower propensity for branching and tend to follow the periphery instead of crossing into the central pore.² This characteristic pattern, as well as the appearance of multiple similar lesions elsewhere on a patient’s body, suggests a diagnosis of SGH. If the lesion is atypical, solitary, or has other features that make the diagnosis uncertain, a biopsy is recommended.

SGH is not malignant and is asymptomatic, so treatment is not required. However, the cosmetic appearance can be distressing or undesirable for some patients.¹ The most common cosmetic remedies are destructive and include electrodessication, cryosurgery, and treatments with laser and intense pulsed light. Unfortunately, if there is residual tissue after treatment, recurrence is common, and due to the destructive nature of treatment, scarring is possible. It is important to counsel the patient regarding both of these possibilities and to balance the extent of destruction.

In patients with multiple lesions, oral isotretinoin may be used, but SGH will recur if treatment is discontinued. Additionally, isotretinoin, which is also used for cystic acne, is a high-risk medication due its potential to cause fetal anomalies and death if used during pregnancy. Patients usually get cheilitis and dyshidrosis due to its drying effect, but those symptoms are manageable with topical emollients.

This patient declined treatment, as he already had scars from previous NMSCs and was not concerned about the appearance of SGH.

‌

Photo courtesy of Daniel Stulberg, MD. Text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Dermoscopy revealed multiple small white structures around a central pore and tortuous, but not arborizing, blood vessels around the periphery (frequently called a crown pattern). These features pointed to the diagnosis of sebaceous gland hyperplasia (SGH).

SGH is a common benign condition seen predominantly in middle- to older-age people and patients on immunosuppressant drugs (especially ciclosporin). SGH tends to manifest as multiple lesions on the face and forehead, although the lesions can appear elsewhere.¹

As the name implies, SGH is hyperplasia of the sebocytes of the hair follicle, which results in white-to-yellow clusters around the dilated opening of the follicle.¹ In contrast to BCCs, which have arborizing blood vessels that can occur throughout the lesion, the vessels in SGH have a lower propensity for branching and tend to follow the periphery instead of crossing into the central pore.² This characteristic pattern, as well as the appearance of multiple similar lesions elsewhere on a patient’s body, suggests a diagnosis of SGH. If the lesion is atypical, solitary, or has other features that make the diagnosis uncertain, a biopsy is recommended.

SGH is not malignant and is asymptomatic, so treatment is not required. However, the cosmetic appearance can be distressing or undesirable for some patients.¹ The most common cosmetic remedies are destructive and include electrodessication, cryosurgery, and treatments with laser and intense pulsed light. Unfortunately, if there is residual tissue after treatment, recurrence is common, and due to the destructive nature of treatment, scarring is possible. It is important to counsel the patient regarding both of these possibilities and to balance the extent of destruction.

In patients with multiple lesions, oral isotretinoin may be used, but SGH will recur if treatment is discontinued. Additionally, isotretinoin, which is also used for cystic acne, is a high-risk medication due its potential to cause fetal anomalies and death if used during pregnancy. Patients usually get cheilitis and dyshidrosis due to its drying effect, but those symptoms are manageable with topical emollients.

This patient declined treatment, as he already had scars from previous NMSCs and was not concerned about the appearance of SGH.

‌

Photo courtesy of Daniel Stulberg, MD. Text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Dermoscopy revealed multiple small white structures around a central pore and tortuous, but not arborizing, blood vessels around the periphery (frequently called a crown pattern). These features pointed to the diagnosis of sebaceous gland hyperplasia (SGH).

SGH is a common benign condition seen predominantly in middle- to older-age people and patients on immunosuppressant drugs (especially ciclosporin). SGH tends to manifest as multiple lesions on the face and forehead, although the lesions can appear elsewhere.¹

As the name implies, SGH is hyperplasia of the sebocytes of the hair follicle, which results in white-to-yellow clusters around the dilated opening of the follicle.¹ In contrast to BCCs, which have arborizing blood vessels that can occur throughout the lesion, the vessels in SGH have a lower propensity for branching and tend to follow the periphery instead of crossing into the central pore.² This characteristic pattern, as well as the appearance of multiple similar lesions elsewhere on a patient’s body, suggests a diagnosis of SGH. If the lesion is atypical, solitary, or has other features that make the diagnosis uncertain, a biopsy is recommended.

SGH is not malignant and is asymptomatic, so treatment is not required. However, the cosmetic appearance can be distressing or undesirable for some patients.¹ The most common cosmetic remedies are destructive and include electrodessication, cryosurgery, and treatments with laser and intense pulsed light. Unfortunately, if there is residual tissue after treatment, recurrence is common, and due to the destructive nature of treatment, scarring is possible. It is important to counsel the patient regarding both of these possibilities and to balance the extent of destruction.

In patients with multiple lesions, oral isotretinoin may be used, but SGH will recur if treatment is discontinued. Additionally, isotretinoin, which is also used for cystic acne, is a high-risk medication due its potential to cause fetal anomalies and death if used during pregnancy. Patients usually get cheilitis and dyshidrosis due to its drying effect, but those symptoms are manageable with topical emollients.

This patient declined treatment, as he already had scars from previous NMSCs and was not concerned about the appearance of SGH.

‌

Photo courtesy of Daniel Stulberg, MD. Text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Pneumatosis intestinalis (PI) is the finding of gas within the walls of the intestine on imaging. It is most commonly detected via radiograph or computed tomography (CT). The diseases leading to the accumulation of gas within the submucosal space of the gastrointestinal (GI) tract are heterogenous, and the finding of PI itself has a wide range of clinical implications from impending clinical deterioration to an incidental finding of minimal consequence.

We present the case of a veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have PI without signs of intra-abdominal catastrophe. An exclusion of other, more lifethreatening causes of PI led to a diagnosis of benign PI secondary to the presence of his gastrostomy tube. This case highlights the importance of interpreting the finding of PI in the clinical context of the specific patient and how conservative management may be appropriate in some cases.

Case Presentation

A 61-year-old male patient was admitted for fever. The patient had a remote history of cardiac arrest complicated by anoxic brain injury requiring tracheostomy, gastrostomy tube, and a suprapubic catheter with recurrent catheter-associated urinary tract infections (CAUTI), secondary seizure disorder, atrial fibrillation off anticoagulation due to recurrent GI bleeding, and treatment naive chronic hepatitis C virus. His ability to provide a clinical history was limited by his nonverbal status. He had no prior surgical history but had presented a month earlier for a high-grade small bowel obstruction (SBO) with pneumobilia that was managed conservatively as the surgical team deemed him a poor candidate for surgical intervention with his extensive comorbidities. A bioethics consultation at the time supported minimizing potential surgical risk in favor of conservative medical management; this was discussed with the patient’s surrogate decision maker, who also wished to avoid surgery. The SBO resolved with conservative management. He had been residing in a nursing home and doing well until 24 hours prior to admission when he developed fevers.

Vital signs on admission showed a temperature of 100.8 °F, heart rate 100 beats per minute, blood pressure 116/85, respiratory rate 22 per minute, and oxygen saturation of 100% on 6 L of oxygen via tracheostomy collar. His initial examination was notable for clear lung sounds, a nondistended nonrigid abdomen with an indwelling percutaneous gastrostomy tube, and absence of areas of skin breakdown or erythema. Notable laboratory studies showed a leukocytosis and urinalysis suggestive of CAUTI (Table). His urinary catheter was exchanged, he was fluid resuscitated and started on empiric vancomycin and piperacillin-tazobactam for management of sepsis due to CAUTI.

For the first 3 days of his hospitalization, he demonstrated clinical improvement on vancomycin and piperacillin-tazobactam while awaiting results from his urine bacterial culture. On hospital day 3, hedeveloped recurrent nonbloody, nonbilious emesis despite no change in the rate or formulation of his enteral nutrition. He also had 3 watery brown bowel movements. His vital signs remained within normal limits. His abdominal examination at this point showed mild distention and was hypertympanic to percussion, but there was no rigidity or involuntary guarding. On hospital day 4, he continued to have emesis with an unchanged abdominal examination. The differential diagnosis included recurrence of prior SBO, ileus, intestinal ischemia, enteral nutrition intolerance, Clostridioides difficile (C difficile) colitis, and GI dysmotility because of his anoxic brain injury.

Testing for C difficile was negative. An abdominal radiograph was obtained and revealed no bowel obstruction but, alarmingly, showed extensive intramural bowel gas, suggestive of PI (Figure 1). His leukocyte count, serum bicarbonate, and serum lactate levels remained within normal limits. A CT with contrast of the abdomen and pelvis demonstrated no vascular obstruction but confirmed the presence of diffuse intramural gas in his stomach and proximal small bowel, as well as the presence of mesenteric and portal venous gas (Figures 2 and 3). Although his abdominal examination had not changed and did not suggest peritonitis, general surgery was consulted to discuss the need for surgical intervention. Given his overall clinical stability and high surgical risk due to his many comorbidities, surgery recommended a conservative approach.

Through the following hospital days, his enteral nutrition was held and serial abdominal examinations were performed without change. Serial laboratory studies, including serum lactate and leukocyte count, remained reassuringly within normal limits. His urine culture eventually revealed multidrugresistant Pseudomonas aeruginosa. Antimicrobial therapy was narrowed to piperacillintazobactam for a complete course. Enteral nutrition was gradually reintroduced at a low rate, ultimately reaching goal rate with return of bowel function by hospital day 9. Despite extensive workup, the etiology of his transient enteral nutrition intolerance remained uncertain, though an adverse effect of antibiotic therapy was thought possible. Follow-up abdominal radiographs demonstrated interval improvement of PI. He was discharged back to his skilled nursing facility on hospital day 11 without incident.

Discussion

PI is an incompletely understood condition seen in multiple diseases. Patients may present with highly variable symptoms, often more attributable to the underlying disease causing the PI than the presence of PI, as patients may be entirely asymptomatic. When symptoms are attributed to PI, those most reported are abdominal pain, bloody stools, and diarrhea.¹ It is often detected on abdominal plain films. Alternative methods of diagnosis include ultrasonography, barium enema, and endoscopy although the last method has been known to occasionally lead to bowel perforation.^2-6 The most sensitive method of detection is CT, which also provides additional information about abdominal pathology and may identify the underlying process responsible for the PI.⁷

While not fully understood, much information about PI and its pathogenesis is known. Understanding the mechanisms of PI is vital to direct the clinician’s evaluation of the patient for reversible conditions that may cause PI. Early descriptions of PI in the literature documented an association with pyloric stenosis, leading to the theory that gas from the intestinal lumen is driven into the submucosal space during episodes of forceful vomiting with increased intraluminal pressure.⁸ As PI was subsequently described in multiple other disease states not typically associated with increased intraluminal pressure such as inflammatory bowel disease, GI malignancy, cryptosporidiosis and CMV infection, additional theories about the pathogenesis of PI have arisen.^9-24 There is now experimental data to support multiple mechanisms of intramural gas accumulation. It has become accepted that PI represents a common pathway shared across various pathologic states and results from multifactorial mechanisms of gas entry into the intestinal wall.^25-29

Factors leading to the development of PI include bacterial production of gas, intraluminal GI gas compositions, increased intraluminal pressure, pulmonary gas tracking through vessels communicating with the thorax, and mucosal disruption. PI has been linked to bacterial infections of the GI tract in humans including C difficile, Klebsiella, and Whipple disease.^14-18 In animal models, C difficile within the walls of rat intestine results in the appearance of pneumocysts, or discrete collections of submucosal gas, which are the hallmark feature of PI.³⁰ It is thought that direct invasion of bacteria into intramural spaces can cause PI in humans, although bacteria have yet to be directly isolated from the pneumocysts. Translocation of luminal gas into pneumocysts found in PI is theorized to be driven by differences in partial pressures.³¹ The concentration of hydrogen within the intestinal lumen is high due to bacterial production. Hydrogen, diffusing along its partial pressure gradient between the lumen and blood, accumulates within the intestinal wall and causes the formation of pneumocysts. This phenomenon has been hypothesized to explain the tendency for pneumocysts to form around the mesenteric vasculature.

Gas from the lumen can also be forced into the intestinal wall during an abrupt increase in intra-abdominal pressure, such as that seen with forceful vomiting. The final possible origin of the gas is the lungs, as PI has been associated with lung disease. It was previously thought that gas from ruptured alveoli tracks along mediastinal vessels, below the diaphragm, and into the mesentery.³⁰ Newer theories argue that increased intra-abdominal pressure, typical of patients with obstructive lung disease and frequent coughing, is the driver of PI by the mechanism previously described.^32-34 Additionally, mucosal disruption leads to increased permeability and allows accumulation of gas within the intestinal walls. Mucosal abnormalities have been described in histopathologic studies of patients with PI and associated with conditions known to compromise mucosal integrity, such as immunodeficiencies, inflammatory bowel disease, and the receipt of cytotoxic chemotherapy.^10,12,19-23

Our patient likely had mucosal disruption due to his gastrostomy tube as well as increased intraluminal pressure from recurrent vomiting, contributing to translocation of otherwise normal intraluminal gas. The presence of portal venous gas, as seen in this case, has historically portended a worse prognosis, with 37% mortality in one series.^7,35,36 However, portal venous gas as well as pneumoperitoneum occur in benign etiologies of PI as well. It is thought that this occurs due to rupture of the submucosal pneumocysts through the wall opposite the intestinal lumen and thus does not result in a direct communication between the intestinal lumen and the peritoneal cavity.¹²

PI is not a diagnosis but a manifestation of an underlying disease. As such, the treatment of PI is targeted toward the underlying condition. Of note, the pattern and extent of PI seen on imaging has not been shown to correlate with the severity of the underlying pathologic process.^35,37 Instead, assessment of the patient and their clinical trajectory should determine the appropriate treatment. The decision facing the clinician when PI is discovered is whether urgent surgery is indicated, as is the case in mesenteric ischemia, bowel necrosis, or intestinal perforation, conditions known to be associated with PI. Otherwise, there is no definitive treatment for PI. Bowel rest is almost universally pursued. There are reports of treating with supranormal levels of supplemental oxygen, maintaining arterial partial pressure of oxygen above 300 mm Hg, with a face mask and 8 L/min flow rate.^38,39 The proposed mechanisms of benefit include establishing a favorable diffusion gradient for intramural gas to exit the pneumocysts as well as creating an inhospitable, aerobic environment for hydrogenproducing anaerobic enteric bacteria. A prudent approach for most cases of PI is conservative management with bowel rest and supplemental oxygen unless there is a definitive indication for urgent surgical intervention, such as peritonitis, abdominal sepsis, or perforation.^40,41 Management recommendations suggest that up to 50% of cases can be successfully managed nonoperatively.⁴²

Conclusions

PI is the radiographic finding of gas within the walls of the intestinal tract and has variable clinical significance. It can represent a benign incidental finding or a sequela of intraabdominal emergencies such as mesenteric ischemia or bowel necrosis. Because PI is seen in a variety of disorders, several proposed mechanisms are supported in the medical literature. These include bacterial production of gas, gas pressure gradients between the intestinal lumen and the blood, increased intraluminal pressure, pulmonary gas tracking from intrathoracic vessels, and mucosal disruption. The evaluation of a patient with PI must begin with an assessment for the need for urgent surgical intervention. Additional management measures include bowel rest, IV hydration, and supplemental oxygen administration. Because of its wide variety of etiologies of varying clinical urgency, placing the finding of PI in the context of the patient is paramount to selecting an appropriate management strategy.

Pneumatosis intestinalis (PI) is the finding of gas within the walls of the intestine on imaging. It is most commonly detected via radiograph or computed tomography (CT). The diseases leading to the accumulation of gas within the submucosal space of the gastrointestinal (GI) tract are heterogenous, and the finding of PI itself has a wide range of clinical implications from impending clinical deterioration to an incidental finding of minimal consequence.

We present the case of a veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have PI without signs of intra-abdominal catastrophe. An exclusion of other, more lifethreatening causes of PI led to a diagnosis of benign PI secondary to the presence of his gastrostomy tube. This case highlights the importance of interpreting the finding of PI in the clinical context of the specific patient and how conservative management may be appropriate in some cases.

Case Presentation

A 61-year-old male patient was admitted for fever. The patient had a remote history of cardiac arrest complicated by anoxic brain injury requiring tracheostomy, gastrostomy tube, and a suprapubic catheter with recurrent catheter-associated urinary tract infections (CAUTI), secondary seizure disorder, atrial fibrillation off anticoagulation due to recurrent GI bleeding, and treatment naive chronic hepatitis C virus. His ability to provide a clinical history was limited by his nonverbal status. He had no prior surgical history but had presented a month earlier for a high-grade small bowel obstruction (SBO) with pneumobilia that was managed conservatively as the surgical team deemed him a poor candidate for surgical intervention with his extensive comorbidities. A bioethics consultation at the time supported minimizing potential surgical risk in favor of conservative medical management; this was discussed with the patient’s surrogate decision maker, who also wished to avoid surgery. The SBO resolved with conservative management. He had been residing in a nursing home and doing well until 24 hours prior to admission when he developed fevers.

Vital signs on admission showed a temperature of 100.8 °F, heart rate 100 beats per minute, blood pressure 116/85, respiratory rate 22 per minute, and oxygen saturation of 100% on 6 L of oxygen via tracheostomy collar. His initial examination was notable for clear lung sounds, a nondistended nonrigid abdomen with an indwelling percutaneous gastrostomy tube, and absence of areas of skin breakdown or erythema. Notable laboratory studies showed a leukocytosis and urinalysis suggestive of CAUTI (Table). His urinary catheter was exchanged, he was fluid resuscitated and started on empiric vancomycin and piperacillin-tazobactam for management of sepsis due to CAUTI.

For the first 3 days of his hospitalization, he demonstrated clinical improvement on vancomycin and piperacillin-tazobactam while awaiting results from his urine bacterial culture. On hospital day 3, hedeveloped recurrent nonbloody, nonbilious emesis despite no change in the rate or formulation of his enteral nutrition. He also had 3 watery brown bowel movements. His vital signs remained within normal limits. His abdominal examination at this point showed mild distention and was hypertympanic to percussion, but there was no rigidity or involuntary guarding. On hospital day 4, he continued to have emesis with an unchanged abdominal examination. The differential diagnosis included recurrence of prior SBO, ileus, intestinal ischemia, enteral nutrition intolerance, Clostridioides difficile (C difficile) colitis, and GI dysmotility because of his anoxic brain injury.

Testing for C difficile was negative. An abdominal radiograph was obtained and revealed no bowel obstruction but, alarmingly, showed extensive intramural bowel gas, suggestive of PI (Figure 1). His leukocyte count, serum bicarbonate, and serum lactate levels remained within normal limits. A CT with contrast of the abdomen and pelvis demonstrated no vascular obstruction but confirmed the presence of diffuse intramural gas in his stomach and proximal small bowel, as well as the presence of mesenteric and portal venous gas (Figures 2 and 3). Although his abdominal examination had not changed and did not suggest peritonitis, general surgery was consulted to discuss the need for surgical intervention. Given his overall clinical stability and high surgical risk due to his many comorbidities, surgery recommended a conservative approach.

Through the following hospital days, his enteral nutrition was held and serial abdominal examinations were performed without change. Serial laboratory studies, including serum lactate and leukocyte count, remained reassuringly within normal limits. His urine culture eventually revealed multidrugresistant Pseudomonas aeruginosa. Antimicrobial therapy was narrowed to piperacillintazobactam for a complete course. Enteral nutrition was gradually reintroduced at a low rate, ultimately reaching goal rate with return of bowel function by hospital day 9. Despite extensive workup, the etiology of his transient enteral nutrition intolerance remained uncertain, though an adverse effect of antibiotic therapy was thought possible. Follow-up abdominal radiographs demonstrated interval improvement of PI. He was discharged back to his skilled nursing facility on hospital day 11 without incident.

Discussion

PI is an incompletely understood condition seen in multiple diseases. Patients may present with highly variable symptoms, often more attributable to the underlying disease causing the PI than the presence of PI, as patients may be entirely asymptomatic. When symptoms are attributed to PI, those most reported are abdominal pain, bloody stools, and diarrhea.¹ It is often detected on abdominal plain films. Alternative methods of diagnosis include ultrasonography, barium enema, and endoscopy although the last method has been known to occasionally lead to bowel perforation.^2-6 The most sensitive method of detection is CT, which also provides additional information about abdominal pathology and may identify the underlying process responsible for the PI.⁷

While not fully understood, much information about PI and its pathogenesis is known. Understanding the mechanisms of PI is vital to direct the clinician’s evaluation of the patient for reversible conditions that may cause PI. Early descriptions of PI in the literature documented an association with pyloric stenosis, leading to the theory that gas from the intestinal lumen is driven into the submucosal space during episodes of forceful vomiting with increased intraluminal pressure.⁸ As PI was subsequently described in multiple other disease states not typically associated with increased intraluminal pressure such as inflammatory bowel disease, GI malignancy, cryptosporidiosis and CMV infection, additional theories about the pathogenesis of PI have arisen.^9-24 There is now experimental data to support multiple mechanisms of intramural gas accumulation. It has become accepted that PI represents a common pathway shared across various pathologic states and results from multifactorial mechanisms of gas entry into the intestinal wall.^25-29

Factors leading to the development of PI include bacterial production of gas, intraluminal GI gas compositions, increased intraluminal pressure, pulmonary gas tracking through vessels communicating with the thorax, and mucosal disruption. PI has been linked to bacterial infections of the GI tract in humans including C difficile, Klebsiella, and Whipple disease.^14-18 In animal models, C difficile within the walls of rat intestine results in the appearance of pneumocysts, or discrete collections of submucosal gas, which are the hallmark feature of PI.³⁰ It is thought that direct invasion of bacteria into intramural spaces can cause PI in humans, although bacteria have yet to be directly isolated from the pneumocysts. Translocation of luminal gas into pneumocysts found in PI is theorized to be driven by differences in partial pressures.³¹ The concentration of hydrogen within the intestinal lumen is high due to bacterial production. Hydrogen, diffusing along its partial pressure gradient between the lumen and blood, accumulates within the intestinal wall and causes the formation of pneumocysts. This phenomenon has been hypothesized to explain the tendency for pneumocysts to form around the mesenteric vasculature.

Gas from the lumen can also be forced into the intestinal wall during an abrupt increase in intra-abdominal pressure, such as that seen with forceful vomiting. The final possible origin of the gas is the lungs, as PI has been associated with lung disease. It was previously thought that gas from ruptured alveoli tracks along mediastinal vessels, below the diaphragm, and into the mesentery.³⁰ Newer theories argue that increased intra-abdominal pressure, typical of patients with obstructive lung disease and frequent coughing, is the driver of PI by the mechanism previously described.^32-34 Additionally, mucosal disruption leads to increased permeability and allows accumulation of gas within the intestinal walls. Mucosal abnormalities have been described in histopathologic studies of patients with PI and associated with conditions known to compromise mucosal integrity, such as immunodeficiencies, inflammatory bowel disease, and the receipt of cytotoxic chemotherapy.^10,12,19-23

Our patient likely had mucosal disruption due to his gastrostomy tube as well as increased intraluminal pressure from recurrent vomiting, contributing to translocation of otherwise normal intraluminal gas. The presence of portal venous gas, as seen in this case, has historically portended a worse prognosis, with 37% mortality in one series.^7,35,36 However, portal venous gas as well as pneumoperitoneum occur in benign etiologies of PI as well. It is thought that this occurs due to rupture of the submucosal pneumocysts through the wall opposite the intestinal lumen and thus does not result in a direct communication between the intestinal lumen and the peritoneal cavity.¹²

PI is not a diagnosis but a manifestation of an underlying disease. As such, the treatment of PI is targeted toward the underlying condition. Of note, the pattern and extent of PI seen on imaging has not been shown to correlate with the severity of the underlying pathologic process.^35,37 Instead, assessment of the patient and their clinical trajectory should determine the appropriate treatment. The decision facing the clinician when PI is discovered is whether urgent surgery is indicated, as is the case in mesenteric ischemia, bowel necrosis, or intestinal perforation, conditions known to be associated with PI. Otherwise, there is no definitive treatment for PI. Bowel rest is almost universally pursued. There are reports of treating with supranormal levels of supplemental oxygen, maintaining arterial partial pressure of oxygen above 300 mm Hg, with a face mask and 8 L/min flow rate.^38,39 The proposed mechanisms of benefit include establishing a favorable diffusion gradient for intramural gas to exit the pneumocysts as well as creating an inhospitable, aerobic environment for hydrogenproducing anaerobic enteric bacteria. A prudent approach for most cases of PI is conservative management with bowel rest and supplemental oxygen unless there is a definitive indication for urgent surgical intervention, such as peritonitis, abdominal sepsis, or perforation.^40,41 Management recommendations suggest that up to 50% of cases can be successfully managed nonoperatively.⁴²

Conclusions

PI is the radiographic finding of gas within the walls of the intestinal tract and has variable clinical significance. It can represent a benign incidental finding or a sequela of intraabdominal emergencies such as mesenteric ischemia or bowel necrosis. Because PI is seen in a variety of disorders, several proposed mechanisms are supported in the medical literature. These include bacterial production of gas, gas pressure gradients between the intestinal lumen and the blood, increased intraluminal pressure, pulmonary gas tracking from intrathoracic vessels, and mucosal disruption. The evaluation of a patient with PI must begin with an assessment for the need for urgent surgical intervention. Additional management measures include bowel rest, IV hydration, and supplemental oxygen administration. Because of its wide variety of etiologies of varying clinical urgency, placing the finding of PI in the context of the patient is paramount to selecting an appropriate management strategy.

Pneumatosis intestinalis (PI) is the finding of gas within the walls of the intestine on imaging. It is most commonly detected via radiograph or computed tomography (CT). The diseases leading to the accumulation of gas within the submucosal space of the gastrointestinal (GI) tract are heterogenous, and the finding of PI itself has a wide range of clinical implications from impending clinical deterioration to an incidental finding of minimal consequence.

We present the case of a veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have PI without signs of intra-abdominal catastrophe. An exclusion of other, more lifethreatening causes of PI led to a diagnosis of benign PI secondary to the presence of his gastrostomy tube. This case highlights the importance of interpreting the finding of PI in the clinical context of the specific patient and how conservative management may be appropriate in some cases.

Case Presentation

A 61-year-old male patient was admitted for fever. The patient had a remote history of cardiac arrest complicated by anoxic brain injury requiring tracheostomy, gastrostomy tube, and a suprapubic catheter with recurrent catheter-associated urinary tract infections (CAUTI), secondary seizure disorder, atrial fibrillation off anticoagulation due to recurrent GI bleeding, and treatment naive chronic hepatitis C virus. His ability to provide a clinical history was limited by his nonverbal status. He had no prior surgical history but had presented a month earlier for a high-grade small bowel obstruction (SBO) with pneumobilia that was managed conservatively as the surgical team deemed him a poor candidate for surgical intervention with his extensive comorbidities. A bioethics consultation at the time supported minimizing potential surgical risk in favor of conservative medical management; this was discussed with the patient’s surrogate decision maker, who also wished to avoid surgery. The SBO resolved with conservative management. He had been residing in a nursing home and doing well until 24 hours prior to admission when he developed fevers.

Vital signs on admission showed a temperature of 100.8 °F, heart rate 100 beats per minute, blood pressure 116/85, respiratory rate 22 per minute, and oxygen saturation of 100% on 6 L of oxygen via tracheostomy collar. His initial examination was notable for clear lung sounds, a nondistended nonrigid abdomen with an indwelling percutaneous gastrostomy tube, and absence of areas of skin breakdown or erythema. Notable laboratory studies showed a leukocytosis and urinalysis suggestive of CAUTI (Table). His urinary catheter was exchanged, he was fluid resuscitated and started on empiric vancomycin and piperacillin-tazobactam for management of sepsis due to CAUTI.

For the first 3 days of his hospitalization, he demonstrated clinical improvement on vancomycin and piperacillin-tazobactam while awaiting results from his urine bacterial culture. On hospital day 3, hedeveloped recurrent nonbloody, nonbilious emesis despite no change in the rate or formulation of his enteral nutrition. He also had 3 watery brown bowel movements. His vital signs remained within normal limits. His abdominal examination at this point showed mild distention and was hypertympanic to percussion, but there was no rigidity or involuntary guarding. On hospital day 4, he continued to have emesis with an unchanged abdominal examination. The differential diagnosis included recurrence of prior SBO, ileus, intestinal ischemia, enteral nutrition intolerance, Clostridioides difficile (C difficile) colitis, and GI dysmotility because of his anoxic brain injury.

Testing for C difficile was negative. An abdominal radiograph was obtained and revealed no bowel obstruction but, alarmingly, showed extensive intramural bowel gas, suggestive of PI (Figure 1). His leukocyte count, serum bicarbonate, and serum lactate levels remained within normal limits. A CT with contrast of the abdomen and pelvis demonstrated no vascular obstruction but confirmed the presence of diffuse intramural gas in his stomach and proximal small bowel, as well as the presence of mesenteric and portal venous gas (Figures 2 and 3). Although his abdominal examination had not changed and did not suggest peritonitis, general surgery was consulted to discuss the need for surgical intervention. Given his overall clinical stability and high surgical risk due to his many comorbidities, surgery recommended a conservative approach.

Through the following hospital days, his enteral nutrition was held and serial abdominal examinations were performed without change. Serial laboratory studies, including serum lactate and leukocyte count, remained reassuringly within normal limits. His urine culture eventually revealed multidrugresistant Pseudomonas aeruginosa. Antimicrobial therapy was narrowed to piperacillintazobactam for a complete course. Enteral nutrition was gradually reintroduced at a low rate, ultimately reaching goal rate with return of bowel function by hospital day 9. Despite extensive workup, the etiology of his transient enteral nutrition intolerance remained uncertain, though an adverse effect of antibiotic therapy was thought possible. Follow-up abdominal radiographs demonstrated interval improvement of PI. He was discharged back to his skilled nursing facility on hospital day 11 without incident.

Discussion

PI is an incompletely understood condition seen in multiple diseases. Patients may present with highly variable symptoms, often more attributable to the underlying disease causing the PI than the presence of PI, as patients may be entirely asymptomatic. When symptoms are attributed to PI, those most reported are abdominal pain, bloody stools, and diarrhea.¹ It is often detected on abdominal plain films. Alternative methods of diagnosis include ultrasonography, barium enema, and endoscopy although the last method has been known to occasionally lead to bowel perforation.^2-6 The most sensitive method of detection is CT, which also provides additional information about abdominal pathology and may identify the underlying process responsible for the PI.⁷

While not fully understood, much information about PI and its pathogenesis is known. Understanding the mechanisms of PI is vital to direct the clinician’s evaluation of the patient for reversible conditions that may cause PI. Early descriptions of PI in the literature documented an association with pyloric stenosis, leading to the theory that gas from the intestinal lumen is driven into the submucosal space during episodes of forceful vomiting with increased intraluminal pressure.⁸ As PI was subsequently described in multiple other disease states not typically associated with increased intraluminal pressure such as inflammatory bowel disease, GI malignancy, cryptosporidiosis and CMV infection, additional theories about the pathogenesis of PI have arisen.^9-24 There is now experimental data to support multiple mechanisms of intramural gas accumulation. It has become accepted that PI represents a common pathway shared across various pathologic states and results from multifactorial mechanisms of gas entry into the intestinal wall.^25-29

Factors leading to the development of PI include bacterial production of gas, intraluminal GI gas compositions, increased intraluminal pressure, pulmonary gas tracking through vessels communicating with the thorax, and mucosal disruption. PI has been linked to bacterial infections of the GI tract in humans including C difficile, Klebsiella, and Whipple disease.^14-18 In animal models, C difficile within the walls of rat intestine results in the appearance of pneumocysts, or discrete collections of submucosal gas, which are the hallmark feature of PI.³⁰ It is thought that direct invasion of bacteria into intramural spaces can cause PI in humans, although bacteria have yet to be directly isolated from the pneumocysts. Translocation of luminal gas into pneumocysts found in PI is theorized to be driven by differences in partial pressures.³¹ The concentration of hydrogen within the intestinal lumen is high due to bacterial production. Hydrogen, diffusing along its partial pressure gradient between the lumen and blood, accumulates within the intestinal wall and causes the formation of pneumocysts. This phenomenon has been hypothesized to explain the tendency for pneumocysts to form around the mesenteric vasculature.

Gas from the lumen can also be forced into the intestinal wall during an abrupt increase in intra-abdominal pressure, such as that seen with forceful vomiting. The final possible origin of the gas is the lungs, as PI has been associated with lung disease. It was previously thought that gas from ruptured alveoli tracks along mediastinal vessels, below the diaphragm, and into the mesentery.³⁰ Newer theories argue that increased intra-abdominal pressure, typical of patients with obstructive lung disease and frequent coughing, is the driver of PI by the mechanism previously described.^32-34 Additionally, mucosal disruption leads to increased permeability and allows accumulation of gas within the intestinal walls. Mucosal abnormalities have been described in histopathologic studies of patients with PI and associated with conditions known to compromise mucosal integrity, such as immunodeficiencies, inflammatory bowel disease, and the receipt of cytotoxic chemotherapy.^10,12,19-23

Our patient likely had mucosal disruption due to his gastrostomy tube as well as increased intraluminal pressure from recurrent vomiting, contributing to translocation of otherwise normal intraluminal gas. The presence of portal venous gas, as seen in this case, has historically portended a worse prognosis, with 37% mortality in one series.^7,35,36 However, portal venous gas as well as pneumoperitoneum occur in benign etiologies of PI as well. It is thought that this occurs due to rupture of the submucosal pneumocysts through the wall opposite the intestinal lumen and thus does not result in a direct communication between the intestinal lumen and the peritoneal cavity.¹²

PI is not a diagnosis but a manifestation of an underlying disease. As such, the treatment of PI is targeted toward the underlying condition. Of note, the pattern and extent of PI seen on imaging has not been shown to correlate with the severity of the underlying pathologic process.^35,37 Instead, assessment of the patient and their clinical trajectory should determine the appropriate treatment. The decision facing the clinician when PI is discovered is whether urgent surgery is indicated, as is the case in mesenteric ischemia, bowel necrosis, or intestinal perforation, conditions known to be associated with PI. Otherwise, there is no definitive treatment for PI. Bowel rest is almost universally pursued. There are reports of treating with supranormal levels of supplemental oxygen, maintaining arterial partial pressure of oxygen above 300 mm Hg, with a face mask and 8 L/min flow rate.^38,39 The proposed mechanisms of benefit include establishing a favorable diffusion gradient for intramural gas to exit the pneumocysts as well as creating an inhospitable, aerobic environment for hydrogenproducing anaerobic enteric bacteria. A prudent approach for most cases of PI is conservative management with bowel rest and supplemental oxygen unless there is a definitive indication for urgent surgical intervention, such as peritonitis, abdominal sepsis, or perforation.^40,41 Management recommendations suggest that up to 50% of cases can be successfully managed nonoperatively.⁴²

Conclusions

PI is the radiographic finding of gas within the walls of the intestinal tract and has variable clinical significance. It can represent a benign incidental finding or a sequela of intraabdominal emergencies such as mesenteric ischemia or bowel necrosis. Because PI is seen in a variety of disorders, several proposed mechanisms are supported in the medical literature. These include bacterial production of gas, gas pressure gradients between the intestinal lumen and the blood, increased intraluminal pressure, pulmonary gas tracking from intrathoracic vessels, and mucosal disruption. The evaluation of a patient with PI must begin with an assessment for the need for urgent surgical intervention. Additional management measures include bowel rest, IV hydration, and supplemental oxygen administration. Because of its wide variety of etiologies of varying clinical urgency, placing the finding of PI in the context of the patient is paramount to selecting an appropriate management strategy.

Federal advisers to the U.S. Food and Drug Administration voted unanimously June 15 to recommend the use of the Moderna and Pfizer-BioNTech COVID-19 vaccines in infants and young children.

The Vaccines and Related Biological Products Advisory Committee (VRBPAC) of the FDA voted 21-0 to say that benefits of a two-dose series of Moderna’s mRNA vaccine outweigh risk for use in infants and children 6 months through 5 years of age.

The panel then voted 21-0 to say that benefits of a three-dose series of the Pfizer-BioNTech mRNA vaccine outweigh risk for use in infants and children 6 months through 4 years of age.

The FDA is not bound to follow the suggestions of its advisory committees, but it often does. Moderna and Pfizer are seeking to expand emergency use authorization (EUA) for their vaccines. EUAs are special clearances used to allow use of products in connection with public health crises such as the pandemic.

The Pfizer vaccine has standard, nonemergency FDA approval for use in people 16 years of age and older. The FDA also has granted EUA clearance for use of the shot in people ages 5 to 15.

The VRBPAC on June 15 recommended granting EUA clearance for Moderna’s COVID-19 vaccine for people ages 6 to 17. The Moderna vaccine already has full approval for use in people 18 years of age and older.

Many parents have been waiting for a clearance of COVID vaccines for their infants and young children, seeking protection for them at a time of continued spread of the virus.

The White House on June 9 outlined plans for making 10 million doses of COVID vaccines available for children under the age of 5 in the coming weeks.

The Centers for Disease Control and Prevention (CDC) has scheduled a June 18 meeting of its Advisory Committee on Immunization Practices, where members of that panel will vote on recommendations about use of the Moderna and Pfizer-BioNTech vaccines in infants and young children. The last step in the approval process to get shots into arms will be endorsement by the CDC director if the committee votes in favor of the vaccines.

For and against

During the public session during the June 15 FDA meeting, speakers offered varied opinions.

Some urged the panel to vote against the EUA expansion, citing concerns about risks of COVID vaccines in general.

But at the close of the meeting, top FDA vaccine official Peter Marks, MD, PhD, urged the public to be cautious about drawing conclusions from reading incident reports of side effects.

He said he has seen a “Twitter storm” during the day about claims of side effects. but stressed that the FDA has reported to the public on the rare side effects linked to the COVID vaccines, such as myocarditis, with advisories based on a review of reports of side effects. But many of these reports, gathered from the Vaccine Adverse Event Reporting System (VAERS) system, will turn out on further inspection not to be related to vaccination.

Many other speakers urged members of the panel to support expanded use of the vaccines for infants and young children. These speakers emphasized how lack of a vaccine to date has isolated young children who remain unprotected, even with about 83% of those age 5 and older in the United States having received at least one COVID shot.

Dr. Marks noted that there have been 442 deaths from COVID among children under 4 years of age during the pandemic, a number that he compared with the 78 deaths reported in the H1N1 flu. He urged the panel “to be careful that we don’t become numb to the number of pediatric deaths because of the overwhelming number of older deaths here.”

Panelist H. Cody Meissner, MD, a pediatric infectious disease specialist from Tufts University, said the vaccine should be made available -- particularly for children considered to be at high risk for complications from COVID --but health officials need to present a clear picture of the relatively low risks to children of harm from the vaccines-- and from COVID.

“That has to be communicated clearly to parents so that they can participate in the decision about vaccinating a child in this age group,” Dr. Meissner said.

The results presented June 15 from studies of the shots in younger children were less impressive than those from the initial COVID vaccine trials done in adults. This was not a surprise to panelists given the rise of the omicron variant and the evolution of the pandemic, but it still led to comments about the need for further continued study of the vaccines in young children even if they are authorized.

Consider that in 2020, Pfizer won the first EUA for a COVID vaccine of any kind with data that pegged the shot’s efficacy rate at 95%. Statisticians estimated a likely possible range, or 95% confidence interval, for the vaccine efficacy rate at 90.3% to 97.6%.

Those estimates were based on finding eight cases of COVID reported among 18,198 study participants who got the Pfizer-BioNTech shot, compared with 162 cases among the 18,325 people in the placebo group, according to the FDA review of Pifzer’s initial application.

Study data

But on June 15, FDA advisers had to consider an EUA application for which the data did not make as strong a case for the vaccine’s benefit among younger patients.

Pfizer presented what the FDA called a “preliminary descriptive analysis” of vaccine efficacy among participants in Study C4591007 who received three study vaccinations, following accrual of 10 total confirmed COVID-19 cases occurring at least 7 days after the third dose.

Looking at results for study participants ages 6 to 23 months of age, there was one case in the group that got the Pfizer-BioNTech shot and two in the placebo group, pegged as a 75.6% vaccine efficacy rate -- but one with caveats to the small numbers of cases. The 95% confidence interval for this vaccine efficacy rate was reported as-369.1% to 99.6% according to the FDA staff review.

For participants 2-4 years of age with and without evidence of prior SARS-CoV-

2 infection, there were two cases in the group that got the shot and five in the placebo group showing a vaccine efficacy rate of 82.4%, with a 95% confidence interval estimated ranging between -7.6% and 98.3%. For the combined analysis of both age groups, the efficacy rate was estimated at 80.4%, with a 95% confidence interval of 14.1% and 96.7%.

Doran Fink, MD, PhD, a top official in the FDA’s vaccines division, noted that the current EUA application for expanded pediatric use involved “some very preliminary” results that involved “a small number of cases and limited follow up time.”

But he stressed that the evidence gathered to date for the Pifzer application for use of its COVID shot in infants and young children met the threshold for conditional clearance during a crisis.

“We do feel very confident that the evidentiary standard for benefit for an EUA has been met here,” but added that more data would be needed to address questions about the efficacy of the vaccine beyond a third dose and whether an additional dose may be needed.

Pfizer also used a comparison known as “immunobridging” in support of the application. This looked at SARS- CoV-2 50% neutralizing antibody titers for the children in the age group covered by the EUA application and compared them to a randomly selected subset of 16-25-year-old participants in another study,

Key data for the pending Moderna EUA for use of its shot in infants and young children came from study P204. In it, Moderna found 51 cases of COVID among 1,511 children ages 6 months to 23 months who got the vaccines, versus 34 cases among 513 children who received a placebo, according to an FDA staff review.

That resulted in a vaccine efficacy rate pegged at 50.6%, with a 95% confidence interval of 21.4% to 68.6%.

Looking at the children ages 2 to 5 years in the P204 study, there were 119 cases out of 2,594 participants who got the shot, versus 61 cases of 858 in the placebo arm, or 7.1%. That translated to a 36.8% vaccine efficacy rate, with a confidence interval 12.5% to 54.0%.

Panelist Jay Portnoy, MD, of Children’s Mercy Hospital in Kansas City said all of the pediatricians he knows are waiting for the FDA to authorize the new uses of these vaccines in infants and young children.

“The death rate from COVID in young children may not be extremely high, but it’s absolutely terrifying to parents to have their child be sick, have to go to the hospital or even go to the emergency room or their primary care doctor because they’re sick and having trouble breathing,” said Dr. Portnoy, who served as the panel’s consumer representative.

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

This article was updated on 6/16/22.

Federal advisers to the U.S. Food and Drug Administration voted unanimously June 15 to recommend the use of the Moderna and Pfizer-BioNTech COVID-19 vaccines in infants and young children.

The Vaccines and Related Biological Products Advisory Committee (VRBPAC) of the FDA voted 21-0 to say that benefits of a two-dose series of Moderna’s mRNA vaccine outweigh risk for use in infants and children 6 months through 5 years of age.

The panel then voted 21-0 to say that benefits of a three-dose series of the Pfizer-BioNTech mRNA vaccine outweigh risk for use in infants and children 6 months through 4 years of age.

The FDA is not bound to follow the suggestions of its advisory committees, but it often does. Moderna and Pfizer are seeking to expand emergency use authorization (EUA) for their vaccines. EUAs are special clearances used to allow use of products in connection with public health crises such as the pandemic.

The Pfizer vaccine has standard, nonemergency FDA approval for use in people 16 years of age and older. The FDA also has granted EUA clearance for use of the shot in people ages 5 to 15.

The VRBPAC on June 15 recommended granting EUA clearance for Moderna’s COVID-19 vaccine for people ages 6 to 17. The Moderna vaccine already has full approval for use in people 18 years of age and older.

Many parents have been waiting for a clearance of COVID vaccines for their infants and young children, seeking protection for them at a time of continued spread of the virus.

The White House on June 9 outlined plans for making 10 million doses of COVID vaccines available for children under the age of 5 in the coming weeks.

The Centers for Disease Control and Prevention (CDC) has scheduled a June 18 meeting of its Advisory Committee on Immunization Practices, where members of that panel will vote on recommendations about use of the Moderna and Pfizer-BioNTech vaccines in infants and young children. The last step in the approval process to get shots into arms will be endorsement by the CDC director if the committee votes in favor of the vaccines.

For and against

During the public session during the June 15 FDA meeting, speakers offered varied opinions.

Some urged the panel to vote against the EUA expansion, citing concerns about risks of COVID vaccines in general.

But at the close of the meeting, top FDA vaccine official Peter Marks, MD, PhD, urged the public to be cautious about drawing conclusions from reading incident reports of side effects.

He said he has seen a “Twitter storm” during the day about claims of side effects. but stressed that the FDA has reported to the public on the rare side effects linked to the COVID vaccines, such as myocarditis, with advisories based on a review of reports of side effects. But many of these reports, gathered from the Vaccine Adverse Event Reporting System (VAERS) system, will turn out on further inspection not to be related to vaccination.

Many other speakers urged members of the panel to support expanded use of the vaccines for infants and young children. These speakers emphasized how lack of a vaccine to date has isolated young children who remain unprotected, even with about 83% of those age 5 and older in the United States having received at least one COVID shot.

Dr. Marks noted that there have been 442 deaths from COVID among children under 4 years of age during the pandemic, a number that he compared with the 78 deaths reported in the H1N1 flu. He urged the panel “to be careful that we don’t become numb to the number of pediatric deaths because of the overwhelming number of older deaths here.”

Panelist H. Cody Meissner, MD, a pediatric infectious disease specialist from Tufts University, said the vaccine should be made available -- particularly for children considered to be at high risk for complications from COVID --but health officials need to present a clear picture of the relatively low risks to children of harm from the vaccines-- and from COVID.

“That has to be communicated clearly to parents so that they can participate in the decision about vaccinating a child in this age group,” Dr. Meissner said.

The results presented June 15 from studies of the shots in younger children were less impressive than those from the initial COVID vaccine trials done in adults. This was not a surprise to panelists given the rise of the omicron variant and the evolution of the pandemic, but it still led to comments about the need for further continued study of the vaccines in young children even if they are authorized.

Consider that in 2020, Pfizer won the first EUA for a COVID vaccine of any kind with data that pegged the shot’s efficacy rate at 95%. Statisticians estimated a likely possible range, or 95% confidence interval, for the vaccine efficacy rate at 90.3% to 97.6%.

Those estimates were based on finding eight cases of COVID reported among 18,198 study participants who got the Pfizer-BioNTech shot, compared with 162 cases among the 18,325 people in the placebo group, according to the FDA review of Pifzer’s initial application.

Study data

But on June 15, FDA advisers had to consider an EUA application for which the data did not make as strong a case for the vaccine’s benefit among younger patients.

Pfizer presented what the FDA called a “preliminary descriptive analysis” of vaccine efficacy among participants in Study C4591007 who received three study vaccinations, following accrual of 10 total confirmed COVID-19 cases occurring at least 7 days after the third dose.

Looking at results for study participants ages 6 to 23 months of age, there was one case in the group that got the Pfizer-BioNTech shot and two in the placebo group, pegged as a 75.6% vaccine efficacy rate -- but one with caveats to the small numbers of cases. The 95% confidence interval for this vaccine efficacy rate was reported as-369.1% to 99.6% according to the FDA staff review.

For participants 2-4 years of age with and without evidence of prior SARS-CoV-

2 infection, there were two cases in the group that got the shot and five in the placebo group showing a vaccine efficacy rate of 82.4%, with a 95% confidence interval estimated ranging between -7.6% and 98.3%. For the combined analysis of both age groups, the efficacy rate was estimated at 80.4%, with a 95% confidence interval of 14.1% and 96.7%.

Doran Fink, MD, PhD, a top official in the FDA’s vaccines division, noted that the current EUA application for expanded pediatric use involved “some very preliminary” results that involved “a small number of cases and limited follow up time.”

But he stressed that the evidence gathered to date for the Pifzer application for use of its COVID shot in infants and young children met the threshold for conditional clearance during a crisis.

“We do feel very confident that the evidentiary standard for benefit for an EUA has been met here,” but added that more data would be needed to address questions about the efficacy of the vaccine beyond a third dose and whether an additional dose may be needed.

Pfizer also used a comparison known as “immunobridging” in support of the application. This looked at SARS- CoV-2 50% neutralizing antibody titers for the children in the age group covered by the EUA application and compared them to a randomly selected subset of 16-25-year-old participants in another study,

Key data for the pending Moderna EUA for use of its shot in infants and young children came from study P204. In it, Moderna found 51 cases of COVID among 1,511 children ages 6 months to 23 months who got the vaccines, versus 34 cases among 513 children who received a placebo, according to an FDA staff review.

That resulted in a vaccine efficacy rate pegged at 50.6%, with a 95% confidence interval of 21.4% to 68.6%.

Looking at the children ages 2 to 5 years in the P204 study, there were 119 cases out of 2,594 participants who got the shot, versus 61 cases of 858 in the placebo arm, or 7.1%. That translated to a 36.8% vaccine efficacy rate, with a confidence interval 12.5% to 54.0%.

Panelist Jay Portnoy, MD, of Children’s Mercy Hospital in Kansas City said all of the pediatricians he knows are waiting for the FDA to authorize the new uses of these vaccines in infants and young children.

“The death rate from COVID in young children may not be extremely high, but it’s absolutely terrifying to parents to have their child be sick, have to go to the hospital or even go to the emergency room or their primary care doctor because they’re sick and having trouble breathing,” said Dr. Portnoy, who served as the panel’s consumer representative.

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

This article was updated on 6/16/22.

Federal advisers to the U.S. Food and Drug Administration voted unanimously June 15 to recommend the use of the Moderna and Pfizer-BioNTech COVID-19 vaccines in infants and young children.

The Vaccines and Related Biological Products Advisory Committee (VRBPAC) of the FDA voted 21-0 to say that benefits of a two-dose series of Moderna’s mRNA vaccine outweigh risk for use in infants and children 6 months through 5 years of age.

The panel then voted 21-0 to say that benefits of a three-dose series of the Pfizer-BioNTech mRNA vaccine outweigh risk for use in infants and children 6 months through 4 years of age.

The FDA is not bound to follow the suggestions of its advisory committees, but it often does. Moderna and Pfizer are seeking to expand emergency use authorization (EUA) for their vaccines. EUAs are special clearances used to allow use of products in connection with public health crises such as the pandemic.

The Pfizer vaccine has standard, nonemergency FDA approval for use in people 16 years of age and older. The FDA also has granted EUA clearance for use of the shot in people ages 5 to 15.

The VRBPAC on June 15 recommended granting EUA clearance for Moderna’s COVID-19 vaccine for people ages 6 to 17. The Moderna vaccine already has full approval for use in people 18 years of age and older.

Many parents have been waiting for a clearance of COVID vaccines for their infants and young children, seeking protection for them at a time of continued spread of the virus.

The White House on June 9 outlined plans for making 10 million doses of COVID vaccines available for children under the age of 5 in the coming weeks.

The Centers for Disease Control and Prevention (CDC) has scheduled a June 18 meeting of its Advisory Committee on Immunization Practices, where members of that panel will vote on recommendations about use of the Moderna and Pfizer-BioNTech vaccines in infants and young children. The last step in the approval process to get shots into arms will be endorsement by the CDC director if the committee votes in favor of the vaccines.

For and against

During the public session during the June 15 FDA meeting, speakers offered varied opinions.

Some urged the panel to vote against the EUA expansion, citing concerns about risks of COVID vaccines in general.

But at the close of the meeting, top FDA vaccine official Peter Marks, MD, PhD, urged the public to be cautious about drawing conclusions from reading incident reports of side effects.

He said he has seen a “Twitter storm” during the day about claims of side effects. but stressed that the FDA has reported to the public on the rare side effects linked to the COVID vaccines, such as myocarditis, with advisories based on a review of reports of side effects. But many of these reports, gathered from the Vaccine Adverse Event Reporting System (VAERS) system, will turn out on further inspection not to be related to vaccination.

Many other speakers urged members of the panel to support expanded use of the vaccines for infants and young children. These speakers emphasized how lack of a vaccine to date has isolated young children who remain unprotected, even with about 83% of those age 5 and older in the United States having received at least one COVID shot.

Dr. Marks noted that there have been 442 deaths from COVID among children under 4 years of age during the pandemic, a number that he compared with the 78 deaths reported in the H1N1 flu. He urged the panel “to be careful that we don’t become numb to the number of pediatric deaths because of the overwhelming number of older deaths here.”

Panelist H. Cody Meissner, MD, a pediatric infectious disease specialist from Tufts University, said the vaccine should be made available -- particularly for children considered to be at high risk for complications from COVID --but health officials need to present a clear picture of the relatively low risks to children of harm from the vaccines-- and from COVID.

“That has to be communicated clearly to parents so that they can participate in the decision about vaccinating a child in this age group,” Dr. Meissner said.

The results presented June 15 from studies of the shots in younger children were less impressive than those from the initial COVID vaccine trials done in adults. This was not a surprise to panelists given the rise of the omicron variant and the evolution of the pandemic, but it still led to comments about the need for further continued study of the vaccines in young children even if they are authorized.

Consider that in 2020, Pfizer won the first EUA for a COVID vaccine of any kind with data that pegged the shot’s efficacy rate at 95%. Statisticians estimated a likely possible range, or 95% confidence interval, for the vaccine efficacy rate at 90.3% to 97.6%.

Those estimates were based on finding eight cases of COVID reported among 18,198 study participants who got the Pfizer-BioNTech shot, compared with 162 cases among the 18,325 people in the placebo group, according to the FDA review of Pifzer’s initial application.

Study data

But on June 15, FDA advisers had to consider an EUA application for which the data did not make as strong a case for the vaccine’s benefit among younger patients.

Pfizer presented what the FDA called a “preliminary descriptive analysis” of vaccine efficacy among participants in Study C4591007 who received three study vaccinations, following accrual of 10 total confirmed COVID-19 cases occurring at least 7 days after the third dose.

Looking at results for study participants ages 6 to 23 months of age, there was one case in the group that got the Pfizer-BioNTech shot and two in the placebo group, pegged as a 75.6% vaccine efficacy rate -- but one with caveats to the small numbers of cases. The 95% confidence interval for this vaccine efficacy rate was reported as-369.1% to 99.6% according to the FDA staff review.

For participants 2-4 years of age with and without evidence of prior SARS-CoV-

2 infection, there were two cases in the group that got the shot and five in the placebo group showing a vaccine efficacy rate of 82.4%, with a 95% confidence interval estimated ranging between -7.6% and 98.3%. For the combined analysis of both age groups, the efficacy rate was estimated at 80.4%, with a 95% confidence interval of 14.1% and 96.7%.

Doran Fink, MD, PhD, a top official in the FDA’s vaccines division, noted that the current EUA application for expanded pediatric use involved “some very preliminary” results that involved “a small number of cases and limited follow up time.”

But he stressed that the evidence gathered to date for the Pifzer application for use of its COVID shot in infants and young children met the threshold for conditional clearance during a crisis.

“We do feel very confident that the evidentiary standard for benefit for an EUA has been met here,” but added that more data would be needed to address questions about the efficacy of the vaccine beyond a third dose and whether an additional dose may be needed.

Pfizer also used a comparison known as “immunobridging” in support of the application. This looked at SARS- CoV-2 50% neutralizing antibody titers for the children in the age group covered by the EUA application and compared them to a randomly selected subset of 16-25-year-old participants in another study,

Key data for the pending Moderna EUA for use of its shot in infants and young children came from study P204. In it, Moderna found 51 cases of COVID among 1,511 children ages 6 months to 23 months who got the vaccines, versus 34 cases among 513 children who received a placebo, according to an FDA staff review.

That resulted in a vaccine efficacy rate pegged at 50.6%, with a 95% confidence interval of 21.4% to 68.6%.

Looking at the children ages 2 to 5 years in the P204 study, there were 119 cases out of 2,594 participants who got the shot, versus 61 cases of 858 in the placebo arm, or 7.1%. That translated to a 36.8% vaccine efficacy rate, with a confidence interval 12.5% to 54.0%.

Panelist Jay Portnoy, MD, of Children’s Mercy Hospital in Kansas City said all of the pediatricians he knows are waiting for the FDA to authorize the new uses of these vaccines in infants and young children.

“The death rate from COVID in young children may not be extremely high, but it’s absolutely terrifying to parents to have their child be sick, have to go to the hospital or even go to the emergency room or their primary care doctor because they’re sick and having trouble breathing,” said Dr. Portnoy, who served as the panel’s consumer representative.

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

This article was updated on 6/16/22.

A phase 3 trial has associated the neurokinin-3 (NK3)–receptor inhibitor fezolinetant, an oral therapy taken once daily, with substantial control over the symptoms of menopause, according to results of the randomized SKYLIGHT 2 trial.

The nonhormonal therapy has the potential to address an important unmet need, Genevieve Neal-Perry, MD, PhD, said at the annual meeting of the Endocrine Society.

The health risks of hormone therapy (HT) have “caused quite a few women to consider whether hormone replacement is right for them, and, in addition, there are other individuals who have hormone-responsive cancers or other disorders that might prohibit them [from using HT],” Dr. Neal-Perry said.

The NK3 receptor stimulates the thermoregulatory center in the hypothalamus. By blocking the NK3 receptor, vasodilation and other downstream effects are inhibited, explained Dr. Neal-Perry. She credited relatively recent advances in understanding the mechanisms of menopausal symptoms for identifying this and other potentially targetable mediators.

SKYLIGHT 2 trial: Two phases

In the double-blind multinational phase 3 SKYLIGHT 2 trial, 484 otherwise healthy symptomatic menopausal women were randomized to 30 mg of fezolinetant, 45 mg of fezolinetant, or placebo. The 120 participating centers were in North American and Europe.

In the first phase, safety and efficacy were evaluated over 12 weeks. In a second extension phase, placebo patients were rerandomized to one of the fezolinetant study doses. Those on active therapy remained in their assigned groups. All patients were then followed for an additional 40 weeks.

The coprimary endpoints were frequency and severity of moderate to severe vasomotor symptoms as reported by patients using an electronic diary. There were several secondary endpoints, including patient-reported outcomes regarding sleep quality.

As expected from other controlled trials, placebo patients achieved about a 40% reduction in moderate to severe vasomotor symptom frequency over the first 12 weeks. Relative to placebo, symptom frequency declined more quickly and steeply on fezolinetant. By week 12, both achieved reductions of about 60%. Statistical P values for the differences in the three arms were not provided, but Dr. Neal-Perry reported they were significant.

Vasomotor severity, like frequency, is reduced

The change in vasomotor severity, which subjects in the trial rated as better or worse, was also significant. The differences in the severity curves were less, but they separated in favor of the two active treatment arms by about 2 weeks, and the curves continued to show an advantage for fezolinetant over both the first 12 weeks and then the remaining 40 weeks.

Overall, the decline in vasomotor symptom frequency remained on a persistent downward slope on both doses of fezolinetant for the full 52 weeks of the study, so that the reduction at 52 weeks was on the order of 25% greater than that seen at 12 weeks.

At 52 weeks, “you can see that individuals on placebo who were crossed over to an active treatment had a significant reduction in their hot flashes and look very much like those who were randomized to fezolinetant at the beginning of the study,” said Dr. Neal-Perry, who is chair of the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill.

Other outcomes also favored fezolinetant over placebo. For example, a reduction in sleep disturbance observed at 12 weeks was sustained over the full 52 weeks of the study. The reduction in sleep symptoms appeared to be slightly greater on the higher dose, but the benefit at 52 weeks among patients after the crossover was similar on either active arm.

No serious side effects identified

There were no serious drug-related treatment-emergent adverse events in any treatment group. One patient in the placebo arm (< 1%), two patients in the 30-mg fezolinetant arm (1.2%), and five patients in the 45-mg arm (3%) discontinued therapy for an adverse event considered to be treatment related.

“The most common side effect associated with fezolinetant was headache. There were no other side effects that led patients to pull out of the study,” Dr. Neal-Perry reported at the meeting, which was held in Atlanta and virtually.

According to Dr. Neal-Perry the vasomotor symptoms relative to menopause, which occur in almost all women, are moderate to severe in an estimated 35%-45%. Some groups, such as those with an elevated body mass index and African Americans, appear to be at even greater risk. Study enrollment was specifically designed to include these high-risk groups, but the subgroup efficacy data have not yet been analyzed.

Other drugs with a similar mechanism of action have not been brought forward because of concern about elevated liver enzymes, but Dr. Neal-Perry said that this does not appear to be an issue for fezolinetant, which was designed with greater specificity for the NK3 target than previous treatments.

If fezolinetant is approved, Dr. Neal-Perry expects this agent to fulfill an important unmet need because of the limitations of other nonhormonal solutions for control of menopause symptoms.

HT alternatives limited

For control of many menopause symptoms, particularly hot flashes, hormone therapy (HT) is the most efficacious, but Richard J. Santen, MD, emeritus professor and an endocrinologist at the University of Virginia, Charlottesville, agreed there is a need for alternatives.

In addition to those who have contraindications for HT, Dr. Santen said in an interview that this option is not acceptable to others “for a variety of reasons.” The problem is that the alternatives are limited.

“The SSRI agents and gabapentin are alternative nonhormonal agents, but they have side effects and are not as effective,” he said. Hot flashes “can be a major disruptor of quality of life,” so he is intrigued with the positive results achieved with fezolinetant.

“A new drug such as reported at the Endocrine Society meeting would be an important new addition to the armamentarium,” he said.

Dr. Neal-Perry reports no conflicts of interest.

A phase 3 trial has associated the neurokinin-3 (NK3)–receptor inhibitor fezolinetant, an oral therapy taken once daily, with substantial control over the symptoms of menopause, according to results of the randomized SKYLIGHT 2 trial.

The nonhormonal therapy has the potential to address an important unmet need, Genevieve Neal-Perry, MD, PhD, said at the annual meeting of the Endocrine Society.

The health risks of hormone therapy (HT) have “caused quite a few women to consider whether hormone replacement is right for them, and, in addition, there are other individuals who have hormone-responsive cancers or other disorders that might prohibit them [from using HT],” Dr. Neal-Perry said.

The NK3 receptor stimulates the thermoregulatory center in the hypothalamus. By blocking the NK3 receptor, vasodilation and other downstream effects are inhibited, explained Dr. Neal-Perry. She credited relatively recent advances in understanding the mechanisms of menopausal symptoms for identifying this and other potentially targetable mediators.

SKYLIGHT 2 trial: Two phases

In the double-blind multinational phase 3 SKYLIGHT 2 trial, 484 otherwise healthy symptomatic menopausal women were randomized to 30 mg of fezolinetant, 45 mg of fezolinetant, or placebo. The 120 participating centers were in North American and Europe.

In the first phase, safety and efficacy were evaluated over 12 weeks. In a second extension phase, placebo patients were rerandomized to one of the fezolinetant study doses. Those on active therapy remained in their assigned groups. All patients were then followed for an additional 40 weeks.

The coprimary endpoints were frequency and severity of moderate to severe vasomotor symptoms as reported by patients using an electronic diary. There were several secondary endpoints, including patient-reported outcomes regarding sleep quality.

As expected from other controlled trials, placebo patients achieved about a 40% reduction in moderate to severe vasomotor symptom frequency over the first 12 weeks. Relative to placebo, symptom frequency declined more quickly and steeply on fezolinetant. By week 12, both achieved reductions of about 60%. Statistical P values for the differences in the three arms were not provided, but Dr. Neal-Perry reported they were significant.

Vasomotor severity, like frequency, is reduced

The change in vasomotor severity, which subjects in the trial rated as better or worse, was also significant. The differences in the severity curves were less, but they separated in favor of the two active treatment arms by about 2 weeks, and the curves continued to show an advantage for fezolinetant over both the first 12 weeks and then the remaining 40 weeks.

Overall, the decline in vasomotor symptom frequency remained on a persistent downward slope on both doses of fezolinetant for the full 52 weeks of the study, so that the reduction at 52 weeks was on the order of 25% greater than that seen at 12 weeks.

At 52 weeks, “you can see that individuals on placebo who were crossed over to an active treatment had a significant reduction in their hot flashes and look very much like those who were randomized to fezolinetant at the beginning of the study,” said Dr. Neal-Perry, who is chair of the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill.

Other outcomes also favored fezolinetant over placebo. For example, a reduction in sleep disturbance observed at 12 weeks was sustained over the full 52 weeks of the study. The reduction in sleep symptoms appeared to be slightly greater on the higher dose, but the benefit at 52 weeks among patients after the crossover was similar on either active arm.

No serious side effects identified

There were no serious drug-related treatment-emergent adverse events in any treatment group. One patient in the placebo arm (< 1%), two patients in the 30-mg fezolinetant arm (1.2%), and five patients in the 45-mg arm (3%) discontinued therapy for an adverse event considered to be treatment related.

“The most common side effect associated with fezolinetant was headache. There were no other side effects that led patients to pull out of the study,” Dr. Neal-Perry reported at the meeting, which was held in Atlanta and virtually.

According to Dr. Neal-Perry the vasomotor symptoms relative to menopause, which occur in almost all women, are moderate to severe in an estimated 35%-45%. Some groups, such as those with an elevated body mass index and African Americans, appear to be at even greater risk. Study enrollment was specifically designed to include these high-risk groups, but the subgroup efficacy data have not yet been analyzed.

Other drugs with a similar mechanism of action have not been brought forward because of concern about elevated liver enzymes, but Dr. Neal-Perry said that this does not appear to be an issue for fezolinetant, which was designed with greater specificity for the NK3 target than previous treatments.

If fezolinetant is approved, Dr. Neal-Perry expects this agent to fulfill an important unmet need because of the limitations of other nonhormonal solutions for control of menopause symptoms.

HT alternatives limited

For control of many menopause symptoms, particularly hot flashes, hormone therapy (HT) is the most efficacious, but Richard J. Santen, MD, emeritus professor and an endocrinologist at the University of Virginia, Charlottesville, agreed there is a need for alternatives.

In addition to those who have contraindications for HT, Dr. Santen said in an interview that this option is not acceptable to others “for a variety of reasons.” The problem is that the alternatives are limited.

“The SSRI agents and gabapentin are alternative nonhormonal agents, but they have side effects and are not as effective,” he said. Hot flashes “can be a major disruptor of quality of life,” so he is intrigued with the positive results achieved with fezolinetant.

“A new drug such as reported at the Endocrine Society meeting would be an important new addition to the armamentarium,” he said.

Dr. Neal-Perry reports no conflicts of interest.

A phase 3 trial has associated the neurokinin-3 (NK3)–receptor inhibitor fezolinetant, an oral therapy taken once daily, with substantial control over the symptoms of menopause, according to results of the randomized SKYLIGHT 2 trial.

The nonhormonal therapy has the potential to address an important unmet need, Genevieve Neal-Perry, MD, PhD, said at the annual meeting of the Endocrine Society.

The health risks of hormone therapy (HT) have “caused quite a few women to consider whether hormone replacement is right for them, and, in addition, there are other individuals who have hormone-responsive cancers or other disorders that might prohibit them [from using HT],” Dr. Neal-Perry said.

The NK3 receptor stimulates the thermoregulatory center in the hypothalamus. By blocking the NK3 receptor, vasodilation and other downstream effects are inhibited, explained Dr. Neal-Perry. She credited relatively recent advances in understanding the mechanisms of menopausal symptoms for identifying this and other potentially targetable mediators.

SKYLIGHT 2 trial: Two phases

In the double-blind multinational phase 3 SKYLIGHT 2 trial, 484 otherwise healthy symptomatic menopausal women were randomized to 30 mg of fezolinetant, 45 mg of fezolinetant, or placebo. The 120 participating centers were in North American and Europe.

In the first phase, safety and efficacy were evaluated over 12 weeks. In a second extension phase, placebo patients were rerandomized to one of the fezolinetant study doses. Those on active therapy remained in their assigned groups. All patients were then followed for an additional 40 weeks.

The coprimary endpoints were frequency and severity of moderate to severe vasomotor symptoms as reported by patients using an electronic diary. There were several secondary endpoints, including patient-reported outcomes regarding sleep quality.

As expected from other controlled trials, placebo patients achieved about a 40% reduction in moderate to severe vasomotor symptom frequency over the first 12 weeks. Relative to placebo, symptom frequency declined more quickly and steeply on fezolinetant. By week 12, both achieved reductions of about 60%. Statistical P values for the differences in the three arms were not provided, but Dr. Neal-Perry reported they were significant.

Vasomotor severity, like frequency, is reduced

The change in vasomotor severity, which subjects in the trial rated as better or worse, was also significant. The differences in the severity curves were less, but they separated in favor of the two active treatment arms by about 2 weeks, and the curves continued to show an advantage for fezolinetant over both the first 12 weeks and then the remaining 40 weeks.

Overall, the decline in vasomotor symptom frequency remained on a persistent downward slope on both doses of fezolinetant for the full 52 weeks of the study, so that the reduction at 52 weeks was on the order of 25% greater than that seen at 12 weeks.

At 52 weeks, “you can see that individuals on placebo who were crossed over to an active treatment had a significant reduction in their hot flashes and look very much like those who were randomized to fezolinetant at the beginning of the study,” said Dr. Neal-Perry, who is chair of the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill.

Other outcomes also favored fezolinetant over placebo. For example, a reduction in sleep disturbance observed at 12 weeks was sustained over the full 52 weeks of the study. The reduction in sleep symptoms appeared to be slightly greater on the higher dose, but the benefit at 52 weeks among patients after the crossover was similar on either active arm.

No serious side effects identified

There were no serious drug-related treatment-emergent adverse events in any treatment group. One patient in the placebo arm (< 1%), two patients in the 30-mg fezolinetant arm (1.2%), and five patients in the 45-mg arm (3%) discontinued therapy for an adverse event considered to be treatment related.

“The most common side effect associated with fezolinetant was headache. There were no other side effects that led patients to pull out of the study,” Dr. Neal-Perry reported at the meeting, which was held in Atlanta and virtually.

According to Dr. Neal-Perry the vasomotor symptoms relative to menopause, which occur in almost all women, are moderate to severe in an estimated 35%-45%. Some groups, such as those with an elevated body mass index and African Americans, appear to be at even greater risk. Study enrollment was specifically designed to include these high-risk groups, but the subgroup efficacy data have not yet been analyzed.

Other drugs with a similar mechanism of action have not been brought forward because of concern about elevated liver enzymes, but Dr. Neal-Perry said that this does not appear to be an issue for fezolinetant, which was designed with greater specificity for the NK3 target than previous treatments.

If fezolinetant is approved, Dr. Neal-Perry expects this agent to fulfill an important unmet need because of the limitations of other nonhormonal solutions for control of menopause symptoms.

HT alternatives limited

For control of many menopause symptoms, particularly hot flashes, hormone therapy (HT) is the most efficacious, but Richard J. Santen, MD, emeritus professor and an endocrinologist at the University of Virginia, Charlottesville, agreed there is a need for alternatives.

In addition to those who have contraindications for HT, Dr. Santen said in an interview that this option is not acceptable to others “for a variety of reasons.” The problem is that the alternatives are limited.

“The SSRI agents and gabapentin are alternative nonhormonal agents, but they have side effects and are not as effective,” he said. Hot flashes “can be a major disruptor of quality of life,” so he is intrigued with the positive results achieved with fezolinetant.

“A new drug such as reported at the Endocrine Society meeting would be an important new addition to the armamentarium,” he said.

Dr. Neal-Perry reports no conflicts of interest.

“No matter who the patient is, whether a child, adolescent, or adult, the key to figuring out hair disease is getting a good history,” Maria Hordinsky, MD, professor and chair of the department of dermatology at the University of Minnesota, Minneapolis, said at the Medscape Live Women’s and Pediatric Dermatology Seminar.

During her presentation on what’s new in hair disorders, Dr. Hordinsky covered a range of disorders and treatments, with some common denominators, such as the need for a good history. She also urged physicians and other health care providers to use the electronic medical record and to be thorough in documenting information – noting nutrition, hair care habits, supplement use, and other details.

Cunaplus_M.Faba/Getty Images

Lab tests should be selected based on that history, she said. For instance, low iron stores can be associated with hair shedding; and thyroid function studies might be needed.

Other highlights of her presentation included comments on different types of alopecia, and some new treatment approaches:

Androgenetic alopecia. In a meta-analysis and systematic review published in 2017, all treatments tested (2% and 5% minoxidil in men, 1 mg finasteride in men, 2% minoxidil in women, and low-level laser light therapy in men) were superior to placebo. Several photobiomodulation (PBM) devices (also known as low-level laser light) for home use have been cleared for androgenetic alopecia by the Food and Drug Administration; a clinician’s guide, published in 2018, provides information on these devices.

Hair and hormones. Combination therapy for female-pattern hair loss – low-dose minoxidil and spironolactone – is important to know about, she said, adding there are data from an observational pilot study supporting this treatment. Women should not become pregnant while on this treatment, Dr. Hordinsky cautioned.

PRP (platelet rich plasma). This treatment for hair loss can be costly, she cautioned, as it’s viewed as a cosmetic technique, “but it actually can work rather well.”

Hair regrowth measures. Traditionally, measures center on global assessment, the patient’s self-assessment, investigator assessment, and an independent photo review. Enter the dermatoscope. “We can now get pictures as a baseline. Patients can see, and also see the health of their scalp,” and if treatments make it look better or worse, she noted.

Alopecia areata (AA). Patients and families need to be made aware that this is an autoimmune disease that can recur, and if it does recur, the extent of hair loss is not predictable. According to Dr. Hordinsky, the most widely used tool to halt disease activity has been treatment with a corticosteroid (topical, intralesional, oral, or even intravenous corticosteroids).

Clinical trials and publications from 2018 to 2020 have triggered interest in off-label use and further studies of JAK inhibitors for treating AA, which include baricitinib, ruxolitinib, and tofacitinib. At the American Academy of Dermatology meeting in March 2022, results of the ALLEGRO phase 2b/3 trial found that the JAK inhibitor ritlecitinib (50 mg or 20 mg daily, with or without a 200-mg loading dose), was efficacious in adults and adolescents with AA, compared with placebo, with no safety concerns noted. “This looks to be very, very promising,” she said, “and also very safe.” Two phase 3 trials of baricitinib also presented at the same meeting found it was superior to placebo for hair regrowth in adults with severe AA at 36 weeks. (On June 13, shortly after Dr. Hordinsky spoke at the meeting, the FDA approved baricitinib for treating AA in adults, making this the first systemic treatment to be approved for AA).

Research on topical JAK inhibitors for AA has been disappointing, Dr. Hordinsky said.

Alopecia areata and atopic dermatitis. For patients with both AA and AD, dupilumab may provide relief, she said. She referred to a recently published phase 2a trial in patients with AA (including some with both AA and AD), which found that Severity of Alopecia Tool (SALT) scores improved after 48 weeks of treatment, with higher response rates among those with baseline IgE levels of 200 IU/mL or higher. “If your patient has both, and their immunoglobulin-E level is greater than 200, then they may be a good candidate for dupilumab and both diseases may respond,” she said.

Scalp symptoms. It can be challenging when patients complain of itch, pain, or burning on the scalp, but have no obvious skin disease, Dr. Hordinsky said. Her tips: Some of these patients may be experiencing scalp symptoms secondary to a neuropathy; others may have mast cell degranulation, but for others, the basis of the symptoms may be unclear. Special nerve studies may be needed. For relief, a trial of antihistamines or topical or oral gabapentin may be needed, she said.

Frontal fibrosing alopecia (FFA). This condition, first described in postmenopausal women, is now reported in men and in younger women. While sunscreen has been suspected, there are no good data that have proven that link, she said. Cosmetics are also considered a possible culprit. For treatment, “the first thing we try to do is treat the inflammation,” Dr. Hordinsky said. Treatment options include topical high-potency corticosteroids, intralesional steroids, and topical nonsteroid anti-inflammatory creams (tier 1); hydroxychloroquine, low-dose antibiotics, and acitretin (tier 2); and cyclosporin and mycophenolate mofetil (tier 3).

In an observational study of mostly women with FFA, she noted, treatment with dutasteride was more effective than commonly used systemic treatments.

“Don’t forget to address the psychosocial needs of the hair loss patient,” Dr. Hordinsky advised. “Hair loss patients are very distressed, and you have to learn how to be fast and nimble and address those needs.” Working with a behavioral health specialist or therapist can help, she said.

She also recommended directing patients to appropriate organizations such as the National Alopecia Areata Foundation and the Scarring Alopecia Foundation, as well as conferences, such as the upcoming NAAF conference in Washington. “These organizations do give good information that should complement what you are doing.”

Medscape Live and this news organization are owned by the same parent company. Dr. Hordinsky reported no disclosures.

“No matter who the patient is, whether a child, adolescent, or adult, the key to figuring out hair disease is getting a good history,” Maria Hordinsky, MD, professor and chair of the department of dermatology at the University of Minnesota, Minneapolis, said at the Medscape Live Women’s and Pediatric Dermatology Seminar.

During her presentation on what’s new in hair disorders, Dr. Hordinsky covered a range of disorders and treatments, with some common denominators, such as the need for a good history. She also urged physicians and other health care providers to use the electronic medical record and to be thorough in documenting information – noting nutrition, hair care habits, supplement use, and other details.

Cunaplus_M.Faba/Getty Images

Lab tests should be selected based on that history, she said. For instance, low iron stores can be associated with hair shedding; and thyroid function studies might be needed.

Other highlights of her presentation included comments on different types of alopecia, and some new treatment approaches:

Androgenetic alopecia. In a meta-analysis and systematic review published in 2017, all treatments tested (2% and 5% minoxidil in men, 1 mg finasteride in men, 2% minoxidil in women, and low-level laser light therapy in men) were superior to placebo. Several photobiomodulation (PBM) devices (also known as low-level laser light) for home use have been cleared for androgenetic alopecia by the Food and Drug Administration; a clinician’s guide, published in 2018, provides information on these devices.

Hair and hormones. Combination therapy for female-pattern hair loss – low-dose minoxidil and spironolactone – is important to know about, she said, adding there are data from an observational pilot study supporting this treatment. Women should not become pregnant while on this treatment, Dr. Hordinsky cautioned.

PRP (platelet rich plasma). This treatment for hair loss can be costly, she cautioned, as it’s viewed as a cosmetic technique, “but it actually can work rather well.”

Hair regrowth measures. Traditionally, measures center on global assessment, the patient’s self-assessment, investigator assessment, and an independent photo review. Enter the dermatoscope. “We can now get pictures as a baseline. Patients can see, and also see the health of their scalp,” and if treatments make it look better or worse, she noted.

Alopecia areata (AA). Patients and families need to be made aware that this is an autoimmune disease that can recur, and if it does recur, the extent of hair loss is not predictable. According to Dr. Hordinsky, the most widely used tool to halt disease activity has been treatment with a corticosteroid (topical, intralesional, oral, or even intravenous corticosteroids).

Clinical trials and publications from 2018 to 2020 have triggered interest in off-label use and further studies of JAK inhibitors for treating AA, which include baricitinib, ruxolitinib, and tofacitinib. At the American Academy of Dermatology meeting in March 2022, results of the ALLEGRO phase 2b/3 trial found that the JAK inhibitor ritlecitinib (50 mg or 20 mg daily, with or without a 200-mg loading dose), was efficacious in adults and adolescents with AA, compared with placebo, with no safety concerns noted. “This looks to be very, very promising,” she said, “and also very safe.” Two phase 3 trials of baricitinib also presented at the same meeting found it was superior to placebo for hair regrowth in adults with severe AA at 36 weeks. (On June 13, shortly after Dr. Hordinsky spoke at the meeting, the FDA approved baricitinib for treating AA in adults, making this the first systemic treatment to be approved for AA).

Research on topical JAK inhibitors for AA has been disappointing, Dr. Hordinsky said.

Alopecia areata and atopic dermatitis. For patients with both AA and AD, dupilumab may provide relief, she said. She referred to a recently published phase 2a trial in patients with AA (including some with both AA and AD), which found that Severity of Alopecia Tool (SALT) scores improved after 48 weeks of treatment, with higher response rates among those with baseline IgE levels of 200 IU/mL or higher. “If your patient has both, and their immunoglobulin-E level is greater than 200, then they may be a good candidate for dupilumab and both diseases may respond,” she said.

Scalp symptoms. It can be challenging when patients complain of itch, pain, or burning on the scalp, but have no obvious skin disease, Dr. Hordinsky said. Her tips: Some of these patients may be experiencing scalp symptoms secondary to a neuropathy; others may have mast cell degranulation, but for others, the basis of the symptoms may be unclear. Special nerve studies may be needed. For relief, a trial of antihistamines or topical or oral gabapentin may be needed, she said.

Frontal fibrosing alopecia (FFA). This condition, first described in postmenopausal women, is now reported in men and in younger women. While sunscreen has been suspected, there are no good data that have proven that link, she said. Cosmetics are also considered a possible culprit. For treatment, “the first thing we try to do is treat the inflammation,” Dr. Hordinsky said. Treatment options include topical high-potency corticosteroids, intralesional steroids, and topical nonsteroid anti-inflammatory creams (tier 1); hydroxychloroquine, low-dose antibiotics, and acitretin (tier 2); and cyclosporin and mycophenolate mofetil (tier 3).

In an observational study of mostly women with FFA, she noted, treatment with dutasteride was more effective than commonly used systemic treatments.

“Don’t forget to address the psychosocial needs of the hair loss patient,” Dr. Hordinsky advised. “Hair loss patients are very distressed, and you have to learn how to be fast and nimble and address those needs.” Working with a behavioral health specialist or therapist can help, she said.

She also recommended directing patients to appropriate organizations such as the National Alopecia Areata Foundation and the Scarring Alopecia Foundation, as well as conferences, such as the upcoming NAAF conference in Washington. “These organizations do give good information that should complement what you are doing.”

Medscape Live and this news organization are owned by the same parent company. Dr. Hordinsky reported no disclosures.

“No matter who the patient is, whether a child, adolescent, or adult, the key to figuring out hair disease is getting a good history,” Maria Hordinsky, MD, professor and chair of the department of dermatology at the University of Minnesota, Minneapolis, said at the Medscape Live Women’s and Pediatric Dermatology Seminar.

During her presentation on what’s new in hair disorders, Dr. Hordinsky covered a range of disorders and treatments, with some common denominators, such as the need for a good history. She also urged physicians and other health care providers to use the electronic medical record and to be thorough in documenting information – noting nutrition, hair care habits, supplement use, and other details.

Cunaplus_M.Faba/Getty Images

Lab tests should be selected based on that history, she said. For instance, low iron stores can be associated with hair shedding; and thyroid function studies might be needed.

Other highlights of her presentation included comments on different types of alopecia, and some new treatment approaches:

Androgenetic alopecia. In a meta-analysis and systematic review published in 2017, all treatments tested (2% and 5% minoxidil in men, 1 mg finasteride in men, 2% minoxidil in women, and low-level laser light therapy in men) were superior to placebo. Several photobiomodulation (PBM) devices (also known as low-level laser light) for home use have been cleared for androgenetic alopecia by the Food and Drug Administration; a clinician’s guide, published in 2018, provides information on these devices.

Hair and hormones. Combination therapy for female-pattern hair loss – low-dose minoxidil and spironolactone – is important to know about, she said, adding there are data from an observational pilot study supporting this treatment. Women should not become pregnant while on this treatment, Dr. Hordinsky cautioned.

PRP (platelet rich plasma). This treatment for hair loss can be costly, she cautioned, as it’s viewed as a cosmetic technique, “but it actually can work rather well.”

Hair regrowth measures. Traditionally, measures center on global assessment, the patient’s self-assessment, investigator assessment, and an independent photo review. Enter the dermatoscope. “We can now get pictures as a baseline. Patients can see, and also see the health of their scalp,” and if treatments make it look better or worse, she noted.

Alopecia areata (AA). Patients and families need to be made aware that this is an autoimmune disease that can recur, and if it does recur, the extent of hair loss is not predictable. According to Dr. Hordinsky, the most widely used tool to halt disease activity has been treatment with a corticosteroid (topical, intralesional, oral, or even intravenous corticosteroids).

Clinical trials and publications from 2018 to 2020 have triggered interest in off-label use and further studies of JAK inhibitors for treating AA, which include baricitinib, ruxolitinib, and tofacitinib. At the American Academy of Dermatology meeting in March 2022, results of the ALLEGRO phase 2b/3 trial found that the JAK inhibitor ritlecitinib (50 mg or 20 mg daily, with or without a 200-mg loading dose), was efficacious in adults and adolescents with AA, compared with placebo, with no safety concerns noted. “This looks to be very, very promising,” she said, “and also very safe.” Two phase 3 trials of baricitinib also presented at the same meeting found it was superior to placebo for hair regrowth in adults with severe AA at 36 weeks. (On June 13, shortly after Dr. Hordinsky spoke at the meeting, the FDA approved baricitinib for treating AA in adults, making this the first systemic treatment to be approved for AA).

Research on topical JAK inhibitors for AA has been disappointing, Dr. Hordinsky said.

Alopecia areata and atopic dermatitis. For patients with both AA and AD, dupilumab may provide relief, she said. She referred to a recently published phase 2a trial in patients with AA (including some with both AA and AD), which found that Severity of Alopecia Tool (SALT) scores improved after 48 weeks of treatment, with higher response rates among those with baseline IgE levels of 200 IU/mL or higher. “If your patient has both, and their immunoglobulin-E level is greater than 200, then they may be a good candidate for dupilumab and both diseases may respond,” she said.

Scalp symptoms. It can be challenging when patients complain of itch, pain, or burning on the scalp, but have no obvious skin disease, Dr. Hordinsky said. Her tips: Some of these patients may be experiencing scalp symptoms secondary to a neuropathy; others may have mast cell degranulation, but for others, the basis of the symptoms may be unclear. Special nerve studies may be needed. For relief, a trial of antihistamines or topical or oral gabapentin may be needed, she said.

Frontal fibrosing alopecia (FFA). This condition, first described in postmenopausal women, is now reported in men and in younger women. While sunscreen has been suspected, there are no good data that have proven that link, she said. Cosmetics are also considered a possible culprit. For treatment, “the first thing we try to do is treat the inflammation,” Dr. Hordinsky said. Treatment options include topical high-potency corticosteroids, intralesional steroids, and topical nonsteroid anti-inflammatory creams (tier 1); hydroxychloroquine, low-dose antibiotics, and acitretin (tier 2); and cyclosporin and mycophenolate mofetil (tier 3).

In an observational study of mostly women with FFA, she noted, treatment with dutasteride was more effective than commonly used systemic treatments.

“Don’t forget to address the psychosocial needs of the hair loss patient,” Dr. Hordinsky advised. “Hair loss patients are very distressed, and you have to learn how to be fast and nimble and address those needs.” Working with a behavioral health specialist or therapist can help, she said.

She also recommended directing patients to appropriate organizations such as the National Alopecia Areata Foundation and the Scarring Alopecia Foundation, as well as conferences, such as the upcoming NAAF conference in Washington. “These organizations do give good information that should complement what you are doing.”

Medscape Live and this news organization are owned by the same parent company. Dr. Hordinsky reported no disclosures.

A 32-year-old woman had sex with a man she met while on vacation 6 weeks ago. She was intoxicated at the time and does not know much about the person. She recalls having engaged in vaginal intercourse without a condom. She does not have any symptoms.

She previously received baseline lab testing per Centers for Disease Control and Prevention guidelines 2 years ago with a negative HIV test and negative hepatitis C test. She asks for testing for STIs. What would you recommend?

A. HIV, hepatitis C, gonorrhea, chlamydia, and human papillomavirus

B. HIV, hepatitis C, gonorrhea, chlamydia, and herpes simplex virus

C. HIV, hepatitis C, gonorrhea, and chlamydia

D. HIV, gonorrhea, and chlamydia

E. Gonorrhea and chlamydia

HIV risk estimate

The most practical answer is E, check for gonorrhea and chlamydia. Many protocols in place for evaluating people for STIs will test for hepatitis C as well as HIV with single exposures. In this column, we will look at the lack of evidence of heterosexual sexual transmission of hepatitis C.

In regards to HIV risk, the estimated risk of transmission male to female from an HIV-infected individual is 0.08% per sexual encounter.¹ The prevalence in the United States – where HIV occurs in about 0.5% of the adult population – was used to estimate the risk of a person with unknown HIV status acquiring HIV. The calculated risk from one sexual encounter would be 0.0004 (1 in 250,000).
 

Studies of hepatitis C transmission

Tahan and colleagues did a prospective study of 600 heterosexual couples where one partner had hepatitis C and the other didn’t. Over a mean of 3 years of follow-up, none of the seronegative spouses developed hepatitis C.²

Terrault and colleagues completed a cross-sectional study of hepatitis C virus (HCV)–positive individuals and their monogamous heterosexual partners to evaluate risk of sexual transmission of HCV.³ Based on 8,377 person-years of follow-up, the estimated maximum transmission rate was 0.07%/year, which was about 1/190,000 sexual contacts. No specific sexual practices were associated with transmission. The authors of this study concurred with CDC recommendations that persons with HCV infection in long-term monogamous relationships need not change their sexual practices.⁴

Vandelli and colleagues followed 776 heterosexual partners of HCV-infected individuals over 10 years.⁵ None of the couples reported condom use. Over the follow up period, three HCV infections occurred, but based on discordance of the typing of viral isolates, sexual transmission was excluded.

Jin and colleagues completed a systematic review of studies looking at possible sexual transmission of HCV in gay and bisexual men.⁶ HIV-positive men had a HCV incidence of 6.4 per 1,000 person-years, compared with 0.4 per 1000 person-years in HIV-negative men. The authors discussed several possible causes for increased transmission risk in HIV-infected individuals including coexisting STIs and higher HCV viral load in semen of HIV-infected individuals, as well as lower immunity.
 

Summary

In hepatitis C–discordant heterosexual couples, hepatitis C does not appear to be sexually transmitted.

The risk of sexual transmission of hepatitis C to non–HIV-infected individuals appears to be exceedingly low.

Many thanks to Hunter Handsfield, MD, for suggesting this topic and sharing supporting articles.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

1. Boily MC et al. Lancet Infect Dis. 2009 Feb;9(2):118-29.

2. Tahan V et al. Am J Gastroenterol. 2005;100:821-4.

3. Terrault NA et al. Hepatology. 2013;57:881-9

4. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-38.

5. Vandelli C et al. Am J Gastroenterol. 2004;99:855-9.

6. Jin F et al. Sexual Health.2017;14:28-41.

A 32-year-old woman had sex with a man she met while on vacation 6 weeks ago. She was intoxicated at the time and does not know much about the person. She recalls having engaged in vaginal intercourse without a condom. She does not have any symptoms.

She previously received baseline lab testing per Centers for Disease Control and Prevention guidelines 2 years ago with a negative HIV test and negative hepatitis C test. She asks for testing for STIs. What would you recommend?

A. HIV, hepatitis C, gonorrhea, chlamydia, and human papillomavirus

B. HIV, hepatitis C, gonorrhea, chlamydia, and herpes simplex virus

C. HIV, hepatitis C, gonorrhea, and chlamydia

D. HIV, gonorrhea, and chlamydia

E. Gonorrhea and chlamydia

HIV risk estimate

The most practical answer is E, check for gonorrhea and chlamydia. Many protocols in place for evaluating people for STIs will test for hepatitis C as well as HIV with single exposures. In this column, we will look at the lack of evidence of heterosexual sexual transmission of hepatitis C.

In regards to HIV risk, the estimated risk of transmission male to female from an HIV-infected individual is 0.08% per sexual encounter.¹ The prevalence in the United States – where HIV occurs in about 0.5% of the adult population – was used to estimate the risk of a person with unknown HIV status acquiring HIV. The calculated risk from one sexual encounter would be 0.0004 (1 in 250,000).
 

Studies of hepatitis C transmission

Tahan and colleagues did a prospective study of 600 heterosexual couples where one partner had hepatitis C and the other didn’t. Over a mean of 3 years of follow-up, none of the seronegative spouses developed hepatitis C.²

Terrault and colleagues completed a cross-sectional study of hepatitis C virus (HCV)–positive individuals and their monogamous heterosexual partners to evaluate risk of sexual transmission of HCV.³ Based on 8,377 person-years of follow-up, the estimated maximum transmission rate was 0.07%/year, which was about 1/190,000 sexual contacts. No specific sexual practices were associated with transmission. The authors of this study concurred with CDC recommendations that persons with HCV infection in long-term monogamous relationships need not change their sexual practices.⁴

Vandelli and colleagues followed 776 heterosexual partners of HCV-infected individuals over 10 years.⁵ None of the couples reported condom use. Over the follow up period, three HCV infections occurred, but based on discordance of the typing of viral isolates, sexual transmission was excluded.

Jin and colleagues completed a systematic review of studies looking at possible sexual transmission of HCV in gay and bisexual men.⁶ HIV-positive men had a HCV incidence of 6.4 per 1,000 person-years, compared with 0.4 per 1000 person-years in HIV-negative men. The authors discussed several possible causes for increased transmission risk in HIV-infected individuals including coexisting STIs and higher HCV viral load in semen of HIV-infected individuals, as well as lower immunity.
 

Summary

In hepatitis C–discordant heterosexual couples, hepatitis C does not appear to be sexually transmitted.

The risk of sexual transmission of hepatitis C to non–HIV-infected individuals appears to be exceedingly low.

Many thanks to Hunter Handsfield, MD, for suggesting this topic and sharing supporting articles.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

1. Boily MC et al. Lancet Infect Dis. 2009 Feb;9(2):118-29.

2. Tahan V et al. Am J Gastroenterol. 2005;100:821-4.

3. Terrault NA et al. Hepatology. 2013;57:881-9

4. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-38.

5. Vandelli C et al. Am J Gastroenterol. 2004;99:855-9.

6. Jin F et al. Sexual Health.2017;14:28-41.

A 32-year-old woman had sex with a man she met while on vacation 6 weeks ago. She was intoxicated at the time and does not know much about the person. She recalls having engaged in vaginal intercourse without a condom. She does not have any symptoms.

She previously received baseline lab testing per Centers for Disease Control and Prevention guidelines 2 years ago with a negative HIV test and negative hepatitis C test. She asks for testing for STIs. What would you recommend?

A. HIV, hepatitis C, gonorrhea, chlamydia, and human papillomavirus

B. HIV, hepatitis C, gonorrhea, chlamydia, and herpes simplex virus

C. HIV, hepatitis C, gonorrhea, and chlamydia

D. HIV, gonorrhea, and chlamydia

E. Gonorrhea and chlamydia

HIV risk estimate

The most practical answer is E, check for gonorrhea and chlamydia. Many protocols in place for evaluating people for STIs will test for hepatitis C as well as HIV with single exposures. In this column, we will look at the lack of evidence of heterosexual sexual transmission of hepatitis C.

In regards to HIV risk, the estimated risk of transmission male to female from an HIV-infected individual is 0.08% per sexual encounter.¹ The prevalence in the United States – where HIV occurs in about 0.5% of the adult population – was used to estimate the risk of a person with unknown HIV status acquiring HIV. The calculated risk from one sexual encounter would be 0.0004 (1 in 250,000).
 

Studies of hepatitis C transmission

Tahan and colleagues did a prospective study of 600 heterosexual couples where one partner had hepatitis C and the other didn’t. Over a mean of 3 years of follow-up, none of the seronegative spouses developed hepatitis C.²

Terrault and colleagues completed a cross-sectional study of hepatitis C virus (HCV)–positive individuals and their monogamous heterosexual partners to evaluate risk of sexual transmission of HCV.³ Based on 8,377 person-years of follow-up, the estimated maximum transmission rate was 0.07%/year, which was about 1/190,000 sexual contacts. No specific sexual practices were associated with transmission. The authors of this study concurred with CDC recommendations that persons with HCV infection in long-term monogamous relationships need not change their sexual practices.⁴

Vandelli and colleagues followed 776 heterosexual partners of HCV-infected individuals over 10 years.⁵ None of the couples reported condom use. Over the follow up period, three HCV infections occurred, but based on discordance of the typing of viral isolates, sexual transmission was excluded.

Jin and colleagues completed a systematic review of studies looking at possible sexual transmission of HCV in gay and bisexual men.⁶ HIV-positive men had a HCV incidence of 6.4 per 1,000 person-years, compared with 0.4 per 1000 person-years in HIV-negative men. The authors discussed several possible causes for increased transmission risk in HIV-infected individuals including coexisting STIs and higher HCV viral load in semen of HIV-infected individuals, as well as lower immunity.
 

Summary

In hepatitis C–discordant heterosexual couples, hepatitis C does not appear to be sexually transmitted.

The risk of sexual transmission of hepatitis C to non–HIV-infected individuals appears to be exceedingly low.

Many thanks to Hunter Handsfield, MD, for suggesting this topic and sharing supporting articles.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

1. Boily MC et al. Lancet Infect Dis. 2009 Feb;9(2):118-29.

2. Tahan V et al. Am J Gastroenterol. 2005;100:821-4.

3. Terrault NA et al. Hepatology. 2013;57:881-9

4. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-38.

5. Vandelli C et al. Am J Gastroenterol. 2004;99:855-9.

6. Jin F et al. Sexual Health.2017;14:28-41.