The Diagnosis: Demodicosis 

A clinical diagnosis of facial demodicosis triggered by topical corticosteroid therapy was suspected in our patient. A 3-mm punch biopsy of the right forehead demonstrated a follicular infundibulum rich in Demodex folliculorum with a discrete mononuclear infiltrate in the dermis (Figure 1), confirming the diagnosis. The patient was prescribed metronidazole gel 2% twice daily. Complete clearance of the facial rash was observed at 1-week follow-up (Figure 2). 

Demodex folliculorum is a mite that parasitizes the pilosebaceous follicles of human skin, becoming pathogenic with excessive colonization.^1-3 Facial demodicosis presents as pruritic papules and pustules in a pilosebaceous distribution on the face.^2,3 The diagnosis of facial demodicosis can be difficult due to similarities with many other common facial rashes such as acne, rosacea, contact dermatitis, and folliculitis.  

Similar to facial demodicosis, rosacea can present with erythema, papules, and pustules on the face. Patients with rosacea also have a higher prevalence and degree of Demodex mite infestation.⁴ However, these facial rashes can be differentiated when symptom acuity and personal and family histories are considered. In patients with a long-standing personal and/or family history of erythema, papules, and pustules, the chronicity of disease implies a diagnosis of rosacea. The acute onset of symptomatology and absence of personal or family history of rosacea in our patient favored a diagnosis of demodicosis. 

Pityrosporum folliculitis is an eruption caused by Malassezia furfur, the organism implicated in tinea versicolor. It can present similarly to Demodex folliculitis with follicular papules and pustules on the forehead and back. Features that help to differentiate Pityrosporum folliculitis from Demodex folliculitis include involvement of the upper trunk and onset after antibiotic usage.⁵ Diagnosis of Pityrosporum folliculitis can be confirmed by potassium hydroxide preparation, which demonstrates spaghetti-and-meatball-like hyphae and spores. 

Eosinophilic folliculitis is a chronic sterile folliculitis that usually presents as intensely pruritic papules and pustules on the face with an eruptive onset. There are 3 variants of disease: the classic form (also known as Ofuji disease), immunosuppression-associated disease, and infancy-associated disease.⁶ Eosinophilic folliculitis also may present with annular plaques and peripheral blood eosinophilia, and it is more prevalent in patients of Japanese descent. Differentiation from Demodex folliculitis can be done by histologic examination, which demonstrates spongiosis with exocytosis of eosinophils into the epithelium and a clear deficiency of infiltrating mites.⁶ 

Miliaria, also known as sweat rash, is a common condition that occurs due to occlusion of eccrine sweat glands.⁷ Clinically, miliaria is characterized by erythematous papules ranging from 2 to 4 mm in size that may be vesicular or pustular. Miliaria and demodicosis may have similar clinical presentations; however, several characteristic differences can be noted. Based on the pathophysiology, miliaria will not be folliculocentric, which differs from demodicosis. Additionally, miliaria most commonly occurs in areas of occlusion, such as in skin folds or on the trunk under tight clothing. Miliaria rarely can appear confluent and sunburnlike.⁸ Furthermore, miliaria is less common on the face, while demodicosis almost exclusively is found on the face. 

We present the case of an otherwise healthy patient with acute onset of pruritic papules and pustules involving the superior face following topical corticosteroid use. Similar cases frequently are encountered by dermatologists and require broad differential diagnoses. 

The Diagnosis: Demodicosis 

A clinical diagnosis of facial demodicosis triggered by topical corticosteroid therapy was suspected in our patient. A 3-mm punch biopsy of the right forehead demonstrated a follicular infundibulum rich in Demodex folliculorum with a discrete mononuclear infiltrate in the dermis (Figure 1), confirming the diagnosis. The patient was prescribed metronidazole gel 2% twice daily. Complete clearance of the facial rash was observed at 1-week follow-up (Figure 2). 

Demodex folliculorum is a mite that parasitizes the pilosebaceous follicles of human skin, becoming pathogenic with excessive colonization.^1-3 Facial demodicosis presents as pruritic papules and pustules in a pilosebaceous distribution on the face.^2,3 The diagnosis of facial demodicosis can be difficult due to similarities with many other common facial rashes such as acne, rosacea, contact dermatitis, and folliculitis.  

Similar to facial demodicosis, rosacea can present with erythema, papules, and pustules on the face. Patients with rosacea also have a higher prevalence and degree of Demodex mite infestation.⁴ However, these facial rashes can be differentiated when symptom acuity and personal and family histories are considered. In patients with a long-standing personal and/or family history of erythema, papules, and pustules, the chronicity of disease implies a diagnosis of rosacea. The acute onset of symptomatology and absence of personal or family history of rosacea in our patient favored a diagnosis of demodicosis. 

Pityrosporum folliculitis is an eruption caused by Malassezia furfur, the organism implicated in tinea versicolor. It can present similarly to Demodex folliculitis with follicular papules and pustules on the forehead and back. Features that help to differentiate Pityrosporum folliculitis from Demodex folliculitis include involvement of the upper trunk and onset after antibiotic usage.⁵ Diagnosis of Pityrosporum folliculitis can be confirmed by potassium hydroxide preparation, which demonstrates spaghetti-and-meatball-like hyphae and spores. 

Eosinophilic folliculitis is a chronic sterile folliculitis that usually presents as intensely pruritic papules and pustules on the face with an eruptive onset. There are 3 variants of disease: the classic form (also known as Ofuji disease), immunosuppression-associated disease, and infancy-associated disease.⁶ Eosinophilic folliculitis also may present with annular plaques and peripheral blood eosinophilia, and it is more prevalent in patients of Japanese descent. Differentiation from Demodex folliculitis can be done by histologic examination, which demonstrates spongiosis with exocytosis of eosinophils into the epithelium and a clear deficiency of infiltrating mites.⁶ 

Miliaria, also known as sweat rash, is a common condition that occurs due to occlusion of eccrine sweat glands.⁷ Clinically, miliaria is characterized by erythematous papules ranging from 2 to 4 mm in size that may be vesicular or pustular. Miliaria and demodicosis may have similar clinical presentations; however, several characteristic differences can be noted. Based on the pathophysiology, miliaria will not be folliculocentric, which differs from demodicosis. Additionally, miliaria most commonly occurs in areas of occlusion, such as in skin folds or on the trunk under tight clothing. Miliaria rarely can appear confluent and sunburnlike.⁸ Furthermore, miliaria is less common on the face, while demodicosis almost exclusively is found on the face. 

We present the case of an otherwise healthy patient with acute onset of pruritic papules and pustules involving the superior face following topical corticosteroid use. Similar cases frequently are encountered by dermatologists and require broad differential diagnoses. 

The Diagnosis: Demodicosis 

A clinical diagnosis of facial demodicosis triggered by topical corticosteroid therapy was suspected in our patient. A 3-mm punch biopsy of the right forehead demonstrated a follicular infundibulum rich in Demodex folliculorum with a discrete mononuclear infiltrate in the dermis (Figure 1), confirming the diagnosis. The patient was prescribed metronidazole gel 2% twice daily. Complete clearance of the facial rash was observed at 1-week follow-up (Figure 2). 

Demodex folliculorum is a mite that parasitizes the pilosebaceous follicles of human skin, becoming pathogenic with excessive colonization.^1-3 Facial demodicosis presents as pruritic papules and pustules in a pilosebaceous distribution on the face.^2,3 The diagnosis of facial demodicosis can be difficult due to similarities with many other common facial rashes such as acne, rosacea, contact dermatitis, and folliculitis.  

Similar to facial demodicosis, rosacea can present with erythema, papules, and pustules on the face. Patients with rosacea also have a higher prevalence and degree of Demodex mite infestation.⁴ However, these facial rashes can be differentiated when symptom acuity and personal and family histories are considered. In patients with a long-standing personal and/or family history of erythema, papules, and pustules, the chronicity of disease implies a diagnosis of rosacea. The acute onset of symptomatology and absence of personal or family history of rosacea in our patient favored a diagnosis of demodicosis. 

Pityrosporum folliculitis is an eruption caused by Malassezia furfur, the organism implicated in tinea versicolor. It can present similarly to Demodex folliculitis with follicular papules and pustules on the forehead and back. Features that help to differentiate Pityrosporum folliculitis from Demodex folliculitis include involvement of the upper trunk and onset after antibiotic usage.⁵ Diagnosis of Pityrosporum folliculitis can be confirmed by potassium hydroxide preparation, which demonstrates spaghetti-and-meatball-like hyphae and spores. 

Eosinophilic folliculitis is a chronic sterile folliculitis that usually presents as intensely pruritic papules and pustules on the face with an eruptive onset. There are 3 variants of disease: the classic form (also known as Ofuji disease), immunosuppression-associated disease, and infancy-associated disease.⁶ Eosinophilic folliculitis also may present with annular plaques and peripheral blood eosinophilia, and it is more prevalent in patients of Japanese descent. Differentiation from Demodex folliculitis can be done by histologic examination, which demonstrates spongiosis with exocytosis of eosinophils into the epithelium and a clear deficiency of infiltrating mites.⁶ 

Miliaria, also known as sweat rash, is a common condition that occurs due to occlusion of eccrine sweat glands.⁷ Clinically, miliaria is characterized by erythematous papules ranging from 2 to 4 mm in size that may be vesicular or pustular. Miliaria and demodicosis may have similar clinical presentations; however, several characteristic differences can be noted. Based on the pathophysiology, miliaria will not be folliculocentric, which differs from demodicosis. Additionally, miliaria most commonly occurs in areas of occlusion, such as in skin folds or on the trunk under tight clothing. Miliaria rarely can appear confluent and sunburnlike.⁸ Furthermore, miliaria is less common on the face, while demodicosis almost exclusively is found on the face. 

We present the case of an otherwise healthy patient with acute onset of pruritic papules and pustules involving the superior face following topical corticosteroid use. Similar cases frequently are encountered by dermatologists and require broad differential diagnoses. 

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Earlier this spring, Kimberly D. Manning, MD, FACP, FAAP, was caring for an elderly Black man with multiple comorbidities at Grady Memorial Hospital in Atlanta, assembling an order for medications and a discharge plan.

“It was very challenging,” Dr. Manning, professor of medicine and associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, recalled during a May 4 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

At one point, the patient glanced at her, shrugged, and said: “You know, Doc, we get in where we fit in.”

“He was talking about the idea that people who come from historically disadvantaged backgrounds just have to try to figure it out, have to try to make a dollar out of 15 cents,” Dr. Manning said. “This, to me, really underscores what we mean when we say health disparities, this idea that there are people who are working hard and doing the best that they can but who still are forced to ‘get in where they fit in.’”

The Centers for Disease Control and Prevention defines health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. “When we think about health disparities we often think about many diagnoses,” Dr. Manning continued. “We think about HIV and the disparate care and outcomes we’ve seen in populations of individuals who come from minority backgrounds. We see disparities in obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions, and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are economically disadvantaged have poorer outcomes. It plays out with all of these diagnoses.”

In her opinion, health disparities in hospital medicine fall into in one of three buckets: diagnosis and triage, hospital stay and treatment, and sticking the landing – “that is, after a patient leaves the hospital,” Dr. Manning explained. “The hospital stay is the turn on the balance beam. You can do everything perfectly, but then you must dismount. To score a ‘10’ you have to stick the landing. That means being able to get your medications, being able to get to and from clinic appointments, being able to understand the directions you’ve been given. All of these things are intertwined, the inpatient and outpatient care.”

The roots of health disparities in hospitalized patients stem from centuries ago, she said, when America’s health care system was built to benefit white male landowners and their families. Health care for Blacks, on the other hand, “was focused on function, almost like veterinary care, or experimentation,” Dr. Manning said. “After slavery ended, many historically Black institutions of higher learning opened, including medical schools. In 1909, there were seven historically Black medical schools. Acknowledging the history that preceded disparities is essential.”

In her view, the path to improving health care disparities starts with conceding that structural racism exists in the practice of medicine. “This means that health disparities are connected to systemic and individual issues, including our biases,” Dr. Manning said. “Our system was built on this idea that there is greater value of one group of people above others. Access to care, physician workforce, and biases are impacted by system design. Health equity and health equality are not the same.”

She also underscored the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good food, community and social context, and the idea of health care as a human right and understanding our health care system. “This is what is necessary,” she declared. “Without all of these together, we can’t have the health outcomes that we desire.”

As hospital leaders work to build a more diverse physician workforce, Dr. Manning emphasized the importance of forming antiracism policies by addressing questions such as what will we not stand for? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and in trainees? What is our commitment to implicit bias training and bystander training?

“We have to get uncomfortable enough to advocate with urgency because all of these are necessary factors to mitigate health disparities,” she said. “Though the systemic issues are the most urgent, on an individual level, we must continue to disrupt the negative ideology and stereotypes that threaten our environment every day. When we see those negative things, we have to call them out. We need to continue to listen, to humanize those things that are happening around us, and to understand historical context.”

Dr. Manning reported having no financial disclosures.

Endoscopists are at high risk of musculoskeletal issues, and a multifaceted strategy is needed to reduce rates of injury, including better body posture and endoscopic suite layout, according to leading experts.

Andrey Shevchuk/iStock/Getty Images

Latha Alaparthi, MD, director of committee operations at Gastroenterology Center of Connecticut, Hamden, and assistant clinical professor at Yale University, New Haven, Conn., noted that female gastroenterologists are at particular risk because they often work with outsize equipment and suboptimal room setup.

“I think it’s something for us to recognize, and [we need to] find ways to protect ourselves,” Dr. Alaparthi said during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.
 

Prevalence of musculoskeletal injuries in gastroenterology

Gastroenterologists spend 43% of their time performing procedures, Dr. Alaparthi said, and all those hours take a toll on the body. Up to 89% of gastroenterologists report musculoskeletal symptoms – most often back pain, followed by neck pain and hand pain.

Even newcomers to the field are at risk, she added, noting that 47% of gastroenterology fellows report injury in their first year of training. And with one out of three fellows now female, the issue may be a growing concern.

“As female gastroenterologists, we are even more at risk,” Dr. Alaparthi said. This is partly due to differences in equipment and room design, which “take into consideration 5% of female average measurements and 95% of that of males.”

The resultant injuries may be enough to drive female doctors from the field. Dr. Alaparthi recounted her colleague’s experience in leaving gastroenterology for the pharmaceutical industry after experiencing ongoing neck pain.

“She called me and said 1 week after she stopped doing endoscopies, her neck pain was gone.”

For gastroenterologists of any gender, musculoskeletal injuries can cause pain and suffering, reduced quality of life, lost or reduced work output, short-term or permanent disability, lost wages, and impediment to career advancement. Yet physicians aren’t the only stakeholders affected by these injuries. Employers stand to lose financially from decreased productivity and increased compensation costs.

“[Injuries have] implications not just to the individual but to the company and to patient care,” Dr. Alaparthi said.

She went on to suggest that an effective solution to the problem will require efforts from both gastroenterologists and institutions, including greater self-awareness of body positioning, access to anthropometrically suitable equipment, better room design, and a work culture that supports breaks during procedures, if needed.

“We definitely need programs to provide comprehensive work force injury prevention and protection specific to GI endoscopy – not just for gastroenterologists, but for the whole team involved.”

Ergonomics in endoscopy training

Presenting after Dr. Alaparthi, Katherine Garman, MD, associate professor of medicine and vice chief of research, gastroenterology, at Duke University, Durham, N.C., offered ways to incorporate ergonomics into an endoscopy training curriculum.

“Ergonomics evaluates how a job can best fit to an individual, instead of forcing an individual to fit into a job,” Dr. Garman said. “[This] is a really important concept when we think about training,”

Yet this concept may run counter to most fellows’ natural instinct to fit in and avoid being obtrusive, she noted.

“We need to think about empowering [fellows] from the very beginning to be proactive about how [they] interact with the equipment and the space,” Dr. Garman said. “[They should know] it is perfectly acceptable to adjust the monitor height, move the bed height to an appropriate level, and make the space comfortable ... at the beginning of what should be a long, productive career.”

Dr. Garman offered several more key points to include in a training program, including increased postural awareness, microbreaks during procedures, and early intervention for prior injuries that may increase risk.

“We’ve had fellows who’ve come in who’ve had fractures, wrist [injuries], shoulder injuries,” she said. “We advise early consultation with a physical therapist for those fellows.”

In a recently published study, Dr. Garman and colleagues invited a physical therapist into the endoscopy suite, allowing for real-time assessment of ergonomic positioning and posturing, as well as wellness planning. Out of eight participating endoscopists, all said that the posture education and procedure suite recommendations were helpful, 87.5% said that the pictures of their posture and movement analysis were helpful, 50% said that the pain education was helpful, and 25% found the personalized exercise plans helpful.

“Endoscopists are not always excited about doing exercises at home,” Dr. Garman said.
 

The ergonomically optimized endoscopy suite

In the next presentation, Mehnaz Shafi, MD, professor of medicine and ad interim chair of the department of gastroenterology, hepatology, and nutrition at MD Anderson Cancer Center, Houston, described how clinicians and institutions can create ergonomically optimized endoscopy suites.

She began by reviewing specific causes of injury, including repetitive motion, high pinch force, and awkward posture, the latter of which can lead to microtrauma, inflammation, and connective tissue injury.

According to Dr. Shafi, endoscopists should stand in a neutral position with back straight and knees slightly bent. The patient should be positioned at the edge of the bed, which should be 85-120 cm off the floor. Monitors should be 93-162 cm off the floor and 15-25 degrees below eye level. When interacting with multiple monitors, endoscopists should rotate their entire bodies to maintain a neutral position. Hands and elbows also should be kept neutral, with less than 10 degrees of angulation from the height of the bed. To ensure safer hand grip, Dr. Shafi suggested removing any cord loops that may increase tension and using a towel to more evenly distribute gripping force.

Finally, Dr. Shafi encouraged awareness of other room hazards, such as slippery floors and exposed wires and tubing.

The presenters reported having no conflicts of interest.

This article was updated May 5, 2021.

Endoscopists are at high risk of musculoskeletal issues, and a multifaceted strategy is needed to reduce rates of injury, including better body posture and endoscopic suite layout, according to leading experts.

Andrey Shevchuk/iStock/Getty Images

Latha Alaparthi, MD, director of committee operations at Gastroenterology Center of Connecticut, Hamden, and assistant clinical professor at Yale University, New Haven, Conn., noted that female gastroenterologists are at particular risk because they often work with outsize equipment and suboptimal room setup.

“I think it’s something for us to recognize, and [we need to] find ways to protect ourselves,” Dr. Alaparthi said during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.
 

Prevalence of musculoskeletal injuries in gastroenterology

Gastroenterologists spend 43% of their time performing procedures, Dr. Alaparthi said, and all those hours take a toll on the body. Up to 89% of gastroenterologists report musculoskeletal symptoms – most often back pain, followed by neck pain and hand pain.

Even newcomers to the field are at risk, she added, noting that 47% of gastroenterology fellows report injury in their first year of training. And with one out of three fellows now female, the issue may be a growing concern.

“As female gastroenterologists, we are even more at risk,” Dr. Alaparthi said. This is partly due to differences in equipment and room design, which “take into consideration 5% of female average measurements and 95% of that of males.”

The resultant injuries may be enough to drive female doctors from the field. Dr. Alaparthi recounted her colleague’s experience in leaving gastroenterology for the pharmaceutical industry after experiencing ongoing neck pain.

“She called me and said 1 week after she stopped doing endoscopies, her neck pain was gone.”

For gastroenterologists of any gender, musculoskeletal injuries can cause pain and suffering, reduced quality of life, lost or reduced work output, short-term or permanent disability, lost wages, and impediment to career advancement. Yet physicians aren’t the only stakeholders affected by these injuries. Employers stand to lose financially from decreased productivity and increased compensation costs.

“[Injuries have] implications not just to the individual but to the company and to patient care,” Dr. Alaparthi said.

She went on to suggest that an effective solution to the problem will require efforts from both gastroenterologists and institutions, including greater self-awareness of body positioning, access to anthropometrically suitable equipment, better room design, and a work culture that supports breaks during procedures, if needed.

“We definitely need programs to provide comprehensive work force injury prevention and protection specific to GI endoscopy – not just for gastroenterologists, but for the whole team involved.”

Ergonomics in endoscopy training

Presenting after Dr. Alaparthi, Katherine Garman, MD, associate professor of medicine and vice chief of research, gastroenterology, at Duke University, Durham, N.C., offered ways to incorporate ergonomics into an endoscopy training curriculum.

“Ergonomics evaluates how a job can best fit to an individual, instead of forcing an individual to fit into a job,” Dr. Garman said. “[This] is a really important concept when we think about training,”

Yet this concept may run counter to most fellows’ natural instinct to fit in and avoid being obtrusive, she noted.

“We need to think about empowering [fellows] from the very beginning to be proactive about how [they] interact with the equipment and the space,” Dr. Garman said. “[They should know] it is perfectly acceptable to adjust the monitor height, move the bed height to an appropriate level, and make the space comfortable ... at the beginning of what should be a long, productive career.”

Dr. Garman offered several more key points to include in a training program, including increased postural awareness, microbreaks during procedures, and early intervention for prior injuries that may increase risk.

“We’ve had fellows who’ve come in who’ve had fractures, wrist [injuries], shoulder injuries,” she said. “We advise early consultation with a physical therapist for those fellows.”

In a recently published study, Dr. Garman and colleagues invited a physical therapist into the endoscopy suite, allowing for real-time assessment of ergonomic positioning and posturing, as well as wellness planning. Out of eight participating endoscopists, all said that the posture education and procedure suite recommendations were helpful, 87.5% said that the pictures of their posture and movement analysis were helpful, 50% said that the pain education was helpful, and 25% found the personalized exercise plans helpful.

“Endoscopists are not always excited about doing exercises at home,” Dr. Garman said.
 

The ergonomically optimized endoscopy suite

In the next presentation, Mehnaz Shafi, MD, professor of medicine and ad interim chair of the department of gastroenterology, hepatology, and nutrition at MD Anderson Cancer Center, Houston, described how clinicians and institutions can create ergonomically optimized endoscopy suites.

She began by reviewing specific causes of injury, including repetitive motion, high pinch force, and awkward posture, the latter of which can lead to microtrauma, inflammation, and connective tissue injury.

According to Dr. Shafi, endoscopists should stand in a neutral position with back straight and knees slightly bent. The patient should be positioned at the edge of the bed, which should be 85-120 cm off the floor. Monitors should be 93-162 cm off the floor and 15-25 degrees below eye level. When interacting with multiple monitors, endoscopists should rotate their entire bodies to maintain a neutral position. Hands and elbows also should be kept neutral, with less than 10 degrees of angulation from the height of the bed. To ensure safer hand grip, Dr. Shafi suggested removing any cord loops that may increase tension and using a towel to more evenly distribute gripping force.

Finally, Dr. Shafi encouraged awareness of other room hazards, such as slippery floors and exposed wires and tubing.

The presenters reported having no conflicts of interest.

This article was updated May 5, 2021.

Endoscopists are at high risk of musculoskeletal issues, and a multifaceted strategy is needed to reduce rates of injury, including better body posture and endoscopic suite layout, according to leading experts.

Andrey Shevchuk/iStock/Getty Images

Latha Alaparthi, MD, director of committee operations at Gastroenterology Center of Connecticut, Hamden, and assistant clinical professor at Yale University, New Haven, Conn., noted that female gastroenterologists are at particular risk because they often work with outsize equipment and suboptimal room setup.

“I think it’s something for us to recognize, and [we need to] find ways to protect ourselves,” Dr. Alaparthi said during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.
 

Prevalence of musculoskeletal injuries in gastroenterology

Gastroenterologists spend 43% of their time performing procedures, Dr. Alaparthi said, and all those hours take a toll on the body. Up to 89% of gastroenterologists report musculoskeletal symptoms – most often back pain, followed by neck pain and hand pain.

Even newcomers to the field are at risk, she added, noting that 47% of gastroenterology fellows report injury in their first year of training. And with one out of three fellows now female, the issue may be a growing concern.

“As female gastroenterologists, we are even more at risk,” Dr. Alaparthi said. This is partly due to differences in equipment and room design, which “take into consideration 5% of female average measurements and 95% of that of males.”

The resultant injuries may be enough to drive female doctors from the field. Dr. Alaparthi recounted her colleague’s experience in leaving gastroenterology for the pharmaceutical industry after experiencing ongoing neck pain.

“She called me and said 1 week after she stopped doing endoscopies, her neck pain was gone.”

For gastroenterologists of any gender, musculoskeletal injuries can cause pain and suffering, reduced quality of life, lost or reduced work output, short-term or permanent disability, lost wages, and impediment to career advancement. Yet physicians aren’t the only stakeholders affected by these injuries. Employers stand to lose financially from decreased productivity and increased compensation costs.

“[Injuries have] implications not just to the individual but to the company and to patient care,” Dr. Alaparthi said.

She went on to suggest that an effective solution to the problem will require efforts from both gastroenterologists and institutions, including greater self-awareness of body positioning, access to anthropometrically suitable equipment, better room design, and a work culture that supports breaks during procedures, if needed.

“We definitely need programs to provide comprehensive work force injury prevention and protection specific to GI endoscopy – not just for gastroenterologists, but for the whole team involved.”

Ergonomics in endoscopy training

Presenting after Dr. Alaparthi, Katherine Garman, MD, associate professor of medicine and vice chief of research, gastroenterology, at Duke University, Durham, N.C., offered ways to incorporate ergonomics into an endoscopy training curriculum.

“Ergonomics evaluates how a job can best fit to an individual, instead of forcing an individual to fit into a job,” Dr. Garman said. “[This] is a really important concept when we think about training,”

Yet this concept may run counter to most fellows’ natural instinct to fit in and avoid being obtrusive, she noted.

“We need to think about empowering [fellows] from the very beginning to be proactive about how [they] interact with the equipment and the space,” Dr. Garman said. “[They should know] it is perfectly acceptable to adjust the monitor height, move the bed height to an appropriate level, and make the space comfortable ... at the beginning of what should be a long, productive career.”

Dr. Garman offered several more key points to include in a training program, including increased postural awareness, microbreaks during procedures, and early intervention for prior injuries that may increase risk.

“We’ve had fellows who’ve come in who’ve had fractures, wrist [injuries], shoulder injuries,” she said. “We advise early consultation with a physical therapist for those fellows.”

In a recently published study, Dr. Garman and colleagues invited a physical therapist into the endoscopy suite, allowing for real-time assessment of ergonomic positioning and posturing, as well as wellness planning. Out of eight participating endoscopists, all said that the posture education and procedure suite recommendations were helpful, 87.5% said that the pictures of their posture and movement analysis were helpful, 50% said that the pain education was helpful, and 25% found the personalized exercise plans helpful.

“Endoscopists are not always excited about doing exercises at home,” Dr. Garman said.
 

The ergonomically optimized endoscopy suite

In the next presentation, Mehnaz Shafi, MD, professor of medicine and ad interim chair of the department of gastroenterology, hepatology, and nutrition at MD Anderson Cancer Center, Houston, described how clinicians and institutions can create ergonomically optimized endoscopy suites.

She began by reviewing specific causes of injury, including repetitive motion, high pinch force, and awkward posture, the latter of which can lead to microtrauma, inflammation, and connective tissue injury.

According to Dr. Shafi, endoscopists should stand in a neutral position with back straight and knees slightly bent. The patient should be positioned at the edge of the bed, which should be 85-120 cm off the floor. Monitors should be 93-162 cm off the floor and 15-25 degrees below eye level. When interacting with multiple monitors, endoscopists should rotate their entire bodies to maintain a neutral position. Hands and elbows also should be kept neutral, with less than 10 degrees of angulation from the height of the bed. To ensure safer hand grip, Dr. Shafi suggested removing any cord loops that may increase tension and using a towel to more evenly distribute gripping force.

Finally, Dr. Shafi encouraged awareness of other room hazards, such as slippery floors and exposed wires and tubing.

The presenters reported having no conflicts of interest.

This article was updated May 5, 2021.

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.

Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.

At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.

The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.

The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.

“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.

It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.

“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.

The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.

“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.

The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.

ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.

ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.

They also experienced greater bleeding and clotting events (P < .01).

Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.

The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.

Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.

These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.

“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.

“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.

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

Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.

Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.

At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.

The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.

The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.

“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.

It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.

“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.

The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.

“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.

The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.

ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.

ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.

They also experienced greater bleeding and clotting events (P < .01).

Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.

The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.

Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.

These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.

“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.

“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.

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

Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.

Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.

At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.

The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.

The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.

“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.

It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.

“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.

The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.

“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.

The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.

ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.

ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.

They also experienced greater bleeding and clotting events (P < .01).

Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.

The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.

Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.

These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.

“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.

“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.

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

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

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

Recognize the high-risk patient

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

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

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

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

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

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

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

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

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

Prevention plans with monoclonal antibodies

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

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

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

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

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

More on MIS-C

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

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

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

Dr. Zachariah had no relevant financial conflicts to disclose.

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

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

Recognize the high-risk patient

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

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

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

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

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

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

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

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

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

Prevention plans with monoclonal antibodies

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

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

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

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

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

More on MIS-C

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

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

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

Dr. Zachariah had no relevant financial conflicts to disclose.

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

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

Recognize the high-risk patient

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

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

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

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

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

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

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

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

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

Prevention plans with monoclonal antibodies

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

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

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

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

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

More on MIS-C

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

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

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

Dr. Zachariah had no relevant financial conflicts to disclose.

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

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

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

Referendum on remdesivir

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

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

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

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

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

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

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

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

Taking on tocilizumab

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

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

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

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

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

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

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

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

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

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

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

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

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

Referendum on remdesivir

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

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

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

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

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

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

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

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

Taking on tocilizumab

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

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

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

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

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

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

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

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

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

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

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

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

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

Referendum on remdesivir

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

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

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

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

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

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

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

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

Taking on tocilizumab

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

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

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

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

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

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

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

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

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

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

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

Crystal/Wikimedia Commons/Creative Commons Attribution 2.0

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

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

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

Conflicting results

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

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

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

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

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

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

[email protected]

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

Crystal/Wikimedia Commons/Creative Commons Attribution 2.0

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

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

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

Conflicting results

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

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

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

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

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

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

[email protected]

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

Crystal/Wikimedia Commons/Creative Commons Attribution 2.0

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

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

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

Conflicting results

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

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

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

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

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

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

[email protected]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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