A recent study published in the Canadian Medical Association Journal revealed that virtual urgent care (VUC) had minimal impact on emergency department visits or hospital admissions in Ontario, Canada, during the COVID-19 pandemic.1 However, a significant number of study participants who initially sought virtual urgent care eventually attended an emergency department in person.
Virtual urgent cares purpose is to assist in redirecting folks with minor health concerns away from in-person emergency department visits to decrease high volumes of patients that dont necessarily need to be there.
The COVID-19 pandemic significantly impacted the Canadian healthcare system, especially early on when social distancing posed challenges for arranging non-urgent, in-person visits. This period witnessed an almost 80% decline in in-person primary care visits and a 50% decrease in emergency department visits, which led to a surge in the adoption of virtual care tools.
For a better understanding of healthcare use and the outcomes of VUC, researchers of the study observed both variables in comparison to similar patients who opted for an in-person emergency department visit.
Researchers used patient-level encounter data from 14 pilot programs in Ontario where individuals used VUC services. Researchers then collected the data and connected it to administrative databases, which helped them figure out how people used healthcare services and what happened in the 30 days after.
Results revealed that out of the 19,595 patients who used VUC, researchers matched 2,129 patients who were quickly referred to the emergency department by a VUC provider with those who physically went to the emergency department.
The rates of hospital admissions during the first visit (9.4% vs. 8.7%), 30-day emergency department visits (17.0% vs. 17.5%) and hospital admissions (12.9% vs. 11.0%) were similar between these two groups.
Of the 14,179 patients seen by a VUC provider without a documented referral to the emergency department, those who used VUC were more likely to have in-person emergency department visits within 72 hours (13.7% vs. 7.0%), 7 days (16.5% vs. 10.3%), and 30 days (21.9% vs. 17.9%).
However, hospital admissions were similar within 72 hours (1.1% vs. 1.3%) and higher within 30 days for patients discharged home from the emergency department (2.6% vs. 3.4%).
Authors of the study suggest that the increased use of healthcare services following virtual follow-up visits might be due to virtual clinicians facing limitations in physically examining patients.
This limitation could lead clinicians to refer patients back to the emergency department for an in-person evaluation more readily if they have persistent symptoms, they said.
Its recommended that future research efforts should focus on identifying quality-of-care and virtual care practices care to foster a culture of continuous improvement.
Researchers suggest future investigations should highlight and examine the root causes of low healthcare use after a VUC visit as it will help determine necessary changes and improvements that will help improve these trials.
This article originally appeared in Managed Healthcare Executive.
Study design and setting
This longitudinal study utilized a cohort of Indonesian post-COVID-19 patients recruited since September 2021 and extracted in January 2023. Participants with a history of COVID-19 were followed up for residual symptoms. We assessed cognitive function 6months after diagnosis and their first symptoms through an online submission system, and this platform was disseminated to the entire country through social media, health care providers, and survivor groups.
Subjects with previous COVID-19 infection (at least thirty days from the onset or diagnosis) were diagnosed using either Indonesian Food and Drug Administration-approved antigen test for the anterior nasal sample (sensitivity over 80%)11 or real-time polymerase chain reaction (RT-PCR) of the nasopharyngeal, nasal, or pooled samples12. These procedures were performed by trained staff, as the self-administered antigen test was not recognized during the study period. This study covered all types of patients, from asymptomatic to hospitalized. After the provision of consent given by the participants, a follow-up cognitive assessment was made, and those without responses of expected outcomes were omitted. Aside from having self-reported mental illness and stroke, there is no other exclusion or limit for those with specific morbidities, age, and digital literacy. Moreover, the snowball sampling approach recruited more individuals to this cohort.
Demographic characteristics, health behaviour, chronic diseases, and other comorbidities were the baseline information covered in the questionnaire. Additionally, this study recorded the latest COVID-19 episode, including date and diagnostic methods, duration of symptoms, type of medication, vaccination status, type of vaccine, and time between doses. Investigators also identified the date from vaccination to infection and the type of care received (home isolation, hospitalization, or both). These variables may interact with each other and affect the relationship between COVID-19 and cognitive failure.
This study cited the definition of cognitive failure as a cognitive mistake made while performing a task that a person would typically complete successfully in daily life. Problems with memory, perception, and focus are signs of cognitive failure13.
This study measured the cognitive failure 6months after the COVID-19 infection. Investigators implemented the assessment using a questionnaire that is in proximity to clinical cognitive assessment, the Cognitive Failures Questionnaire (CFQ)(14), consisting of 25 5-Likert scale questions. The responses range from 0 to 4, where a higher number indicates frequent cognitive failure events. The Indonesian version of this questionnaire was derived from a study with a Cronbach alpha value of 0.94214. Furthermore, one study disclosed three domains in the questionnaire which are forgetfulness (related to something known or planned), distractibility (alteration of attention and focus), and false triggering15.
Investigators assessed other residual COVID-19 symptoms and neuropsychiatry conditions to identify the possible contribution of these symptoms to cognitive failure. Investigators evaluated any presence of residual symptoms after the first onset or diagnosis using a set of measurement tools such as the Fatigue Severity Scale (FSS)16 over the past 6months, Generalised-Anxiety Disorder (GAD-7) to screen for recent anxiety and a 10-Likert scale question to identify its incidence over the past two weeks.
Investigators admit that the quality of baseline data was heavily affected by recall bias. Therefore, participants were required to provide the answers based on the observation chart, written source (such as medical records summary), and through the PeduliLindungi application (for data related to testing, vaccinations, and individual information).
Participants might experience reinfection. Hence, only the last episode of COVID-19 should be provided as the response. By applying this approach, the investigators could not examine in detail the previous infection and, possibly, its latent impact on cognitive function.
Investigators knew that robust cognitive assessments such as Cambridge Neuropsychological Test Automated Battery (CANTAB) could provide objective cognitive results. However, the investigators considered the survey exhaustion and other factors affecting the response, such as internet connection and adaptation to the measurement tools. The questionnaire was deemed sufficient to represent the domains tested by these standardized clinical tests.
There is limited information on long-term cognitive situations after COVID-19. However, a study of CFQ application to neurosarcoidosis (a subset of sarcoidosis, a multi-inflammatory systemic disorder) shows a mean score of 45.620.713. Therefore, investigators assumed that the variance of cognitive failure values of COVID-19 survivors is approximately 20.7. Using the equivalence formula from the assumed score, with 5% type 1 error, 90% power of the study, the absolute mean difference between the assumpted mean and sample means of 1, a 5% equivalence limit, and 10% listwise deletion of incomplete response, a total of 5653 participants should be drawn from the cohort.
Several data were presented as discrete variables, including the duration of symptoms and administration of drugs. Moreover, to assume the possible variant, the investigators matched the date of diagnosis with the variant surveillance reports issued by the Ministry of Health according to surveillance week and region. Other continuous data were kept at their original values. Each type of vaccine possesses different efficacy17. Hence an ordinal level of this variable was made, where a higher ordinal level of vaccination means worse vaccination status (unvaccinated) (Supplementary Data 1).
The analysis involved participants with complete responses; hence no imputation and other missing data analysis were undertaken. Descriptive statistics and bivariate analysis of variables were conducted before the final analysis. We performed the structural equation model. First, the whole model was built (Fig.1) and simplified by the trimming approach. The structure of the model consists of exogenous variables, latent variables, and CFQ score as endogenous factors. The assumption was that vaccination, medication, virus variant, and comorbidity might affect the severity of COVID-19 and, eventually, cognitive failure. Aside from COVID-19, demography, chronic fatigue over the past 6months, recent headaches, and anxiety may affect the cognitive situation. The investigators constructed latent variables with confirmatory factor analysis. The selection of the explanatory factors was based on bivariate analysis and model fitting assessed using the Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Standardized Root Mean Square Residual (SRMR), and Root Square Mean Error of Approximation (RMSEA). The Lavaan library in R performed the analysis and produced the final plot.
Proposed Model of Cognitive Failure post-COVID-19. This model comprises four exogenous latent variables (circle variables), and one variable acts as both an exogenous and endogenous latent variable (severity). The final endogenous factor is cognitive failure. Factor loadings of the latent variable are presented with diverging arrows from the latent variable (Recent Headache with six elements. Demography with three factors. Vaccination with two factors. Severity with three factors, and comorbidities with four factors). Converging arrows indicate the impact of the exogenous variable on the endogenous factor.
This study was authorized by the Hasanuddin University Research Ethics Review Committee for Research Involving Human Research Participants (full-board review number 758/UN4.6.4.5.31/PP36/2021). We confirm that all procedures, particularly the clinical data collection, were performed following relevant guidelines and regulations. Informed consent was obtained from all participants when they provided information to the cohort. We appropriately de-identified, stored, and used the data while respecting confidentiality. Any circumstances that needed immediate action were directed to a professional. This research is a subset of a clinical trial with the identifier NCT05060562 on clinicaltrials.gov.
Picture of computer with CDC on the screen.
(Adobe Stock, unknown)
The CDCs HICPAC (Healthcare Infection Control Practices Advisory Committee Committee) on November 3 and 4, 2023, advanced changes in their infection control guidance, which will impact the control of SARS-CoV-2, the virus that causes COVID-19, and other airborne pathogens.
A letter to the CDC1 was submitted on Oct 24, 2023, supporting the safety of immunocompromised individuals in health care settings. This concern was further underscored by the findings of the INFORM2 and EPOCH3 research initiatives. The EPOCH study concluded:
Immunocompromised populations appear to be at substantial risk of severe COVID-19 outcomes, leading to increased costs and HCRU. Effective prophylactic options are still needed for these high-risk populations as the COVID-19 landscape evolves.3
The action letter was signed by 11 prominent patient advocacy and professional organizations and 21 patient advocates. This letter stresses that our healthcare system frequently encounters and treats airborne pathogens, including seasonal influenza, respiratory syncytial virus (RSV), and SARS-CoV-2.
Another group is concerned with HICPACs charter. The World Health Network has filed a complaint with the Office of the Inspector General charging Xavier Bacerra, secretary of the Department of Health and Human Services, Dr. Mandy Cohen, director of the CDC, and Dr. Alexander Kallen, the lead for HICPAC, with gross misconduct, according to Forbes.
Kevin Bell, a retired lawyer and member of the World Health Network, explained that the HICPAC committee violates its charter, which requires 14 members; it only has 9. Also, theFederal Advisory Committee Actrequires that committee memberships be fairly balanced in terms of the points of view representedand the functions to be performed. The Act adds, 'In balancing committee memberships, agencies are expected to consider a cross-section of those directly affected, interested, and qualified.'
Bell expressed his concern about the need for more balance in the committee. He found it surprising that the committee had only a few voting members who were an expert in aerosol science. He pointed out that the guidelines needed to give more importance to the aerosol transmission of COVID-19, the primary mode of virus transmission.
The complaint by the World Health Network challenges the legality of HICPAC's formal guidance on "Preventing Transmission of Infectious Agents in Healthcare Settings." It questions the legitimacy of this guidance due to a purported violation of the committee's charter membership requirements. Specifically, the World Health Network argues that HICPAC should include a substantial representation of experts in specialized fields like aerosol science, industrial hygiene, UV and HEPA filtration, ventilation engineering, respiratory protection, and occupational health and safety to comply with the Federal Advisory Committee Act. However, the complaint highlights the absence of such members within the Committee. This void in the representation of these critical fields is the core contention within the complaint, aiming to challenge the credibility and legal standing of the guidance provided by HICPAC.
The current CDC draft guidance4 appears to be conflicting and in places in error. For example, some provisions allow for the use of surgical masks when treating patients who have airborne infections (COVID-19 and seasonal influenza). Surgical masks are not designed for or intended to prevent the spread of airborne pathogens.
In a statement to CNN and posted on WSILTV.com, Jane Thomason, the principal industrial hygienist at National Nurses United (NNU), the biggest nursing union in the US, expressed concern that the draft incorrectly classified surgical and medical masks as both personal protective equipment (PPE) and respiratory protection.
A surgical or medical mask does not provide protection against inhalation of infectious aerosols, Thomason wrote in a statement to CNN on HICPACs draft recommendations. NNU urges CDC to fully recognize the science on aerosol transmission of infectious diseases and respiratory protection (including N95s, powered air-purifying respirators, and elastomeric respirators) in creating infection prevention guidance, Thomason wrote.
Patients reactions were similar. During one of the public comment periods, a member of the public said, I am deeply afraid of being in a situation where avoiding health care is not an option, said Seifer Almasy, who spoke as a member of the public. He said he was recently in that situation when he decided he couldnt put off getting his updated COVID-19 and influenza vaccines. He said he made 34 phone calls and was on hold for more than four hours to find a provider that would wear an N95 while giving him his vaccines.
HICPAC must recommend clear, robust, and authoritative precautions against the airborne transmission of pathogens.Anything less is malpractice and will do harm, Almasy said. Negative pressure rooms are not recommended for patients infected with MERS, SARS-CoV-1, SARS-CoV-2, and influenza. United States modern health care facilities often prioritize energy efficiency by sequestering indoor air from the outside air. This sequestration allows deadly pathogens to circulate throughout a facility, placing not just immunocompromised individuals but everyone at risk.
Finally, another disputed CDC strategy involves Enhanced Barrier Precautions (EBP).5,6 This strategy is not supported by the predicated data7 upon which it is based and allows patients colonized with candida auris to walk around a facility. This seems contradictory to attempts to prevent outbreaks of this deadly pathogen.8
CDC interim guidance recommends EBP as a strategy in nursing homes to interrupt the spread of novel or targeted MDROs (eg carbapenem-resistant organisms or C auris).
There is also a lack of provisions for air quality standards, such as ASHRAE Standard 241 for the Control of Infectious Aerosols" and for screening of these pathogens.
The inertia and back peddling of standards is often justified by the imposed burden preventive strategies would place on facilities. However, the burdensome argument has had little, if any, supportive data regarding the actual impact on an institution. The Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, considers an intervention cost-effective if the cost is less than 9.6 million dollars per life saved.9
During the August 22, 2013, CDC HICPAC meeting, a commentator stated, The only COVID-19 risks we are forced to take is when seeking out medical care. As stated in an action letter sent to the CDC, for the immunocompromised the status quo is unacceptable, and weakening current regulations will result in a direct threat (Section 36.208) to their safety and well-being and does not maintain accessible features (Section 36.211) for safe and adequate access to a facility.10 The conclusion of the action letter emphasizes that the CDC be mindful of the provisions of the ADA and the impact recommendations will have regarding vulnerable individuals who both work in health care settings or are experiencing reduced access to healthcare because of unsafe healthcare environments.
References
Key Takeaways
Since the pandemic began, researchers have used several metrics to try to track the infectiousness of COVID-19. One mainstay is viral shedding, which is the subject of a new study that aims to determine just how long kids are infectious after being diagnosed with COVID-19.
The study, which was published in JAMA Pediatrics, looked at data from 76 children between the ages of 7 and 18 who tested positive for COVID-19. The researchers took throat swabs during five home visits over 10 days to track viral shedding over time. They determined that most kids were infectious up through day three of their infection, although 18.4% of kids were still infectious on day five. Three kids (or 3.9% of participants) were still infectious on day 10.
The results raise a lot of questions about viral shedding and where things stand with going back to school or work after having a positive COVID-19 test result. Infectious disease experts explain.
Viral shedding means that a live virus is still detectable for a period of time after someone is infected with an illness, William Schaffner, MD, an infectious disease specialist and professor at the Vanderbilt University School of Medicine, told Verywell.
Viral shedding suggests that, during the period of time that someone is shedding the live virus, that they might be contagious or able to spread the virus to others, he said. Over time, the amount of virus that people shed drops.
The way viruses work is that they invade our cells, multiply and then can spread to other cells in the body or to other individuals, Thomas Russo, MD, a professor and chief of infectious diseases at the University at Buffalo in New York, told Verywell. People use the term viral shedding to talk about when an individual is expelling a virus into the air.
In general, viral shedding indicates how potentially infectious someone isbut not all viral shedding can make people around you sick.
If you shed the virus at low levels, you might not be infectious, Russo said.
Study coauthor Eran Bendavid, MD, associate professor of medicine at Stanford University, told Verywell that he and his colleagues wanted to help determine how long kids are infectious with COVID-19 after they get sick. But he also said that viral shedding alone is a poor measure of how infectious someone isthats why his study also looked at viral shedding that also caused evidence of infection in cell cultures.
Viral shedding is what a PCR test would pick up, and it does not tell you, in isolation, if the virus is capable of causing disease, Bendavid said. Why do researchers continue to look at it? Because its easy to measure. Infectivity is much more informative but hard to measure. Thats why our study was important.
Other data has been collected on different aspects of viral shedding. A study published in Open Forum Infectious Diseases in August 2020 found that people with COVID-19 with higher levels of viral shedding were more likely to be older, have pre-existing chronic conditions, and have more severe forms of the illness than those who shed less of the virus. But it didnt track the length of time people were infectious.
Another study published in the journal Emerging Infectious Diseases in 2022 found that adults who had the Omicron COVID-19 variant shed the most virus between days two and five after they were diagnosed. The researchers also found that infectious virus was detected up to nine days after people were diagnosed.
But Schaffner said that theres no clear information on how viral shedding has changed over the course of the pandemic, given that studies on the virusincluding viral sheddingwerent as robust early on.
Early in the pandemic, we were using PCR tests, which could detect pieces of the virus, he said. Those could have been dead soldiers. Some studies showed that people could be PCR positive for a week, two weeks, and sometimes even longer after they recovered, even though its unlikely they were infectious then.
Bendavid agrees that its hard to know how viral shedding has changed over time with the pandemic.
There are some reasonable implicationsfor example, that as the disease has become more mild, that shedding has decreasedbut we do not actually know that, Bendavid said. He also pointed out that his study found that children who were unvaccinatedand likely had a more intense illnessshed virus for the same amount of time as those who were vaccinated.
The Centers for Disease Control and Prevention (CDC) currently suggests that people who test positive for COVID-19 isolate until five days after their symptoms started, with isolation ending after someone has been fever-free for 24 hours without the help of medication. However, the CDC also recommends wearing a mask around others through day 10.
Despite the latest studys findings, Schaffner said that the CDC is unlikely to shorten isolation recommendations around COVID-19.
Russo agrees. With these findings, nearly one out of five kids going back to school could infect othersbut its also important to get kids back in school, he said. What protocols are we willing to maintain as a functioning society as the risk of COVID goes down, but isnt zero? We still need to figure that out, he said.
New research shows that children who are infected with COVID-19 are typically infectious through day three of their illness. However, nearly 20% are infectious through day five of their illness. If you test positive for COVID-19, doctors say its safest to follow CDC guidance and isolate for five days to lower your risk of infecting someone else.
The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit ourcoronavirus news page.
Kumar N, Bendavid E, Sood N. Duration of SARS-CoV-2 culturable virus shedding in children. JAMA Pediatr. Published online October 23, 2023. doi:10.1001/jamapediatrics.2023.4511
Tingting Liao, Zhengrong Yin, Juanjuan Xu, Zhilei Lv, Sufei Wang, Limin Duan, Jinshuo Fan, Yang Jin. The correlation between clinical features and viral RNA shedding in outpatients with COVID-19. Open Forum Infectious Diseases. August 2020, doi:10.1093/ofid/ofaa331
Takahashi K, Ishikane M, Ujiie M, et al. Duration of infectious virus shedding by SARS-CoV-2 Omicron variant-infected vaccinees. Emerg Infect Dis. 2022;28(5):998-1001. doi:10.3201/eid2805.220197
Centers for Disease Control and Prevention. Isolation and precautions for people with COVID-19.
By Korin Miller Korin Miller is a health and lifestyle journalist who has been published in The Washington Post, Prevention, SELF, Women's Health, The Bump, and Yahoo, among other outlets.
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The Haverhill Public Health Department plans a flu and COVID-19 vaccine clinic next Tuesday.
Shots are administered Tuesday, Nov. 14, from 1-6 p.m., at the Citizens Center, 10 Welcome St., Haverhill. The clinic is open only to Haverhill residents and walk-in space is limited. Pre-registration takes place online here.
Those with questions may call 978-374-2390, ext. 3900.
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MODERN ECONOMIC statistics are best thought of as a work in progress. As new information becomes available to national statistics offices they update and revise previously published numbers. The picture of the economy comes into focus only slowly, more like an old-fashioned polaroid than a snap on a modern smartphone. Revisions of older data are part and parcel of the process and rarely make the headlines. But in the past two months revisions in Britain and Italy have come close to rewriting recent economic history. What happened?
Data published in Britain during 2022 and early 2023 had depicted the country as the only G7 economy that by the end of 2021 had still not recovered its pre-pandemic output levels. But after revisions to the 2020 and 2021 figures, in September GDP was found to be 0.6% above its pre-covid size rather than 1.2% below it. The Office for National Statistics added almost 2% to its estimate of national income and transformed Britains economic performance from that of a global laggard to something more respectable. Also in September Italys statistics office upgraded its estimate of growth in 2021, at current prices, from 7% to 8.3%. That was not enough to offer the government the room it hoped for to justify tax cuts, but was still a significant revision.
In both countries the absolute size of the revisions is partially explained by the magnitude of the swings in GDP in nearly all economies in 2020 and 2021. The lockdowns of 2020 caused output to plummet at a pace not seen in decades and the unwinding of restrictions in 2021 prompted a strong bounce-back in most places. Proportionally normal revisions to large swings in GDP add up to big numbers.
These revisions are driven by what the statisticians call input-output tables (IOT). The initial estimates are based on partial data and on headline revenue figures reported by companies. As more detailed data become available, statisticians are able to use IOT to measure the inputs and outputs of each sector more minutely. That allows them to get a better look at how profit margins evolved over time. Margins, it is now thought, held up better than once believed, leading to higher estimates of profits, income and hence total GDP.
Over the coming months more rich countries will be able to update their data in light of better information. More revisions will follow. Changes of 1-2% in the estimated level of national output can grab the headlines, but the fundamental economic picture remains unchanged. The broad story is that 2020, though still dreadful, was not quite as economically disastrous as once thought and the recovery in 2021 was a touch stronger than it first seemed.
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Maintenance immunosuppressive drugs, including steroids, used for organ transplant patients are associated with an increased risk of COVID-19 hospitalization in solid-organ transplant recipients, according to new findings.
The study, published yesterday in JAMA Network Open, was based on findings among a cohort of 60,456 solid-organ transplant recipients in France. The average age of participants was 59, and 63.7% were male. Patients were tracked from February 15, 2020, to July 31, 2022.
Among participants found in the French National Health Data System, 41,463 (68.6%) had kidney transplants, 14,464 (23.9%) had liver transplants, 5,327 (8.8%) had heart transplants, and 2,823 (4.6%) had lung transplants. Overall, 11.4% were hospitalized for COVID-19, including 12.7% of kidney transplant recipients, 6.4% of liver transplant recipients, 12.9% of heart transplant recipients, and 18.0% of lung transplant recipients.
In kidney transplant recipients, steroids (adjusted odds ratio [AOR], 1.60; 95% confidence interval [CI], 1.49 to 1.73) and mycophenolic acid (AOR, 1.37; 95% CI, 1.25 to 1.51) were associated with a high risk of hospitalization.
Steroids were also associated with an increased risk of hospitalization for COVID-19.
"We observed an increased risk of COVID-19 hospitalization associated with using sirolimus in heart transplant recipients and using mycophenolic acid in kidney and liver transplant recipients independent of other drugs," the authors wrote. "Steroids were also associated with an increased risk of hospitalization for COVID-19 in each transplant subgroup."
Tacrolimus and cyclosporine were the only two maintenance therapies associated with a low risk of hospitalization in liver and heart transplant recipients, respectively.
Among all participants, heart transplant recipients treated with sirolimus were at the greatest increased risk of COVID-19 hospitalization (AOR, 2.71; 95% CI, 1.20 to 6.09).
November 08, 2023
3 min read
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Pediatric ED visits for firearm injuries nearly doubled during the COVID-19 pandemic compared with earlier trends, according to a study published in Pediatrics.
Last year, the AAP issued a policy statement recommending that firearms which remain the leading cause of death for children and young adults in the United States be regulated on the level of motor vehicles, with requirements for training, licensing, insurance coverage and registration.
One of the authors of the new study said the investigation was prompted by her own experiences as a pediatric emergency medicine physician.
What I've seen on the ground is that more children are coming into my own emergency department with firearm injuries over the last few years, Jennifer Hoffmann, MD, MS, a pediatric emergency medicine physician at Lurie Childrens Hospital of Chicago and assistant professor of pediatrics at Northwestern University Feinberg School of Medicine, told Healio. We wanted to see if this trend was occurring across the country.
Hoffman and colleagues studied ED visits by children for firearm injuries from 2017 through November 2022.
This [was] captured a few years before and a few years after the onset of the COVID-19 pandemic, Hoffmann said. We looked at health record data from nine children's hospitals across the country.
They identified 1,904 ED visits by children for firearm injuries during the study period 694 before the pandemic and 1,210 during it. Just over 52% involved older adolescents aged 15 to 17 years old, 63.5% involved Black youth, and two out of three firearm injury visits were by youth from under-resourced neighborhoods.
Increases beyond expected rates were seen for 10- to 14-year-old children (RR = 2.61; 95% CI, 1.69-5.71), females (RR = 2.46; 95% CI, 1.55-6), males (RR = 2; 95% CI, 1.53-2.86), Hispanic children (RR = 2.3; 95% CI, 1.3-9.91), and Black non-Hispanic children (RR = 1.88; 95% CI, 1.34-3.1).
Unfortunately, we found that emergency visits for firearm injuries by Black and Hispanic youth increased after the pandemic, while visits by white youth remained steady, Hoffmann said. This showed widening disparity and injury rates, which is troubling. We also found that two out of three firearm injuries visits were by children from under-resourced neighborhoods.
Visits increased in multiple different neighborhood types, including both poor and wealthy neighborhoods, Hoffman added.
This shows that no child is immune to the growing risks of firearm violence in our society, Hoffman said.
She noted the worsening of U.S. teens mental health during the pandemic.
Other studies have shown increases in suicide attempts among teenagers, Hoffmann said. We know that firearms are the leading means for teens to die by suicide, and so it's important to understand how much that's contributing to the increases.
Hoffman said the data show a need to do more to protect children and keep them safe from guns.
Overall, these data should serve as a wake-up call, Hoffmann said. It doesn't have to be this way. Children deserve to be safe, and the fact is that we already know some evidence-based strategies that work.
A second study exploring firearm homicides among American children precipitated by intimate partner violence (IPV) found that, from 2003 to 2020, among a total of 11,594 child homicides captured by the National Violent Death Reporting System, 49.3% were firearm homicides, and 12% of those were related to IPV.
Additionally, 86% of the homicides involved children who were in a home where ongoing conflict was occurring between current or former partners, and the remaining 14% of homicides involved adolescents whose death was caused by a current or former dating partner.
In an accompanying commentary, Maya I. Ragavan, MD, MPH, MS, and Alison J. Culyba, MD, PhD, MPH, from the University of Pittsburgh School of Medicine, wrote that a public health approach focused on evidence-based policies and practices is urgently needed.
There must be a significant investment in evidenced-based prevention programming focused on strength-based approaches to prevent youth violence, they wrote. Health care, community, and policy-level solutions are critical to protect IPV survivors and their children and promote family-centered thriving.
Hoffman JA, et al. Pediatrics. 2023;doi:10.1542/peds.2023-063129.
Ragavan MI, Culyba AJ. Pediatrics. 2023;doi:10.1542/peds.2023-063805.
Wilson RF, et al. Pediatrics. 2023;doi:10.1542/peds.2023-063004.
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November 08, 2023
3 min read
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VANCOUVER, British Columbia With alcohol-related disease still on the rise after surging during the COVID-19 pandemic, an expert here discussed treatment options, including liver transplantation, for patients with alcoholic hepatitis.
You have to realize alcoholic liver disease, especially alcoholic hepatitis, is increasing, Stanley M. Cohen, MD, FACG, professor of medicine and medical director of hepatology at Case Western Reserve School of Medicine, said during his presentation at the ACG Annual Scientific Meeting. Keep it in your mind as part of your history.
Cohen attributed the recent jump in alcoholic hepatitis and subsequent mortality to a rise in drinking among younger individuals, specifically women aged 25 to 34 years, and the impact of COVID-19.
Citing the Explorys database study, which grouped individuals in pre-COVID and COVID cohorts, Cohen noted that findings should be of no surprise to anybody here.
What we saw with regard to alcoholic liver disease was almost three times increased risk of alcoholic hepatitis, he said. We saw varices, alcoholic pancreatitis. So bottom line, were not just seeing more alcohol were seeing more downstream effects.
According to Cohen, alcoholic hepatitis is a specific syndrome with mortality ranging from 35% to 45% in 1 month. We see it commonly in hospitalized patients with alcoholic liver disease, he said. Theyre usually hospitalized because of alcoholic hepatitis, and most of them have cirrhosis by the time we see them.
In addition to clinical indicators, Cohen noted that Maddrey discriminant function or MELD are the most commonly used prognostic scores, with Maddrey over 32 and MELD higher than 20 indicative of severe alcoholic hepatitis.
Why do we care? Because thats the group that were going to use therapy on and again probably steroids. Also, it translates to about a 20% 90-day mortality, he said.
Cohen reviewed options for treatment, although many are unsuccessful, including absolute alcohol abstinence, nutritional therapy, corticosteroids and LT.
Although other treatments such as pentoxifylline have been studied, Cohen said corticosteroids remain the first-line treatment in patients with no contraindications. When treating with steroids, he recommended using Lille score to gauge effect.
It allows us to look at them on day 0 and day 7 of steroids and we see if theyre having a response, he said. What were going to look for is a Lille score of less than 0.45: Less than 0.45, the survival is dramatically better. If its greater than 0.45, its essentially futility and we stop the steroids.
Cohen also noted that IV N-acetylcysteine can be used as an adjunct to steroids, and that granulocyte-colony stimulating factor warrants further study.
Lastly, Cohen discussed how LT may be considered in a select group of patients, noting that the traditional 6-month sobriety rule has no scientific basis.
Were starting to see a paradigm shift that we can now evaluate people with a psychologist or a social worker, he said. We can really get an idea of whos at higher risk for recidivism, who isnt and who would be good candidate.
Cohen highlighted a 2011 French study, which showed that a very select group of patients without previous alcoholic liver disease, among other factors underwent transplant for alcoholic hepatitis and had a 6-month survival of 77%; only 10% resumed drinking alcohol afterward. In a U.S. study of 147 similarly chosen patients, the 3-year survival was 84%.
One predictor to consider is the Sustained Alcohol use after Liver Transplant (SALT) score, which basically looks at the amount of alcohol, how many failed prior rehabs, any legal issues, and if [a patients] score was less than five, they had a 95% negative predictive value for sustained alcohol use after transplant, Cohen said.
I dont want you leaving thinking transplant is great for all these patients, but there is a subset that you want to think about, he added.
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Cohen SM. Updates in the treatment approach for alcohol-associated hepatitis (AAH). Presented at: ACG Annual Scientific Meeting; Oct. 20-25, 2023; Vancouver, British Columbia (hybrid meeting).
Disclosures: Cohen reports serving on the advisory committee, board or speakers bureau for AbbVie, Gilead and Intercept.
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Last June, when COVID was still raging, Oregon health officials warned the public about the states first case of monkeypox, now known as mpox.
Cases continued to rise, peaking at 85 cases in August. By years end, health officials had tracked 270 cases, mostly among gay and bisexual men, though two Oregon children were also infected.
Health care providers administered thousands of doses of a vaccine and cases slowed, with only one case in December and four in January. But in recent months infections have been on the rise.
Jonathan Modie, a senior Oregon Health Authority spokesman, said the agency expected an increase following the festivals and parties in summer.
Cases began to increase then, and we have seen a consistent trickling of cases each week since mid-July, Modie said in an email.
We never declared the 2022 outbreak over because we were concerned about increases like the one we are seeing now, Dr. Tim Menza, the health authoritys senior mpox adviser, said in a news release. It gives us an opportunity to remind folks in the community that vaccination against mpox remains a valuable tool for reducing the risk of mpox infection.
The disease mainly spreads through skin contact, and symptoms can emerge within a few days or weeks. The most common are flu-like fever, chills, sweats, headache, muscle aches, swollen lymph nodes and fatigue. Patients usually develop a rash that looks like pimples or blisters, perhaps first in the genital area and then on the hands, feet, chest, face or mouth. The scabs usually fall off within four weeks.
Most people recover at home without special treatment, though the blisters are often painful.
When the outbreak first emerged in the U.S., there was a shortage of the vaccine, Jynneos. But the health authority said the two-dose vaccine is now readily available and free. The Centers for Disease Control and Prevention and Oregon health officials say its safe and effective: A study published in May by the Centers for Disease Control and Prevention found that one dose of the vaccine prevented illness among 75% of people and that two doses protected 86%.
The health authority urges anyone at risk to get vaccinated. Modie said they include people who have been in intimate contact in the prior two weeks with someone whos infected or anyone in close contact with them along with laboratory workers who test for the virus and providers who treat infected patients.
Anyone who suspects they have mpox should contact their primary care provider first to find out whether they should be tested before going in for a visit. If you dont have a provider, call 211 for help.
Infections are not expected to go away, Modie said.
The virus is now endemic to the United States and will continue to circulate among unvaccinated persons and those whose vaccine-based immunity has started to decline over time, Modie said.
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