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Published on Leave a comment on Is There More to Life Than Infectious Diseases?

Well of course there is, that's why I try to sprinkle my weekly posts with comments on bird feeders, squirrels, novels I've been reading, and other escapades. This past week I happened upon a former colleague of mine who has taken this to new levels, much to my enjoyment.

We seem to be free of serious infectious diseases drama in the past week, unless you are a dairy cow.

Avian Flu

Initially only previewed in news reports and even now lacking details, one thing is clear: influenza A H5N1 infection in US dairy cows is much more widespread than previously revealed. We were surprised by this because asymptomatic infection is common and cow testing was only being performed in symptomatic animals. (This is reminiscent of the early days of covid!) The FDA and Department of Agriculture both report finding positive avian flu PCR tests in 1 out of 5 samples of pasteurized milk tested, although I can't find details about the total numbers and the geographic distribution of milk samples tested.

Of course, a positive PCR merely means that nucleic acid has been detected. It is highly likely that pasteurization inactivates H5N1 virus, and preliminary reports from FDA suggest this is true. Again, details are not available, but certainly no cause for panic about drinking pasteurized milk.

The take-home messages are clear: 1) H5N1 infection is highly prevalent in US dairy cow herds if 20% of all milk samples are PCR positive; 2) there is even more reason now to avoid ingestion of unpasteurized dairy products; and 3) USDA, FDA, and CDC are performing poorly in providing transparency and detailed evidence to the public. They say they are working on this, let's hope we see the fruits of that labor in the coming few weeks.

And, to give our federal agencies some credit, CDC has a spiffed-up web site for avian flu now, with weekly updates. Here's a quick view for the week ending April 20:

Note that this site deals only with human disease. If you want to get more on dairy cattle, you'll need to go to the USDA site. Here you can realize how geographically widespread the situation is.

USDA now has new guidelines for testing dairy cattle being transported interstate. Perhaps testing needs to be expanded beyond just interstate transport.

Covid Calm

Covid activity continues to fall, and weekly deaths now appear to be consistently less than 1000 even considering there is significant reporting delay for covid deaths. The vast majority are in the elderly.

Two new studies appeared highlighting covid vaccine side effects in children. One was a prospective cohort study utilizing insurance databases that likely carried some risk of classification errors because the authors did not perform any medical records review for verification. The study confirmed the known risks for myocarditis or pericarditis for ages 12 - 17 years with the Pfizer vaccine. Also, they found a possible safety signal for seizure occurring following both Pfizer and Moderna vaccination in 2 - 4 or 5 year-old children. This is pretty iffy; as they explained in the body of the text, it may simply be an artifact of how they defined the baseline seizure rate as a comparison number. This is worthy of further study, but in my opinion not something that should be put on the list of definite side effects yet.

The other study was a massive (3.9 million children) look at covid cases in California from 4/1/20 through 2/27/23, again using an administrative database. The article has too many explanatory graphs to show here, but the bottom line from the authors' predictive models suggests that vaccination prevented about 146,000 covid cases in 12 - 15 year-olds, 230,000 cases in 5 - 11 year-olds, and 168 hospitalizations in 6 - 59 month-olds. The authors did not find any association of vaccination with numbers of cases in the youngest age group, possibly because the numbers of vaccinated children were too small during the study period.

Our friends across the pond reported on various covid features from this past winter, November 2023 through March 2024. Results are based on self-reported data from a longitudinal survey study. Here are the main points:

  • An estimated 3.3% (2 million) of people living in private households in England and Scotland were experiencing self-reported long COVID (symptoms continuing for more than four weeks after a confirmed or suspected coronavirus (COVID-19) infection that were not explained by something else).
  • Long COVID symptoms adversely affected the day-to-day activities of 1.5 million people (74.7% of those with self-reported long COVID), with 381,000 (19.2% of those with self-reported long COVID) reporting that their ability to undertake their day-to-day activities had been "limited a lot".
  • Those in the youngest (aged 3 to 17 years) and oldest (65 years and over) age groups were the least likely to test positive for COVID-19 during the study period.
  • Those who have had a vaccination since September 2023 were less likely to test positive in the early waves of the study period (1 and 2); in later waves of the study period (3 and 4) there was no statistical difference.
  • Participants in the oldest and youngest age groups who did test positive in the study period were also less likely to report symptoms consistent with "influenza-like illness" compared with those in the middle age groups.

It's hard to find such recent data. I think this gives us a good peek at the future, assuming we don't have some major change in virus virulence or transmissibility.

Encouraging Progress in Malaria Prevention

I don't usually mention phase 2 trials because they are often much removed from clinical applicability and might change significantly once phase 3 trials are completed. This study is cause for optimism, so I'll break my custom here. Investigators in Mali performed the trial, part of which looked at 225 children randomized in equal numbers to a long-acting monoclonal antibody against Plasmodium falciparum with low dose, high dose, and placebo groups. Infection and clinical malaria was much less in the treatment groups.

The antibody is administered subcutaneously, a plus in resource-poor environments. If further studies confirm efficacy, this could save many lives.

Measles

No new cases were reported in the past week, good news though we know there will be more eventually. Also, I've been looking for more reliable assessments of worldwide activity and found another resource for Europe, the European Centre for Disease Control and Prevention. Updates appear only monthly. Here's what the most recent report, February, looked like:

Romania is the major hot spot, but note that many popular tourist destinations are represented. Here are current CDC recommendations that apply for all international travel:

Fiddlin' Will

By a happy occurrence in my web wanderings, I discovered a former colleague of mine was performing with his band, the Goldbug Revival, at a Salvadoran restaurant near my home. I crossed paths briefly with Will Sears when he was an infectious diseases fellow at NIH; he is now a medical officer at NIAID. However, in his "spare time," he is an accomplished musician. I was thrilled to see him on the fiddle and his wife Sarah singing lead at the band's first live performance and Sarah's first performance in front of a microphone ever. They were excellent!

See you next week. I'll be listening to some John Prine music in the meantime, waiting for Goldbug Revival's first album to drop. Prine was an early covid victim, dying in April 2020.

Published on Leave a comment on It’s Winter Respiratory Season, Complete with Hype

Yes, the winter respiratory illness season has ramped up in the US. Predictably, so has the hype. I even saw a term, "white lung syndrome," tossed out. It's a completely inappropriate description especially when one considers the main lower respiratory disease agent circulating now is a mild one, Mycoplasma pneumoniae.

Before we dive into winter respiratory pathogens, let's touch on a few other noteworthy events from the past week.

Watch Out for Cantaloupes (and many other foods)

CDC announced a new Salmonella outbreak alert this past week, covering 34 states and resulting in over 60 hospitalizations so far. Be particularly cautious of pre-cut cantaloupe products. Perhaps more revealing, however, is the fact that we have 2 other Salmonella outbreaks being monitored now (dry dog food and fresh diced onions) plus 4 others that have ended recently (backyard poultry, raw cookie dough, ground beef, and small turtles). Salmonellosis can mostly be avoided by knowing about high risk situations (e.g. poultry, ground meats, reptiles, poorly washed raw foods) and practicing good handwashing, food washing, and cooking thoroughly, as well as by refrigerating leftovers promptly.

WHO World Malaria Report

WHO released its annual report, and it's no surprise we are behind schedule for decreasing malaria cases worldwide. It's a very long, detailed report even allowing for the fact that some details appear in a few different languages. Some key details:

  • Rapid detection assays have been very helpful in diagnosing Plasmodium falciparum infections in particular, but new mutations in the histidine-rich protein 2 gene may allow these organisms to escape detection.
  • As always, resistance to antimalarials is spreading, requiring ongoing monitoring.
  • Not to be outdone by the pathogen, the vectors (mosquitoes) are increasingly becoming resistant to insecticides. This has led to new recommendations for mosquito netting in malaria-endemic countries.
  • And last, but not least, climate change. Here's a direct quote: "WHO has declared climate change to be the single greatest threat facing humanity."

I liked this graphic for visualizing malaria case distribution geographically.

More Concern for Invasive Group A Streptococcus

The Pan American Health Organism just issued a new alert for iGAS infections in Argentina. This joins a growing list of reports in a number of countries, primarily in Europe. Research is pointing to new M1 mutations with toxin production that might confer increased virulence.

Winter Respiratory Illness Season

Clearly I need to switch from calling this a winter respiratory viral season to a winter respiratory illness season; not all the pathogens are viruses, and of particular note is M. pneumoniae, a free-living organism in the class called Mollicutes. Technically they are bacteria, but they lack a cell wall and I think it's a bit misleading to the general public to refer to them as bacteria. Nonetheless, they aren't viruses. The organism is very difficult to grow in culture, requiring special media and expertise as well as 1-3 weeks incubation, but now it is included in most multiplex respiratory pathogen panels so easier to diagnose. Serologic diagnosis is fraught with false positives, about the least useful serologic testing for human disease that I know of.

"Fried egg" image of M. pneumoniae in culture:

One important thing to know about mycoplasma disease is that it is endemic everywhere, but epidemics occur about every 3 to 7 years and last anywhere from 1 to 2.5 years. I've witnessed this myself several times in my practice in the DC area, and it appears that a new mycoplasma epidemic partially explains the larger numbers of respiratory diseases in Denmark (you may need Google translate) and the Netherlands.

Perhaps more importantly, it's been very difficult to show that antimicrobial treatment has any benefit for illness caused by M. pneumoniae, which is clearly a self-limited infection. Probably if treatment has a benefit it would need to be initiated very early in the disease course. Testing for the organism requires a relatively expensive multiplex PCR assay and probably isn't worthwhile to test for the usually mild "walking pneumonia" version of the infection.

By far the biggest hype in the lay press (and from some congressmen) is the surge in respiratory illness in China, especially in northern regions. However, we do have some reassurance from the WHO taken from review of Chinese reports (Google translate again helps somewhat here). It appears that what is going on is simply an increase in known respiratory pathogens, rather than a new pathogen that China is hiding from us. I can add anecdotally that, as I track reports in real time and compare to the December 2019/January 2020 tracking I was doing, this looks nothing like the new appearance we saw with SARS-CoV-2. That doesn't mean there isn't something new circulating at low levels, but certainly no cause for alarm or to call for travel restrictions.

Remember that China only emerged from their "zero covid" lockdown a year ago, so this is their first full winter respiratory season with most children having no experience with any of these respiratory pathogens the past 4 years. As we saw in the US last winter, this likely produces a temporary situation resulting in increased numbers of cases and increased disease severity.

On the sort of good news side of covid, CDC reported benefits of covid vaccination for children 6 months to 4 years of age from a very recent time period covering July 2022 through September 2023. Vaccine effectiveness (receipt of at least 2 vaccine doses) for preventing acute care visit or hospitalization was 40%, though with a large confidence interval due to the relatively small numbers of events. The somewhat downer side of the report was that only 10% of the 7400+ children in the study had actually received > 2 vaccine doses.

Moving on from covid, RSV activity in RSV-NET is taking off, it is now full-blown RSV season.

Flu is heating up in more parts of the country, but not widespread yet.

Covid also is increasing, and now CDC has a better display for wastewater tracking:

The above is current for the week ending November 25 and predicts we will see a winter increase in covid illness. This is supported by a slight increase in positivity rate in covid testing in CDC data. However, you can see most of the recent uptick in positivity rate is being driven by influenza and RSV. If wastewater is truly predictive, we'll see the covid curve start to rise more dramatically in the coming weeks.

A Chuckle to Share

I loved this brief blurb in the November 20 issue of The New Yorker (I'm way behind in my magazine reading, blame Thanksgiving holidays). Every parent (and grandparent) will identify with this fictional list of communications from a nursery school to parents, announcing outbreaks of lice, pink eye, smallpox, "pirate's gastroenteritis," and rinderpest.

I Didn't Forget Diego Rivera

Last week I challenged you to name the organisms depicted in various Diego Rivera murals as collected in a recent article. According to the authors, figure A represents Salmonella typhi, though that seems a stretch to me. Figure B is easier, it looks a lot like the Gram negative intracellular diplococci seen with gonorrhea. Figure C shows spirochetes, mostly likely syphilis, but D is vague again, some sort of Gram positive intracellular cocci. Take your pick.

Published on Leave a comment on A Week of Autochthony

Last week I was struggling to come up with enough new items to fill the post; this week I'm wrestling to pare down the list of topics. We've had some more concerning news about autochthonous tropical infectious diseases cropping up, but before I turn to that....

Is Covid Coming Out of the Doldrums?

Lots of headlines about this in the past week, some more hysterical than others. Staying alert, not panic, is the appropriate response.

First to wastewater. Looking at the past 6 months in Biobot, every US region is trending up, notwithstanding a slight drop in the purple midwest region.

Now look at the same graph spread out over a longer time:

So yes, we've had an upward blip recently, but nothing as dramatic as what accompanied serious clinical outbreaks in the past.

The other hype is about newer variants. Fortunately, we're still talking about omicron and primarily from the XBB subvariant group. I'll turn to the UK's nice graphs to highlight; results are similar but not identical to the US.

This Sankey diagram gives you an idea of the relatedness of strains:

The key question is how well the proposed autumn covid vaccine, derived from XBB.1.5, works against these newer variants. The answer is based mostly on conjecture at this time, we have no peer-reviewed hard data yet. The best guess is that it will not protect much against infection itself, nor will prior natural immunity. However, for the more important protection against severe disease, hospitalization, or death, it is likely to have an impact. Jennifer Abassi, a medical news reporter for JAMA, published a nice discussion. CDC and IDSA recently posted a brief explanation. Also in the news the past few days has been a newer variant, BA.2.86, now seen in a few countries sporadically including the US. It's much too early to know if this will become prominent.

CDC published updated data about monovalent and bivalent vaccination in the 6-month to 4- or 5-year-old age groups that showed good effectiveness in protection against urgent and emergency care visits. Also important to note is that these are relatively uncommon events in this age group, which is why you see different recommendations for vaccination in the US versus the UK for example. Going from the last section of Table 2 in the article, rates of these care visits from 12/24/22 to 6/17/23 were 4.4% in the unvaccinated group versus 0.9% in those who had received at least one bivalent vaccine dose. With a little arithmetic, the number needed to vaccinate at this level to prevent one additional ED/urgent care visit is about 30.

Reason to Avoid Proton Pump Inhibitors

French investigators published a cohort study linking use of PPIs in children to higher risk of serious infections. It included over 600,000 children receiving PPIs and a similar number as a control group not receiving PPIs, followed for a few years. The risks for serious infections as well as a number of categories of infection types were significantly increased. Most of the children had significant comorbidities. This association has been known in adults for a long while and is likely based on a variety of PPI effects including elevated gastric pH and alteration of the GI microbiome. That's not to say PPIs shouldn't be used in children, but there is a clear risk that should be explained to parents.

RSV Already in Florida

Florida is now seeing RSV infections in some jurisdictions. This isn't too surprising; Florida has a very different seasonal epidemiology than does most of the US:

It remains to be seen how RSV seasonality will stabilize in the post-pandemic/isolation era. A group in the Netherlands recently reported a switch to year-round transmission during the pandemic.

Along similar lines, a US study showed that ICU admissions for RSV consisted primarily of infants without risk factors; the study does have significant limitations. Findings may reflect the lack of partial RSV immunity conferred by prior RSV exposure of both mothers and infants.

It's still time to plan for use of monoclonal antibody and, if approved, maternal RSV vaccination. AAP and ACIP have a nice discussion available. Lots of logistical hurdles remain.

Autochthonous Malaria and Dengue

I posted about autochthonous malaria in Florida and Texas on July 2 and 9, and on autochthonous dengue fever in Arizona on 11/20/22. See the July 2 post for more about the definition of autochthonous infections.

Now we have a report of 11 autochthonous dengue cases in Florida. Closer to home, we've had a report of 1 case of autochthonous P. falciparum in a Maryland resident in the National Capital Area region. Falciparum malaria is significantly more dangerous than the vivax forms reported in Florida and Texas. Very little information was provided, but the letter does have links to good clinical information sites.

Autochthonous infections are tricky to diagnose given the lack of travel history to an endemic area. Climate change has expanded the geographic range of many insect vectors of disease. All clinicians should be aware of these diseases when evaluating febrile patients.

As a final note, my web wanderings about autochthony taught me something new about the term. Sadly, it has been used in a negative political (and racist) sense. An "autochthonous" flag protest disrupted a 2014 soccer match between Serbia and Albania.

Published on Leave a comment on Hotter Than a Pepper Sprout

I'm a longtime Johnny Cash fan, and the weather reminds me of his cover of the song Jackson with his wife June Carter Cash. Things are heating up in the country and world-wide now. We'll certainly see all kinds of health effects from this, including but not limited to infectious diseases. For now, try to keep cool, hydrated, and apply plenty of sun screen.

Also Remember Mosquito Protection

Speaking of climate change, the Florida Department of Health reported 2 more cases of autochthonous malaria in Sarasota County (see below), bringing the total to 6 cases in that region. Now is the time to take extra precautions for mosquitoes for residents of and travelers to that area.

By David Benbennick - The maps use data from nationalatlas.gov, specifically countyp020.tar.gz on the Raw Data Download page. The maps also use state outline data from statesp020.tar.gz. The Florida maps use hydrogm020.tar.gz to display Lake Okeechobee., Public Domain, https://commons.wikimedia.org/w/index.php?curid=570156.

CDC Budget Cuts

I can't find any official announcement on the CDC website, but Kaiser Family Foundation and various media entities have reported seeing emails from CDC to state health departments detailing some of the effects of the recent Biden administration budget cuts. Specifically, funding for sexually transmitted infection and pediatric vaccine support are being cut significantly. This couldn't come at a worse time. The impact will be most severe on those populations already at high risk such as rural populations and others lacking medical insurance coverage and access to healthcare. Here's hoping the feds find a workaround for these cuts.

'Demic Doldrums

We continue in a covid lull worldwide, with only a few areas showing increasing activity according to WHO.

On the variant front, not a lot to report although a new omicron subvariant, XBB.1.5.26.1 abbreviated as EU.1, may be the latest to watch. It's still at very low numbers in the US but has a significant growth advantage over other circulating variants. Remember that XBB.1.5 is the variant included in the upcoming covid vaccine for this fall.

My Entomophobia

I don't strictly fulfill diagnostic criteria for entomophobia, but my long-suffering wife would disagree when it comes to my fear of mosquitoes. I believe it dates back to a camping trip to Big Bend National Park when I was maybe 7 or 8 years old. I woke up to about 100 bites on my body, while my best friend in the same tent had about 2. It was then that I realized I was very popular with mosquitoes; I'm a mosquito magnet.

I'm particularly reminded of this with the current malaria transmission in Florida and Texas. One of my earliest childhood memories is of my father intermittently taking to his bed with high fevers and shaking chills, a vigorous man reduced almost to an invalid for a few days. He knew this was his malaria relapsing, related to his World War II service in North Africa. He had either Plasmodium ovale or Plasmodian vivax, the 2 types of malaria that have an exoerythocytic phase that requires primaquine treatment to eradicate, after initial treatment with choroquine or other agent. Apparently he didn't have access to primaquine, although it was discovered in 1946 and approved for use in the US in 1952, before I was born. Either he ultimately did get treatment or the episodes just burned out by themselves, but he didn't suffer from relapses in later life. Even though these forms of malaria aren't as deadly as P. falciparum, morbidity is still significant.

So, make my summer cocktail sunscreen, plenty of water, and DEET. (Not to be confused with prior advice of some extremists for covid treatment, the sunscreen and DEET are topical agents, only the water is to be ingested!)

Published on Leave a comment on Try to See It From Grendel’s Perspective

Ever read Beowulf? Me neither. Nor do I plan to ever read this epic poem consisting of 3182 lines of alliterative verse. Recently I did read Grendel by John Gardner. Grendel is the monster who was killed by Beowulf in the famous poem. Gardner's book is told entirely from Grendel's perspective, very different from how Beowulf and the other humans saw things of course.

Malaria Season

Practicing in the Washington, DC, area for almost 40 years meant that I had a steady diet of malaria. Our "malaria season" was towards the end of summer when vacationing families returned home after visiting relatives in malaria-endemic countries. This seasonality abated a bit during the pandemic when international travel was scarce, then came back with a vengeance. Now, however, autochthonous malaria has been reported in Florida and Texas.

Autochthonous, from the Greek autokhthon meaning "sprung from the land itself," in this instance refers to malaria acquired without visiting a malaria-endemic country. I didn't mention the initial CDC report a couple weeks ago, but now that a second state is involved and CDC issued a health alert advisory, I'll attempt to summarize what's happening.

We still have virtually no clinical details about any of the 5 cases, but CDC implied they are all due to Plasmodium vivax which is not as severe/deadly as P. falciparum. Autochthonous malaria in the US was common in the old days, but since effective mosquito control programs in the 1950s it has been scarce. Prior to the current reports, we hadn't seen autochthonous malaria since 2003. High risk areas in the US are those that have high population density, plenty of Anopheles mosquitoes (including favorable conditions for their reproduction), and a source of people who have recently traveled from malaria-endemic areas. So, it's not surprising that Florida and Texas are points of origin now.

Speaking of mosquitoes, climate change has greatly increased the range of various insect vectors of disease; for example, Lyme disease risk has expanded geographically in recent years as deer ticks broaden their range. Anopheles mosquitoes are present in virtually the entire US.

For frontline providers, malaria shouldn't be the first thing to suspect in a child with fever in the US, but recognize that in cases of prolonged fever it is a consideration even without a history of international travel. Look at the CDC's malaria website for more details, and read this article if you want to see a longer discussion of (prepandemic) autochthonous malaria.

Foodborne Disease is Back

Another sign that the pandemic is lifting is this CDC report of 2022 data. Certain foodborne illnesses such as Shiga toxin-producing Escherichia coli, Yersinia, Vibrio, and Cyclospora infections increased compared to 2016–2018 data; Campylobacter, Salmonella, Shigella, and Listeria incidences didn't change much. Although they didn't show the data in this report, foodborne diseases decreased in the 2020-2021 time period.

I was a bit disappointed that, although the report did mention increased use of culture-independent diagnostic testing rather than culture, it did not mention the fact that the highly sensitive CIDT methods can be more prone to false positives. This makes it difficult to compare trends across time periods.

Ideally one would perform a backup culture test for bacterial pathogens particularly to detect antimicrobial resistance; CIDT can not test for this.

Can We Shorten Treatment Duration for Pediatric Urinary Tract Infection?

The short answer is yes, but the more difficult question is how to decide which patients are appropriate for shortened therapy. Even this randomized controlled trial couldn't answer that question. The study compared 5 versus 10 days of therapy for UTI in children 2 months to 10 years of age. Children who showed clinical improvement at 5 days treatment were then randomized to another 5 days of antibiotic versus placebo. Failure rate in the 10-day treatment group was 0.6% versus 4.2% in the 5-day group.

Ultimately I think the details of study design doomed this trial to leave this question mostly unanswered. In particular the duration of followup after stopping antibiotic was too short for the 10-day group (which would have skewed results to a falsely low failure rate). Fundamentally the problem with UTI treatment in children is trying to determine which children have pyelonephritis versus just cystitis, much more difficult in children than in adults. Pyelonephritis likely requires more than 5 days of treatment.

This study definitely adds to our understanding of pediatric UTI but I don't think is immediately transferrable to clinical practice. The accompanying editorial offers some ideas in this regard.

'Demic Doldrums

We continue to enjoy relief from covid from the standpoint of no evidence of major surges around the world, just continued pockets of upswings in disease activity (tempered by the knowledge that we aren't tracking it very well now). Of course, the number of total cases in this WHO graph, as of June 28, is pretty depressing overall.

According to WHO, confirmed covid deaths now number 6,947,192.

Blood Group and Covid

I have blood group A positive. Should I be worried? It's been known for a while that individuals with type A blood have a slightly higher risk of SARS-CoV-2 infection, and this recent article lends some credence to these observations by supplying a biologic explanation. The A blood group antigen is very attractive to the receptor binding domain of the virus, including omicron variants. But no, I'm not concerned. The increase in infection risk attributable to blood group is very small, paling in comparison to other risk factors.

Whatever Happened to Wastewater Monitoring?

In the US, wastewater monitoring for viruses like SARS-CoV-2 has great potential but is ineffective because it involves voluntary reporting by states. Most people in the US live in areas that don't monitor wastewater. Our northern neighbors in Canada, specifically Peel, Ontario, provide evidence that wastewater monitoring truly can be an early warning for increased infections. Investigators reported that wastewater levels predicted very reliably 1 day before the rise in infections and 4 days before a rise in hospitalizations during the omicron period of November 2021 to June 2022. At this point I'm not sure if the US has the resources to implement wastewater virus monitoring on a larger scale.

Better Evidence for MIS-C Treatment

The multi-system inflammatory syndrome in children is still difficult to diagnose precisely. Thankfully MIS-C seems less common in today's covid era with omicron dominance and high levels of antibody in the population. Now we have some better guidance for immunomodulatory therapy for MIS-C. This meta-analysis suggests that the combination of intravenous immunoglobulin plus glucocorticoid therapy improved cardiovascular dysfunction better than either agent alone. The study was very well done but had to rely heavily on nonrandomized cohort studies which introduces a great degree of bias in the results. We missed a chance by not conducting large RCTs of MIS-C treatment early in the pandemic.

Understanding Grendel

I needed to consult Wikipedia and other Cliff Notes-like versions of Beowulf to understand Gardner's book. As with everything I read, I think about what, if anything, might apply to me. With Grendel and Beowulf it was relatively easy. When faced with dramatically different perspectives, say for example pandemic deniers or anti-vaxxers (Grendel) versus traditional science and medicine (Beowulf), it's a good idea to try to see things from the opposing perspective. If one can do this without resorting to raised voices or worse, it's possible to have a meaningful dialog and even occasionally change minds, even my own! Next time you see me, look for Grendel perched on my shoulder. For those less prone to wild fantasies I recognize this is quite a stretch, but regular readers are accustomed to my tangents.

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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