Markedly increased risk in adolescents after 2nd dose may warrant refined vaccination strategies
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A case-control study found that despite low absolute risk, there is an increased relative risk of carditis associated with BNT162b2 (commonly-known as Pfizer/BioNTech vaccine) vaccination. Considering the markedly increased risk in adolescents after the second dose, vaccination strategies may need to continuously consider the risk and benefits for different sub-populations, rather than taking a ‘one-size-fits-all’ approach. The findings are published in Annals of Internal Medicine.
Carditis is a rare inflammation of the heart often caused by bacterial, viral, and parasitic infections. Common subtypes of carditis include myocarditis, an inflammation of the heart muscle, and pericarditis, an inflammation of the outer lining of the heart. Case reports of carditis after BNT162b2 vaccination have accrued globally. Several studies have also reported similar findings, but analytic research on the speculative association is limited.
Researchers from the University of Hong Kong studied 160 case patients (with carditis) and 1,533 control patients (without carditis) to examine the potential risk of carditis associated with vaccination with BNT162b2 or CoronaVac. Ten control patients were matched with case patients based on age, sex, and date of hospital admission. After conducting analyses, the authors found 20 cases of carditis associated with BNT162b2 and 7 associated with CoronaVac vaccination. Patients who received BNT162b2 were 3 times more likely to experience carditis than unvaccinated patients. On the other hand, patients who received CoronaVac had a similar chance as unvaccinated patients to experience carditis. The authors also observed that risk increase associated with BNT162b2 was predominant in males and was more likely to be seen after the second dose. Cumulative incidence of carditis after vaccination was 0.57 per 100,000 doses of BNT162b2 and 0.31 per 100,000 doses of CoronaVac, demonstrating a very low absolute risk of carditis after vaccination. According to the authors, none of the 20 case patients with carditis after BNT162b2 vaccination were admitted to the ICU or died within the observation period, compared with 14 of 133 unvaccinated patients admitted to the ICU and 12 deaths.
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2. ACP updates Rapid, Living Practice Points on antibody response and its role in conferring natural immunity after SARS-CoV-2 infection
Practice Point: https://www.acpjournals.org/doi/10.7326/M21-3272
The American College of Physicians (ACP) has updated its Rapid, Living Practice Points on the antibody response to SARS-CoV-2 after initial infection and protection against reinfection with SARS-CoV-2. ACP's evidence-based clinical advice for physicians is published in Annals of Internal Medicine.
Researchers from the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center Program's Scientific Resource Center at the Portland VA Research Foundation identified new studies on the risk of reinfection and duration of protection following SARS-CoV-2 to inform ACP’s update. That data provided strong evidence that the immunity afforded by recent infection conferred substantial protection against symptomatic reinfection with the Alpha variant of COVID-19 for at least 7 months. However, that durability of protection in the setting of the Delta and Omicron variants is unknown.
Based on the evidence, ACP advises against using SARS-CoV-2 antibody tests for the diagnosis of SARS-CoV-2 infection. ACP also advises against using SARS-CoV-2 antibody tests to predict the degree or duration of natural immunity conferred by antibodies against reinfection, including natural immunity against different variants. The authors note that these practice points do not evaluate vaccine-acquired immunity or cellular immunity. Vaccination is currently the best clinical recommendation for preventing infection, reinfection and serious illness from SARS-CoV-2 infection and its variants. Additionally, a previous practice point concerning the use of antibody tests to estimate community prevalence of SARS-CoV-2 infection has been retired due to limited relevance, as vaccinations have become widely available in the U.S.
According to ACP, evidence is emerging about natural immunity from COVID-19 but there is still important uncertainty about how protection varies between individuals, how long it lasts, and the role of variants. In light of these evidence gaps, it is important that individuals and communities continue to use all available tools to help slow and reduce further spread.
3. Allopurinol treatment not associated with increased mortality rate in patients with CKD and gout
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A population-based cohort study found that a using allopurinol to achieve target serum urate levels did not increase mortality risk in patients with gout and chronic kidney disease (CKD). These findings provide reassurance that a treat-to-target strategy does not have an apparent harmful effect in these patients. The study is published in Annals of Internal Medicine.
CKD is a common comorbidity in patients with gout. The recommended treatment for long-term gout management is lowering serum urate levels to below 0.36 mmol/L for patients experiencing flares, tophi, or radiographic joint damage. Lowered serum urate levels are also considered a potential therapeutic option for halting the progression of CKD. Allopurinol is a commonly used medication for gout treatment, but two recent randomized control trials indicated that allopurinol was associated with a 2-fold increased risk for death in patients with renal disease but without gout.
Researchers from Xiangya Hospital, Central South University, Harvard Medical School, and several other institutions studied electronic health records for 5,277 adults in the United Kingdom with gout and moderate to severe CKD to examine the relation of allopurinol initiation, allopurinol dose escalation, and achieving target serum urate level after allopurinol initiation to all-cause mortality. Mortality over 5-year follow-up in propensity score–matched cohorts was examined for each dosing stage/strategy. The data showed that neither allopurinol initiation, nor achieving target SU level with allopurinol, nor allopurinol dose escalation were associated with an increased risk for death in patients with gout and concurrent CKD. According to the authors, these findings may alleviate concern about utilizing allopurinol in this patient population.
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4. Racial/ethnic minorities still widely underrepresented in internal medicine residency programs
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A brief research report found that marked disparities in racial/ethnic representation still persist in internal medicine residency programs, despite efforts to increase diversity. These findings suggest that significant transformative work remains to be done to increase representation of minoritized populations that are underrepresented in medicine among students, residents, and faculty. The report is published in Annals of Internal Medicine.
A racially and ethnically diverse physician workforce could improve access to care, communication, patient satisfaction, and health outcomes, particularly for underserved and systemically marginalized patients. Despite this need, members of racially/ethnically minoritized groups are still underrepresented in medicine. These include those identifying as American Indian or Alaska Native; Native Hawaiian or other Pacific Islander; Black or African American; and Hispanic, Latino, or of Spanish origin.
Researchers from the University of Washington School of Medicine studied data from the American Association of Medical Colleges to elucidate trends in representation for internal medicine residency applicants and matriculants who identify as underrepresented in medicine. Between 2010 and 2018, a total of 214,656 individuals applied to internal medicine residency programs and 87,489 matriculated. Of those 13.2% of the applicants and 10.6% of the matriculated students identified as a member of a race or ethnicity underrepresented in medicine. In examining disaggregated matriculant data for those in underrepresented groups, only the proportion of matriculants who were Hispanic, Latino, or of Spanish origin significantly changed. For every year studied, a greater proportion of White persons were represented among matriculants compared with applicants. According to the study authors, diversifying internal medicine residencies will require dramatic, innovative approaches before, during, and after the application process.
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Annals of Internal Medicine
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Carditis After COVID-19 Vaccination With a Messenger RNA Vaccine and an Inactivated Virus Vaccine
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