Anonymous
05/05/2020 15:53
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
There was a study out of Denver Children's Hospital that found even during regular non-pandemic times -- including that parents were not trying to isolate themselves and kids from medical areas unless absolutely necessary -- about 1/3 the cases weren't picked up within the 10 days of start of fever that is needed to begin treatment for successful resolution.
The range of presentation is wide. Children can look very, very sick, or not really all that terribly ill. Close to half the children (about 44%) were seen by a medical provider at least 4 times before the diagnosis was made. That's really not happening now.
It's like untreated strep. You can clear it yourself -- yes, that happens -- but that doesn't mean you don't figure out the cardiovascular (of for strep, sometimes kidney) problems for several months. Not everyone gets the serious complications, AND the complications can lay silent for months.
The range of presentation is wide. Children can look very, very sick, or not really all that terribly ill. Close to half the children (about 44%) were seen by a medical provider at least 4 times before the diagnosis was made. That's really not happening now.
It's like untreated strep. You can clear it yourself -- yes, that happens -- but that doesn't mean you don't figure out the cardiovascular (of for strep, sometimes kidney) problems for several months. Not everyone gets the serious complications, AND the complications can lay silent for months.
Anonymous
05/05/2020 15:48
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:New syndrome in kids may be linked to covid:
https://www.nytimes.com/2020/05/05/nyregion/coronavirus-new-york-update.html?type=styln-live-updates&label=new%20york%20&index=2&action=click&module=Spotlight&pgtype=Homepage#link-1aca38d0
"Fifteen children, many of whom had the coronavirus, have recently been hospitalized in New York City with a mysterious syndrome that doctors do not yet fully understand but that has also been reported in several European countries, health officials announced on Monday night.
Many of the children, ages 2 to 15, have shown symptoms associated with toxic shock or Kawasaki disease, a rare illness in children that involves inflammation of the blood vessels, including coronary arteries, the city’s health department said..."
Too much disinfecting in the house. It all gets into the blood from touching the surfaces that should be RINSED after bleaching or lysoling, and also from the sprays. .. maybe.
Um, no.
Anonymous
05/05/2020 15:45
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:PS: In general, it's a good idea to look at how a study was done before making claims about what it shows.
I did.
My point was that I want to know if I misread something when reading about the study.
I am so sorry -- that was a really snippy comment I made. No excuse, but the explanation is coming off long hours working with very sick people and then trying to sort out the Kawasaki info coming in through emails and working groups. I was frustrated, but should not have been unkind or bitchy.
From what I can see of that study, it was a random selection from NYC supermarkets, not a representative sample stratified by age. I think we have even less of a clue about who widespread this virus is in kids, in part because they are (understandably) deprioritized for testing: it looked like there was not much risk of significant sequelae, and they are not essential workers, and they are generally not the ones shopping in the stores or otherwise interacting with other people (with the exception of play dates, I suppose).
I really hope this concern peters out. That would be great! I have never seen "outbreaks" of Kawasaki -- it does not come in significant waves in kids. There was a Yale report back in 2005 that they had isolated a novel coronavirus (HCoV-NH) from eight of eleven children with Kawasaki disease. However, this finding was not replicated at other sites. It looks like it is being replicated this time, in multiple cities and multiple countries.
Part of my concern is that I know it is not an easy diagnosis to catch, and there are often delays. If treatment is delayed, that's a big problem. And we neither are seeing many kids in clinics and EDs right now, nor do we want to, unless it is necessary. Nobody wants to increase anybody's exposure at medical settings.
I don't know. It might not pan out. If it does, this is very likely the tip of an iceberg, and I'm not saying we shouldn't start phasing a reopening, but -- this is really unsettling.
Understood. Thank you for what you do.
I guess my question is why would we suddenly see a big outbreak of Kawasaki when kids have been getting COVID throughout this pandemic (aka since at least November)? It just doesn’t make sense that it would suddenly crop up now.
It's really easy to miss the diagnosis in regular times, much less when you are focused on the pandemic and other patients. Just with the natural history of the disease, it could easily be a few months before you started to figure out what you were missing.
One of the problems is that not all of the criteria may be present at the same time -- so you get a kid with what looks like a non-specific viral exanthum (rash), history of a few days of fever ("atypical" presentation), no "strawberry tongue" that you can see, and you don't do a full palpation of all the major lymph node site, because why would you? And only about 20-25% go on to have coronary aneurysms -- those are usually silent (until they are not) and may not show up for awhile on echos, even if you are looking for them.
And how many kids when they do go in for evaluation are being seen by pediatricians, rather than Family Med docs or ED docs, for whom this would be even lower on the radar, especially dealing with primarily adults in a freaky pandemic.
Anonymous
05/05/2020 15:38
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:The rash that shows up early - does it clear up with Benadryl or would it persist?
It's not a histamine response, and although Benedryl might lessen the redness, I expect it would be unlikely to take it away completely. It's also not known to be particularly itchy.
But the rash isn't uniform. It can be patchy, measles-like, target lesions, or other presentations, and either evanescent (comes and goes) or persistent.
Anonymous
05/05/2020 15:37
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Also, I’m not talking about an antibody response. I’m talking about the antibody testing that was done in NYC to estimate the true number of COVID cases.
I’m doing that to estimate the commonality of Kawasaki among NYC COVID-positive children.
You realize that the testing measures the level of antibody response to the virus, right?
Or what was it you were thinking was being tested?
You’re still not getting it.
I brought up the antibody testing TO ESTIMATE THE ACTUAL NUMBER OF CASES. That’s it. I’m not interested in the antibody response specifically. I was estimating how common Kawasaki is, percentage-wise, in NYC.
[Are you confusing Kawasaki with COVID-19 here? They aren't the same thing.]
You need the actual number of cases to estimate that. Actual number of cases can be derived—roughly—from the results of the antibody testing they did.
Antibody testing is dependent on the antibody response. That is LITERALLY what it measures -- if you cite the test, you are measuring the response. And kids have a different antibody response than adults do -- e.g., this is why the DTap has higher levels of tetanus toxoid than the TDaP, because kids don't respond the same way to the bacteria.
Tests that pick up prior cases in adults might not pick them up in kids, or they might overrepresent them, or they might underrepresent them. You can't extrapolate from the adult response (measured by the antibody test) to make conclusions about what it says about kids. Kids aren't just short adults.
Ok. I’ll try to explain more clearly.
This was my goal: to estimate the percentage of actual pediatric COVID cases that also show Kawasaki.
How do I get there? I use the antibody testing in NYC because that’s the best way to estimate actual COVID cases. That testing was done with a REPRESENTATIVE SAMPLE OF THE POPULATION.
What is a representative sample? It’s a sub-section of the population that mimics the characteristics of the whole population. That includes age.
What does that mean? It means that because the antibody testing suggested the actual number of cases in NYC was about 5 times higher than the confirmed, I can use that to extrapolate the actual case number in any demographic group I want to look at.
So what did I do with that information? I took the confirmed number of pediatric COVID cases—4,088–and multiplied it by 5 to get about 20,000. Then I computed 15/20,000 to estimate the percentage of actual pediatric COVID cases with Kawasaki.
I hope that’s clearer.
I think this methodology falls apart where you assume the proportion of confirmed cases in children to actual cases is the same as adults. Knowing that children tend to have mild or no symptoms and that only very sick people, first responders, and people in group living situations (none of these groups contain many kids), children are probably underrepresented in confirmed tests.
If the people tested are a random sample from grocery stores, they'd probably have very few children, no? Most stores only allow one person in. I don't think I've seen a kid in a grocery store since we shut down in March.
Anonymous
05/05/2020 15:35
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Also, I’m not talking about an antibody response. I’m talking about the antibody testing that was done in NYC to estimate the true number of COVID cases.
I’m doing that to estimate the commonality of Kawasaki among NYC COVID-positive children.
You realize that the testing measures the level of antibody response to the virus, right?
Or what was it you were thinking was being tested?
You’re still not getting it.
I brought up the antibody testing TO ESTIMATE THE ACTUAL NUMBER OF CASES. That’s it. I’m not interested in the antibody response specifically. I was estimating how common Kawasaki is, percentage-wise, in NYC.
[Are you confusing Kawasaki with COVID-19 here? They aren't the same thing.]
You need the actual number of cases to estimate that. Actual number of cases can be derived—roughly—from the results of the antibody testing they did.
Antibody testing is dependent on the antibody response. That is LITERALLY what it measures -- if you cite the test, you are measuring the response. And kids have a different antibody response than adults do -- e.g., this is why the DTap has higher levels of tetanus toxoid than the TDaP, because kids don't respond the same way to the bacteria.
Tests that pick up prior cases in adults might not pick them up in kids, or they might overrepresent them, or they might underrepresent them. You can't extrapolate from the adult response (measured by the antibody test) to make conclusions about what it says about kids. Kids aren't just short adults.
Ok. I’ll try to explain more clearly.
This was my goal: to estimate the percentage of actual pediatric COVID cases that also show Kawasaki.
How do I get there? I use the antibody testing in NYC because that’s the best way to estimate actual COVID cases. That testing was done with a REPRESENTATIVE SAMPLE OF THE POPULATION.
What is a representative sample? It’s a sub-section of the population that mimics the characteristics of the whole population. That includes age.
What does that mean? It means that because the antibody testing suggested the actual number of cases in NYC was about 5 times higher than the confirmed, I can use that to extrapolate the actual case number in any demographic group I want to look at.
So what did I do with that information? I took the confirmed number of pediatric COVID cases—4,088–and multiplied it by 5 to get about 20,000. Then I computed 15/20,000 to estimate the percentage of actual pediatric COVID cases with Kawasaki.
I hope that’s clearer.
I think this methodology falls apart where you assume the proportion of confirmed cases in children to actual cases is the same as adults. Knowing that children tend to have mild or no symptoms and that only very sick people, first responders, and people in group living situations (none of these groups contain many kids), children are probably underrepresented in confirmed tests.
If that’s true, then that makes this Kawasaki thing even rarer.
Anonymous
05/05/2020 15:34
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
The rash that shows up early - does it clear up with Benadryl or would it persist?
Anonymous
05/05/2020 15:33
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Also, I’m not talking about an antibody response. I’m talking about the antibody testing that was done in NYC to estimate the true number of COVID cases.
I’m doing that to estimate the commonality of Kawasaki among NYC COVID-positive children.
You realize that the testing measures the level of antibody response to the virus, right?
Or what was it you were thinking was being tested?
You’re still not getting it.
I brought up the antibody testing TO ESTIMATE THE ACTUAL NUMBER OF CASES. That’s it. I’m not interested in the antibody response specifically. I was estimating how common Kawasaki is, percentage-wise, in NYC.
[Are you confusing Kawasaki with COVID-19 here? They aren't the same thing.]
You need the actual number of cases to estimate that. Actual number of cases can be derived—roughly—from the results of the antibody testing they did.
Antibody testing is dependent on the antibody response. That is LITERALLY what it measures -- if you cite the test, you are measuring the response. And kids have a different antibody response than adults do -- e.g., this is why the DTap has higher levels of tetanus toxoid than the TDaP, because kids don't respond the same way to the bacteria.
Tests that pick up prior cases in adults might not pick them up in kids, or they might overrepresent them, or they might underrepresent them. You can't extrapolate from the adult response (measured by the antibody test) to make conclusions about what it says about kids. Kids aren't just short adults.
Ok. I’ll try to explain more clearly.
This was my goal: to estimate the percentage of actual pediatric COVID cases that also show Kawasaki.
How do I get there? I use the antibody testing in NYC because that’s the best way to estimate actual COVID cases. That testing was done with a REPRESENTATIVE SAMPLE OF THE POPULATION.
What is a representative sample? It’s a sub-section of the population that mimics the characteristics of the whole population. That includes age.
What does that mean? It means that because the antibody testing suggested the actual number of cases in NYC was about 5 times higher than the confirmed, I can use that to extrapolate the actual case number in any demographic group I want to look at.
So what did I do with that information? I took the confirmed number of pediatric COVID cases—4,088–and multiplied it by 5 to get about 20,000. Then I computed 15/20,000 to estimate the percentage of actual pediatric COVID cases with Kawasaki.
I hope that’s clearer.
I think this methodology falls apart where you assume the proportion of confirmed cases in children to actual cases is the same as adults. Knowing that children tend to have mild or no symptoms and that only very sick people, first responders, and people in group living situations (none of these groups contain many kids), children are probably underrepresented in confirmed tests.
Anonymous
05/05/2020 15:32
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:Anonymous wrote:PS: In general, it's a good idea to look at how a study was done before making claims about what it shows.
I did.
My point was that I want to know if I misread something when reading about the study.
I am so sorry -- that was a really snippy comment I made. No excuse, but the explanation is coming off long hours working with very sick people and then trying to sort out the Kawasaki info coming in through emails and working groups. I was frustrated, but should not have been unkind or bitchy.
From what I can see of that study, it was a random selection from NYC supermarkets, not a representative sample stratified by age. I think we have even less of a clue about who widespread this virus is in kids, in part because they are (understandably) deprioritized for testing: it looked like there was not much risk of significant sequelae, and they are not essential workers, and they are generally not the ones shopping in the stores or otherwise interacting with other people (with the exception of play dates, I suppose).
I really hope this concern peters out. That would be great! I have never seen "outbreaks" of Kawasaki -- it does not come in significant waves in kids. There was a Yale report back in 2005 that they had isolated a novel coronavirus (HCoV-NH) from eight of eleven children with Kawasaki disease. However, this finding was not replicated at other sites. It looks like it is being replicated this time, in multiple cities and multiple countries.
Part of my concern is that I know it is not an easy diagnosis to catch, and there are often delays. If treatment is delayed, that's a big problem. And we neither are seeing many kids in clinics and EDs right now, nor do we want to, unless it is necessary. Nobody wants to increase anybody's exposure at medical settings.
I don't know. It might not pan out. If it does, this is very likely the tip of an iceberg, and I'm not saying we shouldn't start phasing a reopening, but -- this is really unsettling.
Understood. Thank you for what you do.
I guess my question is why would we suddenly see a big outbreak of Kawasaki when kids have been getting COVID throughout this pandemic (aka since at least November)? It just doesn’t make sense that it would suddenly crop up now.
Anonymous
05/05/2020 15:29
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
I’m so tired of hysterical media pieces on statistical anomalies. The fact remains: unless you are old/unhealthy, the likelihood of death or serious complications is incredibly slim.
Anonymous
05/05/2020 15:29
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:PS: In general, it's a good idea to look at how a study was done before making claims about what it shows.
I did.
My point was that I want to know if I misread something when reading about the study.
I am so sorry -- that was a really snippy comment I made. No excuse, but the explanation is coming off long hours working with very sick people and then trying to sort out the Kawasaki info coming in through emails and working groups. I was frustrated, but should not have been unkind or bitchy.
From what I can see of that study, it was a random selection from NYC supermarkets, not a representative sample stratified by age. I think we have even less of a clue about who widespread this virus is in kids, in part because they are (understandably) deprioritized for testing: it looked like there was not much risk of significant sequelae, and they are not essential workers, and they are generally not the ones shopping in the stores or otherwise interacting with other people (with the exception of play dates, I suppose).
I really hope this concern peters out. That would be great! I have never seen "outbreaks" of Kawasaki -- it does not come in significant waves in kids. There was a Yale report back in 2005 that they had isolated a novel coronavirus (HCoV-NH) from eight of eleven children with Kawasaki disease. However, this finding was not replicated at other sites. It looks like it is being replicated this time, in multiple cities and multiple countries.
Part of my concern is that I know it is not an easy diagnosis to catch, and there are often delays. If treatment is delayed, that's a big problem. And we neither are seeing many kids in clinics and EDs right now, nor do we want to, unless it is necessary. Nobody wants to increase anybody's exposure at medical settings.
I don't know. It might not pan out. If it does, this is very likely the tip of an iceberg, and I'm not saying we shouldn't start phasing a reopening, but -- this is really unsettling.
Anonymous
05/05/2020 15:28
Subject: Re:There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:15 children. 15. Cautious yes, but this number is not significant at all.
This.
Anonymous
05/05/2020 15:23
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:New syndrome in kids may be linked to covid:
https://www.nytimes.com/2020/05/05/nyregion/coronavirus-new-york-update.html?type=styln-live-updates&label=new%20york%20&index=2&action=click&module=Spotlight&pgtype=Homepage#link-1aca38d0
"Fifteen children, many of whom had the coronavirus, have recently been hospitalized in New York City with a mysterious syndrome that doctors do not yet fully understand but that has also been reported in several European countries, health officials announced on Monday night.
Many of the children, ages 2 to 15, have shown symptoms associated with toxic shock or Kawasaki disease, a rare illness in children that involves inflammation of the blood vessels, including coronary arteries, the city’s health department said..."
Too much disinfecting in the house. It all gets into the blood from touching the surfaces that should be RINSED after bleaching or lysoling, and also from the sprays. .. maybe.
Anonymous
05/05/2020 15:19
Subject: Re:There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:Anonymous wrote:you all fail basic math again
something that has a prevalence of less than 0001% please driving is more dangerous
I swear yall are ridiculous
If there is bad potato salad served at a picnic, and if the bacteria responsible is known to take 2-8 hours to cause symptoms, do you conclusively say at hour 3 that only one kid has vomited, so there is nothing at all to worry about? Or do you say that anyone who ate the potato salad MIGHT be showing up with symptoms in the next 5 hours, and geez, maybe it's more than just the first one who's going to be sick?
How do you wake up in the morning and even cook breakfast without thinking the stove will explode or that you’ll set your house on fire? You sound insane.
No, just educated in medicine and interpreting scientific data.
That's not fear. It's not emotions, just education.
Educated in medicine? What does that mean, exactly?
Doctorate in medicine and the subsequent clinical training.
Anonymous
05/05/2020 14:46
Subject: There is so much we don't know about the virus - and here's another reason to be cautious
Anonymous wrote:PS: In general, it's a good idea to look at how a study was done before making claims about what it shows.
I did.
My point was that I want to know if I misread something when reading about the study.