Tag Archives: New England Journal Of Medicine

Covid-19 Vaccines: ‘Frequently Asked Questions Answered’

How does each of the available Covid-19 vaccines work?

Once the vaccine is injected, the mRNA is taken up by the macrophages near the injection site and instructs those cells to make the spike protein. The spike protein then appears on the surface of the macrophages, inducing an immune response that mimics the way we fight off infections and protects us from natural infection with SARS-CoV-2. Enzymes in the body then degrade and dispose of the mRNA. No live virus is involved, and no genetic material enters the nucleus of the cells.

Although these are the first mRNA vaccines to be broadly tested and used in clinical practice, scientists have been working on mRNA vaccines for years. And despite this wonderful parody piece. opens in new tab saying that the technology is “obvious,” in fact the breakthrough insight that put the mRNA inside a lipid coating to prevent it from degrading is quite brilliant — and yes, this may be the first time the New England Journal of Medicine has referenced a piece in The Onion. (Last reviewed/updated on 11 Jan 2021)

How should early side effects be managed?

Analgesics and antipyretics such as acetaminophen or ibuprofen are effective in managing post-vaccine side effects including injection-site pain, myalgias, and fever. However, the CDC does not recommend prevaccine administration of these drugs, as they could theoretically blunt vaccine-induced antibody responses.

Because of the small risk of anaphylaxis, sites that administer the vaccines must have on hand strategies to evaluate and treat these potentially life-threatening reactions. The CDC has issued recommendations on how sites should prepare. opens in new tab. (Last reviewed/updated on 11 Jan 2021)

How long will the vaccines work? Are booster doses required?

Since the vaccines have been tested only since the summer of 2020, we do not have information about the durability of protection. Data from the phase 1 trial of the Moderna vaccine suggested that neutralizing antibodies persisted for nearly 4 months. opens in new tab, with titers declining slightly over time. Given the absence of information on how long the vaccines will be protective, there is currently no specific recommendation for booster doses. (Last reviewed/updated on 11 Jan 2021)

Do the vaccines prevent transmission of the virus to others?

Many commentaries on the results of the vaccine clinical trials cite a lack of information on asymptomatic infection as a limitation in our knowledge about the vaccines’ effectiveness. Indeed, this is a theoretical concern, since up to 40% of people who get infected with SARS-CoV-2 have no symptoms but may still transmit the virus to others.

Nonetheless, there are several good reasons to be optimistic about the vaccines’ effect on disease transmission. First, in the Moderna trial. opens in new tab, participants underwent nasopharyngeal swab PCR testing at baseline and testing at week 4, when they returned for their second dose. Among those who were negative at baseline and without symptoms, 39 (0.3%) in the placebo group and 15 (0.1%) in the mRNA-1273 group had nasopharyngeal swabs that were positive for SARS-CoV-2 by RT-PCR. These data suggest that even after one dose, the vaccine has a protective effect in preventing asymptomatic infection.

Second, findings from population-based studies now suggest that people without symptoms are less likely to transmit the virus to others. Third, it would be highly unlikely in biological terms for a vaccine to prevent disease and not also prevent infection. If there is an example of a vaccine in widespread clinical use that has this selective effect — prevents disease but not infection — I can’t think of one!

Until we know more, however, we should continue to emphasize to our patients that vaccination does not allow us to stop other important measures to prevent the spread of Covid-19. We need to continue social distancing, masking, avoiding crowded indoor settings, and regular hand washing. (Last reviewed/updated on 11 Jan 2021)

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Covid-19 Podcast: New Studies On Transmission

In this audio interview conducted on November 25, 2020, the editors look at new studies of disease transmission in closed environments and provide updates on convalescent plasma and hydroxychloroquine.

Aging Adults: ‘Learning About “End-Of-Life Care” From Grandpa’ (NEJM)

I described another option to Grandpa: he could voluntarily stop eating and drinking. He’d never considered this possibility (which reminded me again how one’s family members and clinicians contribute to inequities in end-of-life care). The option intrigued Grandpa, and during subsequent visits he reinforced his plan to pursue it. I insisted that he first move into my home. I wanted to ensure the quality of his care, knowing that I could enroll him in my health system’s hospice program. But I also wished to test his resolve, reasoning that his mind might change once his isolation ended.

For a month after he entered our home, his spirits were brighter, his gait steadier, and his appetite heartier. He joined my wife, two daughters, and me for dinner each night, typically preceded by a vodka martini that I had stirred for him — a daily pleasure he’d allowed himself for 80 years and had missed as a facility resident. He’d tell stories of the Navy, his career, and his family history and would regularly quip, “If you keep treating me this well, I might just stick around a while longer!”

But eventually he returned to his goal of hastening death. One night, he said he was ready to stop eating and drinking the next morning, but when morning came, he asked for his usual coffee and bagel. He confided that he was scared. When I asked of what, he replied, “It’s like trying to roller skate. I’m scared of starting. Though I know that once I do, I’ll probably roll.”

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Winery Profile Podcast: The Urban Wine Company, London, ‘CHATEAU TOOTING’

Monocle’s Georgina Godwin heads to southwest London to visit The Urban Wine Company, that harvests its bounty from vines across the city.

The Urban Wine Company™ was born out of an idea a few years back. Neighbours Richard and Paul were relaxing underneath a vine enjoying a glass of wine that had been flown half-way across the world. Realising they were sat in an urban garden of Eden surrounded by grape vines, they asked the impossible…
“Would it be possible to make a wine made from London grapes?”

So, in September 2009 they set about harvesting grapes grown in gardens, allotments, behind supermarkets and even at the side of railways. They teamed up with winemaking experts to produce the very first batch of ‘Chateau Tooting’. Pleasantly surprised, if not a little amazed by its ‘Drinkability’ The Urban Wine Company™ was formed. Not only had a fantastic tasting wine been created using grapes grown in a city centre, something unique had also been born.

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Health: “Compression Therapy” Reduces Chronic Cellulitis & Leg Edema

New England Journal of Medicine (Aug 13, 2020) – In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment.

The researchers have conducted a single-center, randomized, nonblinded trial that aimed to find out an association between the compression therapy and controlled incidents of chronic edema of the leg and people with cellulitis that can be defined as an infection of the skin that involves subcutaneous tissues or the innermost layer of the skin. Cellulitis can be caused by trauma or scratching of other lesions due to animal or human bites that result in fever, extreme pain, and redness of the skin.

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Health: Lung Cancer Deaths Drop As Targeted Therapies Improve (NEJM)

NEJM (Aug 13, 2020)Population-level mortality from NSCLC in the United States fell sharply from 2013 to 2016, and survival after diagnosis improved substantially. Our analysis suggests that a reduction in incidence along with treatment advances — particularly approvals for and use of targeted therapies — is likely to explain the reduction in mortality observed during this period.

“The survival benefit for patients with non-small cell lung cancer treated with targeted therapies has been demonstrated in clinical trials, but this study highlights the impact of these treatments at the population level,” said Nadia Howlader, Ph.D., of NCI’s Division of Cancer Control and Population Sciences, who led the study. “We can now see the impact of advances in lung cancer treatment on survival.”

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Health: New Studies Find “Coffee & Caffeine” Lower Heart Disease, Cancer Risk

NEW ENGLAND JOURNAL OF MEDICINE (JULY 23, 2020): A large body of evidence suggests that consumption of caffeinated coffee, the main source of caffeine intake in adults in the United States, does not increase the risk of cardiovascular diseases and cancers. In fact, consumption of 3 to 5 standard cups of coffee daily has been consistently associated with a reduced risk of several chronic diseases. 

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The New England Journal of Medicine LogoCoffee and tea have been consumed for hundreds of years and have become an important part of cultural traditions and social life.5 In addition, people use coffee beverages to increase wakefulness and work productivity. The caffeine content of commonly used sources of caffeine is shown in Table 1. For a typical serving, the caffeine content is highest in coffee, energy drinks, and caffeine tablets; intermediate in tea; and lowest in soft drinks. In the United States, 85% of adults consume caffeine daily,6 and average caffeine intake is 135 mg per day, which is equivalent to about 1.5 standard cups of coffee (with a standard cup defined as 8 fluid oz [235 ml]).7 Coffee is the predominant source of caffeine ingested by adults, whereas soft drinks and tea are more important sources of caffeine ingested by adolescents,

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Podcasts Interviews: The Diagnosis And Early Treatment Of Covid-19

In this audio interview conducted on June 3, 2020, the editors discuss two new studies: one comparing test swabs collected by health care workers with swabs collected by the patients themselves and one assessing hydroxychloroquine treatment in people who had been exposed to Covid-19 but weren’t yet ill.

The continuing spread of SARS-CoV-2 remains a Public Health Emergency of International Concern. What physicians need to know about transmission, diagnosis, and treatment of Covid-19 is the subject of ongoing updates from infectious disease experts at the Journal.

Eric Rubin is the Editor-in-Chief of the Journal. Lindsey Baden is a Deputy Editor of the Journal. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal.

Podcasts: “Developing Covid-19 Vaccines At Pandemic Speed” (NEJM)

NEJM InterviewsInterview with Dr. Nicole Lurie on rapid vaccine development, including new tools to facilitate vaccine testing and manufacturing and persistent challenges.

The need to rapidly develop a vaccine against SARS-CoV-2 comes at a time of explosion in basic scientific understanding, including in areas such as genomics and structural biology, that is supporting a new era in vaccine development. Over the past decade, the scientific community and the vaccine industry have been asked to respond urgently to epidemics of H1N1 influenza, Ebola, Zika, and now SARS-CoV-2. An H1N1 influenza vaccine was developed relatively rapidly, largely because influenza-vaccine technology was well developed and key regulators had previously decided that vaccines made using egg- and cell-based platforms could be licensed under the rules used for a strain change. Although a monovalent H1N1 vaccine was not available before the pandemic peaked in the Northern Hemisphere, it was available soon afterward as a stand-alone vaccine and was ultimately incorporated into commercially available seasonal influenza vaccines.

Nicole Lurie is a strategic advisor to the CEO of the Coalition for Epidemic Preparedness Innovations. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal.

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