Kids' COVID vaccines explained; a look at X-rays, MRIs, CTs and other medical imaging: Upstate Medical University's HealthLink on Air for Sunday, Nov. 14, 2021

[00:00:00] Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pediatrician with expertise in vaccines and infectious disease answers what parents want to know about the COVID-19 vaccine for kids from five to 11 years old...

[00:00:15] Joseph Domachowske, MD: "The way this vaccine works, especially in kids is that we can finally let those kids unmask and spend time with their grandparents, as long as everyone in that group has been fully immunized."

[00:00:26] Host Amber Smith: ...and a radiologist talks about medical imaging that's available today and what's coming in the near future...

[00:00:32] Michele Lisi, MD: "We have a lot of dose reducing techniques now that are built into our machines so that the images are inherently safer than they used to be."

[00:00:42] Host Amber Smith: All that, and a visit from The Healing Muse coming up after the news.

[00:01:07] Host Amber Smith: This is Upstate Medical University's "HealthLink on Air," your chance to explore health science and medicine with the experts from Central New York's only academic medical center. I'm your host Amber Smith. On this week's show, a radiologist explains medical imaging. But first, a pediatrician and scientist provides straight talk about the COVID-19 vaccine for children.

[00:01:42] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is HealthLink on Air. Now that children ages five to 11 are eligible for COVID-19 vaccination. I'm talking with a pediatric infectious disease expert, Dr. Joe Domachowske, MD. He's a professor of pediatrics and of microbiology and immunology at Upstate.

[00:02:01] Host Amber Smith: And he's also the principal investigator of the Pfizer COVID-19 vaccine trial underway at Upstate that was one of the first sites in the world to enroll children under five years of age. Welcome back to HealthLink on Air, Dr. Domachowske. '

[00:02:15] Joseph Domachowske, MD: Thanks, Amber. Thanks very much.

[00:02:17] Host Amber Smith: Now parents have a lot of questions, so let's make it clear that we're talking about the vaccine that would, that was authorized for use in children five to 11. So was the lower age set at five just to coincide with the age kids start school or is there a big difference in the bodies of three and four year olds versus five year-olds?

[00:02:37] Joseph Domachowske, MD: Well, the emergency use authorization in vaccine that was approved as the Pfizer formulation and the clinical trials have a cutoff, a younger age cutoff of five years. That will change when we start hearing about the data coming from the clinical trials for Moderna where the young age cutoff was at six. Both trials continue to enroll kids under the age of five and six, but we don't have those data yet for EUA (emergency use authorization.)

[00:03:05] Host Amber Smith: So it's just being done differently by different vaccine makers?

[00:03:09] Joseph Domachowske, MD: It's a fairly arbitrary cutoff, but it's also based on some prior experience with age groups that do need different dosing regimens when compared to adults.

[00:03:19] Host Amber Smith: All right. So the one right now, Pfizer, that's available now, is this the same vaccine that adults have already had access to? Or is there a difference?

[00:03:30] Joseph Domachowske, MD: The vaccine that is emergency use authorized for five to 11 is exactly the same as the one that's emergency use authorized for 12 to 16 and approved now, fully approved, for use at 16 and over. But the, the subtle difference is the dosing -- the amount of antigen or immunizing agent in the vaccine -- is one third the concentration.

[00:03:57] Joseph Domachowske, MD: So the adult dose is 30 micrograms delivered as a single dose. And then a second dose is given three weeks later. For the five to 11 year olds, the first dose is 10 micrograms, one-third the adult dose. A second dose of 10 micrograms is then given three weeks later.

[00:04:13] Host Amber Smith: And it doesn't matter how large or the weight of the child, any, any child from five to 11 gets the same 10 micrograms is that right?

[00:04:22] Joseph Domachowske, MD: That's exactly right. The way the clinical vaccine trial was developed was the age cutoffs, not by weight. And if we look at other examples for pediatric vaccines, we do similar strategies for vaccines that we use all the time, where we use age cutoff breaks for changing the dosing formulation for other vaccines as well. So it's, it's something that pediatricians are certainly accustomed to.

[00:04:47] Host Amber Smith: Now do you expect a Moderna and a Johnson and Johnson vaccine to be authorized for those under age 18 anytime soon?

[00:04:55] Joseph Domachowske, MD: The emergency use authorization discussion for the Moderna formulation is on a temporary hold, while more safety information is being collected. That Moderna strategy clinical trial is just slightly behind the Pfizer formulation. But I do think that ultimately we will have a pediatric formulations for both Pfizer and Moderna starting at six months of age. For Johnson and Johnson, they have started some very early phase pediatric trials, but I'm not sure they will continue on. I think they need to see how well the market share is and how much uptake there is based on the mRNA vaccines that are, uh, several months, if not a year ahead of the efforts at J and J.

[00:05:39] Host Amber Smith: Now you used the word safety. And I think that's the main thing for parents. How do we know that these vaccines are safe for our children?

[00:05:48] Joseph Domachowske, MD: Well we have so far safety data on approximately 4,000, uh, five to 11 year olds that have been immunized in the clinical vaccine trials. And tens of thousands of those individuals are 12 and older who have received the adult formulation of the vaccine, and the side effect profile that we're seeing in the five to 11 year olds is very similar to what we see with vaccines that we use every day that we've used for decades in these kids. So some injection site reactions. Some low grade fevers that are self-limiting. They last maybe for a day or two. Um, most of the people that have gotten the Pfizer or Moderna vaccines as adults have experienced similar side effects. And I can tell you that the rates of those side effects using this lower dose for the five to 11 year olds is a smaller percentage of the total vaccinated.

[00:06:38] Joseph Domachowske, MD: So I think one of the benefits of going to the lower dose for the kids is that we're seeing a much better tolerated reaction profile. And we already know that there's no trade off in the form of how well we can induce the antibody responses in those kids. So there's no, trade-off, the antibody responses are just as good, even though the dose is one third.

[00:07:00] Host Amber Smith: And you mentioned a lot of the temporary sort of side effects. Are there any serious side effects that were noticed or that parents should be on the lookout for?

[00:07:09] Joseph Domachowske, MD: The only serious side effect that has been noted so far with either of the mRNA vaccines, the Pfizer formulation or the Moderna formulation is this very rare side effect of myocarditis within a week or so of receiving usually the second dose.

[00:07:27] Joseph Domachowske, MD: And that was noticed first in young adults, mostly young adult men. The first findings came out of Israel, where they launched a vaccine program for 7 million of their population. And what they were seeing in Israel was an uptick in the reported cases of myocarditis. So this led to some very active surveillance for myocarditis in the adult trial in the United States for the Pfizer and Moderna vaccines. And now of course there's much interest in looking to see if this side effect ever occurs in young children. So far from the clinical trials. I can tell you that in the five to 11 group, there has not been any cases of myocarditis in the vaccine trials. Of course we've been only vaccinating starting today in the five to 11 group. So we may see some very, very rare reports of myocarditis in that age group going forward in each case, those individuals that develop myocarditis from the vaccine, it's typically a very brief, mild condition. Sometimes hospitalization is necessary for some treatment, but the hospitalizations are also brief, and there have been no deaths associated with vaccine-induced myocarditis. But I can tell you the rates of myocarditis from active COVID infection are at least 10 times the rates that we see from the vaccine, and death is a known complication when it occurs from the, the wild-type infection.

[00:08:51] Host Amber Smith: Well, good to know. I want to ask you about the urgency in vaccinating children. Is it true that children are at low risk for getting seriously ill from COVID?

[00:09:01] Joseph Domachowske, MD: As a general population, if we compare the 28 million children that are age five to 11 in the United States as a group, they are at low risk for serious consequences of COVID-19 infection. When we compare them to older adults, especially older adults with risk factors that we know. But I can tell you that we've seen dozens of kids hospitalized with COVID, especially the young teenagers or adolescents who have underlying risk factors, such as asthma or being overweight. And while those kids generally do better than the adults do, and mortality is low, they end up in the hospital often for a week or longer. There have been about 100 reported cases of COVID deaths in children in the U S so far since the pandemic started, and compared to the death numbers in adults, that's an impressively low number, but a single death in a child is unacceptable, especially when we have a vaccine to prevent this infection.

[00:10:05] Joseph Domachowske, MD: The other issue related to children that doesn't appear to occur in adults is that following COVID infection, even those infections that are very mild, or we don't even know about, a week or two later, a very small subset of those kids will end up with a post-infectious inflammatory condition that we refer to as MIS-C or multi-system inflammatory condition of childhood. This is a life-threatening inflammatory condition. We get those kids in the hospital right away, and we are challenged to quiet down their inflammation. This is a very difficult condition to treat. And I do know of one MIS-C related death that we had locally. So this, this is not something that should be trivialized.

[00:10:49] Joseph Domachowske, MD: We really need to pay attention that while children are much less likely to suffer the severe consequences of COVID compared with adults, the morbidity, and even the mortality is significant enough to warrant widespread vaccination of every single person who's eligible.

[00:11:05] Host Amber Smith: Well, I've also heard that COVID-19 has become one of the top 10 causes of deaths among children, even though it's rare, that it's one of the top 10 causes among children ages five to 11. Could widespread vaccination of this population change that? Would it make an impact?

[00:11:24] Joseph Domachowske, MD: Absolutely. We know that prior to use of influenza vaccines, for example, that influenza related mortality was in the several hundred to five or 600-range in a particularly bad flu season in children. And now, from year to year, if we see more than 80 or 90 deaths in children from influenza, it's an unusually severe year. So already we've identified COVID with these 100 cases as being more likely to cause death than something that we're much more familiar with that thankfully is also vaccine preventable.

[00:12:01] Host Amber Smith: Now, what do you say to parents who are concerned about how quickly the vaccine seemed to have been developed?

[00:12:08] Joseph Domachowske, MD: It didn't seem very quick to me. I've been doing the clinical trials. But yes, I do see their point. From the outside looking in, it appears that this got rushed, but remember that the adult trials started about a year before the pediatric trials were even designed to allow for early phase one enrollment.

[00:12:28] Joseph Domachowske, MD: So there was substantial amount of safety data in 16 years and older that we relied on as we started immunizing and younger and younger populations in the clinical trial efforts. The efforts that we started here for the phase two-three, which are the advanced efficacy type placebo controlled trials, they started in June and it's October. So that seems really fast compared to any other vaccine study that we do. The two differences here are that when a new vaccine is being investigated, typically it has to go through the full phase one series of trials. Then there's a stop. The FDA looks at the phase one data and then makes a decision about allowing to go to phase two or to phase two-three. That stop can be a year long, and it can really slow the progress down.

[00:13:24] Joseph Domachowske, MD: The difference here was that phase one, two and three were all put together as part of the same protocol and very carefully evaluating safety on a day to day basis as new information came in. And we were prepared to stop enrollment in the trial at a moment's notice, if there was a single event that was considered vaccine associated, that was severe, if there was a single death related to the vaccine that was going to shut everything down right away. And then there were softer criteria for the seriousness of the side effects that were being seen. And in fact, as we were dose selecting for each age group in the younger ages, we saw a little bit too much fever in the five to 11 year olds that got close to the adult dose.

[00:14:08] Joseph Domachowske, MD: So 20 micrograms or even 30 micrograms, they had a little too much side effect reactions. Not that it was severe, but it was so common that we thought it doesn't make sense to provide a vaccine for a population like children, where we're going to see fever and almost every single one of them. So how can we figure out what the dose needed is that can achieve the same result with the same antibody responses and the same efficacy that we already know for adults? And that's how the 10 micrograms was decided. And I can already tell you that the dose for the six month up to the five-year-olds is three micrograms. So that's going to be one 10th of the adult dose. That's how impressive thethe profiles are. When we look at them one by one-- much better safety as we get younger and younger with lower and lower doses, but without any trade-off, as far as the antibodies that are being produced in response to the vaccine.

[00:15:06] Host Amber Smith: That's good to know. Upstate's HealthLink on Air has to take a short break, but we'll be back shortly with more information about the COVID-19 vaccine for kids from pediatric infectious disease specialist, Dr. Joe Domachowske.

[00:15:35] Host Amber Smith: You're listening to Upstate's HealthLink on Air. I'm your host, Amber Smith talking with Dr. Joseph Domachowske. He's a professor of pediatrics and of microbiology and immunology at Upstate. And he's giving us some straight talk about how the COVID-19 vaccine works for kids ages five to 11. Let me ask you about the vaccine trials and whether they revealed any concerns about the vaccine affecting a child's development through puberty or a child's future fertility.

[00:16:03] Joseph Domachowske, MD: Yeah, that's a great point. Because very early on, there were basic research scientists looking at animal models and proteins that are expressed on the surface of placental cells that seemed to very weakly cross-react with the antibodies that we make when we have COVID infection, or when we use a COVID vaccine. So there was this basic science hypothesis that we could interfere with placental development. If we have antibodies that are directed against those placental proteins. Well, it turns out that -- It was important to study it -- but it turns out that those antibodies are so weakly attracted to those particular cross-reacting proteins in the placenta that they don't really bind much at all, so it ends up being a non concern. Unfortunately got translated and in some of the literature and some of the social media as a indicative that we may have some problems with puberty or fertility and those types of things. If you go back to the source where the idea came from, it's easy to prove that wrong already.

[00:17:13] Host Amber Smith: Okay. Now are the vaccines appropriate for children with compromised immune systems or children that have chronic health conditions?

[00:17:22] Joseph Domachowske, MD: Yes. So of course we want to protect those who are most at risk most carefully. So are the vaccines that we have, or the one for the Pfizer formulation for the five to 11 year olds that now has authorization for use, is it appropriate for those immune compromised patients who are medically complex patients? Well, in the clinical trials, those particular groups of children were excluded particularly because we know that in general, they respond less well to all vaccines. And we wanted a real world look at how well these vaccines did at producing antibodies in the general population. So the corollary is that we expect these vaccines to work reasonably well in those medically complex patients, but they may not do what we expect them to do in otherwise healthy kids. And that is a trade-off that we always take in children and in adults. And it's one of the reasons why now, if you're following the recommendations for boosters, that booster vaccines for adults that are transplant recipients -- talk about immune compromised, right? That population, really has a very compromised ability to respond to things that are trying to come and infect them or to vaccines. And in that situation, it's clear that for adults with transplants, we need to re vaccinate them with multiple boosters. Currently the total regimen is four doses, but it won't surprise me if that goes up.

[00:18:56] Joseph Domachowske, MD: So when we talk about children who are compromised, as far as their immune system goes, or they're medically complex, maybe they have a trach, or they need a ventilator at night in order to maintain their breathing. Those are among the highest risk for morbidity or death from COVID infection. So they should be first in line for vaccination and we should be doing everything that we can to protect them-- social distancing, masking, making sure that people around them are vaccinated, especially if they have healthier immune systems, we don't want to bring the virus to those kids. And of course, vaccinating the kids in the hope that their immune systems are healthy enough to at least give them some level of protection.

[00:19:39] Host Amber Smith: So what you just said pretty much applies to adults too, that have health conditions that they still have to take care, whether they're vaccinated or not, they still have to use common sense and the social distancing and the masking just to protect themselves still.

[00:19:56] Joseph Domachowske, MD: Absolutely. Now, there are a subset of vaccines that we call live vaccines. Most of them are live viral vaccines, meaning they're weakened viruses that are very similar to the virus that causes the infection. Like, measles is a good example. Chickenpox is another good example. Those vaccines, even though they're weakened vaccines, because they're still alive, they are not appropriate to give to our very immune compromised patients because they may not even be able to fight off that very weakened vaccine strain. But for the COVID vaccines, none of them have been developed as live vaccines. So we don't have to consider the live vaccine issue as far as a contra-indication to receiving vaccines for those who have immune compromised conditions. In fact, those are the patients that should be at the top of the list and prioritize to get the vaccines themselves.

[00:20:48] Host Amber Smith: Are there any children who should not get the vaccine?

[00:20:52] Joseph Domachowske, MD: The only absolute contraindication to receiving the UA, a vaccine, the Pfizer formulation. Is a known allergy to a vaccine component. And thankfully these mRNA vaccines are the simplest biochemically, the simplest vaccines that we use across the board. They have RNA in them and they have some cholesterol like a fatty lipid particles to protect the mRNA from being degraded before we inject it as a vaccine into an individual. That's it. The rest is just some salts and buffers that all of us are exposed to every day when we have a Gatorade or drink drinking water. So they're very unlikely for individuals to be allergic to one of those lipid components. But there are a very, very small number of individuals who have received those types of lipids in another medication or even who receive a single dose who have an acute, severe allergic reaction to it, who should never receive another dose of that particular formulation. Since the formulation of the J and J vaccine is quite different. It is often an alternative if we do have someone who can't receive one of the RNA vaccines. For now, that's limited to adults, but hopefully one day it will be extended to children as well.

[00:22:13] Host Amber Smith: Now, what about a child who was sick with COVID or who tested positive before? Do they still need to be vaccinated?

[00:22:21] Joseph Domachowske, MD: Absolutely. Yes. And the data for this are becoming more and more clear that immunity from natural infection is nowhere as good as the immunity that's achieved following two doses of mRNA vaccines, for children or for adults. And ironically, the people that are best protected, who are immunized, are those who were infected with COVID before they started their vaccine series. So that's an even added incentive in my mind to say, 'wow, you can really be even better protected for a longer period of time if you already had COVID and now you're going to get your, two dose mRNA vaccine series, Pfizer, or, Moderna. THose individuals now clearly show that their longevity or their durability of protection is going to be for many months longer than those of us weren't infected before we started the vaccine series. It's great information and it's really carefully described.

[00:23:16] Host Amber Smith: So how soon after a child is vaccinated, are they protected? And they need the two dose series. So that's, they're three weeks apart right ?

[00:23:24] Joseph Domachowske, MD: Correct. So if they get their first dose today, they would get their second dose right before Thanksgiving, three weeks from now. And then two weeks after that two dose series they're considered protected. They're considered fully vaccinated.

[00:23:41] Joseph Domachowske, MD: Whether or not boosters will be recommended based on the clinical trial data that we're continuing to gather is still an unanswered question, but we will have an answer for the community once we get to that point, because the clinical vaccine trials are several months ahead of the emergency use authorization community availability for the five to 11 year-olds.

[00:24:06] Host Amber Smith: Can children get the COVID-19 vaccine at the same time they get other childhood vaccines?

[00:24:12] Joseph Domachowske, MD: Yeah. So the Advisory Committee on Immunization Practices, this is the advisory committee to the centers for disease control. This is the group that met on November 2nd of this year to basically recommend that COVID vaccine be used in children five to 11 now that it was emergency-use authorized by the FDA. So the ACIP has stated that other recommended vaccines can be given, can be given safely at the same time the COVID vaccine is administered. This is based on limited amount of data because we didn't do that during the clinical vaccine trials, intentionally, but some of those kids did get vaccines sort of on the side, even though they weren't supposed to in the vaccine trial.

[00:25:02] Joseph Domachowske, MD: So based on what we know about, vaccinology in general, there's very few instances where all of the vaccines that an individual is due for, cannot be given at that same visit. So the ACIP is using that historical information to provide this guidance, completely understanding that doing so offers a level of logistical convenience, and also will improve both our immunization rates for COVID and for influenza, because spacing them out or doing them at different times means that we start losing some of those kids to having one or the other full series of vaccination. So the current recommendation is yes, COVID vaccine can be given along with influenza vaccine at the same time in a different injection spot, and other vaccines that are also necessary could also be considered at the same time. The downside of doing so is that if there are moderate or severe side effects, it's unclear which of the vaccines that were given has caused the side effect. So in children who have a history of maybe having excessive swelling or injection site reactions and response to other vaccines, it might be better to space these out and give the COVID vaccine separately and independently so that a vaccine specific side effects can be determined for the future.

[00:26:26] Host Amber Smith: Now I know we talked about the dosage of the vaccine being about a third or 10 micrograms for kids from age five to 11, compared with the adults that get the 30. And we talked about size, but let me ask you this. If a person has a large 11 year old, who's turning 12 next month, should they just wait a month to get the full dose? Or should they vaccinate now?

[00:26:54] Joseph Domachowske, MD: My recommendation in that situation is to go forward with the 10 microgram dose, times two, three weeks apart. And the reason I say that is that we know the side effect profile in the 12 to 16 year olds from the adult dose, the 30 microgram dose that's emergency use authorized for 12 to 16, is more reactogenic than the 10 microgram dose is for the five to 11 year olds, meaning it causes more side effects, injection site reactions, more fever. A higher percentage of those kids will, will end up with those things. The FDA asks both Pfizer and Moderna to do an extension of the safety study for the clinical trials that we're involved with now, looking specifically at a lower dose for 12 to 30 years old. So we're not just stopping in the teenage age group. These clinical trials are going from 12 up to 30, where a 10 microgram dose is now being evaluated for exactly the same reason. Can we bring that dose down to 10 micrograms without trading off how well it works and thereby reduce the, the tolerability profile, reduce the percentage of those individuals having moderate side effects? And I'm going to predict that we start soon using a 10 microgram dose as a two dose series for many individuals, at least through the teenage years. We have to wait for the formal clinical trial results, but it won't surprise me at all. And that's why I would recommend that an 11 year old, soon turning 12, even if they're not a large 11 year old, go ahead and get vaccinated under the current EUA 10 microgram dose regimen.

[00:28:35] Host Amber Smith: All right. Well, let's talk a little bit more about what the vaccine provides to children. If a child is vaccinated, can they still be infected with COVID-19?

[00:28:43] Joseph Domachowske, MD: Yes. There, there's no doubt that none of the vaccines that we use for anything are 100% effective. There's differences in immune responses for many, many different reasons, but there's always going to be a small percentage of individuals that just aren't fully protected. Now, the vaccinology tells us, the science tells us, and experience tells us that those who are vaccinated, if they do get a breakthrough infection, will have a much milder, and be less likely to be hospitalized for example, or have a severe complication from the infection.

[00:29:16] Host Amber Smith: Well, for children who get vaccinated, for most children who get vaccinated, if they are exposed to COVID-19, does the fact that they're vaccinated, is that going to prevent them from spreading the virus to other people?

[00:29:30] Joseph Domachowske, MD: Well, the clinical trial data that we have so far, so the purest data, for the clinical trial participants, one third of them got placebo, meaning they didn't get active vaccine at all. Two-thirds of them got vaccine at three months after their second dose in the clinical trial, there were 16 total cases of COVID infection documented in the placebo group, which is, again, one third of the total enrolled and in the vaccinated group there were only three. So 91%, almost 91% efficacy at preventing infection altogether. And if you don't get infected, you're not going to spread it to someone else. Will those few that do have breakthrough infections have enough virus replication and have respiratory hygiene that's sloppy enough, if you will, that they can be transmitting that infection? Sure. But it's much less likely than a child who's never been vaccinated who's replicating very, very high amounts of virus and, you know, coughing or sneezing. Those individuals are going to easily transmit, especially the Delta variant.

[00:30:42] Host Amber Smith: Do we know how well this vaccine is going to protect against future variants?

[00:30:48] Joseph Domachowske, MD: We don't, because we don't know what variants are going to emerge. This virus is kind of tricky. We have to try to keep up with it and watch it very carefully. The virologic testing that's being done is molecular, and it's being followed and tracked to try to predict what variants might emerge, especially variants that could evade the protection provided by the current vaccine strategies. Luckily the mRNA vaccine production process is simple enough compared to every other vaccine that's being made for other reasons, that changing the mRNA in that vaccine is fairly straightforward and simple so that we can use a change or a mutation in our vaccine to change the way our antibodies are made so that it's directed specifically against a mutant that we can't currently provide protection for. So it won't be done over the course of two or three years, like we would expect for a different type of vaccine strategy, but we're talking about within a couple of months, we could have a new formulation or an added mRNA a subgroup of subspecies in the vaccine to provide that extra protection on top of the current antibodies that we're already making from the widespread Delta variant.

[00:32:11] Host Amber Smith: That's good to know. Now, kids who get vaccinated, once they're fully vaccinated, can they safely interact with grandparents? Can they go out and sort of start living life again?

[00:32:23] Joseph Domachowske, MD: Now we have to look at both sides. So we need to make sure that those grandparents are also vaccinated. And if those family members are now vaccinated, I say, let those families come together. as long as nobody is feeling ill. You know, if anybody's feeling sick, it's not a good idea to be hanging around with, folks who are older, especially the more frail elderly who have comorbidities, other medical conditions underlying. And that's just good, common sense even before the pandemic. Right. I would say that the, the way this vaccine works, especially in kids, that we can finally let those kids unmask and spend time with the grandparents, as long as everyone in that group has been, fully immunized.

[00:33:04] Host Amber Smith: Well, before we wrap up, can you tell us where things stand with the vaccine for children under the age of five? I know you're involved in trials for that, but can you predict how soon things might wrap up?

[00:33:15] Joseph Domachowske, MD: Yes, it's very exciting. So, we have been involved in recruiting and enrolling children in the clinical vaccine trial down to age 6 months. The total trial enrollment has been completed, but we're now waiting for the rest of the antibody response data from the blood testing that's done in those immunized to be finished and analyzed, and once that's done, Pfizer will certainly be pulling together an emergency use authorization packet for submission to the FDA. It's likely that will first happen for the two to five-year-old group, just because that group is really a good four to six weeks ahead of the six month to two year old group in the clinical trials. And then to follow in a wave, sort of, is the the data for the younger kids. And as we gain more information about the safety profile and the immunogenicity profile of that three microgram dose, right? This is one 10th of the adult dose we're studying in the under five-year-olds, then I think that the FDA will be eager to evaluate its safety profile and how well it's working.

[00:34:23] Host Amber Smith: Thank you for taking time to talk about this. My guest has been Dr. Joe Domachowske. a professor of pediatrics and microbiology and immunology at Upstate I'm Amber Smith for Upstate's HealthLink

[00:34:34] Music: on Air.

[00:34:38] Host Amber Smith: A look at different types of medical imaging techniques. Next on Upstate's HealthLink on Air.

[00:35:00] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is HealthLink on Air. Lots of times because of illness or injury, doctors need to have a look inside our bodies and often they can accomplish that through one or more medical imaging techniques to help us understand what's available in medical imaging today and in the future is Dr. Michelle Lisi. She's an associate professor of radiology and interim chair of radiology at Upstate. I appreciate you taking time for HealthLink on Air, Dr. Lisi.

[00:35:30] Michele Lisi, MD: My pleasure. Thank you for having me.

[00:35:32] Host Amber Smith: I think listeners have probably heard of x-rays ultrasound, cat scans, MRIs, but I'm not sure we really understand which is used for what. So I'd like to have you explain the differences. Can we start with X-rays, which I believe have probably been around the longest, is that right?

[00:35:48] Michele Lisi, MD: Correct. X-ray has been around for quite a while, since the 1800s actually. Plain x-rays are a two dimensional picture of our body. So we look at, for example, a chest X-ray, and that's giving us a two dimensional picture of what's inside our lungs and allows us to look at the bones.

[00:36:06] Host Amber Smith: Does an X-ray let you see tissue and organs?

[00:36:10] Michele Lisi, MD: We can see tissue and organs with X-ray, but the main reason for X-ray is looking at bones and we do that for fractures, dislocations--when a joint becomes separated. It's very common in the emergency department. Also good in terms of the chest for looking for pneumonia. And so there are some soft tissue applications for plain X-rays, but the applications are much fewer than with other modalities.

[00:36:38] Host Amber Smith: Now, what about ultrasounds? We've heard about ultrasounds being used during pregnancy, but there's other things they're used for as well, right?

[00:36:46] Michele Lisi, MD: Definitely. Ultrasound is a great tool, mainly because it doesn't give the patient any radiation. It's based on sound waves and yes, it is very common to be used in pregnancy for looking at the anatomy of the baby. But we also use it for the gallbladder. That's a very common reason to use it in the emergency department. If somebody is having pain, you can find gallstones or infection in the gallbladder. But it's a very good screening tool to look at the liver, for example, or the kidneys for certain types of ailments, kidney stones. So, yeah, there are many reasons that we would use ultrasound rather than just pregnancy.

[00:37:23] Host Amber Smith: Is mammogram the same type of thing? Is that an ultrasound or is that something else?

[00:37:29] Michele Lisi, MD: No, mammography is another form of X-ray. Kind of like the plain X-ray that we talked about in the beginning, mammogram does use radiation, but it's a different type of radiation than what we use for the X-ray. So it does allow us to see tissue better. So it's very good for looking at the breast tissue and looking for cancers.

[00:37:49] Host Amber Smith: We've probably heard of cat scans. Now, am I correct that that is computerized tomography?

[00:37:55] Michele Lisi, MD: Correct.

[00:37:56] Host Amber Smith: What is that used for? And is it the same thing as a PET scan?

[00:38:01] Michele Lisi, MD: No, PET scans and CT scans are different. So a CT scan is a way that we can look at cross sections of the body. So as I mentioned with plain, X-rays, you're looking at a two dimensional picture of a three-dimensional structure like our body. The cat scan actually allows us to look at things in a three-dimensional way. It does use radiation, X-ray radiation, just like the plain x-rays do, but it takes them in such a way that we can see the body as if we sliced it. And so you get much more anatomy in a CAT scan, it's more sensitive for certain things. And it's used for the entire body, from the head all the way down through the legs. We have various applications for that.

[00:38:43] Host Amber Smith: I like how you described it as like a 3d X-ray.

[00:38:46] Michele Lisi, MD: Yeah. We take the pictures and then with the computer, we can reconstruct them or form them into three-dimensional images.

[00:38:54] Host Amber Smith: Now, a PET scan is entirely something different?

[00:38:56] Michele Lisi, MD: A PET scan is entirely different. That is something where we are actually injecting a form of radiation into the patient. And we are looking at where it comes from within the body. That's very common for cancer imaging. The radioactive tracer that we call it, that you inject into the patient is a sugar. It's a type of sugar that cancer cells or cells that are active in the body actually want to eat the sugar. And so that tracer will go to those types of cells, and then we can generate an image based on where those sugar molecules go in the body. So totally different, but yet the same in a way.

[00:39:37] Host Amber Smith: Now, when are MRIs used, and that's magnetic resonance imaging?

[00:39:42] Michele Lisi, MD: Yes. Magnetic resonance imaging. That's used in many different applications as well. Probably, I would say, the most common indications are for the brain. You get very nice pictures of the brain with MRI, and for joints. People that have joint injuries or ligaments when they tear the ligaments or the tendons and muscles, MRI is very good at looking at those tissues. So, whereas with the X-ray we see bone very well, MRI kind of gives us a little bit better depiction of the soft tissues. And also I will point out with MRI that we do not use radiation. It's a magnetic field, so there's no radiation to the patient with MRI

[00:40:23] Host Amber Smith: Let me ask you, as a radiologist, do you have physicians coming to you and saying 'here's the situation, which imaging is the best thing for what I need?'

[00:40:32] Michele Lisi, MD: Definitely. There are so many things now that we're able to do with imaging. I mean, there's always new technology. So very often there'll be a conundrum that a physician may have and need our opinion on what to do next.

[00:40:46] Host Amber Smith: Well, what have I left out? Does nuclear imaging fit in anywhere?

[00:40:50] Michele Lisi, MD: It does. Yeah, so nuclear imaging sort of goes back to thePET scan. That's a form of nuclear imaging, or as we now call it molecular imaging. And we do quite a bit of that as well. We have various tracers, as I mentioned, that can be injected into patients and will go to places in the body of various pathological conditions. For example, we do something called bone scanning, where we inject a tracer, and the tracer will go to areas in the bone that may be fractured, that may have cancer. Then we can take pictures of that and see where that goes and detect where those abnormalities are. And molecular imaging is a very interesting upcoming technique for looking at various types of pathology.

[00:41:36] Host Amber Smith: This is Upstate's HealthLink on Air. I'm your host, Amber Smith. And I'm talking with Dr. Michele Lisi. She's an associate professor of radiology and the interim chair of radiology at Upstate. And we've been talking about medical imaging. We've talked about X-rays and CT scans and MRIs and sonograms, a variety of things. I wanted to know are these modalities that we've talked about? Are they widely available, even in small hospitals or medical centers, or do you have to go to a specialized center?

[00:42:05] Michele Lisi, MD: For the most part they are. Most places nowadays will have all modalities available. Some of the higher end imaging PET scans, for example, may not be available in all hospitals or in all medical systems, but definitely more widely available than they were in the past.

[00:42:23] Host Amber Smith: Are there risks that patients should be aware of? I know the different modalities, some of them have radiation, some of them don't, but in general, what do patients need to be aware of before they have medical images?

[00:42:36] Michele Lisi, MD: I think just the fact that there is a dose of radiation that the patients will receive with X -ray or CAT scan or some of the molecular imaging or PET scan studies. But the dose is minimal. We have a lot of dose reducing techniques now that are built into our machines so that the images are inherently safer than they used to be in terms of the radiation dose. Sonography or ultrasound really doesn't have a risk associated with it since that's all based on sound waves and not radiation. And magnetic, resonance, or MRI.

[00:43:11] Michele Lisi, MD: When we screen patients for those examinations, we just want to make sure that they don't have any metallic implants. Or if they do, there are many of the metallic implants that are very safe, actually. And most of them nowadays are safe for going into the magnet. But we do screen the patients and ask if they've ever had any implants or if they have any metal that we need to be aware of just in case there may be a problem. But for the most part, the medical implants are safe for the magnet.

[00:43:40] Host Amber Smith: Now the medical imaging we've talked about, are they all static images or are there modalities that allow for live video of a medical image?

[00:43:50] Host Amber Smith: With x-ray, there's something called fluoroscopy that we can look at live images, for example, patients that are having difficulty swallowing, when they're concerned that they're aspirating or getting pneumonia because contents are going into their lungs. We can do studies where we actually watch them swallow. We give them food that's labeled with something we can see on the X-ray and have them eat in front of us. And we can watch their swallowing mechanism. And then ultrasound as well. We do take static pictures with ultrasound, but when you are in the room scanning the patient that is basically like a live video image.

[00:44:28] Host Amber Smith: Now do radiologists learn all of these medical imaging modalities, and then do they specialize in one or two or are they expected to be able to do all of them?

[00:44:40] Michele Lisi, MD: Well, that depends definitely during the residency, we learn all about all of the modalities and pretty much everything there is in radiology as a general knowledge base, but then people typically do subspecialize after their residency. And it's not necessarily modality specialized. It's more of, how should I say, body parts specialized. So for example, you have people that specialize in abdominal imaging or people that specialize in neuro, the brain, the spine, or the chest, for example, when those required different training, you have people that specialize in nuclear medicine, or mammography. So there are definitely subspecialties within our scope, but again, it's more body part based than modality based.

[00:45:28] Host Amber Smith: I want to ask you about types of imaging that are in development. Now you mentioned molecular imaging, so that's already in use, but it sounds like it's pretty new, right?

[00:45:37] Michele Lisi, MD: Well, it's not new. Actually, molecular imaging used to be referred to as nuclear medicine. It has been around for quite a while. As a matter of fact, a lot of the pioneering in nuclear medicine took place here at Upstate back in the seventies. One of the agents that's most commonly used for bone scanning was developed here at Upstate. Just a little piece of history, which is great.

[00:46:00] Host Amber Smith: I had no idea. What is the element called?

[00:46:02] Michele Lisi, MD: It's called MDP. And it was developed here in our lab, downstairs in the basement back in, I believe, the early seventies. We had quite an extensive department here at one time. So it has been around for quite a while, but so many new tracers are being developed. And many of these tracers now, not only are we able to use them to image patients, but we're using them to treat patients as well by labeling them with, say, different molecules that are capable of treatment of cancer specifically. And that's something that's just rapidly developing, which is very exciting.

[00:46:42] Host Amber Smith: What would doctors like to be able to do with imaging that they aren't able to do right now?

[00:46:47] Michele Lisi, MD: A lot of times we do get asked to make a definitive decision about something. We see a lesion or something in the body and they say, "well, what is it? We need to know what it is." And sometimes we can't tell them. We wish we could, but sometimes you actually need to look at the cells. We're not pathologists or radiologists. I wish we could sometimes be a little more definitive, but I think that's probably what physicians would want the most from us, but we can't always tell exactly what something is. Just give our best guess a lot of times.

[00:47:17] Host Amber Smith: The images today, are you looking at a computer screen or do they get printed out still on paper of some sort?

[00:47:25] Michele Lisi, MD: No, that went away. Here at Upstate. We started using what we call a PAC, Picture and Archiving Communication system, which is what gives us the images on computer. Back in 2004 is when we started doing that, so I think most places now are obviously in the computer screen mode.

[00:47:42] Host Amber Smith: Are computers or artificial intelligence being used to help read and interpret images? Or do you think it will be in the future?

[00:47:49] Michele Lisi, MD: I do. That's something that's really been talked about quite a bit in radiology, not only for diagnosis, but also using artificial intelligence for making images look better while using less radiation to make the images. That's something that's being studied quite extensively, and we've been using artificial intelligence for mammography for quite a while to help define or to recognize lesions on mammography. And there are other applications that are coming along as well with chest imaging, abdominal imaging. We're not using it yet, but I think it's on the horizon.

[00:48:28] Host Amber Smith: I really appreciate you making time to give us this overview. My guest has been associate professor of radiology, Dr. Michelle Lisi, who is interim chair of the radiology department at Upstate I'm Amber Smith for Upstate's HealthLink on Air.

[00:49:00] Host Amber Smith: Dierdre Neilen, editor of Upstate Medical University's literary and visual arts journal, "The Healing Muse" with this week's selection.

[00:49:09] Deirdre Neilen, PhD: Marilyn McVickers has published several books of poetry and non-fiction. The poem she sent us, deftly separates good doctors from poor doctors. She reminds patients to speak up and not settle for less than a caring professional.

[00:49:25] Deirdre Neilen, PhD: Here is "Doctors:"

[00:49:27] Deirdre Neilen, PhD: I breathe, review my notes while the clock ticks the minutes, weeks, years of illness, decanted into a 20-minute appointment. I have driven so many miles. Will she listen? Will she walk in with a smile? I have had so many doctors wear their impertinence like stethoscopes. 'Well you certainly don't look sick.' 'Your diagnosis is too complicated.' 'There's nothing I can do to help you.'

[00:49:56] Deirdre Neilen, PhD: This poem is not for all those smirking frenzied physicians who push judgment and peddle fear. This poem is for the doctor who pulled up a chair, made eye contact, listened. This poem is for the doctor who ventured from behind the computer, listened, asked intelligent questions. This poem is for the doctor who did not reflexively grab the prescription pad, realized I needed medical care, admitted he couldn't help, found someone who could.

[00:50:32] Deirdre Neilen, PhD: This poem is for the doctor who worked to find the right diagnosis, taught me to give my own injections, started home infusions, called each week to check in. This poem is for the doctor who understood this partnership was more important than healing that would never

[00:50:52] Music: come

[00:51:12] Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air"-- fall prevention for seniors. If you missed any of today's show or for more consumer health podcasts, visit our website at HealthLinkonAir.Org. Or do a podcast search for the phrase "HealthLink on Air." Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw.

[00:51:47] Host Amber Smith: This is your host, Amber Smith, thanking you for listening.