In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

In the analysis of images for detecting potential pathology, artificial intelligence (AI) is showing enormous promise across multiple fields of medicine. But the technology in dermatology is bound to fail in skin of color if training does not specifically address these skin types, according to Adewole S. Adamson, MD, who outlined this issue at the American Academy of Dermatology Virtual Meeting Experience.

“Machine learning algorithms are only as good as the inputs through which they learn. Without representation from individuals with skin of color, we are at risk of creating a new source of racial disparity in patient care,” Dr. Adamson, assistant professor in the division of dermatology, department of internal medicine, University of Texas at Austin, said at the meeting.

Diagnostic algorithms using AI are typically based on deep learning, a subset of machine learning that depends on artificial neural networks. In the case of image processing, neural networks can “learn” to recognize objects, faces, or, in the realm of health care, disease, from exposure to multiple images.

There are many other variables that affect the accuracy of deep learning for diagnostic algorithms, including the depth of the layering through which the process distills multiple inputs of information, but the number of inputs is critical. In the case of skin lesions, machines cannot learn to recognize features of different skin types without exposure.

“There are studies demonstrating that dermatologists can be outperformed for detection of skin cancers by AI, so this is going to be an increasingly powerful tool,” Dr. Adamson said. The problem is that “there has been very little representation in darker skin types” in the algorithms developed so far.

The risk is that AI will exacerbate an existing problem. Skin cancer in darker skin is less common but already underdiagnosed, independent of AI. Per 100,000 males in the United States, the rate of melanoma is about 30-fold greater in White men than in Black men (33.0 vs. 1.0). Among females, the racial difference is smaller but still enormous (20.2 vs. 1.2 per 100,000 females), according to U.S. data.

For the low representation of darker skin in studies so far with AI, “one of the arguments is that skin cancer is not a big deal in darker skin types,” Dr. Adamson said.

It might be the other way around. The relative infrequency with which skin cancer occurs in the Black population in the United States might explain a low level of suspicion and ultimately delays in diagnosis, which, in turn, leads to worse outcomes. According to one analysis drawn from the Surveillance, Epidemiology and End-Result (SEER) database (1998-2011), the proportion of patients with regionally advanced or distant disease was nearly twice as great (11.6% vs. 6.0%; P < .05) in Black patients, relative to White patients.

Not surprisingly, given the importance of early diagnosis of cancers overall and skin cancer specifically, the mean survival for malignant melanoma in Black patients was almost 4 years lower than in White patients (10.8 vs. 14.6 years; P < .001) for nodular melanoma, the same study found.

In humans, bias is reasonably attributed in many cases to judgments made on a small sample size. The problem in AI is analogous. Dr. Adamson, who has published research on the potential for machine learning to contribute to health care disparities in dermatology, cited work done by Joy Buolamwini, a graduate researcher in the media lab at the Massachusetts Institute of Technology. In one study she conducted, the rate of AI facial recognition failure was 1% in White males, 7% in White females, 12% in skin-of-color males, and 35% in skin-of-color females. Fewer inputs of skin of color is the likely explanation, Dr. Adamson said.

The potential for racial bias from AI in the diagnosis of disease increases and becomes more complex when inputs beyond imaging, such as past medical history, are included. Dr. Adamson warned of the potential for “bias to creep in” when there is failure to account for societal, cultural, or other differences that distinguish one patient group from another. However, for skin cancer or other diseases based on images alone, he said there are solutions.

“We are in the early days, and there is time to change this,” Dr. Adamson said, referring to the low representation of skin of color in AI training sets. In addition to including more skin types to train recognition, creating AI algorithms specifically for dark skin is another potential approach.

However, his key point was the importance of recognizing the need for solutions.

“AI is the future, but we must apply the same rigor to AI as to other medical interventions to ensure that the technology is not applied in a biased fashion,” he said.

Susan M. Swetter, MD, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, agreed. As someone who has been following the progress of AI in the diagnosis of skin cancer, Dr. Swetter recognizes the potential for this technology to increase diagnostic efficiency and accuracy, but she also called for studies specific to skin of color.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

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Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Asthma care coordination for children can be improved through a school-based asthma program involving the child’s school, their family, and clinicians, according to a recent presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“Partnerships among schools, families, and clinicians can be powerful agents to improve the recognition of childhood asthma symptoms, asthma diagnosis and in particular management,” Sujani Kakumanu, MD, clinical associate professor of allergy and immunology at the University of Wisconsin–Madison, said in her presentation. “Emergency treatment plans and asthma action plans, as well as comprehensive education for all school personnel and school environmental mitigation plans, are crucial to controlling asthma symptoms in schools.”

The school is a unique location where families and clinicians can affect asthma outcomes because of the consistent amount of time a student spends there each day, Dr. Kakumanu explained, but everyone involved in allergy care for a child should be aware of and attempt to reduce environmental exposures and triggers found in schools that can worsen asthma, such as irritants, cleaning solutions, dust mites, pests, air pollution, and indoor air quality.
 

SAMPRO expansion

In 2016, the AAAAI and National Association of School Nurses provided financial support for the School-based Asthma Management Program (SAMPRO). “The impetus behind this initiative was a recognition that coordination with schools was essential to controlling pediatric asthma care,” Dr. Kakumanu said. Initially focusing on asthma alone, SAMPRO has since expanded to include resources for allergy and anaphylaxis and is known as the School-based Asthma, Allergy & Anaphylaxis Management Program (SA3MPRO).

SA3MPRO’s first tenet is the need for an engaged circle of support that includes families, schools, and clinicians of children with asthma. “Establishing and maintaining a healthy circle of support is a critical component to a school-based asthma partnership. It requires an understanding of how care is delivered in clinics as well as in hospitals and at schools,” Dr. Kakumanu said.

School nurses are uniquely positioned to help address gaps in care for children with asthma during the school day by administering medications and limiting the number of student absences caused by asthma. “In addition, school nurses and school personnel often provide key information to the health system about a student’s health status that can impact their prescriptions and their medical care,” she noted.
 

Setting an action plan

The second SA3MPRO tenet is the development of an asthma action plan by schools for situations when a child presents with urgent asthma symptoms that require quick action. SA3MPRO’s asthma action plan describes a child’s severity of asthma, known asthma triggers and what medications can be delivered at school, and how clinicians and schools can share HIPAA and FERPA-protected information.

Some programs are allowing school nurses to access electronic medical records to share information, Dr. Kakumanu said. UW Health at the University of Wisconsin developed the project, led by Dr. Kakumanu and Robert F. Lemanske Jr., MD, in 2017 that gave school nurses in the Madison Metropolitan School District access to the EMR. Prior to the COVID-19 pandemic, the program was linked to decreased prescriptions of steroids among pediatric clinicians, she said.

“This program allowed the quick and efficient delivery of asthma action plans to schools along with necessary authorizations, prescriptions and a consent to share information electronically. With this information and subsequent authorizations, the school nurses were able to update the school health record, manage symptoms at school as directed by the individualized asthma action plan, and coordinate school resources needed to care for the child asthma symptoms during the school day,” Dr. Kakumanu said.

“This program also addressed a common barrier with school-based partnerships, which was the lack of efficient asynchronous communication, and it did this by including the ability of school nurses and clinicians to direct message each other within a protected EMR,” she added. “In order to continue our support for families, there were also measures to include families with corresponding [EMR] messaging and with communication by phone.”

Barriers in the program at UW Health included needing annual training, sustaining momentum for organizational support and interest, monitoring infrastructure, and maintaining documents. Other challenges were in the management of systems that facilitated messaging and the need to obtain additional electronic consents separately from written consents.
 

Training vital

The third tenet in SA3MPRO is training, which should incorporate a recognition and treatment of asthma symptoms among school staff, students, and families; proper inhaler technique; how medical care will be delivered at the school and by whom; what emergency asthma symptoms look like; and a plan for getting the child to an emergency medical facility. “Regardless of the program that is chosen, asthma education should address health literacy and multiple multicultural beliefs and be delivered in the language that is appropriate for that school and that student body,” Dr. Kakumanu said. “Teachers, janitors, school administrators, and all levels of school personnel should be educated on how to recognize and treat asthma symptoms, especially if a school nurse is not always available on site.”

Marathon not a sprint

The last tenet in SA3MPRO is improving air quality and decreasing environmental exposure to triggers, which involves “the use of environmental recognition and mitigation plans to minimize the effect of allergens, irritants, and air pollutants within the outside and indoor environment that may affect a child with asthma during the school day.”

While these measures may seem daunting, Dr. Kakumanu said the communities that have successfully implemented a SA3MPRO plan are ones that prioritized updated and accurate data, developed a team-based approach, and secured long-term funding for the program. “Important lessons for all of us in this work is remembering that it’s a marathon and not a sprint, and that effective care coordination requires continual and consistent resources,” she said.

Dr. Kakumanu reported no relevant conflicts of interest.

Asthma care coordination for children can be improved through a school-based asthma program involving the child’s school, their family, and clinicians, according to a recent presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“Partnerships among schools, families, and clinicians can be powerful agents to improve the recognition of childhood asthma symptoms, asthma diagnosis and in particular management,” Sujani Kakumanu, MD, clinical associate professor of allergy and immunology at the University of Wisconsin–Madison, said in her presentation. “Emergency treatment plans and asthma action plans, as well as comprehensive education for all school personnel and school environmental mitigation plans, are crucial to controlling asthma symptoms in schools.”

The school is a unique location where families and clinicians can affect asthma outcomes because of the consistent amount of time a student spends there each day, Dr. Kakumanu explained, but everyone involved in allergy care for a child should be aware of and attempt to reduce environmental exposures and triggers found in schools that can worsen asthma, such as irritants, cleaning solutions, dust mites, pests, air pollution, and indoor air quality.
 

SAMPRO expansion

In 2016, the AAAAI and National Association of School Nurses provided financial support for the School-based Asthma Management Program (SAMPRO). “The impetus behind this initiative was a recognition that coordination with schools was essential to controlling pediatric asthma care,” Dr. Kakumanu said. Initially focusing on asthma alone, SAMPRO has since expanded to include resources for allergy and anaphylaxis and is known as the School-based Asthma, Allergy & Anaphylaxis Management Program (SA3MPRO).

SA3MPRO’s first tenet is the need for an engaged circle of support that includes families, schools, and clinicians of children with asthma. “Establishing and maintaining a healthy circle of support is a critical component to a school-based asthma partnership. It requires an understanding of how care is delivered in clinics as well as in hospitals and at schools,” Dr. Kakumanu said.

School nurses are uniquely positioned to help address gaps in care for children with asthma during the school day by administering medications and limiting the number of student absences caused by asthma. “In addition, school nurses and school personnel often provide key information to the health system about a student’s health status that can impact their prescriptions and their medical care,” she noted.
 

Setting an action plan

The second SA3MPRO tenet is the development of an asthma action plan by schools for situations when a child presents with urgent asthma symptoms that require quick action. SA3MPRO’s asthma action plan describes a child’s severity of asthma, known asthma triggers and what medications can be delivered at school, and how clinicians and schools can share HIPAA and FERPA-protected information.

Some programs are allowing school nurses to access electronic medical records to share information, Dr. Kakumanu said. UW Health at the University of Wisconsin developed the project, led by Dr. Kakumanu and Robert F. Lemanske Jr., MD, in 2017 that gave school nurses in the Madison Metropolitan School District access to the EMR. Prior to the COVID-19 pandemic, the program was linked to decreased prescriptions of steroids among pediatric clinicians, she said.

“This program allowed the quick and efficient delivery of asthma action plans to schools along with necessary authorizations, prescriptions and a consent to share information electronically. With this information and subsequent authorizations, the school nurses were able to update the school health record, manage symptoms at school as directed by the individualized asthma action plan, and coordinate school resources needed to care for the child asthma symptoms during the school day,” Dr. Kakumanu said.

“This program also addressed a common barrier with school-based partnerships, which was the lack of efficient asynchronous communication, and it did this by including the ability of school nurses and clinicians to direct message each other within a protected EMR,” she added. “In order to continue our support for families, there were also measures to include families with corresponding [EMR] messaging and with communication by phone.”

Barriers in the program at UW Health included needing annual training, sustaining momentum for organizational support and interest, monitoring infrastructure, and maintaining documents. Other challenges were in the management of systems that facilitated messaging and the need to obtain additional electronic consents separately from written consents.
 

Training vital

The third tenet in SA3MPRO is training, which should incorporate a recognition and treatment of asthma symptoms among school staff, students, and families; proper inhaler technique; how medical care will be delivered at the school and by whom; what emergency asthma symptoms look like; and a plan for getting the child to an emergency medical facility. “Regardless of the program that is chosen, asthma education should address health literacy and multiple multicultural beliefs and be delivered in the language that is appropriate for that school and that student body,” Dr. Kakumanu said. “Teachers, janitors, school administrators, and all levels of school personnel should be educated on how to recognize and treat asthma symptoms, especially if a school nurse is not always available on site.”

Marathon not a sprint

The last tenet in SA3MPRO is improving air quality and decreasing environmental exposure to triggers, which involves “the use of environmental recognition and mitigation plans to minimize the effect of allergens, irritants, and air pollutants within the outside and indoor environment that may affect a child with asthma during the school day.”

While these measures may seem daunting, Dr. Kakumanu said the communities that have successfully implemented a SA3MPRO plan are ones that prioritized updated and accurate data, developed a team-based approach, and secured long-term funding for the program. “Important lessons for all of us in this work is remembering that it’s a marathon and not a sprint, and that effective care coordination requires continual and consistent resources,” she said.

Dr. Kakumanu reported no relevant conflicts of interest.

Asthma care coordination for children can be improved through a school-based asthma program involving the child’s school, their family, and clinicians, according to a recent presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“Partnerships among schools, families, and clinicians can be powerful agents to improve the recognition of childhood asthma symptoms, asthma diagnosis and in particular management,” Sujani Kakumanu, MD, clinical associate professor of allergy and immunology at the University of Wisconsin–Madison, said in her presentation. “Emergency treatment plans and asthma action plans, as well as comprehensive education for all school personnel and school environmental mitigation plans, are crucial to controlling asthma symptoms in schools.”

The school is a unique location where families and clinicians can affect asthma outcomes because of the consistent amount of time a student spends there each day, Dr. Kakumanu explained, but everyone involved in allergy care for a child should be aware of and attempt to reduce environmental exposures and triggers found in schools that can worsen asthma, such as irritants, cleaning solutions, dust mites, pests, air pollution, and indoor air quality.
 

SAMPRO expansion

In 2016, the AAAAI and National Association of School Nurses provided financial support for the School-based Asthma Management Program (SAMPRO). “The impetus behind this initiative was a recognition that coordination with schools was essential to controlling pediatric asthma care,” Dr. Kakumanu said. Initially focusing on asthma alone, SAMPRO has since expanded to include resources for allergy and anaphylaxis and is known as the School-based Asthma, Allergy & Anaphylaxis Management Program (SA3MPRO).

SA3MPRO’s first tenet is the need for an engaged circle of support that includes families, schools, and clinicians of children with asthma. “Establishing and maintaining a healthy circle of support is a critical component to a school-based asthma partnership. It requires an understanding of how care is delivered in clinics as well as in hospitals and at schools,” Dr. Kakumanu said.

School nurses are uniquely positioned to help address gaps in care for children with asthma during the school day by administering medications and limiting the number of student absences caused by asthma. “In addition, school nurses and school personnel often provide key information to the health system about a student’s health status that can impact their prescriptions and their medical care,” she noted.
 

Setting an action plan

The second SA3MPRO tenet is the development of an asthma action plan by schools for situations when a child presents with urgent asthma symptoms that require quick action. SA3MPRO’s asthma action plan describes a child’s severity of asthma, known asthma triggers and what medications can be delivered at school, and how clinicians and schools can share HIPAA and FERPA-protected information.

Some programs are allowing school nurses to access electronic medical records to share information, Dr. Kakumanu said. UW Health at the University of Wisconsin developed the project, led by Dr. Kakumanu and Robert F. Lemanske Jr., MD, in 2017 that gave school nurses in the Madison Metropolitan School District access to the EMR. Prior to the COVID-19 pandemic, the program was linked to decreased prescriptions of steroids among pediatric clinicians, she said.

“This program allowed the quick and efficient delivery of asthma action plans to schools along with necessary authorizations, prescriptions and a consent to share information electronically. With this information and subsequent authorizations, the school nurses were able to update the school health record, manage symptoms at school as directed by the individualized asthma action plan, and coordinate school resources needed to care for the child asthma symptoms during the school day,” Dr. Kakumanu said.

“This program also addressed a common barrier with school-based partnerships, which was the lack of efficient asynchronous communication, and it did this by including the ability of school nurses and clinicians to direct message each other within a protected EMR,” she added. “In order to continue our support for families, there were also measures to include families with corresponding [EMR] messaging and with communication by phone.”

Barriers in the program at UW Health included needing annual training, sustaining momentum for organizational support and interest, monitoring infrastructure, and maintaining documents. Other challenges were in the management of systems that facilitated messaging and the need to obtain additional electronic consents separately from written consents.
 

Training vital

The third tenet in SA3MPRO is training, which should incorporate a recognition and treatment of asthma symptoms among school staff, students, and families; proper inhaler technique; how medical care will be delivered at the school and by whom; what emergency asthma symptoms look like; and a plan for getting the child to an emergency medical facility. “Regardless of the program that is chosen, asthma education should address health literacy and multiple multicultural beliefs and be delivered in the language that is appropriate for that school and that student body,” Dr. Kakumanu said. “Teachers, janitors, school administrators, and all levels of school personnel should be educated on how to recognize and treat asthma symptoms, especially if a school nurse is not always available on site.”

Marathon not a sprint

The last tenet in SA3MPRO is improving air quality and decreasing environmental exposure to triggers, which involves “the use of environmental recognition and mitigation plans to minimize the effect of allergens, irritants, and air pollutants within the outside and indoor environment that may affect a child with asthma during the school day.”

While these measures may seem daunting, Dr. Kakumanu said the communities that have successfully implemented a SA3MPRO plan are ones that prioritized updated and accurate data, developed a team-based approach, and secured long-term funding for the program. “Important lessons for all of us in this work is remembering that it’s a marathon and not a sprint, and that effective care coordination requires continual and consistent resources,” she said.

Dr. Kakumanu reported no relevant conflicts of interest.

Click here for the preview issue of the SHM Converge Daily News newsletter.

Click here for the preview issue of the SHM Converge Daily News newsletter.

Click here for the preview issue of the SHM Converge Daily News newsletter.

I’ve taken care of both Bill and his wife for a few years. They’re a sweet couple, each with their own neurological issues. Bill has also battled depression on and off over time. He can be a challenge, and I’ve never envied his psychiatrist.

Bill committed suicide in the final week of April.

Patient deaths are unavoidable in medicine. It’s part of the job. Suicides, though less common, also happen. Sometimes they’re related to a sad diagnosis we’ve made, but more commonly (as in Bill’s case) they result from demons we had no control over.

I had a patient commit suicide about 6 months after I started my practice, and probably average one every 2 years (that I hear about) since then. They’re still the deaths that surprise me the most, make me take pause for a few minutes, even after doing this for 23 years.

Suicide is as old as humanity, and gets worse during difficult societal and economic times. It disproportionately affects doctors, dentists, veterinarians, and police officers, and leaves devastated families and friends in its wake.

Death because of the progression of time and disease is never easy, but perhaps more psychologically acceptable to those left behind. Death because of a tragic accident at any age is more difficult.

But when the person involved makes a conscious decision to end his or her own life, the effects on those left behind are terrible. Wondering why, questioning if they could have done something different, and, as with any loss, grieving.

Suicide remains extremely difficult to prevent. In a world where major advances have been made in many areas of medicine, including mental health, death from despair shows no sign of abating.

Maybe it’s part of the price of sentience and reason. Or civilization. I doubt it will ever stop being a public health issue, no matter how many other diseases we cure.

But, as I write a letter to Bill’s wife, that’s little consolation for those they’ve left behind.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’ve taken care of both Bill and his wife for a few years. They’re a sweet couple, each with their own neurological issues. Bill has also battled depression on and off over time. He can be a challenge, and I’ve never envied his psychiatrist.

Bill committed suicide in the final week of April.

Patient deaths are unavoidable in medicine. It’s part of the job. Suicides, though less common, also happen. Sometimes they’re related to a sad diagnosis we’ve made, but more commonly (as in Bill’s case) they result from demons we had no control over.

I had a patient commit suicide about 6 months after I started my practice, and probably average one every 2 years (that I hear about) since then. They’re still the deaths that surprise me the most, make me take pause for a few minutes, even after doing this for 23 years.

Suicide is as old as humanity, and gets worse during difficult societal and economic times. It disproportionately affects doctors, dentists, veterinarians, and police officers, and leaves devastated families and friends in its wake.

Death because of the progression of time and disease is never easy, but perhaps more psychologically acceptable to those left behind. Death because of a tragic accident at any age is more difficult.

But when the person involved makes a conscious decision to end his or her own life, the effects on those left behind are terrible. Wondering why, questioning if they could have done something different, and, as with any loss, grieving.

Suicide remains extremely difficult to prevent. In a world where major advances have been made in many areas of medicine, including mental health, death from despair shows no sign of abating.

Maybe it’s part of the price of sentience and reason. Or civilization. I doubt it will ever stop being a public health issue, no matter how many other diseases we cure.

But, as I write a letter to Bill’s wife, that’s little consolation for those they’ve left behind.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’ve taken care of both Bill and his wife for a few years. They’re a sweet couple, each with their own neurological issues. Bill has also battled depression on and off over time. He can be a challenge, and I’ve never envied his psychiatrist.

Bill committed suicide in the final week of April.

Patient deaths are unavoidable in medicine. It’s part of the job. Suicides, though less common, also happen. Sometimes they’re related to a sad diagnosis we’ve made, but more commonly (as in Bill’s case) they result from demons we had no control over.

I had a patient commit suicide about 6 months after I started my practice, and probably average one every 2 years (that I hear about) since then. They’re still the deaths that surprise me the most, make me take pause for a few minutes, even after doing this for 23 years.

Suicide is as old as humanity, and gets worse during difficult societal and economic times. It disproportionately affects doctors, dentists, veterinarians, and police officers, and leaves devastated families and friends in its wake.

Death because of the progression of time and disease is never easy, but perhaps more psychologically acceptable to those left behind. Death because of a tragic accident at any age is more difficult.

But when the person involved makes a conscious decision to end his or her own life, the effects on those left behind are terrible. Wondering why, questioning if they could have done something different, and, as with any loss, grieving.

Suicide remains extremely difficult to prevent. In a world where major advances have been made in many areas of medicine, including mental health, death from despair shows no sign of abating.

Maybe it’s part of the price of sentience and reason. Or civilization. I doubt it will ever stop being a public health issue, no matter how many other diseases we cure.

But, as I write a letter to Bill’s wife, that’s little consolation for those they’ve left behind.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The COVID-19 pandemic has exposed a wave of general and mental health-related problems, such as stress, addiction, weight gain, depression, and social isolation. Those problems have been exacerbated in patients with mental illness who are already struggling to cope with personal problems.

One might expect those with agoraphobia to be adversely affected by the pandemic and experience increased feelings of anxiety. It appears that people with agoraphobia might especially feel uncertain of other people’s actions during this time. Some might perceive being alone and cut off from help, and those feelings might make them more susceptible to panic attacks.

In my (R.W.C.) clinical experience, however, my patients with agoraphobia are actually functioning better than usual throughout this challenging course.

Personalizing treatment

Agoraphobia is a type of anxiety disorder that often develops after a panic attack and involves an intense fear of a place or situation. In my 40 years of clinical experience, I have treated about 300 patients with agoraphobia, and all of them exhibit the following three symptoms: depression (from losses in life), dependency (dependent on other people to help with activities of daily living), and panic attacks (an abrupt surge of intense fear or intense discomfort that may cause a person to avoid crowded areas or other public spaces outside of the home).

To manage these clients, I individualize treatment and use different strategies for different patients to help them cope with their agoraphobia. I normally treat my agoraphobic patients with a combination of medication and therapy. I most often use a selective serotonin reuptake inhibitor (SSRI), and my SSRI drug of choice is usually paroxetine (Paxil). Or, instead of an SSRI, I sometimes prescribe a tricyclic antidepressant, often Tofranil (imipramine). As an adjunct, I might prescribe a benzodiazepine, Xanax (alprazolam), p.r.n. My prescription decision is based on a patient’s side effect profile, medical history, and close blood relatives’ responses to those medications.

The therapy I use is behavior modification with systematic desensitization and flooding. Desensitization is a coping technique that helps the patient overcome triggers associated with the panic attacks and anxiety. In normal times, I use both in vitro (imaginary) and in vivo (real situation) desensitization. However, during the pandemic, I can use only in vitro desensitization, since I am treating patients through phone calls and telemedicine rather than in-person visits.

I also teach my patients with agoraphobia relaxation techniques to work through their fears and anxieties, and thus to reduce feelings of stress and anxiety. The patients can practice these learned techniques on their own in an effort to reduce panic and avoidance behaviors, and create a relaxation response.
 

Treating the key symptoms

As stated earlier, all of my agoraphobic patients exhibit the following three symptoms: depression, dependency, and panic attacks.

• Depression – My agoraphobia patients are less depressed during the pandemic and are not feeling intense losses as they did prepandemic.
• Dependency – During the pandemic, everyone has been interdependent upon other people in their households. Therefore, the patients’ support systems are more readily available, and the patients can help others as much as others help them in their own households or “havens of safety.”
• Panic attacks – As depression has declined, panic attacks have also declined, since they are interrelated.

Understanding why functioning might be better

I attribute the improved functioning I am seeing to five factors:

1. Some people with agoraphobia may find that physical distancing provides relief, because it discourages situations that may trigger fear.

2. Staying in their homes can make people with agoraphobia feel like part of mainstream America, rather than outside the norm. Also, they become egosyntonic, and sense both acceptance and comfort in their homes.

3. Isolating, staying home, and avoidance behavior is now applauded and has become the norm for the entire population. Thus, people with agoraphobia might feel heightened self-esteem.

4. Since many people have been staying in for the most part, people with agoraphobia do not feel they are missing out by staying in. As a result, they are experiencing less depression.

5. Normally, leaving home, traveling, and sitting in the doctor’s office for therapy causes great anxiety for my patients with agoraphobia. Now, I treat my patients through the use of telemedicine or by phone, and thus, patients are more relaxed and calm because they do not have to leave their homes and travel to my office. Thus, patients can avoid this dreaded anxiety trigger.

It might have been logical to assume that patients living with agoraphobia would be negatively affected by the pandemic, and experience increased feelings of anxiety and/or panic attacks – since the pandemic forced those with the illness to face fearful situations from which they cannot escape.

Fortunately, my agoraphobia patients have fared very well. They have remained on their prescribed medications and have adapted well to phone and telemedicine therapy. In fact, the adjustment of my patients with agoraphobia to the stringent mitigation measures surpassed the adjustment of my other patients. These patients with agoraphobia have proved to be a strong and resilient group in the face of extreme stress.
 

Dr. Cohen, who is married to Nancy S. Cohen, is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include agoraphobia, sports psychiatry, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no disclosures.

The COVID-19 pandemic has exposed a wave of general and mental health-related problems, such as stress, addiction, weight gain, depression, and social isolation. Those problems have been exacerbated in patients with mental illness who are already struggling to cope with personal problems.

One might expect those with agoraphobia to be adversely affected by the pandemic and experience increased feelings of anxiety. It appears that people with agoraphobia might especially feel uncertain of other people’s actions during this time. Some might perceive being alone and cut off from help, and those feelings might make them more susceptible to panic attacks.

In my (R.W.C.) clinical experience, however, my patients with agoraphobia are actually functioning better than usual throughout this challenging course.

Personalizing treatment

Agoraphobia is a type of anxiety disorder that often develops after a panic attack and involves an intense fear of a place or situation. In my 40 years of clinical experience, I have treated about 300 patients with agoraphobia, and all of them exhibit the following three symptoms: depression (from losses in life), dependency (dependent on other people to help with activities of daily living), and panic attacks (an abrupt surge of intense fear or intense discomfort that may cause a person to avoid crowded areas or other public spaces outside of the home).

To manage these clients, I individualize treatment and use different strategies for different patients to help them cope with their agoraphobia. I normally treat my agoraphobic patients with a combination of medication and therapy. I most often use a selective serotonin reuptake inhibitor (SSRI), and my SSRI drug of choice is usually paroxetine (Paxil). Or, instead of an SSRI, I sometimes prescribe a tricyclic antidepressant, often Tofranil (imipramine). As an adjunct, I might prescribe a benzodiazepine, Xanax (alprazolam), p.r.n. My prescription decision is based on a patient’s side effect profile, medical history, and close blood relatives’ responses to those medications.

The therapy I use is behavior modification with systematic desensitization and flooding. Desensitization is a coping technique that helps the patient overcome triggers associated with the panic attacks and anxiety. In normal times, I use both in vitro (imaginary) and in vivo (real situation) desensitization. However, during the pandemic, I can use only in vitro desensitization, since I am treating patients through phone calls and telemedicine rather than in-person visits.

I also teach my patients with agoraphobia relaxation techniques to work through their fears and anxieties, and thus to reduce feelings of stress and anxiety. The patients can practice these learned techniques on their own in an effort to reduce panic and avoidance behaviors, and create a relaxation response.
 

Treating the key symptoms

As stated earlier, all of my agoraphobic patients exhibit the following three symptoms: depression, dependency, and panic attacks.

• Depression – My agoraphobia patients are less depressed during the pandemic and are not feeling intense losses as they did prepandemic.
• Dependency – During the pandemic, everyone has been interdependent upon other people in their households. Therefore, the patients’ support systems are more readily available, and the patients can help others as much as others help them in their own households or “havens of safety.”
• Panic attacks – As depression has declined, panic attacks have also declined, since they are interrelated.

Understanding why functioning might be better

I attribute the improved functioning I am seeing to five factors:

1. Some people with agoraphobia may find that physical distancing provides relief, because it discourages situations that may trigger fear.

2. Staying in their homes can make people with agoraphobia feel like part of mainstream America, rather than outside the norm. Also, they become egosyntonic, and sense both acceptance and comfort in their homes.

3. Isolating, staying home, and avoidance behavior is now applauded and has become the norm for the entire population. Thus, people with agoraphobia might feel heightened self-esteem.

4. Since many people have been staying in for the most part, people with agoraphobia do not feel they are missing out by staying in. As a result, they are experiencing less depression.

5. Normally, leaving home, traveling, and sitting in the doctor’s office for therapy causes great anxiety for my patients with agoraphobia. Now, I treat my patients through the use of telemedicine or by phone, and thus, patients are more relaxed and calm because they do not have to leave their homes and travel to my office. Thus, patients can avoid this dreaded anxiety trigger.

It might have been logical to assume that patients living with agoraphobia would be negatively affected by the pandemic, and experience increased feelings of anxiety and/or panic attacks – since the pandemic forced those with the illness to face fearful situations from which they cannot escape.

Fortunately, my agoraphobia patients have fared very well. They have remained on their prescribed medications and have adapted well to phone and telemedicine therapy. In fact, the adjustment of my patients with agoraphobia to the stringent mitigation measures surpassed the adjustment of my other patients. These patients with agoraphobia have proved to be a strong and resilient group in the face of extreme stress.
 

Dr. Cohen, who is married to Nancy S. Cohen, is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include agoraphobia, sports psychiatry, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no disclosures.

The COVID-19 pandemic has exposed a wave of general and mental health-related problems, such as stress, addiction, weight gain, depression, and social isolation. Those problems have been exacerbated in patients with mental illness who are already struggling to cope with personal problems.

One might expect those with agoraphobia to be adversely affected by the pandemic and experience increased feelings of anxiety. It appears that people with agoraphobia might especially feel uncertain of other people’s actions during this time. Some might perceive being alone and cut off from help, and those feelings might make them more susceptible to panic attacks.

In my (R.W.C.) clinical experience, however, my patients with agoraphobia are actually functioning better than usual throughout this challenging course.

Personalizing treatment

Agoraphobia is a type of anxiety disorder that often develops after a panic attack and involves an intense fear of a place or situation. In my 40 years of clinical experience, I have treated about 300 patients with agoraphobia, and all of them exhibit the following three symptoms: depression (from losses in life), dependency (dependent on other people to help with activities of daily living), and panic attacks (an abrupt surge of intense fear or intense discomfort that may cause a person to avoid crowded areas or other public spaces outside of the home).

To manage these clients, I individualize treatment and use different strategies for different patients to help them cope with their agoraphobia. I normally treat my agoraphobic patients with a combination of medication and therapy. I most often use a selective serotonin reuptake inhibitor (SSRI), and my SSRI drug of choice is usually paroxetine (Paxil). Or, instead of an SSRI, I sometimes prescribe a tricyclic antidepressant, often Tofranil (imipramine). As an adjunct, I might prescribe a benzodiazepine, Xanax (alprazolam), p.r.n. My prescription decision is based on a patient’s side effect profile, medical history, and close blood relatives’ responses to those medications.

The therapy I use is behavior modification with systematic desensitization and flooding. Desensitization is a coping technique that helps the patient overcome triggers associated with the panic attacks and anxiety. In normal times, I use both in vitro (imaginary) and in vivo (real situation) desensitization. However, during the pandemic, I can use only in vitro desensitization, since I am treating patients through phone calls and telemedicine rather than in-person visits.

I also teach my patients with agoraphobia relaxation techniques to work through their fears and anxieties, and thus to reduce feelings of stress and anxiety. The patients can practice these learned techniques on their own in an effort to reduce panic and avoidance behaviors, and create a relaxation response.
 

Treating the key symptoms

As stated earlier, all of my agoraphobic patients exhibit the following three symptoms: depression, dependency, and panic attacks.

• Depression – My agoraphobia patients are less depressed during the pandemic and are not feeling intense losses as they did prepandemic.
• Dependency – During the pandemic, everyone has been interdependent upon other people in their households. Therefore, the patients’ support systems are more readily available, and the patients can help others as much as others help them in their own households or “havens of safety.”
• Panic attacks – As depression has declined, panic attacks have also declined, since they are interrelated.

Understanding why functioning might be better

I attribute the improved functioning I am seeing to five factors:

1. Some people with agoraphobia may find that physical distancing provides relief, because it discourages situations that may trigger fear.

2. Staying in their homes can make people with agoraphobia feel like part of mainstream America, rather than outside the norm. Also, they become egosyntonic, and sense both acceptance and comfort in their homes.

3. Isolating, staying home, and avoidance behavior is now applauded and has become the norm for the entire population. Thus, people with agoraphobia might feel heightened self-esteem.

4. Since many people have been staying in for the most part, people with agoraphobia do not feel they are missing out by staying in. As a result, they are experiencing less depression.

5. Normally, leaving home, traveling, and sitting in the doctor’s office for therapy causes great anxiety for my patients with agoraphobia. Now, I treat my patients through the use of telemedicine or by phone, and thus, patients are more relaxed and calm because they do not have to leave their homes and travel to my office. Thus, patients can avoid this dreaded anxiety trigger.

It might have been logical to assume that patients living with agoraphobia would be negatively affected by the pandemic, and experience increased feelings of anxiety and/or panic attacks – since the pandemic forced those with the illness to face fearful situations from which they cannot escape.

Fortunately, my agoraphobia patients have fared very well. They have remained on their prescribed medications and have adapted well to phone and telemedicine therapy. In fact, the adjustment of my patients with agoraphobia to the stringent mitigation measures surpassed the adjustment of my other patients. These patients with agoraphobia have proved to be a strong and resilient group in the face of extreme stress.
 

Dr. Cohen, who is married to Nancy S. Cohen, is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include agoraphobia, sports psychiatry, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no disclosures.

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Repetitive weight loss and gain in overweight or obese patients with knee osteoarthritis is associated with significantly greater cartilage and bone marrow edema degeneration than stable weight or steady weight loss, research suggests.

©pixologicstudio/Thinkstock

A presentation at the OARSI 2021 World Congress outlined the results of a study using Osteoarthritis Initiative data from 2,271 individuals with knee osteoarthritis and a body mass index (BMI) of 25 kg/m² or above, which examined the effects of “weight cycling” on OA outcomes.

Gabby Joseph, PhD, of the University of California, San Francisco, told the conference – which was sponsored by the Osteoarthritis Research Society International – that previous studies had shown weight loss improves OA symptoms and slow progression, and weight gain increases OA risk. However no studies had yet examined the effects of weight cycling.

The study compared 4 years of MRI data for those who showed less than 3% loss or gain in weight over that time – the control group – versus those who lost more than 5% over that time and those who gained more than 5%. Among these were 249 individuals in the top 10% of annual weight change over that period, who were designated as weight cyclers. They tended to be younger, female, and with slightly higher average BMI than noncyclers.

Weight cyclers had significantly greater progression of cartilage degeneration and bone marrow edema degeneration – as measured by whole-organ magnetic resonance score – than did noncyclers, regardless of their overall weight gain or loss by the end of the study period.

However, the study did not see any significant differences in meniscus progression between cyclers and noncyclers, and cartilage thickness decreased in all groups over the 4 years with no significant effects associated with weight gain, loss, or cycling. Dr. Joseph commented that future studies could use voxel-based relaxometry to more closely study localized cartilage abnormalities.

Researchers also examined the effect of weight cycling on changes to walking speed, and found weight cyclers had significantly lower walking speeds by the end of the 4 years, regardless of overall weight change.

“What we’ve seen is that fluctuations are not beneficial for your joints,” Dr. Joseph told the conference. “When we advise patients that they want to lose weight, we want to do this in a very steady fashion; we don’t want yo-yo dieting.” She gave the example of one patient who started the study with a BMI of 36, went up to 40 then went down to 32.

Commenting on the study, Lisa Carlesso, PhD, of McMaster University, Hamilton, Ont., said it addresses an important issue because weight cycling is common as people struggle to maintain weight loss.

While it is difficult to speculate on the physiological mechanisms that might explain the effect, Dr. Carlesso noted that there were significantly more women than men among the weight cyclers.

“We know, for example, that obese women with knee OA have significantly higher levels of the adipokine leptin, compared to men, and leptin is involved in cartilage degeneration,” Dr. Carlesso said. “Similarly, we don’t have any information about joint alignment or measures of joint load, two things that could factor into the structural changes found.”

She suggested both these possibilities could be explored in future studies of weight cycling and its effects.

“It has opened up new lines of inquiry to be examined to mechanistically explain the relationship between cycling and worse cartilage and bone marrow degeneration,” Dr. Carlesso said.

The study was supported by the National Institutes of Health. No conflicts of interest were declared.

Repetitive weight loss and gain in overweight or obese patients with knee osteoarthritis is associated with significantly greater cartilage and bone marrow edema degeneration than stable weight or steady weight loss, research suggests.

©pixologicstudio/Thinkstock

A presentation at the OARSI 2021 World Congress outlined the results of a study using Osteoarthritis Initiative data from 2,271 individuals with knee osteoarthritis and a body mass index (BMI) of 25 kg/m² or above, which examined the effects of “weight cycling” on OA outcomes.

Gabby Joseph, PhD, of the University of California, San Francisco, told the conference – which was sponsored by the Osteoarthritis Research Society International – that previous studies had shown weight loss improves OA symptoms and slow progression, and weight gain increases OA risk. However no studies had yet examined the effects of weight cycling.

The study compared 4 years of MRI data for those who showed less than 3% loss or gain in weight over that time – the control group – versus those who lost more than 5% over that time and those who gained more than 5%. Among these were 249 individuals in the top 10% of annual weight change over that period, who were designated as weight cyclers. They tended to be younger, female, and with slightly higher average BMI than noncyclers.

Weight cyclers had significantly greater progression of cartilage degeneration and bone marrow edema degeneration – as measured by whole-organ magnetic resonance score – than did noncyclers, regardless of their overall weight gain or loss by the end of the study period.

However, the study did not see any significant differences in meniscus progression between cyclers and noncyclers, and cartilage thickness decreased in all groups over the 4 years with no significant effects associated with weight gain, loss, or cycling. Dr. Joseph commented that future studies could use voxel-based relaxometry to more closely study localized cartilage abnormalities.

Researchers also examined the effect of weight cycling on changes to walking speed, and found weight cyclers had significantly lower walking speeds by the end of the 4 years, regardless of overall weight change.

“What we’ve seen is that fluctuations are not beneficial for your joints,” Dr. Joseph told the conference. “When we advise patients that they want to lose weight, we want to do this in a very steady fashion; we don’t want yo-yo dieting.” She gave the example of one patient who started the study with a BMI of 36, went up to 40 then went down to 32.

Commenting on the study, Lisa Carlesso, PhD, of McMaster University, Hamilton, Ont., said it addresses an important issue because weight cycling is common as people struggle to maintain weight loss.

While it is difficult to speculate on the physiological mechanisms that might explain the effect, Dr. Carlesso noted that there were significantly more women than men among the weight cyclers.

“We know, for example, that obese women with knee OA have significantly higher levels of the adipokine leptin, compared to men, and leptin is involved in cartilage degeneration,” Dr. Carlesso said. “Similarly, we don’t have any information about joint alignment or measures of joint load, two things that could factor into the structural changes found.”

She suggested both these possibilities could be explored in future studies of weight cycling and its effects.

“It has opened up new lines of inquiry to be examined to mechanistically explain the relationship between cycling and worse cartilage and bone marrow degeneration,” Dr. Carlesso said.

The study was supported by the National Institutes of Health. No conflicts of interest were declared.

Repetitive weight loss and gain in overweight or obese patients with knee osteoarthritis is associated with significantly greater cartilage and bone marrow edema degeneration than stable weight or steady weight loss, research suggests.

©pixologicstudio/Thinkstock

A presentation at the OARSI 2021 World Congress outlined the results of a study using Osteoarthritis Initiative data from 2,271 individuals with knee osteoarthritis and a body mass index (BMI) of 25 kg/m² or above, which examined the effects of “weight cycling” on OA outcomes.

Gabby Joseph, PhD, of the University of California, San Francisco, told the conference – which was sponsored by the Osteoarthritis Research Society International – that previous studies had shown weight loss improves OA symptoms and slow progression, and weight gain increases OA risk. However no studies had yet examined the effects of weight cycling.

The study compared 4 years of MRI data for those who showed less than 3% loss or gain in weight over that time – the control group – versus those who lost more than 5% over that time and those who gained more than 5%. Among these were 249 individuals in the top 10% of annual weight change over that period, who were designated as weight cyclers. They tended to be younger, female, and with slightly higher average BMI than noncyclers.

Weight cyclers had significantly greater progression of cartilage degeneration and bone marrow edema degeneration – as measured by whole-organ magnetic resonance score – than did noncyclers, regardless of their overall weight gain or loss by the end of the study period.

However, the study did not see any significant differences in meniscus progression between cyclers and noncyclers, and cartilage thickness decreased in all groups over the 4 years with no significant effects associated with weight gain, loss, or cycling. Dr. Joseph commented that future studies could use voxel-based relaxometry to more closely study localized cartilage abnormalities.

Researchers also examined the effect of weight cycling on changes to walking speed, and found weight cyclers had significantly lower walking speeds by the end of the 4 years, regardless of overall weight change.

“What we’ve seen is that fluctuations are not beneficial for your joints,” Dr. Joseph told the conference. “When we advise patients that they want to lose weight, we want to do this in a very steady fashion; we don’t want yo-yo dieting.” She gave the example of one patient who started the study with a BMI of 36, went up to 40 then went down to 32.

Commenting on the study, Lisa Carlesso, PhD, of McMaster University, Hamilton, Ont., said it addresses an important issue because weight cycling is common as people struggle to maintain weight loss.

While it is difficult to speculate on the physiological mechanisms that might explain the effect, Dr. Carlesso noted that there were significantly more women than men among the weight cyclers.

“We know, for example, that obese women with knee OA have significantly higher levels of the adipokine leptin, compared to men, and leptin is involved in cartilage degeneration,” Dr. Carlesso said. “Similarly, we don’t have any information about joint alignment or measures of joint load, two things that could factor into the structural changes found.”

She suggested both these possibilities could be explored in future studies of weight cycling and its effects.

“It has opened up new lines of inquiry to be examined to mechanistically explain the relationship between cycling and worse cartilage and bone marrow degeneration,” Dr. Carlesso said.

The study was supported by the National Institutes of Health. No conflicts of interest were declared.