Power Outage: An Ignored Risk Factor for Chronic Obstructive Pulmonary Disease ExacerbationsBy Dr. Wangjian Zhang, et al.



PROPHETIC: Prospective Identification of Pneumonia in Hospitalized Patients in the ICU By Dr. Stephen P. Bergin, et al.



Chronic Beryllium Disease: Update on a Moving Target By Dr. Maeve MacMurdo, et al.



Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees By Dr. Nha Voduc, et al.



Bias and Racism Teaching Rounds at an Academic Medical Center By Dr. Quinn Capers, IV, et al.

Power Outage: An Ignored Risk Factor for Chronic Obstructive Pulmonary Disease ExacerbationsBy Dr. Wangjian Zhang, et al.



PROPHETIC: Prospective Identification of Pneumonia in Hospitalized Patients in the ICU By Dr. Stephen P. Bergin, et al.



Chronic Beryllium Disease: Update on a Moving Target By Dr. Maeve MacMurdo, et al.



Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees By Dr. Nha Voduc, et al.



Bias and Racism Teaching Rounds at an Academic Medical Center By Dr. Quinn Capers, IV, et al.

Power Outage: An Ignored Risk Factor for Chronic Obstructive Pulmonary Disease ExacerbationsBy Dr. Wangjian Zhang, et al.



PROPHETIC: Prospective Identification of Pneumonia in Hospitalized Patients in the ICU By Dr. Stephen P. Bergin, et al.



Chronic Beryllium Disease: Update on a Moving Target By Dr. Maeve MacMurdo, et al.



Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees By Dr. Nha Voduc, et al.



Bias and Racism Teaching Rounds at an Academic Medical Center By Dr. Quinn Capers, IV, et al.

Three genes that could predict susceptibility to congenital Zika virus (ZIKV) infection have been identified, Dr. Irene Rivero-Calle, MD, shared at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.

ZIKV, an emerging flavivirus, is responsible for one the most critical pandemic emergencies of the last decade and has been associated with severe neonatal brain disabilities, declared Dr. Rivero-Calle, of the Hospital Clínico Universitario de Santiago de Compostela in Santiago de Compostela, Spain. “We think that understanding the genomic background could explain some of the most relevant symptoms of congenital Zika syndrome (CZS) and could be essential to better comprehend this disease.”

To achieve this understanding, Dr. Rivero-Calle and her colleagues conducted a study aiming to analyze any genetic factors that could explain the variation in phenotypes in newborns from mothers who had a Zika infection during their pregnancy. Additionally, they strove to “elucidate if the possible genetic association is specific to mothers or their newborns, and to check if this genomic background or any genomic ancestry pattern could be related with the phenotype,” she explained.

In their study, Dr. Rivero-Calle and her team analyzed 80 samples, comprising 40 samples from mothers who had been infected by ZIKV during their pregnancy and 40 from their newborns. Of those descendants, 20 were asymptomatic and 20 were symptomatic (13 had CZS, 3 had microcephaly, 2 had a pathologic MRI, 1 had hearing loss, and 1 was born preterm).

Population stratification, which Dr. Rivero-Calle explained “lets us know if the population is African, European, or Native American looking at the genes,” did not show any relation with the phenotype. We had a mixture of population genomics among all samples.”

Dr. Rivero-Calle and her team then performed three analyses: genotype analysis, an allelic test, and gene analysis. The allelic test and gene-collapsing method highlighted three genes (PANO1, PIDD1, and SLC25A22) as potential determinants of the varying phenotypes in the newborns from ZIKV-infected mothers. Overrepresentation analysis of gene ontology terms shows that PIDD1 and PANO1 are related to apoptosis and cell death, which is closely related to early infantile epilepsy. This could explain the most severe complications of CZS: seizures, brain damage, microcephaly, and detrimental neurodevelopmental growth. Regarding reactome and KEGG analysis, gene PIID1 is related with p53 pathway, which correlates with cell’s death and apoptosis, and with microcephaly, a typical phenotypic feature of CZS.

“So, in conclusion, we found three genes which could predict susceptibility to congenital Zika infection; we saw that the functionality of these genes seems to be deeply related with mechanisms which could explain the different phenotypes; and we saw that these three genes only appear in the children’s cohort, so there is no candidate gene in the mother’s genomic background which can help predict the phenotype of the newborn,” Dr. Rivero-Calle declared. “Finally, there is no ancestry pattern associated with disabilities caused by Zika infection.”

Dr. Rivero-Calle reported that this project (ZikAction) has received funding from the European Union’s Horizon 2020 research and innovation program, under grant agreement 734857.

Three genes that could predict susceptibility to congenital Zika virus (ZIKV) infection have been identified, Dr. Irene Rivero-Calle, MD, shared at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.

ZIKV, an emerging flavivirus, is responsible for one the most critical pandemic emergencies of the last decade and has been associated with severe neonatal brain disabilities, declared Dr. Rivero-Calle, of the Hospital Clínico Universitario de Santiago de Compostela in Santiago de Compostela, Spain. “We think that understanding the genomic background could explain some of the most relevant symptoms of congenital Zika syndrome (CZS) and could be essential to better comprehend this disease.”

To achieve this understanding, Dr. Rivero-Calle and her colleagues conducted a study aiming to analyze any genetic factors that could explain the variation in phenotypes in newborns from mothers who had a Zika infection during their pregnancy. Additionally, they strove to “elucidate if the possible genetic association is specific to mothers or their newborns, and to check if this genomic background or any genomic ancestry pattern could be related with the phenotype,” she explained.

In their study, Dr. Rivero-Calle and her team analyzed 80 samples, comprising 40 samples from mothers who had been infected by ZIKV during their pregnancy and 40 from their newborns. Of those descendants, 20 were asymptomatic and 20 were symptomatic (13 had CZS, 3 had microcephaly, 2 had a pathologic MRI, 1 had hearing loss, and 1 was born preterm).

Population stratification, which Dr. Rivero-Calle explained “lets us know if the population is African, European, or Native American looking at the genes,” did not show any relation with the phenotype. We had a mixture of population genomics among all samples.”

Dr. Rivero-Calle and her team then performed three analyses: genotype analysis, an allelic test, and gene analysis. The allelic test and gene-collapsing method highlighted three genes (PANO1, PIDD1, and SLC25A22) as potential determinants of the varying phenotypes in the newborns from ZIKV-infected mothers. Overrepresentation analysis of gene ontology terms shows that PIDD1 and PANO1 are related to apoptosis and cell death, which is closely related to early infantile epilepsy. This could explain the most severe complications of CZS: seizures, brain damage, microcephaly, and detrimental neurodevelopmental growth. Regarding reactome and KEGG analysis, gene PIID1 is related with p53 pathway, which correlates with cell’s death and apoptosis, and with microcephaly, a typical phenotypic feature of CZS.

“So, in conclusion, we found three genes which could predict susceptibility to congenital Zika infection; we saw that the functionality of these genes seems to be deeply related with mechanisms which could explain the different phenotypes; and we saw that these three genes only appear in the children’s cohort, so there is no candidate gene in the mother’s genomic background which can help predict the phenotype of the newborn,” Dr. Rivero-Calle declared. “Finally, there is no ancestry pattern associated with disabilities caused by Zika infection.”

Dr. Rivero-Calle reported that this project (ZikAction) has received funding from the European Union’s Horizon 2020 research and innovation program, under grant agreement 734857.

Three genes that could predict susceptibility to congenital Zika virus (ZIKV) infection have been identified, Dr. Irene Rivero-Calle, MD, shared at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.

ZIKV, an emerging flavivirus, is responsible for one the most critical pandemic emergencies of the last decade and has been associated with severe neonatal brain disabilities, declared Dr. Rivero-Calle, of the Hospital Clínico Universitario de Santiago de Compostela in Santiago de Compostela, Spain. “We think that understanding the genomic background could explain some of the most relevant symptoms of congenital Zika syndrome (CZS) and could be essential to better comprehend this disease.”

To achieve this understanding, Dr. Rivero-Calle and her colleagues conducted a study aiming to analyze any genetic factors that could explain the variation in phenotypes in newborns from mothers who had a Zika infection during their pregnancy. Additionally, they strove to “elucidate if the possible genetic association is specific to mothers or their newborns, and to check if this genomic background or any genomic ancestry pattern could be related with the phenotype,” she explained.

In their study, Dr. Rivero-Calle and her team analyzed 80 samples, comprising 40 samples from mothers who had been infected by ZIKV during their pregnancy and 40 from their newborns. Of those descendants, 20 were asymptomatic and 20 were symptomatic (13 had CZS, 3 had microcephaly, 2 had a pathologic MRI, 1 had hearing loss, and 1 was born preterm).

Population stratification, which Dr. Rivero-Calle explained “lets us know if the population is African, European, or Native American looking at the genes,” did not show any relation with the phenotype. We had a mixture of population genomics among all samples.”

Dr. Rivero-Calle and her team then performed three analyses: genotype analysis, an allelic test, and gene analysis. The allelic test and gene-collapsing method highlighted three genes (PANO1, PIDD1, and SLC25A22) as potential determinants of the varying phenotypes in the newborns from ZIKV-infected mothers. Overrepresentation analysis of gene ontology terms shows that PIDD1 and PANO1 are related to apoptosis and cell death, which is closely related to early infantile epilepsy. This could explain the most severe complications of CZS: seizures, brain damage, microcephaly, and detrimental neurodevelopmental growth. Regarding reactome and KEGG analysis, gene PIID1 is related with p53 pathway, which correlates with cell’s death and apoptosis, and with microcephaly, a typical phenotypic feature of CZS.

“So, in conclusion, we found three genes which could predict susceptibility to congenital Zika infection; we saw that the functionality of these genes seems to be deeply related with mechanisms which could explain the different phenotypes; and we saw that these three genes only appear in the children’s cohort, so there is no candidate gene in the mother’s genomic background which can help predict the phenotype of the newborn,” Dr. Rivero-Calle declared. “Finally, there is no ancestry pattern associated with disabilities caused by Zika infection.”

Dr. Rivero-Calle reported that this project (ZikAction) has received funding from the European Union’s Horizon 2020 research and innovation program, under grant agreement 734857.

Clostridioides difficile (C. diff) infection (CDI) is a pathogen of both humans and animals, and to control it will require an integrated approach that encompasses human health care, veterinary health care, environmental regulation, and public policy. That is the conclusion of a group led by Su-Chen Lim, MD, and Tom Riley, MD, of Edith Cowan University in Australia, who published a review in Clinical Microbiology and Infection.

CDI was generally considered a nuisance infection until the early 21st century, when a hypervirulent fluoroquinolone-resistant strain emerged in North America. The strain is now documented In the United States, Canada, and most countries in Europe.

Another new feature of CDI is increased evidence of community transmission, which was previously rare. This is defined as cases where the patient experienced symptom onset outside the hospital, and had no history of hospitalization in the previous 12 weeks or symptom onset within 48 hours of hospital admission. Community-associated CDI now accounts for 41% of U.S. cases, nearly 30% of Australian cases, and about 14% in Europe, according to recent studies.

Several features of CDI suggest a need for an integrated management plan. The preferred habitat of C. diff is the gastrointestinal track of mammals, and likely colonizes all mammalian neonates. Over time, colonization by other microbes likely crowd it out and prevent overgrowth. But widespread use of antimicrobials in animal production can lead to the creation of an environment resembling that of the neonate, allowing C. diff to expand. That has led to food animals becoming a major C. diff reservoir, and whole-genome studies showed that strains found in humans, food, animals, and the environment are closely related and sometimes genetically indistinguishable, suggesting transmission between humans and animals that may be attributable to contaminated food and environments.

The authors suggest that C. diff infection control should be guided by the One Health initiative, which seeks cooperation between physicians, osteopathic physicians, veterinarians, dentists, nurses, and other scientific and environmental disciplines. The goal is to enhance surveillance and interdisciplinary communication, as well as integrated policies. The authors note that C. diff is often thought of by physicians as primarily a hospital problem, who may be unaware of the increased prevalence of community-acquired disease. It is also a significant problem in agriculture, since as many as 50% of piglets succumb to the disease. Other studies have recently shown that asymptomatic carriers of toxigenic strains are likely to transmit the bacteria to C. diff-negative patients. Asymptomatic carriers cluster with symptomatic patients. In one Cleveland hospital, more than 25% of hospital-associated CDI cases were found to have been colonized prior to admission, suggesting that these were not true hospital-associated cases.

C. diff has been isolated from a wide range of sources, including food animals, meat, seafood, vegetables, household environments, and natural environments like rivers, lakes, and soil. About 20% of calves and 70% of piglets are colonized with C. diff. It has a high prevalence in meat products in the United States, but lower in the Europe, possibly because of different slaughtering practices.

The authors suggest that zoonotic C. diff spread is unlikely to be confined to any geographic region or population, and that widespread C. diff contamination is occurring through food or the environment. This could be occurring because spores can withstand cooking temperatures and disseminate through the air, and even through manure from food animals made into compost or fertilizer.

Veterinary efforts mimicking hospital measures have reduced animal CDI, but there are no rapid diagnostic tests for CDI in animals, making it challenging to control its spread in this context.

The authors call for enhanced antimicrobial stewardship in both human and animal settings, including banning of antimicrobial agents as growth promoters. This has been done in the United States and Europe, but not in Brazil, China, Canada, India, and Australia. They also call for research on inactivation of C. diff spores during waste treatment.

Even better, the authors suggest that vaccines should be developed and employed in both animals and humans. No such vaccine exists in animals, but Pfizer has one for humans in a phase 3 clinical trial, but it does not prevent colonization. Others are in development.

The epidemiology of CDI is an ongoing challenge, with emerging new strains and changing social and environmental conditions. “However, it is with the collaborative efforts of industry partners, policymakers, veterinarians, clinicians, and researchers that CDI needs to be approached, a perfect example of One Health. Opening an interdisciplinary dialogue to address CDI and One Health issues has to be the focus of future studies,” the authors concluded.

SOURCE: SC Lim et al. Clinical Microbiology and Infection. 2020;26:85-863.

Clostridioides difficile (C. diff) infection (CDI) is a pathogen of both humans and animals, and to control it will require an integrated approach that encompasses human health care, veterinary health care, environmental regulation, and public policy. That is the conclusion of a group led by Su-Chen Lim, MD, and Tom Riley, MD, of Edith Cowan University in Australia, who published a review in Clinical Microbiology and Infection.

CDI was generally considered a nuisance infection until the early 21st century, when a hypervirulent fluoroquinolone-resistant strain emerged in North America. The strain is now documented In the United States, Canada, and most countries in Europe.

Another new feature of CDI is increased evidence of community transmission, which was previously rare. This is defined as cases where the patient experienced symptom onset outside the hospital, and had no history of hospitalization in the previous 12 weeks or symptom onset within 48 hours of hospital admission. Community-associated CDI now accounts for 41% of U.S. cases, nearly 30% of Australian cases, and about 14% in Europe, according to recent studies.

Several features of CDI suggest a need for an integrated management plan. The preferred habitat of C. diff is the gastrointestinal track of mammals, and likely colonizes all mammalian neonates. Over time, colonization by other microbes likely crowd it out and prevent overgrowth. But widespread use of antimicrobials in animal production can lead to the creation of an environment resembling that of the neonate, allowing C. diff to expand. That has led to food animals becoming a major C. diff reservoir, and whole-genome studies showed that strains found in humans, food, animals, and the environment are closely related and sometimes genetically indistinguishable, suggesting transmission between humans and animals that may be attributable to contaminated food and environments.

The authors suggest that C. diff infection control should be guided by the One Health initiative, which seeks cooperation between physicians, osteopathic physicians, veterinarians, dentists, nurses, and other scientific and environmental disciplines. The goal is to enhance surveillance and interdisciplinary communication, as well as integrated policies. The authors note that C. diff is often thought of by physicians as primarily a hospital problem, who may be unaware of the increased prevalence of community-acquired disease. It is also a significant problem in agriculture, since as many as 50% of piglets succumb to the disease. Other studies have recently shown that asymptomatic carriers of toxigenic strains are likely to transmit the bacteria to C. diff-negative patients. Asymptomatic carriers cluster with symptomatic patients. In one Cleveland hospital, more than 25% of hospital-associated CDI cases were found to have been colonized prior to admission, suggesting that these were not true hospital-associated cases.

C. diff has been isolated from a wide range of sources, including food animals, meat, seafood, vegetables, household environments, and natural environments like rivers, lakes, and soil. About 20% of calves and 70% of piglets are colonized with C. diff. It has a high prevalence in meat products in the United States, but lower in the Europe, possibly because of different slaughtering practices.

The authors suggest that zoonotic C. diff spread is unlikely to be confined to any geographic region or population, and that widespread C. diff contamination is occurring through food or the environment. This could be occurring because spores can withstand cooking temperatures and disseminate through the air, and even through manure from food animals made into compost or fertilizer.

Veterinary efforts mimicking hospital measures have reduced animal CDI, but there are no rapid diagnostic tests for CDI in animals, making it challenging to control its spread in this context.

The authors call for enhanced antimicrobial stewardship in both human and animal settings, including banning of antimicrobial agents as growth promoters. This has been done in the United States and Europe, but not in Brazil, China, Canada, India, and Australia. They also call for research on inactivation of C. diff spores during waste treatment.

Even better, the authors suggest that vaccines should be developed and employed in both animals and humans. No such vaccine exists in animals, but Pfizer has one for humans in a phase 3 clinical trial, but it does not prevent colonization. Others are in development.

The epidemiology of CDI is an ongoing challenge, with emerging new strains and changing social and environmental conditions. “However, it is with the collaborative efforts of industry partners, policymakers, veterinarians, clinicians, and researchers that CDI needs to be approached, a perfect example of One Health. Opening an interdisciplinary dialogue to address CDI and One Health issues has to be the focus of future studies,” the authors concluded.

SOURCE: SC Lim et al. Clinical Microbiology and Infection. 2020;26:85-863.

Clostridioides difficile (C. diff) infection (CDI) is a pathogen of both humans and animals, and to control it will require an integrated approach that encompasses human health care, veterinary health care, environmental regulation, and public policy. That is the conclusion of a group led by Su-Chen Lim, MD, and Tom Riley, MD, of Edith Cowan University in Australia, who published a review in Clinical Microbiology and Infection.

CDI was generally considered a nuisance infection until the early 21st century, when a hypervirulent fluoroquinolone-resistant strain emerged in North America. The strain is now documented In the United States, Canada, and most countries in Europe.

Another new feature of CDI is increased evidence of community transmission, which was previously rare. This is defined as cases where the patient experienced symptom onset outside the hospital, and had no history of hospitalization in the previous 12 weeks or symptom onset within 48 hours of hospital admission. Community-associated CDI now accounts for 41% of U.S. cases, nearly 30% of Australian cases, and about 14% in Europe, according to recent studies.

Several features of CDI suggest a need for an integrated management plan. The preferred habitat of C. diff is the gastrointestinal track of mammals, and likely colonizes all mammalian neonates. Over time, colonization by other microbes likely crowd it out and prevent overgrowth. But widespread use of antimicrobials in animal production can lead to the creation of an environment resembling that of the neonate, allowing C. diff to expand. That has led to food animals becoming a major C. diff reservoir, and whole-genome studies showed that strains found in humans, food, animals, and the environment are closely related and sometimes genetically indistinguishable, suggesting transmission between humans and animals that may be attributable to contaminated food and environments.

The authors suggest that C. diff infection control should be guided by the One Health initiative, which seeks cooperation between physicians, osteopathic physicians, veterinarians, dentists, nurses, and other scientific and environmental disciplines. The goal is to enhance surveillance and interdisciplinary communication, as well as integrated policies. The authors note that C. diff is often thought of by physicians as primarily a hospital problem, who may be unaware of the increased prevalence of community-acquired disease. It is also a significant problem in agriculture, since as many as 50% of piglets succumb to the disease. Other studies have recently shown that asymptomatic carriers of toxigenic strains are likely to transmit the bacteria to C. diff-negative patients. Asymptomatic carriers cluster with symptomatic patients. In one Cleveland hospital, more than 25% of hospital-associated CDI cases were found to have been colonized prior to admission, suggesting that these were not true hospital-associated cases.

C. diff has been isolated from a wide range of sources, including food animals, meat, seafood, vegetables, household environments, and natural environments like rivers, lakes, and soil. About 20% of calves and 70% of piglets are colonized with C. diff. It has a high prevalence in meat products in the United States, but lower in the Europe, possibly because of different slaughtering practices.

The authors suggest that zoonotic C. diff spread is unlikely to be confined to any geographic region or population, and that widespread C. diff contamination is occurring through food or the environment. This could be occurring because spores can withstand cooking temperatures and disseminate through the air, and even through manure from food animals made into compost or fertilizer.

Veterinary efforts mimicking hospital measures have reduced animal CDI, but there are no rapid diagnostic tests for CDI in animals, making it challenging to control its spread in this context.

The authors call for enhanced antimicrobial stewardship in both human and animal settings, including banning of antimicrobial agents as growth promoters. This has been done in the United States and Europe, but not in Brazil, China, Canada, India, and Australia. They also call for research on inactivation of C. diff spores during waste treatment.

Even better, the authors suggest that vaccines should be developed and employed in both animals and humans. No such vaccine exists in animals, but Pfizer has one for humans in a phase 3 clinical trial, but it does not prevent colonization. Others are in development.

The epidemiology of CDI is an ongoing challenge, with emerging new strains and changing social and environmental conditions. “However, it is with the collaborative efforts of industry partners, policymakers, veterinarians, clinicians, and researchers that CDI needs to be approached, a perfect example of One Health. Opening an interdisciplinary dialogue to address CDI and One Health issues has to be the focus of future studies,” the authors concluded.

SOURCE: SC Lim et al. Clinical Microbiology and Infection. 2020;26:85-863.

A Spanish survey of COVID-19 patients suggests that upper gastrointestinal bleeding (UGB) does not affect in-hospital mortality. It also found that fewer COVID-19–positive patients underwent endoscopies, but there was no statistically significant difference in in-hospital mortality outcome as a result of delays.

“In-hospital mortality in COVID-19 patients with upper-GI bleeding seemed to be more influenced by COVID-19 than by upper-GI bleeding, and that’s something I think is important for us to know,” Gyanprakash Ketwaroo, MD, associate professor at Baylor College of Medicine, Houston, said in an interview. Dr. Ketwaroo was not involved in the study.

The results weren’t a surprise, but they do provide some reassurance. “It’s probably what I expected. Initially, we thought there might be some COVID-19 related (GI) lesions, but that didn’t seem to be borne out. So we thought the bleeding was related to (the patient) being in a hospital or the typical reasons for bleeding. It’s also what I expected that less endoscopies would be performed in these patients, and even though fewer endoscopies were performed, the outcomes were still similar. I think it’s what most people expected,” said Dr. Ketwaroo.

The study was published online Nov. 25 in the Journal of Clinical Gastroenterology, and led by Rebeca González González, MD, of Severo Ochoa University Hospital in Leganés, Madrid, and Pascual Piñera-Salmerón, MD, of Reina Sofia University General Hospital in Murcia, Spain. The researchers retrospectively analyzed data on 71,904 COVID-19 patients at 62 emergency departments in Spain, and compared 83 patients who had COVID-19 and UGB to two control groups: 249 randomly selected COVID-19 patients without UGB, and 249 randomly selected non-COVID-19 patients with UGB.

They found that 1.11% of COVID-19 patients presented with UGB, compared with 1.78% of non-COVID-19 patients at emergency departments. In patients with COVID-19, risk of UGB was associated with hemoglobin values < 10 g/L (odds ratio [OR], 34.255, 95% confidence interval [CI], 12.752-92.021), abdominal pain (OR, 11.4; 95% CI, 5.092-25.944), and systolic blood pressure < 90 mm Hg (OR, 11.096; 95% CI, 2.975-41.390).

Compared with non-COVID-19 patients with UGB, those COVID-19 patients with UGB were more likely to have interstitial lung infiltrates (OR, 66.42; 95% CI, 15.364-287.223) and ground-glass opacities (OR, 21.27; 95% CI, 9.720-46.567) in chest radiograph, as well as fever (OR, 34.67; 95% CI, 11.719-102.572) and cough (OR, 26.4; 95% CI, 8.845-78.806).

Gastroscopy and endoscopic procedures were lower in patients with COVID-19 than in the general population (gastroscopy OR, 0.269; 95% CI, 0.160-0.453: endoscopy OR, 0.26; 95% CI, 0.165-0.623). There was no difference between the two groups with respect to endoscopic findings. After adjustment for age and sex, the only significant difference between COVID-19 patients with UGB and COVID-19 patients without UGB was a higher rate of intensive care unit admission (OR, 2.98; 95% CI, 1.16-7.65). Differences between COVID-19 patients with UGB and non–COVID-19 patients with UGB included higher rates of ICU admission (OR, 3.29; 95% CI, 1.28-8.47), prolonged hospitalizations (OR, 2.02; 95% CI, 1.15-3.55), and in-hospital mortality (OR, 2.05; 95% CI, 1.09-3.86).

UGB development was not associated with increased in-hospital mortality in COVID-19 patients (OR, 1.14; 95% CI, 0.59-2.19).

A limitation to the study it was that it was performed in Spain, where endoscopies are performed in the emergency department, and where there are different thresholds for admission to the intensive care unit than in the United States.

The authors did not report a funding source. Dr. Ketwaroo has no relevant financial disclosures.

SOURCE: González González R et al. J Clin Gastroenterol. 10.1097/MCG.0000000000001465.

A Spanish survey of COVID-19 patients suggests that upper gastrointestinal bleeding (UGB) does not affect in-hospital mortality. It also found that fewer COVID-19–positive patients underwent endoscopies, but there was no statistically significant difference in in-hospital mortality outcome as a result of delays.

“In-hospital mortality in COVID-19 patients with upper-GI bleeding seemed to be more influenced by COVID-19 than by upper-GI bleeding, and that’s something I think is important for us to know,” Gyanprakash Ketwaroo, MD, associate professor at Baylor College of Medicine, Houston, said in an interview. Dr. Ketwaroo was not involved in the study.

The results weren’t a surprise, but they do provide some reassurance. “It’s probably what I expected. Initially, we thought there might be some COVID-19 related (GI) lesions, but that didn’t seem to be borne out. So we thought the bleeding was related to (the patient) being in a hospital or the typical reasons for bleeding. It’s also what I expected that less endoscopies would be performed in these patients, and even though fewer endoscopies were performed, the outcomes were still similar. I think it’s what most people expected,” said Dr. Ketwaroo.

The study was published online Nov. 25 in the Journal of Clinical Gastroenterology, and led by Rebeca González González, MD, of Severo Ochoa University Hospital in Leganés, Madrid, and Pascual Piñera-Salmerón, MD, of Reina Sofia University General Hospital in Murcia, Spain. The researchers retrospectively analyzed data on 71,904 COVID-19 patients at 62 emergency departments in Spain, and compared 83 patients who had COVID-19 and UGB to two control groups: 249 randomly selected COVID-19 patients without UGB, and 249 randomly selected non-COVID-19 patients with UGB.

They found that 1.11% of COVID-19 patients presented with UGB, compared with 1.78% of non-COVID-19 patients at emergency departments. In patients with COVID-19, risk of UGB was associated with hemoglobin values < 10 g/L (odds ratio [OR], 34.255, 95% confidence interval [CI], 12.752-92.021), abdominal pain (OR, 11.4; 95% CI, 5.092-25.944), and systolic blood pressure < 90 mm Hg (OR, 11.096; 95% CI, 2.975-41.390).

Compared with non-COVID-19 patients with UGB, those COVID-19 patients with UGB were more likely to have interstitial lung infiltrates (OR, 66.42; 95% CI, 15.364-287.223) and ground-glass opacities (OR, 21.27; 95% CI, 9.720-46.567) in chest radiograph, as well as fever (OR, 34.67; 95% CI, 11.719-102.572) and cough (OR, 26.4; 95% CI, 8.845-78.806).

Gastroscopy and endoscopic procedures were lower in patients with COVID-19 than in the general population (gastroscopy OR, 0.269; 95% CI, 0.160-0.453: endoscopy OR, 0.26; 95% CI, 0.165-0.623). There was no difference between the two groups with respect to endoscopic findings. After adjustment for age and sex, the only significant difference between COVID-19 patients with UGB and COVID-19 patients without UGB was a higher rate of intensive care unit admission (OR, 2.98; 95% CI, 1.16-7.65). Differences between COVID-19 patients with UGB and non–COVID-19 patients with UGB included higher rates of ICU admission (OR, 3.29; 95% CI, 1.28-8.47), prolonged hospitalizations (OR, 2.02; 95% CI, 1.15-3.55), and in-hospital mortality (OR, 2.05; 95% CI, 1.09-3.86).

UGB development was not associated with increased in-hospital mortality in COVID-19 patients (OR, 1.14; 95% CI, 0.59-2.19).

A limitation to the study it was that it was performed in Spain, where endoscopies are performed in the emergency department, and where there are different thresholds for admission to the intensive care unit than in the United States.

The authors did not report a funding source. Dr. Ketwaroo has no relevant financial disclosures.

SOURCE: González González R et al. J Clin Gastroenterol. 10.1097/MCG.0000000000001465.

A Spanish survey of COVID-19 patients suggests that upper gastrointestinal bleeding (UGB) does not affect in-hospital mortality. It also found that fewer COVID-19–positive patients underwent endoscopies, but there was no statistically significant difference in in-hospital mortality outcome as a result of delays.

“In-hospital mortality in COVID-19 patients with upper-GI bleeding seemed to be more influenced by COVID-19 than by upper-GI bleeding, and that’s something I think is important for us to know,” Gyanprakash Ketwaroo, MD, associate professor at Baylor College of Medicine, Houston, said in an interview. Dr. Ketwaroo was not involved in the study.

The results weren’t a surprise, but they do provide some reassurance. “It’s probably what I expected. Initially, we thought there might be some COVID-19 related (GI) lesions, but that didn’t seem to be borne out. So we thought the bleeding was related to (the patient) being in a hospital or the typical reasons for bleeding. It’s also what I expected that less endoscopies would be performed in these patients, and even though fewer endoscopies were performed, the outcomes were still similar. I think it’s what most people expected,” said Dr. Ketwaroo.

The study was published online Nov. 25 in the Journal of Clinical Gastroenterology, and led by Rebeca González González, MD, of Severo Ochoa University Hospital in Leganés, Madrid, and Pascual Piñera-Salmerón, MD, of Reina Sofia University General Hospital in Murcia, Spain. The researchers retrospectively analyzed data on 71,904 COVID-19 patients at 62 emergency departments in Spain, and compared 83 patients who had COVID-19 and UGB to two control groups: 249 randomly selected COVID-19 patients without UGB, and 249 randomly selected non-COVID-19 patients with UGB.

They found that 1.11% of COVID-19 patients presented with UGB, compared with 1.78% of non-COVID-19 patients at emergency departments. In patients with COVID-19, risk of UGB was associated with hemoglobin values < 10 g/L (odds ratio [OR], 34.255, 95% confidence interval [CI], 12.752-92.021), abdominal pain (OR, 11.4; 95% CI, 5.092-25.944), and systolic blood pressure < 90 mm Hg (OR, 11.096; 95% CI, 2.975-41.390).

Compared with non-COVID-19 patients with UGB, those COVID-19 patients with UGB were more likely to have interstitial lung infiltrates (OR, 66.42; 95% CI, 15.364-287.223) and ground-glass opacities (OR, 21.27; 95% CI, 9.720-46.567) in chest radiograph, as well as fever (OR, 34.67; 95% CI, 11.719-102.572) and cough (OR, 26.4; 95% CI, 8.845-78.806).

Gastroscopy and endoscopic procedures were lower in patients with COVID-19 than in the general population (gastroscopy OR, 0.269; 95% CI, 0.160-0.453: endoscopy OR, 0.26; 95% CI, 0.165-0.623). There was no difference between the two groups with respect to endoscopic findings. After adjustment for age and sex, the only significant difference between COVID-19 patients with UGB and COVID-19 patients without UGB was a higher rate of intensive care unit admission (OR, 2.98; 95% CI, 1.16-7.65). Differences between COVID-19 patients with UGB and non–COVID-19 patients with UGB included higher rates of ICU admission (OR, 3.29; 95% CI, 1.28-8.47), prolonged hospitalizations (OR, 2.02; 95% CI, 1.15-3.55), and in-hospital mortality (OR, 2.05; 95% CI, 1.09-3.86).

UGB development was not associated with increased in-hospital mortality in COVID-19 patients (OR, 1.14; 95% CI, 0.59-2.19).

A limitation to the study it was that it was performed in Spain, where endoscopies are performed in the emergency department, and where there are different thresholds for admission to the intensive care unit than in the United States.

The authors did not report a funding source. Dr. Ketwaroo has no relevant financial disclosures.

SOURCE: González González R et al. J Clin Gastroenterol. 10.1097/MCG.0000000000001465.

An analysis of nearly 29,000 U.S. women with early-onset colorectal cancer (CRC) showed that physical inactivity and fertility correlated modestly with living in “hot spots,” or counties with high early-onset CRC mortality rates among women.

Approximately one-third of the variation in early-onset CRC survival among women was accounted for by differences in individual- or community-level features.

Andreana N. Holowatyj, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues reported these findings in Clinical and Translational Gastroenterology.

Dr. Holowatyj and colleagues noted that prior studies have linked health behaviors with an increased risk of early-onset CRC among women. However, the impact of health behaviors on outcomes of early-onset CRC is unknown.

The researchers hypothesized that biological-, individual-, and community-level factors may be contributing to known sex-specific differences in CRC outcomes and geographic variations in survival by sex.
 

Hot spot counties with high mortality

The researchers identified geographic hot spots using three geospatial autocorrelation approaches with Centers for Disease Control and Prevention national

mortality data. The team also analyzed data from the Surveillance, Epidemiology, and End Results program on 28,790 women (aged 15-49 years) diagnosed with CRC during 1999-2016.

Of the 3,108 counties in the contiguous United States, 191 were identified as hot spots. Among these, 101 (52.9%) were located in the South.

Earlier research had shown a predominance of hot spots for early-onset CRC mortality among both men and women in the South.

However, the current study of women showed that almost half of these counties were located in the Midwest and the Northeast as well as the South.

Also in the current analysis, about one in every seven women (13.7%) with early-onset CRC resided in hot spot counties.

Race/ethnicity, stage at diagnosis, histopathology, and receipt of first-course therapies also differed significantly (P ≤ .0001) between women residing in hot spot versus non–hot spot counties.

Non-Hispanic Black patients, for example, accounted for 23.7% of early-onset CRC cases in hot spot counties, as compared with 14.3% in non–hot spot counties (P < .0001). The county-level proportion of non-Hispanic Black patients also modestly correlated with hot spot residence (r_s = .26; P < .0001).

Race and ethnicity accounted for less than 0.5% of the variation in early-onset CRC survival among women in non–hot spot counties. In hot spot counties, however, this factor explained 1.4% of the variation in early-onset CRC-specific survival among women.
 

Inactivity correlates with hot spot residence

Dr. Holowatyj and colleagues also identified physical inactivity and lower fertility as county-level factors modestly correlated with hot spot residence (r_s = .21, r_s = –.23: P < .01).

Nearly a quarter of adults living in hot spot counties reported no physical activity during their leisure time (24.1% vs. 21.7% in non–hot spot counties; P < .01).

The rate of live births in the last year among women aged 15-50 years was lower in hot spot counties than in non–hot spot counties (4.9% vs. 5.4%; P < .01).

Individual- and community-level features overall accounted for different proportions of variance in early-onset CRC survival among women residing in hot spot counties (33.8%) versus non–hot spot counties (34.1%).

In addition to race and ethnicity, age at diagnosis, tumor histology, county-level proportions of the non-Hispanic Black population, women with a live birth in the last year, and annual household income of less than $20,000 all explained greater variance in CRC survival in young women in hot spot counties versus non–hot spot counties.
 

Keep CRC in differential diagnosis

“These individual- and community-level feature differences between hot spot and non–hot spot counties illustrate the importance of understanding how these factors may be contributing to early-onset CRC mortality among women – particularly in hot spot counties,” Dr. Holowatyj said in an interview. “They may provide us with key clues for developing effective strategies to reduce the burden of CRC in young women across the United States.

“Every primary care physician and gastroenterologist, particularly in hot spot counties, should keep CRC in their differential diagnosis, particularly if a patient is presenting with typical signs and symptoms, even if they are not yet of screening age. Early-stage diagnosis increases survival odds because the cancer may be easier to treat.”

Health professionals can also encourage physical activity and a healthy lifestyle, she added.

The authors declared no competing interests. Their research was funded by grants from the federal government and foundations.

SOURCE: Holowatyj AN et al. Clin and Transl Gastroenterol. 2020;11:e00266.

An analysis of nearly 29,000 U.S. women with early-onset colorectal cancer (CRC) showed that physical inactivity and fertility correlated modestly with living in “hot spots,” or counties with high early-onset CRC mortality rates among women.

Approximately one-third of the variation in early-onset CRC survival among women was accounted for by differences in individual- or community-level features.

Andreana N. Holowatyj, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues reported these findings in Clinical and Translational Gastroenterology.

Dr. Holowatyj and colleagues noted that prior studies have linked health behaviors with an increased risk of early-onset CRC among women. However, the impact of health behaviors on outcomes of early-onset CRC is unknown.

The researchers hypothesized that biological-, individual-, and community-level factors may be contributing to known sex-specific differences in CRC outcomes and geographic variations in survival by sex.
 

Hot spot counties with high mortality

The researchers identified geographic hot spots using three geospatial autocorrelation approaches with Centers for Disease Control and Prevention national

mortality data. The team also analyzed data from the Surveillance, Epidemiology, and End Results program on 28,790 women (aged 15-49 years) diagnosed with CRC during 1999-2016.

Of the 3,108 counties in the contiguous United States, 191 were identified as hot spots. Among these, 101 (52.9%) were located in the South.

Earlier research had shown a predominance of hot spots for early-onset CRC mortality among both men and women in the South.

However, the current study of women showed that almost half of these counties were located in the Midwest and the Northeast as well as the South.

Also in the current analysis, about one in every seven women (13.7%) with early-onset CRC resided in hot spot counties.

Race/ethnicity, stage at diagnosis, histopathology, and receipt of first-course therapies also differed significantly (P ≤ .0001) between women residing in hot spot versus non–hot spot counties.

Non-Hispanic Black patients, for example, accounted for 23.7% of early-onset CRC cases in hot spot counties, as compared with 14.3% in non–hot spot counties (P < .0001). The county-level proportion of non-Hispanic Black patients also modestly correlated with hot spot residence (r_s = .26; P < .0001).

Race and ethnicity accounted for less than 0.5% of the variation in early-onset CRC survival among women in non–hot spot counties. In hot spot counties, however, this factor explained 1.4% of the variation in early-onset CRC-specific survival among women.
 

Inactivity correlates with hot spot residence

Dr. Holowatyj and colleagues also identified physical inactivity and lower fertility as county-level factors modestly correlated with hot spot residence (r_s = .21, r_s = –.23: P < .01).

Nearly a quarter of adults living in hot spot counties reported no physical activity during their leisure time (24.1% vs. 21.7% in non–hot spot counties; P < .01).

The rate of live births in the last year among women aged 15-50 years was lower in hot spot counties than in non–hot spot counties (4.9% vs. 5.4%; P < .01).

Individual- and community-level features overall accounted for different proportions of variance in early-onset CRC survival among women residing in hot spot counties (33.8%) versus non–hot spot counties (34.1%).

In addition to race and ethnicity, age at diagnosis, tumor histology, county-level proportions of the non-Hispanic Black population, women with a live birth in the last year, and annual household income of less than $20,000 all explained greater variance in CRC survival in young women in hot spot counties versus non–hot spot counties.
 

Keep CRC in differential diagnosis

“These individual- and community-level feature differences between hot spot and non–hot spot counties illustrate the importance of understanding how these factors may be contributing to early-onset CRC mortality among women – particularly in hot spot counties,” Dr. Holowatyj said in an interview. “They may provide us with key clues for developing effective strategies to reduce the burden of CRC in young women across the United States.

“Every primary care physician and gastroenterologist, particularly in hot spot counties, should keep CRC in their differential diagnosis, particularly if a patient is presenting with typical signs and symptoms, even if they are not yet of screening age. Early-stage diagnosis increases survival odds because the cancer may be easier to treat.”

Health professionals can also encourage physical activity and a healthy lifestyle, she added.

The authors declared no competing interests. Their research was funded by grants from the federal government and foundations.

SOURCE: Holowatyj AN et al. Clin and Transl Gastroenterol. 2020;11:e00266.

An analysis of nearly 29,000 U.S. women with early-onset colorectal cancer (CRC) showed that physical inactivity and fertility correlated modestly with living in “hot spots,” or counties with high early-onset CRC mortality rates among women.

Approximately one-third of the variation in early-onset CRC survival among women was accounted for by differences in individual- or community-level features.

Andreana N. Holowatyj, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues reported these findings in Clinical and Translational Gastroenterology.

Dr. Holowatyj and colleagues noted that prior studies have linked health behaviors with an increased risk of early-onset CRC among women. However, the impact of health behaviors on outcomes of early-onset CRC is unknown.

The researchers hypothesized that biological-, individual-, and community-level factors may be contributing to known sex-specific differences in CRC outcomes and geographic variations in survival by sex.
 

Hot spot counties with high mortality

The researchers identified geographic hot spots using three geospatial autocorrelation approaches with Centers for Disease Control and Prevention national

mortality data. The team also analyzed data from the Surveillance, Epidemiology, and End Results program on 28,790 women (aged 15-49 years) diagnosed with CRC during 1999-2016.

Of the 3,108 counties in the contiguous United States, 191 were identified as hot spots. Among these, 101 (52.9%) were located in the South.

Earlier research had shown a predominance of hot spots for early-onset CRC mortality among both men and women in the South.

However, the current study of women showed that almost half of these counties were located in the Midwest and the Northeast as well as the South.

Also in the current analysis, about one in every seven women (13.7%) with early-onset CRC resided in hot spot counties.

Race/ethnicity, stage at diagnosis, histopathology, and receipt of first-course therapies also differed significantly (P ≤ .0001) between women residing in hot spot versus non–hot spot counties.

Non-Hispanic Black patients, for example, accounted for 23.7% of early-onset CRC cases in hot spot counties, as compared with 14.3% in non–hot spot counties (P < .0001). The county-level proportion of non-Hispanic Black patients also modestly correlated with hot spot residence (r_s = .26; P < .0001).

Race and ethnicity accounted for less than 0.5% of the variation in early-onset CRC survival among women in non–hot spot counties. In hot spot counties, however, this factor explained 1.4% of the variation in early-onset CRC-specific survival among women.
 

Inactivity correlates with hot spot residence

Dr. Holowatyj and colleagues also identified physical inactivity and lower fertility as county-level factors modestly correlated with hot spot residence (r_s = .21, r_s = –.23: P < .01).

Nearly a quarter of adults living in hot spot counties reported no physical activity during their leisure time (24.1% vs. 21.7% in non–hot spot counties; P < .01).

The rate of live births in the last year among women aged 15-50 years was lower in hot spot counties than in non–hot spot counties (4.9% vs. 5.4%; P < .01).

Individual- and community-level features overall accounted for different proportions of variance in early-onset CRC survival among women residing in hot spot counties (33.8%) versus non–hot spot counties (34.1%).

In addition to race and ethnicity, age at diagnosis, tumor histology, county-level proportions of the non-Hispanic Black population, women with a live birth in the last year, and annual household income of less than $20,000 all explained greater variance in CRC survival in young women in hot spot counties versus non–hot spot counties.
 

Keep CRC in differential diagnosis

“These individual- and community-level feature differences between hot spot and non–hot spot counties illustrate the importance of understanding how these factors may be contributing to early-onset CRC mortality among women – particularly in hot spot counties,” Dr. Holowatyj said in an interview. “They may provide us with key clues for developing effective strategies to reduce the burden of CRC in young women across the United States.

“Every primary care physician and gastroenterologist, particularly in hot spot counties, should keep CRC in their differential diagnosis, particularly if a patient is presenting with typical signs and symptoms, even if they are not yet of screening age. Early-stage diagnosis increases survival odds because the cancer may be easier to treat.”

Health professionals can also encourage physical activity and a healthy lifestyle, she added.

The authors declared no competing interests. Their research was funded by grants from the federal government and foundations.

SOURCE: Holowatyj AN et al. Clin and Transl Gastroenterol. 2020;11:e00266.

COVID-19’s toll on member facilities pushed the American Academy of Sleep Medicine (AASM) recently to take a sizable gamble.

AASM announced in September that it would waive facility fees at all 2,648 AASM-accredited sleep facilities for 2021.

At $1,800-$2,600 for each facility, that will mean lost revenue of between $4.8 million and $6.9 million, but it’s a risk the academy felt it had to take.

AASM President Kannan Ramar, MBBS, MD, said in an interview that they are betting on the future of the field.

An internal survey of members, he said, found that nearly half (46%) of the 551 respondents thought they might have to close by the end of the year.

In addition, 66% reported a lower patient volume in the past month, and 36% reported that their practice or facility had to apply for loans or other financial assistance because of COVID-19, AASM said in its press release.

“We are hoping that if we help our members through this, they will be there for our patients,” Dr. Ramar said.

Other medical societies also are weighing options, straddling the line between needing income to provide resources for members but being acutely aware of the financial toll the pandemic is taking, according to one sampling.

As previously reported, primary care practices are projected to lose more than $68,000 in revenue per full-time physician in 2020, after steep drops in office visits and the collection of fees from March to May, according to a study led by researchers in the Blavatnik Institute at Harvard Medical School, Boston.

Those losses were calculated without considering a potential second wave of COVID-19 this year, the authors noted.
 

‘We can survive this’

Although AASM waived fees for its member facilities, individual physician fees have not been reduced so far. But the group is looking for more ways to help lower the economic burden on members, Dr. Ramar said.

“I don’t think we’ve ever been in this situation in the 45 years of the academy. This is a once-in-a-lifetime event for challenges we’re going through,” he said. “The board and the leadership realized that, if we’re going to do something, this is the time to do it.”

In addition to waiving the fees, AASM and the AASM Foundation are offering relief funding to state and regional sleep societies and research award recipients through programs created in response to COVID-19.

Some societies said they are not making changes to their dues or fees, some are forgoing cost-of-living fee increases, and some are waiving registration fees for annual meetings.

The American College of Allergy, Asthma and Immunology (ACAAI) waived most members’ registration fees for its annual meeting in November. Typically, that fee would be $500-$800 per member, plus charges for some premium sessions, Michael Blaiss, MD, ACAAI executive medical director, said.

Dr. Blaiss said in an interview that the college thought offering its 6,000 members essentially 25 free hours of CME would benefit them more than waiving annual membership dues, which are about $425 for physicians in the United States.

If the pandemic stretches through 2021, Dr. Blaiss said, “We can survive this. I’m not worried about that at all.”

But he acknowledged the painful effect on medical societies.

“I don’t think any organization would tell you it’s not having an effect on their income,” he said. “I know it is for us and for virtually any medical organization. A high percentage of income comes from the annual meeting.”

Waiving dues has not been a high priority among members in communications so far, Blaiss said.

American Academy of Dermatology President Bruce H. Thiers, MD, said in an interview that there will be no cost-of-living increase for 2021 dues, and AAD members can request a reduction in dues, which will be considered on a case-by-case basis.

“We understand that many members will have to make tough financial decisions,” he said.

In addition, AAD, which has more than 20,000 members, is exploring payment options to help members spread out the cost of membership.
 

ACP extends membership

The American College of Physicians, whose membership cycle starts in July, did not reduce dues but extended membership at no cost for 3 months through September to its 163,000 members, Phil Masters, MD, ACP’s vice president of membership, said in an interview.

It also expanded its educational offerings related to the pandemic, including webinars on physician wellness and issues regarding telemedicine.

He said expanding educational resources rather than waiving dues was an intentional decision after much discussion because “we’re primarily a services resource organization.”

Membership data are still being calculated, but early indications are that membership is not increasing this year, after seeing annual growth of about 2%-2.5%, Dr. Masters said. He noted that income is down “by several percent.” Annual membership dues average about $500 for physicians who have been practicing for 10 years.

“We’re well positioned to tolerate the ups and downs,” he said, but he acknowledged that “there’s no question the financial impact has been devastating on some practices.”

Like some other associations, ACP decided to cancel this year’s annual meeting, which had been planned for April. The 2021 annual meeting will be conducted online from April 29 to May 1.

Smaller organizations that rely heavily on income from the annual meeting will be severely challenged the longer the pandemic continues, Dr. Masters said.

The decision is not as simple as whether to reduce or eliminate dues, he noted. Organizations will have to reexamine their missions and structure their fees and offerings according to the needs of members.

“It’s a balance in doing things for the community at large and balancing the need to be sensitive to financial implications,” Dr. Masters said.

This article first appeared on Medscape.com.

COVID-19’s toll on member facilities pushed the American Academy of Sleep Medicine (AASM) recently to take a sizable gamble.

AASM announced in September that it would waive facility fees at all 2,648 AASM-accredited sleep facilities for 2021.

At $1,800-$2,600 for each facility, that will mean lost revenue of between $4.8 million and $6.9 million, but it’s a risk the academy felt it had to take.

AASM President Kannan Ramar, MBBS, MD, said in an interview that they are betting on the future of the field.

An internal survey of members, he said, found that nearly half (46%) of the 551 respondents thought they might have to close by the end of the year.

In addition, 66% reported a lower patient volume in the past month, and 36% reported that their practice or facility had to apply for loans or other financial assistance because of COVID-19, AASM said in its press release.

“We are hoping that if we help our members through this, they will be there for our patients,” Dr. Ramar said.

Other medical societies also are weighing options, straddling the line between needing income to provide resources for members but being acutely aware of the financial toll the pandemic is taking, according to one sampling.

As previously reported, primary care practices are projected to lose more than $68,000 in revenue per full-time physician in 2020, after steep drops in office visits and the collection of fees from March to May, according to a study led by researchers in the Blavatnik Institute at Harvard Medical School, Boston.

Those losses were calculated without considering a potential second wave of COVID-19 this year, the authors noted.
 

‘We can survive this’

Although AASM waived fees for its member facilities, individual physician fees have not been reduced so far. But the group is looking for more ways to help lower the economic burden on members, Dr. Ramar said.

“I don’t think we’ve ever been in this situation in the 45 years of the academy. This is a once-in-a-lifetime event for challenges we’re going through,” he said. “The board and the leadership realized that, if we’re going to do something, this is the time to do it.”

In addition to waiving the fees, AASM and the AASM Foundation are offering relief funding to state and regional sleep societies and research award recipients through programs created in response to COVID-19.

Some societies said they are not making changes to their dues or fees, some are forgoing cost-of-living fee increases, and some are waiving registration fees for annual meetings.

The American College of Allergy, Asthma and Immunology (ACAAI) waived most members’ registration fees for its annual meeting in November. Typically, that fee would be $500-$800 per member, plus charges for some premium sessions, Michael Blaiss, MD, ACAAI executive medical director, said.

Dr. Blaiss said in an interview that the college thought offering its 6,000 members essentially 25 free hours of CME would benefit them more than waiving annual membership dues, which are about $425 for physicians in the United States.

If the pandemic stretches through 2021, Dr. Blaiss said, “We can survive this. I’m not worried about that at all.”

But he acknowledged the painful effect on medical societies.

“I don’t think any organization would tell you it’s not having an effect on their income,” he said. “I know it is for us and for virtually any medical organization. A high percentage of income comes from the annual meeting.”

Waiving dues has not been a high priority among members in communications so far, Blaiss said.

American Academy of Dermatology President Bruce H. Thiers, MD, said in an interview that there will be no cost-of-living increase for 2021 dues, and AAD members can request a reduction in dues, which will be considered on a case-by-case basis.

“We understand that many members will have to make tough financial decisions,” he said.

In addition, AAD, which has more than 20,000 members, is exploring payment options to help members spread out the cost of membership.
 

ACP extends membership

The American College of Physicians, whose membership cycle starts in July, did not reduce dues but extended membership at no cost for 3 months through September to its 163,000 members, Phil Masters, MD, ACP’s vice president of membership, said in an interview.

It also expanded its educational offerings related to the pandemic, including webinars on physician wellness and issues regarding telemedicine.

He said expanding educational resources rather than waiving dues was an intentional decision after much discussion because “we’re primarily a services resource organization.”

Membership data are still being calculated, but early indications are that membership is not increasing this year, after seeing annual growth of about 2%-2.5%, Dr. Masters said. He noted that income is down “by several percent.” Annual membership dues average about $500 for physicians who have been practicing for 10 years.

“We’re well positioned to tolerate the ups and downs,” he said, but he acknowledged that “there’s no question the financial impact has been devastating on some practices.”

Like some other associations, ACP decided to cancel this year’s annual meeting, which had been planned for April. The 2021 annual meeting will be conducted online from April 29 to May 1.

Smaller organizations that rely heavily on income from the annual meeting will be severely challenged the longer the pandemic continues, Dr. Masters said.

The decision is not as simple as whether to reduce or eliminate dues, he noted. Organizations will have to reexamine their missions and structure their fees and offerings according to the needs of members.

“It’s a balance in doing things for the community at large and balancing the need to be sensitive to financial implications,” Dr. Masters said.

This article first appeared on Medscape.com.

COVID-19’s toll on member facilities pushed the American Academy of Sleep Medicine (AASM) recently to take a sizable gamble.

AASM announced in September that it would waive facility fees at all 2,648 AASM-accredited sleep facilities for 2021.

At $1,800-$2,600 for each facility, that will mean lost revenue of between $4.8 million and $6.9 million, but it’s a risk the academy felt it had to take.

AASM President Kannan Ramar, MBBS, MD, said in an interview that they are betting on the future of the field.

An internal survey of members, he said, found that nearly half (46%) of the 551 respondents thought they might have to close by the end of the year.

In addition, 66% reported a lower patient volume in the past month, and 36% reported that their practice or facility had to apply for loans or other financial assistance because of COVID-19, AASM said in its press release.

“We are hoping that if we help our members through this, they will be there for our patients,” Dr. Ramar said.

Other medical societies also are weighing options, straddling the line between needing income to provide resources for members but being acutely aware of the financial toll the pandemic is taking, according to one sampling.

As previously reported, primary care practices are projected to lose more than $68,000 in revenue per full-time physician in 2020, after steep drops in office visits and the collection of fees from March to May, according to a study led by researchers in the Blavatnik Institute at Harvard Medical School, Boston.

Those losses were calculated without considering a potential second wave of COVID-19 this year, the authors noted.
 

‘We can survive this’

Although AASM waived fees for its member facilities, individual physician fees have not been reduced so far. But the group is looking for more ways to help lower the economic burden on members, Dr. Ramar said.

“I don’t think we’ve ever been in this situation in the 45 years of the academy. This is a once-in-a-lifetime event for challenges we’re going through,” he said. “The board and the leadership realized that, if we’re going to do something, this is the time to do it.”

In addition to waiving the fees, AASM and the AASM Foundation are offering relief funding to state and regional sleep societies and research award recipients through programs created in response to COVID-19.

Some societies said they are not making changes to their dues or fees, some are forgoing cost-of-living fee increases, and some are waiving registration fees for annual meetings.

The American College of Allergy, Asthma and Immunology (ACAAI) waived most members’ registration fees for its annual meeting in November. Typically, that fee would be $500-$800 per member, plus charges for some premium sessions, Michael Blaiss, MD, ACAAI executive medical director, said.

Dr. Blaiss said in an interview that the college thought offering its 6,000 members essentially 25 free hours of CME would benefit them more than waiving annual membership dues, which are about $425 for physicians in the United States.

If the pandemic stretches through 2021, Dr. Blaiss said, “We can survive this. I’m not worried about that at all.”

But he acknowledged the painful effect on medical societies.

“I don’t think any organization would tell you it’s not having an effect on their income,” he said. “I know it is for us and for virtually any medical organization. A high percentage of income comes from the annual meeting.”

Waiving dues has not been a high priority among members in communications so far, Blaiss said.

American Academy of Dermatology President Bruce H. Thiers, MD, said in an interview that there will be no cost-of-living increase for 2021 dues, and AAD members can request a reduction in dues, which will be considered on a case-by-case basis.

“We understand that many members will have to make tough financial decisions,” he said.

In addition, AAD, which has more than 20,000 members, is exploring payment options to help members spread out the cost of membership.
 

ACP extends membership

The American College of Physicians, whose membership cycle starts in July, did not reduce dues but extended membership at no cost for 3 months through September to its 163,000 members, Phil Masters, MD, ACP’s vice president of membership, said in an interview.

It also expanded its educational offerings related to the pandemic, including webinars on physician wellness and issues regarding telemedicine.

He said expanding educational resources rather than waiving dues was an intentional decision after much discussion because “we’re primarily a services resource organization.”

Membership data are still being calculated, but early indications are that membership is not increasing this year, after seeing annual growth of about 2%-2.5%, Dr. Masters said. He noted that income is down “by several percent.” Annual membership dues average about $500 for physicians who have been practicing for 10 years.

“We’re well positioned to tolerate the ups and downs,” he said, but he acknowledged that “there’s no question the financial impact has been devastating on some practices.”

Like some other associations, ACP decided to cancel this year’s annual meeting, which had been planned for April. The 2021 annual meeting will be conducted online from April 29 to May 1.

Smaller organizations that rely heavily on income from the annual meeting will be severely challenged the longer the pandemic continues, Dr. Masters said.

The decision is not as simple as whether to reduce or eliminate dues, he noted. Organizations will have to reexamine their missions and structure their fees and offerings according to the needs of members.

“It’s a balance in doing things for the community at large and balancing the need to be sensitive to financial implications,” Dr. Masters said.

This article first appeared on Medscape.com.

There was a low prevalence of meningococcal colonization in health care professionals working in pediatrics and adolescent medicine at a university – lower than expected for all age groups, Lisa-Maria Steurer, MD, said regarding study findings reported at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.

CDC/Sarah Bailey Cutchin/Illustrator Dan Higgins

“This implicates that the risk of horizontal meningococcal transmission via this health care professional cohort seems to be low,” said Dr. Steurer, of the Medical University of Vienna.

Her data were based on a survey conducted between April and October 2018 at the department of paediatrics and adolescent medicine at the tertiary university pediatric hospital. The study aimed to determine colonization rates of Neisseria meningitidis and the serogroup distribution of carried meningococcal isolates in asymptomatic health care professionals employed there, reported Dr. Steurer. Her research team also sought to identify what factors increased risk of N. meningitidis carriage.

“We who work in pediatrics and adolescent medicine are exposed to those patient cohorts with the highest risk for meningococcal carriage, but also to those patients who have the highest risk for serious, invasive meningococcal disease, which peaks at the extremities of age,” declared Dr. Steurer. “But currently, there is no surveillance of asymptomatic carriers in this health care professional cohort.”

A total of 437 oropharyngeal swabs were collected from enrolled nurses, pediatricians, and medical students working in the department and immediately plated onto selective agar plates. Conventional culture was used to identify bacteria, and meningococcal isolates were characterized further through whole-genome sequencing. Sociodemographic data and information on participants’ vaccination status were collected via questionnaire.

The main finding was an overall meningococcal prevalence of 1.14%. Among the participants, the median age was 33 years, and the highest rate of carriage, 4.4%, was observed in those aged 18-25 years. None of the carriers were older than 35 years. There was a negative association found between carriage and participants’ age and time employed in the field, Dr. Steurer said.

“Risk-factor analysis found an inverse correlation with meningococcal carriage for age and timespan working in pediatrics. On the contrary, no correlations with carriage could be found for all other factors evaluated,” she said. These factors included recent contact with an immunodeficient patient, respiratory tract infection, smoking, vaccination against any meningococcal serogroup, different professions, main work settings, month of swab collection, and living with children or adolescents in the same household.

Of the study population, 29% reported that they had been vaccinated against at least one meningococcal serogroup. “Interestingly, while more than 50% of doctors and medical students had a vaccination against at least one meningococcal serogroup, only 17% of nurses were vaccinated,” Dr. Steurer remarked.

The study was financially supported by Pfizer. Dr. Steurer had no other relevant financial disclosures.

There was a low prevalence of meningococcal colonization in health care professionals working in pediatrics and adolescent medicine at a university – lower than expected for all age groups, Lisa-Maria Steurer, MD, said regarding study findings reported at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.

CDC/Sarah Bailey Cutchin/Illustrator Dan Higgins

“This implicates that the risk of horizontal meningococcal transmission via this health care professional cohort seems to be low,” said Dr. Steurer, of the Medical University of Vienna.

Her data were based on a survey conducted between April and October 2018 at the department of paediatrics and adolescent medicine at the tertiary university pediatric hospital. The study aimed to determine colonization rates of Neisseria meningitidis and the serogroup distribution of carried meningococcal isolates in asymptomatic health care professionals employed there, reported Dr. Steurer. Her research team also sought to identify what factors increased risk of N. meningitidis carriage.

“We who work in pediatrics and adolescent medicine are exposed to those patient cohorts with the highest risk for meningococcal carriage, but also to those patients who have the highest risk for serious, invasive meningococcal disease, which peaks at the extremities of age,” declared Dr. Steurer. “But currently, there is no surveillance of asymptomatic carriers in this health care professional cohort.”

A total of 437 oropharyngeal swabs were collected from enrolled nurses, pediatricians, and medical students working in the department and immediately plated onto selective agar plates. Conventional culture was used to identify bacteria, and meningococcal isolates were characterized further through whole-genome sequencing. Sociodemographic data and information on participants’ vaccination status were collected via questionnaire.

The main finding was an overall meningococcal prevalence of 1.14%. Among the participants, the median age was 33 years, and the highest rate of carriage, 4.4%, was observed in those aged 18-25 years. None of the carriers were older than 35 years. There was a negative association found between carriage and participants’ age and time employed in the field, Dr. Steurer said.

“Risk-factor analysis found an inverse correlation with meningococcal carriage for age and timespan working in pediatrics. On the contrary, no correlations with carriage could be found for all other factors evaluated,” she said. These factors included recent contact with an immunodeficient patient, respiratory tract infection, smoking, vaccination against any meningococcal serogroup, different professions, main work settings, month of swab collection, and living with children or adolescents in the same household.

Of the study population, 29% reported that they had been vaccinated against at least one meningococcal serogroup. “Interestingly, while more than 50% of doctors and medical students had a vaccination against at least one meningococcal serogroup, only 17% of nurses were vaccinated,” Dr. Steurer remarked.

The study was financially supported by Pfizer. Dr. Steurer had no other relevant financial disclosures.

There was a low prevalence of meningococcal colonization in health care professionals working in pediatrics and adolescent medicine at a university – lower than expected for all age groups, Lisa-Maria Steurer, MD, said regarding study findings reported at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year.

CDC/Sarah Bailey Cutchin/Illustrator Dan Higgins

“This implicates that the risk of horizontal meningococcal transmission via this health care professional cohort seems to be low,” said Dr. Steurer, of the Medical University of Vienna.

Her data were based on a survey conducted between April and October 2018 at the department of paediatrics and adolescent medicine at the tertiary university pediatric hospital. The study aimed to determine colonization rates of Neisseria meningitidis and the serogroup distribution of carried meningococcal isolates in asymptomatic health care professionals employed there, reported Dr. Steurer. Her research team also sought to identify what factors increased risk of N. meningitidis carriage.

“We who work in pediatrics and adolescent medicine are exposed to those patient cohorts with the highest risk for meningococcal carriage, but also to those patients who have the highest risk for serious, invasive meningococcal disease, which peaks at the extremities of age,” declared Dr. Steurer. “But currently, there is no surveillance of asymptomatic carriers in this health care professional cohort.”

A total of 437 oropharyngeal swabs were collected from enrolled nurses, pediatricians, and medical students working in the department and immediately plated onto selective agar plates. Conventional culture was used to identify bacteria, and meningococcal isolates were characterized further through whole-genome sequencing. Sociodemographic data and information on participants’ vaccination status were collected via questionnaire.

The main finding was an overall meningococcal prevalence of 1.14%. Among the participants, the median age was 33 years, and the highest rate of carriage, 4.4%, was observed in those aged 18-25 years. None of the carriers were older than 35 years. There was a negative association found between carriage and participants’ age and time employed in the field, Dr. Steurer said.

“Risk-factor analysis found an inverse correlation with meningococcal carriage for age and timespan working in pediatrics. On the contrary, no correlations with carriage could be found for all other factors evaluated,” she said. These factors included recent contact with an immunodeficient patient, respiratory tract infection, smoking, vaccination against any meningococcal serogroup, different professions, main work settings, month of swab collection, and living with children or adolescents in the same household.

Of the study population, 29% reported that they had been vaccinated against at least one meningococcal serogroup. “Interestingly, while more than 50% of doctors and medical students had a vaccination against at least one meningococcal serogroup, only 17% of nurses were vaccinated,” Dr. Steurer remarked.

The study was financially supported by Pfizer. Dr. Steurer had no other relevant financial disclosures.

Individuals experiencing a current episode of major depressive disorder (MDD) are significantly more likely to have insulin resistance (IR), research shows.

Investigators found patients with MDD were 51% more likely to have IR, compared with their counterparts without depressive disorder. In addition, in individuals experiencing current depression, IR was also associated with depression severity and depression chronicity.

“We learned two things from this study – first, that insulin resistance was associated with being in a depressive episode and with the severity of that episode,” Kathleen Watson, PhD, a postdoctoral research fellow in the department of psychiatry, Stanford (Calif.) University, told this news organization. “Second, we learned that we can estimate insulin resistance using a surrogate measure that is clinically accessible – the triglyceride/HDL ratio.”

The study was published online Dec. 2 in JAMA Psychiatry.
 

Targeted approach

Many studies have linked MDD and IR. However, said Dr. Watson, “We did not have much description of the nature of this relationship.” She added that her team wanted to gain a better understanding of how IR relates to depression characteristics, such as remission status, severity, and chronicity.

Characterizing these associations will “represent a critical step at better phenotyping, a prelude to longitudinal studies, and a more targeted approach to the treatment of MDD,” the authors note.

For the study, the researchers drew on data from the Netherlands Study of Depression and Anxiety, a longitudinal Dutch study of adults that “describes the course and consequences of depressive and anxiety disorders.”

The study included 1,269 study participants with current MDD (n = 536), remitted MDD (n = 394), and control participants without a history of MDD (n = 339).

In addition to investigating the association between MDD and IR, the researchers also wanted to understand “whether using different surrogate IR measures has consistent association with MDD.” IR was determined using two surrogate markers – the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein ratio. Participants in the bottom quartile of the QUICKI were categorized as IR, while all other participants were categorized as being “insulin sensitive.”

The second surrogate IR measure – the triglyceride-HDL ratio – is an index based on fasting blood sample measurements, in which the determination of IR was based on sex-specific cut points (female ratio, IR > 1.9; male ratio, IR > 2.8).

Depression was determined based on the Composite International Diagnostic Interview (version 2.1), while depression severity was based on the Inventory of Depression Symptomatology. “Chronicity” was defined as depression during the preceding 4 years and was measured using the life chart review.
 

State vs. trait

Insulin resistance was associated with current, but not with remitted, MDD (odds ratio, 1.51; 95% confidence interval, 1.08-2.12 and OR, 1.14; 95% CI, 0.79-1.64, respectively).

In a model adjusted for age, sex, education, partner status, smoking status, and alcohol consumption, IR, as assessed by both measures, was linked to depression severity – but only the triglyceride-HDL ratio yielded an association between IR and depression chronicity.

IR was not associated with depression severity or chronicity in remitted MDD on either measure.

The findings – specifically the association between current, but not remitted, MDD – suggest that “IR is a state, rather than a trait, biomarker of depression,” the authors note.

“There are many plausible mechanisms between IR and MDD,” said Dr. Watson. “Some hypotheses for the link include inflammations, alterations to the hypothalamic-pituitary-adrenal axis, and changes in health behavior.

“Understanding these nuances helped us to lay the foundation for future research, including asking whether IR can lead to the development of MDD,” she added.

Finally, Dr. Watson noted that her team is collaborating with neuroscientists to better identify the brain mechanisms at the genetic, molecular, and cellular level that link IR and MDD and ways to target them with potential treatments or interventions.
 

Shared biological mechanisms?

Commenting on the study in an interview, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto and head of the Mood Disorders Psychopharmacology Unit, said the results “suggest that a subpopulation of people with depression have what might be referred to as ‘metabolic syndrome type II’ – the depression is a consequence of abnormal metabolic processes.”

The results also suggest “maybe metabolic markers can be used as biomarkers of disease presence vs. absence,” said Dr. McIntyre, who is also the chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, and was not involved with the study.

Also commenting on the study, Andrea Fagiolini, MD, professor of psychiatry, University of Siena (Italy), said depression, metabolic, and inflammatory diseases “likely share some common biological mechanism, as they share risk factors such as unhealthy diet, unhealthy lifestyles, and frequent exposure to physical and psychological distress.”

It is “possible that treatment of depression improves IR; conversely, it is possible that lifestyle programs or medications that are able to improve IR may improve depressive symptoms,” suggested Dr. Fagiolini, who was not involved with the study. “It remains to be established which symptoms of depression are most involved in this correlation and whether their improvement precedes or follows the improvement in IR,” he noted.

The Netherlands Study of Depression and Anxiety is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development and is supported by several participating universities and mental health care organizations. Dr. Watson has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reported research grant support from CIHR/GACD/Chinese National Natural Research Foundation and speaker/consultation fees from multiple pharmaceutical companies. Dr. McIntyre is also CEO of AltMed. Dr. Fagiolini has served or is currently serving as consultant or speaker for or is a research grant recipient from multiple pharmaceutical companies.

A version of this article originally appeared on Medscape.com.

Individuals experiencing a current episode of major depressive disorder (MDD) are significantly more likely to have insulin resistance (IR), research shows.

Investigators found patients with MDD were 51% more likely to have IR, compared with their counterparts without depressive disorder. In addition, in individuals experiencing current depression, IR was also associated with depression severity and depression chronicity.

“We learned two things from this study – first, that insulin resistance was associated with being in a depressive episode and with the severity of that episode,” Kathleen Watson, PhD, a postdoctoral research fellow in the department of psychiatry, Stanford (Calif.) University, told this news organization. “Second, we learned that we can estimate insulin resistance using a surrogate measure that is clinically accessible – the triglyceride/HDL ratio.”

The study was published online Dec. 2 in JAMA Psychiatry.
 

Targeted approach

Many studies have linked MDD and IR. However, said Dr. Watson, “We did not have much description of the nature of this relationship.” She added that her team wanted to gain a better understanding of how IR relates to depression characteristics, such as remission status, severity, and chronicity.

Characterizing these associations will “represent a critical step at better phenotyping, a prelude to longitudinal studies, and a more targeted approach to the treatment of MDD,” the authors note.

For the study, the researchers drew on data from the Netherlands Study of Depression and Anxiety, a longitudinal Dutch study of adults that “describes the course and consequences of depressive and anxiety disorders.”

The study included 1,269 study participants with current MDD (n = 536), remitted MDD (n = 394), and control participants without a history of MDD (n = 339).

In addition to investigating the association between MDD and IR, the researchers also wanted to understand “whether using different surrogate IR measures has consistent association with MDD.” IR was determined using two surrogate markers – the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein ratio. Participants in the bottom quartile of the QUICKI were categorized as IR, while all other participants were categorized as being “insulin sensitive.”

The second surrogate IR measure – the triglyceride-HDL ratio – is an index based on fasting blood sample measurements, in which the determination of IR was based on sex-specific cut points (female ratio, IR > 1.9; male ratio, IR > 2.8).

Depression was determined based on the Composite International Diagnostic Interview (version 2.1), while depression severity was based on the Inventory of Depression Symptomatology. “Chronicity” was defined as depression during the preceding 4 years and was measured using the life chart review.
 

State vs. trait

Insulin resistance was associated with current, but not with remitted, MDD (odds ratio, 1.51; 95% confidence interval, 1.08-2.12 and OR, 1.14; 95% CI, 0.79-1.64, respectively).

In a model adjusted for age, sex, education, partner status, smoking status, and alcohol consumption, IR, as assessed by both measures, was linked to depression severity – but only the triglyceride-HDL ratio yielded an association between IR and depression chronicity.

IR was not associated with depression severity or chronicity in remitted MDD on either measure.

The findings – specifically the association between current, but not remitted, MDD – suggest that “IR is a state, rather than a trait, biomarker of depression,” the authors note.

“There are many plausible mechanisms between IR and MDD,” said Dr. Watson. “Some hypotheses for the link include inflammations, alterations to the hypothalamic-pituitary-adrenal axis, and changes in health behavior.

“Understanding these nuances helped us to lay the foundation for future research, including asking whether IR can lead to the development of MDD,” she added.

Finally, Dr. Watson noted that her team is collaborating with neuroscientists to better identify the brain mechanisms at the genetic, molecular, and cellular level that link IR and MDD and ways to target them with potential treatments or interventions.
 

Shared biological mechanisms?

Commenting on the study in an interview, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto and head of the Mood Disorders Psychopharmacology Unit, said the results “suggest that a subpopulation of people with depression have what might be referred to as ‘metabolic syndrome type II’ – the depression is a consequence of abnormal metabolic processes.”

The results also suggest “maybe metabolic markers can be used as biomarkers of disease presence vs. absence,” said Dr. McIntyre, who is also the chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, and was not involved with the study.

Also commenting on the study, Andrea Fagiolini, MD, professor of psychiatry, University of Siena (Italy), said depression, metabolic, and inflammatory diseases “likely share some common biological mechanism, as they share risk factors such as unhealthy diet, unhealthy lifestyles, and frequent exposure to physical and psychological distress.”

It is “possible that treatment of depression improves IR; conversely, it is possible that lifestyle programs or medications that are able to improve IR may improve depressive symptoms,” suggested Dr. Fagiolini, who was not involved with the study. “It remains to be established which symptoms of depression are most involved in this correlation and whether their improvement precedes or follows the improvement in IR,” he noted.

The Netherlands Study of Depression and Anxiety is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development and is supported by several participating universities and mental health care organizations. Dr. Watson has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reported research grant support from CIHR/GACD/Chinese National Natural Research Foundation and speaker/consultation fees from multiple pharmaceutical companies. Dr. McIntyre is also CEO of AltMed. Dr. Fagiolini has served or is currently serving as consultant or speaker for or is a research grant recipient from multiple pharmaceutical companies.

A version of this article originally appeared on Medscape.com.

Individuals experiencing a current episode of major depressive disorder (MDD) are significantly more likely to have insulin resistance (IR), research shows.

Investigators found patients with MDD were 51% more likely to have IR, compared with their counterparts without depressive disorder. In addition, in individuals experiencing current depression, IR was also associated with depression severity and depression chronicity.

“We learned two things from this study – first, that insulin resistance was associated with being in a depressive episode and with the severity of that episode,” Kathleen Watson, PhD, a postdoctoral research fellow in the department of psychiatry, Stanford (Calif.) University, told this news organization. “Second, we learned that we can estimate insulin resistance using a surrogate measure that is clinically accessible – the triglyceride/HDL ratio.”

The study was published online Dec. 2 in JAMA Psychiatry.
 

Targeted approach

Many studies have linked MDD and IR. However, said Dr. Watson, “We did not have much description of the nature of this relationship.” She added that her team wanted to gain a better understanding of how IR relates to depression characteristics, such as remission status, severity, and chronicity.

Characterizing these associations will “represent a critical step at better phenotyping, a prelude to longitudinal studies, and a more targeted approach to the treatment of MDD,” the authors note.

For the study, the researchers drew on data from the Netherlands Study of Depression and Anxiety, a longitudinal Dutch study of adults that “describes the course and consequences of depressive and anxiety disorders.”

The study included 1,269 study participants with current MDD (n = 536), remitted MDD (n = 394), and control participants without a history of MDD (n = 339).

In addition to investigating the association between MDD and IR, the researchers also wanted to understand “whether using different surrogate IR measures has consistent association with MDD.” IR was determined using two surrogate markers – the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein ratio. Participants in the bottom quartile of the QUICKI were categorized as IR, while all other participants were categorized as being “insulin sensitive.”

The second surrogate IR measure – the triglyceride-HDL ratio – is an index based on fasting blood sample measurements, in which the determination of IR was based on sex-specific cut points (female ratio, IR > 1.9; male ratio, IR > 2.8).

Depression was determined based on the Composite International Diagnostic Interview (version 2.1), while depression severity was based on the Inventory of Depression Symptomatology. “Chronicity” was defined as depression during the preceding 4 years and was measured using the life chart review.
 

State vs. trait

Insulin resistance was associated with current, but not with remitted, MDD (odds ratio, 1.51; 95% confidence interval, 1.08-2.12 and OR, 1.14; 95% CI, 0.79-1.64, respectively).

In a model adjusted for age, sex, education, partner status, smoking status, and alcohol consumption, IR, as assessed by both measures, was linked to depression severity – but only the triglyceride-HDL ratio yielded an association between IR and depression chronicity.

IR was not associated with depression severity or chronicity in remitted MDD on either measure.

The findings – specifically the association between current, but not remitted, MDD – suggest that “IR is a state, rather than a trait, biomarker of depression,” the authors note.

“There are many plausible mechanisms between IR and MDD,” said Dr. Watson. “Some hypotheses for the link include inflammations, alterations to the hypothalamic-pituitary-adrenal axis, and changes in health behavior.

“Understanding these nuances helped us to lay the foundation for future research, including asking whether IR can lead to the development of MDD,” she added.

Finally, Dr. Watson noted that her team is collaborating with neuroscientists to better identify the brain mechanisms at the genetic, molecular, and cellular level that link IR and MDD and ways to target them with potential treatments or interventions.
 

Shared biological mechanisms?

Commenting on the study in an interview, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto and head of the Mood Disorders Psychopharmacology Unit, said the results “suggest that a subpopulation of people with depression have what might be referred to as ‘metabolic syndrome type II’ – the depression is a consequence of abnormal metabolic processes.”

The results also suggest “maybe metabolic markers can be used as biomarkers of disease presence vs. absence,” said Dr. McIntyre, who is also the chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, and was not involved with the study.

Also commenting on the study, Andrea Fagiolini, MD, professor of psychiatry, University of Siena (Italy), said depression, metabolic, and inflammatory diseases “likely share some common biological mechanism, as they share risk factors such as unhealthy diet, unhealthy lifestyles, and frequent exposure to physical and psychological distress.”

It is “possible that treatment of depression improves IR; conversely, it is possible that lifestyle programs or medications that are able to improve IR may improve depressive symptoms,” suggested Dr. Fagiolini, who was not involved with the study. “It remains to be established which symptoms of depression are most involved in this correlation and whether their improvement precedes or follows the improvement in IR,” he noted.

The Netherlands Study of Depression and Anxiety is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development and is supported by several participating universities and mental health care organizations. Dr. Watson has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reported research grant support from CIHR/GACD/Chinese National Natural Research Foundation and speaker/consultation fees from multiple pharmaceutical companies. Dr. McIntyre is also CEO of AltMed. Dr. Fagiolini has served or is currently serving as consultant or speaker for or is a research grant recipient from multiple pharmaceutical companies.

A version of this article originally appeared on Medscape.com.

Countries across the world are in the process of closing and reopening schools to contain the spread of COVID-19. Should there be universal testing and quarantining of sick school children and their classmates?

miodrag ignjatovic/E+

In a lively debate at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year, Andreea M. Panciu, MD, from the National Institute of Infectious Diseases in Bucharest, argued for routine testing and quarantining of all school children. Her opposite number, Danilo Buonsenso, MD, from the Centre for Global Health Research and Studies, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, made the case for a more selective approach.
 

Should children be sent to school?

“Risk-reduction strategies and detection of cases must be in place to allow children to return safely to school,” stated Dr. Panciu as she started the debate by explaining the challenges faced by schools in adhering to key mitigation strategies. The U.S. Centers for Disease Control and Prevention recommends that students keep 1.8 m (6 feet) distance from one another. “In many school settings this is not feasible without drastically limiting the number of students,” she explained. “This is a massive challenge for many schools that are already overcrowded.”

The use of facemasks also is a challenge in classrooms. Children have a lower tolerance or may not be able to use the mask properly. There also are concerns regarding impaired learning, speech development, social development, and facial recognition. “We need to look at the evidence; preventive measures work,” responded Dr. Buonsenso. If distance can be implemented, the more distance the lower the transmission of infection, with 1.5-2 meters having the best effects. “Distance can be difficult when school buildings do not allow it, however, governments have had time to plan, and this should not be a limitation to education for kids.”

A recent review clearly showed that children and adolescents aged under 20 years have a much lower risk of susceptibility to COVID-19 infection, compared with adults. This is especially the case for children younger than 14 years. “There is no excuse, let’s bring the children back to school,” argued Dr. Buonsenso.

Dr. Panciu responded with several studies that have tried to quantify the amount of SARS-CoV-2 virus that is carried by infected children. Viral load in the nasopharynx in children under 5 years with mild to moderate COVID-19 symptoms was higher than that of both children over 5 as well as adults. The viral load in young children did not seem to differ by age or symptom severity. “There doesn’t appear to be a significant difference in viral load between symptomatic children and symptomatic adults,” she stated.

“But the question is: ‘How infectious are children?’ ” reacted Dr. Buonsenso. Data from South Korea showed that, for children, particularly those under 10 years, the number of secondary cases of contacts was very low, suggesting that children are rarely spreading the virus.

Dr. Buonsenso and colleagues assessed 30 households containing children aged under 18 years where an adult had been infected with COVID-19 in Rome during the peak of the pandemic. In no cases was it found that a child was the index case. This was supported by data from China, also obtained during the peak of the pandemic, which showed that the number of children infected was very low, but more importantly the number of secondary attacks from contact with children was also very low.
 

What about children who are sick at school?

The debate moved to discussing what should be done when a child is sick at school. Dr. Panciu clarified recommendations by the CDC regarding what steps to take if a student displays signs of infection consistent with COVID-19: Should they test positive, they are to stay at home for 10 days from the time signs and symptoms first appeared. Further, any teachers or students identified as close contacts are advised to stay at home for 14 days. (Since the ESPID meeting, the CDC has made changes in quarantine times for COVID-19. People can now quarantine for 10 days without a COVID-19 test if they have no symptoms. Alternatively, a quarantine can end after 7 days for someone with a negative test and no symptoms. The agency recommends a polymerase chain reaction test or an antigen assay within 48 hours before the end of a quarantine.)

A significant problem is the overlap between COVID-19 symptoms and those associated with other common illnesses because of a range of viruses. This is particularly true in younger children who often suffer from viral infections. “It is common for children to have up to eight respiratory illnesses a year,” explained Dr. Panciu, “and some may have symptoms so mild that they don’t notice them.”

“We need to be a little bit more children focused, otherwise we are going to be isolating children all the time,” said Dr. Buonsenso. The Royal College of Paediatrics and Child Health state that a child with a simple runny nose or sporadic cough without a fever, who would have attended school in other times, should not be tested for COVID-19. He moved on to then cite several studies that show little or no evidence of COVID-19 transmission between school children. This included a prospective cohort study in Australia showing that child-to-child transmission occurred in 0.3%. “To date, the advantages from routine quarantine and over testing seem too low to balance the social consequences on children and families,” he concluded.

As the debate drew to a close, Dr. Panciu reported several studies that did demonstrate transmission between school-age children. Data from an overnight camp in Georgia where the median age was 12 years showed the attack rate was 44% for ages 11-17 years and 51% for ages 6-10 years. Similar conclusions were reached in an Israeli study looking at a large COVID-19 outbreak in a school. This occurred 10 days after reopening, in spite of preventive measures being in place. “Opening safely isn’t just about the adjustments a school makes,” she said, “it’s also about how much of the virus is circulating in the community, which affects the likelihood that students and staff will bring COVID-19 into their classrooms.”

Damian Roland, consultant and honorary associate professor in pediatric emergency medicine at the University of Leicester (England), commented: “Maximizing educational potential while reducing the spread of COVID19 is a challenge laden with scientific equipoise while simultaneously infused with emotion. The evidence of transmission between, and infectivity from, children is not complete, as this debate has demonstrated. It is important scientists, clinicians, educators, and policy makers make collaborative decisions, aware there is not one perfect answer, and willing to understand and incorporate others views and objectives rather than holding onto single beliefs or approaches.”

No financial conflicts of interest were declared.

Countries across the world are in the process of closing and reopening schools to contain the spread of COVID-19. Should there be universal testing and quarantining of sick school children and their classmates?

miodrag ignjatovic/E+

In a lively debate at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year, Andreea M. Panciu, MD, from the National Institute of Infectious Diseases in Bucharest, argued for routine testing and quarantining of all school children. Her opposite number, Danilo Buonsenso, MD, from the Centre for Global Health Research and Studies, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, made the case for a more selective approach.
 

Should children be sent to school?

“Risk-reduction strategies and detection of cases must be in place to allow children to return safely to school,” stated Dr. Panciu as she started the debate by explaining the challenges faced by schools in adhering to key mitigation strategies. The U.S. Centers for Disease Control and Prevention recommends that students keep 1.8 m (6 feet) distance from one another. “In many school settings this is not feasible without drastically limiting the number of students,” she explained. “This is a massive challenge for many schools that are already overcrowded.”

The use of facemasks also is a challenge in classrooms. Children have a lower tolerance or may not be able to use the mask properly. There also are concerns regarding impaired learning, speech development, social development, and facial recognition. “We need to look at the evidence; preventive measures work,” responded Dr. Buonsenso. If distance can be implemented, the more distance the lower the transmission of infection, with 1.5-2 meters having the best effects. “Distance can be difficult when school buildings do not allow it, however, governments have had time to plan, and this should not be a limitation to education for kids.”

A recent review clearly showed that children and adolescents aged under 20 years have a much lower risk of susceptibility to COVID-19 infection, compared with adults. This is especially the case for children younger than 14 years. “There is no excuse, let’s bring the children back to school,” argued Dr. Buonsenso.

Dr. Panciu responded with several studies that have tried to quantify the amount of SARS-CoV-2 virus that is carried by infected children. Viral load in the nasopharynx in children under 5 years with mild to moderate COVID-19 symptoms was higher than that of both children over 5 as well as adults. The viral load in young children did not seem to differ by age or symptom severity. “There doesn’t appear to be a significant difference in viral load between symptomatic children and symptomatic adults,” she stated.

“But the question is: ‘How infectious are children?’ ” reacted Dr. Buonsenso. Data from South Korea showed that, for children, particularly those under 10 years, the number of secondary cases of contacts was very low, suggesting that children are rarely spreading the virus.

Dr. Buonsenso and colleagues assessed 30 households containing children aged under 18 years where an adult had been infected with COVID-19 in Rome during the peak of the pandemic. In no cases was it found that a child was the index case. This was supported by data from China, also obtained during the peak of the pandemic, which showed that the number of children infected was very low, but more importantly the number of secondary attacks from contact with children was also very low.
 

What about children who are sick at school?

The debate moved to discussing what should be done when a child is sick at school. Dr. Panciu clarified recommendations by the CDC regarding what steps to take if a student displays signs of infection consistent with COVID-19: Should they test positive, they are to stay at home for 10 days from the time signs and symptoms first appeared. Further, any teachers or students identified as close contacts are advised to stay at home for 14 days. (Since the ESPID meeting, the CDC has made changes in quarantine times for COVID-19. People can now quarantine for 10 days without a COVID-19 test if they have no symptoms. Alternatively, a quarantine can end after 7 days for someone with a negative test and no symptoms. The agency recommends a polymerase chain reaction test or an antigen assay within 48 hours before the end of a quarantine.)

A significant problem is the overlap between COVID-19 symptoms and those associated with other common illnesses because of a range of viruses. This is particularly true in younger children who often suffer from viral infections. “It is common for children to have up to eight respiratory illnesses a year,” explained Dr. Panciu, “and some may have symptoms so mild that they don’t notice them.”

“We need to be a little bit more children focused, otherwise we are going to be isolating children all the time,” said Dr. Buonsenso. The Royal College of Paediatrics and Child Health state that a child with a simple runny nose or sporadic cough without a fever, who would have attended school in other times, should not be tested for COVID-19. He moved on to then cite several studies that show little or no evidence of COVID-19 transmission between school children. This included a prospective cohort study in Australia showing that child-to-child transmission occurred in 0.3%. “To date, the advantages from routine quarantine and over testing seem too low to balance the social consequences on children and families,” he concluded.

As the debate drew to a close, Dr. Panciu reported several studies that did demonstrate transmission between school-age children. Data from an overnight camp in Georgia where the median age was 12 years showed the attack rate was 44% for ages 11-17 years and 51% for ages 6-10 years. Similar conclusions were reached in an Israeli study looking at a large COVID-19 outbreak in a school. This occurred 10 days after reopening, in spite of preventive measures being in place. “Opening safely isn’t just about the adjustments a school makes,” she said, “it’s also about how much of the virus is circulating in the community, which affects the likelihood that students and staff will bring COVID-19 into their classrooms.”

Damian Roland, consultant and honorary associate professor in pediatric emergency medicine at the University of Leicester (England), commented: “Maximizing educational potential while reducing the spread of COVID19 is a challenge laden with scientific equipoise while simultaneously infused with emotion. The evidence of transmission between, and infectivity from, children is not complete, as this debate has demonstrated. It is important scientists, clinicians, educators, and policy makers make collaborative decisions, aware there is not one perfect answer, and willing to understand and incorporate others views and objectives rather than holding onto single beliefs or approaches.”

No financial conflicts of interest were declared.

Countries across the world are in the process of closing and reopening schools to contain the spread of COVID-19. Should there be universal testing and quarantining of sick school children and their classmates?

miodrag ignjatovic/E+

In a lively debate at the annual meeting of the European Society for Paediatric Infectious Diseases, held virtually this year, Andreea M. Panciu, MD, from the National Institute of Infectious Diseases in Bucharest, argued for routine testing and quarantining of all school children. Her opposite number, Danilo Buonsenso, MD, from the Centre for Global Health Research and Studies, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, made the case for a more selective approach.
 

Should children be sent to school?

“Risk-reduction strategies and detection of cases must be in place to allow children to return safely to school,” stated Dr. Panciu as she started the debate by explaining the challenges faced by schools in adhering to key mitigation strategies. The U.S. Centers for Disease Control and Prevention recommends that students keep 1.8 m (6 feet) distance from one another. “In many school settings this is not feasible without drastically limiting the number of students,” she explained. “This is a massive challenge for many schools that are already overcrowded.”

The use of facemasks also is a challenge in classrooms. Children have a lower tolerance or may not be able to use the mask properly. There also are concerns regarding impaired learning, speech development, social development, and facial recognition. “We need to look at the evidence; preventive measures work,” responded Dr. Buonsenso. If distance can be implemented, the more distance the lower the transmission of infection, with 1.5-2 meters having the best effects. “Distance can be difficult when school buildings do not allow it, however, governments have had time to plan, and this should not be a limitation to education for kids.”

A recent review clearly showed that children and adolescents aged under 20 years have a much lower risk of susceptibility to COVID-19 infection, compared with adults. This is especially the case for children younger than 14 years. “There is no excuse, let’s bring the children back to school,” argued Dr. Buonsenso.

Dr. Panciu responded with several studies that have tried to quantify the amount of SARS-CoV-2 virus that is carried by infected children. Viral load in the nasopharynx in children under 5 years with mild to moderate COVID-19 symptoms was higher than that of both children over 5 as well as adults. The viral load in young children did not seem to differ by age or symptom severity. “There doesn’t appear to be a significant difference in viral load between symptomatic children and symptomatic adults,” she stated.

“But the question is: ‘How infectious are children?’ ” reacted Dr. Buonsenso. Data from South Korea showed that, for children, particularly those under 10 years, the number of secondary cases of contacts was very low, suggesting that children are rarely spreading the virus.

Dr. Buonsenso and colleagues assessed 30 households containing children aged under 18 years where an adult had been infected with COVID-19 in Rome during the peak of the pandemic. In no cases was it found that a child was the index case. This was supported by data from China, also obtained during the peak of the pandemic, which showed that the number of children infected was very low, but more importantly the number of secondary attacks from contact with children was also very low.
 

What about children who are sick at school?

The debate moved to discussing what should be done when a child is sick at school. Dr. Panciu clarified recommendations by the CDC regarding what steps to take if a student displays signs of infection consistent with COVID-19: Should they test positive, they are to stay at home for 10 days from the time signs and symptoms first appeared. Further, any teachers or students identified as close contacts are advised to stay at home for 14 days. (Since the ESPID meeting, the CDC has made changes in quarantine times for COVID-19. People can now quarantine for 10 days without a COVID-19 test if they have no symptoms. Alternatively, a quarantine can end after 7 days for someone with a negative test and no symptoms. The agency recommends a polymerase chain reaction test or an antigen assay within 48 hours before the end of a quarantine.)

A significant problem is the overlap between COVID-19 symptoms and those associated with other common illnesses because of a range of viruses. This is particularly true in younger children who often suffer from viral infections. “It is common for children to have up to eight respiratory illnesses a year,” explained Dr. Panciu, “and some may have symptoms so mild that they don’t notice them.”

“We need to be a little bit more children focused, otherwise we are going to be isolating children all the time,” said Dr. Buonsenso. The Royal College of Paediatrics and Child Health state that a child with a simple runny nose or sporadic cough without a fever, who would have attended school in other times, should not be tested for COVID-19. He moved on to then cite several studies that show little or no evidence of COVID-19 transmission between school children. This included a prospective cohort study in Australia showing that child-to-child transmission occurred in 0.3%. “To date, the advantages from routine quarantine and over testing seem too low to balance the social consequences on children and families,” he concluded.

As the debate drew to a close, Dr. Panciu reported several studies that did demonstrate transmission between school-age children. Data from an overnight camp in Georgia where the median age was 12 years showed the attack rate was 44% for ages 11-17 years and 51% for ages 6-10 years. Similar conclusions were reached in an Israeli study looking at a large COVID-19 outbreak in a school. This occurred 10 days after reopening, in spite of preventive measures being in place. “Opening safely isn’t just about the adjustments a school makes,” she said, “it’s also about how much of the virus is circulating in the community, which affects the likelihood that students and staff will bring COVID-19 into their classrooms.”

Damian Roland, consultant and honorary associate professor in pediatric emergency medicine at the University of Leicester (England), commented: “Maximizing educational potential while reducing the spread of COVID19 is a challenge laden with scientific equipoise while simultaneously infused with emotion. The evidence of transmission between, and infectivity from, children is not complete, as this debate has demonstrated. It is important scientists, clinicians, educators, and policy makers make collaborative decisions, aware there is not one perfect answer, and willing to understand and incorporate others views and objectives rather than holding onto single beliefs or approaches.”

No financial conflicts of interest were declared.