Clinical Psychiatry News

As the pandemic shows no signs of ending, primary care doctors may be reassured that delivering care via video teleconferencing can be as effective as usual in-person consultation for several common health conditions.

This was a finding of a new study published in Annals of Internal Medicine involving a review of literature on video teleconferencing (VTC) visits, which was authored by Jordan Albritton, PhD, MPH and his colleagues.

The authors found generally comparable patient outcomes as well as no differences in health care use, patient satisfaction, and quality of life when visits conducted using VTC were compared with usual care.

While VTC may work best for monitoring patients with chronic conditions, it can also be effective for acute care, said Dr. Albritton, who is a research public health analyst at RTI International in Research Triangle Park, N.C., in an interview.

The investigators analyzed 20 randomized controlled trials of at least 50 patients and acceptable risk of bias in which VTC was used either for main or adjunct care delivery. Published from 2013 to 2019, these studies looked at care for diabetes and pain management, as well as some respiratory, neurologic, and cardiovascular conditions. Studies comparing VTC with usual care that did not involve any added in-person care were more likely to favor the VTC group, the investigators found.

“We excluded conditions such as substance use disorders, maternal care, and weight management for which there was sufficient prior evidence of the benefit of VTC,” Dr. Albritton said in an interview. “But I don’t think our results would have been substantially different if we had included these other diseases. We found general evidence in the literature that VTC is effective for a broader range of conditions.”

In some cases, such as if changes in a patient’s condition triggered an automatic virtual visit, the author said he thinks VTC may lead to even greater effectiveness.

“The doctor and patient could figure out on the spot what’s going on and perhaps change the medication,” Dr. Albritton explained.

In general agreement is Julia L. Frydman, MD, assistant professor in the Brookdale Department of Geriatric and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York, who was not involved in the RTI research.

“Telemedicine has promise across many medical subspecialties, and what we need now are more studies to understand the perspectives of patients, caregivers, and clinicians as well as the impact of telemedicine on health outcomes and healthcare utilization.”

In acknowledgment of their utility, video visits are on the rise in the United States. A 2020 survey found that 22% of patients and 80% of physicians reported having participated in a video visit, three times the rate of the previous year. The authors noted that policy changes enacted to support telehealth strategies during the pandemic are expected to remain in place, and although patients are returning to in-person care, the virtual visit market will likely continue growing.
 

Increased telemedicine use by older adults

“We’ve seen an exciting expansion of telemedicine use among older adults, and we need to focus on continuing to meet their needs,” Dr. Frydman said.

In a recent study of televisits during the pandemic, Dr. Frydman’s group found a fivefold greater uptake of remote consultations by seniors – from 5% to 25%. Although in-person visits were far more common among older adults.

A specific advantage of video-based over audio-only telehealth, noted Dr. Albritton, is that physicians can directly observe patients in their home environment. Sharing that view is Deepa Iyengar, MBBS/MD,MPH, professor of family medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, where, she said, “the pandemic has put VTC use into overdrive.”

According to Dr. Iyengar, who was not involved in the RTI research, the video component definitely represents value-added over phone calls. “You can pick up visual cues on video that you might not see if the patient came in and you can see what the home environment is like – whether there are a lot of loose rugs on the floor or broken or missing light bulbs,” she said in an interview.
 

‘VTC is here to stay’

In other parts of the country, doctors are finding virtual care useful – and more common. “VTC is here to stay, for sure – the horse is out of the barn,” said Cheryl L. Wilkes, MD, an internist at Northwestern Medicine and assistant professor of medicine at Northwestern University in Chicago. “The RTI study shows no harm from VTC and also shows it may even improve clinical outcomes.”

Video visits can also save patients high parking fees at clinics and spare the sick or elderly from having to hire caregivers to bring them into the office or from having to walk blocks in dangerous weather conditions, she added. “And I can do a virtual visit on the fly or at night when a relative or caregiver is home from work to be there with the patient.”

In addition to being beneficial for following up with patients with chronic diseases such as hypertension or diabetes, VTC may be able to replace some visits that have traditionally required hands-on care, said Dr. Wilkes.

She said she knows a cardiologist who has refined a process whereby a patient – say, one who may have edema – is asked to perform a maneuver via VTC and then display the result to the doctor: The doctor says, “put your leg up and press on it hard for 10 seconds and then show me what it looks like,” according to Dr. Wilkes.

The key now is to identify the best persons across specialties from neurology to rheumatology to videotape ways they’ve created to help their patients participate virtually in consults traditionally done at the office, Dr. Wilkes noted.

But some conditions will always require palpation and the use of a stethoscope, according Dr. Iyengar.

“If someone has an ulcer, I have to be able to feel it,” she said.

And while some maternity care can be given virtually – for instance, if a mother-to be develops a bad cold – hands-on obstetrical care to check the position and health of the baby obviously has to be done in person. “So VTC is definitely going to be a welcome addition but not a replacement,” Dr. Iyengar said.

Gaps in research on VTC visits

Many questions remain regarding the overall usefulness of VTC visits for certain patient groups, according to the authors.

They highlighted, for example, the dearth of data on subgroups or on underserved and vulnerable populations, with no head-to-head studies identified in their review. In addition, they found no studies examining VTC versus usual care for patients with concurrent conditions or on its effect on health equity and disparities.

“It’s now our job to understand the ongoing barriers to telemedicine access, including the digital divide and the usability of telemedicine platforms, and design interventions that overcome them,” Dr. Frydman said. “At the same time, we need to make sure we’re understanding and respecting the preferences of older adults in terms of how they access health care.”

This study was supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Albritton is employed by RTI International, the contractor responsible for conducting the research and developing the manuscript. Several coauthors disclosed support from or contracts with PCORI. One coauthor’s spouse holds stock in private health companies. Dr. Frydman, Dr. Iyengar, and Dr. Wilkes disclosed no competing interests relevant to their comments.

As the pandemic shows no signs of ending, primary care doctors may be reassured that delivering care via video teleconferencing can be as effective as usual in-person consultation for several common health conditions.

This was a finding of a new study published in Annals of Internal Medicine involving a review of literature on video teleconferencing (VTC) visits, which was authored by Jordan Albritton, PhD, MPH and his colleagues.

The authors found generally comparable patient outcomes as well as no differences in health care use, patient satisfaction, and quality of life when visits conducted using VTC were compared with usual care.

While VTC may work best for monitoring patients with chronic conditions, it can also be effective for acute care, said Dr. Albritton, who is a research public health analyst at RTI International in Research Triangle Park, N.C., in an interview.

The investigators analyzed 20 randomized controlled trials of at least 50 patients and acceptable risk of bias in which VTC was used either for main or adjunct care delivery. Published from 2013 to 2019, these studies looked at care for diabetes and pain management, as well as some respiratory, neurologic, and cardiovascular conditions. Studies comparing VTC with usual care that did not involve any added in-person care were more likely to favor the VTC group, the investigators found.

“We excluded conditions such as substance use disorders, maternal care, and weight management for which there was sufficient prior evidence of the benefit of VTC,” Dr. Albritton said in an interview. “But I don’t think our results would have been substantially different if we had included these other diseases. We found general evidence in the literature that VTC is effective for a broader range of conditions.”

In some cases, such as if changes in a patient’s condition triggered an automatic virtual visit, the author said he thinks VTC may lead to even greater effectiveness.

“The doctor and patient could figure out on the spot what’s going on and perhaps change the medication,” Dr. Albritton explained.

In general agreement is Julia L. Frydman, MD, assistant professor in the Brookdale Department of Geriatric and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York, who was not involved in the RTI research.

“Telemedicine has promise across many medical subspecialties, and what we need now are more studies to understand the perspectives of patients, caregivers, and clinicians as well as the impact of telemedicine on health outcomes and healthcare utilization.”

In acknowledgment of their utility, video visits are on the rise in the United States. A 2020 survey found that 22% of patients and 80% of physicians reported having participated in a video visit, three times the rate of the previous year. The authors noted that policy changes enacted to support telehealth strategies during the pandemic are expected to remain in place, and although patients are returning to in-person care, the virtual visit market will likely continue growing.
 

Increased telemedicine use by older adults

“We’ve seen an exciting expansion of telemedicine use among older adults, and we need to focus on continuing to meet their needs,” Dr. Frydman said.

In a recent study of televisits during the pandemic, Dr. Frydman’s group found a fivefold greater uptake of remote consultations by seniors – from 5% to 25%. Although in-person visits were far more common among older adults.

A specific advantage of video-based over audio-only telehealth, noted Dr. Albritton, is that physicians can directly observe patients in their home environment. Sharing that view is Deepa Iyengar, MBBS/MD,MPH, professor of family medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, where, she said, “the pandemic has put VTC use into overdrive.”

According to Dr. Iyengar, who was not involved in the RTI research, the video component definitely represents value-added over phone calls. “You can pick up visual cues on video that you might not see if the patient came in and you can see what the home environment is like – whether there are a lot of loose rugs on the floor or broken or missing light bulbs,” she said in an interview.
 

‘VTC is here to stay’

In other parts of the country, doctors are finding virtual care useful – and more common. “VTC is here to stay, for sure – the horse is out of the barn,” said Cheryl L. Wilkes, MD, an internist at Northwestern Medicine and assistant professor of medicine at Northwestern University in Chicago. “The RTI study shows no harm from VTC and also shows it may even improve clinical outcomes.”

Video visits can also save patients high parking fees at clinics and spare the sick or elderly from having to hire caregivers to bring them into the office or from having to walk blocks in dangerous weather conditions, she added. “And I can do a virtual visit on the fly or at night when a relative or caregiver is home from work to be there with the patient.”

In addition to being beneficial for following up with patients with chronic diseases such as hypertension or diabetes, VTC may be able to replace some visits that have traditionally required hands-on care, said Dr. Wilkes.

She said she knows a cardiologist who has refined a process whereby a patient – say, one who may have edema – is asked to perform a maneuver via VTC and then display the result to the doctor: The doctor says, “put your leg up and press on it hard for 10 seconds and then show me what it looks like,” according to Dr. Wilkes.

The key now is to identify the best persons across specialties from neurology to rheumatology to videotape ways they’ve created to help their patients participate virtually in consults traditionally done at the office, Dr. Wilkes noted.

But some conditions will always require palpation and the use of a stethoscope, according Dr. Iyengar.

“If someone has an ulcer, I have to be able to feel it,” she said.

And while some maternity care can be given virtually – for instance, if a mother-to be develops a bad cold – hands-on obstetrical care to check the position and health of the baby obviously has to be done in person. “So VTC is definitely going to be a welcome addition but not a replacement,” Dr. Iyengar said.

Gaps in research on VTC visits

Many questions remain regarding the overall usefulness of VTC visits for certain patient groups, according to the authors.

They highlighted, for example, the dearth of data on subgroups or on underserved and vulnerable populations, with no head-to-head studies identified in their review. In addition, they found no studies examining VTC versus usual care for patients with concurrent conditions or on its effect on health equity and disparities.

“It’s now our job to understand the ongoing barriers to telemedicine access, including the digital divide and the usability of telemedicine platforms, and design interventions that overcome them,” Dr. Frydman said. “At the same time, we need to make sure we’re understanding and respecting the preferences of older adults in terms of how they access health care.”

This study was supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Albritton is employed by RTI International, the contractor responsible for conducting the research and developing the manuscript. Several coauthors disclosed support from or contracts with PCORI. One coauthor’s spouse holds stock in private health companies. Dr. Frydman, Dr. Iyengar, and Dr. Wilkes disclosed no competing interests relevant to their comments.

As the pandemic shows no signs of ending, primary care doctors may be reassured that delivering care via video teleconferencing can be as effective as usual in-person consultation for several common health conditions.

This was a finding of a new study published in Annals of Internal Medicine involving a review of literature on video teleconferencing (VTC) visits, which was authored by Jordan Albritton, PhD, MPH and his colleagues.

The authors found generally comparable patient outcomes as well as no differences in health care use, patient satisfaction, and quality of life when visits conducted using VTC were compared with usual care.

While VTC may work best for monitoring patients with chronic conditions, it can also be effective for acute care, said Dr. Albritton, who is a research public health analyst at RTI International in Research Triangle Park, N.C., in an interview.

The investigators analyzed 20 randomized controlled trials of at least 50 patients and acceptable risk of bias in which VTC was used either for main or adjunct care delivery. Published from 2013 to 2019, these studies looked at care for diabetes and pain management, as well as some respiratory, neurologic, and cardiovascular conditions. Studies comparing VTC with usual care that did not involve any added in-person care were more likely to favor the VTC group, the investigators found.

“We excluded conditions such as substance use disorders, maternal care, and weight management for which there was sufficient prior evidence of the benefit of VTC,” Dr. Albritton said in an interview. “But I don’t think our results would have been substantially different if we had included these other diseases. We found general evidence in the literature that VTC is effective for a broader range of conditions.”

In some cases, such as if changes in a patient’s condition triggered an automatic virtual visit, the author said he thinks VTC may lead to even greater effectiveness.

“The doctor and patient could figure out on the spot what’s going on and perhaps change the medication,” Dr. Albritton explained.

In general agreement is Julia L. Frydman, MD, assistant professor in the Brookdale Department of Geriatric and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York, who was not involved in the RTI research.

“Telemedicine has promise across many medical subspecialties, and what we need now are more studies to understand the perspectives of patients, caregivers, and clinicians as well as the impact of telemedicine on health outcomes and healthcare utilization.”

In acknowledgment of their utility, video visits are on the rise in the United States. A 2020 survey found that 22% of patients and 80% of physicians reported having participated in a video visit, three times the rate of the previous year. The authors noted that policy changes enacted to support telehealth strategies during the pandemic are expected to remain in place, and although patients are returning to in-person care, the virtual visit market will likely continue growing.
 

Increased telemedicine use by older adults

“We’ve seen an exciting expansion of telemedicine use among older adults, and we need to focus on continuing to meet their needs,” Dr. Frydman said.

In a recent study of televisits during the pandemic, Dr. Frydman’s group found a fivefold greater uptake of remote consultations by seniors – from 5% to 25%. Although in-person visits were far more common among older adults.

A specific advantage of video-based over audio-only telehealth, noted Dr. Albritton, is that physicians can directly observe patients in their home environment. Sharing that view is Deepa Iyengar, MBBS/MD,MPH, professor of family medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, where, she said, “the pandemic has put VTC use into overdrive.”

According to Dr. Iyengar, who was not involved in the RTI research, the video component definitely represents value-added over phone calls. “You can pick up visual cues on video that you might not see if the patient came in and you can see what the home environment is like – whether there are a lot of loose rugs on the floor or broken or missing light bulbs,” she said in an interview.
 

‘VTC is here to stay’

In other parts of the country, doctors are finding virtual care useful – and more common. “VTC is here to stay, for sure – the horse is out of the barn,” said Cheryl L. Wilkes, MD, an internist at Northwestern Medicine and assistant professor of medicine at Northwestern University in Chicago. “The RTI study shows no harm from VTC and also shows it may even improve clinical outcomes.”

Video visits can also save patients high parking fees at clinics and spare the sick or elderly from having to hire caregivers to bring them into the office or from having to walk blocks in dangerous weather conditions, she added. “And I can do a virtual visit on the fly or at night when a relative or caregiver is home from work to be there with the patient.”

In addition to being beneficial for following up with patients with chronic diseases such as hypertension or diabetes, VTC may be able to replace some visits that have traditionally required hands-on care, said Dr. Wilkes.

She said she knows a cardiologist who has refined a process whereby a patient – say, one who may have edema – is asked to perform a maneuver via VTC and then display the result to the doctor: The doctor says, “put your leg up and press on it hard for 10 seconds and then show me what it looks like,” according to Dr. Wilkes.

The key now is to identify the best persons across specialties from neurology to rheumatology to videotape ways they’ve created to help their patients participate virtually in consults traditionally done at the office, Dr. Wilkes noted.

But some conditions will always require palpation and the use of a stethoscope, according Dr. Iyengar.

“If someone has an ulcer, I have to be able to feel it,” she said.

And while some maternity care can be given virtually – for instance, if a mother-to be develops a bad cold – hands-on obstetrical care to check the position and health of the baby obviously has to be done in person. “So VTC is definitely going to be a welcome addition but not a replacement,” Dr. Iyengar said.

Gaps in research on VTC visits

Many questions remain regarding the overall usefulness of VTC visits for certain patient groups, according to the authors.

They highlighted, for example, the dearth of data on subgroups or on underserved and vulnerable populations, with no head-to-head studies identified in their review. In addition, they found no studies examining VTC versus usual care for patients with concurrent conditions or on its effect on health equity and disparities.

“It’s now our job to understand the ongoing barriers to telemedicine access, including the digital divide and the usability of telemedicine platforms, and design interventions that overcome them,” Dr. Frydman said. “At the same time, we need to make sure we’re understanding and respecting the preferences of older adults in terms of how they access health care.”

This study was supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Albritton is employed by RTI International, the contractor responsible for conducting the research and developing the manuscript. Several coauthors disclosed support from or contracts with PCORI. One coauthor’s spouse holds stock in private health companies. Dr. Frydman, Dr. Iyengar, and Dr. Wilkes disclosed no competing interests relevant to their comments.

The emergence of COVID-19 has given the medical world a bewildering array of prevention and treatment protocols. Some physicians are advocating treatments that have not been validated by sound scientific studies. This has already led to licensing issues and other disciplinary actions being taken against physicians, pharmacies, and other health care providers across the country.

Kuzma/istockphoto

Medical professionals try their very best to give sound advice to patients. A medical license does not, however, confer immunity from being misled.

The supporting “science” for alternative prevention and treatments may look legitimate, but these claims are often based on anecdotal evidence. Some studies involve small populations, some are meta-analyses of several small or single-case studies, and others are not properly designed, interpreted, or executed in line with U.S. research and requirements. Yet others have been conducted only in nonhuman analogues, such as frogs or mice.

Many people are refusing a vaccine that has been proven to be relatively safe and effective in numerous repeated and validated studies in the best medical centers across the globe – all in favor of less validated alternatives. Well-intentioned medical professionals may be tempted to promote the information and products featured on websites that advocate for unproven products and protocols. This can have serious legal consequences.
 

The crux of the issue

This is not a question of a physician’s first amendment rights. Nor is it a question of advocating for a scientifically valid minority medical opinion. The point of this article is that promoting unproven products, preventives, treatments, and cures can have dire consequences for licensed medical professionals.

On July 29, 2021, the Federation of State Medical Boards’ Board of Directors released a statement in response to a dramatic increase in the dissemination of COVID-19 vaccine misinformation and disinformation by physicians and other health care professionals on social media platforms, online, and in the media. The statement reads as follows:

“Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession, and puts all patients at risk.”

 

What are the legal consequences?

Medical malpractice

The first consequence to consider is professional liability or medical malpractice. This applies if a patient claims harm as a result of the health care practitioner’s recommendation of an unproven treatment, product, or protocol. For example, strongly discouraging vaccination can result in a wrongful death claim if the patient follows the doctor’s advice, chooses not to vaccinate, contracts COVID-19, and does not recover. Recommending or providing unproven approaches and unapproved treatments is arguably a violation of the standard of care.

The standard of care is grounded in evidence-based medicine: It is commonly defined as the degree of care and skill that would be used by the average physician, who is practicing in his or her relevant specialty, under the same or similar circumstances, given the generally accepted medical knowledge at the time in question.

By way of example, one can see why inhaling peroxide, drinking bleach, or even taking Food and Drug Administration–approved medications that have little or no proven efficacy in treating or preventing COVID-19 is not what the average physician would advocate for under the same or similar circumstances, considering available and commonly accepted medical knowledge. Recommending or providing such treatments can be a breach of the standard of care and can form the basis of a medical malpractice action if, in fact, compensable harm has occurred.

In addition, recommending unproven and unapproved COVID-19 preventives and treatments without appropriate informed consent from patients is arguably also a breach of the standard of care. The claim would be that the patient has not been appropriately informed of the all the known benefits, risks, costs, and other legally required information such as proven efficacy and reasonably available alternatives.

In any event, physicians can rest assured that if a patient is harmed as a result of any of these situations, they’ll probably be answering to someone in the legal system.
 

Professional licensing action

Regardless of whether there is a medical malpractice action, there is still the potential for a patient complaint to be filed with the state licensing authority on the basis of the same facts and grounds. This can result in an investigation or an administrative complaint against the license of the health care provider.

This is not a mere potential risk. Licensing investigations are underway across the country. Disciplinary licensing actions have already taken place. For example, a Washington Medical Commission panel suspended the license of a physician assistant (PA) on Oct. 12, 2021, after an allegation that his treatment of COVID-19 patients fell below the standard of care. The PA allegedly began a public campaign promoting ivermectin as a curative agent for COVID-19 and prescribed it without adequate examination to at least one person, with no evidence from reliable clinical studies that establish its efficacy in preventing or treating COVID-19.

In licensing claims, alleged violations of failing to comply with the standard of care are usually asserted. These claims may also cite violations of other state statutes that encompass such concepts as negligence; breach of the duty of due care; incompetence; lack of good moral character; and lack of ability to serve the public in a fair, honest, and open manner. A licensing complaint may include alleged violations of statutes that address prescribing protocols, reckless endangerment, failure to supervise, and other issues.

The filing of an administrative complaint is a different animal from a medical malpractice action – they are not even in the same system or branch of government. The focus is not just about what happened to the one patient who complained; it is about protection of the public.

The states’ power to put a clinician on probation, condition, limit, suspend, or revoke the clinician’s license, as well as issue other sanctions such as physician monitoring and fines), is profound. The discipline imposed can upend a clinician’s career and potentially end it entirely.

Administrative discipline determinations are usually available to the public and are required to be reported to all employers (current and future). These discipline determinations are also sent to the National Practitioner Data Bank, other professional clearinghouse organizations (such as the Federation of State Medical Boards), state offices, professional liability insurers, payers with whom the clinician contracts, accreditation and certification organizations, and the clinician’s patients.

Discipline determinations must be promptly reported to licensing agencies in other states where the clinician holds a license, and often results in “sister state” actions because discipline was issued against the clinician in another state. It must be disclosed every time a clinician applies for hospital privileges or new employment. It can result in de-participation from health care insurance programs and can affect board certification, recertification, or accreditation for care programs in which the clinician participates.

In sum, licensing actions can be much worse than medical malpractice judgments and can have longer-term consequences.
 

Peer review and affected privileges

Recommending, promoting, and providing unapproved or unproven treatments, cures, or preventives to patients may violate hospital/health system, practice group, or surgical center bylaws. This can trigger the peer review process, which serves to improve patient safety and the quality of care.

The peer review process may be commenced because of a concern about the clinician’s compliance with the standard of care; potential patient safety issues; ethical issues; and the clinician’s stability, credibility, or professional competence. Any hospital disciplinary penalty is generally reported to state licensing authorities, which can trigger a licensing investigation. If clinical privileges are affected for a period of more than 30 days, the organization must report the situation to the National Practitioner Data Bank.
 

Criminal charges

Depending on the facts, a physician or other health care professional could be charged with reckless endangerment, criminal negligence, or manslaughter. If the clinician was assisting someone else who profited from that clinician’s actions, then we can look to a variety of potential federal and state fraud charges as well.

Conviction of a fraud-related felony may also lead to federal health care program and Centers for Medicare & Medicaid Services (CMS) exclusion for several years, and then CMS preclusion that can be imposed for years beyond the conclusion of the statutorily required exclusion.
 

Breach of contract

Some practice groups or other organizational employers have provisions in employment contracts that treat discipline for this type of conduct as a breach of contract. Because of this, the clinician committing breach may be subject to liquidated damages clauses, forfeiture of monies (such as bonuses or other incentives or rewards), termination of employment, forced withdrawal from ownership status, and being sued for breach of contract to recover damages.

Reputation/credibility damage and the attendant consequences

In regard to hospitals and health care system practice groups, another risk is the loss of referrals and revenue. Local media may air or publish exposés. Such stories may widely publicize the media’s version of the facts – true or not. This can cause immediate reputation and credibility damage within the community and may adversely affect a clinician’s patient base. Any information that is publicly broadcast might attract the attention of licensing and law enforcement authorities and taint potential jurors.

Hospitals and health care systems may pull privileges; post on websites; make official statements about the termination of affiliation; or denounce the clinician’s behavior, conduct, and beliefs as being inconsistent with quality care and patient safety. This causes further damage to a physician’s reputation and credibility.

In a group practice, accusations of this sort, licensing discipline, medical malpractice liability, investigations, loss of privileges, and the other sequelae of this conduct can force the withdrawal of the clinician as a member or shareholder in multiprovider groups. Adverse effects on the financial bottom line, patient referrals, and patient volume and bad press are often the basis for voting a clinician out.
 

Violation of the COVID-19 Consumer Protection Act of 2020

For the duration of the COVID-19 public health emergency, the FTC COVID-19 Consumer Protection Act makes it unlawful for any person, partnership, or corporation (as those terms are defined broadly in the act) to engage in a deceptive act or practice in or affecting commerce associated with the treatment, cure, prevention, mitigation, or diagnosis of COVID-19 or a government benefit related to COVID-19.

The first enforcement action authorized by this act took place in April 2021 against a chiropractor who promised vitamin treatments and cures for COVID-19. The act provides that such a violation shall be treated as a violation of a rule defining an unfair or deceptive act or practice prescribed under the FTC Act.

Under the act, the FTC is authorized to prescribe “rules that define with specificity acts or practices which are unfair or deceptive acts or practices in or affecting commerce.” Deceptive practices are defined as involving a material representation, omission, or practice that is “likely to mislead a consumer acting reasonably in the circumstances.” An act or practice is unfair if it “causes or is likely to cause substantial injury to consumers which is not reasonably avoidable by consumers themselves and not outweighed by countervailing benefits to consumers or to competition.”

After an investigation, the FTC may initiate an enforcement action using either an administrative or judicial process if it has “reason to believe” that the law has been violated. Violations of some laws may result in injunctive relief or civil monetary penalties, which are adjusted annually for inflation.

In addition, many states have deceptive and unfair trade laws that can be enforced in regard to the recommendation, sale, or provision of unproven or unapproved COVID-19 treatments, cures, and preventives as well.
 

Conclusion

It is difficult even for intelligent, well-intentioned physicians to know precisely what to believe and what to advocate for in the middle of a pandemic. It seems as though new reports and recommendations for preventing and treating COVID-19 are surfacing on a weekly basis. By far, the safest approach for any medical clinician to take is to advocate for positions that are generally accepted in the medical and scientific community at the time advice is given.

Mr. Whitelaw disclosed no relevant financial relationships. Ms. Janeway disclosed various associations with the Michigan Association for Healthcare Quality and the Greater Houston Society for Healthcare Risk Management. A version of this article first appeared on Medscape.com.

The emergence of COVID-19 has given the medical world a bewildering array of prevention and treatment protocols. Some physicians are advocating treatments that have not been validated by sound scientific studies. This has already led to licensing issues and other disciplinary actions being taken against physicians, pharmacies, and other health care providers across the country.

Kuzma/istockphoto

Medical professionals try their very best to give sound advice to patients. A medical license does not, however, confer immunity from being misled.

The supporting “science” for alternative prevention and treatments may look legitimate, but these claims are often based on anecdotal evidence. Some studies involve small populations, some are meta-analyses of several small or single-case studies, and others are not properly designed, interpreted, or executed in line with U.S. research and requirements. Yet others have been conducted only in nonhuman analogues, such as frogs or mice.

Many people are refusing a vaccine that has been proven to be relatively safe and effective in numerous repeated and validated studies in the best medical centers across the globe – all in favor of less validated alternatives. Well-intentioned medical professionals may be tempted to promote the information and products featured on websites that advocate for unproven products and protocols. This can have serious legal consequences.
 

The crux of the issue

This is not a question of a physician’s first amendment rights. Nor is it a question of advocating for a scientifically valid minority medical opinion. The point of this article is that promoting unproven products, preventives, treatments, and cures can have dire consequences for licensed medical professionals.

On July 29, 2021, the Federation of State Medical Boards’ Board of Directors released a statement in response to a dramatic increase in the dissemination of COVID-19 vaccine misinformation and disinformation by physicians and other health care professionals on social media platforms, online, and in the media. The statement reads as follows:

“Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession, and puts all patients at risk.”

 

What are the legal consequences?

Medical malpractice

The first consequence to consider is professional liability or medical malpractice. This applies if a patient claims harm as a result of the health care practitioner’s recommendation of an unproven treatment, product, or protocol. For example, strongly discouraging vaccination can result in a wrongful death claim if the patient follows the doctor’s advice, chooses not to vaccinate, contracts COVID-19, and does not recover. Recommending or providing unproven approaches and unapproved treatments is arguably a violation of the standard of care.

The standard of care is grounded in evidence-based medicine: It is commonly defined as the degree of care and skill that would be used by the average physician, who is practicing in his or her relevant specialty, under the same or similar circumstances, given the generally accepted medical knowledge at the time in question.

By way of example, one can see why inhaling peroxide, drinking bleach, or even taking Food and Drug Administration–approved medications that have little or no proven efficacy in treating or preventing COVID-19 is not what the average physician would advocate for under the same or similar circumstances, considering available and commonly accepted medical knowledge. Recommending or providing such treatments can be a breach of the standard of care and can form the basis of a medical malpractice action if, in fact, compensable harm has occurred.

In addition, recommending unproven and unapproved COVID-19 preventives and treatments without appropriate informed consent from patients is arguably also a breach of the standard of care. The claim would be that the patient has not been appropriately informed of the all the known benefits, risks, costs, and other legally required information such as proven efficacy and reasonably available alternatives.

In any event, physicians can rest assured that if a patient is harmed as a result of any of these situations, they’ll probably be answering to someone in the legal system.
 

Professional licensing action

Regardless of whether there is a medical malpractice action, there is still the potential for a patient complaint to be filed with the state licensing authority on the basis of the same facts and grounds. This can result in an investigation or an administrative complaint against the license of the health care provider.

This is not a mere potential risk. Licensing investigations are underway across the country. Disciplinary licensing actions have already taken place. For example, a Washington Medical Commission panel suspended the license of a physician assistant (PA) on Oct. 12, 2021, after an allegation that his treatment of COVID-19 patients fell below the standard of care. The PA allegedly began a public campaign promoting ivermectin as a curative agent for COVID-19 and prescribed it without adequate examination to at least one person, with no evidence from reliable clinical studies that establish its efficacy in preventing or treating COVID-19.

In licensing claims, alleged violations of failing to comply with the standard of care are usually asserted. These claims may also cite violations of other state statutes that encompass such concepts as negligence; breach of the duty of due care; incompetence; lack of good moral character; and lack of ability to serve the public in a fair, honest, and open manner. A licensing complaint may include alleged violations of statutes that address prescribing protocols, reckless endangerment, failure to supervise, and other issues.

The filing of an administrative complaint is a different animal from a medical malpractice action – they are not even in the same system or branch of government. The focus is not just about what happened to the one patient who complained; it is about protection of the public.

The states’ power to put a clinician on probation, condition, limit, suspend, or revoke the clinician’s license, as well as issue other sanctions such as physician monitoring and fines), is profound. The discipline imposed can upend a clinician’s career and potentially end it entirely.

Administrative discipline determinations are usually available to the public and are required to be reported to all employers (current and future). These discipline determinations are also sent to the National Practitioner Data Bank, other professional clearinghouse organizations (such as the Federation of State Medical Boards), state offices, professional liability insurers, payers with whom the clinician contracts, accreditation and certification organizations, and the clinician’s patients.

Discipline determinations must be promptly reported to licensing agencies in other states where the clinician holds a license, and often results in “sister state” actions because discipline was issued against the clinician in another state. It must be disclosed every time a clinician applies for hospital privileges or new employment. It can result in de-participation from health care insurance programs and can affect board certification, recertification, or accreditation for care programs in which the clinician participates.

In sum, licensing actions can be much worse than medical malpractice judgments and can have longer-term consequences.
 

Peer review and affected privileges

Recommending, promoting, and providing unapproved or unproven treatments, cures, or preventives to patients may violate hospital/health system, practice group, or surgical center bylaws. This can trigger the peer review process, which serves to improve patient safety and the quality of care.

The peer review process may be commenced because of a concern about the clinician’s compliance with the standard of care; potential patient safety issues; ethical issues; and the clinician’s stability, credibility, or professional competence. Any hospital disciplinary penalty is generally reported to state licensing authorities, which can trigger a licensing investigation. If clinical privileges are affected for a period of more than 30 days, the organization must report the situation to the National Practitioner Data Bank.
 

Criminal charges

Depending on the facts, a physician or other health care professional could be charged with reckless endangerment, criminal negligence, or manslaughter. If the clinician was assisting someone else who profited from that clinician’s actions, then we can look to a variety of potential federal and state fraud charges as well.

Conviction of a fraud-related felony may also lead to federal health care program and Centers for Medicare & Medicaid Services (CMS) exclusion for several years, and then CMS preclusion that can be imposed for years beyond the conclusion of the statutorily required exclusion.
 

Breach of contract

Some practice groups or other organizational employers have provisions in employment contracts that treat discipline for this type of conduct as a breach of contract. Because of this, the clinician committing breach may be subject to liquidated damages clauses, forfeiture of monies (such as bonuses or other incentives or rewards), termination of employment, forced withdrawal from ownership status, and being sued for breach of contract to recover damages.

Reputation/credibility damage and the attendant consequences

In regard to hospitals and health care system practice groups, another risk is the loss of referrals and revenue. Local media may air or publish exposés. Such stories may widely publicize the media’s version of the facts – true or not. This can cause immediate reputation and credibility damage within the community and may adversely affect a clinician’s patient base. Any information that is publicly broadcast might attract the attention of licensing and law enforcement authorities and taint potential jurors.

Hospitals and health care systems may pull privileges; post on websites; make official statements about the termination of affiliation; or denounce the clinician’s behavior, conduct, and beliefs as being inconsistent with quality care and patient safety. This causes further damage to a physician’s reputation and credibility.

In a group practice, accusations of this sort, licensing discipline, medical malpractice liability, investigations, loss of privileges, and the other sequelae of this conduct can force the withdrawal of the clinician as a member or shareholder in multiprovider groups. Adverse effects on the financial bottom line, patient referrals, and patient volume and bad press are often the basis for voting a clinician out.
 

Violation of the COVID-19 Consumer Protection Act of 2020

For the duration of the COVID-19 public health emergency, the FTC COVID-19 Consumer Protection Act makes it unlawful for any person, partnership, or corporation (as those terms are defined broadly in the act) to engage in a deceptive act or practice in or affecting commerce associated with the treatment, cure, prevention, mitigation, or diagnosis of COVID-19 or a government benefit related to COVID-19.

The first enforcement action authorized by this act took place in April 2021 against a chiropractor who promised vitamin treatments and cures for COVID-19. The act provides that such a violation shall be treated as a violation of a rule defining an unfair or deceptive act or practice prescribed under the FTC Act.

Under the act, the FTC is authorized to prescribe “rules that define with specificity acts or practices which are unfair or deceptive acts or practices in or affecting commerce.” Deceptive practices are defined as involving a material representation, omission, or practice that is “likely to mislead a consumer acting reasonably in the circumstances.” An act or practice is unfair if it “causes or is likely to cause substantial injury to consumers which is not reasonably avoidable by consumers themselves and not outweighed by countervailing benefits to consumers or to competition.”

After an investigation, the FTC may initiate an enforcement action using either an administrative or judicial process if it has “reason to believe” that the law has been violated. Violations of some laws may result in injunctive relief or civil monetary penalties, which are adjusted annually for inflation.

In addition, many states have deceptive and unfair trade laws that can be enforced in regard to the recommendation, sale, or provision of unproven or unapproved COVID-19 treatments, cures, and preventives as well.
 

Conclusion

It is difficult even for intelligent, well-intentioned physicians to know precisely what to believe and what to advocate for in the middle of a pandemic. It seems as though new reports and recommendations for preventing and treating COVID-19 are surfacing on a weekly basis. By far, the safest approach for any medical clinician to take is to advocate for positions that are generally accepted in the medical and scientific community at the time advice is given.

Mr. Whitelaw disclosed no relevant financial relationships. Ms. Janeway disclosed various associations with the Michigan Association for Healthcare Quality and the Greater Houston Society for Healthcare Risk Management. A version of this article first appeared on Medscape.com.

The emergence of COVID-19 has given the medical world a bewildering array of prevention and treatment protocols. Some physicians are advocating treatments that have not been validated by sound scientific studies. This has already led to licensing issues and other disciplinary actions being taken against physicians, pharmacies, and other health care providers across the country.

Kuzma/istockphoto

Medical professionals try their very best to give sound advice to patients. A medical license does not, however, confer immunity from being misled.

The supporting “science” for alternative prevention and treatments may look legitimate, but these claims are often based on anecdotal evidence. Some studies involve small populations, some are meta-analyses of several small or single-case studies, and others are not properly designed, interpreted, or executed in line with U.S. research and requirements. Yet others have been conducted only in nonhuman analogues, such as frogs or mice.

Many people are refusing a vaccine that has been proven to be relatively safe and effective in numerous repeated and validated studies in the best medical centers across the globe – all in favor of less validated alternatives. Well-intentioned medical professionals may be tempted to promote the information and products featured on websites that advocate for unproven products and protocols. This can have serious legal consequences.
 

The crux of the issue

This is not a question of a physician’s first amendment rights. Nor is it a question of advocating for a scientifically valid minority medical opinion. The point of this article is that promoting unproven products, preventives, treatments, and cures can have dire consequences for licensed medical professionals.

On July 29, 2021, the Federation of State Medical Boards’ Board of Directors released a statement in response to a dramatic increase in the dissemination of COVID-19 vaccine misinformation and disinformation by physicians and other health care professionals on social media platforms, online, and in the media. The statement reads as follows:

“Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession, and puts all patients at risk.”

 

What are the legal consequences?

Medical malpractice

The first consequence to consider is professional liability or medical malpractice. This applies if a patient claims harm as a result of the health care practitioner’s recommendation of an unproven treatment, product, or protocol. For example, strongly discouraging vaccination can result in a wrongful death claim if the patient follows the doctor’s advice, chooses not to vaccinate, contracts COVID-19, and does not recover. Recommending or providing unproven approaches and unapproved treatments is arguably a violation of the standard of care.

The standard of care is grounded in evidence-based medicine: It is commonly defined as the degree of care and skill that would be used by the average physician, who is practicing in his or her relevant specialty, under the same or similar circumstances, given the generally accepted medical knowledge at the time in question.

By way of example, one can see why inhaling peroxide, drinking bleach, or even taking Food and Drug Administration–approved medications that have little or no proven efficacy in treating or preventing COVID-19 is not what the average physician would advocate for under the same or similar circumstances, considering available and commonly accepted medical knowledge. Recommending or providing such treatments can be a breach of the standard of care and can form the basis of a medical malpractice action if, in fact, compensable harm has occurred.

In addition, recommending unproven and unapproved COVID-19 preventives and treatments without appropriate informed consent from patients is arguably also a breach of the standard of care. The claim would be that the patient has not been appropriately informed of the all the known benefits, risks, costs, and other legally required information such as proven efficacy and reasonably available alternatives.

In any event, physicians can rest assured that if a patient is harmed as a result of any of these situations, they’ll probably be answering to someone in the legal system.
 

Professional licensing action

Regardless of whether there is a medical malpractice action, there is still the potential for a patient complaint to be filed with the state licensing authority on the basis of the same facts and grounds. This can result in an investigation or an administrative complaint against the license of the health care provider.

This is not a mere potential risk. Licensing investigations are underway across the country. Disciplinary licensing actions have already taken place. For example, a Washington Medical Commission panel suspended the license of a physician assistant (PA) on Oct. 12, 2021, after an allegation that his treatment of COVID-19 patients fell below the standard of care. The PA allegedly began a public campaign promoting ivermectin as a curative agent for COVID-19 and prescribed it without adequate examination to at least one person, with no evidence from reliable clinical studies that establish its efficacy in preventing or treating COVID-19.

In licensing claims, alleged violations of failing to comply with the standard of care are usually asserted. These claims may also cite violations of other state statutes that encompass such concepts as negligence; breach of the duty of due care; incompetence; lack of good moral character; and lack of ability to serve the public in a fair, honest, and open manner. A licensing complaint may include alleged violations of statutes that address prescribing protocols, reckless endangerment, failure to supervise, and other issues.

The filing of an administrative complaint is a different animal from a medical malpractice action – they are not even in the same system or branch of government. The focus is not just about what happened to the one patient who complained; it is about protection of the public.

The states’ power to put a clinician on probation, condition, limit, suspend, or revoke the clinician’s license, as well as issue other sanctions such as physician monitoring and fines), is profound. The discipline imposed can upend a clinician’s career and potentially end it entirely.

Administrative discipline determinations are usually available to the public and are required to be reported to all employers (current and future). These discipline determinations are also sent to the National Practitioner Data Bank, other professional clearinghouse organizations (such as the Federation of State Medical Boards), state offices, professional liability insurers, payers with whom the clinician contracts, accreditation and certification organizations, and the clinician’s patients.

Discipline determinations must be promptly reported to licensing agencies in other states where the clinician holds a license, and often results in “sister state” actions because discipline was issued against the clinician in another state. It must be disclosed every time a clinician applies for hospital privileges or new employment. It can result in de-participation from health care insurance programs and can affect board certification, recertification, or accreditation for care programs in which the clinician participates.

In sum, licensing actions can be much worse than medical malpractice judgments and can have longer-term consequences.
 

Peer review and affected privileges

Recommending, promoting, and providing unapproved or unproven treatments, cures, or preventives to patients may violate hospital/health system, practice group, or surgical center bylaws. This can trigger the peer review process, which serves to improve patient safety and the quality of care.

The peer review process may be commenced because of a concern about the clinician’s compliance with the standard of care; potential patient safety issues; ethical issues; and the clinician’s stability, credibility, or professional competence. Any hospital disciplinary penalty is generally reported to state licensing authorities, which can trigger a licensing investigation. If clinical privileges are affected for a period of more than 30 days, the organization must report the situation to the National Practitioner Data Bank.
 

Criminal charges

Depending on the facts, a physician or other health care professional could be charged with reckless endangerment, criminal negligence, or manslaughter. If the clinician was assisting someone else who profited from that clinician’s actions, then we can look to a variety of potential federal and state fraud charges as well.

Conviction of a fraud-related felony may also lead to federal health care program and Centers for Medicare & Medicaid Services (CMS) exclusion for several years, and then CMS preclusion that can be imposed for years beyond the conclusion of the statutorily required exclusion.
 

Breach of contract

Some practice groups or other organizational employers have provisions in employment contracts that treat discipline for this type of conduct as a breach of contract. Because of this, the clinician committing breach may be subject to liquidated damages clauses, forfeiture of monies (such as bonuses or other incentives or rewards), termination of employment, forced withdrawal from ownership status, and being sued for breach of contract to recover damages.

Reputation/credibility damage and the attendant consequences

In regard to hospitals and health care system practice groups, another risk is the loss of referrals and revenue. Local media may air or publish exposés. Such stories may widely publicize the media’s version of the facts – true or not. This can cause immediate reputation and credibility damage within the community and may adversely affect a clinician’s patient base. Any information that is publicly broadcast might attract the attention of licensing and law enforcement authorities and taint potential jurors.

Hospitals and health care systems may pull privileges; post on websites; make official statements about the termination of affiliation; or denounce the clinician’s behavior, conduct, and beliefs as being inconsistent with quality care and patient safety. This causes further damage to a physician’s reputation and credibility.

In a group practice, accusations of this sort, licensing discipline, medical malpractice liability, investigations, loss of privileges, and the other sequelae of this conduct can force the withdrawal of the clinician as a member or shareholder in multiprovider groups. Adverse effects on the financial bottom line, patient referrals, and patient volume and bad press are often the basis for voting a clinician out.
 

Violation of the COVID-19 Consumer Protection Act of 2020

For the duration of the COVID-19 public health emergency, the FTC COVID-19 Consumer Protection Act makes it unlawful for any person, partnership, or corporation (as those terms are defined broadly in the act) to engage in a deceptive act or practice in or affecting commerce associated with the treatment, cure, prevention, mitigation, or diagnosis of COVID-19 or a government benefit related to COVID-19.

The first enforcement action authorized by this act took place in April 2021 against a chiropractor who promised vitamin treatments and cures for COVID-19. The act provides that such a violation shall be treated as a violation of a rule defining an unfair or deceptive act or practice prescribed under the FTC Act.

Under the act, the FTC is authorized to prescribe “rules that define with specificity acts or practices which are unfair or deceptive acts or practices in or affecting commerce.” Deceptive practices are defined as involving a material representation, omission, or practice that is “likely to mislead a consumer acting reasonably in the circumstances.” An act or practice is unfair if it “causes or is likely to cause substantial injury to consumers which is not reasonably avoidable by consumers themselves and not outweighed by countervailing benefits to consumers or to competition.”

After an investigation, the FTC may initiate an enforcement action using either an administrative or judicial process if it has “reason to believe” that the law has been violated. Violations of some laws may result in injunctive relief or civil monetary penalties, which are adjusted annually for inflation.

In addition, many states have deceptive and unfair trade laws that can be enforced in regard to the recommendation, sale, or provision of unproven or unapproved COVID-19 treatments, cures, and preventives as well.
 

Conclusion

It is difficult even for intelligent, well-intentioned physicians to know precisely what to believe and what to advocate for in the middle of a pandemic. It seems as though new reports and recommendations for preventing and treating COVID-19 are surfacing on a weekly basis. By far, the safest approach for any medical clinician to take is to advocate for positions that are generally accepted in the medical and scientific community at the time advice is given.

Mr. Whitelaw disclosed no relevant financial relationships. Ms. Janeway disclosed various associations with the Michigan Association for Healthcare Quality and the Greater Houston Society for Healthcare Risk Management. A version of this article first appeared on Medscape.com.

Individuals diagnosed with obstructive sleep apnea (OSA) have higher volumes of white-matter hyperintensities (WMHs), according to a new analysis of data from the SHIP-Trend-0 cohort in Western Pomerania, Germany, which is part of the Study of Health In Pomerania. The association was true for individual measures of OSA, including apnea-hypopnea index (AHI) and oxygen desaturation index (ODI).

WMHs are often seen on MRI in older people and in patients with stroke or dementia, and they may be an indicator of cerebral small-vessel disease. They are linked to greater risk of abnormal gait, worsening balance, depression, cognitive decline, dementia, stroke, and death. Suggested mechanisms for harms from WMHs include ischemia, hypoxia, hypoperfusion, inflammation, and demyelination.

WMHs have been linked to vascular risk factors like smoking, diabetes, and hypertension. Brain pathology studies have found loss of myelin, axonal loss, and scarring close to WMHs.

Although a few studies have looked for associations between WMHs and OSA, they have yielded inconsistent results. The new work employed highly standardized data collection and more complete covariate adjustment. The results, published in JAMA Network Open, suggest a novel, and potentially treatable, pathological WMH mechanism, according to the authors.

“This is an important study. It has strong methodology. The automated analysis of WMH in a large population-based cohort helps to eliminate several biases that can occur in this type of assessment. The data analysis was massive, with adequate control of all potential confounders and testing for interactions. This generated robust results,” said Diego Z. Carvalho, MD, who was asked to comment on the findings. Dr. Carvalho is an assistant professor of neurology at the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn.
 

Worse apnea, worse hyperintensity

“The association varies according to the degree of apnea severity, so mild OSA is probably not associated with increased WMH, while severe OSA is mostly likely driving most of the associations,” said Dr. Carvalho.

If a causal mechanism were to be proven, it would “bring a stronger call for treatment of severe OSA patients, particularly those with increased risk for small-vessel disease, [such as] patients with metabolic syndrome. Likewise, patients with severe OSA would be the best candidates for therapeutic trials with [continuous positive airway pressure] with or without possible adjunctive neuroprotective treatment for halting or slowing down WMH progression,” said Dr. Carvalho.

Stuart McCarter, MD, who is an instructor of neurology at the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn., also found the results interesting but pointed out that much more work needs to be done. “While they found a relationship between OSA as well as OSA severity and WMH despite adjusting for other known confounders, it is unlikely that it is as simple as OSA is the main causal factor for WMH, given the complex relationship between OSA, hypertension, and metabolic syndrome. However, this data does highlight the importance of considering OSA in addition to other more traditional risk factors when considering modifiable risk factors for brain aging,” said Dr. McCarter. The study cohort was mostly of White European ancestry, so more work also needs to be done in other racial groups.

The study underlines the importance of screening among individuals with cognitive impairment. “If OSA represents a modifiable risk factor for WMH and associated cognitive decline, then it would represent one of the few potentially treatable etiologies, or at least contributors of cognitive impairment,” said Dr. McCarter.

The SHIP-Trend-0 cohort is drawn from adults in Western Pomerania. The researchers analyzed data from 529 patients who had WMH and for whom intracranial volume data were available. Each member of the cohort also underwent polysomnography.

Based on AHI criteria, 24% of the overall sample had mild OSA, 10% had moderate OSA, and 6% had severe OSA.

After adjustment for sex, age, intracranial volume, and body weight, WMH volume was associated with AHI (beta = 0.024; P < .001) and ODI (beta = 0.033; P < .001). WMH counts were also associated with AHI (beta = 0.008; P = .01) and ODI (beta = 0.011; P = .02).

The effect size increased with greater OSA severity, as measured by AHI for both WMH volume (beta = 0.312, 0.480, and 1.255 for mild, moderate, and severe OSA, respectively) and WMH count (beta = 0.129, 0.107, and 0.419). The ODI regression models showed similar associations for WMH volume (beta = 0.426, 1.030, and 1.130) and WMH count (beta = 0.141, 0.315, and 0.538).

Dr. Carvalho and Dr. McCarter disclosed no relevant financial relationships.
 

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

Individuals diagnosed with obstructive sleep apnea (OSA) have higher volumes of white-matter hyperintensities (WMHs), according to a new analysis of data from the SHIP-Trend-0 cohort in Western Pomerania, Germany, which is part of the Study of Health In Pomerania. The association was true for individual measures of OSA, including apnea-hypopnea index (AHI) and oxygen desaturation index (ODI).

WMHs are often seen on MRI in older people and in patients with stroke or dementia, and they may be an indicator of cerebral small-vessel disease. They are linked to greater risk of abnormal gait, worsening balance, depression, cognitive decline, dementia, stroke, and death. Suggested mechanisms for harms from WMHs include ischemia, hypoxia, hypoperfusion, inflammation, and demyelination.

WMHs have been linked to vascular risk factors like smoking, diabetes, and hypertension. Brain pathology studies have found loss of myelin, axonal loss, and scarring close to WMHs.

Although a few studies have looked for associations between WMHs and OSA, they have yielded inconsistent results. The new work employed highly standardized data collection and more complete covariate adjustment. The results, published in JAMA Network Open, suggest a novel, and potentially treatable, pathological WMH mechanism, according to the authors.

“This is an important study. It has strong methodology. The automated analysis of WMH in a large population-based cohort helps to eliminate several biases that can occur in this type of assessment. The data analysis was massive, with adequate control of all potential confounders and testing for interactions. This generated robust results,” said Diego Z. Carvalho, MD, who was asked to comment on the findings. Dr. Carvalho is an assistant professor of neurology at the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn.
 

Worse apnea, worse hyperintensity

“The association varies according to the degree of apnea severity, so mild OSA is probably not associated with increased WMH, while severe OSA is mostly likely driving most of the associations,” said Dr. Carvalho.

If a causal mechanism were to be proven, it would “bring a stronger call for treatment of severe OSA patients, particularly those with increased risk for small-vessel disease, [such as] patients with metabolic syndrome. Likewise, patients with severe OSA would be the best candidates for therapeutic trials with [continuous positive airway pressure] with or without possible adjunctive neuroprotective treatment for halting or slowing down WMH progression,” said Dr. Carvalho.

Stuart McCarter, MD, who is an instructor of neurology at the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn., also found the results interesting but pointed out that much more work needs to be done. “While they found a relationship between OSA as well as OSA severity and WMH despite adjusting for other known confounders, it is unlikely that it is as simple as OSA is the main causal factor for WMH, given the complex relationship between OSA, hypertension, and metabolic syndrome. However, this data does highlight the importance of considering OSA in addition to other more traditional risk factors when considering modifiable risk factors for brain aging,” said Dr. McCarter. The study cohort was mostly of White European ancestry, so more work also needs to be done in other racial groups.

The study underlines the importance of screening among individuals with cognitive impairment. “If OSA represents a modifiable risk factor for WMH and associated cognitive decline, then it would represent one of the few potentially treatable etiologies, or at least contributors of cognitive impairment,” said Dr. McCarter.

The SHIP-Trend-0 cohort is drawn from adults in Western Pomerania. The researchers analyzed data from 529 patients who had WMH and for whom intracranial volume data were available. Each member of the cohort also underwent polysomnography.

Based on AHI criteria, 24% of the overall sample had mild OSA, 10% had moderate OSA, and 6% had severe OSA.

After adjustment for sex, age, intracranial volume, and body weight, WMH volume was associated with AHI (beta = 0.024; P < .001) and ODI (beta = 0.033; P < .001). WMH counts were also associated with AHI (beta = 0.008; P = .01) and ODI (beta = 0.011; P = .02).

The effect size increased with greater OSA severity, as measured by AHI for both WMH volume (beta = 0.312, 0.480, and 1.255 for mild, moderate, and severe OSA, respectively) and WMH count (beta = 0.129, 0.107, and 0.419). The ODI regression models showed similar associations for WMH volume (beta = 0.426, 1.030, and 1.130) and WMH count (beta = 0.141, 0.315, and 0.538).

Dr. Carvalho and Dr. McCarter disclosed no relevant financial relationships.
 

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

Individuals diagnosed with obstructive sleep apnea (OSA) have higher volumes of white-matter hyperintensities (WMHs), according to a new analysis of data from the SHIP-Trend-0 cohort in Western Pomerania, Germany, which is part of the Study of Health In Pomerania. The association was true for individual measures of OSA, including apnea-hypopnea index (AHI) and oxygen desaturation index (ODI).

WMHs are often seen on MRI in older people and in patients with stroke or dementia, and they may be an indicator of cerebral small-vessel disease. They are linked to greater risk of abnormal gait, worsening balance, depression, cognitive decline, dementia, stroke, and death. Suggested mechanisms for harms from WMHs include ischemia, hypoxia, hypoperfusion, inflammation, and demyelination.

WMHs have been linked to vascular risk factors like smoking, diabetes, and hypertension. Brain pathology studies have found loss of myelin, axonal loss, and scarring close to WMHs.

Although a few studies have looked for associations between WMHs and OSA, they have yielded inconsistent results. The new work employed highly standardized data collection and more complete covariate adjustment. The results, published in JAMA Network Open, suggest a novel, and potentially treatable, pathological WMH mechanism, according to the authors.

“This is an important study. It has strong methodology. The automated analysis of WMH in a large population-based cohort helps to eliminate several biases that can occur in this type of assessment. The data analysis was massive, with adequate control of all potential confounders and testing for interactions. This generated robust results,” said Diego Z. Carvalho, MD, who was asked to comment on the findings. Dr. Carvalho is an assistant professor of neurology at the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn.
 

Worse apnea, worse hyperintensity

“The association varies according to the degree of apnea severity, so mild OSA is probably not associated with increased WMH, while severe OSA is mostly likely driving most of the associations,” said Dr. Carvalho.

If a causal mechanism were to be proven, it would “bring a stronger call for treatment of severe OSA patients, particularly those with increased risk for small-vessel disease, [such as] patients with metabolic syndrome. Likewise, patients with severe OSA would be the best candidates for therapeutic trials with [continuous positive airway pressure] with or without possible adjunctive neuroprotective treatment for halting or slowing down WMH progression,” said Dr. Carvalho.

Stuart McCarter, MD, who is an instructor of neurology at the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn., also found the results interesting but pointed out that much more work needs to be done. “While they found a relationship between OSA as well as OSA severity and WMH despite adjusting for other known confounders, it is unlikely that it is as simple as OSA is the main causal factor for WMH, given the complex relationship between OSA, hypertension, and metabolic syndrome. However, this data does highlight the importance of considering OSA in addition to other more traditional risk factors when considering modifiable risk factors for brain aging,” said Dr. McCarter. The study cohort was mostly of White European ancestry, so more work also needs to be done in other racial groups.

The study underlines the importance of screening among individuals with cognitive impairment. “If OSA represents a modifiable risk factor for WMH and associated cognitive decline, then it would represent one of the few potentially treatable etiologies, or at least contributors of cognitive impairment,” said Dr. McCarter.

The SHIP-Trend-0 cohort is drawn from adults in Western Pomerania. The researchers analyzed data from 529 patients who had WMH and for whom intracranial volume data were available. Each member of the cohort also underwent polysomnography.

Based on AHI criteria, 24% of the overall sample had mild OSA, 10% had moderate OSA, and 6% had severe OSA.

After adjustment for sex, age, intracranial volume, and body weight, WMH volume was associated with AHI (beta = 0.024; P < .001) and ODI (beta = 0.033; P < .001). WMH counts were also associated with AHI (beta = 0.008; P = .01) and ODI (beta = 0.011; P = .02).

The effect size increased with greater OSA severity, as measured by AHI for both WMH volume (beta = 0.312, 0.480, and 1.255 for mild, moderate, and severe OSA, respectively) and WMH count (beta = 0.129, 0.107, and 0.419). The ODI regression models showed similar associations for WMH volume (beta = 0.426, 1.030, and 1.130) and WMH count (beta = 0.141, 0.315, and 0.538).

Dr. Carvalho and Dr. McCarter disclosed no relevant financial relationships.
 

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

Sleep apnea and other types of sleep disorders appear to elevate the risk for some types of cancer, specifically prostate cancer, more so than others. But the overall risk can be highly variable, and some sleep problems were found to be associated with a lower risk for cancer and cancer-related death, an analysis of a large observational cohort study of cardiovascular patients found.

Results of the analysis were published online in the journal Cancer Epidemiology. Investigators analyzed the presence of sleep apnea and insomnia and cancer risk in more than 8,500 patients in the Cardiovascular Health Study (CHS). “The fact that we observed certain sleep problems, like apneas, to be associated with elevated risk of some cancers but not others reflects the fact that cancer is a heterogeneous disease,” senior author Amanda Phipps, PhD, said in an interview. Dr. Phipps is an associate professor of epidemiology at the University of Washington and the Fred Hutchinson Cancer Research Center, both in Seattle.
 

Variable cancer links

The researchers assessed sleep problems in two groups in the CHS: an incident cancer group of 3,930 patients and a cancer mortality group of 4,580 patients. Within those respective groups, the investigators identified 885 first-incident cancers and 804 cancer deaths with a median follow-up of 12 and 14 years. The average age of the study population was 73 years, and 57% were women.

Sleep apnea symptoms (SAS) were associated with a lower risk for incident cancers – a 16% lower baseline risk and a 24% lower time-dependent risk. The study showed no association between cancer incidence and daytime sleepiness and apneas.

However, there was a significantly elevated risk relationship between sleep problems and prostate cancer. A time-dependent analysis of apnea showed more than double the risk (hazard ratio, 2.34), and baseline snoring carried a 69% greater risk. There was also a dose-response relationship for baseline cumulative SAS, compared with not having symptoms: an HR of 1.30 for one symptom, and 2.22 for two or more symptoms.

Risks for lymphatic or hematopoietic cancers were also associated with baseline daytime sleepiness (HR, 1.81), but not with insomnia (HR, 0.54).

With regard to cancer mortality, the study found no relationship between sleep problems and cancer death. In fact, it found an overall inverse relationship with snoring (time-dependent HR, 0.73; cumulative average HR, 0.67) and baseline apnea (HR, 0.69). Likewise, patients reporting SAS had lower risks than those having no SAS: an HR of 0.90 for one symptom and 0.75 for multiple symptoms. No relationships were found between any insomnia symptom and cancer death.

“We know the pathways that lead to prostate cancer can be very different than the pathways that lead to colorectal cancer,” Dr. Phipps said. “What we don’t yet understand is why these associations differ or what mechanisms are responsible for these cancer site-specific associations.”
 

Need for sleep assessment

The findings don’t change much for how clinicians should evaluate cancer risks in patients with sleep problems, Dr. Phipps said. “Other studies have clearly demonstrated the implications that sleep apnea has for a variety of other important health conditions – such as cardiovascular disease – so there are already plenty of good reasons for clinicians to ask their patients about their sleep and to connect patients with resources for the diagnosis and treatment of sleep apnea,” she added. “This study provides another possible reason.”

These findings provide context for future studies of the relationship between sleep problems and cancer. “But, given that sleep is something we all do and given that sleep problems are so pervasive, it’s important that we keep trying to better understand this relationship,” Dr. Phipps said.

“My hope is that future cancer studies will build in more detailed, longitudinal information on sleep patterns to help us fill current gaps in knowledge.”

Dr. Phipps has disclosed no relevant financial relationships.

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

Sleep apnea and other types of sleep disorders appear to elevate the risk for some types of cancer, specifically prostate cancer, more so than others. But the overall risk can be highly variable, and some sleep problems were found to be associated with a lower risk for cancer and cancer-related death, an analysis of a large observational cohort study of cardiovascular patients found.

Results of the analysis were published online in the journal Cancer Epidemiology. Investigators analyzed the presence of sleep apnea and insomnia and cancer risk in more than 8,500 patients in the Cardiovascular Health Study (CHS). “The fact that we observed certain sleep problems, like apneas, to be associated with elevated risk of some cancers but not others reflects the fact that cancer is a heterogeneous disease,” senior author Amanda Phipps, PhD, said in an interview. Dr. Phipps is an associate professor of epidemiology at the University of Washington and the Fred Hutchinson Cancer Research Center, both in Seattle.
 

Variable cancer links

The researchers assessed sleep problems in two groups in the CHS: an incident cancer group of 3,930 patients and a cancer mortality group of 4,580 patients. Within those respective groups, the investigators identified 885 first-incident cancers and 804 cancer deaths with a median follow-up of 12 and 14 years. The average age of the study population was 73 years, and 57% were women.

Sleep apnea symptoms (SAS) were associated with a lower risk for incident cancers – a 16% lower baseline risk and a 24% lower time-dependent risk. The study showed no association between cancer incidence and daytime sleepiness and apneas.

However, there was a significantly elevated risk relationship between sleep problems and prostate cancer. A time-dependent analysis of apnea showed more than double the risk (hazard ratio, 2.34), and baseline snoring carried a 69% greater risk. There was also a dose-response relationship for baseline cumulative SAS, compared with not having symptoms: an HR of 1.30 for one symptom, and 2.22 for two or more symptoms.

Risks for lymphatic or hematopoietic cancers were also associated with baseline daytime sleepiness (HR, 1.81), but not with insomnia (HR, 0.54).

With regard to cancer mortality, the study found no relationship between sleep problems and cancer death. In fact, it found an overall inverse relationship with snoring (time-dependent HR, 0.73; cumulative average HR, 0.67) and baseline apnea (HR, 0.69). Likewise, patients reporting SAS had lower risks than those having no SAS: an HR of 0.90 for one symptom and 0.75 for multiple symptoms. No relationships were found between any insomnia symptom and cancer death.

“We know the pathways that lead to prostate cancer can be very different than the pathways that lead to colorectal cancer,” Dr. Phipps said. “What we don’t yet understand is why these associations differ or what mechanisms are responsible for these cancer site-specific associations.”
 

Need for sleep assessment

The findings don’t change much for how clinicians should evaluate cancer risks in patients with sleep problems, Dr. Phipps said. “Other studies have clearly demonstrated the implications that sleep apnea has for a variety of other important health conditions – such as cardiovascular disease – so there are already plenty of good reasons for clinicians to ask their patients about their sleep and to connect patients with resources for the diagnosis and treatment of sleep apnea,” she added. “This study provides another possible reason.”

These findings provide context for future studies of the relationship between sleep problems and cancer. “But, given that sleep is something we all do and given that sleep problems are so pervasive, it’s important that we keep trying to better understand this relationship,” Dr. Phipps said.

“My hope is that future cancer studies will build in more detailed, longitudinal information on sleep patterns to help us fill current gaps in knowledge.”

Dr. Phipps has disclosed no relevant financial relationships.

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

Sleep apnea and other types of sleep disorders appear to elevate the risk for some types of cancer, specifically prostate cancer, more so than others. But the overall risk can be highly variable, and some sleep problems were found to be associated with a lower risk for cancer and cancer-related death, an analysis of a large observational cohort study of cardiovascular patients found.

Results of the analysis were published online in the journal Cancer Epidemiology. Investigators analyzed the presence of sleep apnea and insomnia and cancer risk in more than 8,500 patients in the Cardiovascular Health Study (CHS). “The fact that we observed certain sleep problems, like apneas, to be associated with elevated risk of some cancers but not others reflects the fact that cancer is a heterogeneous disease,” senior author Amanda Phipps, PhD, said in an interview. Dr. Phipps is an associate professor of epidemiology at the University of Washington and the Fred Hutchinson Cancer Research Center, both in Seattle.
 

Variable cancer links

The researchers assessed sleep problems in two groups in the CHS: an incident cancer group of 3,930 patients and a cancer mortality group of 4,580 patients. Within those respective groups, the investigators identified 885 first-incident cancers and 804 cancer deaths with a median follow-up of 12 and 14 years. The average age of the study population was 73 years, and 57% were women.

Sleep apnea symptoms (SAS) were associated with a lower risk for incident cancers – a 16% lower baseline risk and a 24% lower time-dependent risk. The study showed no association between cancer incidence and daytime sleepiness and apneas.

However, there was a significantly elevated risk relationship between sleep problems and prostate cancer. A time-dependent analysis of apnea showed more than double the risk (hazard ratio, 2.34), and baseline snoring carried a 69% greater risk. There was also a dose-response relationship for baseline cumulative SAS, compared with not having symptoms: an HR of 1.30 for one symptom, and 2.22 for two or more symptoms.

Risks for lymphatic or hematopoietic cancers were also associated with baseline daytime sleepiness (HR, 1.81), but not with insomnia (HR, 0.54).

With regard to cancer mortality, the study found no relationship between sleep problems and cancer death. In fact, it found an overall inverse relationship with snoring (time-dependent HR, 0.73; cumulative average HR, 0.67) and baseline apnea (HR, 0.69). Likewise, patients reporting SAS had lower risks than those having no SAS: an HR of 0.90 for one symptom and 0.75 for multiple symptoms. No relationships were found between any insomnia symptom and cancer death.

“We know the pathways that lead to prostate cancer can be very different than the pathways that lead to colorectal cancer,” Dr. Phipps said. “What we don’t yet understand is why these associations differ or what mechanisms are responsible for these cancer site-specific associations.”
 

Need for sleep assessment

The findings don’t change much for how clinicians should evaluate cancer risks in patients with sleep problems, Dr. Phipps said. “Other studies have clearly demonstrated the implications that sleep apnea has for a variety of other important health conditions – such as cardiovascular disease – so there are already plenty of good reasons for clinicians to ask their patients about their sleep and to connect patients with resources for the diagnosis and treatment of sleep apnea,” she added. “This study provides another possible reason.”

These findings provide context for future studies of the relationship between sleep problems and cancer. “But, given that sleep is something we all do and given that sleep problems are so pervasive, it’s important that we keep trying to better understand this relationship,” Dr. Phipps said.

“My hope is that future cancer studies will build in more detailed, longitudinal information on sleep patterns to help us fill current gaps in knowledge.”

Dr. Phipps has disclosed no relevant financial relationships.

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

Amid growing concerns about the impact of increased legalized online sports gambling, the American Psychiatric Association has issued an updated guide on gambling disorder.

The guide provides expert guidance based on current research and provides information on the etiology, psychopathology, neurobiology, and treatment of the disorder.

“For doctors who might think of gambling as either innocuous behavior or simply equivalent to, say, an alcohol problem, this guide not only shows the complexity and seriousness of gambling disorder but also evidence-based treatments that may help people actually get better,” the guide’s coeditor, Jon E. Grant, MD, MPH, JD, professor of psychiatry at the University of Chicago, said in an interview.

Online sports betting is booming. “It has really taken off” in recent years and is now a multibillion dollar industry worldwide, Dr. Grant added.

A recent CBS News report highlights a record volume of legally placed online sports bets during the first week of this year’s NFL season. All told, 26 states now have legalized sports betting.

The COVID-19 pandemic has played a large role in boosting online gambling; as in-person casinos shut down, customers shifted to online betting, said Dr. Grant. “They realized they could stay home, stay safe, and still gamble, so there was an uptick in that movement.”

However, the popularity of online gambling is also a sign of the times. “A whole generation of young adults have been raised on the Internet. A lot of companies realize this is not a market that would ever go to a land-based casino, so they essentially took their product to the young people,” said Dr. Grant.
 

Gambling meets technology

In addition to football, online gamblers can bet on other sports, including horse racing, or participate in “fantasy” sports where users assemble virtual teams of stand-ins for real professional players. There are also online casinos where users can play such things as blackjack and roulette.

The new guide devotes a chapter to online gambling and the complex interplay between gambling and technology. It highlights the growth of interactive platforms, the role of new player experiences and reward structures, and the integration into other online activities, such as social media.

Other chapters explore the interface between gambling and the legal system and differences in gender and between age groups.

There is also information on advances in treatments. Although there are no Food and Drug Administration–approved drugs for gambling disorder, new evidence supports the use of certain agents for this disorder, said Dr. Grant.

These include naltrexone, which has long been used for alcohol and drug addiction, and over-the-counter N-acetylcysteine (NAC), an amino acid that affects the reward system in the brain and has been used for cocaine and marijuana addiction.

Research also suggests that brief-format cognitive-behavioral therapy may be effective for gambling disorder, said Dr. Grant.

An estimated 1% of the population has such a disorder, which involves repeated, problem gambling with sufferers struggling to control their gambling behavior. Gambling disorder is associated with decreased self-esteem, comorbid substance abuse disorders, financial and legal difficulties, relationship and family stress, and suicidality.
 

Early intervention is key

Most gamblers don’t have a diagnosable disorder and can participate in the pastime without any long-term harm. However, some will show signs of problem gambling, Dr. Grant noted.

“We believe that’s where interventions may have an even bigger impact,” said Dr. Grant. “We want to get people early on in the illness.” He added that gambling “runs along a continuum” from simply dabbling to serious addiction.

Whereas previous versions of the DSM put gambling in an impulse control category, the latest version – DSM-5 – recognizes gambling as an addiction alongside substances.

“That shows greater awareness of the biological connection to substance addiction,” said Dr. Grant. “It’s important for clinicians who are screening substance use disorder folks to make sure they include gambling in that screening.”

The guide includes information on available screening and assessment instruments for diagnosing gambling disorder and for monitoring symptom changes.

Many clinicians may be unaware of the personal and social consequences of gambling disorder and its implications for public health. The new guide provides a detailed look at the effects of gambling on society and families, as well as on individual health and well-being.

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

Amid growing concerns about the impact of increased legalized online sports gambling, the American Psychiatric Association has issued an updated guide on gambling disorder.

The guide provides expert guidance based on current research and provides information on the etiology, psychopathology, neurobiology, and treatment of the disorder.

“For doctors who might think of gambling as either innocuous behavior or simply equivalent to, say, an alcohol problem, this guide not only shows the complexity and seriousness of gambling disorder but also evidence-based treatments that may help people actually get better,” the guide’s coeditor, Jon E. Grant, MD, MPH, JD, professor of psychiatry at the University of Chicago, said in an interview.

Online sports betting is booming. “It has really taken off” in recent years and is now a multibillion dollar industry worldwide, Dr. Grant added.

A recent CBS News report highlights a record volume of legally placed online sports bets during the first week of this year’s NFL season. All told, 26 states now have legalized sports betting.

The COVID-19 pandemic has played a large role in boosting online gambling; as in-person casinos shut down, customers shifted to online betting, said Dr. Grant. “They realized they could stay home, stay safe, and still gamble, so there was an uptick in that movement.”

However, the popularity of online gambling is also a sign of the times. “A whole generation of young adults have been raised on the Internet. A lot of companies realize this is not a market that would ever go to a land-based casino, so they essentially took their product to the young people,” said Dr. Grant.
 

Gambling meets technology

In addition to football, online gamblers can bet on other sports, including horse racing, or participate in “fantasy” sports where users assemble virtual teams of stand-ins for real professional players. There are also online casinos where users can play such things as blackjack and roulette.

The new guide devotes a chapter to online gambling and the complex interplay between gambling and technology. It highlights the growth of interactive platforms, the role of new player experiences and reward structures, and the integration into other online activities, such as social media.

Other chapters explore the interface between gambling and the legal system and differences in gender and between age groups.

There is also information on advances in treatments. Although there are no Food and Drug Administration–approved drugs for gambling disorder, new evidence supports the use of certain agents for this disorder, said Dr. Grant.

These include naltrexone, which has long been used for alcohol and drug addiction, and over-the-counter N-acetylcysteine (NAC), an amino acid that affects the reward system in the brain and has been used for cocaine and marijuana addiction.

Research also suggests that brief-format cognitive-behavioral therapy may be effective for gambling disorder, said Dr. Grant.

An estimated 1% of the population has such a disorder, which involves repeated, problem gambling with sufferers struggling to control their gambling behavior. Gambling disorder is associated with decreased self-esteem, comorbid substance abuse disorders, financial and legal difficulties, relationship and family stress, and suicidality.
 

Early intervention is key

Most gamblers don’t have a diagnosable disorder and can participate in the pastime without any long-term harm. However, some will show signs of problem gambling, Dr. Grant noted.

“We believe that’s where interventions may have an even bigger impact,” said Dr. Grant. “We want to get people early on in the illness.” He added that gambling “runs along a continuum” from simply dabbling to serious addiction.

Whereas previous versions of the DSM put gambling in an impulse control category, the latest version – DSM-5 – recognizes gambling as an addiction alongside substances.

“That shows greater awareness of the biological connection to substance addiction,” said Dr. Grant. “It’s important for clinicians who are screening substance use disorder folks to make sure they include gambling in that screening.”

The guide includes information on available screening and assessment instruments for diagnosing gambling disorder and for monitoring symptom changes.

Many clinicians may be unaware of the personal and social consequences of gambling disorder and its implications for public health. The new guide provides a detailed look at the effects of gambling on society and families, as well as on individual health and well-being.

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

Amid growing concerns about the impact of increased legalized online sports gambling, the American Psychiatric Association has issued an updated guide on gambling disorder.

The guide provides expert guidance based on current research and provides information on the etiology, psychopathology, neurobiology, and treatment of the disorder.

“For doctors who might think of gambling as either innocuous behavior or simply equivalent to, say, an alcohol problem, this guide not only shows the complexity and seriousness of gambling disorder but also evidence-based treatments that may help people actually get better,” the guide’s coeditor, Jon E. Grant, MD, MPH, JD, professor of psychiatry at the University of Chicago, said in an interview.

Online sports betting is booming. “It has really taken off” in recent years and is now a multibillion dollar industry worldwide, Dr. Grant added.

A recent CBS News report highlights a record volume of legally placed online sports bets during the first week of this year’s NFL season. All told, 26 states now have legalized sports betting.

The COVID-19 pandemic has played a large role in boosting online gambling; as in-person casinos shut down, customers shifted to online betting, said Dr. Grant. “They realized they could stay home, stay safe, and still gamble, so there was an uptick in that movement.”

However, the popularity of online gambling is also a sign of the times. “A whole generation of young adults have been raised on the Internet. A lot of companies realize this is not a market that would ever go to a land-based casino, so they essentially took their product to the young people,” said Dr. Grant.
 

Gambling meets technology

In addition to football, online gamblers can bet on other sports, including horse racing, or participate in “fantasy” sports where users assemble virtual teams of stand-ins for real professional players. There are also online casinos where users can play such things as blackjack and roulette.

The new guide devotes a chapter to online gambling and the complex interplay between gambling and technology. It highlights the growth of interactive platforms, the role of new player experiences and reward structures, and the integration into other online activities, such as social media.

Other chapters explore the interface between gambling and the legal system and differences in gender and between age groups.

There is also information on advances in treatments. Although there are no Food and Drug Administration–approved drugs for gambling disorder, new evidence supports the use of certain agents for this disorder, said Dr. Grant.

These include naltrexone, which has long been used for alcohol and drug addiction, and over-the-counter N-acetylcysteine (NAC), an amino acid that affects the reward system in the brain and has been used for cocaine and marijuana addiction.

Research also suggests that brief-format cognitive-behavioral therapy may be effective for gambling disorder, said Dr. Grant.

An estimated 1% of the population has such a disorder, which involves repeated, problem gambling with sufferers struggling to control their gambling behavior. Gambling disorder is associated with decreased self-esteem, comorbid substance abuse disorders, financial and legal difficulties, relationship and family stress, and suicidality.
 

Early intervention is key

Most gamblers don’t have a diagnosable disorder and can participate in the pastime without any long-term harm. However, some will show signs of problem gambling, Dr. Grant noted.

“We believe that’s where interventions may have an even bigger impact,” said Dr. Grant. “We want to get people early on in the illness.” He added that gambling “runs along a continuum” from simply dabbling to serious addiction.

Whereas previous versions of the DSM put gambling in an impulse control category, the latest version – DSM-5 – recognizes gambling as an addiction alongside substances.

“That shows greater awareness of the biological connection to substance addiction,” said Dr. Grant. “It’s important for clinicians who are screening substance use disorder folks to make sure they include gambling in that screening.”

The guide includes information on available screening and assessment instruments for diagnosing gambling disorder and for monitoring symptom changes.

Many clinicians may be unaware of the personal and social consequences of gambling disorder and its implications for public health. The new guide provides a detailed look at the effects of gambling on society and families, as well as on individual health and well-being.

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

In March 2021, Prime Minister Boris Johnson proposed a 1% pay rise for National Health Service (NHS) workers in the United Kingdom — a move many deemed inadequate after a full year of fighting the COVID-19 pandemic. The next day, James Cowe, a 23-year-old healthcare assistant who had been working in dementia care for 6 years, decided to create a profile on the content subscription site OnlyFans.

The London-based site allows subscribers, or “fans,” to request content, making its name distributing nude pictures, videos, and other sexually explicit content. It garnered mainstream attention in 2020 when housebound individuals and even celebrities began using it to generate income. Back in August, OnlyFans released a statement stating that it would ban “sexually explicit” content beginning in October. Days later, the company recanted the statement after uproar from creators.

“Because of the one-percent pay rise, I’ve started OnlyFans and I’m making more money in three days than I make in a month at work,” Mr. Cowe said in a now-deleted TikTok post. “Sorry Boris, but I’m done with healthcare and now I’m an online whore.”

Mr. Cowe earned the equivalent of a year’s salary from his healthcare assistant job in his first 22 days on OnlyFans.

Mr. Cowe is one of many healthcare workers in the United Kingdom who have supplemented or replaced their health work with sex work. Stories like his have multiplied during the pandemic, at a time when healthcare professionals have been particularly overworked and particularly essential. Meanwhile, the pandemic has exacerbated challenges for many sex workers across the globe.

“[There have been] many, many reports over history that transactional sex is used as a sort of emergency livelihood strategy in all kinds of emergencies,” says Joanne Csete, PhD, associate professor of population and family health at Columbia University, New York, “and I suppose this is an emergency in that sense, like any other.”
 

The relationship between sex work and healthcare

A 2015 study by Leeds University found that 70% of sex workers in the United Kingdom previously worked in healthcare, charities, or education and that more than a third held university degrees.

The relationship between sex workers and healthcare workers has historically been disconnected. Sex workers are at higher risk of experiencing violence, sexually transmitted infections, and substance abuse and mental health problems than the general population, as noted by the American College of Obstetricians and Gynecologists. But according to the UN Population Fund, 63% of sex workers will not seek health services alone because they are distrustful and fearful of healthcare workers. A 2014 study by UNAIDS found that stigmatization also makes sex workers less likely to seek assistance from social services.

“I think it’s almost universally hard for sex workers to get respectful healthcare without judgment, and in some cases actual hostility, because of the stigma of their work,” Dr. Csete says. “Health workers are not always trained to see sex work as anything but either a criminal act or an immoral act.”

In August 2021, U.K. medical students called for the British Medical Association to protect students from being penalized by or expelled from their universities for engaging in sex work. BMA Medical Students Committee chair Becky Bates cited high medical school fees and a lack of financial support as motivations for student sex workers. She told this news organization that sex work often allows for flexible hours that might make it easier for students to balance the demands of medical school than other part-time jobs would.

At the annual BMA conference in September, two thirds of the association’s doctors voted in favor of the motion, while others criticized it as potential encouragement for students to get involved in sex work. “The motion isn’t about the morality of sex work,” Ms. Bates said. “[It’s] about the fact that it’s happening and what we can do to support students.”
 

Healthcare workers on OnlyFans

The rising pressures placed on individuals in the health field have coincided with the rise of online platforms that host pornographic content. During the pandemic, professionals worn down by their healthcare work have embraced sites like OnlyFans as lower-risk, lower-stress, and potentially higher-paying additions or alternatives.

“It’s quite exploitative to work for such low pay in harsh conditions,” Mr. Cowe told this news organizaation of his experience as a dementia care assistant. “It’s soul-destroying. You feel like, ‘It doesn’t matter how many hours I work, it doesn’t matter what I do, I’m still going to be in this same financial position.’ ”

Mr. Cowe earned the equivalent of a year’s salary from his healthcare assistant job in his first 22 days on OnlyFans. Within 8 months, he had earned £150,000, or approximately $205,000.

As an emergency medical services (EMS) worker in New York City, 23-year-old Lauren Kwei lifted obese bariatric patients, administered cardiopulmonary resuscitation to unresponsive recipients, and transported elderly patients and children with terminal illnesses to hospice. She earned $25 an hour, which she says was insufficient for life in one of the world’s most expensive cities. So, in addition to her paramedic work, Ms. Kwei posted photos and videos on OnlyFans to help pay for rent and groceries during the pandemic.

Ms. Kwei started her OnlyFans as a means of paying for necessities like rent and groceries, which her wage as an emergency medical services worker couldn’t cover entirely.

In December 2020, Ms. Kwei got a call from a New York Post reporter who informed her he was writing an article outing her OnlyFans side gig. Ms. Kwei immediately deleted her account on the site for fear of being penalized by her employer, SeniorCare.

“Leave her alone,” U.S. Representative Alexandria Ocasio-Cortez wrote on Twitter in response to the New York Post article. “The actual scandalous headline here is ‘Medics in the United States need two jobs to survive.’ ”

The article quoted an anonymous male paramedic who said Ms. Kwei should have been “pulling extra shifts, instead of pulling off [her] clothes” to earn more money. Ms. Kwei says such advice fails to acknowledge the intensity of the job. “Why would I pick up overtime shifts doing manual labor,” she says, “when I could be doing [OnlyFans] from the comfort of my own home?”
 

The future of the healthcare/sex work relationship

Ms. Kwei is young enough to receive health insurance through her parents, and Mr. Cowe has access to free healthcare through the NHS. But many sex workers — particularly full-service sex workers, who carry out their work in person — have limited access to services such as healthcare and unemployment benefits. Pandemic restrictions have concurrently driven full-service sex work further underground and therefore deepened the health and safety risks associated with its criminalization.

As health workers become increasingly involved in sex work, advocates in both fields are pushing for healthcare systems to involve sex workers.

“Just as we would do with supporting any group, it’s about understanding any specific barriers or specific problems that they’re encountering, and understanding what they think would help, and working together on that solution,” Ms. Bates says of supporting medical students who engage in sex work.

Tlaleng Mofokeng, MD, UN Special Rapporteur on the right to health, says it is crucial for healthcare organizations to partner with sex worker organizations when it comes to planning the resourcing and budgeting of the public health system in order to meet sex workers’ needs. “While we wait for national policy to change and while we wait for decriminalization,” she says, “tangible things can be done to ensure the provision of equitable services that are aligned with the respect of [sex workers’] rights and the restoration of their dignity.”

Today, healthcare professionals can expect to work with classmates, colleagues, and patients who are involved in sex work and who do not fit the socioeconomic stereotypes associated with sex workers. The number of medical students and healthcare workers engaging in sex work is likely to continue to rise as these individuals struggle to find financial and emotional support within the health sector. Ultimately, many health workers and sex workers share a common goal: to be involved in healthcare systems that respect their work and meet their basic needs.

Mr. Cowe doubts he will ever return to the healthcare industry, owing in part to the stigma against sex workers. “I would feel quite unwelcome,” he says. “[The publicity I received] probably made it not possible for me to go back, but even so, I wouldn’t have a desire to because I was just so burnt out in the end.”

Ms. Kwei is taking a break from her EMS work because of the emotional and financial toll it took, but she plans to return in the future. In the meantime, she is back on OnlyFans and advocating for higher wages for EMS workers as a member of the Emergency Medical Services Public Advocacy Council (EMSPAC). “In order to be a good paramedic, my mental health needs to be on point,” she says. “Hopefully down the line, when I decide to pick up EMS [work] again, I can find a job that pays me enough.”

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

In March 2021, Prime Minister Boris Johnson proposed a 1% pay rise for National Health Service (NHS) workers in the United Kingdom — a move many deemed inadequate after a full year of fighting the COVID-19 pandemic. The next day, James Cowe, a 23-year-old healthcare assistant who had been working in dementia care for 6 years, decided to create a profile on the content subscription site OnlyFans.

The London-based site allows subscribers, or “fans,” to request content, making its name distributing nude pictures, videos, and other sexually explicit content. It garnered mainstream attention in 2020 when housebound individuals and even celebrities began using it to generate income. Back in August, OnlyFans released a statement stating that it would ban “sexually explicit” content beginning in October. Days later, the company recanted the statement after uproar from creators.

“Because of the one-percent pay rise, I’ve started OnlyFans and I’m making more money in three days than I make in a month at work,” Mr. Cowe said in a now-deleted TikTok post. “Sorry Boris, but I’m done with healthcare and now I’m an online whore.”

Mr. Cowe earned the equivalent of a year’s salary from his healthcare assistant job in his first 22 days on OnlyFans.

Mr. Cowe is one of many healthcare workers in the United Kingdom who have supplemented or replaced their health work with sex work. Stories like his have multiplied during the pandemic, at a time when healthcare professionals have been particularly overworked and particularly essential. Meanwhile, the pandemic has exacerbated challenges for many sex workers across the globe.

“[There have been] many, many reports over history that transactional sex is used as a sort of emergency livelihood strategy in all kinds of emergencies,” says Joanne Csete, PhD, associate professor of population and family health at Columbia University, New York, “and I suppose this is an emergency in that sense, like any other.”
 

The relationship between sex work and healthcare

A 2015 study by Leeds University found that 70% of sex workers in the United Kingdom previously worked in healthcare, charities, or education and that more than a third held university degrees.

The relationship between sex workers and healthcare workers has historically been disconnected. Sex workers are at higher risk of experiencing violence, sexually transmitted infections, and substance abuse and mental health problems than the general population, as noted by the American College of Obstetricians and Gynecologists. But according to the UN Population Fund, 63% of sex workers will not seek health services alone because they are distrustful and fearful of healthcare workers. A 2014 study by UNAIDS found that stigmatization also makes sex workers less likely to seek assistance from social services.

“I think it’s almost universally hard for sex workers to get respectful healthcare without judgment, and in some cases actual hostility, because of the stigma of their work,” Dr. Csete says. “Health workers are not always trained to see sex work as anything but either a criminal act or an immoral act.”

In August 2021, U.K. medical students called for the British Medical Association to protect students from being penalized by or expelled from their universities for engaging in sex work. BMA Medical Students Committee chair Becky Bates cited high medical school fees and a lack of financial support as motivations for student sex workers. She told this news organization that sex work often allows for flexible hours that might make it easier for students to balance the demands of medical school than other part-time jobs would.

At the annual BMA conference in September, two thirds of the association’s doctors voted in favor of the motion, while others criticized it as potential encouragement for students to get involved in sex work. “The motion isn’t about the morality of sex work,” Ms. Bates said. “[It’s] about the fact that it’s happening and what we can do to support students.”
 

Healthcare workers on OnlyFans

The rising pressures placed on individuals in the health field have coincided with the rise of online platforms that host pornographic content. During the pandemic, professionals worn down by their healthcare work have embraced sites like OnlyFans as lower-risk, lower-stress, and potentially higher-paying additions or alternatives.

“It’s quite exploitative to work for such low pay in harsh conditions,” Mr. Cowe told this news organizaation of his experience as a dementia care assistant. “It’s soul-destroying. You feel like, ‘It doesn’t matter how many hours I work, it doesn’t matter what I do, I’m still going to be in this same financial position.’ ”

Mr. Cowe earned the equivalent of a year’s salary from his healthcare assistant job in his first 22 days on OnlyFans. Within 8 months, he had earned £150,000, or approximately $205,000.

As an emergency medical services (EMS) worker in New York City, 23-year-old Lauren Kwei lifted obese bariatric patients, administered cardiopulmonary resuscitation to unresponsive recipients, and transported elderly patients and children with terminal illnesses to hospice. She earned $25 an hour, which she says was insufficient for life in one of the world’s most expensive cities. So, in addition to her paramedic work, Ms. Kwei posted photos and videos on OnlyFans to help pay for rent and groceries during the pandemic.

Ms. Kwei started her OnlyFans as a means of paying for necessities like rent and groceries, which her wage as an emergency medical services worker couldn’t cover entirely.

In December 2020, Ms. Kwei got a call from a New York Post reporter who informed her he was writing an article outing her OnlyFans side gig. Ms. Kwei immediately deleted her account on the site for fear of being penalized by her employer, SeniorCare.

“Leave her alone,” U.S. Representative Alexandria Ocasio-Cortez wrote on Twitter in response to the New York Post article. “The actual scandalous headline here is ‘Medics in the United States need two jobs to survive.’ ”

The article quoted an anonymous male paramedic who said Ms. Kwei should have been “pulling extra shifts, instead of pulling off [her] clothes” to earn more money. Ms. Kwei says such advice fails to acknowledge the intensity of the job. “Why would I pick up overtime shifts doing manual labor,” she says, “when I could be doing [OnlyFans] from the comfort of my own home?”
 

The future of the healthcare/sex work relationship

Ms. Kwei is young enough to receive health insurance through her parents, and Mr. Cowe has access to free healthcare through the NHS. But many sex workers — particularly full-service sex workers, who carry out their work in person — have limited access to services such as healthcare and unemployment benefits. Pandemic restrictions have concurrently driven full-service sex work further underground and therefore deepened the health and safety risks associated with its criminalization.

As health workers become increasingly involved in sex work, advocates in both fields are pushing for healthcare systems to involve sex workers.

“Just as we would do with supporting any group, it’s about understanding any specific barriers or specific problems that they’re encountering, and understanding what they think would help, and working together on that solution,” Ms. Bates says of supporting medical students who engage in sex work.

Tlaleng Mofokeng, MD, UN Special Rapporteur on the right to health, says it is crucial for healthcare organizations to partner with sex worker organizations when it comes to planning the resourcing and budgeting of the public health system in order to meet sex workers’ needs. “While we wait for national policy to change and while we wait for decriminalization,” she says, “tangible things can be done to ensure the provision of equitable services that are aligned with the respect of [sex workers’] rights and the restoration of their dignity.”

Today, healthcare professionals can expect to work with classmates, colleagues, and patients who are involved in sex work and who do not fit the socioeconomic stereotypes associated with sex workers. The number of medical students and healthcare workers engaging in sex work is likely to continue to rise as these individuals struggle to find financial and emotional support within the health sector. Ultimately, many health workers and sex workers share a common goal: to be involved in healthcare systems that respect their work and meet their basic needs.

Mr. Cowe doubts he will ever return to the healthcare industry, owing in part to the stigma against sex workers. “I would feel quite unwelcome,” he says. “[The publicity I received] probably made it not possible for me to go back, but even so, I wouldn’t have a desire to because I was just so burnt out in the end.”

Ms. Kwei is taking a break from her EMS work because of the emotional and financial toll it took, but she plans to return in the future. In the meantime, she is back on OnlyFans and advocating for higher wages for EMS workers as a member of the Emergency Medical Services Public Advocacy Council (EMSPAC). “In order to be a good paramedic, my mental health needs to be on point,” she says. “Hopefully down the line, when I decide to pick up EMS [work] again, I can find a job that pays me enough.”

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

In March 2021, Prime Minister Boris Johnson proposed a 1% pay rise for National Health Service (NHS) workers in the United Kingdom — a move many deemed inadequate after a full year of fighting the COVID-19 pandemic. The next day, James Cowe, a 23-year-old healthcare assistant who had been working in dementia care for 6 years, decided to create a profile on the content subscription site OnlyFans.

The London-based site allows subscribers, or “fans,” to request content, making its name distributing nude pictures, videos, and other sexually explicit content. It garnered mainstream attention in 2020 when housebound individuals and even celebrities began using it to generate income. Back in August, OnlyFans released a statement stating that it would ban “sexually explicit” content beginning in October. Days later, the company recanted the statement after uproar from creators.

“Because of the one-percent pay rise, I’ve started OnlyFans and I’m making more money in three days than I make in a month at work,” Mr. Cowe said in a now-deleted TikTok post. “Sorry Boris, but I’m done with healthcare and now I’m an online whore.”

Mr. Cowe earned the equivalent of a year’s salary from his healthcare assistant job in his first 22 days on OnlyFans.

Mr. Cowe is one of many healthcare workers in the United Kingdom who have supplemented or replaced their health work with sex work. Stories like his have multiplied during the pandemic, at a time when healthcare professionals have been particularly overworked and particularly essential. Meanwhile, the pandemic has exacerbated challenges for many sex workers across the globe.

“[There have been] many, many reports over history that transactional sex is used as a sort of emergency livelihood strategy in all kinds of emergencies,” says Joanne Csete, PhD, associate professor of population and family health at Columbia University, New York, “and I suppose this is an emergency in that sense, like any other.”
 

The relationship between sex work and healthcare

A 2015 study by Leeds University found that 70% of sex workers in the United Kingdom previously worked in healthcare, charities, or education and that more than a third held university degrees.

The relationship between sex workers and healthcare workers has historically been disconnected. Sex workers are at higher risk of experiencing violence, sexually transmitted infections, and substance abuse and mental health problems than the general population, as noted by the American College of Obstetricians and Gynecologists. But according to the UN Population Fund, 63% of sex workers will not seek health services alone because they are distrustful and fearful of healthcare workers. A 2014 study by UNAIDS found that stigmatization also makes sex workers less likely to seek assistance from social services.

“I think it’s almost universally hard for sex workers to get respectful healthcare without judgment, and in some cases actual hostility, because of the stigma of their work,” Dr. Csete says. “Health workers are not always trained to see sex work as anything but either a criminal act or an immoral act.”

In August 2021, U.K. medical students called for the British Medical Association to protect students from being penalized by or expelled from their universities for engaging in sex work. BMA Medical Students Committee chair Becky Bates cited high medical school fees and a lack of financial support as motivations for student sex workers. She told this news organization that sex work often allows for flexible hours that might make it easier for students to balance the demands of medical school than other part-time jobs would.

At the annual BMA conference in September, two thirds of the association’s doctors voted in favor of the motion, while others criticized it as potential encouragement for students to get involved in sex work. “The motion isn’t about the morality of sex work,” Ms. Bates said. “[It’s] about the fact that it’s happening and what we can do to support students.”
 

Healthcare workers on OnlyFans

The rising pressures placed on individuals in the health field have coincided with the rise of online platforms that host pornographic content. During the pandemic, professionals worn down by their healthcare work have embraced sites like OnlyFans as lower-risk, lower-stress, and potentially higher-paying additions or alternatives.

“It’s quite exploitative to work for such low pay in harsh conditions,” Mr. Cowe told this news organizaation of his experience as a dementia care assistant. “It’s soul-destroying. You feel like, ‘It doesn’t matter how many hours I work, it doesn’t matter what I do, I’m still going to be in this same financial position.’ ”

Mr. Cowe earned the equivalent of a year’s salary from his healthcare assistant job in his first 22 days on OnlyFans. Within 8 months, he had earned £150,000, or approximately $205,000.

As an emergency medical services (EMS) worker in New York City, 23-year-old Lauren Kwei lifted obese bariatric patients, administered cardiopulmonary resuscitation to unresponsive recipients, and transported elderly patients and children with terminal illnesses to hospice. She earned $25 an hour, which she says was insufficient for life in one of the world’s most expensive cities. So, in addition to her paramedic work, Ms. Kwei posted photos and videos on OnlyFans to help pay for rent and groceries during the pandemic.

Ms. Kwei started her OnlyFans as a means of paying for necessities like rent and groceries, which her wage as an emergency medical services worker couldn’t cover entirely.

In December 2020, Ms. Kwei got a call from a New York Post reporter who informed her he was writing an article outing her OnlyFans side gig. Ms. Kwei immediately deleted her account on the site for fear of being penalized by her employer, SeniorCare.

“Leave her alone,” U.S. Representative Alexandria Ocasio-Cortez wrote on Twitter in response to the New York Post article. “The actual scandalous headline here is ‘Medics in the United States need two jobs to survive.’ ”

The article quoted an anonymous male paramedic who said Ms. Kwei should have been “pulling extra shifts, instead of pulling off [her] clothes” to earn more money. Ms. Kwei says such advice fails to acknowledge the intensity of the job. “Why would I pick up overtime shifts doing manual labor,” she says, “when I could be doing [OnlyFans] from the comfort of my own home?”
 

The future of the healthcare/sex work relationship

Ms. Kwei is young enough to receive health insurance through her parents, and Mr. Cowe has access to free healthcare through the NHS. But many sex workers — particularly full-service sex workers, who carry out their work in person — have limited access to services such as healthcare and unemployment benefits. Pandemic restrictions have concurrently driven full-service sex work further underground and therefore deepened the health and safety risks associated with its criminalization.

As health workers become increasingly involved in sex work, advocates in both fields are pushing for healthcare systems to involve sex workers.

“Just as we would do with supporting any group, it’s about understanding any specific barriers or specific problems that they’re encountering, and understanding what they think would help, and working together on that solution,” Ms. Bates says of supporting medical students who engage in sex work.

Tlaleng Mofokeng, MD, UN Special Rapporteur on the right to health, says it is crucial for healthcare organizations to partner with sex worker organizations when it comes to planning the resourcing and budgeting of the public health system in order to meet sex workers’ needs. “While we wait for national policy to change and while we wait for decriminalization,” she says, “tangible things can be done to ensure the provision of equitable services that are aligned with the respect of [sex workers’] rights and the restoration of their dignity.”

Today, healthcare professionals can expect to work with classmates, colleagues, and patients who are involved in sex work and who do not fit the socioeconomic stereotypes associated with sex workers. The number of medical students and healthcare workers engaging in sex work is likely to continue to rise as these individuals struggle to find financial and emotional support within the health sector. Ultimately, many health workers and sex workers share a common goal: to be involved in healthcare systems that respect their work and meet their basic needs.

Mr. Cowe doubts he will ever return to the healthcare industry, owing in part to the stigma against sex workers. “I would feel quite unwelcome,” he says. “[The publicity I received] probably made it not possible for me to go back, but even so, I wouldn’t have a desire to because I was just so burnt out in the end.”

Ms. Kwei is taking a break from her EMS work because of the emotional and financial toll it took, but she plans to return in the future. In the meantime, she is back on OnlyFans and advocating for higher wages for EMS workers as a member of the Emergency Medical Services Public Advocacy Council (EMSPAC). “In order to be a good paramedic, my mental health needs to be on point,” she says. “Hopefully down the line, when I decide to pick up EMS [work] again, I can find a job that pays me enough.”

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

Childhood autism rates are at the highest level since the Centers for Disease Control and Prevention began tracking the disorder in 2000, new data released Dec. 2 show.

The increase likely reflects improvements in diagnosis and identification of autism spectrum disorder (ASD), not an increase in incidence, study authors with the CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network told this news organization.

Using a new surveillance methodology, researchers found that 2.3% of 8-year-olds in communities in 11 states across the United States had an autism diagnosis in 2018, up from 1.9% in 2016.

A separate report on early identification in 4-year-olds shows that children born in 2014 were 50% more likely to receive an autism diagnosis or ASD special education classification by 48 months of age than those born in 2010, signaling improved early diagnosis.

Taken together, the data suggest efforts to raise awareness about autism are working, though researchers were quick to say much work remains.

“It was not surprising to me and in fact it was reassuring that the number of children diagnosed with autism is higher and is actually approaching prevalence of autism that has been noted in some national surveys of parents,” Stuart Shapira, MD, PhD, associate director for science in CDC’s National Center on Birth Defects and Developmental Disability, told this news organization.

“It means we’re doing a better job of identifying children, which helps to get them into services earlier so they can achieve their best developmental outcome.”

The studies, published online in Morbidity and Mortality Weekly Report, are the first to use a new ASD surveillance protocol that relies on ASD diagnosis or special education classification and billing codes and eliminates comprehensive records analysis by trained clinician reviewers.

Racial disparities

The updated methodology was less labor intensive and reduced the time it took to produce the report, but it is not without its critics, who claim the new protocol will undercount the number of children with ASD.

Created in 2000 and funded by the CDC, the ADDM Network is the only surveillance program in the United States that tracks the number and characteristics of children with ASD in multiple communities in the U.S.

When ADDM released its first report in 2007 from six states and based on data from the year 2000, ASD prevalence was 6.7 per 1,000 children, or 1 in 150 children.

In the latest report, which includes data from 2018, the autism prevalence rate across 11 states was 23.0 per 1,000 children, or 1 in 44 children.

That rate is closer to reported autism prevalence from the National Survey of Children’s Health and the National Health Interview Survey, both of which rely on parent-reported ASD diagnoses.

For the report, researchers analyzed medical and special education records of 220,281 children who were born in 2010 in Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin.

Children were counted as having autism if their records included an ASD diagnosis, a special education classification of ASD, or an ASD International Classification of Diseases (ICD) code. A total of 5,058 children met those criteria.

Rates of ASD ranged from a low of 1.7% in Missouri to 3.9% in California and were 4.2 times higher in boys than in girls. Just under half of the children with ASD were evaluated by age 36 months.

Although the overall ASD prevalence was similar among White, Black, Hispanic, and Asian/Pacific Islander children, the report highlighted a number of other racial disparities overall and in individual states.

For example, among those with ASD and data on cognitive ability, 35.2% had an intelligence quotient score of 70 or lower. Black children with ASD were far more likely to have an IQ of 70 or less (49.8%) than Hispanic (33.1%) or White (29.7%) children.

“The persistent disparities in co-occurring intellectual disabilities in children with autism is something that we continue to see and suggests that we need to better understand exactly what’s happening,” Matthew Maenner, PhD, an epidemiologist and autism surveillance team lead with the CDC’s National Center on Birth Defects and Developmental Disabilities, told this news organization.

Another long-standing trend observed again in the new report on prevalence among 8-year-olds is low ASD prevalence among Hispanic children. While the overall estimate showed similar autism rates, a closer review of state-level data reveals a different picture.

“In almost half of the sites, Hispanic children were less likely to be identified as having ASD,” he said. “This gets lost if you look only at the overall estimate.”

New methodology

When ADDM released its first report in 2007, autism diagnosis was widely inadequate in the United States. Relying on only confirmed ASD diagnoses would significantly underestimate the number of children with the disorder, so the CDC added “active case finding” to the protocol.

Trained clinician reviewers analyzed individual notes from medical and educational records for every 8-year-old in ADDM Network sites, looking for evidence of characteristics and behaviors associated with autism. The process was labor- and time-intensive and took up to 4 years to complete.

In 2018, the CDC began investigating ways to speed the process and came up with the strategy used in the latest report. The new protocol was faster, easier, and less expensive. Although he says cost was never the deciding factor, Dr. Maenner acknowledges that had they stuck with the original protocol, they would have been forced to reduce the number of ADDM Network sites.

Dr. Maenner argues that a comparison of the two protocols shows the new method doesn’t compromise accuracy and may actually capture children who lacked the medical or educational records the previous protocol required for a count. But not everyone agrees.

“I thought the point was to be as accurate and complete as possible in doing the surveillance,” Walter Zahorodny, PhD, associate professor of pediatrics at Rutgers University, New Brunswick, N.J., and principal investigator of the New Jersey ADDM Network site, told this news organization. “In states where there’s a high detail of information in records, like New Jersey, it’s going to underestimate the count.”

Dr. Zahorodny says the latest data prove his point. In 2016, under the old methodology, ASD prevalence was 3.1% in the state. In 2018, under the new protocol, prevalence was 2.84%, a decrease of about 20% that Dr. Zahorodny pins squarely on the elimination of ADDM clinical reviewers.

But New Jersey is the only state that participated in both the 2016 and 2018 surveillance periods to report a decrease in ASD prevalence. The other eight states all found autism rates in their states went up.

Sydney Pettygrove, PhD, associate professor of public health and pediatrics at the University of Arizona, Tucson, and a principal investigator for the ADDM site in Arizona, told this news organization that when she first learned the CDC was rolling out a new methodology, she and other investigators were concerned.

“People were really upset. I was really upset,” she said. “I had formed an opinion based on the earlier data that this would not be a good idea.”

In 2000, when ASD surveillance began in Arizona, nearly 30% of children identified by ADDM clinical reviewers as having autism had no mention of the disorder in their records. Today, that percentage is closer to 5%.

“In 2000 it would have been catastrophic to try to estimate the prevalence of autism with the new protocol,” said Dr. Pettygrove. As it turns out, under the new protocol, prevalence rates in Arizona increased from 16.0 per 1,000 children in 2016 to 24.9 in 2018.

Built-in bias eliminated?

In addition to speeding up the process, the new methodology might have other benefits as well. Under the old ADDM surveillance protocol, children who lacked certain medical or educational records did not meet the ASD case definition and weren’t counted.

A 2019 study showed that this disproportionately affected Black and Hispanic children, who had significantly less access to health care professionals than White children.

As a result, “the old methodology had a bias built into it,” Maureen Durkin, PhD, DrPH, coauthor of that study and chair of population health sciences at the University of Wisconsin–Madison and principal investigator for the ADDM site in Wisconsin, told this news organization.

“Clinician reviewers ended up putting these children in the ‘suspected ASD’ category because they couldn’t call it a case under the case definition,” Dr. Durkin said. “There was a fairly large percentage of suspected cases and a disproportionate number of those kids were children of color.”

Although she can’t say for sure, Dr. Durkin said it’s possible the new protocol could eliminate some of that bias.

CDC researchers also attribute the new method to an expanded study of early diagnosis among 4-year-olds. In previous years, only a handful of the ADDM Network sites participating in the 8-year-old surveillance project also studied early diagnosis in 4-year-olds.

This year, all 11 sites took part in the early diagnosis analysis, tripling the number of children included in the analysis. That made it possible to include, for the first time, Asian/Pacific Islander children in this analysis.

In the past, ASD prevalence has trended higher in White children, compared with other racial groups. The new data found that ASD prevalence among 4-year-olds was significantly lower in White children (12.9 per 1,000 children) than in Black, Hispanic, or Asian/Pacific Islander children (16.6, 21.1, and 22.7 per 1,000, respectively). Prevalence in American Indian/Alaska Native children was the lowest among all racial groups (11.5 per 1,000).

It’s the first time researchers have seen this pattern in any ADDM report, Kelly Shaw, PhD, lead author of that study and an epidemiologist with the National Center on Birth Defects and Developmental Disability at the CDC, told this news organization.

These data don’t provide clues about the potential cause of that disparity, Dr. Shaw said. It’s likely an indication of better identification of ASD in those communities, she said, and not a sign of increased incidence of autism among Black, Hispanic, or Asian/Pacific Islander children.

“We don’t have any evidence to suggest or expect that autism would be increasing differentially among groups,” Dr. Shaw said.

The data suggest “we are making some progress but there certainly is still room for improvement,” Dr. Shaw said.

Study authors report no conflicts of interest.

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

Childhood autism rates are at the highest level since the Centers for Disease Control and Prevention began tracking the disorder in 2000, new data released Dec. 2 show.

The increase likely reflects improvements in diagnosis and identification of autism spectrum disorder (ASD), not an increase in incidence, study authors with the CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network told this news organization.

Using a new surveillance methodology, researchers found that 2.3% of 8-year-olds in communities in 11 states across the United States had an autism diagnosis in 2018, up from 1.9% in 2016.

A separate report on early identification in 4-year-olds shows that children born in 2014 were 50% more likely to receive an autism diagnosis or ASD special education classification by 48 months of age than those born in 2010, signaling improved early diagnosis.

Taken together, the data suggest efforts to raise awareness about autism are working, though researchers were quick to say much work remains.

“It was not surprising to me and in fact it was reassuring that the number of children diagnosed with autism is higher and is actually approaching prevalence of autism that has been noted in some national surveys of parents,” Stuart Shapira, MD, PhD, associate director for science in CDC’s National Center on Birth Defects and Developmental Disability, told this news organization.

“It means we’re doing a better job of identifying children, which helps to get them into services earlier so they can achieve their best developmental outcome.”

The studies, published online in Morbidity and Mortality Weekly Report, are the first to use a new ASD surveillance protocol that relies on ASD diagnosis or special education classification and billing codes and eliminates comprehensive records analysis by trained clinician reviewers.

Racial disparities

The updated methodology was less labor intensive and reduced the time it took to produce the report, but it is not without its critics, who claim the new protocol will undercount the number of children with ASD.

Created in 2000 and funded by the CDC, the ADDM Network is the only surveillance program in the United States that tracks the number and characteristics of children with ASD in multiple communities in the U.S.

When ADDM released its first report in 2007 from six states and based on data from the year 2000, ASD prevalence was 6.7 per 1,000 children, or 1 in 150 children.

In the latest report, which includes data from 2018, the autism prevalence rate across 11 states was 23.0 per 1,000 children, or 1 in 44 children.

That rate is closer to reported autism prevalence from the National Survey of Children’s Health and the National Health Interview Survey, both of which rely on parent-reported ASD diagnoses.

For the report, researchers analyzed medical and special education records of 220,281 children who were born in 2010 in Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin.

Children were counted as having autism if their records included an ASD diagnosis, a special education classification of ASD, or an ASD International Classification of Diseases (ICD) code. A total of 5,058 children met those criteria.

Rates of ASD ranged from a low of 1.7% in Missouri to 3.9% in California and were 4.2 times higher in boys than in girls. Just under half of the children with ASD were evaluated by age 36 months.

Although the overall ASD prevalence was similar among White, Black, Hispanic, and Asian/Pacific Islander children, the report highlighted a number of other racial disparities overall and in individual states.

For example, among those with ASD and data on cognitive ability, 35.2% had an intelligence quotient score of 70 or lower. Black children with ASD were far more likely to have an IQ of 70 or less (49.8%) than Hispanic (33.1%) or White (29.7%) children.

“The persistent disparities in co-occurring intellectual disabilities in children with autism is something that we continue to see and suggests that we need to better understand exactly what’s happening,” Matthew Maenner, PhD, an epidemiologist and autism surveillance team lead with the CDC’s National Center on Birth Defects and Developmental Disabilities, told this news organization.

Another long-standing trend observed again in the new report on prevalence among 8-year-olds is low ASD prevalence among Hispanic children. While the overall estimate showed similar autism rates, a closer review of state-level data reveals a different picture.

“In almost half of the sites, Hispanic children were less likely to be identified as having ASD,” he said. “This gets lost if you look only at the overall estimate.”

New methodology

When ADDM released its first report in 2007, autism diagnosis was widely inadequate in the United States. Relying on only confirmed ASD diagnoses would significantly underestimate the number of children with the disorder, so the CDC added “active case finding” to the protocol.

Trained clinician reviewers analyzed individual notes from medical and educational records for every 8-year-old in ADDM Network sites, looking for evidence of characteristics and behaviors associated with autism. The process was labor- and time-intensive and took up to 4 years to complete.

In 2018, the CDC began investigating ways to speed the process and came up with the strategy used in the latest report. The new protocol was faster, easier, and less expensive. Although he says cost was never the deciding factor, Dr. Maenner acknowledges that had they stuck with the original protocol, they would have been forced to reduce the number of ADDM Network sites.

Dr. Maenner argues that a comparison of the two protocols shows the new method doesn’t compromise accuracy and may actually capture children who lacked the medical or educational records the previous protocol required for a count. But not everyone agrees.

“I thought the point was to be as accurate and complete as possible in doing the surveillance,” Walter Zahorodny, PhD, associate professor of pediatrics at Rutgers University, New Brunswick, N.J., and principal investigator of the New Jersey ADDM Network site, told this news organization. “In states where there’s a high detail of information in records, like New Jersey, it’s going to underestimate the count.”

Dr. Zahorodny says the latest data prove his point. In 2016, under the old methodology, ASD prevalence was 3.1% in the state. In 2018, under the new protocol, prevalence was 2.84%, a decrease of about 20% that Dr. Zahorodny pins squarely on the elimination of ADDM clinical reviewers.

But New Jersey is the only state that participated in both the 2016 and 2018 surveillance periods to report a decrease in ASD prevalence. The other eight states all found autism rates in their states went up.

Sydney Pettygrove, PhD, associate professor of public health and pediatrics at the University of Arizona, Tucson, and a principal investigator for the ADDM site in Arizona, told this news organization that when she first learned the CDC was rolling out a new methodology, she and other investigators were concerned.

“People were really upset. I was really upset,” she said. “I had formed an opinion based on the earlier data that this would not be a good idea.”

In 2000, when ASD surveillance began in Arizona, nearly 30% of children identified by ADDM clinical reviewers as having autism had no mention of the disorder in their records. Today, that percentage is closer to 5%.

“In 2000 it would have been catastrophic to try to estimate the prevalence of autism with the new protocol,” said Dr. Pettygrove. As it turns out, under the new protocol, prevalence rates in Arizona increased from 16.0 per 1,000 children in 2016 to 24.9 in 2018.

Built-in bias eliminated?

In addition to speeding up the process, the new methodology might have other benefits as well. Under the old ADDM surveillance protocol, children who lacked certain medical or educational records did not meet the ASD case definition and weren’t counted.

A 2019 study showed that this disproportionately affected Black and Hispanic children, who had significantly less access to health care professionals than White children.

As a result, “the old methodology had a bias built into it,” Maureen Durkin, PhD, DrPH, coauthor of that study and chair of population health sciences at the University of Wisconsin–Madison and principal investigator for the ADDM site in Wisconsin, told this news organization.

“Clinician reviewers ended up putting these children in the ‘suspected ASD’ category because they couldn’t call it a case under the case definition,” Dr. Durkin said. “There was a fairly large percentage of suspected cases and a disproportionate number of those kids were children of color.”

Although she can’t say for sure, Dr. Durkin said it’s possible the new protocol could eliminate some of that bias.

CDC researchers also attribute the new method to an expanded study of early diagnosis among 4-year-olds. In previous years, only a handful of the ADDM Network sites participating in the 8-year-old surveillance project also studied early diagnosis in 4-year-olds.

This year, all 11 sites took part in the early diagnosis analysis, tripling the number of children included in the analysis. That made it possible to include, for the first time, Asian/Pacific Islander children in this analysis.

In the past, ASD prevalence has trended higher in White children, compared with other racial groups. The new data found that ASD prevalence among 4-year-olds was significantly lower in White children (12.9 per 1,000 children) than in Black, Hispanic, or Asian/Pacific Islander children (16.6, 21.1, and 22.7 per 1,000, respectively). Prevalence in American Indian/Alaska Native children was the lowest among all racial groups (11.5 per 1,000).

It’s the first time researchers have seen this pattern in any ADDM report, Kelly Shaw, PhD, lead author of that study and an epidemiologist with the National Center on Birth Defects and Developmental Disability at the CDC, told this news organization.

These data don’t provide clues about the potential cause of that disparity, Dr. Shaw said. It’s likely an indication of better identification of ASD in those communities, she said, and not a sign of increased incidence of autism among Black, Hispanic, or Asian/Pacific Islander children.

“We don’t have any evidence to suggest or expect that autism would be increasing differentially among groups,” Dr. Shaw said.

The data suggest “we are making some progress but there certainly is still room for improvement,” Dr. Shaw said.

Study authors report no conflicts of interest.

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

Childhood autism rates are at the highest level since the Centers for Disease Control and Prevention began tracking the disorder in 2000, new data released Dec. 2 show.

The increase likely reflects improvements in diagnosis and identification of autism spectrum disorder (ASD), not an increase in incidence, study authors with the CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network told this news organization.

Using a new surveillance methodology, researchers found that 2.3% of 8-year-olds in communities in 11 states across the United States had an autism diagnosis in 2018, up from 1.9% in 2016.

A separate report on early identification in 4-year-olds shows that children born in 2014 were 50% more likely to receive an autism diagnosis or ASD special education classification by 48 months of age than those born in 2010, signaling improved early diagnosis.

Taken together, the data suggest efforts to raise awareness about autism are working, though researchers were quick to say much work remains.

“It was not surprising to me and in fact it was reassuring that the number of children diagnosed with autism is higher and is actually approaching prevalence of autism that has been noted in some national surveys of parents,” Stuart Shapira, MD, PhD, associate director for science in CDC’s National Center on Birth Defects and Developmental Disability, told this news organization.

“It means we’re doing a better job of identifying children, which helps to get them into services earlier so they can achieve their best developmental outcome.”

The studies, published online in Morbidity and Mortality Weekly Report, are the first to use a new ASD surveillance protocol that relies on ASD diagnosis or special education classification and billing codes and eliminates comprehensive records analysis by trained clinician reviewers.

Racial disparities

The updated methodology was less labor intensive and reduced the time it took to produce the report, but it is not without its critics, who claim the new protocol will undercount the number of children with ASD.

Created in 2000 and funded by the CDC, the ADDM Network is the only surveillance program in the United States that tracks the number and characteristics of children with ASD in multiple communities in the U.S.

When ADDM released its first report in 2007 from six states and based on data from the year 2000, ASD prevalence was 6.7 per 1,000 children, or 1 in 150 children.

In the latest report, which includes data from 2018, the autism prevalence rate across 11 states was 23.0 per 1,000 children, or 1 in 44 children.

That rate is closer to reported autism prevalence from the National Survey of Children’s Health and the National Health Interview Survey, both of which rely on parent-reported ASD diagnoses.

For the report, researchers analyzed medical and special education records of 220,281 children who were born in 2010 in Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin.

Children were counted as having autism if their records included an ASD diagnosis, a special education classification of ASD, or an ASD International Classification of Diseases (ICD) code. A total of 5,058 children met those criteria.

Rates of ASD ranged from a low of 1.7% in Missouri to 3.9% in California and were 4.2 times higher in boys than in girls. Just under half of the children with ASD were evaluated by age 36 months.

Although the overall ASD prevalence was similar among White, Black, Hispanic, and Asian/Pacific Islander children, the report highlighted a number of other racial disparities overall and in individual states.

For example, among those with ASD and data on cognitive ability, 35.2% had an intelligence quotient score of 70 or lower. Black children with ASD were far more likely to have an IQ of 70 or less (49.8%) than Hispanic (33.1%) or White (29.7%) children.

“The persistent disparities in co-occurring intellectual disabilities in children with autism is something that we continue to see and suggests that we need to better understand exactly what’s happening,” Matthew Maenner, PhD, an epidemiologist and autism surveillance team lead with the CDC’s National Center on Birth Defects and Developmental Disabilities, told this news organization.

Another long-standing trend observed again in the new report on prevalence among 8-year-olds is low ASD prevalence among Hispanic children. While the overall estimate showed similar autism rates, a closer review of state-level data reveals a different picture.

“In almost half of the sites, Hispanic children were less likely to be identified as having ASD,” he said. “This gets lost if you look only at the overall estimate.”

New methodology

When ADDM released its first report in 2007, autism diagnosis was widely inadequate in the United States. Relying on only confirmed ASD diagnoses would significantly underestimate the number of children with the disorder, so the CDC added “active case finding” to the protocol.

Trained clinician reviewers analyzed individual notes from medical and educational records for every 8-year-old in ADDM Network sites, looking for evidence of characteristics and behaviors associated with autism. The process was labor- and time-intensive and took up to 4 years to complete.

In 2018, the CDC began investigating ways to speed the process and came up with the strategy used in the latest report. The new protocol was faster, easier, and less expensive. Although he says cost was never the deciding factor, Dr. Maenner acknowledges that had they stuck with the original protocol, they would have been forced to reduce the number of ADDM Network sites.

Dr. Maenner argues that a comparison of the two protocols shows the new method doesn’t compromise accuracy and may actually capture children who lacked the medical or educational records the previous protocol required for a count. But not everyone agrees.

“I thought the point was to be as accurate and complete as possible in doing the surveillance,” Walter Zahorodny, PhD, associate professor of pediatrics at Rutgers University, New Brunswick, N.J., and principal investigator of the New Jersey ADDM Network site, told this news organization. “In states where there’s a high detail of information in records, like New Jersey, it’s going to underestimate the count.”

Dr. Zahorodny says the latest data prove his point. In 2016, under the old methodology, ASD prevalence was 3.1% in the state. In 2018, under the new protocol, prevalence was 2.84%, a decrease of about 20% that Dr. Zahorodny pins squarely on the elimination of ADDM clinical reviewers.

But New Jersey is the only state that participated in both the 2016 and 2018 surveillance periods to report a decrease in ASD prevalence. The other eight states all found autism rates in their states went up.

Sydney Pettygrove, PhD, associate professor of public health and pediatrics at the University of Arizona, Tucson, and a principal investigator for the ADDM site in Arizona, told this news organization that when she first learned the CDC was rolling out a new methodology, she and other investigators were concerned.

“People were really upset. I was really upset,” she said. “I had formed an opinion based on the earlier data that this would not be a good idea.”

In 2000, when ASD surveillance began in Arizona, nearly 30% of children identified by ADDM clinical reviewers as having autism had no mention of the disorder in their records. Today, that percentage is closer to 5%.

“In 2000 it would have been catastrophic to try to estimate the prevalence of autism with the new protocol,” said Dr. Pettygrove. As it turns out, under the new protocol, prevalence rates in Arizona increased from 16.0 per 1,000 children in 2016 to 24.9 in 2018.

Built-in bias eliminated?

In addition to speeding up the process, the new methodology might have other benefits as well. Under the old ADDM surveillance protocol, children who lacked certain medical or educational records did not meet the ASD case definition and weren’t counted.

A 2019 study showed that this disproportionately affected Black and Hispanic children, who had significantly less access to health care professionals than White children.

As a result, “the old methodology had a bias built into it,” Maureen Durkin, PhD, DrPH, coauthor of that study and chair of population health sciences at the University of Wisconsin–Madison and principal investigator for the ADDM site in Wisconsin, told this news organization.

“Clinician reviewers ended up putting these children in the ‘suspected ASD’ category because they couldn’t call it a case under the case definition,” Dr. Durkin said. “There was a fairly large percentage of suspected cases and a disproportionate number of those kids were children of color.”

Although she can’t say for sure, Dr. Durkin said it’s possible the new protocol could eliminate some of that bias.

CDC researchers also attribute the new method to an expanded study of early diagnosis among 4-year-olds. In previous years, only a handful of the ADDM Network sites participating in the 8-year-old surveillance project also studied early diagnosis in 4-year-olds.

This year, all 11 sites took part in the early diagnosis analysis, tripling the number of children included in the analysis. That made it possible to include, for the first time, Asian/Pacific Islander children in this analysis.

In the past, ASD prevalence has trended higher in White children, compared with other racial groups. The new data found that ASD prevalence among 4-year-olds was significantly lower in White children (12.9 per 1,000 children) than in Black, Hispanic, or Asian/Pacific Islander children (16.6, 21.1, and 22.7 per 1,000, respectively). Prevalence in American Indian/Alaska Native children was the lowest among all racial groups (11.5 per 1,000).

It’s the first time researchers have seen this pattern in any ADDM report, Kelly Shaw, PhD, lead author of that study and an epidemiologist with the National Center on Birth Defects and Developmental Disability at the CDC, told this news organization.

These data don’t provide clues about the potential cause of that disparity, Dr. Shaw said. It’s likely an indication of better identification of ASD in those communities, she said, and not a sign of increased incidence of autism among Black, Hispanic, or Asian/Pacific Islander children.

“We don’t have any evidence to suggest or expect that autism would be increasing differentially among groups,” Dr. Shaw said.

The data suggest “we are making some progress but there certainly is still room for improvement,” Dr. Shaw said.

Study authors report no conflicts of interest.

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

A French population-based study provides further evidence that the BNT162b2 Pfizer-BioNTech mRNA COVID-19 vaccine does not increase the short-term risk for serious cardiovascular adverse events in older people.

The study showed no increased risk of myocardial infarction (MI), stroke, or pulmonary embolism (PE) following vaccination in adults aged 75 years or older in the 14 days following vaccination.

“These findings regarding the BNT162b2 vaccine’s short-term cardiovascular safety profile in older people are reassuring. They should be taken into account by doctors when considering implementing a third dose of the vaccine in older people,” Marie Joelle Jabagi, PharmD, PhD, with the French National Agency for Medicines and Health Products Safety, Saint-Denis, France, said in an interview.

Ridofranz/Getty Images

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

A French population-based study provides further evidence that the BNT162b2 Pfizer-BioNTech mRNA COVID-19 vaccine does not increase the short-term risk for serious cardiovascular adverse events in older people.

The study showed no increased risk of myocardial infarction (MI), stroke, or pulmonary embolism (PE) following vaccination in adults aged 75 years or older in the 14 days following vaccination.

“These findings regarding the BNT162b2 vaccine’s short-term cardiovascular safety profile in older people are reassuring. They should be taken into account by doctors when considering implementing a third dose of the vaccine in older people,” Marie Joelle Jabagi, PharmD, PhD, with the French National Agency for Medicines and Health Products Safety, Saint-Denis, France, said in an interview.

Ridofranz/Getty Images

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

A French population-based study provides further evidence that the BNT162b2 Pfizer-BioNTech mRNA COVID-19 vaccine does not increase the short-term risk for serious cardiovascular adverse events in older people.

The study showed no increased risk of myocardial infarction (MI), stroke, or pulmonary embolism (PE) following vaccination in adults aged 75 years or older in the 14 days following vaccination.

“These findings regarding the BNT162b2 vaccine’s short-term cardiovascular safety profile in older people are reassuring. They should be taken into account by doctors when considering implementing a third dose of the vaccine in older people,” Marie Joelle Jabagi, PharmD, PhD, with the French National Agency for Medicines and Health Products Safety, Saint-Denis, France, said in an interview.

Ridofranz/Getty Images

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

According to an analysis by the Pew Research Center and a report by the National Women’s Law Center, women were earning approximately $0.83-$0.84 for every $1.00 earned by their male counterparts in 2020. Accordingly, women would need to work an additional 42 days to receive compensation for earnings by men during that year. Moreover, these gaps exist with respect to race inequalities. For example, Black and Latinx women who are working full-time were reported to earn approximately $0.64 and $0.57, respectively, for every $1.00 compared with their white, non-Hispanic male counterparts. Striking, isn’t it?

The gender pay gap also affects physicians. A 2021 Medscape survey found that male physicians earn 35% more than female physicians. The biggest gap seems to be between male and female specialists, with men earning $376,000 and women $283,000.
 

Gender inequality and COVID-19

In addition to workplace responsibilities, women are more likely to take on unpaid positions in the informal care economy – examples of these tasks include cleaning, grocery shopping, and child care. In fact, the COVID-19 pandemic has increased the burden of unpaid care work among women, which often incurs a significant impact on their participation in the paid economy.

A study in the United States evaluating the impact of gender inequality during COVID-19 suggested that the rise in unemployment among women during this time may be related to decreased occupational flexibility. Accordingly, the closure of schools and caregiving facilities has translated into increased responsibilities as the informal caregiver, and a decreased ability to fulfill work obligations. Consequently, women may be overwhelmed and unable to maintain their employment status, are limited in their work opportunities, and/or are furloughed or passed over for promotions.
 

Gendered pay gaps affect mental health

A study by Platt and colleagues investigated the relationship between gendered wage gaps and gendered disparities in depression and anxiety disorders. Researchers found that females with a lower income compared with their matched male counterparts were more likely to experience depression and generalized anxiety disorders (i.e., they were 2.4 times more likely to experience depression and 4 times more likely to experience anxiety), while women who earned more than men did not report a significant difference in depression there were reduced gaps in the prevalence of anxiety disorders. As such, it has been suggested that wage gap inequalities are a contributing factor to gendered mental health disparities.

Reduced pay is not only a signifier of reduced returns on human capital. It may also have implications for one’s role in the care economy (e.g., greater time allocation as a result of reduced return), and may result in a higher likelihood for relocation as it relates to a partner’s work, overqualification for a position, inflexible work schedules, and reduced work autonomy.

Wage inequalities may act as a proxy for workplace inequalities such as promotions, prestigious projects, limited upward mobility, and internalized negative workplace experiences, all of which may contribute to increased sleep loss, stress, and related mental health stressors.

One might say, “A few cents, so what?” In addition to income itself, there’s a broader theme at play, which is gender discrimination and inequality. We should encourage conversations around the gender pay gap and develop strategies to combat this economic and social disparity.
 

Ms. Lui completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc candidate. She has received income from Braxia Scientific Corp. A version of this article first appeared on Medscape.com.

According to an analysis by the Pew Research Center and a report by the National Women’s Law Center, women were earning approximately $0.83-$0.84 for every $1.00 earned by their male counterparts in 2020. Accordingly, women would need to work an additional 42 days to receive compensation for earnings by men during that year. Moreover, these gaps exist with respect to race inequalities. For example, Black and Latinx women who are working full-time were reported to earn approximately $0.64 and $0.57, respectively, for every $1.00 compared with their white, non-Hispanic male counterparts. Striking, isn’t it?

The gender pay gap also affects physicians. A 2021 Medscape survey found that male physicians earn 35% more than female physicians. The biggest gap seems to be between male and female specialists, with men earning $376,000 and women $283,000.
 

Gender inequality and COVID-19

In addition to workplace responsibilities, women are more likely to take on unpaid positions in the informal care economy – examples of these tasks include cleaning, grocery shopping, and child care. In fact, the COVID-19 pandemic has increased the burden of unpaid care work among women, which often incurs a significant impact on their participation in the paid economy.

A study in the United States evaluating the impact of gender inequality during COVID-19 suggested that the rise in unemployment among women during this time may be related to decreased occupational flexibility. Accordingly, the closure of schools and caregiving facilities has translated into increased responsibilities as the informal caregiver, and a decreased ability to fulfill work obligations. Consequently, women may be overwhelmed and unable to maintain their employment status, are limited in their work opportunities, and/or are furloughed or passed over for promotions.
 

Gendered pay gaps affect mental health

A study by Platt and colleagues investigated the relationship between gendered wage gaps and gendered disparities in depression and anxiety disorders. Researchers found that females with a lower income compared with their matched male counterparts were more likely to experience depression and generalized anxiety disorders (i.e., they were 2.4 times more likely to experience depression and 4 times more likely to experience anxiety), while women who earned more than men did not report a significant difference in depression there were reduced gaps in the prevalence of anxiety disorders. As such, it has been suggested that wage gap inequalities are a contributing factor to gendered mental health disparities.

Reduced pay is not only a signifier of reduced returns on human capital. It may also have implications for one’s role in the care economy (e.g., greater time allocation as a result of reduced return), and may result in a higher likelihood for relocation as it relates to a partner’s work, overqualification for a position, inflexible work schedules, and reduced work autonomy.

Wage inequalities may act as a proxy for workplace inequalities such as promotions, prestigious projects, limited upward mobility, and internalized negative workplace experiences, all of which may contribute to increased sleep loss, stress, and related mental health stressors.

One might say, “A few cents, so what?” In addition to income itself, there’s a broader theme at play, which is gender discrimination and inequality. We should encourage conversations around the gender pay gap and develop strategies to combat this economic and social disparity.
 

Ms. Lui completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc candidate. She has received income from Braxia Scientific Corp. A version of this article first appeared on Medscape.com.

According to an analysis by the Pew Research Center and a report by the National Women’s Law Center, women were earning approximately $0.83-$0.84 for every $1.00 earned by their male counterparts in 2020. Accordingly, women would need to work an additional 42 days to receive compensation for earnings by men during that year. Moreover, these gaps exist with respect to race inequalities. For example, Black and Latinx women who are working full-time were reported to earn approximately $0.64 and $0.57, respectively, for every $1.00 compared with their white, non-Hispanic male counterparts. Striking, isn’t it?

The gender pay gap also affects physicians. A 2021 Medscape survey found that male physicians earn 35% more than female physicians. The biggest gap seems to be between male and female specialists, with men earning $376,000 and women $283,000.
 

Gender inequality and COVID-19

In addition to workplace responsibilities, women are more likely to take on unpaid positions in the informal care economy – examples of these tasks include cleaning, grocery shopping, and child care. In fact, the COVID-19 pandemic has increased the burden of unpaid care work among women, which often incurs a significant impact on their participation in the paid economy.

A study in the United States evaluating the impact of gender inequality during COVID-19 suggested that the rise in unemployment among women during this time may be related to decreased occupational flexibility. Accordingly, the closure of schools and caregiving facilities has translated into increased responsibilities as the informal caregiver, and a decreased ability to fulfill work obligations. Consequently, women may be overwhelmed and unable to maintain their employment status, are limited in their work opportunities, and/or are furloughed or passed over for promotions.
 

Gendered pay gaps affect mental health

A study by Platt and colleagues investigated the relationship between gendered wage gaps and gendered disparities in depression and anxiety disorders. Researchers found that females with a lower income compared with their matched male counterparts were more likely to experience depression and generalized anxiety disorders (i.e., they were 2.4 times more likely to experience depression and 4 times more likely to experience anxiety), while women who earned more than men did not report a significant difference in depression there were reduced gaps in the prevalence of anxiety disorders. As such, it has been suggested that wage gap inequalities are a contributing factor to gendered mental health disparities.

Reduced pay is not only a signifier of reduced returns on human capital. It may also have implications for one’s role in the care economy (e.g., greater time allocation as a result of reduced return), and may result in a higher likelihood for relocation as it relates to a partner’s work, overqualification for a position, inflexible work schedules, and reduced work autonomy.

Wage inequalities may act as a proxy for workplace inequalities such as promotions, prestigious projects, limited upward mobility, and internalized negative workplace experiences, all of which may contribute to increased sleep loss, stress, and related mental health stressors.

One might say, “A few cents, so what?” In addition to income itself, there’s a broader theme at play, which is gender discrimination and inequality. We should encourage conversations around the gender pay gap and develop strategies to combat this economic and social disparity.
 

Ms. Lui completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc candidate. She has received income from Braxia Scientific Corp. A version of this article first appeared on Medscape.com.

Like so many of you, I have weathered COVID-19 for the last almost 2 years. We’ve dealt with anxiety in our patients and ourselves, ever conflicting directives over masks, and uncertainty and hope over vaccinations.

In the beginning, it seemed elsewhere. Wuhan, China, the state of Washington, New York City.

In the beginning, I awoke with rising anxiety every morning at 4 a.m.

Now, it is part of life. We know how to do this.

I work in a D.C. hospital that takes care of COVID-19 patients. I don’t intubate or come into direct contact with patients’ secretions.

I felt lucky.

Last summer, I felt relief, after being fully vaccinated. We thought we were almost over it. But the numbers abroad and in the United States keep rising.

We have developed protocols. We test every patient for COVID-19 before admitting them to psychiatry, which is now routine. COVID-19–positive patients with suicidal ideation go to our medicine-psychiatric unit. We are single-room occupancy. No visitors.

Now, it feels like COVID is closing in. Lots of my patients on consultation-liaison psychiatry had COVID-19 or do now. The number of patients with long COVID is increasing. My elderly mother-in-law picked it up from a hospital. My young, healthy adult son got it but is now doing relatively OK. We will see if his ADHD worsens.

I received contact tracing recently for going into a patient room with contact precautions. I had put on the gown and gloves, but did I wear my goggles? I keep them on my forehead but could not remember if I had slipped them over my eyes.

I get tested weekly. My nose runs inside my mask. I sneeze. Is this COVID?

Of course, I am vaccinated with a booster shot. But breakthrough infections occur.

I am lucky, I keep reminding myself. I have a job and income and good PPE.

So, we are learning how to manage this disease. But it still closes in. My brain screams: “I do not want to catch this disease. I do not want to get sick. I do not want to get long COVID.”

“Calm down, Cam,” I tell myself. “You can do this!” I have learned how to do all the PPE, including tying the plastic ties along the backs of the plastic gowns.

All psychiatry meetings are virtual now. I cannot do virtual with enthusiasm. I say I will, but then do not log on. I miss the camaraderie.

All appointments are mainly telehealth. That has its pros and cons.

So bottom line – I will keep keeping on.

But I really want others to get vaccinated and wear masks. More than that, how can we as a psychiatric community get us through this pandemic? How can we support each other and our patients?

Here are a few suggestions, some of which I have made before:

• Focus on what we can control, especially exercise and sleep. Walk during times when the sun is shining. Rake the gorgeous autumn yellow and orange leaves.
• Give small (or large) gifts of kindness to others. Give to food banks, provide large tips to those who bring you takeout, help out at an animal shelter.
• Talk through established media about self-care and therapy for anxiety and depression.
• Clean out your closets. Give clothes to Afghan refugees.
• Read good books about trying times – such as World War II and the long wars in Afghanistan and Iraq.
• Take care of veterans and the elderly and homeless.
• Take care of yourself and your family.

Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center. She has no conflicts of interest.

Like so many of you, I have weathered COVID-19 for the last almost 2 years. We’ve dealt with anxiety in our patients and ourselves, ever conflicting directives over masks, and uncertainty and hope over vaccinations.

In the beginning, it seemed elsewhere. Wuhan, China, the state of Washington, New York City.

In the beginning, I awoke with rising anxiety every morning at 4 a.m.

Now, it is part of life. We know how to do this.

I work in a D.C. hospital that takes care of COVID-19 patients. I don’t intubate or come into direct contact with patients’ secretions.

I felt lucky.

Last summer, I felt relief, after being fully vaccinated. We thought we were almost over it. But the numbers abroad and in the United States keep rising.

We have developed protocols. We test every patient for COVID-19 before admitting them to psychiatry, which is now routine. COVID-19–positive patients with suicidal ideation go to our medicine-psychiatric unit. We are single-room occupancy. No visitors.

Now, it feels like COVID is closing in. Lots of my patients on consultation-liaison psychiatry had COVID-19 or do now. The number of patients with long COVID is increasing. My elderly mother-in-law picked it up from a hospital. My young, healthy adult son got it but is now doing relatively OK. We will see if his ADHD worsens.

I received contact tracing recently for going into a patient room with contact precautions. I had put on the gown and gloves, but did I wear my goggles? I keep them on my forehead but could not remember if I had slipped them over my eyes.

I get tested weekly. My nose runs inside my mask. I sneeze. Is this COVID?

Of course, I am vaccinated with a booster shot. But breakthrough infections occur.

I am lucky, I keep reminding myself. I have a job and income and good PPE.

So, we are learning how to manage this disease. But it still closes in. My brain screams: “I do not want to catch this disease. I do not want to get sick. I do not want to get long COVID.”

“Calm down, Cam,” I tell myself. “You can do this!” I have learned how to do all the PPE, including tying the plastic ties along the backs of the plastic gowns.

All psychiatry meetings are virtual now. I cannot do virtual with enthusiasm. I say I will, but then do not log on. I miss the camaraderie.

All appointments are mainly telehealth. That has its pros and cons.

So bottom line – I will keep keeping on.

But I really want others to get vaccinated and wear masks. More than that, how can we as a psychiatric community get us through this pandemic? How can we support each other and our patients?

Here are a few suggestions, some of which I have made before:

• Focus on what we can control, especially exercise and sleep. Walk during times when the sun is shining. Rake the gorgeous autumn yellow and orange leaves.
• Give small (or large) gifts of kindness to others. Give to food banks, provide large tips to those who bring you takeout, help out at an animal shelter.
• Talk through established media about self-care and therapy for anxiety and depression.
• Clean out your closets. Give clothes to Afghan refugees.
• Read good books about trying times – such as World War II and the long wars in Afghanistan and Iraq.
• Take care of veterans and the elderly and homeless.
• Take care of yourself and your family.

Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center. She has no conflicts of interest.

Like so many of you, I have weathered COVID-19 for the last almost 2 years. We’ve dealt with anxiety in our patients and ourselves, ever conflicting directives over masks, and uncertainty and hope over vaccinations.

In the beginning, it seemed elsewhere. Wuhan, China, the state of Washington, New York City.

In the beginning, I awoke with rising anxiety every morning at 4 a.m.

Now, it is part of life. We know how to do this.

I work in a D.C. hospital that takes care of COVID-19 patients. I don’t intubate or come into direct contact with patients’ secretions.

I felt lucky.

Last summer, I felt relief, after being fully vaccinated. We thought we were almost over it. But the numbers abroad and in the United States keep rising.

We have developed protocols. We test every patient for COVID-19 before admitting them to psychiatry, which is now routine. COVID-19–positive patients with suicidal ideation go to our medicine-psychiatric unit. We are single-room occupancy. No visitors.

Now, it feels like COVID is closing in. Lots of my patients on consultation-liaison psychiatry had COVID-19 or do now. The number of patients with long COVID is increasing. My elderly mother-in-law picked it up from a hospital. My young, healthy adult son got it but is now doing relatively OK. We will see if his ADHD worsens.

I received contact tracing recently for going into a patient room with contact precautions. I had put on the gown and gloves, but did I wear my goggles? I keep them on my forehead but could not remember if I had slipped them over my eyes.

I get tested weekly. My nose runs inside my mask. I sneeze. Is this COVID?

Of course, I am vaccinated with a booster shot. But breakthrough infections occur.

I am lucky, I keep reminding myself. I have a job and income and good PPE.

So, we are learning how to manage this disease. But it still closes in. My brain screams: “I do not want to catch this disease. I do not want to get sick. I do not want to get long COVID.”

“Calm down, Cam,” I tell myself. “You can do this!” I have learned how to do all the PPE, including tying the plastic ties along the backs of the plastic gowns.

All psychiatry meetings are virtual now. I cannot do virtual with enthusiasm. I say I will, but then do not log on. I miss the camaraderie.

All appointments are mainly telehealth. That has its pros and cons.

So bottom line – I will keep keeping on.

But I really want others to get vaccinated and wear masks. More than that, how can we as a psychiatric community get us through this pandemic? How can we support each other and our patients?

Here are a few suggestions, some of which I have made before:

• Focus on what we can control, especially exercise and sleep. Walk during times when the sun is shining. Rake the gorgeous autumn yellow and orange leaves.
• Give small (or large) gifts of kindness to others. Give to food banks, provide large tips to those who bring you takeout, help out at an animal shelter.
• Talk through established media about self-care and therapy for anxiety and depression.
• Clean out your closets. Give clothes to Afghan refugees.
• Read good books about trying times – such as World War II and the long wars in Afghanistan and Iraq.
• Take care of veterans and the elderly and homeless.
• Take care of yourself and your family.

Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center. She has no conflicts of interest.