Federal Practitioner

The editorials I have written so far in this series on COVID-19 have been on weighty topics as befits the serious situation of the pandemic, which as of June 30, 2020 had taken more than 500,000 lives across the globe and caused anguish and sorrow such as the world has not known since the 1918 influenza pandemic.²

The human spirit can bear only so much distress and tragedy before it is bowed and unable to stand. Stand though we must; not just against the inanimate invasion of viruses from the outside, but also our own endemic national tensions and conflicts. A periodic lifting of our burdens and a recharging of our psychological and spiritual energies are crucial to the resilience and flexibility that are necessary to walk the long difficult road ahead of us as a nation and as public servants in health care. This column takes a lighter look at COVID-19 and considers the restorative role companion animals, especially, for me, my beloved canines, have played in caring for and about us humans during the pandemic.

You will likely read this editorial during the official dog days of summer, which run from July 22 to August 22. We all may imagine a big dog laying on a porch in the American South while his owners drink lemonade and quietly rock in chairs watching the long lazy days pass in a simpler time.

However pleasant this bucolic picture, it has little to do with the origin of the expression, which dates back to ancient Greece. The dog refers not to our literal furry friends but, according to National Geographic (and who should know better), to the position of the “dog star” in a constellation in the night sky.³ Unfortunately, we cannot completely get away from the sobering theme of the pandemic: The rise of the star to prominence during the peak of the Mediterranean summer’s heat was a period associated with disaster and illness.

Real dogs, cats, and assorted other so-called pandemic pets, though, have been another type of star in this difficult period. Early in the shelter-in-place, pet adoptions from city and county animal shelters and rescue organizations skyrocketed.⁴ Although animal welfare experts have legitimate concerns that some of these adoptees will be surrendered if there is ever a return to normal. For now many people feel it is the perfect time to adopt, precisely because they now have space to bring a new member into the family. Before adopting, as a recent National Public Radio report emphasized, individuals should consider whether they truly have the resources both material and emotional to care for a pet.⁵ For those who take stock honestly and believe they have the room in their heart and budget, rescuing a companion is good psychological news, arguably even more for the human than for the animal.

Sheltering-in-place has reduced the transmission of the virus, which scientists estimate has saved thousands of lives.⁶ But it also has triggered a second health crisis, this time of mental health with an unprecedented increase in rates of depression, anxiety, suicide attempts, and substance use that is expected to worsen over the coming months and years.⁷ Companion animals certainly cannot solve this complex and mammoth public health problem; however, they can contribute in simple and small yet very significant ways to the mental health of individuals.⁸

Caring for a pet who shows unconditional love and loyalty to you can reduce isolation; foster hope; provide meaning, comfort, and cheer to you when you are down or afraid; and offer a routine and reason to get out of bed every day and take a walk outside. Research shows that those positive effects can decrease the risk of the very mental health conditions that are now plaguing us in such alarming numbers.^9,10

“How many more lives are we willing to sacrifice in the name of containing the virus?” Elinore McCance-Katz, MD, PhD, the nation’s top mental health official ominously asked about the potential effects of another shutdown during a cabinet meeting.¹¹ For some of us, a companion animal who does not require physical distancing (at least when you are healthy) may permit us to prevent the spread of the virus while protecting our mental health.

Nor is emotional support the only clinical way in which animals are helping pandemic- beleaguered humans. There is a low risk we can infect household pets, and dogs are not likely to transmit the virus. In fact, they even can be trained to serve as highly efficient virus testers who don’t need scarce reagents or carry high price tags—just a pat on the head and an occasional treat.¹² Medscape reported that clinical trials starting in the United Kingdom are set to evaluate the accuracy of these “bio-detection” dogs. The story quotes a leading British public health official as saying, “Properly trained sniffer dogs could revolutionise our approach to this whole pandemic, screening 250 people an hour for the virus.”¹³

Canines are not only healers who can ease our troubles through the pandemic but also peacemakers. As injustice and violence rock the country, we would do well to imitate their attitudes of nonjudgmental acceptance. “Dogs are our link to paradise. They do not know evil or jealousy or discontent,” wrote novelist Milan Kundera. “To sit with a dog on a hillside on a glorious afternoon is to be back in Eden, where doing nothing was not boring—it was peace.”¹⁴ Those indeed would be dog days as when better nature we sometimes share with animals prevailed.

The editorials I have written so far in this series on COVID-19 have been on weighty topics as befits the serious situation of the pandemic, which as of June 30, 2020 had taken more than 500,000 lives across the globe and caused anguish and sorrow such as the world has not known since the 1918 influenza pandemic.²

The human spirit can bear only so much distress and tragedy before it is bowed and unable to stand. Stand though we must; not just against the inanimate invasion of viruses from the outside, but also our own endemic national tensions and conflicts. A periodic lifting of our burdens and a recharging of our psychological and spiritual energies are crucial to the resilience and flexibility that are necessary to walk the long difficult road ahead of us as a nation and as public servants in health care. This column takes a lighter look at COVID-19 and considers the restorative role companion animals, especially, for me, my beloved canines, have played in caring for and about us humans during the pandemic.

You will likely read this editorial during the official dog days of summer, which run from July 22 to August 22. We all may imagine a big dog laying on a porch in the American South while his owners drink lemonade and quietly rock in chairs watching the long lazy days pass in a simpler time.

However pleasant this bucolic picture, it has little to do with the origin of the expression, which dates back to ancient Greece. The dog refers not to our literal furry friends but, according to National Geographic (and who should know better), to the position of the “dog star” in a constellation in the night sky.³ Unfortunately, we cannot completely get away from the sobering theme of the pandemic: The rise of the star to prominence during the peak of the Mediterranean summer’s heat was a period associated with disaster and illness.

Real dogs, cats, and assorted other so-called pandemic pets, though, have been another type of star in this difficult period. Early in the shelter-in-place, pet adoptions from city and county animal shelters and rescue organizations skyrocketed.⁴ Although animal welfare experts have legitimate concerns that some of these adoptees will be surrendered if there is ever a return to normal. For now many people feel it is the perfect time to adopt, precisely because they now have space to bring a new member into the family. Before adopting, as a recent National Public Radio report emphasized, individuals should consider whether they truly have the resources both material and emotional to care for a pet.⁵ For those who take stock honestly and believe they have the room in their heart and budget, rescuing a companion is good psychological news, arguably even more for the human than for the animal.

Sheltering-in-place has reduced the transmission of the virus, which scientists estimate has saved thousands of lives.⁶ But it also has triggered a second health crisis, this time of mental health with an unprecedented increase in rates of depression, anxiety, suicide attempts, and substance use that is expected to worsen over the coming months and years.⁷ Companion animals certainly cannot solve this complex and mammoth public health problem; however, they can contribute in simple and small yet very significant ways to the mental health of individuals.⁸

Caring for a pet who shows unconditional love and loyalty to you can reduce isolation; foster hope; provide meaning, comfort, and cheer to you when you are down or afraid; and offer a routine and reason to get out of bed every day and take a walk outside. Research shows that those positive effects can decrease the risk of the very mental health conditions that are now plaguing us in such alarming numbers.^9,10

“How many more lives are we willing to sacrifice in the name of containing the virus?” Elinore McCance-Katz, MD, PhD, the nation’s top mental health official ominously asked about the potential effects of another shutdown during a cabinet meeting.¹¹ For some of us, a companion animal who does not require physical distancing (at least when you are healthy) may permit us to prevent the spread of the virus while protecting our mental health.

Nor is emotional support the only clinical way in which animals are helping pandemic- beleaguered humans. There is a low risk we can infect household pets, and dogs are not likely to transmit the virus. In fact, they even can be trained to serve as highly efficient virus testers who don’t need scarce reagents or carry high price tags—just a pat on the head and an occasional treat.¹² Medscape reported that clinical trials starting in the United Kingdom are set to evaluate the accuracy of these “bio-detection” dogs. The story quotes a leading British public health official as saying, “Properly trained sniffer dogs could revolutionise our approach to this whole pandemic, screening 250 people an hour for the virus.”¹³

Canines are not only healers who can ease our troubles through the pandemic but also peacemakers. As injustice and violence rock the country, we would do well to imitate their attitudes of nonjudgmental acceptance. “Dogs are our link to paradise. They do not know evil or jealousy or discontent,” wrote novelist Milan Kundera. “To sit with a dog on a hillside on a glorious afternoon is to be back in Eden, where doing nothing was not boring—it was peace.”¹⁴ Those indeed would be dog days as when better nature we sometimes share with animals prevailed.

The editorials I have written so far in this series on COVID-19 have been on weighty topics as befits the serious situation of the pandemic, which as of June 30, 2020 had taken more than 500,000 lives across the globe and caused anguish and sorrow such as the world has not known since the 1918 influenza pandemic.²

The human spirit can bear only so much distress and tragedy before it is bowed and unable to stand. Stand though we must; not just against the inanimate invasion of viruses from the outside, but also our own endemic national tensions and conflicts. A periodic lifting of our burdens and a recharging of our psychological and spiritual energies are crucial to the resilience and flexibility that are necessary to walk the long difficult road ahead of us as a nation and as public servants in health care. This column takes a lighter look at COVID-19 and considers the restorative role companion animals, especially, for me, my beloved canines, have played in caring for and about us humans during the pandemic.

You will likely read this editorial during the official dog days of summer, which run from July 22 to August 22. We all may imagine a big dog laying on a porch in the American South while his owners drink lemonade and quietly rock in chairs watching the long lazy days pass in a simpler time.

However pleasant this bucolic picture, it has little to do with the origin of the expression, which dates back to ancient Greece. The dog refers not to our literal furry friends but, according to National Geographic (and who should know better), to the position of the “dog star” in a constellation in the night sky.³ Unfortunately, we cannot completely get away from the sobering theme of the pandemic: The rise of the star to prominence during the peak of the Mediterranean summer’s heat was a period associated with disaster and illness.

Real dogs, cats, and assorted other so-called pandemic pets, though, have been another type of star in this difficult period. Early in the shelter-in-place, pet adoptions from city and county animal shelters and rescue organizations skyrocketed.⁴ Although animal welfare experts have legitimate concerns that some of these adoptees will be surrendered if there is ever a return to normal. For now many people feel it is the perfect time to adopt, precisely because they now have space to bring a new member into the family. Before adopting, as a recent National Public Radio report emphasized, individuals should consider whether they truly have the resources both material and emotional to care for a pet.⁵ For those who take stock honestly and believe they have the room in their heart and budget, rescuing a companion is good psychological news, arguably even more for the human than for the animal.

Sheltering-in-place has reduced the transmission of the virus, which scientists estimate has saved thousands of lives.⁶ But it also has triggered a second health crisis, this time of mental health with an unprecedented increase in rates of depression, anxiety, suicide attempts, and substance use that is expected to worsen over the coming months and years.⁷ Companion animals certainly cannot solve this complex and mammoth public health problem; however, they can contribute in simple and small yet very significant ways to the mental health of individuals.⁸

Caring for a pet who shows unconditional love and loyalty to you can reduce isolation; foster hope; provide meaning, comfort, and cheer to you when you are down or afraid; and offer a routine and reason to get out of bed every day and take a walk outside. Research shows that those positive effects can decrease the risk of the very mental health conditions that are now plaguing us in such alarming numbers.^9,10

“How many more lives are we willing to sacrifice in the name of containing the virus?” Elinore McCance-Katz, MD, PhD, the nation’s top mental health official ominously asked about the potential effects of another shutdown during a cabinet meeting.¹¹ For some of us, a companion animal who does not require physical distancing (at least when you are healthy) may permit us to prevent the spread of the virus while protecting our mental health.

Nor is emotional support the only clinical way in which animals are helping pandemic- beleaguered humans. There is a low risk we can infect household pets, and dogs are not likely to transmit the virus. In fact, they even can be trained to serve as highly efficient virus testers who don’t need scarce reagents or carry high price tags—just a pat on the head and an occasional treat.¹² Medscape reported that clinical trials starting in the United Kingdom are set to evaluate the accuracy of these “bio-detection” dogs. The story quotes a leading British public health official as saying, “Properly trained sniffer dogs could revolutionise our approach to this whole pandemic, screening 250 people an hour for the virus.”¹³

Canines are not only healers who can ease our troubles through the pandemic but also peacemakers. As injustice and violence rock the country, we would do well to imitate their attitudes of nonjudgmental acceptance. “Dogs are our link to paradise. They do not know evil or jealousy or discontent,” wrote novelist Milan Kundera. “To sit with a dog on a hillside on a glorious afternoon is to be back in Eden, where doing nothing was not boring—it was peace.”¹⁴ Those indeed would be dog days as when better nature we sometimes share with animals prevailed.

International medical graduates (IMGs) constitute more than 24% of the total percentage of active physicians, 30% of active psychiatrists, and 33% of psychiatry residents in the United States.¹ IMGs serve in various medical specialties and provide medical care to socioeconomically disadvantaged patients in underserved communities.² Evidence suggests that patient outcomes among elderly patients admitted in U.S. hospitals for those treated by IMGs were on par with outcomes of U.S. graduates. Moreover, patients who were treated by IMGs had a lower mortality rates.³

IMGs trained in the United States make considerable contributions to psychiatry and have been very successful as educators, researchers, and leaders. Over the last 3 decades, for example, three American Psychiatric Association (APA) presidents and one past president of the American Academy of Child and Adolescent Psychiatry were IMGs. Many of them also hold department chair positions at many academic institutions.^4,5

In short, IMGs are an important part of the U.S. health care system – particularly in psychiatry.

In addition to participating in psychiatry residency programs, IMG physicians are heavily represented in subspecialties, including geriatric psychiatry (45%), addiction psychiatry (42%), child and adolescent psychiatry (36%), psychosomatic medicine (32%), and forensic psychiatry (25%).⁶ IMG trainees face multiple challenges that begin as they transition to psychiatry residency in the United States, including understanding the American health care system, electronic medical records and documentation, and evidence-based medicine. In addition, they need to adapt to cultural changes, and work on language barriers, communication skills, and social isolation.^7,8 Training programs account for these challenges and proactively take essential steps to facilitate the transition of IMGs into the U.S. system.^9,10

As training programs prepare for the new academic year starting from July 2020 and continue to provide educational experiences to current trainees, the COVID-19 pandemic has brought additional challenges for the training programs. The gravity of the novel coronavirus pandemic continues to deepen, causing immense fear and uncertainty globally. An APA poll of more than 1,000 adults conducted early in the pandemic showed that about 40% of Americans were anxious about becoming seriously ill or dying with COVID-19. Nearly half of the respondents (48%) were anxious about the possibility of getting COVID-19, and even more (62%) were anxious about the possibility of their loved ones getting infected by this virus. Also, one-third of Americans reported a serious impact on their mental health.

Furthermore, the ailing economy and increasing unemployment are raising financial concerns for individuals and families. This pandemic also has had an impact on our patients’ sleep hygiene, relationships with their loved ones, and consumption of alcohol or other drugs/substances.¹¹ Deteriorating mental health raises concerns about increased suicide risk as a secondary consequence.¹²

Physicians and other frontline teams who are taking care of these patients and their families continue to provide unexcelled, compassionate care in these unprecedented times. Selfless care continues despite awareness of the high probability of getting exposed to the virus and spreading it further to family members. Physicians involved in direct patient care for COVID-19 patients are at high risk for demoralization, burnout, depression, and anxiety.¹³

Struggles experienced by IMGs

On the personal front, IMGs often struggle with multiple stressors, such as lack of social support, ethnic-minority prejudice, and the need to understand financial structures such as mortgages in the new countries even after extended periods of residence.¹⁴ This virus has killed many health care professionals, including physicians around the world. There was a report of suicide by an emergency medicine physician who was treating patients with COVID-19 and ended up contracting the virus. That news was devastating and overwhelming for everyone, especially health care clinicians. It also adds to the stress and worries of IMGs who are still on nonimmigrant visas.

Bigger concerns exist if there is a demise of a nonimmigrant IMG and the implications of that loss for dependent families – who might face deportation. Even for those who were recently granted permanent residency status, worries about limited support systems and financial hardships to their families can be stressors.

Also, a large number of IMGs represent the geographical area where the pandemic began. Fortunately, the World Health Organization has taken a firm stance against possible discrimination by calling for global solidarity in these times. Furthermore, the WHO has emphasized the importance of referring to the disease caused by SARS-CoV-2 as “COVID-19” only – and not by the name of a particular country or city.¹⁵ Despite those official positions, people continue to express racially discriminatory opinions related to the virus, and those comments are not only disturbing to IMGs, they also are demoralizing.
 

Travel restrictions

In addition to the worries that IMGs might have about their own health and that of their families residing with them, the well-being of their extended families, including their aging parents back in their countries of origin, is unsettling as well. It is even more unnerving during the pandemic because the Centers for Disease Control and Prevention and the State Department advised avoiding all international travel at this time. Under these circumstances, IMGs are concerned about travel to their countries of origin in the event of a family emergency and the quarantine protocols in place, at both the country of origin and at residences.

Immigration issues

The U.S. administration temporarily suspended all immigration for 60 days, starting from April 2020. Recently, an executive order was signed suspending entry in the country on several visas, including the J-1 and the H1-B. Those are two categories that allow physicians to train and work in the United States.

IMGs in the United States reside and practice here under different types of immigrant and nonimmigrant visas (J-1, H1-B). This year, the Match results coincided with the timeline of those new immigration restrictions. Many IMGs are currently in the process of renewing their H1-B visas. They are worried because their visas will expire in the coming months. During the pandemic, U.S. Citizenship and Immigration Services suspended routine visa services and premium processing for visa renewals. This halt led to a delay in visa processing for graduating residents in June and practicing physicians seeking visa renewal. Those delays add to personal stress, and furthermore, distract these immigrant physicians from fighting this pandemic.

Another complication is that rules for J-1 visa holders have changed so that trainees must return to their countries of origin for at least 2 years after completing their training. If they decide to continue practicing medicine in the United States, they need a specific type of J-1 waiver and must gain a pathway to be a lawful permanent resident (Green Card). Many IMGs who are on waiver positions might not be able to treat patients ailing from COVID-19 to the full extent because waivers restrict them to practicing only in certain identified health systems.

IMGs who are coming from a country such India have to wait for more than 11 years after completing their accredited training to get permanent residency because of backlog for the permanent residency process.¹⁶ While waiting for a Green Card, they must continue to work on an H1-B visa, which requires periodic renewal.
 

Potential impact on training

Non-U.S. citizen IMGs accounted for 13% of the total of first-year positions in the 2020 Match. They will start medical training in residency programs in the United States in the coming months. The numbers for psychiatry residency matches are higher; about 16% of total first-year positions are filled by non-U.S. IMGs.¹⁷ At this time, when they should be celebrating their successful Match after many years of hard work and persistence, there is increased anxiety. They wonder whether they will be able to enter the United States to begin their training program on time. Their concerns are multifold, but the main concern is related to uncertainties around getting visas on time. With the recent executive order in place, physicians only working actively with COVID-19 patients will be able to enter the country on visas. As mental health concerns continue to rise during these times, incoming residents might not be able to start training if they are out of the country.

Furthermore, because of travel/air restrictions, there are worries about whether physicians will be able to get flights to the United States, given the lockdown in many countries around the world. Conversely, IMGs who will be graduating from residency and fellowship programs this summer and have accepted new positions also are dealing with similar uncertainty. Their new jobs will require visa processing, and the current scenario provides limited insight, so far, about whether they will be able to start their respective jobs or whether they will have to return to their home countries until their visa processing is completed.

The American Medical Association has advised the Secretary of State and acting Secretary of Homeland Security to expedite physician workforce expansion in an effort to meet the growing need for health care services during this pandemic.¹⁸ It is encouraging that, recently, the State Department declared that visa processing will continue for medical professionals and that cases would be expedited for those who meet the criteria. However, the requirement for in-person interviews remains for individuals who are seeking a U.S. visa outside the country. In the current lockdown situation in various countries, temporarily suspending the need for in-person interviews, such as those required for H-2 temporary work visas, would be helpful.

As residency programs are trying their best to continue to provide educational experiences to trainees during this phase, if psychiatry residents are placed on quarantine because of either getting exposed or contracting the illness, there is a possibility that they might need to extend their training. This would bring another challenge for IMGs, requiring them to extend their visas to complete their training. Future J-1 waiver jobs could be compromised.
 

Investment in physician wellness critical

Psychiatrists, along with other health care workers, are front-line soldiers in the fight against COVID-19. All physicians are at high risk for demoralization, burnout, depression, anxiety, and suicide. It is of utmost importance that we invest immediately in physicians’ wellness. As noted, significant numbers of psychiatrists are IMGs who are dealing with additional challenges while responding to the pandemic. There are certain challenges for IMGs, such as the well-being of their extended families in other countries, and travel bans put in place because of the pandemic. Those issues are not easy to resolve. However, addressing visa issues and providing support to their families in the event that something happens to physicians during the pandemic would be reassuring and would help alleviate additional stress. Those kinds of actions also would allow immigrant physicians to focus on clinical work and to improve their overall well-being. Given the health risks and numerous other insecurities that go along with living amid a pandemic, IMGs should not have the additional pressure of visa uncertainty.

Public health crises such as COVID-19 are associated with increased rates of anxiety,¹⁹ depression,²⁰ illicit substance use,²¹ and an increased rate of suicide.²² Patients with serious mental illness might be among the hardest hit both physically and mentally during the pandemic.²³ Even in the absence of a pandemic, there is already a shortage of psychiatrists at the national level, and it is expected that this shortage will grow in the future. Rural and underserved areas are expected to experience the physician deficit more acutely.²⁴

The pandemic is likely to resolve gradually and unpredictably – and might recur along the way over the next 1-2 years. However, the psychiatrist shortage will escalate more, as the mental health needs in the United States increase further in coming months. We need psychiatrists now more than ever, and it will be crucial that prospective residents, graduating residents, and fellows are able to come on board to join the American health care system promptly. In addition to national-level interventions, residency programs, potential employers, and communities must be aware of and do whatever they can to address the challenges faced by IMGs during these times.
 

Dr. Raman Baweja is affiliated with the department of psychiatry and behavioral health at Penn State University, Hershey. He has no conflicts of interest. Dr. Verma is affiliated with Rogers Behavioral Health in Kenosha County, Wis., and the department of psychiatry and behavioral health at Rosalind Franklin University of Medicine and Science in North Chicago. She has no conflicts of interest. Dr. Ritika Baweja is affiliated with the department of psychiatry and behavioral health at Penn State. Dr. Ritika Baweja is the spouse of Dr. Raman Baweja. Dr. Adam is affiliated with the department of psychiatry at the University of Missouri, Columbia.

References

1. American Psychiatric Association. Navigating psychiatry residency in the United States. A Guide for IMG Physicians.

2. Berg S. 5 IMG physicians who speak up for patients and fellow doctors. American Medical Association. 2019 Oct 22.

3. Tsugawa Y et al. BMJ. 2017 Feb 3;256. doi: 10.1136/bmj.j273.

4. Gogineni RR et al. Child Adolesc Psychiatr Clin N Am. 2010 Oct 1;19(4):833-53.

5. Majeed MH et al. Academic Psychiatry. 2017 Dec 1;41(6):849-51.

6. Brotherton SE and Etzel SI. JAMA. 2018 Sep 11;320(10):1051-70.

7. Sockalingam S et al. Acad Psychiatry. 2012 Jul 1;36(4):277-81.

8. Singareddy R et al. Acad Psychiatry. 2008 Jul-Aug;32(4):343-4.

9. Kramer MN. Acad Psychiatry. 2005 Jul-Aug;29(3):322-4.

10. Rao NR and Kotapati VP. Pathways for success in academic medicine for an international medical graduate: Challenges and opportunities. In “Roberts Academic Medicine Handbook” 2020. Springer:163-70.

11. American Psychiatric Association. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. 2020 Mar 25.

12. Reger MA et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

13. Lai J et al. JAMA Netw Open. 2020 Mar 23;3(3):e203976-e203976. doi: 10.1001/jamanetworkopen.2020.3976.

14. Kalra G et al. Acad Psychiatry. 2012 Jul;36(4):323-9.

15. WHO best practices for the naming of new human infectious diseases. World Health Organization. 2015.

16. U.S. Department of State. Bureau of Consular Affairs. Visa Bulletin for March 2020.

17. National Resident Matching Program® (NRMP®). Thousands of medical students and graduates celebrate NRMP Match results.

18. American Medical Association. AMA: U.S. should open visas to international physicians amid COVID-19. AMA press release. 2020 Mar 25.

19. McKay D et al. J Anxiety Disord. 2020 Jun;73:02233. doi: 10.1016/j.janxdis.2020.102233.

20. Tang W et al. J Affect Disord. 2020 May 13;274:1-7.

21. Collins F et al. NIH Director’s Blog. NIH.gov. 2020 Apr 21.

22. Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

23. Druss BG. JAMA Psychiatry. 2020 Apr 3. doi: 10.1001/jamapsychiatry.2020.0894.

24. American Association of Medical Colleges. “The complexities of physician supply and demand: Projections from 2018-2033.” 2020 Jun.

International medical graduates (IMGs) constitute more than 24% of the total percentage of active physicians, 30% of active psychiatrists, and 33% of psychiatry residents in the United States.¹ IMGs serve in various medical specialties and provide medical care to socioeconomically disadvantaged patients in underserved communities.² Evidence suggests that patient outcomes among elderly patients admitted in U.S. hospitals for those treated by IMGs were on par with outcomes of U.S. graduates. Moreover, patients who were treated by IMGs had a lower mortality rates.³

IMGs trained in the United States make considerable contributions to psychiatry and have been very successful as educators, researchers, and leaders. Over the last 3 decades, for example, three American Psychiatric Association (APA) presidents and one past president of the American Academy of Child and Adolescent Psychiatry were IMGs. Many of them also hold department chair positions at many academic institutions.^4,5

In short, IMGs are an important part of the U.S. health care system – particularly in psychiatry.

In addition to participating in psychiatry residency programs, IMG physicians are heavily represented in subspecialties, including geriatric psychiatry (45%), addiction psychiatry (42%), child and adolescent psychiatry (36%), psychosomatic medicine (32%), and forensic psychiatry (25%).⁶ IMG trainees face multiple challenges that begin as they transition to psychiatry residency in the United States, including understanding the American health care system, electronic medical records and documentation, and evidence-based medicine. In addition, they need to adapt to cultural changes, and work on language barriers, communication skills, and social isolation.^7,8 Training programs account for these challenges and proactively take essential steps to facilitate the transition of IMGs into the U.S. system.^9,10

As training programs prepare for the new academic year starting from July 2020 and continue to provide educational experiences to current trainees, the COVID-19 pandemic has brought additional challenges for the training programs. The gravity of the novel coronavirus pandemic continues to deepen, causing immense fear and uncertainty globally. An APA poll of more than 1,000 adults conducted early in the pandemic showed that about 40% of Americans were anxious about becoming seriously ill or dying with COVID-19. Nearly half of the respondents (48%) were anxious about the possibility of getting COVID-19, and even more (62%) were anxious about the possibility of their loved ones getting infected by this virus. Also, one-third of Americans reported a serious impact on their mental health.

Furthermore, the ailing economy and increasing unemployment are raising financial concerns for individuals and families. This pandemic also has had an impact on our patients’ sleep hygiene, relationships with their loved ones, and consumption of alcohol or other drugs/substances.¹¹ Deteriorating mental health raises concerns about increased suicide risk as a secondary consequence.¹²

Physicians and other frontline teams who are taking care of these patients and their families continue to provide unexcelled, compassionate care in these unprecedented times. Selfless care continues despite awareness of the high probability of getting exposed to the virus and spreading it further to family members. Physicians involved in direct patient care for COVID-19 patients are at high risk for demoralization, burnout, depression, and anxiety.¹³

Struggles experienced by IMGs

On the personal front, IMGs often struggle with multiple stressors, such as lack of social support, ethnic-minority prejudice, and the need to understand financial structures such as mortgages in the new countries even after extended periods of residence.¹⁴ This virus has killed many health care professionals, including physicians around the world. There was a report of suicide by an emergency medicine physician who was treating patients with COVID-19 and ended up contracting the virus. That news was devastating and overwhelming for everyone, especially health care clinicians. It also adds to the stress and worries of IMGs who are still on nonimmigrant visas.

Bigger concerns exist if there is a demise of a nonimmigrant IMG and the implications of that loss for dependent families – who might face deportation. Even for those who were recently granted permanent residency status, worries about limited support systems and financial hardships to their families can be stressors.

Also, a large number of IMGs represent the geographical area where the pandemic began. Fortunately, the World Health Organization has taken a firm stance against possible discrimination by calling for global solidarity in these times. Furthermore, the WHO has emphasized the importance of referring to the disease caused by SARS-CoV-2 as “COVID-19” only – and not by the name of a particular country or city.¹⁵ Despite those official positions, people continue to express racially discriminatory opinions related to the virus, and those comments are not only disturbing to IMGs, they also are demoralizing.
 

Travel restrictions

In addition to the worries that IMGs might have about their own health and that of their families residing with them, the well-being of their extended families, including their aging parents back in their countries of origin, is unsettling as well. It is even more unnerving during the pandemic because the Centers for Disease Control and Prevention and the State Department advised avoiding all international travel at this time. Under these circumstances, IMGs are concerned about travel to their countries of origin in the event of a family emergency and the quarantine protocols in place, at both the country of origin and at residences.

Immigration issues

The U.S. administration temporarily suspended all immigration for 60 days, starting from April 2020. Recently, an executive order was signed suspending entry in the country on several visas, including the J-1 and the H1-B. Those are two categories that allow physicians to train and work in the United States.

IMGs in the United States reside and practice here under different types of immigrant and nonimmigrant visas (J-1, H1-B). This year, the Match results coincided with the timeline of those new immigration restrictions. Many IMGs are currently in the process of renewing their H1-B visas. They are worried because their visas will expire in the coming months. During the pandemic, U.S. Citizenship and Immigration Services suspended routine visa services and premium processing for visa renewals. This halt led to a delay in visa processing for graduating residents in June and practicing physicians seeking visa renewal. Those delays add to personal stress, and furthermore, distract these immigrant physicians from fighting this pandemic.

Another complication is that rules for J-1 visa holders have changed so that trainees must return to their countries of origin for at least 2 years after completing their training. If they decide to continue practicing medicine in the United States, they need a specific type of J-1 waiver and must gain a pathway to be a lawful permanent resident (Green Card). Many IMGs who are on waiver positions might not be able to treat patients ailing from COVID-19 to the full extent because waivers restrict them to practicing only in certain identified health systems.

IMGs who are coming from a country such India have to wait for more than 11 years after completing their accredited training to get permanent residency because of backlog for the permanent residency process.¹⁶ While waiting for a Green Card, they must continue to work on an H1-B visa, which requires periodic renewal.
 

Potential impact on training

Non-U.S. citizen IMGs accounted for 13% of the total of first-year positions in the 2020 Match. They will start medical training in residency programs in the United States in the coming months. The numbers for psychiatry residency matches are higher; about 16% of total first-year positions are filled by non-U.S. IMGs.¹⁷ At this time, when they should be celebrating their successful Match after many years of hard work and persistence, there is increased anxiety. They wonder whether they will be able to enter the United States to begin their training program on time. Their concerns are multifold, but the main concern is related to uncertainties around getting visas on time. With the recent executive order in place, physicians only working actively with COVID-19 patients will be able to enter the country on visas. As mental health concerns continue to rise during these times, incoming residents might not be able to start training if they are out of the country.

Furthermore, because of travel/air restrictions, there are worries about whether physicians will be able to get flights to the United States, given the lockdown in many countries around the world. Conversely, IMGs who will be graduating from residency and fellowship programs this summer and have accepted new positions also are dealing with similar uncertainty. Their new jobs will require visa processing, and the current scenario provides limited insight, so far, about whether they will be able to start their respective jobs or whether they will have to return to their home countries until their visa processing is completed.

The American Medical Association has advised the Secretary of State and acting Secretary of Homeland Security to expedite physician workforce expansion in an effort to meet the growing need for health care services during this pandemic.¹⁸ It is encouraging that, recently, the State Department declared that visa processing will continue for medical professionals and that cases would be expedited for those who meet the criteria. However, the requirement for in-person interviews remains for individuals who are seeking a U.S. visa outside the country. In the current lockdown situation in various countries, temporarily suspending the need for in-person interviews, such as those required for H-2 temporary work visas, would be helpful.

As residency programs are trying their best to continue to provide educational experiences to trainees during this phase, if psychiatry residents are placed on quarantine because of either getting exposed or contracting the illness, there is a possibility that they might need to extend their training. This would bring another challenge for IMGs, requiring them to extend their visas to complete their training. Future J-1 waiver jobs could be compromised.
 

Investment in physician wellness critical

Psychiatrists, along with other health care workers, are front-line soldiers in the fight against COVID-19. All physicians are at high risk for demoralization, burnout, depression, anxiety, and suicide. It is of utmost importance that we invest immediately in physicians’ wellness. As noted, significant numbers of psychiatrists are IMGs who are dealing with additional challenges while responding to the pandemic. There are certain challenges for IMGs, such as the well-being of their extended families in other countries, and travel bans put in place because of the pandemic. Those issues are not easy to resolve. However, addressing visa issues and providing support to their families in the event that something happens to physicians during the pandemic would be reassuring and would help alleviate additional stress. Those kinds of actions also would allow immigrant physicians to focus on clinical work and to improve their overall well-being. Given the health risks and numerous other insecurities that go along with living amid a pandemic, IMGs should not have the additional pressure of visa uncertainty.

Public health crises such as COVID-19 are associated with increased rates of anxiety,¹⁹ depression,²⁰ illicit substance use,²¹ and an increased rate of suicide.²² Patients with serious mental illness might be among the hardest hit both physically and mentally during the pandemic.²³ Even in the absence of a pandemic, there is already a shortage of psychiatrists at the national level, and it is expected that this shortage will grow in the future. Rural and underserved areas are expected to experience the physician deficit more acutely.²⁴

The pandemic is likely to resolve gradually and unpredictably – and might recur along the way over the next 1-2 years. However, the psychiatrist shortage will escalate more, as the mental health needs in the United States increase further in coming months. We need psychiatrists now more than ever, and it will be crucial that prospective residents, graduating residents, and fellows are able to come on board to join the American health care system promptly. In addition to national-level interventions, residency programs, potential employers, and communities must be aware of and do whatever they can to address the challenges faced by IMGs during these times.
 

Dr. Raman Baweja is affiliated with the department of psychiatry and behavioral health at Penn State University, Hershey. He has no conflicts of interest. Dr. Verma is affiliated with Rogers Behavioral Health in Kenosha County, Wis., and the department of psychiatry and behavioral health at Rosalind Franklin University of Medicine and Science in North Chicago. She has no conflicts of interest. Dr. Ritika Baweja is affiliated with the department of psychiatry and behavioral health at Penn State. Dr. Ritika Baweja is the spouse of Dr. Raman Baweja. Dr. Adam is affiliated with the department of psychiatry at the University of Missouri, Columbia.

References

1. American Psychiatric Association. Navigating psychiatry residency in the United States. A Guide for IMG Physicians.

2. Berg S. 5 IMG physicians who speak up for patients and fellow doctors. American Medical Association. 2019 Oct 22.

3. Tsugawa Y et al. BMJ. 2017 Feb 3;256. doi: 10.1136/bmj.j273.

4. Gogineni RR et al. Child Adolesc Psychiatr Clin N Am. 2010 Oct 1;19(4):833-53.

5. Majeed MH et al. Academic Psychiatry. 2017 Dec 1;41(6):849-51.

6. Brotherton SE and Etzel SI. JAMA. 2018 Sep 11;320(10):1051-70.

7. Sockalingam S et al. Acad Psychiatry. 2012 Jul 1;36(4):277-81.

8. Singareddy R et al. Acad Psychiatry. 2008 Jul-Aug;32(4):343-4.

9. Kramer MN. Acad Psychiatry. 2005 Jul-Aug;29(3):322-4.

10. Rao NR and Kotapati VP. Pathways for success in academic medicine for an international medical graduate: Challenges and opportunities. In “Roberts Academic Medicine Handbook” 2020. Springer:163-70.

11. American Psychiatric Association. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. 2020 Mar 25.

12. Reger MA et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

13. Lai J et al. JAMA Netw Open. 2020 Mar 23;3(3):e203976-e203976. doi: 10.1001/jamanetworkopen.2020.3976.

14. Kalra G et al. Acad Psychiatry. 2012 Jul;36(4):323-9.

15. WHO best practices for the naming of new human infectious diseases. World Health Organization. 2015.

16. U.S. Department of State. Bureau of Consular Affairs. Visa Bulletin for March 2020.

17. National Resident Matching Program® (NRMP®). Thousands of medical students and graduates celebrate NRMP Match results.

18. American Medical Association. AMA: U.S. should open visas to international physicians amid COVID-19. AMA press release. 2020 Mar 25.

19. McKay D et al. J Anxiety Disord. 2020 Jun;73:02233. doi: 10.1016/j.janxdis.2020.102233.

20. Tang W et al. J Affect Disord. 2020 May 13;274:1-7.

21. Collins F et al. NIH Director’s Blog. NIH.gov. 2020 Apr 21.

22. Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

23. Druss BG. JAMA Psychiatry. 2020 Apr 3. doi: 10.1001/jamapsychiatry.2020.0894.

24. American Association of Medical Colleges. “The complexities of physician supply and demand: Projections from 2018-2033.” 2020 Jun.

International medical graduates (IMGs) constitute more than 24% of the total percentage of active physicians, 30% of active psychiatrists, and 33% of psychiatry residents in the United States.¹ IMGs serve in various medical specialties and provide medical care to socioeconomically disadvantaged patients in underserved communities.² Evidence suggests that patient outcomes among elderly patients admitted in U.S. hospitals for those treated by IMGs were on par with outcomes of U.S. graduates. Moreover, patients who were treated by IMGs had a lower mortality rates.³

IMGs trained in the United States make considerable contributions to psychiatry and have been very successful as educators, researchers, and leaders. Over the last 3 decades, for example, three American Psychiatric Association (APA) presidents and one past president of the American Academy of Child and Adolescent Psychiatry were IMGs. Many of them also hold department chair positions at many academic institutions.^4,5

In short, IMGs are an important part of the U.S. health care system – particularly in psychiatry.

In addition to participating in psychiatry residency programs, IMG physicians are heavily represented in subspecialties, including geriatric psychiatry (45%), addiction psychiatry (42%), child and adolescent psychiatry (36%), psychosomatic medicine (32%), and forensic psychiatry (25%).⁶ IMG trainees face multiple challenges that begin as they transition to psychiatry residency in the United States, including understanding the American health care system, electronic medical records and documentation, and evidence-based medicine. In addition, they need to adapt to cultural changes, and work on language barriers, communication skills, and social isolation.^7,8 Training programs account for these challenges and proactively take essential steps to facilitate the transition of IMGs into the U.S. system.^9,10

As training programs prepare for the new academic year starting from July 2020 and continue to provide educational experiences to current trainees, the COVID-19 pandemic has brought additional challenges for the training programs. The gravity of the novel coronavirus pandemic continues to deepen, causing immense fear and uncertainty globally. An APA poll of more than 1,000 adults conducted early in the pandemic showed that about 40% of Americans were anxious about becoming seriously ill or dying with COVID-19. Nearly half of the respondents (48%) were anxious about the possibility of getting COVID-19, and even more (62%) were anxious about the possibility of their loved ones getting infected by this virus. Also, one-third of Americans reported a serious impact on their mental health.

Furthermore, the ailing economy and increasing unemployment are raising financial concerns for individuals and families. This pandemic also has had an impact on our patients’ sleep hygiene, relationships with their loved ones, and consumption of alcohol or other drugs/substances.¹¹ Deteriorating mental health raises concerns about increased suicide risk as a secondary consequence.¹²

Physicians and other frontline teams who are taking care of these patients and their families continue to provide unexcelled, compassionate care in these unprecedented times. Selfless care continues despite awareness of the high probability of getting exposed to the virus and spreading it further to family members. Physicians involved in direct patient care for COVID-19 patients are at high risk for demoralization, burnout, depression, and anxiety.¹³

Struggles experienced by IMGs

On the personal front, IMGs often struggle with multiple stressors, such as lack of social support, ethnic-minority prejudice, and the need to understand financial structures such as mortgages in the new countries even after extended periods of residence.¹⁴ This virus has killed many health care professionals, including physicians around the world. There was a report of suicide by an emergency medicine physician who was treating patients with COVID-19 and ended up contracting the virus. That news was devastating and overwhelming for everyone, especially health care clinicians. It also adds to the stress and worries of IMGs who are still on nonimmigrant visas.

Bigger concerns exist if there is a demise of a nonimmigrant IMG and the implications of that loss for dependent families – who might face deportation. Even for those who were recently granted permanent residency status, worries about limited support systems and financial hardships to their families can be stressors.

Also, a large number of IMGs represent the geographical area where the pandemic began. Fortunately, the World Health Organization has taken a firm stance against possible discrimination by calling for global solidarity in these times. Furthermore, the WHO has emphasized the importance of referring to the disease caused by SARS-CoV-2 as “COVID-19” only – and not by the name of a particular country or city.¹⁵ Despite those official positions, people continue to express racially discriminatory opinions related to the virus, and those comments are not only disturbing to IMGs, they also are demoralizing.
 

Travel restrictions

In addition to the worries that IMGs might have about their own health and that of their families residing with them, the well-being of their extended families, including their aging parents back in their countries of origin, is unsettling as well. It is even more unnerving during the pandemic because the Centers for Disease Control and Prevention and the State Department advised avoiding all international travel at this time. Under these circumstances, IMGs are concerned about travel to their countries of origin in the event of a family emergency and the quarantine protocols in place, at both the country of origin and at residences.

Immigration issues

The U.S. administration temporarily suspended all immigration for 60 days, starting from April 2020. Recently, an executive order was signed suspending entry in the country on several visas, including the J-1 and the H1-B. Those are two categories that allow physicians to train and work in the United States.

IMGs in the United States reside and practice here under different types of immigrant and nonimmigrant visas (J-1, H1-B). This year, the Match results coincided with the timeline of those new immigration restrictions. Many IMGs are currently in the process of renewing their H1-B visas. They are worried because their visas will expire in the coming months. During the pandemic, U.S. Citizenship and Immigration Services suspended routine visa services and premium processing for visa renewals. This halt led to a delay in visa processing for graduating residents in June and practicing physicians seeking visa renewal. Those delays add to personal stress, and furthermore, distract these immigrant physicians from fighting this pandemic.

Another complication is that rules for J-1 visa holders have changed so that trainees must return to their countries of origin for at least 2 years after completing their training. If they decide to continue practicing medicine in the United States, they need a specific type of J-1 waiver and must gain a pathway to be a lawful permanent resident (Green Card). Many IMGs who are on waiver positions might not be able to treat patients ailing from COVID-19 to the full extent because waivers restrict them to practicing only in certain identified health systems.

IMGs who are coming from a country such India have to wait for more than 11 years after completing their accredited training to get permanent residency because of backlog for the permanent residency process.¹⁶ While waiting for a Green Card, they must continue to work on an H1-B visa, which requires periodic renewal.
 

Potential impact on training

Non-U.S. citizen IMGs accounted for 13% of the total of first-year positions in the 2020 Match. They will start medical training in residency programs in the United States in the coming months. The numbers for psychiatry residency matches are higher; about 16% of total first-year positions are filled by non-U.S. IMGs.¹⁷ At this time, when they should be celebrating their successful Match after many years of hard work and persistence, there is increased anxiety. They wonder whether they will be able to enter the United States to begin their training program on time. Their concerns are multifold, but the main concern is related to uncertainties around getting visas on time. With the recent executive order in place, physicians only working actively with COVID-19 patients will be able to enter the country on visas. As mental health concerns continue to rise during these times, incoming residents might not be able to start training if they are out of the country.

Furthermore, because of travel/air restrictions, there are worries about whether physicians will be able to get flights to the United States, given the lockdown in many countries around the world. Conversely, IMGs who will be graduating from residency and fellowship programs this summer and have accepted new positions also are dealing with similar uncertainty. Their new jobs will require visa processing, and the current scenario provides limited insight, so far, about whether they will be able to start their respective jobs or whether they will have to return to their home countries until their visa processing is completed.

The American Medical Association has advised the Secretary of State and acting Secretary of Homeland Security to expedite physician workforce expansion in an effort to meet the growing need for health care services during this pandemic.¹⁸ It is encouraging that, recently, the State Department declared that visa processing will continue for medical professionals and that cases would be expedited for those who meet the criteria. However, the requirement for in-person interviews remains for individuals who are seeking a U.S. visa outside the country. In the current lockdown situation in various countries, temporarily suspending the need for in-person interviews, such as those required for H-2 temporary work visas, would be helpful.

As residency programs are trying their best to continue to provide educational experiences to trainees during this phase, if psychiatry residents are placed on quarantine because of either getting exposed or contracting the illness, there is a possibility that they might need to extend their training. This would bring another challenge for IMGs, requiring them to extend their visas to complete their training. Future J-1 waiver jobs could be compromised.
 

Investment in physician wellness critical

Psychiatrists, along with other health care workers, are front-line soldiers in the fight against COVID-19. All physicians are at high risk for demoralization, burnout, depression, anxiety, and suicide. It is of utmost importance that we invest immediately in physicians’ wellness. As noted, significant numbers of psychiatrists are IMGs who are dealing with additional challenges while responding to the pandemic. There are certain challenges for IMGs, such as the well-being of their extended families in other countries, and travel bans put in place because of the pandemic. Those issues are not easy to resolve. However, addressing visa issues and providing support to their families in the event that something happens to physicians during the pandemic would be reassuring and would help alleviate additional stress. Those kinds of actions also would allow immigrant physicians to focus on clinical work and to improve their overall well-being. Given the health risks and numerous other insecurities that go along with living amid a pandemic, IMGs should not have the additional pressure of visa uncertainty.

Public health crises such as COVID-19 are associated with increased rates of anxiety,¹⁹ depression,²⁰ illicit substance use,²¹ and an increased rate of suicide.²² Patients with serious mental illness might be among the hardest hit both physically and mentally during the pandemic.²³ Even in the absence of a pandemic, there is already a shortage of psychiatrists at the national level, and it is expected that this shortage will grow in the future. Rural and underserved areas are expected to experience the physician deficit more acutely.²⁴

The pandemic is likely to resolve gradually and unpredictably – and might recur along the way over the next 1-2 years. However, the psychiatrist shortage will escalate more, as the mental health needs in the United States increase further in coming months. We need psychiatrists now more than ever, and it will be crucial that prospective residents, graduating residents, and fellows are able to come on board to join the American health care system promptly. In addition to national-level interventions, residency programs, potential employers, and communities must be aware of and do whatever they can to address the challenges faced by IMGs during these times.
 

Dr. Raman Baweja is affiliated with the department of psychiatry and behavioral health at Penn State University, Hershey. He has no conflicts of interest. Dr. Verma is affiliated with Rogers Behavioral Health in Kenosha County, Wis., and the department of psychiatry and behavioral health at Rosalind Franklin University of Medicine and Science in North Chicago. She has no conflicts of interest. Dr. Ritika Baweja is affiliated with the department of psychiatry and behavioral health at Penn State. Dr. Ritika Baweja is the spouse of Dr. Raman Baweja. Dr. Adam is affiliated with the department of psychiatry at the University of Missouri, Columbia.

References

1. American Psychiatric Association. Navigating psychiatry residency in the United States. A Guide for IMG Physicians.

2. Berg S. 5 IMG physicians who speak up for patients and fellow doctors. American Medical Association. 2019 Oct 22.

3. Tsugawa Y et al. BMJ. 2017 Feb 3;256. doi: 10.1136/bmj.j273.

4. Gogineni RR et al. Child Adolesc Psychiatr Clin N Am. 2010 Oct 1;19(4):833-53.

5. Majeed MH et al. Academic Psychiatry. 2017 Dec 1;41(6):849-51.

6. Brotherton SE and Etzel SI. JAMA. 2018 Sep 11;320(10):1051-70.

7. Sockalingam S et al. Acad Psychiatry. 2012 Jul 1;36(4):277-81.

8. Singareddy R et al. Acad Psychiatry. 2008 Jul-Aug;32(4):343-4.

9. Kramer MN. Acad Psychiatry. 2005 Jul-Aug;29(3):322-4.

10. Rao NR and Kotapati VP. Pathways for success in academic medicine for an international medical graduate: Challenges and opportunities. In “Roberts Academic Medicine Handbook” 2020. Springer:163-70.

11. American Psychiatric Association. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. 2020 Mar 25.

12. Reger MA et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

13. Lai J et al. JAMA Netw Open. 2020 Mar 23;3(3):e203976-e203976. doi: 10.1001/jamanetworkopen.2020.3976.

14. Kalra G et al. Acad Psychiatry. 2012 Jul;36(4):323-9.

15. WHO best practices for the naming of new human infectious diseases. World Health Organization. 2015.

16. U.S. Department of State. Bureau of Consular Affairs. Visa Bulletin for March 2020.

17. National Resident Matching Program® (NRMP®). Thousands of medical students and graduates celebrate NRMP Match results.

18. American Medical Association. AMA: U.S. should open visas to international physicians amid COVID-19. AMA press release. 2020 Mar 25.

19. McKay D et al. J Anxiety Disord. 2020 Jun;73:02233. doi: 10.1016/j.janxdis.2020.102233.

20. Tang W et al. J Affect Disord. 2020 May 13;274:1-7.

21. Collins F et al. NIH Director’s Blog. NIH.gov. 2020 Apr 21.

22. Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

23. Druss BG. JAMA Psychiatry. 2020 Apr 3. doi: 10.1001/jamapsychiatry.2020.0894.

24. American Association of Medical Colleges. “The complexities of physician supply and demand: Projections from 2018-2033.” 2020 Jun.

Family environment may influence subsequent functional outcomes in patients with first-episode psychosis, new research suggests.

A study of more than 300 patients with first-episode psychosis (FEP) showed that although family environment was not associated with functioning at initial presentation, an interaction developed over time that could have “important implications for early interventions for both patients and caregivers,” investigators reported.

The results highlight the need for intervention in patients with FEP as well as their families, study coinvestigator Norma Verdolini, MD, PhD, bipolar and depressive disorders unit, hospital Clinic Barcelona, University of Barcelona, said in an interview.

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society 2020, but the meeting was canceled because of the coronavirus pandemic.

FAST measures

Previous research has shown that family environment influences the development of psychotic symptoms, with negative family environmental factors associated with poor prognoses.

Conversely, one study indicated that a positive family environment is linked to greater improvement in negative and disorganized symptoms in adolescents at imminent risk for psychosis onset.

However, the current investigators noted that the impact of family environment on longitudinal functioning in individuals presenting with FEP is unclear.

To investigate further, they conducted an analysis as part of the PEPs study, which included 335 patients with FEP and 253 healthy controls. Functioning was measured using the Functional Assessment Short Test (FAST), and family environmental styles were evaluated using the Family Environment Scale (FES), which assesses “emotional climate” of a family across 10 domains.

At baseline, the mean total FAST score was 27.8 in patients with FEP versus 3.5 in the healthy controls, indicating substantially worse functioning among the patients. Linear regression analysis indicated that at baseline there was no significant association between aspects of family environment on the FES and functional scores.

Patients were assessed again at 2 years, by which point 283 had been diagnosed with psychotic disorders and 52 with bipolar disorder. The mean total FAST scores were 20.98 among patients with psychotic disorders and 13.8 in those with bipolar disorder.

Family conflict

Results showed that, among those with bipolar disorder, worse functioning on FAST at 2 years was significantly associated with higher rates of open expression of conflict in the family (P = .004).

In patients with psychotic disorders, worse functioning was significantly associated with lower rates of participation in social activities (P = .006) and an achievement-oriented family environment (P = .039). Worse functioning in patients with psychotic disorders was also significantly associated with higher rates of religious practice and values (P = .003).

Dr. Verdolini noted the reason family environment does not appear to have an impact at initial FEP presentation may be that the “first kick” is given by an individual’s genetic liability for psychiatric disorders in combination with the family environment. In reality, the two are intertwined, especially when considering what it means to a family to have one member with a psychiatric disorder, which “will have an impact on the family environment.”

Dr. Verdolini added: “This is not actually the objective family environment,” but the perceived family environment.

“So maybe in the following 2 years the patient who experiences a first episode of psychosis may change their idea of the family environment itself,” she noted. She added that at her institution psychoeducation is offered to FEP patients’ families.

‘Interesting’ findings

Commenting on the study, Nicole Kozloff, MD, from the child, youth, and emerging adult program at the Centre for Addiction and Mental Health in Toronto, said one limitation of the study is that it’s not clear what care patients received – or who in the family completed the FES.

It is also important to note that “measures of association do not necessarily imply that one factor caused the other factor,” said Dr. Kozloff, who was not involved in the research. “For example, it may be that, among people with bipolar disorder, open expression of conflict in the family can lead to worse functioning, or that worse functioning can lead to more conflict in the family.”

Nevertheless, Dr. Kozloff described the finding of an emerging association between the family environment and functioning over time as “interesting.”

When young people with FEP enter treatment, “they have reached a crisis point and are functioning poorly,” she noted.

“It could be that there is less to differentiate among levels of functioning at treatment entry but, after 2 years, the individuals have separated into those who have been responsive to treatment and are functioning well, and those who continue to have functional challenges. And this is where we start to see a relationship with family environment emerge,” Dr. Kozloff said.

She also agreed with Dr. Verdolini’s take on the findings, and that family psychoeducation “can reduce relapse rates in schizophrenia and the emotional burden on the family.”

“We also know that having family involvement in care is one of the most robust predictors that young people with psychosis will remain engaged in mental health services,” she said.

Teaching families about psychosis and its treatment, about problem-solving and communication skills, and providing support to ensure that family members know how to get help in a crisis, “is a key part of comprehensive early psychosis intervention,” Dr. Kozloff said. “It is good for the patient and good for the family, and allows the clinicians to provide better care.”

Articulates clinical practice findings

Also commenting on the results, Brian O’Donoghue, MD, PhD, senior clinical research fellow at Orygen, the National Centre of Excellence in Youth Mental Health in Melbourne, described the research as important, adding that the study highlights the need for sufficient follow-up.

“It makes sense that the involvement of family over time has a strong impact upon outcome and functioning,” he said in an interview.

“These research findings articulate what we see in clinical practice, so it is good to see that it is captured,” added Dr. O’Donoghue, who was not associated with the study.

He noted that it is common for family involvement to influence outcome, especially if the family is positively involved. “It is invaluable toward their recovery. However, conversely, if there are ongoing family stressors, then this can be a trigger for relapse or lack of improvement.”

Overall, the results “really emphasize that the family needs to be involved in care.”

The Early Psychosis Prevention and Intervention Centre where Dr. O’Donoghue is a consultant psychiatrist offers a psychoeducational course “to inform families about psychosis, treatment, and how they can support their family members.”

“We also have family peer support workers and family therapists, which are essential to the service and for the young person’s recovery,” Dr. O’Donoghue said.

The investigators and Dr. O’Donoghue disclosed no relevant financial relationships. Dr. Kozloff reported receiving research funding from the CAMH Foundation, Brain & Behavior Research Foundation, Canadian Institutes of Health Research, and AFP Innovation Fund; honoraria from Humber River Hospital, the University of Calgary (Alta.), and the Canadian Consortium for Early Intervention in Psychosis; and salary support from Inner City Health Associates.

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

Family environment may influence subsequent functional outcomes in patients with first-episode psychosis, new research suggests.

A study of more than 300 patients with first-episode psychosis (FEP) showed that although family environment was not associated with functioning at initial presentation, an interaction developed over time that could have “important implications for early interventions for both patients and caregivers,” investigators reported.

The results highlight the need for intervention in patients with FEP as well as their families, study coinvestigator Norma Verdolini, MD, PhD, bipolar and depressive disorders unit, hospital Clinic Barcelona, University of Barcelona, said in an interview.

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society 2020, but the meeting was canceled because of the coronavirus pandemic.

FAST measures

Previous research has shown that family environment influences the development of psychotic symptoms, with negative family environmental factors associated with poor prognoses.

Conversely, one study indicated that a positive family environment is linked to greater improvement in negative and disorganized symptoms in adolescents at imminent risk for psychosis onset.

However, the current investigators noted that the impact of family environment on longitudinal functioning in individuals presenting with FEP is unclear.

To investigate further, they conducted an analysis as part of the PEPs study, which included 335 patients with FEP and 253 healthy controls. Functioning was measured using the Functional Assessment Short Test (FAST), and family environmental styles were evaluated using the Family Environment Scale (FES), which assesses “emotional climate” of a family across 10 domains.

At baseline, the mean total FAST score was 27.8 in patients with FEP versus 3.5 in the healthy controls, indicating substantially worse functioning among the patients. Linear regression analysis indicated that at baseline there was no significant association between aspects of family environment on the FES and functional scores.

Patients were assessed again at 2 years, by which point 283 had been diagnosed with psychotic disorders and 52 with bipolar disorder. The mean total FAST scores were 20.98 among patients with psychotic disorders and 13.8 in those with bipolar disorder.

Family conflict

Results showed that, among those with bipolar disorder, worse functioning on FAST at 2 years was significantly associated with higher rates of open expression of conflict in the family (P = .004).

In patients with psychotic disorders, worse functioning was significantly associated with lower rates of participation in social activities (P = .006) and an achievement-oriented family environment (P = .039). Worse functioning in patients with psychotic disorders was also significantly associated with higher rates of religious practice and values (P = .003).

Dr. Verdolini noted the reason family environment does not appear to have an impact at initial FEP presentation may be that the “first kick” is given by an individual’s genetic liability for psychiatric disorders in combination with the family environment. In reality, the two are intertwined, especially when considering what it means to a family to have one member with a psychiatric disorder, which “will have an impact on the family environment.”

Dr. Verdolini added: “This is not actually the objective family environment,” but the perceived family environment.

“So maybe in the following 2 years the patient who experiences a first episode of psychosis may change their idea of the family environment itself,” she noted. She added that at her institution psychoeducation is offered to FEP patients’ families.

‘Interesting’ findings

Commenting on the study, Nicole Kozloff, MD, from the child, youth, and emerging adult program at the Centre for Addiction and Mental Health in Toronto, said one limitation of the study is that it’s not clear what care patients received – or who in the family completed the FES.

It is also important to note that “measures of association do not necessarily imply that one factor caused the other factor,” said Dr. Kozloff, who was not involved in the research. “For example, it may be that, among people with bipolar disorder, open expression of conflict in the family can lead to worse functioning, or that worse functioning can lead to more conflict in the family.”

Nevertheless, Dr. Kozloff described the finding of an emerging association between the family environment and functioning over time as “interesting.”

When young people with FEP enter treatment, “they have reached a crisis point and are functioning poorly,” she noted.

“It could be that there is less to differentiate among levels of functioning at treatment entry but, after 2 years, the individuals have separated into those who have been responsive to treatment and are functioning well, and those who continue to have functional challenges. And this is where we start to see a relationship with family environment emerge,” Dr. Kozloff said.

She also agreed with Dr. Verdolini’s take on the findings, and that family psychoeducation “can reduce relapse rates in schizophrenia and the emotional burden on the family.”

“We also know that having family involvement in care is one of the most robust predictors that young people with psychosis will remain engaged in mental health services,” she said.

Teaching families about psychosis and its treatment, about problem-solving and communication skills, and providing support to ensure that family members know how to get help in a crisis, “is a key part of comprehensive early psychosis intervention,” Dr. Kozloff said. “It is good for the patient and good for the family, and allows the clinicians to provide better care.”

Articulates clinical practice findings

Also commenting on the results, Brian O’Donoghue, MD, PhD, senior clinical research fellow at Orygen, the National Centre of Excellence in Youth Mental Health in Melbourne, described the research as important, adding that the study highlights the need for sufficient follow-up.

“It makes sense that the involvement of family over time has a strong impact upon outcome and functioning,” he said in an interview.

“These research findings articulate what we see in clinical practice, so it is good to see that it is captured,” added Dr. O’Donoghue, who was not associated with the study.

He noted that it is common for family involvement to influence outcome, especially if the family is positively involved. “It is invaluable toward their recovery. However, conversely, if there are ongoing family stressors, then this can be a trigger for relapse or lack of improvement.”

Overall, the results “really emphasize that the family needs to be involved in care.”

The Early Psychosis Prevention and Intervention Centre where Dr. O’Donoghue is a consultant psychiatrist offers a psychoeducational course “to inform families about psychosis, treatment, and how they can support their family members.”

“We also have family peer support workers and family therapists, which are essential to the service and for the young person’s recovery,” Dr. O’Donoghue said.

The investigators and Dr. O’Donoghue disclosed no relevant financial relationships. Dr. Kozloff reported receiving research funding from the CAMH Foundation, Brain & Behavior Research Foundation, Canadian Institutes of Health Research, and AFP Innovation Fund; honoraria from Humber River Hospital, the University of Calgary (Alta.), and the Canadian Consortium for Early Intervention in Psychosis; and salary support from Inner City Health Associates.

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

Family environment may influence subsequent functional outcomes in patients with first-episode psychosis, new research suggests.

A study of more than 300 patients with first-episode psychosis (FEP) showed that although family environment was not associated with functioning at initial presentation, an interaction developed over time that could have “important implications for early interventions for both patients and caregivers,” investigators reported.

The results highlight the need for intervention in patients with FEP as well as their families, study coinvestigator Norma Verdolini, MD, PhD, bipolar and depressive disorders unit, hospital Clinic Barcelona, University of Barcelona, said in an interview.

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society 2020, but the meeting was canceled because of the coronavirus pandemic.

FAST measures

Previous research has shown that family environment influences the development of psychotic symptoms, with negative family environmental factors associated with poor prognoses.

Conversely, one study indicated that a positive family environment is linked to greater improvement in negative and disorganized symptoms in adolescents at imminent risk for psychosis onset.

However, the current investigators noted that the impact of family environment on longitudinal functioning in individuals presenting with FEP is unclear.

To investigate further, they conducted an analysis as part of the PEPs study, which included 335 patients with FEP and 253 healthy controls. Functioning was measured using the Functional Assessment Short Test (FAST), and family environmental styles were evaluated using the Family Environment Scale (FES), which assesses “emotional climate” of a family across 10 domains.

At baseline, the mean total FAST score was 27.8 in patients with FEP versus 3.5 in the healthy controls, indicating substantially worse functioning among the patients. Linear regression analysis indicated that at baseline there was no significant association between aspects of family environment on the FES and functional scores.

Patients were assessed again at 2 years, by which point 283 had been diagnosed with psychotic disorders and 52 with bipolar disorder. The mean total FAST scores were 20.98 among patients with psychotic disorders and 13.8 in those with bipolar disorder.

Family conflict

Results showed that, among those with bipolar disorder, worse functioning on FAST at 2 years was significantly associated with higher rates of open expression of conflict in the family (P = .004).

In patients with psychotic disorders, worse functioning was significantly associated with lower rates of participation in social activities (P = .006) and an achievement-oriented family environment (P = .039). Worse functioning in patients with psychotic disorders was also significantly associated with higher rates of religious practice and values (P = .003).

Dr. Verdolini noted the reason family environment does not appear to have an impact at initial FEP presentation may be that the “first kick” is given by an individual’s genetic liability for psychiatric disorders in combination with the family environment. In reality, the two are intertwined, especially when considering what it means to a family to have one member with a psychiatric disorder, which “will have an impact on the family environment.”

Dr. Verdolini added: “This is not actually the objective family environment,” but the perceived family environment.

“So maybe in the following 2 years the patient who experiences a first episode of psychosis may change their idea of the family environment itself,” she noted. She added that at her institution psychoeducation is offered to FEP patients’ families.

‘Interesting’ findings

Commenting on the study, Nicole Kozloff, MD, from the child, youth, and emerging adult program at the Centre for Addiction and Mental Health in Toronto, said one limitation of the study is that it’s not clear what care patients received – or who in the family completed the FES.

It is also important to note that “measures of association do not necessarily imply that one factor caused the other factor,” said Dr. Kozloff, who was not involved in the research. “For example, it may be that, among people with bipolar disorder, open expression of conflict in the family can lead to worse functioning, or that worse functioning can lead to more conflict in the family.”

Nevertheless, Dr. Kozloff described the finding of an emerging association between the family environment and functioning over time as “interesting.”

When young people with FEP enter treatment, “they have reached a crisis point and are functioning poorly,” she noted.

“It could be that there is less to differentiate among levels of functioning at treatment entry but, after 2 years, the individuals have separated into those who have been responsive to treatment and are functioning well, and those who continue to have functional challenges. And this is where we start to see a relationship with family environment emerge,” Dr. Kozloff said.

She also agreed with Dr. Verdolini’s take on the findings, and that family psychoeducation “can reduce relapse rates in schizophrenia and the emotional burden on the family.”

“We also know that having family involvement in care is one of the most robust predictors that young people with psychosis will remain engaged in mental health services,” she said.

Teaching families about psychosis and its treatment, about problem-solving and communication skills, and providing support to ensure that family members know how to get help in a crisis, “is a key part of comprehensive early psychosis intervention,” Dr. Kozloff said. “It is good for the patient and good for the family, and allows the clinicians to provide better care.”

Articulates clinical practice findings

Also commenting on the results, Brian O’Donoghue, MD, PhD, senior clinical research fellow at Orygen, the National Centre of Excellence in Youth Mental Health in Melbourne, described the research as important, adding that the study highlights the need for sufficient follow-up.

“It makes sense that the involvement of family over time has a strong impact upon outcome and functioning,” he said in an interview.

“These research findings articulate what we see in clinical practice, so it is good to see that it is captured,” added Dr. O’Donoghue, who was not associated with the study.

He noted that it is common for family involvement to influence outcome, especially if the family is positively involved. “It is invaluable toward their recovery. However, conversely, if there are ongoing family stressors, then this can be a trigger for relapse or lack of improvement.”

Overall, the results “really emphasize that the family needs to be involved in care.”

The Early Psychosis Prevention and Intervention Centre where Dr. O’Donoghue is a consultant psychiatrist offers a psychoeducational course “to inform families about psychosis, treatment, and how they can support their family members.”

“We also have family peer support workers and family therapists, which are essential to the service and for the young person’s recovery,” Dr. O’Donoghue said.

The investigators and Dr. O’Donoghue disclosed no relevant financial relationships. Dr. Kozloff reported receiving research funding from the CAMH Foundation, Brain & Behavior Research Foundation, Canadian Institutes of Health Research, and AFP Innovation Fund; honoraria from Humber River Hospital, the University of Calgary (Alta.), and the Canadian Consortium for Early Intervention in Psychosis; and salary support from Inner City Health Associates.

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

Among adults who drink alcohol at relatively high amounts, regular weekly physical activity may reduce the mortality risk posed by alcohol-related cancers, concludes a new observational study involving 50,000-plus British adults.

Being physically active – for example, by walking, house cleaning, or playing a sport – could be promoted as a risk-minimization measure for alcohol-related cancers, say the authors, led by Emmanuel Stamatakis, PhD, professor of Physical Activity, Lifestyle, and Population Health, University of Sydney, Australia.

The researchers found a “strong direct association between alcohol consumption and mortality risk of [10] alcohol-related cancers.”

Specifically, when compared with never drinkers, there was a significantly higher risk of dying from such cancers among drinkers who consumed “hazardous” and “harmful” amounts of alcohol, and also for ex-drinkers.

Notably, occasional drinkers and drinkers within guidelines did not have statistically significantly higher risks for alcohol-related cancer mortality.

But the analysis also found that among the bigger drinkers, the risks were “substantially attenuated” in physically active participants who met at least the lower recommended limit of activity (>7.5 metabolic equivalent task [MET]–hours/week).

That’s not a taxing amount of activity because, for example, general household cleaning results in 3 METs/hour and walking slowly translates into 2 METs/hour. However, nearly a quarter of survey participants reported no physical activity.

The study was published online May 14 in the International Journal of Cancer.

The new results require confirmation because the findings “are limited in their statistical power,” with small numbers of cases in several categories, said Alpa Patel, PhD, an epidemiologist at the American Cancer Society, who was not involved in the study. For example, there were only 55 alcohol-related cancer deaths among the 1540 harmful drinkers.

Patel stressed that, “based on the collective evidence to date, it is best to both avoid alcohol consumption and engage in sufficient amounts of physical activity.” That amount is 150-300 minutes of moderate or 75-150 minutes of vigorous activity per week for cancer prevention.

Her message about abstinence is in-line with new ACS guidelines issued last month, as reported by Medscape Medical News. The ACS’s guidance was criticized by many readers in the comments section, who repeatedly encouraged “moderation.”

However, the ACS also recommended moderation, saying, for those adults who do drink, intake should be no more than 1 drink/day for women or 2 drinks/day for men. 

Study author Dr. Stamatakis commented on the alcohol debate.

“Any advice for complete abstinence is bound to alienate many people,” he told Medscape Medical News in an email. “Alcohol drinking has been an integral part of many societies for thousands of years.”

Dr. Stamatakis, who is an occasional beer drinker, also said, “there is no healthy level of alcohol drinking.”

This was also the conclusion of a 2018 study published in the Lancet, which stated that there is “no safe limit,” as even one drink a day increases the risk of cancer. A few years earlier, the 2014 World Cancer Report found a dose-response relationship between alcohol consumption and certain cancers.

However, epidemiological findings are not necessarily “clinically relevant,” commented Jennifer Ligibel, MD, a medical oncologist at the Dana-Farber Cancer Institute, Boston, Massachusetts, in a 2018 interview with Medscape Medical News.

Dr. Ligibel explained that there are 50 years of studies linking alcohol and cancers. “With the huge amount of data we have, even small differences [in consumption] are statistically significant.”

Dr. Ligibel cited an often-repeated statistic: for the average woman, there is a 12% lifetime risk of breast cancer. “If a woman consumes a drink a day, which is considered a low-level intake, that risk may become about 13% – which is statistically significant,” Dr. Ligibel explained.

But that risk increase is not clinically relevant, she added.

Mean 10 years of follow-up

The new study is the first to examine physical activity, drinking, and the 10 cancers that have been linked to alcohol consumption (oral cavity, throat, larynx, esophagus, liver, colorectal, stomach, breast, pancreas, and lung).

The authors used data from 10 British population-based health surveys from 1994-2008 and looked at adults aged 30 years and older. The mean follow-up period was 9.9 years.

Among 54,686 participants, there were 2039 alcohol-related site-specific cancer deaths.

Alcohol consumption categories were based on U.K. guidelines, with 1 unit equal to 8 grams (about 2 ounces) of pure alcohol. The categories were as follows: drinking within guidelines (<14 units/week for women, <21 units/week for men), hazardous level (14-35 units/week for women, 21-49 units/week for men), and harmful level (> 35 units/week for women, >49 units/week for men). The survey also queried participants about being ex-drinkers, occasional drinkers, and never drinkers.

Physical activity was assessed using self-reported accounts of the 4 weeks preceding the health survey and intensity of activity (light, moderate, or vigorous) was queried. Physical activity was categorized using the upper (15 MET-hours/week) and lower (the aforementioned <7 MET-hours/week) recommended limits.

The median age of participants was 51 years; 7.9% were never drinkers and 14.7% exceeded guideline amounts. For physical activity, 23% reported none. The median level of activity was 9 MET-hours/week.

The authors say that the “increased risks [among the harmful, hazardous, and ex-drinker categories] were eliminated” among the individuals who reported physical activity >7.5 MET-hours/week. That meant the hazard ratios for cancer mortality for each category were reduced to the point that they were no longer statistically significant.

For example, for all drinkers in the “hazardous” category, the risk of cancer-related mortality was significantly higher than for nondrinkers (with a hazard ratio of 1.39), but in the subgroup of these participants who were physically active at the lower recommended limit, the hazard ratio dropped to 1.21.

These “broad patterns of effect modification by physical activity persisted when the upper physical activity limit [15 MET-hours/week] was used,” write the authors.

The new study adds to the literature on cancer mortality and alcohol consumption. In another recent study, researchers looked at eight British cohorts and reported overall cancer mortality associated with alcohol consumption was eliminated among those meeting physical activity recommendations (Br J Sports Med. 2017;51:651-7). The new study added two more cohorts to this base of eight and only focused on cancers that have been linked to alcohol consumption. The earlier study included deaths from all types of cancer.

The refinement of focus in the current study is important, say Dr. Stamatakis and colleagues.

“This specificity adds biological plausibility and permits a more immediate translation of our findings into policy and practice,” they write. 

Dr. Stamatakis practices what he advocates, but is not a teetotaler.

“I exercise (e.g., dynamic yoga, HIIT cardio workouts, run, cycle, lift weights) for 45-60 minutes a day and I walk 8,000-14,000 steps daily. That would categorize me perhaps in the top 3%-5% for my age/sex group. And I enjoy 1-2 cans of craft beer a couple of times a week,” he said in an email.

Dr. Stamatakis and Dr. Patel have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Among adults who drink alcohol at relatively high amounts, regular weekly physical activity may reduce the mortality risk posed by alcohol-related cancers, concludes a new observational study involving 50,000-plus British adults.

Being physically active – for example, by walking, house cleaning, or playing a sport – could be promoted as a risk-minimization measure for alcohol-related cancers, say the authors, led by Emmanuel Stamatakis, PhD, professor of Physical Activity, Lifestyle, and Population Health, University of Sydney, Australia.

The researchers found a “strong direct association between alcohol consumption and mortality risk of [10] alcohol-related cancers.”

Specifically, when compared with never drinkers, there was a significantly higher risk of dying from such cancers among drinkers who consumed “hazardous” and “harmful” amounts of alcohol, and also for ex-drinkers.

Notably, occasional drinkers and drinkers within guidelines did not have statistically significantly higher risks for alcohol-related cancer mortality.

But the analysis also found that among the bigger drinkers, the risks were “substantially attenuated” in physically active participants who met at least the lower recommended limit of activity (>7.5 metabolic equivalent task [MET]–hours/week).

That’s not a taxing amount of activity because, for example, general household cleaning results in 3 METs/hour and walking slowly translates into 2 METs/hour. However, nearly a quarter of survey participants reported no physical activity.

The study was published online May 14 in the International Journal of Cancer.

The new results require confirmation because the findings “are limited in their statistical power,” with small numbers of cases in several categories, said Alpa Patel, PhD, an epidemiologist at the American Cancer Society, who was not involved in the study. For example, there were only 55 alcohol-related cancer deaths among the 1540 harmful drinkers.

Patel stressed that, “based on the collective evidence to date, it is best to both avoid alcohol consumption and engage in sufficient amounts of physical activity.” That amount is 150-300 minutes of moderate or 75-150 minutes of vigorous activity per week for cancer prevention.

Her message about abstinence is in-line with new ACS guidelines issued last month, as reported by Medscape Medical News. The ACS’s guidance was criticized by many readers in the comments section, who repeatedly encouraged “moderation.”

However, the ACS also recommended moderation, saying, for those adults who do drink, intake should be no more than 1 drink/day for women or 2 drinks/day for men. 

Study author Dr. Stamatakis commented on the alcohol debate.

“Any advice for complete abstinence is bound to alienate many people,” he told Medscape Medical News in an email. “Alcohol drinking has been an integral part of many societies for thousands of years.”

Dr. Stamatakis, who is an occasional beer drinker, also said, “there is no healthy level of alcohol drinking.”

This was also the conclusion of a 2018 study published in the Lancet, which stated that there is “no safe limit,” as even one drink a day increases the risk of cancer. A few years earlier, the 2014 World Cancer Report found a dose-response relationship between alcohol consumption and certain cancers.

However, epidemiological findings are not necessarily “clinically relevant,” commented Jennifer Ligibel, MD, a medical oncologist at the Dana-Farber Cancer Institute, Boston, Massachusetts, in a 2018 interview with Medscape Medical News.

Dr. Ligibel explained that there are 50 years of studies linking alcohol and cancers. “With the huge amount of data we have, even small differences [in consumption] are statistically significant.”

Dr. Ligibel cited an often-repeated statistic: for the average woman, there is a 12% lifetime risk of breast cancer. “If a woman consumes a drink a day, which is considered a low-level intake, that risk may become about 13% – which is statistically significant,” Dr. Ligibel explained.

But that risk increase is not clinically relevant, she added.

Mean 10 years of follow-up

The new study is the first to examine physical activity, drinking, and the 10 cancers that have been linked to alcohol consumption (oral cavity, throat, larynx, esophagus, liver, colorectal, stomach, breast, pancreas, and lung).

The authors used data from 10 British population-based health surveys from 1994-2008 and looked at adults aged 30 years and older. The mean follow-up period was 9.9 years.

Among 54,686 participants, there were 2039 alcohol-related site-specific cancer deaths.

Alcohol consumption categories were based on U.K. guidelines, with 1 unit equal to 8 grams (about 2 ounces) of pure alcohol. The categories were as follows: drinking within guidelines (<14 units/week for women, <21 units/week for men), hazardous level (14-35 units/week for women, 21-49 units/week for men), and harmful level (> 35 units/week for women, >49 units/week for men). The survey also queried participants about being ex-drinkers, occasional drinkers, and never drinkers.

Physical activity was assessed using self-reported accounts of the 4 weeks preceding the health survey and intensity of activity (light, moderate, or vigorous) was queried. Physical activity was categorized using the upper (15 MET-hours/week) and lower (the aforementioned <7 MET-hours/week) recommended limits.

The median age of participants was 51 years; 7.9% were never drinkers and 14.7% exceeded guideline amounts. For physical activity, 23% reported none. The median level of activity was 9 MET-hours/week.

The authors say that the “increased risks [among the harmful, hazardous, and ex-drinker categories] were eliminated” among the individuals who reported physical activity >7.5 MET-hours/week. That meant the hazard ratios for cancer mortality for each category were reduced to the point that they were no longer statistically significant.

For example, for all drinkers in the “hazardous” category, the risk of cancer-related mortality was significantly higher than for nondrinkers (with a hazard ratio of 1.39), but in the subgroup of these participants who were physically active at the lower recommended limit, the hazard ratio dropped to 1.21.

These “broad patterns of effect modification by physical activity persisted when the upper physical activity limit [15 MET-hours/week] was used,” write the authors.

The new study adds to the literature on cancer mortality and alcohol consumption. In another recent study, researchers looked at eight British cohorts and reported overall cancer mortality associated with alcohol consumption was eliminated among those meeting physical activity recommendations (Br J Sports Med. 2017;51:651-7). The new study added two more cohorts to this base of eight and only focused on cancers that have been linked to alcohol consumption. The earlier study included deaths from all types of cancer.

The refinement of focus in the current study is important, say Dr. Stamatakis and colleagues.

“This specificity adds biological plausibility and permits a more immediate translation of our findings into policy and practice,” they write. 

Dr. Stamatakis practices what he advocates, but is not a teetotaler.

“I exercise (e.g., dynamic yoga, HIIT cardio workouts, run, cycle, lift weights) for 45-60 minutes a day and I walk 8,000-14,000 steps daily. That would categorize me perhaps in the top 3%-5% for my age/sex group. And I enjoy 1-2 cans of craft beer a couple of times a week,” he said in an email.

Dr. Stamatakis and Dr. Patel have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Among adults who drink alcohol at relatively high amounts, regular weekly physical activity may reduce the mortality risk posed by alcohol-related cancers, concludes a new observational study involving 50,000-plus British adults.

Being physically active – for example, by walking, house cleaning, or playing a sport – could be promoted as a risk-minimization measure for alcohol-related cancers, say the authors, led by Emmanuel Stamatakis, PhD, professor of Physical Activity, Lifestyle, and Population Health, University of Sydney, Australia.

The researchers found a “strong direct association between alcohol consumption and mortality risk of [10] alcohol-related cancers.”

Specifically, when compared with never drinkers, there was a significantly higher risk of dying from such cancers among drinkers who consumed “hazardous” and “harmful” amounts of alcohol, and also for ex-drinkers.

Notably, occasional drinkers and drinkers within guidelines did not have statistically significantly higher risks for alcohol-related cancer mortality.

But the analysis also found that among the bigger drinkers, the risks were “substantially attenuated” in physically active participants who met at least the lower recommended limit of activity (>7.5 metabolic equivalent task [MET]–hours/week).

That’s not a taxing amount of activity because, for example, general household cleaning results in 3 METs/hour and walking slowly translates into 2 METs/hour. However, nearly a quarter of survey participants reported no physical activity.

The study was published online May 14 in the International Journal of Cancer.

The new results require confirmation because the findings “are limited in their statistical power,” with small numbers of cases in several categories, said Alpa Patel, PhD, an epidemiologist at the American Cancer Society, who was not involved in the study. For example, there were only 55 alcohol-related cancer deaths among the 1540 harmful drinkers.

Patel stressed that, “based on the collective evidence to date, it is best to both avoid alcohol consumption and engage in sufficient amounts of physical activity.” That amount is 150-300 minutes of moderate or 75-150 minutes of vigorous activity per week for cancer prevention.

Her message about abstinence is in-line with new ACS guidelines issued last month, as reported by Medscape Medical News. The ACS’s guidance was criticized by many readers in the comments section, who repeatedly encouraged “moderation.”

However, the ACS also recommended moderation, saying, for those adults who do drink, intake should be no more than 1 drink/day for women or 2 drinks/day for men. 

Study author Dr. Stamatakis commented on the alcohol debate.

“Any advice for complete abstinence is bound to alienate many people,” he told Medscape Medical News in an email. “Alcohol drinking has been an integral part of many societies for thousands of years.”

Dr. Stamatakis, who is an occasional beer drinker, also said, “there is no healthy level of alcohol drinking.”

This was also the conclusion of a 2018 study published in the Lancet, which stated that there is “no safe limit,” as even one drink a day increases the risk of cancer. A few years earlier, the 2014 World Cancer Report found a dose-response relationship between alcohol consumption and certain cancers.

However, epidemiological findings are not necessarily “clinically relevant,” commented Jennifer Ligibel, MD, a medical oncologist at the Dana-Farber Cancer Institute, Boston, Massachusetts, in a 2018 interview with Medscape Medical News.

Dr. Ligibel explained that there are 50 years of studies linking alcohol and cancers. “With the huge amount of data we have, even small differences [in consumption] are statistically significant.”

Dr. Ligibel cited an often-repeated statistic: for the average woman, there is a 12% lifetime risk of breast cancer. “If a woman consumes a drink a day, which is considered a low-level intake, that risk may become about 13% – which is statistically significant,” Dr. Ligibel explained.

But that risk increase is not clinically relevant, she added.

Mean 10 years of follow-up

The new study is the first to examine physical activity, drinking, and the 10 cancers that have been linked to alcohol consumption (oral cavity, throat, larynx, esophagus, liver, colorectal, stomach, breast, pancreas, and lung).

The authors used data from 10 British population-based health surveys from 1994-2008 and looked at adults aged 30 years and older. The mean follow-up period was 9.9 years.

Among 54,686 participants, there were 2039 alcohol-related site-specific cancer deaths.

Alcohol consumption categories were based on U.K. guidelines, with 1 unit equal to 8 grams (about 2 ounces) of pure alcohol. The categories were as follows: drinking within guidelines (<14 units/week for women, <21 units/week for men), hazardous level (14-35 units/week for women, 21-49 units/week for men), and harmful level (> 35 units/week for women, >49 units/week for men). The survey also queried participants about being ex-drinkers, occasional drinkers, and never drinkers.

Physical activity was assessed using self-reported accounts of the 4 weeks preceding the health survey and intensity of activity (light, moderate, or vigorous) was queried. Physical activity was categorized using the upper (15 MET-hours/week) and lower (the aforementioned <7 MET-hours/week) recommended limits.

The median age of participants was 51 years; 7.9% were never drinkers and 14.7% exceeded guideline amounts. For physical activity, 23% reported none. The median level of activity was 9 MET-hours/week.

The authors say that the “increased risks [among the harmful, hazardous, and ex-drinker categories] were eliminated” among the individuals who reported physical activity >7.5 MET-hours/week. That meant the hazard ratios for cancer mortality for each category were reduced to the point that they were no longer statistically significant.

For example, for all drinkers in the “hazardous” category, the risk of cancer-related mortality was significantly higher than for nondrinkers (with a hazard ratio of 1.39), but in the subgroup of these participants who were physically active at the lower recommended limit, the hazard ratio dropped to 1.21.

These “broad patterns of effect modification by physical activity persisted when the upper physical activity limit [15 MET-hours/week] was used,” write the authors.

The new study adds to the literature on cancer mortality and alcohol consumption. In another recent study, researchers looked at eight British cohorts and reported overall cancer mortality associated with alcohol consumption was eliminated among those meeting physical activity recommendations (Br J Sports Med. 2017;51:651-7). The new study added two more cohorts to this base of eight and only focused on cancers that have been linked to alcohol consumption. The earlier study included deaths from all types of cancer.

The refinement of focus in the current study is important, say Dr. Stamatakis and colleagues.

“This specificity adds biological plausibility and permits a more immediate translation of our findings into policy and practice,” they write. 

Dr. Stamatakis practices what he advocates, but is not a teetotaler.

“I exercise (e.g., dynamic yoga, HIIT cardio workouts, run, cycle, lift weights) for 45-60 minutes a day and I walk 8,000-14,000 steps daily. That would categorize me perhaps in the top 3%-5% for my age/sex group. And I enjoy 1-2 cans of craft beer a couple of times a week,” he said in an email.

Dr. Stamatakis and Dr. Patel have reported no relevant financial relationships.

This article first appeared on Medscape.com.

The COVID-19 literature has been peppered with reports about myocarditis accompanying the disease. If true, this could, in part, explain some of the observed cardiac injury and arrhythmias in seriously ill patients, but also have implications for prognosis.

But endomyocardial biopsies and autopsies, the gold-standard confirmation tests, have been few and far between. That has led some cardiologists to question the true rate of myocarditis with SARS-CoV-2, or even if there is definitive proof the virus causes myocarditis.

Predictors of death in COVID-19 are older age, cardiovascular comorbidities, and elevated troponin or NT-proBNP – none of which actually fit well with the epidemiology of myocarditis due to other causes, Alida L.P. Caforio, MD, of Padua (Italy) University said in an interview. Myocarditis is traditionally a disease of the young, and most cases are immune-mediated and do not release troponin.

Moreover, myocarditis is a diagnosis of exclusion. For it to be made with any certainty requires proof, by biopsy or autopsy, of inflammatory infiltrates within the myocardium with myocyte necrosis not typical of myocardial infarction, said Dr. Caforio, who chaired the European Society of Cardiology’s writing committee for its 2013 position statement on myocardial and pericardial diseases.

“We have one biopsy-proven case, and in this case there were no viruses in the myocardium, including COVID-19,” she said. “There’s no proof that we have COVID-19 causing myocarditis because it has not been found in the cardiomyocytes.”
 

Emerging evidence

The virus-negative case from Lombardy, Italy, followed an early case series suggesting fulminant myocarditis was involved in 7% of COVID-related deaths in Wuhan, China.

Other case reports include cardiac magnetic resonance (CMR) findings typical of acute myocarditis in a man with no lung involvement or fever but a massive troponin spike, and myocarditis presenting as reverse takotsubo syndrome in a woman undergoing CMR and endomyocardial biopsy.

A CMR analysis in May said acute myocarditis, by 2018 Lake Louise Criteria, was present in eight of 10 patients with “myocarditis-like syndrome,” and a study just out June 30 said the coronavirus can infect heart cells in a lab dish.

Among the few autopsy series, a preprint on 12 patients with COVID-19 in the Seattle area showed coronavirus in the heart tissue of 1 patient.

“It was a low level, so there’s the possibility that it could be viremia, but the fact we do see actual cardiomyocyte injury associated with inflammation, that’s a myocarditis pattern. So it could be related to the SARS-CoV-2 virus,” said Desiree Marshall, MD, director of autopsy and after-death services, University of Washington Medical Center, Seattle.

The “waters are a little bit muddy,” however, because the patient had a coinfection clinically with influenza and methicillin-susceptible Staphylococcus aureus, which raises the specter that influenza could also have contributed, she said.

Data pending publication from two additional patients show no coronavirus in the heart. Acute respiratory distress syndrome pathology was common in all patients, but there was no evidence of vascular inflammation, such as endotheliitis, Dr. Marshall said.

SARS-CoV-2 cell entry depends on the angiotensin-converting enzyme 2 (ACE2) receptor, which is widely expressed in the heart and on endothelial cells and is linked to inflammatory activation. Autopsy data from three COVID-19 patients showed endothelial cell infection in the heart and diffuse endothelial inflammation, but no sign of lymphocytic myocarditis.
 

Defining myocarditis

“There are some experts who believe we’re likely still dealing with myocarditis but with atypical features, while others suggest there is no myocarditis by strict classic criteria,” said Peter Liu, MD, chief scientific officer/vice president of research, University of Ottawa Heart Institute.

“I don’t think either extreme is accurate,” he said. “The truth is likely somewhere in between, with evidence of both cardiac injury and inflammation. But nothing in COVID-19, as we know today, is classic; it’s a new disease, so we need to be more open minded as new data emerge.”

Part of the divide may indeed stem from the way myocarditis is defined. “Based on traditional Dallas criteria, classic myocarditis requires evidence of myocyte necrosis, which we have, but also inflammatory cell infiltrate, which we don’t consistently have,” he said. “But on the other hand, there is evidence of inflammation-induced cardiac damage, often aggregated around blood vessels.”

The situation is evolving in recent days, and new data under review demonstrated inflammatory infiltrates, which fits the traditional myocarditis criteria, Dr. Liu noted. Yet the viral etiology for the inflammation is still elusive in definitive proof.

In traditional myocarditis, there is an abundance of lymphocytes and foci of inflammation in the myocardium, but COVID-19 is very unusual, in that these lymphocytes are not as exuberant, he said. Lymphopenia or low lymphocyte counts occur in up to 80% of patients. Also, older patients, who initially made up the bulk of the severe COVID-19 cases, are less T-lymphocyte responsive.

“So the lower your lymphocyte count, the worse your outcome is going to be and the more likely you’re going to get cytokine storm,” Dr. Liu said. “And that may be the reason the suspected myocarditis in COVID-19 is atypical because the lymphocytes, in fact, are being suppressed and there is instead more vasculitis.”

Recent data from myocardial gene expression analysis showed that the viral receptor ACE2 is present in the myocardium, and can be upregulated in conditions such as heart failure, he said. However, the highest ACE2 expression is found in pericytes around blood vessels, not myocytes. “This may explain the preferential vascular involvement often observed.”
 

Cardiac damage in the young

Evidence started evolving in early April that young COVID-19 patients without lung disease, generally in their 20s and 30s, can have very high troponin peaks and a form of cardiac damage that does not appear to be related to sepsis, systemic shock, or cytokine storm.

“That’s the group that I do think has some myocarditis, but it’s different. It’s not lymphocytic myocarditis, like enteroviral myocarditis,” Leslie T. Cooper Jr., MD, a myocarditis expert at Mayo Clinic, Jacksonville, Florida, said in an interview.

“The data to date suggest that most SARS cardiac injury is related to stress or high circulating cytokine levels. However, myocarditis probably does affect some patients, he added. “The few published cases suggest a role for macrophages or endothelial cells, which could affect cardiac myocyte function. This type of injury could cause the ST-segment elevation MI-like patterns we have seen in young people with normal epicardial coronary arteries.”

Dr. Cooper, who coauthored a report on the management of COVID-19 cardiovascular syndrome, pointed out that it’s been hard for researchers to isolate genome from autopsy samples because of RNA degradation prior to autopsy and the use of formalin fixation for tissues prior to RNA extraction.

“Most labs are not doing next-generation sequencing, and even with that, RNA protection and fresh tissue may be required to detect viral genome,” he said.
 

No proven therapy

Although up to 50% of acute myocarditis cases undergo spontaneous healing, recognition and multidisciplinary management of clinically suspected myocarditis is important. The optimal treatment remains unclear.

An early case report suggested use of methylprednisolone and intravenous immunoglobulin helped spare the life of a 37-year-old with clinically suspected fulminant myocarditis with cardiogenic shock.

In a related commentary, Dr. Caforio and colleagues pointed out that the World Health Organization considers the use of IV corticosteroids controversial, even in pneumonia due to COVID-19, because it may reduce viral clearance and increase sepsis risk. Intravenous immunoglobulin is also questionable because there is no IgG response to COVID-19 in the plasma donors’ pool.

“Immunosuppression should be reserved for only virus-negative non-COVID myocarditis,” Dr. Caforio said in an interview. “There is no appropriate treatment nowadays for clinically suspected COVID-19 myocarditis. There is no proven therapy for COVID-19, even less for COVID-19 myocarditis.”

Although definitive publication of the RECOVERY trial is still pending, the benefits of dexamethasone – a steroid that works predominantly through its anti-inflammatory effects – appear to be in the sickest patients, such as those requiring ICU admission or respiratory support.

“Many of the same patients would have systemic inflammation and would have also shown elevated cardiac biomarkers,” Dr. Liu observed. “Therefore, it is conceivable that a subset who had cardiac inflammation also benefited from the treatment. Further data, possibly through subgroup analysis and eventually meta-analysis, may help us to understand if dexamethasone also benefited patients with dominant cardiac injury.”

Dr. Caforio, Dr. Marshall, Dr. Liu, and Dr. Cooper reported having no relevant conflicts of interest.

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

The COVID-19 literature has been peppered with reports about myocarditis accompanying the disease. If true, this could, in part, explain some of the observed cardiac injury and arrhythmias in seriously ill patients, but also have implications for prognosis.

But endomyocardial biopsies and autopsies, the gold-standard confirmation tests, have been few and far between. That has led some cardiologists to question the true rate of myocarditis with SARS-CoV-2, or even if there is definitive proof the virus causes myocarditis.

Predictors of death in COVID-19 are older age, cardiovascular comorbidities, and elevated troponin or NT-proBNP – none of which actually fit well with the epidemiology of myocarditis due to other causes, Alida L.P. Caforio, MD, of Padua (Italy) University said in an interview. Myocarditis is traditionally a disease of the young, and most cases are immune-mediated and do not release troponin.

Moreover, myocarditis is a diagnosis of exclusion. For it to be made with any certainty requires proof, by biopsy or autopsy, of inflammatory infiltrates within the myocardium with myocyte necrosis not typical of myocardial infarction, said Dr. Caforio, who chaired the European Society of Cardiology’s writing committee for its 2013 position statement on myocardial and pericardial diseases.

“We have one biopsy-proven case, and in this case there were no viruses in the myocardium, including COVID-19,” she said. “There’s no proof that we have COVID-19 causing myocarditis because it has not been found in the cardiomyocytes.”
 

Emerging evidence

The virus-negative case from Lombardy, Italy, followed an early case series suggesting fulminant myocarditis was involved in 7% of COVID-related deaths in Wuhan, China.

Other case reports include cardiac magnetic resonance (CMR) findings typical of acute myocarditis in a man with no lung involvement or fever but a massive troponin spike, and myocarditis presenting as reverse takotsubo syndrome in a woman undergoing CMR and endomyocardial biopsy.

A CMR analysis in May said acute myocarditis, by 2018 Lake Louise Criteria, was present in eight of 10 patients with “myocarditis-like syndrome,” and a study just out June 30 said the coronavirus can infect heart cells in a lab dish.

Among the few autopsy series, a preprint on 12 patients with COVID-19 in the Seattle area showed coronavirus in the heart tissue of 1 patient.

“It was a low level, so there’s the possibility that it could be viremia, but the fact we do see actual cardiomyocyte injury associated with inflammation, that’s a myocarditis pattern. So it could be related to the SARS-CoV-2 virus,” said Desiree Marshall, MD, director of autopsy and after-death services, University of Washington Medical Center, Seattle.

The “waters are a little bit muddy,” however, because the patient had a coinfection clinically with influenza and methicillin-susceptible Staphylococcus aureus, which raises the specter that influenza could also have contributed, she said.

Data pending publication from two additional patients show no coronavirus in the heart. Acute respiratory distress syndrome pathology was common in all patients, but there was no evidence of vascular inflammation, such as endotheliitis, Dr. Marshall said.

SARS-CoV-2 cell entry depends on the angiotensin-converting enzyme 2 (ACE2) receptor, which is widely expressed in the heart and on endothelial cells and is linked to inflammatory activation. Autopsy data from three COVID-19 patients showed endothelial cell infection in the heart and diffuse endothelial inflammation, but no sign of lymphocytic myocarditis.
 

Defining myocarditis

“There are some experts who believe we’re likely still dealing with myocarditis but with atypical features, while others suggest there is no myocarditis by strict classic criteria,” said Peter Liu, MD, chief scientific officer/vice president of research, University of Ottawa Heart Institute.

“I don’t think either extreme is accurate,” he said. “The truth is likely somewhere in between, with evidence of both cardiac injury and inflammation. But nothing in COVID-19, as we know today, is classic; it’s a new disease, so we need to be more open minded as new data emerge.”

Part of the divide may indeed stem from the way myocarditis is defined. “Based on traditional Dallas criteria, classic myocarditis requires evidence of myocyte necrosis, which we have, but also inflammatory cell infiltrate, which we don’t consistently have,” he said. “But on the other hand, there is evidence of inflammation-induced cardiac damage, often aggregated around blood vessels.”

The situation is evolving in recent days, and new data under review demonstrated inflammatory infiltrates, which fits the traditional myocarditis criteria, Dr. Liu noted. Yet the viral etiology for the inflammation is still elusive in definitive proof.

In traditional myocarditis, there is an abundance of lymphocytes and foci of inflammation in the myocardium, but COVID-19 is very unusual, in that these lymphocytes are not as exuberant, he said. Lymphopenia or low lymphocyte counts occur in up to 80% of patients. Also, older patients, who initially made up the bulk of the severe COVID-19 cases, are less T-lymphocyte responsive.

“So the lower your lymphocyte count, the worse your outcome is going to be and the more likely you’re going to get cytokine storm,” Dr. Liu said. “And that may be the reason the suspected myocarditis in COVID-19 is atypical because the lymphocytes, in fact, are being suppressed and there is instead more vasculitis.”

Recent data from myocardial gene expression analysis showed that the viral receptor ACE2 is present in the myocardium, and can be upregulated in conditions such as heart failure, he said. However, the highest ACE2 expression is found in pericytes around blood vessels, not myocytes. “This may explain the preferential vascular involvement often observed.”
 

Cardiac damage in the young

Evidence started evolving in early April that young COVID-19 patients without lung disease, generally in their 20s and 30s, can have very high troponin peaks and a form of cardiac damage that does not appear to be related to sepsis, systemic shock, or cytokine storm.

“That’s the group that I do think has some myocarditis, but it’s different. It’s not lymphocytic myocarditis, like enteroviral myocarditis,” Leslie T. Cooper Jr., MD, a myocarditis expert at Mayo Clinic, Jacksonville, Florida, said in an interview.

“The data to date suggest that most SARS cardiac injury is related to stress or high circulating cytokine levels. However, myocarditis probably does affect some patients, he added. “The few published cases suggest a role for macrophages or endothelial cells, which could affect cardiac myocyte function. This type of injury could cause the ST-segment elevation MI-like patterns we have seen in young people with normal epicardial coronary arteries.”

Dr. Cooper, who coauthored a report on the management of COVID-19 cardiovascular syndrome, pointed out that it’s been hard for researchers to isolate genome from autopsy samples because of RNA degradation prior to autopsy and the use of formalin fixation for tissues prior to RNA extraction.

“Most labs are not doing next-generation sequencing, and even with that, RNA protection and fresh tissue may be required to detect viral genome,” he said.
 

No proven therapy

Although up to 50% of acute myocarditis cases undergo spontaneous healing, recognition and multidisciplinary management of clinically suspected myocarditis is important. The optimal treatment remains unclear.

An early case report suggested use of methylprednisolone and intravenous immunoglobulin helped spare the life of a 37-year-old with clinically suspected fulminant myocarditis with cardiogenic shock.

In a related commentary, Dr. Caforio and colleagues pointed out that the World Health Organization considers the use of IV corticosteroids controversial, even in pneumonia due to COVID-19, because it may reduce viral clearance and increase sepsis risk. Intravenous immunoglobulin is also questionable because there is no IgG response to COVID-19 in the plasma donors’ pool.

“Immunosuppression should be reserved for only virus-negative non-COVID myocarditis,” Dr. Caforio said in an interview. “There is no appropriate treatment nowadays for clinically suspected COVID-19 myocarditis. There is no proven therapy for COVID-19, even less for COVID-19 myocarditis.”

Although definitive publication of the RECOVERY trial is still pending, the benefits of dexamethasone – a steroid that works predominantly through its anti-inflammatory effects – appear to be in the sickest patients, such as those requiring ICU admission or respiratory support.

“Many of the same patients would have systemic inflammation and would have also shown elevated cardiac biomarkers,” Dr. Liu observed. “Therefore, it is conceivable that a subset who had cardiac inflammation also benefited from the treatment. Further data, possibly through subgroup analysis and eventually meta-analysis, may help us to understand if dexamethasone also benefited patients with dominant cardiac injury.”

Dr. Caforio, Dr. Marshall, Dr. Liu, and Dr. Cooper reported having no relevant conflicts of interest.

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

The COVID-19 literature has been peppered with reports about myocarditis accompanying the disease. If true, this could, in part, explain some of the observed cardiac injury and arrhythmias in seriously ill patients, but also have implications for prognosis.

But endomyocardial biopsies and autopsies, the gold-standard confirmation tests, have been few and far between. That has led some cardiologists to question the true rate of myocarditis with SARS-CoV-2, or even if there is definitive proof the virus causes myocarditis.

Predictors of death in COVID-19 are older age, cardiovascular comorbidities, and elevated troponin or NT-proBNP – none of which actually fit well with the epidemiology of myocarditis due to other causes, Alida L.P. Caforio, MD, of Padua (Italy) University said in an interview. Myocarditis is traditionally a disease of the young, and most cases are immune-mediated and do not release troponin.

Moreover, myocarditis is a diagnosis of exclusion. For it to be made with any certainty requires proof, by biopsy or autopsy, of inflammatory infiltrates within the myocardium with myocyte necrosis not typical of myocardial infarction, said Dr. Caforio, who chaired the European Society of Cardiology’s writing committee for its 2013 position statement on myocardial and pericardial diseases.

“We have one biopsy-proven case, and in this case there were no viruses in the myocardium, including COVID-19,” she said. “There’s no proof that we have COVID-19 causing myocarditis because it has not been found in the cardiomyocytes.”
 

Emerging evidence

The virus-negative case from Lombardy, Italy, followed an early case series suggesting fulminant myocarditis was involved in 7% of COVID-related deaths in Wuhan, China.

Other case reports include cardiac magnetic resonance (CMR) findings typical of acute myocarditis in a man with no lung involvement or fever but a massive troponin spike, and myocarditis presenting as reverse takotsubo syndrome in a woman undergoing CMR and endomyocardial biopsy.

A CMR analysis in May said acute myocarditis, by 2018 Lake Louise Criteria, was present in eight of 10 patients with “myocarditis-like syndrome,” and a study just out June 30 said the coronavirus can infect heart cells in a lab dish.

Among the few autopsy series, a preprint on 12 patients with COVID-19 in the Seattle area showed coronavirus in the heart tissue of 1 patient.

“It was a low level, so there’s the possibility that it could be viremia, but the fact we do see actual cardiomyocyte injury associated with inflammation, that’s a myocarditis pattern. So it could be related to the SARS-CoV-2 virus,” said Desiree Marshall, MD, director of autopsy and after-death services, University of Washington Medical Center, Seattle.

The “waters are a little bit muddy,” however, because the patient had a coinfection clinically with influenza and methicillin-susceptible Staphylococcus aureus, which raises the specter that influenza could also have contributed, she said.

Data pending publication from two additional patients show no coronavirus in the heart. Acute respiratory distress syndrome pathology was common in all patients, but there was no evidence of vascular inflammation, such as endotheliitis, Dr. Marshall said.

SARS-CoV-2 cell entry depends on the angiotensin-converting enzyme 2 (ACE2) receptor, which is widely expressed in the heart and on endothelial cells and is linked to inflammatory activation. Autopsy data from three COVID-19 patients showed endothelial cell infection in the heart and diffuse endothelial inflammation, but no sign of lymphocytic myocarditis.
 

Defining myocarditis

“There are some experts who believe we’re likely still dealing with myocarditis but with atypical features, while others suggest there is no myocarditis by strict classic criteria,” said Peter Liu, MD, chief scientific officer/vice president of research, University of Ottawa Heart Institute.

“I don’t think either extreme is accurate,” he said. “The truth is likely somewhere in between, with evidence of both cardiac injury and inflammation. But nothing in COVID-19, as we know today, is classic; it’s a new disease, so we need to be more open minded as new data emerge.”

Part of the divide may indeed stem from the way myocarditis is defined. “Based on traditional Dallas criteria, classic myocarditis requires evidence of myocyte necrosis, which we have, but also inflammatory cell infiltrate, which we don’t consistently have,” he said. “But on the other hand, there is evidence of inflammation-induced cardiac damage, often aggregated around blood vessels.”

The situation is evolving in recent days, and new data under review demonstrated inflammatory infiltrates, which fits the traditional myocarditis criteria, Dr. Liu noted. Yet the viral etiology for the inflammation is still elusive in definitive proof.

In traditional myocarditis, there is an abundance of lymphocytes and foci of inflammation in the myocardium, but COVID-19 is very unusual, in that these lymphocytes are not as exuberant, he said. Lymphopenia or low lymphocyte counts occur in up to 80% of patients. Also, older patients, who initially made up the bulk of the severe COVID-19 cases, are less T-lymphocyte responsive.

“So the lower your lymphocyte count, the worse your outcome is going to be and the more likely you’re going to get cytokine storm,” Dr. Liu said. “And that may be the reason the suspected myocarditis in COVID-19 is atypical because the lymphocytes, in fact, are being suppressed and there is instead more vasculitis.”

Recent data from myocardial gene expression analysis showed that the viral receptor ACE2 is present in the myocardium, and can be upregulated in conditions such as heart failure, he said. However, the highest ACE2 expression is found in pericytes around blood vessels, not myocytes. “This may explain the preferential vascular involvement often observed.”
 

Cardiac damage in the young

Evidence started evolving in early April that young COVID-19 patients without lung disease, generally in their 20s and 30s, can have very high troponin peaks and a form of cardiac damage that does not appear to be related to sepsis, systemic shock, or cytokine storm.

“That’s the group that I do think has some myocarditis, but it’s different. It’s not lymphocytic myocarditis, like enteroviral myocarditis,” Leslie T. Cooper Jr., MD, a myocarditis expert at Mayo Clinic, Jacksonville, Florida, said in an interview.

“The data to date suggest that most SARS cardiac injury is related to stress or high circulating cytokine levels. However, myocarditis probably does affect some patients, he added. “The few published cases suggest a role for macrophages or endothelial cells, which could affect cardiac myocyte function. This type of injury could cause the ST-segment elevation MI-like patterns we have seen in young people with normal epicardial coronary arteries.”

Dr. Cooper, who coauthored a report on the management of COVID-19 cardiovascular syndrome, pointed out that it’s been hard for researchers to isolate genome from autopsy samples because of RNA degradation prior to autopsy and the use of formalin fixation for tissues prior to RNA extraction.

“Most labs are not doing next-generation sequencing, and even with that, RNA protection and fresh tissue may be required to detect viral genome,” he said.
 

No proven therapy

Although up to 50% of acute myocarditis cases undergo spontaneous healing, recognition and multidisciplinary management of clinically suspected myocarditis is important. The optimal treatment remains unclear.

An early case report suggested use of methylprednisolone and intravenous immunoglobulin helped spare the life of a 37-year-old with clinically suspected fulminant myocarditis with cardiogenic shock.

In a related commentary, Dr. Caforio and colleagues pointed out that the World Health Organization considers the use of IV corticosteroids controversial, even in pneumonia due to COVID-19, because it may reduce viral clearance and increase sepsis risk. Intravenous immunoglobulin is also questionable because there is no IgG response to COVID-19 in the plasma donors’ pool.

“Immunosuppression should be reserved for only virus-negative non-COVID myocarditis,” Dr. Caforio said in an interview. “There is no appropriate treatment nowadays for clinically suspected COVID-19 myocarditis. There is no proven therapy for COVID-19, even less for COVID-19 myocarditis.”

Although definitive publication of the RECOVERY trial is still pending, the benefits of dexamethasone – a steroid that works predominantly through its anti-inflammatory effects – appear to be in the sickest patients, such as those requiring ICU admission or respiratory support.

“Many of the same patients would have systemic inflammation and would have also shown elevated cardiac biomarkers,” Dr. Liu observed. “Therefore, it is conceivable that a subset who had cardiac inflammation also benefited from the treatment. Further data, possibly through subgroup analysis and eventually meta-analysis, may help us to understand if dexamethasone also benefited patients with dominant cardiac injury.”

Dr. Caforio, Dr. Marshall, Dr. Liu, and Dr. Cooper reported having no relevant conflicts of interest.

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

Low to moderate alcohol consumption is associated with better cognitive function and slower cognitive decline in middle-aged and older adults, new research suggests. However, at least one expert urges caution in interpreting the findings.

Investigators found that consuming 10-14 alcoholic drinks per week had the strongest cognitive benefit. The findings “add more weight” to the growing body of research identifying beneficial cognitive effects of moderate alcohol consumption, said lead author, Ruiyuan Zhang, MD, of the department of epidemiology and biostatistics at the University of Georgia, Athens. However, Dr. Zhang emphasized that nondrinkers should not take up drinking to protect brain function, as alcohol can have negative effects.

The study was published online in JAMA Network Open.
 

Slower cognitive decline

The observational study was a secondary analysis of data from the Health and Retirement Study, a nationally representative U.S. survey of middle-aged and older adults. The survey, which began in 1992, is conducted every 2 years and collects health and economic data.

The current analysis used data from 1996 to 2008 and included information from individuals who participated in at least three surveys. The study included 19,887 participants, with a mean age 61.8 years. Most (60.1%) were women and white (85.2%). Mean follow-up was 9.1 years.

Researchers measured cognitive domains of mental status, word recall, and vocabulary. They also calculated a total cognition score, with higher scores indicating better cognitive abilities.

For each cognitive function measure, researchers categorized participants into a consistently low–trajectory group in which cognitive test scores from baseline through follow-up were consistently low or a consistently high–trajectory group, where cognitive test scores from baseline through follow-up were consistently high.

Based on self-reports, the investigators categorized participants as never drinkers (41.8%), former drinkers (39.5%), or current drinkers (18.7%). For current drinkers, researchers determined the number of drinking days per week and number of drinks per day. They further categorized these participants as low to moderate drinkers or heavy drinkers.

One drink was defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1.5-ounce shot of spirits, said Dr. Zhang.

Women who consumed 8 or more drinks per week and men who drank 15 or more drinks per week were considered heavy drinkers. Other current drinkers were deemed low to moderate drinkers. Most current drinkers (85.2%) were low to moderate drinkers.

Other covariates included age, sex, race/ethnicity, years of education, marital status, tobacco smoking status, and body mass index.

Results showed moderate drinking was associated with relatively high cognitive test scores. After controlling for all covariates, compared with never drinkers, current low to moderate drinkers were significantly less likely to have consistently low trajectories for total cognitive score (odds ratio, 0.66; 95% confidence interval, 0.59-0.74), mental status (OR, 0.71; 95% CI, 0.63-0.81), word recall (OR, 0.74; 95% CI, 0.69-0.80), and vocabulary (OR, 0.64; 95% CI, 0.56-0.74) (all P < .001).

Former drinkers also had better cognitive outcomes for all cognitive domains. Heavy drinkers had lower odds of being in the consistently low trajectory group only for the vocabulary test.
 

Heavy drinking ‘risky’

Because few participants were deemed to be heavy drinkers, the power to identify an association between heavy drinking and cognitive function was limited. Dr. Zhang acknowledged, though he noted that heavy drinking is “risky.”

“We found that, after the drinking dosage passes the moderate level, the risk of low cognitive function increases very fast, which indicates that heavy drinking may harm cognitive function.” Limiting alcohol consumption “is still very important,” he said.

The associations of alcohol and cognitive functions differed by race/ethnicity. Low to moderate drinking was significantly associated with a lower odds of having a consistently low trajectory for all four cognitive function measures only among white participants.

A possible reason for this is that the study had so few African Americans (who made up only 14.8% of the sample), which limited the ability to identify relationships between alcohol intake and cognitive function, said Dr. Zhang. “Another reason is that the sensitivity to alcohol may be different between white and African American subjects.”

There was a significant U-shaped association between weekly amounts of alcohol and the odds of being in the consistently low–trajectory group for all cognitive functions. Depending on the function tested, the optimal number of weekly drinks ranged from 10-14.

Dr. Zhang noted that, when women were examined separately, alcohol consumption had a significant U-shaped relationship only with word recall, with the optimal dosage being around eight drinks.
 

U-shaped relationship an ‘important finding’

The U-shaped relationship is “an important finding,” said Dr. Zhang. “It shows that the human body may act differently to low and high doses of alcohol. Knowing why and how this happens is very important as it would help us understand how alcohol affects the function of the human body.”

Sensitivity analyses among participants with no chronic diseases showed the U-shaped association was still significant for scores of total word recall and vocabulary, but not for mental status or total cognition score.

The authors noted that 77.2% of participants had at least one chronic disease. They maintained that the association between alcohol consumption and cognitive function may be applicable both to healthy people and to those with a chronic disease.

The study also found that low to moderate drinkers had slower rates of cognitive decline over time for all cognition domains.

Although the mechanisms underlying the cognitive benefits of alcohol consumption are unclear, the authors believe it may be via cerebrovascular and cardiovascular pathways.

Alcohol may increase levels of brain-derived neurotrophic factor, a key regulator of neuronal plasticity and development in the dorsal striatum, they noted.
 

Balancing act

However, there’s also evidence that drinking, especially heavy drinking, increases the risk of hypertension, stroke, liver damage, and some cancers. “We think the role of alcohol drinking in cognitive function may be a balance of its beneficial and harmful effects on the cardiovascular system,” said Dr. Zhang.

“For the low to moderate drinker, the beneficial effects may outweigh the harmful effects on the small blood vessels in the brain. In this way, it could preserve cognition,” he added.

Dr. Zhang also noted that the study focused on middle-aged and older adults. “We can’t say whether or not moderate alcohol could benefit younger people” because they may have different characteristics, he said.

The findings of other studies examining the effects of alcohol on cognitive function are mixed. While studies have identified a beneficial effect, others have uncovered no, minimal, or adverse effects. This could be due to the use of different tests of cognitive function or different study populations, said Dr. Zhang.

A limitation of the current study was that assessment of alcohol consumption was based on self-report, which might have introduced recall bias. In addition, because individuals tend to underestimate their alcohol consumption, heavy drinkers could be misclassified as low to moderate drinkers, and low to moderate drinkers as former drinkers.

“This may make our study underestimate the association between low to moderate drinking and cognitive function,” said Dr. Zhang. In addition, alcohol consumption tended to change with time, and this change may be associated with other factors that led to changes in cognitive function, the authors noted.
 

Interpret with caution

Commenting on the study, Brent P. Forester, MD, chief of the Center of Excellence in Geriatric Psychiatry at McLean Hospital in Belmont, Mass., associate professor of psychiatry at Harvard Medical School, Boston, and a member of the American Psychiatric Association Council on Geriatric Psychiatry, said he views the study with some trepidation.

“As a clinician taking care of older adults, I would be very cautious about overinterpreting the beneficial effects of alcohol before we understand the mechanism better,” he said.

He noted that all of the risk factors associated with heart attack and stroke are also risk factors for Alzheimer’s disease and cognitive decline more broadly. “One of the issues here is how in the world does alcohol reduce cardiovascular and cerebrovascular risks, if you know it increases the risk of hypertension and stroke, regardless of dose.”

With regard to the possible impact of alcohol on brain-derived neurotrophic factor, Dr. Forester said, “it’s an interesting idea” but the actual mechanism is still unclear.

Even with dietary studies, such as those on the Mediterranean diet that include red wine, showing cognitive benefit, Dr. Forester said he’s still concerned about the adverse effects of alcohol on older people. These can include falls and sleep disturbances in addition to cognitive issues, and these effects can increase with age.

He was somewhat surprised at the level of alcohol that the study determined was beneficial. “Essentially, what they’re saying here is that, for men, it’s two drinks a day.” This could be “problematic” as two drinks per day can quickly escalate as individuals build tolerance.

He also pointed out that the study does not determine cause and effect, noting that it’s only an association.

Dr. Forester said the study raises a number of questions, including the type of alcohol study participants consumed and whether this has any impact on cognitive benefit. He also questioned whether the mediating effects of alcohol were associated with something that wasn’t measured, such as socioeconomic status.

Another question, he said, is what factors in individuals’ medical or psychiatric history determine whether they are more or less likely to benefit from low to moderate alcohol intake.

Perhaps alcohol should be recommended only for “select subpopulations” – for example, those who are healthy and have a family history of cognitive decline –but not for those with a history of substance abuse, including alcohol abuse, said Dr. Forester.

“For this population, the last thing you want to do is recommend alcohol to reduce risk of cognitive decline,” he cautioned.

The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. The investigators and Dr. Forester have reported no relevant financial disclosures.

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

Low to moderate alcohol consumption is associated with better cognitive function and slower cognitive decline in middle-aged and older adults, new research suggests. However, at least one expert urges caution in interpreting the findings.

Investigators found that consuming 10-14 alcoholic drinks per week had the strongest cognitive benefit. The findings “add more weight” to the growing body of research identifying beneficial cognitive effects of moderate alcohol consumption, said lead author, Ruiyuan Zhang, MD, of the department of epidemiology and biostatistics at the University of Georgia, Athens. However, Dr. Zhang emphasized that nondrinkers should not take up drinking to protect brain function, as alcohol can have negative effects.

The study was published online in JAMA Network Open.
 

Slower cognitive decline

The observational study was a secondary analysis of data from the Health and Retirement Study, a nationally representative U.S. survey of middle-aged and older adults. The survey, which began in 1992, is conducted every 2 years and collects health and economic data.

The current analysis used data from 1996 to 2008 and included information from individuals who participated in at least three surveys. The study included 19,887 participants, with a mean age 61.8 years. Most (60.1%) were women and white (85.2%). Mean follow-up was 9.1 years.

Researchers measured cognitive domains of mental status, word recall, and vocabulary. They also calculated a total cognition score, with higher scores indicating better cognitive abilities.

For each cognitive function measure, researchers categorized participants into a consistently low–trajectory group in which cognitive test scores from baseline through follow-up were consistently low or a consistently high–trajectory group, where cognitive test scores from baseline through follow-up were consistently high.

Based on self-reports, the investigators categorized participants as never drinkers (41.8%), former drinkers (39.5%), or current drinkers (18.7%). For current drinkers, researchers determined the number of drinking days per week and number of drinks per day. They further categorized these participants as low to moderate drinkers or heavy drinkers.

One drink was defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1.5-ounce shot of spirits, said Dr. Zhang.

Women who consumed 8 or more drinks per week and men who drank 15 or more drinks per week were considered heavy drinkers. Other current drinkers were deemed low to moderate drinkers. Most current drinkers (85.2%) were low to moderate drinkers.

Other covariates included age, sex, race/ethnicity, years of education, marital status, tobacco smoking status, and body mass index.

Results showed moderate drinking was associated with relatively high cognitive test scores. After controlling for all covariates, compared with never drinkers, current low to moderate drinkers were significantly less likely to have consistently low trajectories for total cognitive score (odds ratio, 0.66; 95% confidence interval, 0.59-0.74), mental status (OR, 0.71; 95% CI, 0.63-0.81), word recall (OR, 0.74; 95% CI, 0.69-0.80), and vocabulary (OR, 0.64; 95% CI, 0.56-0.74) (all P < .001).

Former drinkers also had better cognitive outcomes for all cognitive domains. Heavy drinkers had lower odds of being in the consistently low trajectory group only for the vocabulary test.
 

Heavy drinking ‘risky’

Because few participants were deemed to be heavy drinkers, the power to identify an association between heavy drinking and cognitive function was limited. Dr. Zhang acknowledged, though he noted that heavy drinking is “risky.”

“We found that, after the drinking dosage passes the moderate level, the risk of low cognitive function increases very fast, which indicates that heavy drinking may harm cognitive function.” Limiting alcohol consumption “is still very important,” he said.

The associations of alcohol and cognitive functions differed by race/ethnicity. Low to moderate drinking was significantly associated with a lower odds of having a consistently low trajectory for all four cognitive function measures only among white participants.

A possible reason for this is that the study had so few African Americans (who made up only 14.8% of the sample), which limited the ability to identify relationships between alcohol intake and cognitive function, said Dr. Zhang. “Another reason is that the sensitivity to alcohol may be different between white and African American subjects.”

There was a significant U-shaped association between weekly amounts of alcohol and the odds of being in the consistently low–trajectory group for all cognitive functions. Depending on the function tested, the optimal number of weekly drinks ranged from 10-14.

Dr. Zhang noted that, when women were examined separately, alcohol consumption had a significant U-shaped relationship only with word recall, with the optimal dosage being around eight drinks.
 

U-shaped relationship an ‘important finding’

The U-shaped relationship is “an important finding,” said Dr. Zhang. “It shows that the human body may act differently to low and high doses of alcohol. Knowing why and how this happens is very important as it would help us understand how alcohol affects the function of the human body.”

Sensitivity analyses among participants with no chronic diseases showed the U-shaped association was still significant for scores of total word recall and vocabulary, but not for mental status or total cognition score.

The authors noted that 77.2% of participants had at least one chronic disease. They maintained that the association between alcohol consumption and cognitive function may be applicable both to healthy people and to those with a chronic disease.

The study also found that low to moderate drinkers had slower rates of cognitive decline over time for all cognition domains.

Although the mechanisms underlying the cognitive benefits of alcohol consumption are unclear, the authors believe it may be via cerebrovascular and cardiovascular pathways.

Alcohol may increase levels of brain-derived neurotrophic factor, a key regulator of neuronal plasticity and development in the dorsal striatum, they noted.
 

Balancing act

However, there’s also evidence that drinking, especially heavy drinking, increases the risk of hypertension, stroke, liver damage, and some cancers. “We think the role of alcohol drinking in cognitive function may be a balance of its beneficial and harmful effects on the cardiovascular system,” said Dr. Zhang.

“For the low to moderate drinker, the beneficial effects may outweigh the harmful effects on the small blood vessels in the brain. In this way, it could preserve cognition,” he added.

Dr. Zhang also noted that the study focused on middle-aged and older adults. “We can’t say whether or not moderate alcohol could benefit younger people” because they may have different characteristics, he said.

The findings of other studies examining the effects of alcohol on cognitive function are mixed. While studies have identified a beneficial effect, others have uncovered no, minimal, or adverse effects. This could be due to the use of different tests of cognitive function or different study populations, said Dr. Zhang.

A limitation of the current study was that assessment of alcohol consumption was based on self-report, which might have introduced recall bias. In addition, because individuals tend to underestimate their alcohol consumption, heavy drinkers could be misclassified as low to moderate drinkers, and low to moderate drinkers as former drinkers.

“This may make our study underestimate the association between low to moderate drinking and cognitive function,” said Dr. Zhang. In addition, alcohol consumption tended to change with time, and this change may be associated with other factors that led to changes in cognitive function, the authors noted.
 

Interpret with caution

Commenting on the study, Brent P. Forester, MD, chief of the Center of Excellence in Geriatric Psychiatry at McLean Hospital in Belmont, Mass., associate professor of psychiatry at Harvard Medical School, Boston, and a member of the American Psychiatric Association Council on Geriatric Psychiatry, said he views the study with some trepidation.

“As a clinician taking care of older adults, I would be very cautious about overinterpreting the beneficial effects of alcohol before we understand the mechanism better,” he said.

He noted that all of the risk factors associated with heart attack and stroke are also risk factors for Alzheimer’s disease and cognitive decline more broadly. “One of the issues here is how in the world does alcohol reduce cardiovascular and cerebrovascular risks, if you know it increases the risk of hypertension and stroke, regardless of dose.”

With regard to the possible impact of alcohol on brain-derived neurotrophic factor, Dr. Forester said, “it’s an interesting idea” but the actual mechanism is still unclear.

Even with dietary studies, such as those on the Mediterranean diet that include red wine, showing cognitive benefit, Dr. Forester said he’s still concerned about the adverse effects of alcohol on older people. These can include falls and sleep disturbances in addition to cognitive issues, and these effects can increase with age.

He was somewhat surprised at the level of alcohol that the study determined was beneficial. “Essentially, what they’re saying here is that, for men, it’s two drinks a day.” This could be “problematic” as two drinks per day can quickly escalate as individuals build tolerance.

He also pointed out that the study does not determine cause and effect, noting that it’s only an association.

Dr. Forester said the study raises a number of questions, including the type of alcohol study participants consumed and whether this has any impact on cognitive benefit. He also questioned whether the mediating effects of alcohol were associated with something that wasn’t measured, such as socioeconomic status.

Another question, he said, is what factors in individuals’ medical or psychiatric history determine whether they are more or less likely to benefit from low to moderate alcohol intake.

Perhaps alcohol should be recommended only for “select subpopulations” – for example, those who are healthy and have a family history of cognitive decline –but not for those with a history of substance abuse, including alcohol abuse, said Dr. Forester.

“For this population, the last thing you want to do is recommend alcohol to reduce risk of cognitive decline,” he cautioned.

The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. The investigators and Dr. Forester have reported no relevant financial disclosures.

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

Low to moderate alcohol consumption is associated with better cognitive function and slower cognitive decline in middle-aged and older adults, new research suggests. However, at least one expert urges caution in interpreting the findings.

Investigators found that consuming 10-14 alcoholic drinks per week had the strongest cognitive benefit. The findings “add more weight” to the growing body of research identifying beneficial cognitive effects of moderate alcohol consumption, said lead author, Ruiyuan Zhang, MD, of the department of epidemiology and biostatistics at the University of Georgia, Athens. However, Dr. Zhang emphasized that nondrinkers should not take up drinking to protect brain function, as alcohol can have negative effects.

The study was published online in JAMA Network Open.
 

Slower cognitive decline

The observational study was a secondary analysis of data from the Health and Retirement Study, a nationally representative U.S. survey of middle-aged and older adults. The survey, which began in 1992, is conducted every 2 years and collects health and economic data.

The current analysis used data from 1996 to 2008 and included information from individuals who participated in at least three surveys. The study included 19,887 participants, with a mean age 61.8 years. Most (60.1%) were women and white (85.2%). Mean follow-up was 9.1 years.

Researchers measured cognitive domains of mental status, word recall, and vocabulary. They also calculated a total cognition score, with higher scores indicating better cognitive abilities.

For each cognitive function measure, researchers categorized participants into a consistently low–trajectory group in which cognitive test scores from baseline through follow-up were consistently low or a consistently high–trajectory group, where cognitive test scores from baseline through follow-up were consistently high.

Based on self-reports, the investigators categorized participants as never drinkers (41.8%), former drinkers (39.5%), or current drinkers (18.7%). For current drinkers, researchers determined the number of drinking days per week and number of drinks per day. They further categorized these participants as low to moderate drinkers or heavy drinkers.

One drink was defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1.5-ounce shot of spirits, said Dr. Zhang.

Women who consumed 8 or more drinks per week and men who drank 15 or more drinks per week were considered heavy drinkers. Other current drinkers were deemed low to moderate drinkers. Most current drinkers (85.2%) were low to moderate drinkers.

Other covariates included age, sex, race/ethnicity, years of education, marital status, tobacco smoking status, and body mass index.

Results showed moderate drinking was associated with relatively high cognitive test scores. After controlling for all covariates, compared with never drinkers, current low to moderate drinkers were significantly less likely to have consistently low trajectories for total cognitive score (odds ratio, 0.66; 95% confidence interval, 0.59-0.74), mental status (OR, 0.71; 95% CI, 0.63-0.81), word recall (OR, 0.74; 95% CI, 0.69-0.80), and vocabulary (OR, 0.64; 95% CI, 0.56-0.74) (all P < .001).

Former drinkers also had better cognitive outcomes for all cognitive domains. Heavy drinkers had lower odds of being in the consistently low trajectory group only for the vocabulary test.
 

Heavy drinking ‘risky’

Because few participants were deemed to be heavy drinkers, the power to identify an association between heavy drinking and cognitive function was limited. Dr. Zhang acknowledged, though he noted that heavy drinking is “risky.”

“We found that, after the drinking dosage passes the moderate level, the risk of low cognitive function increases very fast, which indicates that heavy drinking may harm cognitive function.” Limiting alcohol consumption “is still very important,” he said.

The associations of alcohol and cognitive functions differed by race/ethnicity. Low to moderate drinking was significantly associated with a lower odds of having a consistently low trajectory for all four cognitive function measures only among white participants.

A possible reason for this is that the study had so few African Americans (who made up only 14.8% of the sample), which limited the ability to identify relationships between alcohol intake and cognitive function, said Dr. Zhang. “Another reason is that the sensitivity to alcohol may be different between white and African American subjects.”

There was a significant U-shaped association between weekly amounts of alcohol and the odds of being in the consistently low–trajectory group for all cognitive functions. Depending on the function tested, the optimal number of weekly drinks ranged from 10-14.

Dr. Zhang noted that, when women were examined separately, alcohol consumption had a significant U-shaped relationship only with word recall, with the optimal dosage being around eight drinks.
 

U-shaped relationship an ‘important finding’

The U-shaped relationship is “an important finding,” said Dr. Zhang. “It shows that the human body may act differently to low and high doses of alcohol. Knowing why and how this happens is very important as it would help us understand how alcohol affects the function of the human body.”

Sensitivity analyses among participants with no chronic diseases showed the U-shaped association was still significant for scores of total word recall and vocabulary, but not for mental status or total cognition score.

The authors noted that 77.2% of participants had at least one chronic disease. They maintained that the association between alcohol consumption and cognitive function may be applicable both to healthy people and to those with a chronic disease.

The study also found that low to moderate drinkers had slower rates of cognitive decline over time for all cognition domains.

Although the mechanisms underlying the cognitive benefits of alcohol consumption are unclear, the authors believe it may be via cerebrovascular and cardiovascular pathways.

Alcohol may increase levels of brain-derived neurotrophic factor, a key regulator of neuronal plasticity and development in the dorsal striatum, they noted.
 

Balancing act

However, there’s also evidence that drinking, especially heavy drinking, increases the risk of hypertension, stroke, liver damage, and some cancers. “We think the role of alcohol drinking in cognitive function may be a balance of its beneficial and harmful effects on the cardiovascular system,” said Dr. Zhang.

“For the low to moderate drinker, the beneficial effects may outweigh the harmful effects on the small blood vessels in the brain. In this way, it could preserve cognition,” he added.

Dr. Zhang also noted that the study focused on middle-aged and older adults. “We can’t say whether or not moderate alcohol could benefit younger people” because they may have different characteristics, he said.

The findings of other studies examining the effects of alcohol on cognitive function are mixed. While studies have identified a beneficial effect, others have uncovered no, minimal, or adverse effects. This could be due to the use of different tests of cognitive function or different study populations, said Dr. Zhang.

A limitation of the current study was that assessment of alcohol consumption was based on self-report, which might have introduced recall bias. In addition, because individuals tend to underestimate their alcohol consumption, heavy drinkers could be misclassified as low to moderate drinkers, and low to moderate drinkers as former drinkers.

“This may make our study underestimate the association between low to moderate drinking and cognitive function,” said Dr. Zhang. In addition, alcohol consumption tended to change with time, and this change may be associated with other factors that led to changes in cognitive function, the authors noted.
 

Interpret with caution

Commenting on the study, Brent P. Forester, MD, chief of the Center of Excellence in Geriatric Psychiatry at McLean Hospital in Belmont, Mass., associate professor of psychiatry at Harvard Medical School, Boston, and a member of the American Psychiatric Association Council on Geriatric Psychiatry, said he views the study with some trepidation.

“As a clinician taking care of older adults, I would be very cautious about overinterpreting the beneficial effects of alcohol before we understand the mechanism better,” he said.

He noted that all of the risk factors associated with heart attack and stroke are also risk factors for Alzheimer’s disease and cognitive decline more broadly. “One of the issues here is how in the world does alcohol reduce cardiovascular and cerebrovascular risks, if you know it increases the risk of hypertension and stroke, regardless of dose.”

With regard to the possible impact of alcohol on brain-derived neurotrophic factor, Dr. Forester said, “it’s an interesting idea” but the actual mechanism is still unclear.

Even with dietary studies, such as those on the Mediterranean diet that include red wine, showing cognitive benefit, Dr. Forester said he’s still concerned about the adverse effects of alcohol on older people. These can include falls and sleep disturbances in addition to cognitive issues, and these effects can increase with age.

He was somewhat surprised at the level of alcohol that the study determined was beneficial. “Essentially, what they’re saying here is that, for men, it’s two drinks a day.” This could be “problematic” as two drinks per day can quickly escalate as individuals build tolerance.

He also pointed out that the study does not determine cause and effect, noting that it’s only an association.

Dr. Forester said the study raises a number of questions, including the type of alcohol study participants consumed and whether this has any impact on cognitive benefit. He also questioned whether the mediating effects of alcohol were associated with something that wasn’t measured, such as socioeconomic status.

Another question, he said, is what factors in individuals’ medical or psychiatric history determine whether they are more or less likely to benefit from low to moderate alcohol intake.

Perhaps alcohol should be recommended only for “select subpopulations” – for example, those who are healthy and have a family history of cognitive decline –but not for those with a history of substance abuse, including alcohol abuse, said Dr. Forester.

“For this population, the last thing you want to do is recommend alcohol to reduce risk of cognitive decline,” he cautioned.

The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. The investigators and Dr. Forester have reported no relevant financial disclosures.

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

During a family medicine rotation at Oregon Health & Sciences University, Portland, third-year medical students are preparing for a patient visit. Only, instead of entering a clinic room, students sit down at a computer. The patient they’re virtually examining – a 42-year-old male cattle rancher with knee problems – is an actor.

He asks for an MRI. A student explains that kneecap pain calls for rehab rather than a scan. The patient pushes back. “It would ease my mind,” he says. “I really need to make sure I can keep the ranch running.” The student must now try to digitally maintain rapport while explaining why imaging isn’t necessary.

When COVID-19 hit, telehealth training and remote learning became major parts of medical education, seemingly overnight. Since the start of the pandemic, students have contended with canceled classes, missed rotations, and revised training timelines, even as the demand for new doctors grows ever more pressing.

Institutions have been forced to rethink how to best establish solid, long-term foundations to ensure that young doctors are adequately trained. “They may find themselves the only doctors to be practicing in a small town,” said Stephen G. Post, PhD, bioethicist and professor at Stony Brook (N.Y.) University. “They have to be ready.”

With limited hands-on access to patients, students must learn in ways most never have before. Medical schools are now test-driving a mix of new and reimagined teaching strategies that aim to produce doctors who will enter medicine just as prepared as their more seasoned peers.

Hands-off education

Soon after starting her pediatrics rotation in March, recent Stanford (Calif.) University graduate Paloma Marin-Nevarez, MD, heard that children were being admitted to her hospital for evaluation to rule out COVID-19. Dr. Marin-Nevarez was assigned to help care for them but never physically met any – an approach called “virtual rounding.”

In virtual rounding, a provider typically goes in, examines a patient, and uses a portable device such as an iPad to send video or take notes about the encounter. Students or others in another room then give input on the patient’s care. “It was bizarre doing rounds on patients I had not met yet, discussing their treatment plans in one of the team rooms,” Dr. Marin-Nevarez said. “There was something very eerie about passing that particular unit that said: ‘Do not enter,’ and never being able to go inside.”

Within weeks, the Association of American Medical Colleges advised medical schools to suspend any activities – including clinical rotations – that involved direct student contact with patients, even those who weren’t COVID-19 positive.

Many schools hope to have students back and participating in some degree of patient care at non–COVID-19 hospital wards as early as July 1, said Michael Gisondi, MD, vice chair of education at Stanford’s department of emergency medicine. Returning students must now adapt to a restricted training environment, often while scrambling to make up training time. “This is uncharted territory for medical schools. Elective cases are down, surgical cases are down. That’s potentially going to decrease exposure to training opportunities.”

When students come back, lectures are still likely to remain on hold at most schools, replaced by Zoom conferences and virtual presentations. That’s not completely new: A trend away from large, traditional classes predated the pandemic. In a 2017-2018 AAMC survey, one in four second-year medical students said they almost never went to in-person lectures. COVID-19 has accelerated this shift.

For faculty who have long emphasized hands-on, in-person learning, the shift presents “a whole pedagogical issue – you don’t necessarily know how to adjust your practices to an online format,” Dr. Gisondi said. Instructors have to be even more flexible in order to engage students. “Every week I ask the students: ‘What’s working? What’s not working?’ ” Dr. Gisondi said about his online classes. “We have to solicit feedback.”

Changes to lectures are the easy part, says Elisabeth Fassas, a second-year student at the University of Maryland, Baltimore County. Before the pandemic, she was taking a clinical medicine course that involved time in the hospital, something that helped link the academic with the practical. “You really get to see the stuff you’re learning being relevant: ‘Here’s a patient who has a cardiology problem,’ ” she said. “[Capturing] that piece of connection to what you’re working toward is going to be tricky, I think.”

Some students who graduated this past spring worry about that clinical time they lost. Many remain acutely conscious of specific knowledge gaps. “I did not get a ton of experience examining crying children or holding babies,” said Dr. Marin-Nevarez, who starts an emergency medicine residency this year. “I am going to have to be transparent with my future instructors and let them know I missed out because of the pandemic.”

Such knowledge gaps mean new doctors will have to make up ground, said Jeremiah Tao, MD, who trains ophthalmology residents at the University of California, Irvine. But Dr. Tao doesn’t see these setbacks as a major long-term problem. His residents are already starting to make up the patient hours they missed in the spring and are refining the skills that got short shrift earlier on. For eligibility, “most boards require a certain number of days of experience. But most of the message from our board is [that] they’re understanding, and they’re going to leave it to the program directors to declare someone competent.”

Robert Johnson, MD, dean of New Jersey Medical School, Newark, said short-term setbacks in training likely won’t translate into longer-term skill deficits. “What most schools have done is overprepare students. We’re sure they have acquired all the skills they need to practice.”

Closing the gaps

To fill existing knowledge gaps and prevent future deficits, institutions hope to strike a balance between keeping trainees safe and providing necessary on-site learning. In line with ongoing AAMC recommendations, which suggest schools curtail student involvement in direct patient care in areas with significant COVID-19 spread, virtual rounding will likely continue.

Many schools may use a hybrid approach, in which students take turns entering patient rooms to perform checkups or observations while other students and instructors watch a video broadcast. “It’s not that different from when I go into the room and supervise a trainee,” Dr. Gisondi said.

Some schools are going even further, transforming education in ways that reflect the demands of a COVID-19–era medical marketplace. Institutions such as Weill Cornell Medicine, New York, and OHSU have invested in telemedicine training for years, but COVID-19 has given telehealth education an additional boost. These types of visits have surged dramatically, underscoring the importance of preparing new doctors to practice in a virtual setting – something that wasn’t common previously. In a 2019 survey, only about a quarter of sampled medical schools offered a telemedicine curriculum.

Simulated telehealth consults such as OHSU’s knee-pain scenario serve several purposes, says Ryan Palmer, EdD, associate dean of education at Northeast Ohio Universities, Rootstown. They virtually teach skills that students need – such as clearly explaining to patients why a care plan is called for – while allowing the trainees to practice forging an emotional connection with patients they are treating remotely.

“It’s less about how you use a specific system,” said Dr. Palmer, who developed OHSU’s TeleOSCE, a telehealth training system that has interested other schools. He sees this as an opportunity, inasmuch as telemedicine is likely to remain an important part of practice for the foreseeable future.

To that end, the AAMC recently hosted an online seminar to help faculty with telehealth instruction. But training such as this can only go so far, said Dr. Johnson. “There are techniques you do have to learn at the patient’s side.”

Dr. Johnson says that a traditional part of medical school at Rutgers has been having students spend time in general practitioners’ offices early on to see what the experience is like. “That’s going to be a problem – I expect many primary care practices will go out of business. Those types of shadowing experiences will probably go away. They may be replaced by experiences at larger clinics.”

Some learning in clinics may soon resume. Although fears about COVID-19 still loom large, Dr. Tao’s ophthalmology residents have started taking on something closer to a normal workload, thanks to patients returning for regular office visits. As people return to medical facilities in larger numbers, hospitals around the country have started separating patients with COVID-19 from others. Dr. Gisondi suggested that this means medical students may be able to circulate in non–COVID-19 wards, provided the institution has enough personal protective equipment. “The inpatient wards are really safe – there’s a low risk of transmission. That’s where core rotations occur.”

The road ahead

In settings where patients’ viral status remains uncertain, such as emergency wards and off-site clinics without rapid testing, in-person learning may be slower to resume. That’s where longer-term changes may come into play. Some schools are preparing digital learning platforms that have the potential to transform medical education.

For example, Haru Okuda, MD, an emergency medicine doctor and director of the Center for Advanced Medical Learning and Simulation at the University of South Florida, Tampa, is testing a new virtual-reality platform called Immertec. Dr. Okuda said that, unlike older teaching tools, the system is not a stale, static virtual environment that will become obsolete. Instead, it uses a live camera to visually teleport students into the space of a real clinic or operating room.

“Let’s say you have students learning gross anatomy, how to dissect the chest. You’d have a cadaver on the table, demonstrating anatomy. The student has a headset – you can see like you’re in the room.” The wraparound visual device allows students to watch surgical maneuvers close up or view additional input from devices such as laparoscopes.

Dr. Okuda acknowledges that educators don’t yet know whether this works as well as older, hands-on methods. As yet, no virtual reality system has touch-based sensors sophisticated enough to simulate even skills such as tying a basic surgical knot, Dr. Gisondi said. And immersive platforms are expensive, which means a gap may occur between schools that can afford them and those that can’t.

The long-term consequences of COVID-19 go beyond costs that institutions may have to bear. Some students are concerned that the pandemic is affecting their mental well-being in ways that may make training a tougher slog. A few students graduated early to serve on the COVID-19 front lines. Others, rather than planning trips to celebrate the gap between medical school and residency, watched from home as young doctors they knew worked under abusive and unsafe conditions.

“Many of us felt powerless, given what we saw happening around us,” said recent University of Michigan, Ann Arbor, graduate Marina Haque, MD. She thinks those feelings, along with the rigors of practicing medicine during a pandemic, may leave her and her colleagues more prone to burnout.

The pandemic has also had a galvanizing effect on students – some excited new doctors are eager to line up for duty on COVID-19 wards. But supervisors say they must weigh young doctors’ desire to serve against the possible risks. “You don’t want people who have a big future ahead of them rushing into these situations and getting severely ill,” said Dr. Post. “There is a balance.”

All these changes, temporary or lasting, have led many to question whether doctors who complete their training under the cloud of the pandemic will be more – or less – prepared than those who came before them. But it’s not really a question of better or worse, says Dr. Johnson, who stresses that medical education has always required flexibility.

“You come into medicine with a plan in mind, but things happen,” he said. He reflected on the HIV pandemic of the late 1980s and early 1990s that influenced his medical career. He hopes young doctors come through the COVID-19 crucible more seasoned, resilient, and confident in crisis situations. “This is a pivotal event in their lives, and it will shape many careers.”

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