Pediatric News

The U.S. Surgeon General says 13 years old is too young to begin using social media.

Most social media platforms including TikTok, Snapchat, Instagram, and Facebook allow users to create accounts if they say they are at least 13 years old.

“I, personally, based on the data I’ve seen, believe that 13 is too early. ... It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships, and the skewed and often distorted environment of social media often does a disservice to many of those children,” U.S. Surgeon General Vivek Murthy, MD, told CNN.

Research has shown that teens are susceptible to cyberbullying and serious mental health impacts from social media usage and online activity during an era when the influence of the Internet has become everywhere for young people.

According to the Pew Research Center, 95% of teens age 13 and up have a smartphone, and 97% of teens say they use the Internet daily. Among 13- and 14-year-olds, 61% say they use TikTok and 51% say they use Snapchat. Older teens ages 15-17 use those social media platforms at higher rates, with 71% saying they use TikTok and 65% using Snapchat.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” Dr. Murthy said.

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

The U.S. Surgeon General says 13 years old is too young to begin using social media.

Most social media platforms including TikTok, Snapchat, Instagram, and Facebook allow users to create accounts if they say they are at least 13 years old.

“I, personally, based on the data I’ve seen, believe that 13 is too early. ... It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships, and the skewed and often distorted environment of social media often does a disservice to many of those children,” U.S. Surgeon General Vivek Murthy, MD, told CNN.

Research has shown that teens are susceptible to cyberbullying and serious mental health impacts from social media usage and online activity during an era when the influence of the Internet has become everywhere for young people.

According to the Pew Research Center, 95% of teens age 13 and up have a smartphone, and 97% of teens say they use the Internet daily. Among 13- and 14-year-olds, 61% say they use TikTok and 51% say they use Snapchat. Older teens ages 15-17 use those social media platforms at higher rates, with 71% saying they use TikTok and 65% using Snapchat.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” Dr. Murthy said.

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

The U.S. Surgeon General says 13 years old is too young to begin using social media.

Most social media platforms including TikTok, Snapchat, Instagram, and Facebook allow users to create accounts if they say they are at least 13 years old.

“I, personally, based on the data I’ve seen, believe that 13 is too early. ... It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships, and the skewed and often distorted environment of social media often does a disservice to many of those children,” U.S. Surgeon General Vivek Murthy, MD, told CNN.

Research has shown that teens are susceptible to cyberbullying and serious mental health impacts from social media usage and online activity during an era when the influence of the Internet has become everywhere for young people.

According to the Pew Research Center, 95% of teens age 13 and up have a smartphone, and 97% of teens say they use the Internet daily. Among 13- and 14-year-olds, 61% say they use TikTok and 51% say they use Snapchat. Older teens ages 15-17 use those social media platforms at higher rates, with 71% saying they use TikTok and 65% using Snapchat.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” Dr. Murthy said.

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

Adhering to six healthy lifestyle behaviors is linked to slower memory decline in older adults, a large population-based study suggests.

Investigators found that a healthy diet, cognitive activity, regular physical exercise, not smoking, and abstaining from alcohol were significantly linked to slowed cognitive decline irrespective of APOE4 status.

After adjusting for health and socioeconomic factors, investigators found that each individual healthy behavior was associated with a slower-than-average decline in memory over a decade. A healthy diet emerged as the strongest deterrent, followed by cognitive activity and physical exercise.

“A healthy lifestyle is associated with slower memory decline, even in the presence of the APOE4 allele,” study investigators led by Jianping Jia, MD, PhD, of the Innovation Center for Neurological Disorders and the department of neurology, Xuan Wu Hospital, Capital Medical University, Beijing, write.

“This study might offer important information to protect older adults against memory decline,” they add.

The study was published online in the BMJ.
 

Preventing memory decline

Memory “continuously declines as people age,” but age-related memory decline is not necessarily a prodrome of dementia and can “merely be senescent forgetfulness,” the investigators note. This can be “reversed or [can] become stable,” instead of progressing to a pathologic state.

Factors affecting memory include aging, APOE4 genotype, chronic diseases, and lifestyle patterns, with lifestyle “receiving increasing attention as a modifiable behavior.”

Nevertheless, few studies have focused on the impact of lifestyle on memory, and those that have are mostly cross-sectional and also “did not consider the interaction between a healthy lifestyle and genetic risk,” the researchers note.

To investigate, the researchers conducted a longitudinal study, known as the China Cognition and Aging Study, that considered genetic risk as well as lifestyle factors.

The study began in 2009 and concluded in 2019. Participants were evaluated and underwent neuropsychological testing in 2012, 2014, 2016, and at the study’s conclusion.

Participants (n = 29,072; mean [SD] age, 72.23 [6.61] years; 48.54% women; 20.43% APOE4 carriers) were required to have normal cognitive function at baseline. Data on those whose condition progressed to mild cognitive impairment (MCI) or dementia during the follow-up period were excluded after their diagnosis.

The Mini–Mental State Examination was used to assess global cognitive function. Memory function was assessed using the World Health Organization/University of California, Los Angeles Auditory Verbal Learning Test.

“Lifestyle” consisted of six modifiable factors: physical exercise (weekly frequency and total time), smoking (current, former, or never-smokers), alcohol consumption (never drank, drank occasionally, low to excess drinking, and heavy drinking), diet (daily intake of 12 food items: fruits, vegetables, fish, meat, dairy products, salt, oil, eggs, cereals, legumes, nuts, tea), cognitive activity (writing, reading, playing cards, mahjong, other games), and social contact (participating in meetings, attending parties, visiting friends/relatives, traveling, chatting online).

Participants’ lifestyles were scored on the basis of the number of healthy factors they engaged in.

Important for public health

During the 10-year period, 7,164 participants died, and 3,567 stopped participating.

Participants in the favorable and average groups showed slower memory decline per increased year of age (0.007 [0.005-0.009], P < .001; and 0.002 [0 .000-0.003], P = .033 points higher, respectively), compared with those in the unfavorable group.

Healthy diet had the strongest protective effect on memory.

‘Important, encouraging’ research

In a comment, Severine Sabia, PhD, a senior researcher at the Université Paris Cité, INSERM Institut National de la Santé et de la Recherche Medicalé, France, called the findings “important and encouraging.”

However, said Dr. Sabia, who was not involved with the study, “there remain important research questions that need to be investigated in order to identify key behaviors: which combination, the cutoff of risk, and when to intervene.”

Future research on prevention “should examine a wider range of possible risk factors” and should also “identify specific exposures associated with the greatest risk, while also considering the risk threshold and age at exposure for each one.”

In an accompanying editorial, Dr. Sabia and co-author Archana Singh-Manoux, PhD, note that the risk of cognitive decline and dementia are probably determined by multiple factors.

They liken it to the “multifactorial risk paradigm introduced by the Framingham study,” which has “led to a substantial reduction in cardiovascular disease.” A similar approach could be used with dementia prevention, they suggest.

The authors received support from the Xuanwu Hospital of Capital Medical University for the submitted work. One of the authors received a grant from the French National Research Agency. The other authors have disclosed no relevant financial relationships. Dr. Sabia received grant funding from the French National Research Agency. Dr. Singh-Manoux received grants from the National Institute on Aging of the National Institutes of Health.

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

Adhering to six healthy lifestyle behaviors is linked to slower memory decline in older adults, a large population-based study suggests.

Investigators found that a healthy diet, cognitive activity, regular physical exercise, not smoking, and abstaining from alcohol were significantly linked to slowed cognitive decline irrespective of APOE4 status.

After adjusting for health and socioeconomic factors, investigators found that each individual healthy behavior was associated with a slower-than-average decline in memory over a decade. A healthy diet emerged as the strongest deterrent, followed by cognitive activity and physical exercise.

“A healthy lifestyle is associated with slower memory decline, even in the presence of the APOE4 allele,” study investigators led by Jianping Jia, MD, PhD, of the Innovation Center for Neurological Disorders and the department of neurology, Xuan Wu Hospital, Capital Medical University, Beijing, write.

“This study might offer important information to protect older adults against memory decline,” they add.

The study was published online in the BMJ.
 

Preventing memory decline

Memory “continuously declines as people age,” but age-related memory decline is not necessarily a prodrome of dementia and can “merely be senescent forgetfulness,” the investigators note. This can be “reversed or [can] become stable,” instead of progressing to a pathologic state.

Factors affecting memory include aging, APOE4 genotype, chronic diseases, and lifestyle patterns, with lifestyle “receiving increasing attention as a modifiable behavior.”

Nevertheless, few studies have focused on the impact of lifestyle on memory, and those that have are mostly cross-sectional and also “did not consider the interaction between a healthy lifestyle and genetic risk,” the researchers note.

To investigate, the researchers conducted a longitudinal study, known as the China Cognition and Aging Study, that considered genetic risk as well as lifestyle factors.

The study began in 2009 and concluded in 2019. Participants were evaluated and underwent neuropsychological testing in 2012, 2014, 2016, and at the study’s conclusion.

Participants (n = 29,072; mean [SD] age, 72.23 [6.61] years; 48.54% women; 20.43% APOE4 carriers) were required to have normal cognitive function at baseline. Data on those whose condition progressed to mild cognitive impairment (MCI) or dementia during the follow-up period were excluded after their diagnosis.

The Mini–Mental State Examination was used to assess global cognitive function. Memory function was assessed using the World Health Organization/University of California, Los Angeles Auditory Verbal Learning Test.

“Lifestyle” consisted of six modifiable factors: physical exercise (weekly frequency and total time), smoking (current, former, or never-smokers), alcohol consumption (never drank, drank occasionally, low to excess drinking, and heavy drinking), diet (daily intake of 12 food items: fruits, vegetables, fish, meat, dairy products, salt, oil, eggs, cereals, legumes, nuts, tea), cognitive activity (writing, reading, playing cards, mahjong, other games), and social contact (participating in meetings, attending parties, visiting friends/relatives, traveling, chatting online).

Participants’ lifestyles were scored on the basis of the number of healthy factors they engaged in.

Important for public health

During the 10-year period, 7,164 participants died, and 3,567 stopped participating.

Participants in the favorable and average groups showed slower memory decline per increased year of age (0.007 [0.005-0.009], P < .001; and 0.002 [0 .000-0.003], P = .033 points higher, respectively), compared with those in the unfavorable group.

Healthy diet had the strongest protective effect on memory.

‘Important, encouraging’ research

In a comment, Severine Sabia, PhD, a senior researcher at the Université Paris Cité, INSERM Institut National de la Santé et de la Recherche Medicalé, France, called the findings “important and encouraging.”

However, said Dr. Sabia, who was not involved with the study, “there remain important research questions that need to be investigated in order to identify key behaviors: which combination, the cutoff of risk, and when to intervene.”

Future research on prevention “should examine a wider range of possible risk factors” and should also “identify specific exposures associated with the greatest risk, while also considering the risk threshold and age at exposure for each one.”

In an accompanying editorial, Dr. Sabia and co-author Archana Singh-Manoux, PhD, note that the risk of cognitive decline and dementia are probably determined by multiple factors.

They liken it to the “multifactorial risk paradigm introduced by the Framingham study,” which has “led to a substantial reduction in cardiovascular disease.” A similar approach could be used with dementia prevention, they suggest.

The authors received support from the Xuanwu Hospital of Capital Medical University for the submitted work. One of the authors received a grant from the French National Research Agency. The other authors have disclosed no relevant financial relationships. Dr. Sabia received grant funding from the French National Research Agency. Dr. Singh-Manoux received grants from the National Institute on Aging of the National Institutes of Health.

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

Adhering to six healthy lifestyle behaviors is linked to slower memory decline in older adults, a large population-based study suggests.

Investigators found that a healthy diet, cognitive activity, regular physical exercise, not smoking, and abstaining from alcohol were significantly linked to slowed cognitive decline irrespective of APOE4 status.

After adjusting for health and socioeconomic factors, investigators found that each individual healthy behavior was associated with a slower-than-average decline in memory over a decade. A healthy diet emerged as the strongest deterrent, followed by cognitive activity and physical exercise.

“A healthy lifestyle is associated with slower memory decline, even in the presence of the APOE4 allele,” study investigators led by Jianping Jia, MD, PhD, of the Innovation Center for Neurological Disorders and the department of neurology, Xuan Wu Hospital, Capital Medical University, Beijing, write.

“This study might offer important information to protect older adults against memory decline,” they add.

The study was published online in the BMJ.
 

Preventing memory decline

Memory “continuously declines as people age,” but age-related memory decline is not necessarily a prodrome of dementia and can “merely be senescent forgetfulness,” the investigators note. This can be “reversed or [can] become stable,” instead of progressing to a pathologic state.

Factors affecting memory include aging, APOE4 genotype, chronic diseases, and lifestyle patterns, with lifestyle “receiving increasing attention as a modifiable behavior.”

Nevertheless, few studies have focused on the impact of lifestyle on memory, and those that have are mostly cross-sectional and also “did not consider the interaction between a healthy lifestyle and genetic risk,” the researchers note.

To investigate, the researchers conducted a longitudinal study, known as the China Cognition and Aging Study, that considered genetic risk as well as lifestyle factors.

The study began in 2009 and concluded in 2019. Participants were evaluated and underwent neuropsychological testing in 2012, 2014, 2016, and at the study’s conclusion.

Participants (n = 29,072; mean [SD] age, 72.23 [6.61] years; 48.54% women; 20.43% APOE4 carriers) were required to have normal cognitive function at baseline. Data on those whose condition progressed to mild cognitive impairment (MCI) or dementia during the follow-up period were excluded after their diagnosis.

The Mini–Mental State Examination was used to assess global cognitive function. Memory function was assessed using the World Health Organization/University of California, Los Angeles Auditory Verbal Learning Test.

“Lifestyle” consisted of six modifiable factors: physical exercise (weekly frequency and total time), smoking (current, former, or never-smokers), alcohol consumption (never drank, drank occasionally, low to excess drinking, and heavy drinking), diet (daily intake of 12 food items: fruits, vegetables, fish, meat, dairy products, salt, oil, eggs, cereals, legumes, nuts, tea), cognitive activity (writing, reading, playing cards, mahjong, other games), and social contact (participating in meetings, attending parties, visiting friends/relatives, traveling, chatting online).

Participants’ lifestyles were scored on the basis of the number of healthy factors they engaged in.

Important for public health

During the 10-year period, 7,164 participants died, and 3,567 stopped participating.

Participants in the favorable and average groups showed slower memory decline per increased year of age (0.007 [0.005-0.009], P < .001; and 0.002 [0 .000-0.003], P = .033 points higher, respectively), compared with those in the unfavorable group.

Healthy diet had the strongest protective effect on memory.

‘Important, encouraging’ research

In a comment, Severine Sabia, PhD, a senior researcher at the Université Paris Cité, INSERM Institut National de la Santé et de la Recherche Medicalé, France, called the findings “important and encouraging.”

However, said Dr. Sabia, who was not involved with the study, “there remain important research questions that need to be investigated in order to identify key behaviors: which combination, the cutoff of risk, and when to intervene.”

Future research on prevention “should examine a wider range of possible risk factors” and should also “identify specific exposures associated with the greatest risk, while also considering the risk threshold and age at exposure for each one.”

In an accompanying editorial, Dr. Sabia and co-author Archana Singh-Manoux, PhD, note that the risk of cognitive decline and dementia are probably determined by multiple factors.

They liken it to the “multifactorial risk paradigm introduced by the Framingham study,” which has “led to a substantial reduction in cardiovascular disease.” A similar approach could be used with dementia prevention, they suggest.

The authors received support from the Xuanwu Hospital of Capital Medical University for the submitted work. One of the authors received a grant from the French National Research Agency. The other authors have disclosed no relevant financial relationships. Dr. Sabia received grant funding from the French National Research Agency. Dr. Singh-Manoux received grants from the National Institute on Aging of the National Institutes of Health.

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

Sustaining even a single head injury has been linked to a significantly increased risk of all-cause mortality in new research.

An analysis of more than 13,000 adult participants in the Atherosclerosis Risk in Communities (ARIC) study showed a dose-response pattern in which one head injury was linked to a 66% increased risk for all-cause mortality, and two or more head injuries were associated with twice the risk in comparison with no head injuries.

These findings underscore the importance of preventing head injuries and of swift clinical intervention once a head injury occurs, lead author Holly Elser, MD, PhD, department of neurology, Hospital of the University of Pennsylvania, Philadelphia, told this news organization.

“Clinicians should counsel patients who are at risk for falls about head injuries and ensure patients are promptly evaluated in the hospital setting if they do have a fall – especially with loss of consciousness or other symptoms, such as headache or dizziness,” Dr. Elser added.

The findings were published online in JAMA Neurology.
 

Consistent evidence

There is “pretty consistent evidence” that mortality rates are increased in the short term after head injury, predominantly among hospitalized patients, Dr. Elser noted.

“But there’s less evidence about the long-term mortality implications of head injuries and less evidence from adults living in the community,” she added.

The analysis included 13,037 participants in the ARIC study, an ongoing study involving adults aged 45-65 years who were recruited from four geographically and racially diverse U.S. communities. The mean age at baseline (1987-1989) was 54 years; 57.7% were women; and 27.9% were Black.

Study participants are followed at routine in-person visits and semiannually via telephone.

Data on head injuries came from hospital diagnostic codes and self-reports. These reports included information on the number of injuries and whether the injury required medical care and involved loss of consciousness.

During the 27-year follow-up, 18.4% of the study sample had at least one head injury. Injuries occurred more frequently among women, which may reflect the predominance of women in the study population, said Dr. Elser.

Overall, about 56% of participants died during the study period. The estimated median amount of survival time after head injury was 4.7 years.

The most common causes of death were neoplasm, cardiovascular disease, and neurologic disorders. Regarding specific neurologic causes of death, the researchers found that 62.2% of deaths were due to neurodegenerative disease among individuals with head injury, vs. 51.4% among those without head injury.

This, said Dr. Elser, raises the possibility of reverse causality. “If you have a neurodegenerative disorder like Alzheimer’s disease dementia or Parkinson’s disease that leads to difficulty walking, you may be more likely to fall and have a head injury. The head injury in turn may lead to increased mortality,” she noted.

However, she stressed that the data on cause-specific mortality are exploratory. “Our research motivates future studies that really examine this time-dependent relationship between neurodegenerative disease and head injuries,” Dr. Elser said.
 

Dose-dependent response

In the unadjusted analysis, the hazard ratio of mortality among individuals with head injury was 2.21 (95% confidence interval, 2.09-2.34) compared with those who did not have head injury.

The association remained significant with adjustment for sociodemographic factors (HR, 1.99; 95% CI, 1.88-2.11) and with additional adjustment for vascular risk factors (HR, 1.92; 95% CI, 1.81-2.03).

The findings also showed a dose-response pattern in the association of head injuries with mortality. Compared with participants who did not have head injury, the HR was 1.66 (95% CI, 1.56-1.77) for those with one head injury and 2.11 (95% CI, 1.89-2.37) for those with two or more head injuries.

“It’s not as though once you’ve had one head injury, you’ve accrued all the damage you possibly can. We see pretty clearly here that recurrent head injury further increased the rate of deaths from all causes,” said Dr. Elser.

Injury severity was determined from hospital diagnostic codes using established algorithms. Results showed that mortality rates were increased with even mild head injury.

Interestingly, the association between head injury and all-cause mortality was weaker among those whose injuries were self-reported. One possibility is that these injuries were less severe, Dr. Elser noted.

“If you have head injury that’s mild enough that you don’t need to go to the hospital, it’s probably going to confer less long-term health risks than one that’s severe enough that you needed to be examined in an acute care setting,” she said.

Results were similar by race and for sex. “Even though there were more women with head injuries, the rate of mortality associated with head injury doesn’t differ from the rate among men,” Dr. Elser reported.

However, the association was stronger among those younger than 54 years at baseline (HR, 2.26) compared with older individuals (HR, 2.0) in the model that adjusted for demographics and lifestyle factors.

This may be explained by the reference group (those without a head injury) – the mortality rate was in general higher for the older participants, said Dr. Elser. It could also be that younger adults are more likely to have severe head injuries from, for example, motor vehicle accidents or violence, she added.

These new findings underscore the importance of public health measures, such as seatbelt laws, to reduce head injuries, the investigators note.

They add that clinicians with patients at risk for head injuries may recommend steps to lessen the risk of falls, such as having access to durable medical equipment, and ensuring driver safety.
 

Shorter life span

Commenting for this news organization, Frank Conidi, MD, director of the Florida Center for Headache and Sports Neurology in Port St. Lucie and past president of the Florida Society of Neurology, said the large number of participants “adds validity” to the finding that individuals with head injury are likely to have a shorter life span than those who do not suffer head trauma – and that this “was not purely by chance or from other causes.”

However, patients may not have accurately reported head injuries, in which case the rate of injury in the self-report subgroup would not reflect the actual incidence, noted Dr. Conidi, who was not involved with the research.

“In my practice, most patients have little knowledge as to the signs and symptoms of concussion and traumatic brain injury. Most think there needs to be some form of loss of consciousness to have a head injury, which is of course not true,” he said.

Dr. Conidi added that the finding of a higher incidence of death from neurodegenerative disorders supports the generally accepted consensus view that about 30% of patients with traumatic brain injury experience progression of symptoms and are at risk for early dementia.

The ARIC study is supported by the National Heart, Lung, and Blood Institute. Dr. Elser and Dr. Conidi have reported no relevant financial relationships.

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

Sustaining even a single head injury has been linked to a significantly increased risk of all-cause mortality in new research.

An analysis of more than 13,000 adult participants in the Atherosclerosis Risk in Communities (ARIC) study showed a dose-response pattern in which one head injury was linked to a 66% increased risk for all-cause mortality, and two or more head injuries were associated with twice the risk in comparison with no head injuries.

These findings underscore the importance of preventing head injuries and of swift clinical intervention once a head injury occurs, lead author Holly Elser, MD, PhD, department of neurology, Hospital of the University of Pennsylvania, Philadelphia, told this news organization.

“Clinicians should counsel patients who are at risk for falls about head injuries and ensure patients are promptly evaluated in the hospital setting if they do have a fall – especially with loss of consciousness or other symptoms, such as headache or dizziness,” Dr. Elser added.

The findings were published online in JAMA Neurology.
 

Consistent evidence

There is “pretty consistent evidence” that mortality rates are increased in the short term after head injury, predominantly among hospitalized patients, Dr. Elser noted.

“But there’s less evidence about the long-term mortality implications of head injuries and less evidence from adults living in the community,” she added.

The analysis included 13,037 participants in the ARIC study, an ongoing study involving adults aged 45-65 years who were recruited from four geographically and racially diverse U.S. communities. The mean age at baseline (1987-1989) was 54 years; 57.7% were women; and 27.9% were Black.

Study participants are followed at routine in-person visits and semiannually via telephone.

Data on head injuries came from hospital diagnostic codes and self-reports. These reports included information on the number of injuries and whether the injury required medical care and involved loss of consciousness.

During the 27-year follow-up, 18.4% of the study sample had at least one head injury. Injuries occurred more frequently among women, which may reflect the predominance of women in the study population, said Dr. Elser.

Overall, about 56% of participants died during the study period. The estimated median amount of survival time after head injury was 4.7 years.

The most common causes of death were neoplasm, cardiovascular disease, and neurologic disorders. Regarding specific neurologic causes of death, the researchers found that 62.2% of deaths were due to neurodegenerative disease among individuals with head injury, vs. 51.4% among those without head injury.

This, said Dr. Elser, raises the possibility of reverse causality. “If you have a neurodegenerative disorder like Alzheimer’s disease dementia or Parkinson’s disease that leads to difficulty walking, you may be more likely to fall and have a head injury. The head injury in turn may lead to increased mortality,” she noted.

However, she stressed that the data on cause-specific mortality are exploratory. “Our research motivates future studies that really examine this time-dependent relationship between neurodegenerative disease and head injuries,” Dr. Elser said.
 

Dose-dependent response

In the unadjusted analysis, the hazard ratio of mortality among individuals with head injury was 2.21 (95% confidence interval, 2.09-2.34) compared with those who did not have head injury.

The association remained significant with adjustment for sociodemographic factors (HR, 1.99; 95% CI, 1.88-2.11) and with additional adjustment for vascular risk factors (HR, 1.92; 95% CI, 1.81-2.03).

The findings also showed a dose-response pattern in the association of head injuries with mortality. Compared with participants who did not have head injury, the HR was 1.66 (95% CI, 1.56-1.77) for those with one head injury and 2.11 (95% CI, 1.89-2.37) for those with two or more head injuries.

“It’s not as though once you’ve had one head injury, you’ve accrued all the damage you possibly can. We see pretty clearly here that recurrent head injury further increased the rate of deaths from all causes,” said Dr. Elser.

Injury severity was determined from hospital diagnostic codes using established algorithms. Results showed that mortality rates were increased with even mild head injury.

Interestingly, the association between head injury and all-cause mortality was weaker among those whose injuries were self-reported. One possibility is that these injuries were less severe, Dr. Elser noted.

“If you have head injury that’s mild enough that you don’t need to go to the hospital, it’s probably going to confer less long-term health risks than one that’s severe enough that you needed to be examined in an acute care setting,” she said.

Results were similar by race and for sex. “Even though there were more women with head injuries, the rate of mortality associated with head injury doesn’t differ from the rate among men,” Dr. Elser reported.

However, the association was stronger among those younger than 54 years at baseline (HR, 2.26) compared with older individuals (HR, 2.0) in the model that adjusted for demographics and lifestyle factors.

This may be explained by the reference group (those without a head injury) – the mortality rate was in general higher for the older participants, said Dr. Elser. It could also be that younger adults are more likely to have severe head injuries from, for example, motor vehicle accidents or violence, she added.

These new findings underscore the importance of public health measures, such as seatbelt laws, to reduce head injuries, the investigators note.

They add that clinicians with patients at risk for head injuries may recommend steps to lessen the risk of falls, such as having access to durable medical equipment, and ensuring driver safety.
 

Shorter life span

Commenting for this news organization, Frank Conidi, MD, director of the Florida Center for Headache and Sports Neurology in Port St. Lucie and past president of the Florida Society of Neurology, said the large number of participants “adds validity” to the finding that individuals with head injury are likely to have a shorter life span than those who do not suffer head trauma – and that this “was not purely by chance or from other causes.”

However, patients may not have accurately reported head injuries, in which case the rate of injury in the self-report subgroup would not reflect the actual incidence, noted Dr. Conidi, who was not involved with the research.

“In my practice, most patients have little knowledge as to the signs and symptoms of concussion and traumatic brain injury. Most think there needs to be some form of loss of consciousness to have a head injury, which is of course not true,” he said.

Dr. Conidi added that the finding of a higher incidence of death from neurodegenerative disorders supports the generally accepted consensus view that about 30% of patients with traumatic brain injury experience progression of symptoms and are at risk for early dementia.

The ARIC study is supported by the National Heart, Lung, and Blood Institute. Dr. Elser and Dr. Conidi have reported no relevant financial relationships.

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

Sustaining even a single head injury has been linked to a significantly increased risk of all-cause mortality in new research.

An analysis of more than 13,000 adult participants in the Atherosclerosis Risk in Communities (ARIC) study showed a dose-response pattern in which one head injury was linked to a 66% increased risk for all-cause mortality, and two or more head injuries were associated with twice the risk in comparison with no head injuries.

These findings underscore the importance of preventing head injuries and of swift clinical intervention once a head injury occurs, lead author Holly Elser, MD, PhD, department of neurology, Hospital of the University of Pennsylvania, Philadelphia, told this news organization.

“Clinicians should counsel patients who are at risk for falls about head injuries and ensure patients are promptly evaluated in the hospital setting if they do have a fall – especially with loss of consciousness or other symptoms, such as headache or dizziness,” Dr. Elser added.

The findings were published online in JAMA Neurology.
 

Consistent evidence

There is “pretty consistent evidence” that mortality rates are increased in the short term after head injury, predominantly among hospitalized patients, Dr. Elser noted.

“But there’s less evidence about the long-term mortality implications of head injuries and less evidence from adults living in the community,” she added.

The analysis included 13,037 participants in the ARIC study, an ongoing study involving adults aged 45-65 years who were recruited from four geographically and racially diverse U.S. communities. The mean age at baseline (1987-1989) was 54 years; 57.7% were women; and 27.9% were Black.

Study participants are followed at routine in-person visits and semiannually via telephone.

Data on head injuries came from hospital diagnostic codes and self-reports. These reports included information on the number of injuries and whether the injury required medical care and involved loss of consciousness.

During the 27-year follow-up, 18.4% of the study sample had at least one head injury. Injuries occurred more frequently among women, which may reflect the predominance of women in the study population, said Dr. Elser.

Overall, about 56% of participants died during the study period. The estimated median amount of survival time after head injury was 4.7 years.

The most common causes of death were neoplasm, cardiovascular disease, and neurologic disorders. Regarding specific neurologic causes of death, the researchers found that 62.2% of deaths were due to neurodegenerative disease among individuals with head injury, vs. 51.4% among those without head injury.

This, said Dr. Elser, raises the possibility of reverse causality. “If you have a neurodegenerative disorder like Alzheimer’s disease dementia or Parkinson’s disease that leads to difficulty walking, you may be more likely to fall and have a head injury. The head injury in turn may lead to increased mortality,” she noted.

However, she stressed that the data on cause-specific mortality are exploratory. “Our research motivates future studies that really examine this time-dependent relationship between neurodegenerative disease and head injuries,” Dr. Elser said.
 

Dose-dependent response

In the unadjusted analysis, the hazard ratio of mortality among individuals with head injury was 2.21 (95% confidence interval, 2.09-2.34) compared with those who did not have head injury.

The association remained significant with adjustment for sociodemographic factors (HR, 1.99; 95% CI, 1.88-2.11) and with additional adjustment for vascular risk factors (HR, 1.92; 95% CI, 1.81-2.03).

The findings also showed a dose-response pattern in the association of head injuries with mortality. Compared with participants who did not have head injury, the HR was 1.66 (95% CI, 1.56-1.77) for those with one head injury and 2.11 (95% CI, 1.89-2.37) for those with two or more head injuries.

“It’s not as though once you’ve had one head injury, you’ve accrued all the damage you possibly can. We see pretty clearly here that recurrent head injury further increased the rate of deaths from all causes,” said Dr. Elser.

Injury severity was determined from hospital diagnostic codes using established algorithms. Results showed that mortality rates were increased with even mild head injury.

Interestingly, the association between head injury and all-cause mortality was weaker among those whose injuries were self-reported. One possibility is that these injuries were less severe, Dr. Elser noted.

“If you have head injury that’s mild enough that you don’t need to go to the hospital, it’s probably going to confer less long-term health risks than one that’s severe enough that you needed to be examined in an acute care setting,” she said.

Results were similar by race and for sex. “Even though there were more women with head injuries, the rate of mortality associated with head injury doesn’t differ from the rate among men,” Dr. Elser reported.

However, the association was stronger among those younger than 54 years at baseline (HR, 2.26) compared with older individuals (HR, 2.0) in the model that adjusted for demographics and lifestyle factors.

This may be explained by the reference group (those without a head injury) – the mortality rate was in general higher for the older participants, said Dr. Elser. It could also be that younger adults are more likely to have severe head injuries from, for example, motor vehicle accidents or violence, she added.

These new findings underscore the importance of public health measures, such as seatbelt laws, to reduce head injuries, the investigators note.

They add that clinicians with patients at risk for head injuries may recommend steps to lessen the risk of falls, such as having access to durable medical equipment, and ensuring driver safety.
 

Shorter life span

Commenting for this news organization, Frank Conidi, MD, director of the Florida Center for Headache and Sports Neurology in Port St. Lucie and past president of the Florida Society of Neurology, said the large number of participants “adds validity” to the finding that individuals with head injury are likely to have a shorter life span than those who do not suffer head trauma – and that this “was not purely by chance or from other causes.”

However, patients may not have accurately reported head injuries, in which case the rate of injury in the self-report subgroup would not reflect the actual incidence, noted Dr. Conidi, who was not involved with the research.

“In my practice, most patients have little knowledge as to the signs and symptoms of concussion and traumatic brain injury. Most think there needs to be some form of loss of consciousness to have a head injury, which is of course not true,” he said.

Dr. Conidi added that the finding of a higher incidence of death from neurodegenerative disorders supports the generally accepted consensus view that about 30% of patients with traumatic brain injury experience progression of symptoms and are at risk for early dementia.

The ARIC study is supported by the National Heart, Lung, and Blood Institute. Dr. Elser and Dr. Conidi have reported no relevant financial relationships.

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

Almost 36% of students and faculty at George Washington University with a history of COVID-19 reported symptoms consistent with long COVID in a new study.

With a median age of 23 years, the study is unique for evaluating mostly healthy, young adults and for its rare look at long COVID in a university community. 

The more symptoms during a bout with COVID, the greater the risk for long COVID, the researchers found. That lines up with previous studies. Also, the more vaccinations and booster shots against SARS-CoV-2, the virus that causes COVID, the lower the long COVID risk.

Women were more likely than men to be affected. Current or prior smoking, seeking medical care for COVID, and receiving antibody treatment also were linked to higher chances for developing long COVID. 

Lead author Megan Landry, DrPH, MPH, and colleagues were already assessing students, staff, and faculty at George Washington University, Washington, who tested positive for COVID. Then they started seeing symptoms that lasted 28 days or more after their 10-day isolation period. 

“We were starting to recognize that individuals ... were still having symptoms longer than the typical isolation period,” said Dr. Landry. So they developed a questionnaire to figure out the how long these symptoms last and how many people are affected by them. 

The list of potential symptoms was long and included trouble thinking, fatigue, loss of smell or taste, shortness of breath, and more. 

The study was published online in Emerging Infectious Diseases. Results are based on records and responses from 1,388 students, faculty, and staff from July 2021 to March 2022.

People had a median of four long COVID symptoms, about 63% were women, and 56% were non-Hispanic White. About three-quarters were students and the remainder were faculty and staff. 

The finding that 36% of people with a history of COVID reported long COVID symptoms did not surprise Dr. Landry.

“Based on the literature that’s currently out there, it ranges from a 10% to an 80% prevalence of long COVID,” she said. “We kind of figured that we would fall somewhere in there.”

In contrast, that figure seemed high to Eric Topol, MD.

“That’s really high,” said Dr. Topol, founder and director of the Scripps Research Translational Institute in La Jolla, Calif. He added most studies estimate that about 10% of people with a history of acute infection develop long COVID. 

Even at 10%, which could be an underestimate, that’s a lot of affected people globally. 

“At least 65 million individuals around the world have long COVID, based on a conservative estimated incidence of 10% of infected people and more than 651 million documented COVID-19 cases worldwide; the number is likely much higher due to many undocumented cases,” Dr. Topol and colleagues wrote in a long COVID review article published in Nature Reviews Microbiology.

Research continues

“Long COVID is still evolving and we continue to learn more about it every day,” Landry said. “It’s just so new and there are still a lot of unknowns. That’s why it’s important to get this information out.” 

People with long COVID often have a hard time with occupational, educational, social, or personal activities, compared with before COVID, with effects that can last for more than 6 months, the authors noted. 

“I think across the board, universities in general need to consider the possibility of folks on their campuses are having symptoms of long COVID,” Dr. Landry said.

Moving forward, Dr. Landry and colleagues would like to continue investigating long COVID. For example, in the current study, they did not ask about severity of symptoms or how the symptoms affected daily functioning. 

“I would like to continue this and dive deeper into how disruptive their symptoms of long COVID are to their everyday studying, teaching, or their activities to keeping a university running,” Dr. Landry said.

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

Almost 36% of students and faculty at George Washington University with a history of COVID-19 reported symptoms consistent with long COVID in a new study.

With a median age of 23 years, the study is unique for evaluating mostly healthy, young adults and for its rare look at long COVID in a university community. 

The more symptoms during a bout with COVID, the greater the risk for long COVID, the researchers found. That lines up with previous studies. Also, the more vaccinations and booster shots against SARS-CoV-2, the virus that causes COVID, the lower the long COVID risk.

Women were more likely than men to be affected. Current or prior smoking, seeking medical care for COVID, and receiving antibody treatment also were linked to higher chances for developing long COVID. 

Lead author Megan Landry, DrPH, MPH, and colleagues were already assessing students, staff, and faculty at George Washington University, Washington, who tested positive for COVID. Then they started seeing symptoms that lasted 28 days or more after their 10-day isolation period. 

“We were starting to recognize that individuals ... were still having symptoms longer than the typical isolation period,” said Dr. Landry. So they developed a questionnaire to figure out the how long these symptoms last and how many people are affected by them. 

The list of potential symptoms was long and included trouble thinking, fatigue, loss of smell or taste, shortness of breath, and more. 

The study was published online in Emerging Infectious Diseases. Results are based on records and responses from 1,388 students, faculty, and staff from July 2021 to March 2022.

People had a median of four long COVID symptoms, about 63% were women, and 56% were non-Hispanic White. About three-quarters were students and the remainder were faculty and staff. 

The finding that 36% of people with a history of COVID reported long COVID symptoms did not surprise Dr. Landry.

“Based on the literature that’s currently out there, it ranges from a 10% to an 80% prevalence of long COVID,” she said. “We kind of figured that we would fall somewhere in there.”

In contrast, that figure seemed high to Eric Topol, MD.

“That’s really high,” said Dr. Topol, founder and director of the Scripps Research Translational Institute in La Jolla, Calif. He added most studies estimate that about 10% of people with a history of acute infection develop long COVID. 

Even at 10%, which could be an underestimate, that’s a lot of affected people globally. 

“At least 65 million individuals around the world have long COVID, based on a conservative estimated incidence of 10% of infected people and more than 651 million documented COVID-19 cases worldwide; the number is likely much higher due to many undocumented cases,” Dr. Topol and colleagues wrote in a long COVID review article published in Nature Reviews Microbiology.

Research continues

“Long COVID is still evolving and we continue to learn more about it every day,” Landry said. “It’s just so new and there are still a lot of unknowns. That’s why it’s important to get this information out.” 

People with long COVID often have a hard time with occupational, educational, social, or personal activities, compared with before COVID, with effects that can last for more than 6 months, the authors noted. 

“I think across the board, universities in general need to consider the possibility of folks on their campuses are having symptoms of long COVID,” Dr. Landry said.

Moving forward, Dr. Landry and colleagues would like to continue investigating long COVID. For example, in the current study, they did not ask about severity of symptoms or how the symptoms affected daily functioning. 

“I would like to continue this and dive deeper into how disruptive their symptoms of long COVID are to their everyday studying, teaching, or their activities to keeping a university running,” Dr. Landry said.

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

Almost 36% of students and faculty at George Washington University with a history of COVID-19 reported symptoms consistent with long COVID in a new study.

With a median age of 23 years, the study is unique for evaluating mostly healthy, young adults and for its rare look at long COVID in a university community. 

The more symptoms during a bout with COVID, the greater the risk for long COVID, the researchers found. That lines up with previous studies. Also, the more vaccinations and booster shots against SARS-CoV-2, the virus that causes COVID, the lower the long COVID risk.

Women were more likely than men to be affected. Current or prior smoking, seeking medical care for COVID, and receiving antibody treatment also were linked to higher chances for developing long COVID. 

Lead author Megan Landry, DrPH, MPH, and colleagues were already assessing students, staff, and faculty at George Washington University, Washington, who tested positive for COVID. Then they started seeing symptoms that lasted 28 days or more after their 10-day isolation period. 

“We were starting to recognize that individuals ... were still having symptoms longer than the typical isolation period,” said Dr. Landry. So they developed a questionnaire to figure out the how long these symptoms last and how many people are affected by them. 

The list of potential symptoms was long and included trouble thinking, fatigue, loss of smell or taste, shortness of breath, and more. 

The study was published online in Emerging Infectious Diseases. Results are based on records and responses from 1,388 students, faculty, and staff from July 2021 to March 2022.

People had a median of four long COVID symptoms, about 63% were women, and 56% were non-Hispanic White. About three-quarters were students and the remainder were faculty and staff. 

The finding that 36% of people with a history of COVID reported long COVID symptoms did not surprise Dr. Landry.

“Based on the literature that’s currently out there, it ranges from a 10% to an 80% prevalence of long COVID,” she said. “We kind of figured that we would fall somewhere in there.”

In contrast, that figure seemed high to Eric Topol, MD.

“That’s really high,” said Dr. Topol, founder and director of the Scripps Research Translational Institute in La Jolla, Calif. He added most studies estimate that about 10% of people with a history of acute infection develop long COVID. 

Even at 10%, which could be an underestimate, that’s a lot of affected people globally. 

“At least 65 million individuals around the world have long COVID, based on a conservative estimated incidence of 10% of infected people and more than 651 million documented COVID-19 cases worldwide; the number is likely much higher due to many undocumented cases,” Dr. Topol and colleagues wrote in a long COVID review article published in Nature Reviews Microbiology.

Research continues

“Long COVID is still evolving and we continue to learn more about it every day,” Landry said. “It’s just so new and there are still a lot of unknowns. That’s why it’s important to get this information out.” 

People with long COVID often have a hard time with occupational, educational, social, or personal activities, compared with before COVID, with effects that can last for more than 6 months, the authors noted. 

“I think across the board, universities in general need to consider the possibility of folks on their campuses are having symptoms of long COVID,” Dr. Landry said.

Moving forward, Dr. Landry and colleagues would like to continue investigating long COVID. For example, in the current study, they did not ask about severity of symptoms or how the symptoms affected daily functioning. 

“I would like to continue this and dive deeper into how disruptive their symptoms of long COVID are to their everyday studying, teaching, or their activities to keeping a university running,” Dr. Landry said.

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

The introduction of the soft drinks industry levy (SDIL) – dubbed the ‘sugar tax’ – in England was followed by a drop in the number of older primary school girls succumbing to obesity, according to researchers from the Universities of Cambridge, Oxford, and Bath, with colleagues at the London School of Hygiene and Tropical Medicine.

The study, published in PLOS Medicine, has led to calls to extend the levy to other unhealthy foods and drinks

Obesity has become a global public health problem, the researchers said. In England, around 10% of 4- to 5-year-old children and 20% of 10- to 11-year-olds were recorded as obese in 2020. Childhood obesity is associated with depression in children and the adults into which they maturate, as well as with serious health problems in later life including high blood pressure and type 2 diabetes.

In the United Kingdom, young people consume significantly more added sugars than are recommended – by late adolescence, typically 70 g of added sugar per day, more than double the recommended 30g. The team said that sugar-sweetened beverages (SSB) are the primary sources of dietary added sugars in children, with high consumption commonly observed in more deprived areas where obesity prevalence is also highest.
 

Protecting children from excessive sugar

The two-tier SDIL on drinks manufacturers was implemented in April 2018 and aimed to protect children from excessive sugar consumption and tackle childhood obesity by incentivizing reformulation of SSBs in the U.K. with reduced sugar content.

To assess the effects of SDIL, the researchers used data from the National Child Measurement Programme on over 1 million children at ages 4 to 5 years (reception class) and 10 to 11 years (school year 6) in state-maintained English primary schools. The surveillance program includes annual repeat cross-sectional measurements, enabling the researchers to examine trajectories in monthly prevalence of obesity from September 2013 to November 2019, 19 months after the implementation of the SDIL.

Taking account of previous trends in obesity levels, they estimated both absolute and relative changes in obesity prevalence, both overall and by sex and deprivation, and compared obesity levels after the SDIL with predicted levels had the tax not been introduced, controlling for children’s sex and the level of deprivation of their school area.

Although they found no significant association with obesity levels in reception-age children or year-6 boys, they noted an overall absolute reduction in obesity prevalence of 1.6 percentage points (PPs) (95% confidence interval, 1.1-2.1) in 10- to 11-year-old (year 6) girls. This equated to an 8% relative reduction in obesity rates compared with a counterfactual estimated from the trend prior to the SDIL announcement in March 2016, adjusted for temporal variations in obesity prevalence.

The researchers estimated that this was equivalent to preventing 5,234 cases of obesity per year in this group of year-6 girls alone.
 

Obesity reductions greatest in most deprived areas

Reductions were greatest in girls whose schools were in the most deprived areas, where children are known to consume the largest amount of sugary drinks. The greatest reductions in obesity were observed in the two most deprived quintiles – such that in the lowest quintile the absolute obesity prevalence reduction was 2.4 PP (95% CI, 1.6-3.2), equivalent to a 9% reduction in those living in the most deprived areas.

There are several reasons why the sugar tax did not lead to changes in levels of obesity among the younger children, the researchers said. Very young children consume fewer sugar-sweetened drinks than older children, so the soft drinks levy would have had a smaller effect. Also, fruit juices are not included in the levy, but contribute similar amounts of sugar in young children’s diets as do sugar-sweetened beverages.
 

Advertising may impact consumption in boys

It’s also unclear why the sugar tax might affect obesity prevalence in girls and boys differently, they said, especially since boys are higher consumers of sugar-sweetened beverages. One explanation is the possible impact of advertising – numerous studies have found that boys are often exposed to more food advertising than girls, both through higher levels of TV viewing and in how adverts are framed. Physical activity is often used to promote junk food and boys, compared with girls, have been shown to be more likely to believe that energy-dense junk foods depicted in adverts will boost physical performance, and so are more likely to choose energy-dense, nutrient-poor products following celebrity endorsements.

Tax ‘led to positive health impacts’

“Our findings suggest that the U.K. SDIL led to positive health impacts in the form of reduced obesity levels in girls aged 10-11 years,” the authors said. However: “Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.”

Dr. Nina Rogers from the MRC Epidemiology Unit at Cambridge (England), who led the study, said: “We urgently need to find ways to tackle the increasing numbers of children living with obesity, otherwise we risk our children growing up to face significant health problems. That was one reason why the U.K.’s SDIL was introduced, and the evidence so far is promising. We’ve shown for the first time that it is likely to have helped prevent thousands of children each year becoming obese.

“It isn’t a straightforward picture, though, as it was mainly older girls who benefited. But the fact that we saw the biggest difference among girls from areas of high deprivation is important and is a step towards reducing the health inequalities they face.”

Although the researchers found an association rather than a causal link, this study adds to previous findings that the levy was associated with a substantial reduction in the amount of sugar in soft drinks.

Senior author Professor Jean Adams from the MRC Epidemiology Unit said: “We know that consuming too many sugary drinks contributes to obesity and that the U.K. soft drinks levy led to a drop in the amount of sugar in soft drinks available in the U.K., so it makes sense that we also see a drop in cases of obesity, although we only found this in girls. Children from more deprived backgrounds tend to consume the largest amount of sugary drinks, and it was among girls in this group that we saw the biggest change.”

Tom Sanders, professor emeritus of nutrition and dietetics at King’s College London, said: “The claim that the soft drink levy might have prevented 5,000 children from becoming obese is speculative because it is based on an association not actual measurements of consumption.”

He added that: “As well as continuing to discourage the consumption of sugar sweetened beverages and sweets, wider recognition should be given to foods such as biscuits [and] deep-fried foods (crisps, corn snacks, chips) that make [a] bigger contribution to excess calorie intake in children. Tackling poverty, however, is probably [the] best way to improve the diets of socially deprived children.”
 

Government ‘should learn from this success’

Asked to comment by this news organization, Katharine Jenner, director of the Obesity Health Alliance, said: “Government should be heartened that their soft drinks policy is already improving the health of young girls, regardless of where they live. The government should learn from this success, especially when compared with the many unsuccessful attempts to persuade industry to change their products voluntarily.  They must now press ahead with policies that make it easier for everyone to eat a healthier diet, including extending the soft drinks industry levy to include other less healthy foods and drinks and measures to take junk food out of the spotlight. 

“The research notes that numerous studies have found that boys are often exposed to more food advertising content than girls, negating the impact of the soft drinks levy [so] we need restriction on junk food marketing now, to put healthy food back in the spotlight.”

The research was supported by the National Institute of Health and Care Research and the Medical Research Council.

A version of this article originally appeared on MedscapeUK.

The introduction of the soft drinks industry levy (SDIL) – dubbed the ‘sugar tax’ – in England was followed by a drop in the number of older primary school girls succumbing to obesity, according to researchers from the Universities of Cambridge, Oxford, and Bath, with colleagues at the London School of Hygiene and Tropical Medicine.

The study, published in PLOS Medicine, has led to calls to extend the levy to other unhealthy foods and drinks

Obesity has become a global public health problem, the researchers said. In England, around 10% of 4- to 5-year-old children and 20% of 10- to 11-year-olds were recorded as obese in 2020. Childhood obesity is associated with depression in children and the adults into which they maturate, as well as with serious health problems in later life including high blood pressure and type 2 diabetes.

In the United Kingdom, young people consume significantly more added sugars than are recommended – by late adolescence, typically 70 g of added sugar per day, more than double the recommended 30g. The team said that sugar-sweetened beverages (SSB) are the primary sources of dietary added sugars in children, with high consumption commonly observed in more deprived areas where obesity prevalence is also highest.
 

Protecting children from excessive sugar

The two-tier SDIL on drinks manufacturers was implemented in April 2018 and aimed to protect children from excessive sugar consumption and tackle childhood obesity by incentivizing reformulation of SSBs in the U.K. with reduced sugar content.

To assess the effects of SDIL, the researchers used data from the National Child Measurement Programme on over 1 million children at ages 4 to 5 years (reception class) and 10 to 11 years (school year 6) in state-maintained English primary schools. The surveillance program includes annual repeat cross-sectional measurements, enabling the researchers to examine trajectories in monthly prevalence of obesity from September 2013 to November 2019, 19 months after the implementation of the SDIL.

Taking account of previous trends in obesity levels, they estimated both absolute and relative changes in obesity prevalence, both overall and by sex and deprivation, and compared obesity levels after the SDIL with predicted levels had the tax not been introduced, controlling for children’s sex and the level of deprivation of their school area.

Although they found no significant association with obesity levels in reception-age children or year-6 boys, they noted an overall absolute reduction in obesity prevalence of 1.6 percentage points (PPs) (95% confidence interval, 1.1-2.1) in 10- to 11-year-old (year 6) girls. This equated to an 8% relative reduction in obesity rates compared with a counterfactual estimated from the trend prior to the SDIL announcement in March 2016, adjusted for temporal variations in obesity prevalence.

The researchers estimated that this was equivalent to preventing 5,234 cases of obesity per year in this group of year-6 girls alone.
 

Obesity reductions greatest in most deprived areas

Reductions were greatest in girls whose schools were in the most deprived areas, where children are known to consume the largest amount of sugary drinks. The greatest reductions in obesity were observed in the two most deprived quintiles – such that in the lowest quintile the absolute obesity prevalence reduction was 2.4 PP (95% CI, 1.6-3.2), equivalent to a 9% reduction in those living in the most deprived areas.

There are several reasons why the sugar tax did not lead to changes in levels of obesity among the younger children, the researchers said. Very young children consume fewer sugar-sweetened drinks than older children, so the soft drinks levy would have had a smaller effect. Also, fruit juices are not included in the levy, but contribute similar amounts of sugar in young children’s diets as do sugar-sweetened beverages.
 

Advertising may impact consumption in boys

It’s also unclear why the sugar tax might affect obesity prevalence in girls and boys differently, they said, especially since boys are higher consumers of sugar-sweetened beverages. One explanation is the possible impact of advertising – numerous studies have found that boys are often exposed to more food advertising than girls, both through higher levels of TV viewing and in how adverts are framed. Physical activity is often used to promote junk food and boys, compared with girls, have been shown to be more likely to believe that energy-dense junk foods depicted in adverts will boost physical performance, and so are more likely to choose energy-dense, nutrient-poor products following celebrity endorsements.

Tax ‘led to positive health impacts’

“Our findings suggest that the U.K. SDIL led to positive health impacts in the form of reduced obesity levels in girls aged 10-11 years,” the authors said. However: “Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.”

Dr. Nina Rogers from the MRC Epidemiology Unit at Cambridge (England), who led the study, said: “We urgently need to find ways to tackle the increasing numbers of children living with obesity, otherwise we risk our children growing up to face significant health problems. That was one reason why the U.K.’s SDIL was introduced, and the evidence so far is promising. We’ve shown for the first time that it is likely to have helped prevent thousands of children each year becoming obese.

“It isn’t a straightforward picture, though, as it was mainly older girls who benefited. But the fact that we saw the biggest difference among girls from areas of high deprivation is important and is a step towards reducing the health inequalities they face.”

Although the researchers found an association rather than a causal link, this study adds to previous findings that the levy was associated with a substantial reduction in the amount of sugar in soft drinks.

Senior author Professor Jean Adams from the MRC Epidemiology Unit said: “We know that consuming too many sugary drinks contributes to obesity and that the U.K. soft drinks levy led to a drop in the amount of sugar in soft drinks available in the U.K., so it makes sense that we also see a drop in cases of obesity, although we only found this in girls. Children from more deprived backgrounds tend to consume the largest amount of sugary drinks, and it was among girls in this group that we saw the biggest change.”

Tom Sanders, professor emeritus of nutrition and dietetics at King’s College London, said: “The claim that the soft drink levy might have prevented 5,000 children from becoming obese is speculative because it is based on an association not actual measurements of consumption.”

He added that: “As well as continuing to discourage the consumption of sugar sweetened beverages and sweets, wider recognition should be given to foods such as biscuits [and] deep-fried foods (crisps, corn snacks, chips) that make [a] bigger contribution to excess calorie intake in children. Tackling poverty, however, is probably [the] best way to improve the diets of socially deprived children.”
 

Government ‘should learn from this success’

Asked to comment by this news organization, Katharine Jenner, director of the Obesity Health Alliance, said: “Government should be heartened that their soft drinks policy is already improving the health of young girls, regardless of where they live. The government should learn from this success, especially when compared with the many unsuccessful attempts to persuade industry to change their products voluntarily.  They must now press ahead with policies that make it easier for everyone to eat a healthier diet, including extending the soft drinks industry levy to include other less healthy foods and drinks and measures to take junk food out of the spotlight. 

“The research notes that numerous studies have found that boys are often exposed to more food advertising content than girls, negating the impact of the soft drinks levy [so] we need restriction on junk food marketing now, to put healthy food back in the spotlight.”

The research was supported by the National Institute of Health and Care Research and the Medical Research Council.

A version of this article originally appeared on MedscapeUK.

The introduction of the soft drinks industry levy (SDIL) – dubbed the ‘sugar tax’ – in England was followed by a drop in the number of older primary school girls succumbing to obesity, according to researchers from the Universities of Cambridge, Oxford, and Bath, with colleagues at the London School of Hygiene and Tropical Medicine.

The study, published in PLOS Medicine, has led to calls to extend the levy to other unhealthy foods and drinks

Obesity has become a global public health problem, the researchers said. In England, around 10% of 4- to 5-year-old children and 20% of 10- to 11-year-olds were recorded as obese in 2020. Childhood obesity is associated with depression in children and the adults into which they maturate, as well as with serious health problems in later life including high blood pressure and type 2 diabetes.

In the United Kingdom, young people consume significantly more added sugars than are recommended – by late adolescence, typically 70 g of added sugar per day, more than double the recommended 30g. The team said that sugar-sweetened beverages (SSB) are the primary sources of dietary added sugars in children, with high consumption commonly observed in more deprived areas where obesity prevalence is also highest.
 

Protecting children from excessive sugar

The two-tier SDIL on drinks manufacturers was implemented in April 2018 and aimed to protect children from excessive sugar consumption and tackle childhood obesity by incentivizing reformulation of SSBs in the U.K. with reduced sugar content.

To assess the effects of SDIL, the researchers used data from the National Child Measurement Programme on over 1 million children at ages 4 to 5 years (reception class) and 10 to 11 years (school year 6) in state-maintained English primary schools. The surveillance program includes annual repeat cross-sectional measurements, enabling the researchers to examine trajectories in monthly prevalence of obesity from September 2013 to November 2019, 19 months after the implementation of the SDIL.

Taking account of previous trends in obesity levels, they estimated both absolute and relative changes in obesity prevalence, both overall and by sex and deprivation, and compared obesity levels after the SDIL with predicted levels had the tax not been introduced, controlling for children’s sex and the level of deprivation of their school area.

Although they found no significant association with obesity levels in reception-age children or year-6 boys, they noted an overall absolute reduction in obesity prevalence of 1.6 percentage points (PPs) (95% confidence interval, 1.1-2.1) in 10- to 11-year-old (year 6) girls. This equated to an 8% relative reduction in obesity rates compared with a counterfactual estimated from the trend prior to the SDIL announcement in March 2016, adjusted for temporal variations in obesity prevalence.

The researchers estimated that this was equivalent to preventing 5,234 cases of obesity per year in this group of year-6 girls alone.
 

Obesity reductions greatest in most deprived areas

Reductions were greatest in girls whose schools were in the most deprived areas, where children are known to consume the largest amount of sugary drinks. The greatest reductions in obesity were observed in the two most deprived quintiles – such that in the lowest quintile the absolute obesity prevalence reduction was 2.4 PP (95% CI, 1.6-3.2), equivalent to a 9% reduction in those living in the most deprived areas.

There are several reasons why the sugar tax did not lead to changes in levels of obesity among the younger children, the researchers said. Very young children consume fewer sugar-sweetened drinks than older children, so the soft drinks levy would have had a smaller effect. Also, fruit juices are not included in the levy, but contribute similar amounts of sugar in young children’s diets as do sugar-sweetened beverages.
 

Advertising may impact consumption in boys

It’s also unclear why the sugar tax might affect obesity prevalence in girls and boys differently, they said, especially since boys are higher consumers of sugar-sweetened beverages. One explanation is the possible impact of advertising – numerous studies have found that boys are often exposed to more food advertising than girls, both through higher levels of TV viewing and in how adverts are framed. Physical activity is often used to promote junk food and boys, compared with girls, have been shown to be more likely to believe that energy-dense junk foods depicted in adverts will boost physical performance, and so are more likely to choose energy-dense, nutrient-poor products following celebrity endorsements.

Tax ‘led to positive health impacts’

“Our findings suggest that the U.K. SDIL led to positive health impacts in the form of reduced obesity levels in girls aged 10-11 years,” the authors said. However: “Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.”

Dr. Nina Rogers from the MRC Epidemiology Unit at Cambridge (England), who led the study, said: “We urgently need to find ways to tackle the increasing numbers of children living with obesity, otherwise we risk our children growing up to face significant health problems. That was one reason why the U.K.’s SDIL was introduced, and the evidence so far is promising. We’ve shown for the first time that it is likely to have helped prevent thousands of children each year becoming obese.

“It isn’t a straightforward picture, though, as it was mainly older girls who benefited. But the fact that we saw the biggest difference among girls from areas of high deprivation is important and is a step towards reducing the health inequalities they face.”

Although the researchers found an association rather than a causal link, this study adds to previous findings that the levy was associated with a substantial reduction in the amount of sugar in soft drinks.

Senior author Professor Jean Adams from the MRC Epidemiology Unit said: “We know that consuming too many sugary drinks contributes to obesity and that the U.K. soft drinks levy led to a drop in the amount of sugar in soft drinks available in the U.K., so it makes sense that we also see a drop in cases of obesity, although we only found this in girls. Children from more deprived backgrounds tend to consume the largest amount of sugary drinks, and it was among girls in this group that we saw the biggest change.”

Tom Sanders, professor emeritus of nutrition and dietetics at King’s College London, said: “The claim that the soft drink levy might have prevented 5,000 children from becoming obese is speculative because it is based on an association not actual measurements of consumption.”

He added that: “As well as continuing to discourage the consumption of sugar sweetened beverages and sweets, wider recognition should be given to foods such as biscuits [and] deep-fried foods (crisps, corn snacks, chips) that make [a] bigger contribution to excess calorie intake in children. Tackling poverty, however, is probably [the] best way to improve the diets of socially deprived children.”
 

Government ‘should learn from this success’

Asked to comment by this news organization, Katharine Jenner, director of the Obesity Health Alliance, said: “Government should be heartened that their soft drinks policy is already improving the health of young girls, regardless of where they live. The government should learn from this success, especially when compared with the many unsuccessful attempts to persuade industry to change their products voluntarily.  They must now press ahead with policies that make it easier for everyone to eat a healthier diet, including extending the soft drinks industry levy to include other less healthy foods and drinks and measures to take junk food out of the spotlight. 

“The research notes that numerous studies have found that boys are often exposed to more food advertising content than girls, negating the impact of the soft drinks levy [so] we need restriction on junk food marketing now, to put healthy food back in the spotlight.”

The research was supported by the National Institute of Health and Care Research and the Medical Research Council.

A version of this article originally appeared on MedscapeUK.

Apparently, offering children effective treatments for a chronic disease that markedly increases their risk for other chronic diseases, regularly erodes their quality of life, and is the No. 1 target of school-based bullying is wrong.

At least that’s my take watching the coverage of the recent American Academy of Pediatrics new pediatric obesity treatment guidelines that, gasp, suggest that children whose severity of obesity warrants medication or surgeries be offered medication or surgery. Because it’s wiser to not try to treat the obesity that›s contributing to a child’s type 2 diabetes, hypertension, fatty liver disease, or reduced quality of life?

The reaction isn’t surprising. Some of those who are up in arms about it have clinical or research careers dependent on championing their own favorite dietary strategies as if they are more effective and reproducible than decades of uniformly disappointing studies proving that they’re not. Others are upset because, for reasons that at times may be personal and at times may be conflicted, they believe that obesity should not be treated and/or that sustained weight loss is impossible. But overarchingly, probably the bulk of the hoopla stems from obesity being seen as a moral failing. Because the notion that those who suffer with obesity are themselves to blame has been the prevailing societal view for decades, if not centuries.

Working with families of children with obesity severe enough for them to seek help, it’s clear that if desire were sufficient to will it away, we wouldn’t need treatment guidelines let alone medications or surgery. Near uniformly, parents describe their children being bullied consequent to and being deeply self-conscious of their weight.

And what would those who think children shouldn’t be offered reproducibly effective treatment for obesity have them do about it? Many seem to think it would be preferable for kids to be placed on formal diets and, of course, that they should go out and play more. And though I’m all for encouraging the improvement of a child’s dietary quality and activity level, anyone suggesting those as panaceas for childhood obesity haven’t a clue. Not to mention the fact that, in most cases, improving overall dietary quality, something worthwhile at any weight, isn’t the dietary goal being recommended. Instead, the prescription seems to be restrictive dieting coupled with overexercising, which, unlike appropriately and thoughtfully informed and utilized medication, may increase a child’s risk of maladaptive thinking around food and fitness as well as disordered eating, not to mention challenge their self-esteem if their lifestyle results are underwhelming.

This brings us to one of the most bizarre takes on this whole business – that medications will be pushed and used when not necessary. No doubt that at times, that may occur, but the issue is that of a clinician’s overzealous prescribing and not of the treatment options or indications. Consider childhood asthma. There is no worry or uproar that children with mild asthma that isn’t having an impact on their quality of life or markedly risking their health will be placed on multiple inhaled steroids and treatments. Why? Because clinicians have been taught how to dispassionately evaluate treatment needs for asthma, monitor disease course, and not simply prescribe everything in our armamentarium.

Shocking, I know, but as is the case with every other medical condition, I think doctors are capable of learning and following an algorithm covering the indications and options for the treatment of childhood obesity.

How that looks also mirrors what’s seen with any other chronic noncommunicable disease with varied severity and impact. Doctors will evaluate each child with obesity to see whether it’s having a detrimental effect on their health or quality of life. They will monitor their patients’ obesity to see if it’s worsening and will, when necessary, undertake investigations to rule out its potential contribution to common comorbidities like type 2 diabetes, hypertension, and fatty liver disease. And, when appropriate, they will provide information on available treatment options – from lifestyle to medication to surgery and the risks, benefits, and realistic expectations associated with each – and then, without judgment, support their patients’ treatment choices because blame-free informed discussion and supportive prescription of care is, in fact, the distillation of our jobs.

If people are looking to be outraged rather than focusing their outrage on what we now need to do about childhood obesity, they should instead look to what got us here: our obesogenic environment. We and our children are swimming against a torrential current of cheap ultraprocessed calories being pushed upon us by a broken societal food culture that values convenience and simultaneously embraces the notion that knowledge is a match versus the thousands of genes and dozens of hormones that increasingly sophisticated food industry marketers and scientists prey upon. When dealing with torrential currents, we need to do more than just recommend swimming lessons.

Like asthma, which may be exacerbated by pollution in our environment both outdoors and indoors, childhood obesity is a modern-day environmentally influenced disease with varied penetrance that does not always require active treatment. Like asthma, childhood obesity is not a disease that children choose to have; it’s not a disease that can be willed away; and it’s not a disease that responds uniformly, dramatically, or enduringly to diet and exercise. Finally, literally and figuratively, like asthma, for childhood obesity, we thankfully now have a number of effective treatment options that we can offer, and it’s only our societal weight bias that leads to thinking that’s anything but great.

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

Apparently, offering children effective treatments for a chronic disease that markedly increases their risk for other chronic diseases, regularly erodes their quality of life, and is the No. 1 target of school-based bullying is wrong.

At least that’s my take watching the coverage of the recent American Academy of Pediatrics new pediatric obesity treatment guidelines that, gasp, suggest that children whose severity of obesity warrants medication or surgeries be offered medication or surgery. Because it’s wiser to not try to treat the obesity that›s contributing to a child’s type 2 diabetes, hypertension, fatty liver disease, or reduced quality of life?

The reaction isn’t surprising. Some of those who are up in arms about it have clinical or research careers dependent on championing their own favorite dietary strategies as if they are more effective and reproducible than decades of uniformly disappointing studies proving that they’re not. Others are upset because, for reasons that at times may be personal and at times may be conflicted, they believe that obesity should not be treated and/or that sustained weight loss is impossible. But overarchingly, probably the bulk of the hoopla stems from obesity being seen as a moral failing. Because the notion that those who suffer with obesity are themselves to blame has been the prevailing societal view for decades, if not centuries.

Working with families of children with obesity severe enough for them to seek help, it’s clear that if desire were sufficient to will it away, we wouldn’t need treatment guidelines let alone medications or surgery. Near uniformly, parents describe their children being bullied consequent to and being deeply self-conscious of their weight.

And what would those who think children shouldn’t be offered reproducibly effective treatment for obesity have them do about it? Many seem to think it would be preferable for kids to be placed on formal diets and, of course, that they should go out and play more. And though I’m all for encouraging the improvement of a child’s dietary quality and activity level, anyone suggesting those as panaceas for childhood obesity haven’t a clue. Not to mention the fact that, in most cases, improving overall dietary quality, something worthwhile at any weight, isn’t the dietary goal being recommended. Instead, the prescription seems to be restrictive dieting coupled with overexercising, which, unlike appropriately and thoughtfully informed and utilized medication, may increase a child’s risk of maladaptive thinking around food and fitness as well as disordered eating, not to mention challenge their self-esteem if their lifestyle results are underwhelming.

This brings us to one of the most bizarre takes on this whole business – that medications will be pushed and used when not necessary. No doubt that at times, that may occur, but the issue is that of a clinician’s overzealous prescribing and not of the treatment options or indications. Consider childhood asthma. There is no worry or uproar that children with mild asthma that isn’t having an impact on their quality of life or markedly risking their health will be placed on multiple inhaled steroids and treatments. Why? Because clinicians have been taught how to dispassionately evaluate treatment needs for asthma, monitor disease course, and not simply prescribe everything in our armamentarium.

Shocking, I know, but as is the case with every other medical condition, I think doctors are capable of learning and following an algorithm covering the indications and options for the treatment of childhood obesity.

How that looks also mirrors what’s seen with any other chronic noncommunicable disease with varied severity and impact. Doctors will evaluate each child with obesity to see whether it’s having a detrimental effect on their health or quality of life. They will monitor their patients’ obesity to see if it’s worsening and will, when necessary, undertake investigations to rule out its potential contribution to common comorbidities like type 2 diabetes, hypertension, and fatty liver disease. And, when appropriate, they will provide information on available treatment options – from lifestyle to medication to surgery and the risks, benefits, and realistic expectations associated with each – and then, without judgment, support their patients’ treatment choices because blame-free informed discussion and supportive prescription of care is, in fact, the distillation of our jobs.

If people are looking to be outraged rather than focusing their outrage on what we now need to do about childhood obesity, they should instead look to what got us here: our obesogenic environment. We and our children are swimming against a torrential current of cheap ultraprocessed calories being pushed upon us by a broken societal food culture that values convenience and simultaneously embraces the notion that knowledge is a match versus the thousands of genes and dozens of hormones that increasingly sophisticated food industry marketers and scientists prey upon. When dealing with torrential currents, we need to do more than just recommend swimming lessons.

Like asthma, which may be exacerbated by pollution in our environment both outdoors and indoors, childhood obesity is a modern-day environmentally influenced disease with varied penetrance that does not always require active treatment. Like asthma, childhood obesity is not a disease that children choose to have; it’s not a disease that can be willed away; and it’s not a disease that responds uniformly, dramatically, or enduringly to diet and exercise. Finally, literally and figuratively, like asthma, for childhood obesity, we thankfully now have a number of effective treatment options that we can offer, and it’s only our societal weight bias that leads to thinking that’s anything but great.

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

Apparently, offering children effective treatments for a chronic disease that markedly increases their risk for other chronic diseases, regularly erodes their quality of life, and is the No. 1 target of school-based bullying is wrong.

At least that’s my take watching the coverage of the recent American Academy of Pediatrics new pediatric obesity treatment guidelines that, gasp, suggest that children whose severity of obesity warrants medication or surgeries be offered medication or surgery. Because it’s wiser to not try to treat the obesity that›s contributing to a child’s type 2 diabetes, hypertension, fatty liver disease, or reduced quality of life?

The reaction isn’t surprising. Some of those who are up in arms about it have clinical or research careers dependent on championing their own favorite dietary strategies as if they are more effective and reproducible than decades of uniformly disappointing studies proving that they’re not. Others are upset because, for reasons that at times may be personal and at times may be conflicted, they believe that obesity should not be treated and/or that sustained weight loss is impossible. But overarchingly, probably the bulk of the hoopla stems from obesity being seen as a moral failing. Because the notion that those who suffer with obesity are themselves to blame has been the prevailing societal view for decades, if not centuries.

Working with families of children with obesity severe enough for them to seek help, it’s clear that if desire were sufficient to will it away, we wouldn’t need treatment guidelines let alone medications or surgery. Near uniformly, parents describe their children being bullied consequent to and being deeply self-conscious of their weight.

And what would those who think children shouldn’t be offered reproducibly effective treatment for obesity have them do about it? Many seem to think it would be preferable for kids to be placed on formal diets and, of course, that they should go out and play more. And though I’m all for encouraging the improvement of a child’s dietary quality and activity level, anyone suggesting those as panaceas for childhood obesity haven’t a clue. Not to mention the fact that, in most cases, improving overall dietary quality, something worthwhile at any weight, isn’t the dietary goal being recommended. Instead, the prescription seems to be restrictive dieting coupled with overexercising, which, unlike appropriately and thoughtfully informed and utilized medication, may increase a child’s risk of maladaptive thinking around food and fitness as well as disordered eating, not to mention challenge their self-esteem if their lifestyle results are underwhelming.

This brings us to one of the most bizarre takes on this whole business – that medications will be pushed and used when not necessary. No doubt that at times, that may occur, but the issue is that of a clinician’s overzealous prescribing and not of the treatment options or indications. Consider childhood asthma. There is no worry or uproar that children with mild asthma that isn’t having an impact on their quality of life or markedly risking their health will be placed on multiple inhaled steroids and treatments. Why? Because clinicians have been taught how to dispassionately evaluate treatment needs for asthma, monitor disease course, and not simply prescribe everything in our armamentarium.

Shocking, I know, but as is the case with every other medical condition, I think doctors are capable of learning and following an algorithm covering the indications and options for the treatment of childhood obesity.

How that looks also mirrors what’s seen with any other chronic noncommunicable disease with varied severity and impact. Doctors will evaluate each child with obesity to see whether it’s having a detrimental effect on their health or quality of life. They will monitor their patients’ obesity to see if it’s worsening and will, when necessary, undertake investigations to rule out its potential contribution to common comorbidities like type 2 diabetes, hypertension, and fatty liver disease. And, when appropriate, they will provide information on available treatment options – from lifestyle to medication to surgery and the risks, benefits, and realistic expectations associated with each – and then, without judgment, support their patients’ treatment choices because blame-free informed discussion and supportive prescription of care is, in fact, the distillation of our jobs.

If people are looking to be outraged rather than focusing their outrage on what we now need to do about childhood obesity, they should instead look to what got us here: our obesogenic environment. We and our children are swimming against a torrential current of cheap ultraprocessed calories being pushed upon us by a broken societal food culture that values convenience and simultaneously embraces the notion that knowledge is a match versus the thousands of genes and dozens of hormones that increasingly sophisticated food industry marketers and scientists prey upon. When dealing with torrential currents, we need to do more than just recommend swimming lessons.

Like asthma, which may be exacerbated by pollution in our environment both outdoors and indoors, childhood obesity is a modern-day environmentally influenced disease with varied penetrance that does not always require active treatment. Like asthma, childhood obesity is not a disease that children choose to have; it’s not a disease that can be willed away; and it’s not a disease that responds uniformly, dramatically, or enduringly to diet and exercise. Finally, literally and figuratively, like asthma, for childhood obesity, we thankfully now have a number of effective treatment options that we can offer, and it’s only our societal weight bias that leads to thinking that’s anything but great.

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

This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I’m Dr Robert Glatter, medical adviser for Medscape Emergency Medicine. Today, we have Dr. Paul Pepe, an emergency physician and highly recognized expert in EMS, critical care, and resuscitation, along with Ryan Quinn, EMS chief for Edina Fire Department in Edina, Minn., joining us to discuss a significant advance in resuscitation for patients with nonshockable rhythms in cardiac arrest with a remarkable increase in neurologically intact survival. Welcome, gentlemen.

Dr. Pepe, I’d like to start off by thanking you for taking time to join us to discuss this novel concept of head-up or what you now refer to as a neuroprotective cardiopulmonary resuscitation (CPR) bundle. Can you define what this entails and why it is referred to as a neuroprotective CPR bundle?

Paul E. Pepe, MD, MPH: CPR has been life saving for 60 years the way we’ve performed it, but probably only in a very small percentage of cases. That’s one of the problems. We have almost a thousand people a day who have sudden cardiac arrest out in the community alone and more in the hospital.

We know that early defibrillation and early CPR can contribute, but it’s still a small percentage of those. About 75%-85% of the cases that we go out to see will have nonshockable rhythms and flatlines. Some cases are what we call “pulseless electrical activity,” meaning that it looks like there is some kind of organized complex, but there is no pulse associated with it.

That’s why it’s a problem, because they don’t come back. Part of the reason why we see poor outcomes is not only that these cases tend to be people who, say, were in ventricular fibrillation and then just went on over time and were not witnessed or resuscitated or had a long response time. They basically either go into flatline or autoconvert into these bizarre rhythms.

The other issue is the way we perform CPR. CPR has been lifesaving, but it only generates about 20% and maybe 15% in some cases of normal blood flow, and particularly, cerebral perfusion pressure. We’ve looked at this nicely in the laboratory.

For example, during chest compressions, we’re hoping during the recoil phase to pull blood down and back into the right heart. The problem is that you’re not only setting a pressure rate up here to the arterial side but also, you’re setting back pressure wave on the venous side. Obviously, the arterial side always wins out, but it’s just not as efficient as it could be, at 20% or 30%.

What does this entail? It entails several independent mechanisms in terms of how they work, but they all do the same thing, which is they help to pull blood out of the brain and back into the right heart by basically manipulating intrathoracic pressure and creating more of a vacuum to get blood back there.

It’s so important that people do quality CPR. You have to have a good release and that helps us suck a little bit of blood and sucks the air in. As soon as the air rushes in, it neutralizes the pressure and there’s no more vacuum and nothing else is happening until the next squeeze.

What we have found is that we can cap the airway just for a second with a little pop-up valve. It acts like when you’re sucking a milkshake through a straw and it creates more of a vacuum in the chest. Just a little pop-up valve that pulls a little bit more blood out of the brain and the rest of the body and into the right heart.

We’ve shown in a human study that, for example, the systolic blood pressure almost doubles. It really goes from 40 mm Hg during standard CPR up to 80 mm Hg, and that would be sustained for 14-15 minutes. That was a nice little study that was done in Milwaukee a few years ago.

The other thing that happens is, if you add on something else, it’s like a toilet plunger. I think many people have seen it; it’s called “active compression-decompression.” It not only compresses, but it decompresses. Where it becomes even more effective is that if you had broken bones or stiff bones as you get older or whatever it may be, as you do the CPR, you’re still getting the push down and then you’re getting the pull out. It helps on several levels. More importantly, when you put the two together, they’re very synergistic.

We, have already done the clinical trial that is the proof of concept, and that was published in The Lancet about 10 years ago. In that study, we found that the combination of those two dramatically improved survival rates by 50%, with 1-year survival neurologically intact. That got us on the right track.

The interesting thing is that someone said, “Can we lift the head up a little bit?” We did a large amount of work in the laboratory over 10 years, fine tuning it. When do you first lift the head? How soon is too soon? It’s probably bad if you just go right to it.

We had to get the pump primed a little bit with these other things to get the flow going better, not only pulling blood out of the brain but now, you have a better flow this way. You have to prime at first for a couple of minutes, and we worked out the timing: Is it 3 or 4 minutes? It seems the timing is right at about 2 minutes, then you gradually elevate the head over about 2 minutes. We’re finding that seems to be the optimal way to do it. About 2 minutes of priming with those other two devices, the adjuncts, and then gradually elevate the head over 2 minutes.

When we do that in the laboratory, we’re getting normalized cerebral perfusion pressures. You’re normalizing the flow back again with that. We’re seeing profound differences in outcome as a result, even in these cases of the nonshockables.
 

Dr. Glatter: What you’re doing basically is resulting in an increase in cardiac output, essentially. That really is important, especially in these nonshockable rhythms, correct?

Dr. Pepe: Absolutely. As you’re doing this compression and you’re getting these intracranial pulse waves that are going up because they’re colliding up there. It could be even damaging in itself, but we’re seeing these intracranial raises. The intracranial pressure starts going up more and more over time. Also, peripherally in most people, you’re not getting good flow out there; then, your vasculature starts to relax. The arterials are starting to not get oxygen, so they don’t go out.

With this technique where we’re returning the pressure, we’re getting to 40% of normal now with the active compression-decompression CPR plus an impedance threshold device (ACD+ITD CPR) approach. Now, you add this, and you’re almost normalizing. In humans, even in these asystole patients, we’re seeing end-title CO₂s which are generally in the 15-20 range with standard CPR are now up with ACD+ITD CPR in the 30%-40% range, where we’re getting through 30 or 40 end-tidal CO₂s. Now, we’re seeing even the end-tidal CO₂s moving up into the 40s and 50s. We know there’s a surrogate marker telling us that we are generating much better flows not only to the rest of the body, but most importantly, to the brain.
 

Dr. Glatter: Ryan, could you tell us about the approach in terms of on scene, what you’re doing and how you use the device itself? Maybe you could talk about the backpack that you developed with your fire department?

Ryan P. Quinn, BS, EMS: Our approach has always been to get to the patient quickly, like everybody’s approach on a cardiac arrest when you’re responding. We are an advanced life-support paramedic ambulance service through the fire department – we’re all cross-trained firefighter paramedics. Our first vehicle from the fire department is typically the ambulance. It’s smaller and a little quicker than the fire engine. Two paramedics are going to jump out with two backpacks. One has the automated compressive device (we use the Lucas), and the other one is the sequential patient lifting device, the EleGARD.

Our two paramedics are quick to the patient’s side, and once they make contact with the patient to verify pulseless cardiac arrest, they will unpack. One person will go right to compressions if there’s nobody on compressions already. Sometimes we have a first responder police officer with an automated external defibrillator (AED). We go right to the patient’s side, concentrate on compressions, and within 90 seconds to 2 minutes, we have our bags unpacked, we’ve got the devices turned on, patient lifted up, slid under the device, and we have a supraglottic airway that is placed within 15 seconds already premade with the ITD on top. We have a sealed airway that we can continue to compress with Dr. Pepe’s original discussion of building on what’s previously been shown to work.

Dr. Pepe: Let me make a comment about this. This is so important, what Ryan is saying, because it’s something we found during the study. It’s really a true pit-crew approach. You’re not only getting these materials, which you think you need a medical Sherpa for, but you don’t. They set it up and then when they open it up, it’s all laid out just exactly as you need it. It’s not just how fast you get there; it’s how fast you get this done.

When we look at all cases combined against high-performance systems that had some of the highest survival rates around, when we compare it to those, we found that overall, even if you looked at the ones that had over 20-minute responses, the odds ratios were still three to four times higher. It was impressive.

If you looked at it under 15 minutes, which is really reasonable for most systems that get there by the way, the average time that people start CPR in any system in these studies has been about 8 minutes if you actually start this thing, which takes about 2 minutes more for this new bundle of care with this triad, it’s almost 12-14 times higher in terms of the odds ratio. I’ve never seen anything like that where the higher end is over 100 in terms of your confidence intervals.

Ryan’s system did really well and is one of those with even higher levels of outcomes, mostly because they got it on quickly. It’s like the AED for nonshockables but better because you have a wider range of efficacy where it will work.
 

Dr. Glatter: When the elapsed time was less than 11 minutes, that seemed to be an inflection point in the study, is that correct? You saw that 11-fold higher incidence in terms of neurologically intact survival, is that correct?

Dr. Pepe: We picked that number because that was the median time to get it on board. Half the people were getting it within that time period. The fact that you have a larger window, we’re talking about 13- almost 14-fold improvements in outcome if it was under 15 minutes. It doesn’t matter about the 11 or the 12. It’s the faster you get it on board, the better off you are.

Dr. Glatter: What’s the next step in the process of doing trials and having implementation on a larger scale based on your Annals of Emergency Medicine study? Where do you go from here?

Dr. Pepe: I’ve come to find out there are many confounding variables. What was the quality of CPR? How did people ventilate? Did they give the breath and hold it? Did they give a large enough breath so that blood can go across the transpulmonary system? There are many confounding variables. That’s why I think, in the future, it’s going to be more of looking at things like propensity score matching because we know all the variables that change outcomes. I think that’s going to be a way for me.

The other thing is that we were looking at only 380 cases here. When this doubles up in numbers, as we accrue more cases around the country of people who are implementing this, these numbers I just quoted are going to go up much higher. Unwitnessed asystole is considered futile, and you just don’t get them back. To be able to get these folks back now, even if it’s a small percentage, and the fact that we know that we’re producing this better flow, is pretty striking.

I’m really impressed, and the main thing is to make sure people are educated about it. Number two is that they understand that it has to be done right. It cannot be done wrong or you’re not going to see the differences. Getting it done right is not only following the procedures, the sequence, and how you do it, but it also has to do with getting there quickly, including assigning the right people to put it on and having well-trained people who know what they’re doing.
 

Dr. Glatter: In general, the lay public obviously should not attempt this in the field lifting someone’s head up in the sense of trying to do chest compressions. I think that message is important that you just said. It’s not ready for prime time yet in any way. It has to be done right.

Dr. Pepe: Bystanders have to learn CPR – they will buy us time and we’ll have better outcomes when they do that. That’s number one. Number two is that as more and more systems adopt this, you’re going to see more people coming back. If you think about what we’re doing now, if we only get back 5% of these nonshockable vs. less than 1%, it’s 5% of 800 people a day because a thousand people a day die. Several dozens of lives can be saved on a daily basis, coming back neurologically intact. That’s the key thing.

Dr. Glatter: Ryan, can you comment about your experience in the field? Is there anything in terms of your current approach that you think would be ideal to change at this point?

Mr. Quinn: We’ve established that this is the approach that we want to take and we’re just fine tuning it to be more efficient. Using the choreography of which person is going to do which role, we have clearly defined roles and clearly defined command of the scene so we’re not missing anything. Training is extremely important.

Dr. Glatter: Paul, I want to ask you about your anecdotal experience of people waking up quickly and talking after elevating their heads and going through this process. Having people talk about it and waking up is really fascinating. Maybe you can comment further on this.

Dr. Pepe: That’s a great point that you bring up because a 40- to 50-year-old guy who got saved with this approach, when he came around, he said he was hearing what people were saying. When he came out of it, he found out he had been getting CPR for about 25 minutes because he had persistent recurring ventricular fibrillation. He said, “How could I have survived that that long?”

When we told him about the new approach, he added, “Well, that’s like neuroprotective.” He’s right, because in the laboratory, we showed it was neuroprotective and we’re also getting better flows back there. It goes along with everything else, and so we’ve adopted the name because it is.

These are really high-powered systems we are comparing against, and we have the same level of return of spontaneous circulation. The major difference was when you started talking about the neurointact survival. We don’t have enough numbers yet, but next go around, we’re going to look at cerebral performance category (CPC) – CPC1 vs. the CPC2 – which were both considered intact, but CPC1 is actually better. We’re seeing many more of those, anecdotally.

I also wanted to mention that people do bring this up and say, “Well, let’s do a trial.” As far as we’re concerned, the trial’s been done in terms of The Lancet study 10 years ago that showed that the active compression-decompression had tremendously better outcomes. We show in the laboratories that you augment that a little bit. These are all [Food and Drug Administration] approved. You can go out and buy it tomorrow and get it done. I have no conflicts of interest, by the way, with any of this.

To have this device that’s going to have the potential of saving so many more lives is really an exciting breakthrough. More importantly, we’re understanding more now about the physiology of CPR and why it works. It could work much better with the approaches that we’ve been developing over the last 20 years or so.

Dr. Glatter: Absolutely. I want to thank both of you gentlemen. It’s been really an incredible experience to learn more about an advance in resuscitation that could truly be lifesaving. Thank you again for taking time to join us.

Dr. Glatter is an attending physician in the department of emergency medicine, Lenox Hill Hospital, New York. Dr. Pepe is professor, department of management, policy, and community health, University of Texas Health Sciences Center, Houston. Mr. Quinn is EMS Chief, Edina (Minn.) Fire Department. No conflicts of interest were reported.

A version of this article first appeared Jan. 26 on Medscape.com.

This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I’m Dr Robert Glatter, medical adviser for Medscape Emergency Medicine. Today, we have Dr. Paul Pepe, an emergency physician and highly recognized expert in EMS, critical care, and resuscitation, along with Ryan Quinn, EMS chief for Edina Fire Department in Edina, Minn., joining us to discuss a significant advance in resuscitation for patients with nonshockable rhythms in cardiac arrest with a remarkable increase in neurologically intact survival. Welcome, gentlemen.

Dr. Pepe, I’d like to start off by thanking you for taking time to join us to discuss this novel concept of head-up or what you now refer to as a neuroprotective cardiopulmonary resuscitation (CPR) bundle. Can you define what this entails and why it is referred to as a neuroprotective CPR bundle?

Paul E. Pepe, MD, MPH: CPR has been life saving for 60 years the way we’ve performed it, but probably only in a very small percentage of cases. That’s one of the problems. We have almost a thousand people a day who have sudden cardiac arrest out in the community alone and more in the hospital.

We know that early defibrillation and early CPR can contribute, but it’s still a small percentage of those. About 75%-85% of the cases that we go out to see will have nonshockable rhythms and flatlines. Some cases are what we call “pulseless electrical activity,” meaning that it looks like there is some kind of organized complex, but there is no pulse associated with it.

That’s why it’s a problem, because they don’t come back. Part of the reason why we see poor outcomes is not only that these cases tend to be people who, say, were in ventricular fibrillation and then just went on over time and were not witnessed or resuscitated or had a long response time. They basically either go into flatline or autoconvert into these bizarre rhythms.

The other issue is the way we perform CPR. CPR has been lifesaving, but it only generates about 20% and maybe 15% in some cases of normal blood flow, and particularly, cerebral perfusion pressure. We’ve looked at this nicely in the laboratory.

For example, during chest compressions, we’re hoping during the recoil phase to pull blood down and back into the right heart. The problem is that you’re not only setting a pressure rate up here to the arterial side but also, you’re setting back pressure wave on the venous side. Obviously, the arterial side always wins out, but it’s just not as efficient as it could be, at 20% or 30%.

What does this entail? It entails several independent mechanisms in terms of how they work, but they all do the same thing, which is they help to pull blood out of the brain and back into the right heart by basically manipulating intrathoracic pressure and creating more of a vacuum to get blood back there.

It’s so important that people do quality CPR. You have to have a good release and that helps us suck a little bit of blood and sucks the air in. As soon as the air rushes in, it neutralizes the pressure and there’s no more vacuum and nothing else is happening until the next squeeze.

What we have found is that we can cap the airway just for a second with a little pop-up valve. It acts like when you’re sucking a milkshake through a straw and it creates more of a vacuum in the chest. Just a little pop-up valve that pulls a little bit more blood out of the brain and the rest of the body and into the right heart.

We’ve shown in a human study that, for example, the systolic blood pressure almost doubles. It really goes from 40 mm Hg during standard CPR up to 80 mm Hg, and that would be sustained for 14-15 minutes. That was a nice little study that was done in Milwaukee a few years ago.

The other thing that happens is, if you add on something else, it’s like a toilet plunger. I think many people have seen it; it’s called “active compression-decompression.” It not only compresses, but it decompresses. Where it becomes even more effective is that if you had broken bones or stiff bones as you get older or whatever it may be, as you do the CPR, you’re still getting the push down and then you’re getting the pull out. It helps on several levels. More importantly, when you put the two together, they’re very synergistic.

We, have already done the clinical trial that is the proof of concept, and that was published in The Lancet about 10 years ago. In that study, we found that the combination of those two dramatically improved survival rates by 50%, with 1-year survival neurologically intact. That got us on the right track.

The interesting thing is that someone said, “Can we lift the head up a little bit?” We did a large amount of work in the laboratory over 10 years, fine tuning it. When do you first lift the head? How soon is too soon? It’s probably bad if you just go right to it.

We had to get the pump primed a little bit with these other things to get the flow going better, not only pulling blood out of the brain but now, you have a better flow this way. You have to prime at first for a couple of minutes, and we worked out the timing: Is it 3 or 4 minutes? It seems the timing is right at about 2 minutes, then you gradually elevate the head over about 2 minutes. We’re finding that seems to be the optimal way to do it. About 2 minutes of priming with those other two devices, the adjuncts, and then gradually elevate the head over 2 minutes.

When we do that in the laboratory, we’re getting normalized cerebral perfusion pressures. You’re normalizing the flow back again with that. We’re seeing profound differences in outcome as a result, even in these cases of the nonshockables.
 

Dr. Glatter: What you’re doing basically is resulting in an increase in cardiac output, essentially. That really is important, especially in these nonshockable rhythms, correct?

Dr. Pepe: Absolutely. As you’re doing this compression and you’re getting these intracranial pulse waves that are going up because they’re colliding up there. It could be even damaging in itself, but we’re seeing these intracranial raises. The intracranial pressure starts going up more and more over time. Also, peripherally in most people, you’re not getting good flow out there; then, your vasculature starts to relax. The arterials are starting to not get oxygen, so they don’t go out.

With this technique where we’re returning the pressure, we’re getting to 40% of normal now with the active compression-decompression CPR plus an impedance threshold device (ACD+ITD CPR) approach. Now, you add this, and you’re almost normalizing. In humans, even in these asystole patients, we’re seeing end-title CO₂s which are generally in the 15-20 range with standard CPR are now up with ACD+ITD CPR in the 30%-40% range, where we’re getting through 30 or 40 end-tidal CO₂s. Now, we’re seeing even the end-tidal CO₂s moving up into the 40s and 50s. We know there’s a surrogate marker telling us that we are generating much better flows not only to the rest of the body, but most importantly, to the brain.
 

Dr. Glatter: Ryan, could you tell us about the approach in terms of on scene, what you’re doing and how you use the device itself? Maybe you could talk about the backpack that you developed with your fire department?

Ryan P. Quinn, BS, EMS: Our approach has always been to get to the patient quickly, like everybody’s approach on a cardiac arrest when you’re responding. We are an advanced life-support paramedic ambulance service through the fire department – we’re all cross-trained firefighter paramedics. Our first vehicle from the fire department is typically the ambulance. It’s smaller and a little quicker than the fire engine. Two paramedics are going to jump out with two backpacks. One has the automated compressive device (we use the Lucas), and the other one is the sequential patient lifting device, the EleGARD.

Our two paramedics are quick to the patient’s side, and once they make contact with the patient to verify pulseless cardiac arrest, they will unpack. One person will go right to compressions if there’s nobody on compressions already. Sometimes we have a first responder police officer with an automated external defibrillator (AED). We go right to the patient’s side, concentrate on compressions, and within 90 seconds to 2 minutes, we have our bags unpacked, we’ve got the devices turned on, patient lifted up, slid under the device, and we have a supraglottic airway that is placed within 15 seconds already premade with the ITD on top. We have a sealed airway that we can continue to compress with Dr. Pepe’s original discussion of building on what’s previously been shown to work.

Dr. Pepe: Let me make a comment about this. This is so important, what Ryan is saying, because it’s something we found during the study. It’s really a true pit-crew approach. You’re not only getting these materials, which you think you need a medical Sherpa for, but you don’t. They set it up and then when they open it up, it’s all laid out just exactly as you need it. It’s not just how fast you get there; it’s how fast you get this done.

When we look at all cases combined against high-performance systems that had some of the highest survival rates around, when we compare it to those, we found that overall, even if you looked at the ones that had over 20-minute responses, the odds ratios were still three to four times higher. It was impressive.

If you looked at it under 15 minutes, which is really reasonable for most systems that get there by the way, the average time that people start CPR in any system in these studies has been about 8 minutes if you actually start this thing, which takes about 2 minutes more for this new bundle of care with this triad, it’s almost 12-14 times higher in terms of the odds ratio. I’ve never seen anything like that where the higher end is over 100 in terms of your confidence intervals.

Ryan’s system did really well and is one of those with even higher levels of outcomes, mostly because they got it on quickly. It’s like the AED for nonshockables but better because you have a wider range of efficacy where it will work.
 

Dr. Glatter: When the elapsed time was less than 11 minutes, that seemed to be an inflection point in the study, is that correct? You saw that 11-fold higher incidence in terms of neurologically intact survival, is that correct?

Dr. Pepe: We picked that number because that was the median time to get it on board. Half the people were getting it within that time period. The fact that you have a larger window, we’re talking about 13- almost 14-fold improvements in outcome if it was under 15 minutes. It doesn’t matter about the 11 or the 12. It’s the faster you get it on board, the better off you are.

Dr. Glatter: What’s the next step in the process of doing trials and having implementation on a larger scale based on your Annals of Emergency Medicine study? Where do you go from here?

Dr. Pepe: I’ve come to find out there are many confounding variables. What was the quality of CPR? How did people ventilate? Did they give the breath and hold it? Did they give a large enough breath so that blood can go across the transpulmonary system? There are many confounding variables. That’s why I think, in the future, it’s going to be more of looking at things like propensity score matching because we know all the variables that change outcomes. I think that’s going to be a way for me.

The other thing is that we were looking at only 380 cases here. When this doubles up in numbers, as we accrue more cases around the country of people who are implementing this, these numbers I just quoted are going to go up much higher. Unwitnessed asystole is considered futile, and you just don’t get them back. To be able to get these folks back now, even if it’s a small percentage, and the fact that we know that we’re producing this better flow, is pretty striking.

I’m really impressed, and the main thing is to make sure people are educated about it. Number two is that they understand that it has to be done right. It cannot be done wrong or you’re not going to see the differences. Getting it done right is not only following the procedures, the sequence, and how you do it, but it also has to do with getting there quickly, including assigning the right people to put it on and having well-trained people who know what they’re doing.
 

Dr. Glatter: In general, the lay public obviously should not attempt this in the field lifting someone’s head up in the sense of trying to do chest compressions. I think that message is important that you just said. It’s not ready for prime time yet in any way. It has to be done right.

Dr. Pepe: Bystanders have to learn CPR – they will buy us time and we’ll have better outcomes when they do that. That’s number one. Number two is that as more and more systems adopt this, you’re going to see more people coming back. If you think about what we’re doing now, if we only get back 5% of these nonshockable vs. less than 1%, it’s 5% of 800 people a day because a thousand people a day die. Several dozens of lives can be saved on a daily basis, coming back neurologically intact. That’s the key thing.

Dr. Glatter: Ryan, can you comment about your experience in the field? Is there anything in terms of your current approach that you think would be ideal to change at this point?

Mr. Quinn: We’ve established that this is the approach that we want to take and we’re just fine tuning it to be more efficient. Using the choreography of which person is going to do which role, we have clearly defined roles and clearly defined command of the scene so we’re not missing anything. Training is extremely important.

Dr. Glatter: Paul, I want to ask you about your anecdotal experience of people waking up quickly and talking after elevating their heads and going through this process. Having people talk about it and waking up is really fascinating. Maybe you can comment further on this.

Dr. Pepe: That’s a great point that you bring up because a 40- to 50-year-old guy who got saved with this approach, when he came around, he said he was hearing what people were saying. When he came out of it, he found out he had been getting CPR for about 25 minutes because he had persistent recurring ventricular fibrillation. He said, “How could I have survived that that long?”

When we told him about the new approach, he added, “Well, that’s like neuroprotective.” He’s right, because in the laboratory, we showed it was neuroprotective and we’re also getting better flows back there. It goes along with everything else, and so we’ve adopted the name because it is.

These are really high-powered systems we are comparing against, and we have the same level of return of spontaneous circulation. The major difference was when you started talking about the neurointact survival. We don’t have enough numbers yet, but next go around, we’re going to look at cerebral performance category (CPC) – CPC1 vs. the CPC2 – which were both considered intact, but CPC1 is actually better. We’re seeing many more of those, anecdotally.

I also wanted to mention that people do bring this up and say, “Well, let’s do a trial.” As far as we’re concerned, the trial’s been done in terms of The Lancet study 10 years ago that showed that the active compression-decompression had tremendously better outcomes. We show in the laboratories that you augment that a little bit. These are all [Food and Drug Administration] approved. You can go out and buy it tomorrow and get it done. I have no conflicts of interest, by the way, with any of this.

To have this device that’s going to have the potential of saving so many more lives is really an exciting breakthrough. More importantly, we’re understanding more now about the physiology of CPR and why it works. It could work much better with the approaches that we’ve been developing over the last 20 years or so.

Dr. Glatter: Absolutely. I want to thank both of you gentlemen. It’s been really an incredible experience to learn more about an advance in resuscitation that could truly be lifesaving. Thank you again for taking time to join us.

Dr. Glatter is an attending physician in the department of emergency medicine, Lenox Hill Hospital, New York. Dr. Pepe is professor, department of management, policy, and community health, University of Texas Health Sciences Center, Houston. Mr. Quinn is EMS Chief, Edina (Minn.) Fire Department. No conflicts of interest were reported.

A version of this article first appeared Jan. 26 on Medscape.com.

This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I’m Dr Robert Glatter, medical adviser for Medscape Emergency Medicine. Today, we have Dr. Paul Pepe, an emergency physician and highly recognized expert in EMS, critical care, and resuscitation, along with Ryan Quinn, EMS chief for Edina Fire Department in Edina, Minn., joining us to discuss a significant advance in resuscitation for patients with nonshockable rhythms in cardiac arrest with a remarkable increase in neurologically intact survival. Welcome, gentlemen.

Dr. Pepe, I’d like to start off by thanking you for taking time to join us to discuss this novel concept of head-up or what you now refer to as a neuroprotective cardiopulmonary resuscitation (CPR) bundle. Can you define what this entails and why it is referred to as a neuroprotective CPR bundle?

Paul E. Pepe, MD, MPH: CPR has been life saving for 60 years the way we’ve performed it, but probably only in a very small percentage of cases. That’s one of the problems. We have almost a thousand people a day who have sudden cardiac arrest out in the community alone and more in the hospital.

We know that early defibrillation and early CPR can contribute, but it’s still a small percentage of those. About 75%-85% of the cases that we go out to see will have nonshockable rhythms and flatlines. Some cases are what we call “pulseless electrical activity,” meaning that it looks like there is some kind of organized complex, but there is no pulse associated with it.

That’s why it’s a problem, because they don’t come back. Part of the reason why we see poor outcomes is not only that these cases tend to be people who, say, were in ventricular fibrillation and then just went on over time and were not witnessed or resuscitated or had a long response time. They basically either go into flatline or autoconvert into these bizarre rhythms.

The other issue is the way we perform CPR. CPR has been lifesaving, but it only generates about 20% and maybe 15% in some cases of normal blood flow, and particularly, cerebral perfusion pressure. We’ve looked at this nicely in the laboratory.

For example, during chest compressions, we’re hoping during the recoil phase to pull blood down and back into the right heart. The problem is that you’re not only setting a pressure rate up here to the arterial side but also, you’re setting back pressure wave on the venous side. Obviously, the arterial side always wins out, but it’s just not as efficient as it could be, at 20% or 30%.

What does this entail? It entails several independent mechanisms in terms of how they work, but they all do the same thing, which is they help to pull blood out of the brain and back into the right heart by basically manipulating intrathoracic pressure and creating more of a vacuum to get blood back there.

It’s so important that people do quality CPR. You have to have a good release and that helps us suck a little bit of blood and sucks the air in. As soon as the air rushes in, it neutralizes the pressure and there’s no more vacuum and nothing else is happening until the next squeeze.

What we have found is that we can cap the airway just for a second with a little pop-up valve. It acts like when you’re sucking a milkshake through a straw and it creates more of a vacuum in the chest. Just a little pop-up valve that pulls a little bit more blood out of the brain and the rest of the body and into the right heart.

We’ve shown in a human study that, for example, the systolic blood pressure almost doubles. It really goes from 40 mm Hg during standard CPR up to 80 mm Hg, and that would be sustained for 14-15 minutes. That was a nice little study that was done in Milwaukee a few years ago.

The other thing that happens is, if you add on something else, it’s like a toilet plunger. I think many people have seen it; it’s called “active compression-decompression.” It not only compresses, but it decompresses. Where it becomes even more effective is that if you had broken bones or stiff bones as you get older or whatever it may be, as you do the CPR, you’re still getting the push down and then you’re getting the pull out. It helps on several levels. More importantly, when you put the two together, they’re very synergistic.

We, have already done the clinical trial that is the proof of concept, and that was published in The Lancet about 10 years ago. In that study, we found that the combination of those two dramatically improved survival rates by 50%, with 1-year survival neurologically intact. That got us on the right track.

The interesting thing is that someone said, “Can we lift the head up a little bit?” We did a large amount of work in the laboratory over 10 years, fine tuning it. When do you first lift the head? How soon is too soon? It’s probably bad if you just go right to it.

We had to get the pump primed a little bit with these other things to get the flow going better, not only pulling blood out of the brain but now, you have a better flow this way. You have to prime at first for a couple of minutes, and we worked out the timing: Is it 3 or 4 minutes? It seems the timing is right at about 2 minutes, then you gradually elevate the head over about 2 minutes. We’re finding that seems to be the optimal way to do it. About 2 minutes of priming with those other two devices, the adjuncts, and then gradually elevate the head over 2 minutes.

When we do that in the laboratory, we’re getting normalized cerebral perfusion pressures. You’re normalizing the flow back again with that. We’re seeing profound differences in outcome as a result, even in these cases of the nonshockables.
 

Dr. Glatter: What you’re doing basically is resulting in an increase in cardiac output, essentially. That really is important, especially in these nonshockable rhythms, correct?

Dr. Pepe: Absolutely. As you’re doing this compression and you’re getting these intracranial pulse waves that are going up because they’re colliding up there. It could be even damaging in itself, but we’re seeing these intracranial raises. The intracranial pressure starts going up more and more over time. Also, peripherally in most people, you’re not getting good flow out there; then, your vasculature starts to relax. The arterials are starting to not get oxygen, so they don’t go out.

With this technique where we’re returning the pressure, we’re getting to 40% of normal now with the active compression-decompression CPR plus an impedance threshold device (ACD+ITD CPR) approach. Now, you add this, and you’re almost normalizing. In humans, even in these asystole patients, we’re seeing end-title CO₂s which are generally in the 15-20 range with standard CPR are now up with ACD+ITD CPR in the 30%-40% range, where we’re getting through 30 or 40 end-tidal CO₂s. Now, we’re seeing even the end-tidal CO₂s moving up into the 40s and 50s. We know there’s a surrogate marker telling us that we are generating much better flows not only to the rest of the body, but most importantly, to the brain.
 

Dr. Glatter: Ryan, could you tell us about the approach in terms of on scene, what you’re doing and how you use the device itself? Maybe you could talk about the backpack that you developed with your fire department?

Ryan P. Quinn, BS, EMS: Our approach has always been to get to the patient quickly, like everybody’s approach on a cardiac arrest when you’re responding. We are an advanced life-support paramedic ambulance service through the fire department – we’re all cross-trained firefighter paramedics. Our first vehicle from the fire department is typically the ambulance. It’s smaller and a little quicker than the fire engine. Two paramedics are going to jump out with two backpacks. One has the automated compressive device (we use the Lucas), and the other one is the sequential patient lifting device, the EleGARD.

Our two paramedics are quick to the patient’s side, and once they make contact with the patient to verify pulseless cardiac arrest, they will unpack. One person will go right to compressions if there’s nobody on compressions already. Sometimes we have a first responder police officer with an automated external defibrillator (AED). We go right to the patient’s side, concentrate on compressions, and within 90 seconds to 2 minutes, we have our bags unpacked, we’ve got the devices turned on, patient lifted up, slid under the device, and we have a supraglottic airway that is placed within 15 seconds already premade with the ITD on top. We have a sealed airway that we can continue to compress with Dr. Pepe’s original discussion of building on what’s previously been shown to work.

Dr. Pepe: Let me make a comment about this. This is so important, what Ryan is saying, because it’s something we found during the study. It’s really a true pit-crew approach. You’re not only getting these materials, which you think you need a medical Sherpa for, but you don’t. They set it up and then when they open it up, it’s all laid out just exactly as you need it. It’s not just how fast you get there; it’s how fast you get this done.

When we look at all cases combined against high-performance systems that had some of the highest survival rates around, when we compare it to those, we found that overall, even if you looked at the ones that had over 20-minute responses, the odds ratios were still three to four times higher. It was impressive.

If you looked at it under 15 minutes, which is really reasonable for most systems that get there by the way, the average time that people start CPR in any system in these studies has been about 8 minutes if you actually start this thing, which takes about 2 minutes more for this new bundle of care with this triad, it’s almost 12-14 times higher in terms of the odds ratio. I’ve never seen anything like that where the higher end is over 100 in terms of your confidence intervals.

Ryan’s system did really well and is one of those with even higher levels of outcomes, mostly because they got it on quickly. It’s like the AED for nonshockables but better because you have a wider range of efficacy where it will work.
 

Dr. Glatter: When the elapsed time was less than 11 minutes, that seemed to be an inflection point in the study, is that correct? You saw that 11-fold higher incidence in terms of neurologically intact survival, is that correct?

Dr. Pepe: We picked that number because that was the median time to get it on board. Half the people were getting it within that time period. The fact that you have a larger window, we’re talking about 13- almost 14-fold improvements in outcome if it was under 15 minutes. It doesn’t matter about the 11 or the 12. It’s the faster you get it on board, the better off you are.

Dr. Glatter: What’s the next step in the process of doing trials and having implementation on a larger scale based on your Annals of Emergency Medicine study? Where do you go from here?

Dr. Pepe: I’ve come to find out there are many confounding variables. What was the quality of CPR? How did people ventilate? Did they give the breath and hold it? Did they give a large enough breath so that blood can go across the transpulmonary system? There are many confounding variables. That’s why I think, in the future, it’s going to be more of looking at things like propensity score matching because we know all the variables that change outcomes. I think that’s going to be a way for me.

The other thing is that we were looking at only 380 cases here. When this doubles up in numbers, as we accrue more cases around the country of people who are implementing this, these numbers I just quoted are going to go up much higher. Unwitnessed asystole is considered futile, and you just don’t get them back. To be able to get these folks back now, even if it’s a small percentage, and the fact that we know that we’re producing this better flow, is pretty striking.

I’m really impressed, and the main thing is to make sure people are educated about it. Number two is that they understand that it has to be done right. It cannot be done wrong or you’re not going to see the differences. Getting it done right is not only following the procedures, the sequence, and how you do it, but it also has to do with getting there quickly, including assigning the right people to put it on and having well-trained people who know what they’re doing.
 

Dr. Glatter: In general, the lay public obviously should not attempt this in the field lifting someone’s head up in the sense of trying to do chest compressions. I think that message is important that you just said. It’s not ready for prime time yet in any way. It has to be done right.

Dr. Pepe: Bystanders have to learn CPR – they will buy us time and we’ll have better outcomes when they do that. That’s number one. Number two is that as more and more systems adopt this, you’re going to see more people coming back. If you think about what we’re doing now, if we only get back 5% of these nonshockable vs. less than 1%, it’s 5% of 800 people a day because a thousand people a day die. Several dozens of lives can be saved on a daily basis, coming back neurologically intact. That’s the key thing.

Dr. Glatter: Ryan, can you comment about your experience in the field? Is there anything in terms of your current approach that you think would be ideal to change at this point?

Mr. Quinn: We’ve established that this is the approach that we want to take and we’re just fine tuning it to be more efficient. Using the choreography of which person is going to do which role, we have clearly defined roles and clearly defined command of the scene so we’re not missing anything. Training is extremely important.

Dr. Glatter: Paul, I want to ask you about your anecdotal experience of people waking up quickly and talking after elevating their heads and going through this process. Having people talk about it and waking up is really fascinating. Maybe you can comment further on this.

Dr. Pepe: That’s a great point that you bring up because a 40- to 50-year-old guy who got saved with this approach, when he came around, he said he was hearing what people were saying. When he came out of it, he found out he had been getting CPR for about 25 minutes because he had persistent recurring ventricular fibrillation. He said, “How could I have survived that that long?”

When we told him about the new approach, he added, “Well, that’s like neuroprotective.” He’s right, because in the laboratory, we showed it was neuroprotective and we’re also getting better flows back there. It goes along with everything else, and so we’ve adopted the name because it is.

These are really high-powered systems we are comparing against, and we have the same level of return of spontaneous circulation. The major difference was when you started talking about the neurointact survival. We don’t have enough numbers yet, but next go around, we’re going to look at cerebral performance category (CPC) – CPC1 vs. the CPC2 – which were both considered intact, but CPC1 is actually better. We’re seeing many more of those, anecdotally.

I also wanted to mention that people do bring this up and say, “Well, let’s do a trial.” As far as we’re concerned, the trial’s been done in terms of The Lancet study 10 years ago that showed that the active compression-decompression had tremendously better outcomes. We show in the laboratories that you augment that a little bit. These are all [Food and Drug Administration] approved. You can go out and buy it tomorrow and get it done. I have no conflicts of interest, by the way, with any of this.

To have this device that’s going to have the potential of saving so many more lives is really an exciting breakthrough. More importantly, we’re understanding more now about the physiology of CPR and why it works. It could work much better with the approaches that we’ve been developing over the last 20 years or so.

Dr. Glatter: Absolutely. I want to thank both of you gentlemen. It’s been really an incredible experience to learn more about an advance in resuscitation that could truly be lifesaving. Thank you again for taking time to join us.

Dr. Glatter is an attending physician in the department of emergency medicine, Lenox Hill Hospital, New York. Dr. Pepe is professor, department of management, policy, and community health, University of Texas Health Sciences Center, Houston. Mr. Quinn is EMS Chief, Edina (Minn.) Fire Department. No conflicts of interest were reported.

A version of this article first appeared Jan. 26 on Medscape.com.

When you became a doctor, you may have moved to one city for med school, another for residency, and a third to be an attending. All that moving can make it hard to maintain friendships. Factor in the challenges from the pandemic, and a physician’s life can be lonely. So, when a patient invites you for coffee or a game of pickleball, do you accept? For almost one-third of the physicians who responded to the Medscape Physician Friendships: The Joys and Challenges 2022, the answer might be yes.

About 29% said they develop friendships with patients. However, a lot depends on the circumstances. As one physician in the report said: “I have been a pediatrician for 35 years, and my patients have grown up and become productive adults in our small, rural, isolated area. You can’t help but know almost everyone.”

As the daughter of a cardiologist, Nishi Mehta, MD, a radiologist and founder of the largest physician-only Facebook group in the country, grew up with that small-town-everyone-knows-the-doctor model.

“When I was a kid, I’d go to the mall, and my friends and I would play a game: How long before a patient [of my dad’s] comes up to me?” she said. At the time, Dr. Mehta was embarrassed, but now she marvels that her dad knew his patients so well that they would recognize his daughter in crowded suburban mall.

In other instances, a physician may develop a friendly relationship after a patient leaves their care. For example, Leo Nissola, MD, now a full-time researcher and immunotherapy scientist in San Francisco, has stayed in touch with some of the patients he treated while at the University of Texas MD Anderson Cancer Center, Houston.

Dr. Nissola said it was important to stay connected with the patients he had meaningful relationships with. “It becomes challenging, though, when a former patient asks for medical advice.” At that moment, “you have to be explicitly clear that the relationship has changed.”
 

A hard line in the sand

The blurring of lines is one reason many doctors refuse to befriend patients, even after they are no longer treating them. The American College of Physicians Ethics Manual advises against treating anyone with whom you have a close relationship, including family and friends.

“Friendships can get in the way of patients being honest with you, which can interfere with medical care,” Dr. Mehta said. “If a patient has a concern related to something they wouldn’t want you to know as friends, it can get awkward. They may elect not to tell you.”

And on the flip side, friendship can provide a view into your private life that you may not welcome in the exam room.

“Let’s say you go out for drinks [with a patient], and you’re up late, but you have surgery the next day,” said Brandi Ring, MD, an ob.gyn. and the associate medical director at the Center for Children and Women in Houston. Now, one of your patients knows you were out until midnight when you had to be in the OR at 5:00 a.m.

Worse still, your relationship could color your decisions about a patient’s care, even unconsciously. It can be hard to maintain objectivity when you have an emotional investment in someone’s well-being.

“We don’t necessarily treat family and friends to the standards of medical care,” said Dr. Ring. “We go above and beyond. We might order more tests and more scans. We don’t always follow the guidelines, especially in critical illness.”

For all these reasons and more, the ACP advises against treating friends.
 

Put physician before friend

But adhering to those guidelines can lead physicians to make some painful decisions. Cutting yourself off from the possibility of friendship is never easy, and the Medscape report found that physicians tend to have fewer friends than the average American.

“Especially earlier in my practice, when I was a young parent, and I would see a lot of other young parents in the same stage in life, I’d think, ‘In other circumstances, I would be hanging out at the park with this person,’ “ said Kathleen Rowland, MD, a family medicine physician and vice chair of education in the department of family medicine at Rush University, Chicago. “But the hard part is, the doctor-patient relationship always comes first.”

To a certain extent, one’s specialty may determine the feasibility of becoming friends with a patient. While Dr. Mehta has never done so, as a radiologist, she doesn’t usually see patients repeatedly. Likewise, a young gerontologist may have little in common with his octogenarian patients. And an older pediatrician is not in the same life stage as his patients’ sleep-deprived new parents, possibly making them less attractive friends.

However, practicing family medicine is all about long-term physician-patient relationships. Getting to know patients and their families over many years can lead to a certain intimacy. Dr. Rowland said that, while a wonderful part of being a physician is getting that unique trust whereby patients tell you all sorts of things about their lives, she’s never gone down the friendship path.

“There’s the assumption I’ll take care of someone for a long period of time, and their partner and their kids, maybe another generation or two,” Dr. Rowland said. “People really do rely on that relationship to contribute to their health.”

Worse, nowadays, when people may be starved for connection, many patients want to feel emotionally close and cared for by their doctor, so it’d be easy to cross the line. While patients deserve a compassionate, caring doctor, the physician is left to walk the line between those boundaries. Dr. Rowland said, “It’s up to the clinician to say: ‘My role is as a doctor. You deserve caring friends, but I have to order your mammogram and your blood counts. My role is different.’ ”
 

Friendly but not friends

It can be tricky to navigate the boundary between a cordial, warm relationship with a patient and that patient inviting you to their daughter’s wedding.

“People may mistake being pleasant and friendly for being friends,” said Larry Blosser, MD, chief medical officer at Central Ohio Primary Care, Westerville. In his position, he sometimes hears from patients who have misunderstood their relationship with a doctor in the practice. When that happens, he advises the physician to consider the persona they’re presenting to the patient. If you’re overly friendly, there’s the potential for confusion, but you can’t be aloof and cold, he said.

Maintaining that awareness helps to prevent a patient’s offhand invitation to catch a movie or go on a hike. And verbalizing it to your patients can make your relationship clear from the get-go.

“I tell patients we’re a team. I’m the captain, and they’re my MVP. When the match is over, whatever the results, we’re done,” said Karenne Fru, MD, PhD, a fertility specialist at Oma Fertility Atlanta. Making deep connections is essential to her practice, so Dr. Fru structures her patient interactions carefully. “Infertility is such an isolating experience. While you’re with us, we care about what’s going on in your life, your pets, and your mom’s chemo. We need mutual trust for you to be compliant with the care.”

However, that approach won’t work when you see patients regularly, as with family practice or specialties that see the same patients repeatedly throughout the year. In those circumstances, the match is never over but one in which the onus is on the physician to establish a friendly yet professional rapport without letting your self-interest, loneliness, or lack of friends interfere.

“It’s been a very difficult couple of years for a lot of us. Depending on what kind of clinical work we do, some of us took care of healthy people that got very sick or passed away,” Dr. Rowland said. “Having the chance to reconnect with people and reestablish some of that closeness, both physical and emotional, is going to be good for us.”

Just continue conveying warm, trusting compassion for your patients without blurring the friend lines.

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

When you became a doctor, you may have moved to one city for med school, another for residency, and a third to be an attending. All that moving can make it hard to maintain friendships. Factor in the challenges from the pandemic, and a physician’s life can be lonely. So, when a patient invites you for coffee or a game of pickleball, do you accept? For almost one-third of the physicians who responded to the Medscape Physician Friendships: The Joys and Challenges 2022, the answer might be yes.

About 29% said they develop friendships with patients. However, a lot depends on the circumstances. As one physician in the report said: “I have been a pediatrician for 35 years, and my patients have grown up and become productive adults in our small, rural, isolated area. You can’t help but know almost everyone.”

As the daughter of a cardiologist, Nishi Mehta, MD, a radiologist and founder of the largest physician-only Facebook group in the country, grew up with that small-town-everyone-knows-the-doctor model.

“When I was a kid, I’d go to the mall, and my friends and I would play a game: How long before a patient [of my dad’s] comes up to me?” she said. At the time, Dr. Mehta was embarrassed, but now she marvels that her dad knew his patients so well that they would recognize his daughter in crowded suburban mall.

In other instances, a physician may develop a friendly relationship after a patient leaves their care. For example, Leo Nissola, MD, now a full-time researcher and immunotherapy scientist in San Francisco, has stayed in touch with some of the patients he treated while at the University of Texas MD Anderson Cancer Center, Houston.

Dr. Nissola said it was important to stay connected with the patients he had meaningful relationships with. “It becomes challenging, though, when a former patient asks for medical advice.” At that moment, “you have to be explicitly clear that the relationship has changed.”
 

A hard line in the sand

The blurring of lines is one reason many doctors refuse to befriend patients, even after they are no longer treating them. The American College of Physicians Ethics Manual advises against treating anyone with whom you have a close relationship, including family and friends.

“Friendships can get in the way of patients being honest with you, which can interfere with medical care,” Dr. Mehta said. “If a patient has a concern related to something they wouldn’t want you to know as friends, it can get awkward. They may elect not to tell you.”

And on the flip side, friendship can provide a view into your private life that you may not welcome in the exam room.

“Let’s say you go out for drinks [with a patient], and you’re up late, but you have surgery the next day,” said Brandi Ring, MD, an ob.gyn. and the associate medical director at the Center for Children and Women in Houston. Now, one of your patients knows you were out until midnight when you had to be in the OR at 5:00 a.m.

Worse still, your relationship could color your decisions about a patient’s care, even unconsciously. It can be hard to maintain objectivity when you have an emotional investment in someone’s well-being.

“We don’t necessarily treat family and friends to the standards of medical care,” said Dr. Ring. “We go above and beyond. We might order more tests and more scans. We don’t always follow the guidelines, especially in critical illness.”

For all these reasons and more, the ACP advises against treating friends.
 

Put physician before friend

But adhering to those guidelines can lead physicians to make some painful decisions. Cutting yourself off from the possibility of friendship is never easy, and the Medscape report found that physicians tend to have fewer friends than the average American.

“Especially earlier in my practice, when I was a young parent, and I would see a lot of other young parents in the same stage in life, I’d think, ‘In other circumstances, I would be hanging out at the park with this person,’ “ said Kathleen Rowland, MD, a family medicine physician and vice chair of education in the department of family medicine at Rush University, Chicago. “But the hard part is, the doctor-patient relationship always comes first.”

To a certain extent, one’s specialty may determine the feasibility of becoming friends with a patient. While Dr. Mehta has never done so, as a radiologist, she doesn’t usually see patients repeatedly. Likewise, a young gerontologist may have little in common with his octogenarian patients. And an older pediatrician is not in the same life stage as his patients’ sleep-deprived new parents, possibly making them less attractive friends.

However, practicing family medicine is all about long-term physician-patient relationships. Getting to know patients and their families over many years can lead to a certain intimacy. Dr. Rowland said that, while a wonderful part of being a physician is getting that unique trust whereby patients tell you all sorts of things about their lives, she’s never gone down the friendship path.

“There’s the assumption I’ll take care of someone for a long period of time, and their partner and their kids, maybe another generation or two,” Dr. Rowland said. “People really do rely on that relationship to contribute to their health.”

Worse, nowadays, when people may be starved for connection, many patients want to feel emotionally close and cared for by their doctor, so it’d be easy to cross the line. While patients deserve a compassionate, caring doctor, the physician is left to walk the line between those boundaries. Dr. Rowland said, “It’s up to the clinician to say: ‘My role is as a doctor. You deserve caring friends, but I have to order your mammogram and your blood counts. My role is different.’ ”
 

Friendly but not friends

It can be tricky to navigate the boundary between a cordial, warm relationship with a patient and that patient inviting you to their daughter’s wedding.

“People may mistake being pleasant and friendly for being friends,” said Larry Blosser, MD, chief medical officer at Central Ohio Primary Care, Westerville. In his position, he sometimes hears from patients who have misunderstood their relationship with a doctor in the practice. When that happens, he advises the physician to consider the persona they’re presenting to the patient. If you’re overly friendly, there’s the potential for confusion, but you can’t be aloof and cold, he said.

Maintaining that awareness helps to prevent a patient’s offhand invitation to catch a movie or go on a hike. And verbalizing it to your patients can make your relationship clear from the get-go.

“I tell patients we’re a team. I’m the captain, and they’re my MVP. When the match is over, whatever the results, we’re done,” said Karenne Fru, MD, PhD, a fertility specialist at Oma Fertility Atlanta. Making deep connections is essential to her practice, so Dr. Fru structures her patient interactions carefully. “Infertility is such an isolating experience. While you’re with us, we care about what’s going on in your life, your pets, and your mom’s chemo. We need mutual trust for you to be compliant with the care.”

However, that approach won’t work when you see patients regularly, as with family practice or specialties that see the same patients repeatedly throughout the year. In those circumstances, the match is never over but one in which the onus is on the physician to establish a friendly yet professional rapport without letting your self-interest, loneliness, or lack of friends interfere.

“It’s been a very difficult couple of years for a lot of us. Depending on what kind of clinical work we do, some of us took care of healthy people that got very sick or passed away,” Dr. Rowland said. “Having the chance to reconnect with people and reestablish some of that closeness, both physical and emotional, is going to be good for us.”

Just continue conveying warm, trusting compassion for your patients without blurring the friend lines.

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

When you became a doctor, you may have moved to one city for med school, another for residency, and a third to be an attending. All that moving can make it hard to maintain friendships. Factor in the challenges from the pandemic, and a physician’s life can be lonely. So, when a patient invites you for coffee or a game of pickleball, do you accept? For almost one-third of the physicians who responded to the Medscape Physician Friendships: The Joys and Challenges 2022, the answer might be yes.

About 29% said they develop friendships with patients. However, a lot depends on the circumstances. As one physician in the report said: “I have been a pediatrician for 35 years, and my patients have grown up and become productive adults in our small, rural, isolated area. You can’t help but know almost everyone.”

As the daughter of a cardiologist, Nishi Mehta, MD, a radiologist and founder of the largest physician-only Facebook group in the country, grew up with that small-town-everyone-knows-the-doctor model.

“When I was a kid, I’d go to the mall, and my friends and I would play a game: How long before a patient [of my dad’s] comes up to me?” she said. At the time, Dr. Mehta was embarrassed, but now she marvels that her dad knew his patients so well that they would recognize his daughter in crowded suburban mall.

In other instances, a physician may develop a friendly relationship after a patient leaves their care. For example, Leo Nissola, MD, now a full-time researcher and immunotherapy scientist in San Francisco, has stayed in touch with some of the patients he treated while at the University of Texas MD Anderson Cancer Center, Houston.

Dr. Nissola said it was important to stay connected with the patients he had meaningful relationships with. “It becomes challenging, though, when a former patient asks for medical advice.” At that moment, “you have to be explicitly clear that the relationship has changed.”
 

A hard line in the sand

The blurring of lines is one reason many doctors refuse to befriend patients, even after they are no longer treating them. The American College of Physicians Ethics Manual advises against treating anyone with whom you have a close relationship, including family and friends.

“Friendships can get in the way of patients being honest with you, which can interfere with medical care,” Dr. Mehta said. “If a patient has a concern related to something they wouldn’t want you to know as friends, it can get awkward. They may elect not to tell you.”

And on the flip side, friendship can provide a view into your private life that you may not welcome in the exam room.

“Let’s say you go out for drinks [with a patient], and you’re up late, but you have surgery the next day,” said Brandi Ring, MD, an ob.gyn. and the associate medical director at the Center for Children and Women in Houston. Now, one of your patients knows you were out until midnight when you had to be in the OR at 5:00 a.m.

Worse still, your relationship could color your decisions about a patient’s care, even unconsciously. It can be hard to maintain objectivity when you have an emotional investment in someone’s well-being.

“We don’t necessarily treat family and friends to the standards of medical care,” said Dr. Ring. “We go above and beyond. We might order more tests and more scans. We don’t always follow the guidelines, especially in critical illness.”

For all these reasons and more, the ACP advises against treating friends.
 

Put physician before friend

But adhering to those guidelines can lead physicians to make some painful decisions. Cutting yourself off from the possibility of friendship is never easy, and the Medscape report found that physicians tend to have fewer friends than the average American.

“Especially earlier in my practice, when I was a young parent, and I would see a lot of other young parents in the same stage in life, I’d think, ‘In other circumstances, I would be hanging out at the park with this person,’ “ said Kathleen Rowland, MD, a family medicine physician and vice chair of education in the department of family medicine at Rush University, Chicago. “But the hard part is, the doctor-patient relationship always comes first.”

To a certain extent, one’s specialty may determine the feasibility of becoming friends with a patient. While Dr. Mehta has never done so, as a radiologist, she doesn’t usually see patients repeatedly. Likewise, a young gerontologist may have little in common with his octogenarian patients. And an older pediatrician is not in the same life stage as his patients’ sleep-deprived new parents, possibly making them less attractive friends.

However, practicing family medicine is all about long-term physician-patient relationships. Getting to know patients and their families over many years can lead to a certain intimacy. Dr. Rowland said that, while a wonderful part of being a physician is getting that unique trust whereby patients tell you all sorts of things about their lives, she’s never gone down the friendship path.

“There’s the assumption I’ll take care of someone for a long period of time, and their partner and their kids, maybe another generation or two,” Dr. Rowland said. “People really do rely on that relationship to contribute to their health.”

Worse, nowadays, when people may be starved for connection, many patients want to feel emotionally close and cared for by their doctor, so it’d be easy to cross the line. While patients deserve a compassionate, caring doctor, the physician is left to walk the line between those boundaries. Dr. Rowland said, “It’s up to the clinician to say: ‘My role is as a doctor. You deserve caring friends, but I have to order your mammogram and your blood counts. My role is different.’ ”
 

Friendly but not friends

It can be tricky to navigate the boundary between a cordial, warm relationship with a patient and that patient inviting you to their daughter’s wedding.

“People may mistake being pleasant and friendly for being friends,” said Larry Blosser, MD, chief medical officer at Central Ohio Primary Care, Westerville. In his position, he sometimes hears from patients who have misunderstood their relationship with a doctor in the practice. When that happens, he advises the physician to consider the persona they’re presenting to the patient. If you’re overly friendly, there’s the potential for confusion, but you can’t be aloof and cold, he said.

Maintaining that awareness helps to prevent a patient’s offhand invitation to catch a movie or go on a hike. And verbalizing it to your patients can make your relationship clear from the get-go.

“I tell patients we’re a team. I’m the captain, and they’re my MVP. When the match is over, whatever the results, we’re done,” said Karenne Fru, MD, PhD, a fertility specialist at Oma Fertility Atlanta. Making deep connections is essential to her practice, so Dr. Fru structures her patient interactions carefully. “Infertility is such an isolating experience. While you’re with us, we care about what’s going on in your life, your pets, and your mom’s chemo. We need mutual trust for you to be compliant with the care.”

However, that approach won’t work when you see patients regularly, as with family practice or specialties that see the same patients repeatedly throughout the year. In those circumstances, the match is never over but one in which the onus is on the physician to establish a friendly yet professional rapport without letting your self-interest, loneliness, or lack of friends interfere.

“It’s been a very difficult couple of years for a lot of us. Depending on what kind of clinical work we do, some of us took care of healthy people that got very sick or passed away,” Dr. Rowland said. “Having the chance to reconnect with people and reestablish some of that closeness, both physical and emotional, is going to be good for us.”

Just continue conveying warm, trusting compassion for your patients without blurring the friend lines.

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

A panel of advisers to the Food and Drug Administration unanimously supported an effort to simplify COVID-19 vaccinations, with the aim of developing a one-dose approach – perhaps annually – for the general population.

The FDA is looking to give clearer direction to vaccine makers about future development of COVID-19 vaccines. The plan is to narrow down the current complex landscape of options for vaccinations, and thus help increase use of these shots. 

COVID remains a serious threat, causing about 4,000 deaths a week recently, according to the Centers for Disease Control and Prevention. The 21 members of the Vaccines and Related Biological Products Advisory Committee (VRBPAC) on Jan. 26 voted unanimously “yes” on a single question posed by the FDA: 

“Does the committee recommend harmonizing the vaccine strain composition of primary series and booster doses in the U.S. to a single composition, e.g., the composition for all vaccines administered currently would be a bivalent vaccine (Original plus Omicron BA.4/BA.5)?”

In other words, would it be better to have one vaccine potentially combining multiple strains of the virus, instead of multiple vaccines – such as a two-shot primary series then a booster containing different combinations of viral strains.

The FDA will consider the panel’s advice as it outlines new strategies for keeping ahead of the evolving virus.

In explaining their support for the FDA plan, panel members said they hoped that a simpler regime would aid in persuading more people to get COVID vaccines.

Pamela McInnes, DDS, MSc, noted that it’s difficult to explain to many people that the vaccine works to protect them from more severe illness if they contract COVID after getting vaccinated. 

“That is a real challenge,” said Dr. McInness, retired deputy director of the National Center for Advancing Translational Sciences at the National Institutes of Health.

“The message that you would have gotten more sick and landed in the hospital resonates with me, but I’m not sure if it resonates with” many people who become infected, she said.
 

The plan

In the briefing document for the meeting, the FDA outlined a plan for transitioning from the current complex landscape of COVID-19 vaccines to a single vaccine composition for the primary series and booster vaccination. 

This would require harmonizing the strain composition of all COVID-19 vaccines; simplifying the immunization schedule for future vaccination campaigns to administer a two-dose series in certain young children and in older adults and persons with compromised immunity, and only one dose in all other individuals; and establishing a process for vaccine strain selection recommendations, similar in many ways to that used for seasonal influenza vaccines, based on prevailing and predicted variants that would take place by June to allow for vaccine production by September.

During the discussion, though, questions arose about the June target date. Given the production schedule for some vaccines, that date might need to shift, said Jerry Weir, PhD, director of the division of viral products at FDA’s Center for Biologics Evaluation and Research. 

“We’re all just going to have to maintain flexibility,” Dr. Weir said, adding that there is not yet a “good pattern” established for updating these vaccines. 
 

Increasing vaccination rates

There was broad consensus about the need to boost public support for COVID-19 vaccinations. While about 81% of the U.S. population has had at least one dose of this vaccine, only 15.3% have had an updated bivalent booster dose, according to the CDC.

“Anything that results in better public communication would be extremely valuable,” said committee member Henry H. Bernstein, DO, MHCM, of the Zucker School of Medicine at Hofstra/Northwell Health in Hempstead, N.Y.

But it’s unclear what expectations will be prioritized for the COVID vaccine program, he said. 

“Realistically, I don’t think we can have it all – less infection, less transmission, less severe disease, and less long COVID,” Dr. Bernstein said. “And that seems to be a major challenge for public messaging.” 
 

Panelists press for more data 

Other committee members also pressed for clearer targets in evaluating the goals for COVID vaccines, and for more robust data. 

Like his fellow VRBPAC members, Cody Meissner, MD, of Dartmouth’s Geisel School of Medicine, Hanover, N.H., supported a move toward harmonizing the strains used in different companies’ vaccines. But he added that it wasn’t clear yet how frequently they should be administered. 

“We need to see what happens with disease burden,” Dr. Meissner said. “We may or may not need annual vaccination. It’s just awfully early, it seems to me, in this process to answer that question.”

Among those serving on VRBPAC was one of the FDA’s more vocal critics on these points, Paul A. Offit, MD, a vaccine expert from Children’s Hospital of Philadelphia. Dr. Offit, for example, joined former FDA officials in writing a November opinion article for the Washington Post, arguing that the evidence for boosters for healthy younger adults was not strong.

At the Jan. 26 meeting, he supported the drive toward simplification of COVID vaccine schedules, while arguing for more data about how well these products are working.

“This virus is going to be with us for years, if not decades, and there will always be vulnerable groups who are going to be hospitalized and killed by the virus,” Dr. Offit said.

The CDC needs to provide more information about the characteristics of people being hospitalized with COVID infections, including their ages and comorbidities as well as details about their vaccine history, he said. In addition, academic researchers should provide a clearer picture of what immunological predictors are at play in increasing people’s risk from COVID.

“Then and only then can we really best make the decision about who gets vaccinated with what and when,” Dr. Offit said. 

VRBPAC member Ofer Levy, MD, PhD, also urged the FDA to press for a collection of more robust and detailed information about the immune response to COVID-19 vaccinations, such as a deeper look at what’s happening with antibodies.

“I hope FDA will continue to reflect on how to best take this information forward, and encourage – or require – sponsors to gather more information in a standardized way across these different arms of the human immune system,” Dr. Levy said. “So we keep learning and keep doing this better.”

In recapping the panel’s suggestions at the end of the meeting, Peter Marks, MD, PhD, the director of the FDA’s Center for Biologics Evaluation and Research, addressed the requests made during the day’s meeting about better data on how the vaccines work. 

“We heard loud and clear that we need to use a data-driven approach to get to the simplest possible scheme that we can for vaccination,” Dr. Marks said. “And it should be as simple as possible but not oversimplified, a little bit like they say about Mozart’s music.”

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

A panel of advisers to the Food and Drug Administration unanimously supported an effort to simplify COVID-19 vaccinations, with the aim of developing a one-dose approach – perhaps annually – for the general population.

The FDA is looking to give clearer direction to vaccine makers about future development of COVID-19 vaccines. The plan is to narrow down the current complex landscape of options for vaccinations, and thus help increase use of these shots. 

COVID remains a serious threat, causing about 4,000 deaths a week recently, according to the Centers for Disease Control and Prevention. The 21 members of the Vaccines and Related Biological Products Advisory Committee (VRBPAC) on Jan. 26 voted unanimously “yes” on a single question posed by the FDA: 

“Does the committee recommend harmonizing the vaccine strain composition of primary series and booster doses in the U.S. to a single composition, e.g., the composition for all vaccines administered currently would be a bivalent vaccine (Original plus Omicron BA.4/BA.5)?”

In other words, would it be better to have one vaccine potentially combining multiple strains of the virus, instead of multiple vaccines – such as a two-shot primary series then a booster containing different combinations of viral strains.

The FDA will consider the panel’s advice as it outlines new strategies for keeping ahead of the evolving virus.

In explaining their support for the FDA plan, panel members said they hoped that a simpler regime would aid in persuading more people to get COVID vaccines.

Pamela McInnes, DDS, MSc, noted that it’s difficult to explain to many people that the vaccine works to protect them from more severe illness if they contract COVID after getting vaccinated. 

“That is a real challenge,” said Dr. McInness, retired deputy director of the National Center for Advancing Translational Sciences at the National Institutes of Health.

“The message that you would have gotten more sick and landed in the hospital resonates with me, but I’m not sure if it resonates with” many people who become infected, she said.
 

The plan

In the briefing document for the meeting, the FDA outlined a plan for transitioning from the current complex landscape of COVID-19 vaccines to a single vaccine composition for the primary series and booster vaccination. 

This would require harmonizing the strain composition of all COVID-19 vaccines; simplifying the immunization schedule for future vaccination campaigns to administer a two-dose series in certain young children and in older adults and persons with compromised immunity, and only one dose in all other individuals; and establishing a process for vaccine strain selection recommendations, similar in many ways to that used for seasonal influenza vaccines, based on prevailing and predicted variants that would take place by June to allow for vaccine production by September.

During the discussion, though, questions arose about the June target date. Given the production schedule for some vaccines, that date might need to shift, said Jerry Weir, PhD, director of the division of viral products at FDA’s Center for Biologics Evaluation and Research. 

“We’re all just going to have to maintain flexibility,” Dr. Weir said, adding that there is not yet a “good pattern” established for updating these vaccines. 
 

Increasing vaccination rates

There was broad consensus about the need to boost public support for COVID-19 vaccinations. While about 81% of the U.S. population has had at least one dose of this vaccine, only 15.3% have had an updated bivalent booster dose, according to the CDC.

“Anything that results in better public communication would be extremely valuable,” said committee member Henry H. Bernstein, DO, MHCM, of the Zucker School of Medicine at Hofstra/Northwell Health in Hempstead, N.Y.

But it’s unclear what expectations will be prioritized for the COVID vaccine program, he said. 

“Realistically, I don’t think we can have it all – less infection, less transmission, less severe disease, and less long COVID,” Dr. Bernstein said. “And that seems to be a major challenge for public messaging.” 
 

Panelists press for more data 

Other committee members also pressed for clearer targets in evaluating the goals for COVID vaccines, and for more robust data. 

Like his fellow VRBPAC members, Cody Meissner, MD, of Dartmouth’s Geisel School of Medicine, Hanover, N.H., supported a move toward harmonizing the strains used in different companies’ vaccines. But he added that it wasn’t clear yet how frequently they should be administered. 

“We need to see what happens with disease burden,” Dr. Meissner said. “We may or may not need annual vaccination. It’s just awfully early, it seems to me, in this process to answer that question.”

Among those serving on VRBPAC was one of the FDA’s more vocal critics on these points, Paul A. Offit, MD, a vaccine expert from Children’s Hospital of Philadelphia. Dr. Offit, for example, joined former FDA officials in writing a November opinion article for the Washington Post, arguing that the evidence for boosters for healthy younger adults was not strong.

At the Jan. 26 meeting, he supported the drive toward simplification of COVID vaccine schedules, while arguing for more data about how well these products are working.

“This virus is going to be with us for years, if not decades, and there will always be vulnerable groups who are going to be hospitalized and killed by the virus,” Dr. Offit said.

The CDC needs to provide more information about the characteristics of people being hospitalized with COVID infections, including their ages and comorbidities as well as details about their vaccine history, he said. In addition, academic researchers should provide a clearer picture of what immunological predictors are at play in increasing people’s risk from COVID.

“Then and only then can we really best make the decision about who gets vaccinated with what and when,” Dr. Offit said. 

VRBPAC member Ofer Levy, MD, PhD, also urged the FDA to press for a collection of more robust and detailed information about the immune response to COVID-19 vaccinations, such as a deeper look at what’s happening with antibodies.

“I hope FDA will continue to reflect on how to best take this information forward, and encourage – or require – sponsors to gather more information in a standardized way across these different arms of the human immune system,” Dr. Levy said. “So we keep learning and keep doing this better.”

In recapping the panel’s suggestions at the end of the meeting, Peter Marks, MD, PhD, the director of the FDA’s Center for Biologics Evaluation and Research, addressed the requests made during the day’s meeting about better data on how the vaccines work. 

“We heard loud and clear that we need to use a data-driven approach to get to the simplest possible scheme that we can for vaccination,” Dr. Marks said. “And it should be as simple as possible but not oversimplified, a little bit like they say about Mozart’s music.”

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

A panel of advisers to the Food and Drug Administration unanimously supported an effort to simplify COVID-19 vaccinations, with the aim of developing a one-dose approach – perhaps annually – for the general population.

The FDA is looking to give clearer direction to vaccine makers about future development of COVID-19 vaccines. The plan is to narrow down the current complex landscape of options for vaccinations, and thus help increase use of these shots. 

COVID remains a serious threat, causing about 4,000 deaths a week recently, according to the Centers for Disease Control and Prevention. The 21 members of the Vaccines and Related Biological Products Advisory Committee (VRBPAC) on Jan. 26 voted unanimously “yes” on a single question posed by the FDA: 

“Does the committee recommend harmonizing the vaccine strain composition of primary series and booster doses in the U.S. to a single composition, e.g., the composition for all vaccines administered currently would be a bivalent vaccine (Original plus Omicron BA.4/BA.5)?”

In other words, would it be better to have one vaccine potentially combining multiple strains of the virus, instead of multiple vaccines – such as a two-shot primary series then a booster containing different combinations of viral strains.

The FDA will consider the panel’s advice as it outlines new strategies for keeping ahead of the evolving virus.

In explaining their support for the FDA plan, panel members said they hoped that a simpler regime would aid in persuading more people to get COVID vaccines.

Pamela McInnes, DDS, MSc, noted that it’s difficult to explain to many people that the vaccine works to protect them from more severe illness if they contract COVID after getting vaccinated. 

“That is a real challenge,” said Dr. McInness, retired deputy director of the National Center for Advancing Translational Sciences at the National Institutes of Health.

“The message that you would have gotten more sick and landed in the hospital resonates with me, but I’m not sure if it resonates with” many people who become infected, she said.
 

The plan

In the briefing document for the meeting, the FDA outlined a plan for transitioning from the current complex landscape of COVID-19 vaccines to a single vaccine composition for the primary series and booster vaccination. 

This would require harmonizing the strain composition of all COVID-19 vaccines; simplifying the immunization schedule for future vaccination campaigns to administer a two-dose series in certain young children and in older adults and persons with compromised immunity, and only one dose in all other individuals; and establishing a process for vaccine strain selection recommendations, similar in many ways to that used for seasonal influenza vaccines, based on prevailing and predicted variants that would take place by June to allow for vaccine production by September.

During the discussion, though, questions arose about the June target date. Given the production schedule for some vaccines, that date might need to shift, said Jerry Weir, PhD, director of the division of viral products at FDA’s Center for Biologics Evaluation and Research. 

“We’re all just going to have to maintain flexibility,” Dr. Weir said, adding that there is not yet a “good pattern” established for updating these vaccines. 
 

Increasing vaccination rates

There was broad consensus about the need to boost public support for COVID-19 vaccinations. While about 81% of the U.S. population has had at least one dose of this vaccine, only 15.3% have had an updated bivalent booster dose, according to the CDC.

“Anything that results in better public communication would be extremely valuable,” said committee member Henry H. Bernstein, DO, MHCM, of the Zucker School of Medicine at Hofstra/Northwell Health in Hempstead, N.Y.

But it’s unclear what expectations will be prioritized for the COVID vaccine program, he said. 

“Realistically, I don’t think we can have it all – less infection, less transmission, less severe disease, and less long COVID,” Dr. Bernstein said. “And that seems to be a major challenge for public messaging.” 
 

Panelists press for more data 

Other committee members also pressed for clearer targets in evaluating the goals for COVID vaccines, and for more robust data. 

Like his fellow VRBPAC members, Cody Meissner, MD, of Dartmouth’s Geisel School of Medicine, Hanover, N.H., supported a move toward harmonizing the strains used in different companies’ vaccines. But he added that it wasn’t clear yet how frequently they should be administered. 

“We need to see what happens with disease burden,” Dr. Meissner said. “We may or may not need annual vaccination. It’s just awfully early, it seems to me, in this process to answer that question.”

Among those serving on VRBPAC was one of the FDA’s more vocal critics on these points, Paul A. Offit, MD, a vaccine expert from Children’s Hospital of Philadelphia. Dr. Offit, for example, joined former FDA officials in writing a November opinion article for the Washington Post, arguing that the evidence for boosters for healthy younger adults was not strong.

At the Jan. 26 meeting, he supported the drive toward simplification of COVID vaccine schedules, while arguing for more data about how well these products are working.

“This virus is going to be with us for years, if not decades, and there will always be vulnerable groups who are going to be hospitalized and killed by the virus,” Dr. Offit said.

The CDC needs to provide more information about the characteristics of people being hospitalized with COVID infections, including their ages and comorbidities as well as details about their vaccine history, he said. In addition, academic researchers should provide a clearer picture of what immunological predictors are at play in increasing people’s risk from COVID.

“Then and only then can we really best make the decision about who gets vaccinated with what and when,” Dr. Offit said. 

VRBPAC member Ofer Levy, MD, PhD, also urged the FDA to press for a collection of more robust and detailed information about the immune response to COVID-19 vaccinations, such as a deeper look at what’s happening with antibodies.

“I hope FDA will continue to reflect on how to best take this information forward, and encourage – or require – sponsors to gather more information in a standardized way across these different arms of the human immune system,” Dr. Levy said. “So we keep learning and keep doing this better.”

In recapping the panel’s suggestions at the end of the meeting, Peter Marks, MD, PhD, the director of the FDA’s Center for Biologics Evaluation and Research, addressed the requests made during the day’s meeting about better data on how the vaccines work. 

“We heard loud and clear that we need to use a data-driven approach to get to the simplest possible scheme that we can for vaccination,” Dr. Marks said. “And it should be as simple as possible but not oversimplified, a little bit like they say about Mozart’s music.”

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

General pediatricians and a multidisciplinary team of specialists agreed most of the time on which children should be diagnosed with autism spectrum disorder (ASD), data from a new study suggest.

But when it came to ruling out ASD, the agreement rate was much lower.

The study by Melanie Penner, MSc, MD, with the Autism Research Centre at Bloorview Research Institute, Toronto, and colleagues found that 89% of the time when a physician determined a child had ASD, the multidisciplinary team agreed. But when a pediatrician thought a child did not have ASD, the multidisciplinary team agreed only 60% of the time. The study was published in JAMA Network Open.

Multidisciplinary team model can’t keep up with demand

The findings are important as many guidelines recommend multidisciplinary teams (MDTs) for all ASD diagnostic assessment. However, the resources for this model can’t meet the demand of children needing a diagnosis and can lead to long waits for ASD therapies.

In Canada, the researchers note, the average wait time from referral to receipt of ASD diagnosis has been reported as 7 months and “has likely lengthened since the COVID-19 pandemic.”

Jennifer Gerdts, PhD, an attending psychologist at the Seattle Children’s Autism Center, said in an interview that the wait there for diagnosis in children older than 4 is “multiple years,” a length of time that’s common across the United States. Meanwhile, in many states families can’t access services without a diagnosis.

Expanding capacity with diagnoses by general pediatricians may improve access, but the diagnostic accuracy is critical.

Dr. Gerdts, who was not part of the study, said this research is “hugely important in the work that is under way to build community capacity for diagnostic evaluation.”

She said this study shows that not all diagnoses need the resources of a multiple-disciplinary team and that “pediatricians can do it, too, and they can do it pretty accurately.” Dr. Gerdts evaluates children for autism and helps train pediatricians to make diagnoses.
 

Pediatricians, specialist team completed blinded assessments

The 17 pediatricians in the study and the specialist team independently completed blinded assessment and each recorded a decision on whether the child had ASD. The prospective diagnostic study was conducted in a specialist assessment center in Toronto and in general pediatrician practices in Ontario from June 2016 to March 2020.

Children were younger than 5.5 years, did not have an ASD diagnosis and were referred because there was a development concern. The pediatricians referred 106 children (75% boys; average age, 3.5 years). More than half (57%) of the participating children were from minority racial and ethnic groups.

The children were randomly assigned to two groups: One included children who had their MDT visits before their pediatrician assessment and the other group included those who had their MDT visits after their pediatrician assessment.

The MDT diagnosed more than two-thirds of the children (68%) with ASD.

Sensitivity and specificity of the pediatrician assessments, compared with that of the specialist team, were 0.75 (95% confidence interval, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively.
 

A look at pediatricians’ accuracy

Pediatricians reported the decisions they would have made had the child not been in the study.

• In 69% of the true-positive cases, pediatricians would have given an ASD diagnosis.
• In 44% of true-negative cases, they would have told the family the child did not have autism; in 30% of those case, they would give alternative diagnoses (most commonly ADHD and language delay).
• The pediatrician would have diagnosed ASD in only one of the seven false-positive cases and would refer those patients to a subspecialist 71% of the time.
• In false-negative cases, the pediatrician would incorrectly tell the family the child does not have autism 44% of the time.

Regarding the false-negative cases, the authors wrote, “more caution is needed for pediatricians when definitively ruling out ASD, which might result in diagnostic delays.”
 

Confidence is key

Physician confidence was also correlated with accuracy.

The authors wrote: “Among true-positive cases (MDT and pediatrician agree the child has ASD), the pediatrician was certain or very certain 80% of the time (43 cases) and the MDT was certain or very certain 96% of the time (52 cases). As such, if pediatricians conferred ASD diagnoses when feeling certain or very certain, they would make 46 correct diagnoses and 2 incorrect diagnoses.”

The high accuracy of diagnosis when physicians are confident suggests “listening to that sense of certainty is important,” Dr. Gerdts said. Conversely, these numbers show when a physician is uncertain about diagnosing ASD, they should listen to that instinct, too, and refer.

The results of the study support having general pediatricians diagnose and move forward with their patients when the signs of ASD are more definitive, saving the less-certain cases for the more resource-intensive teams to diagnose. Many states are moving toward that “tiered” system, Dr. Gerdts said.

“For many, and in fact most children, general pediatricians are pretty accurate when making an autism diagnosis,” she said.

“Let’s get [general pediatricians] confident in recognizing when this is outside their skill and ability level,” she said. “If you’re not sure, it is better to refer them on than to misdiagnose them.”

The important missing piece she said is how to support them “so they don’t feel pressure to make that call,” Dr. Gerdts said.

This project was funded by a grant from the Bloorview Research Institute, a grant from the Canadian Institutes of Health Research and a grant from the Canadian Institutes of Health. Three coauthors consult for and receive grants from several pharmaceutical companies and other organizations. Dr. Gerdts declared no relevant financial relationships.

General pediatricians and a multidisciplinary team of specialists agreed most of the time on which children should be diagnosed with autism spectrum disorder (ASD), data from a new study suggest.

But when it came to ruling out ASD, the agreement rate was much lower.

The study by Melanie Penner, MSc, MD, with the Autism Research Centre at Bloorview Research Institute, Toronto, and colleagues found that 89% of the time when a physician determined a child had ASD, the multidisciplinary team agreed. But when a pediatrician thought a child did not have ASD, the multidisciplinary team agreed only 60% of the time. The study was published in JAMA Network Open.

Multidisciplinary team model can’t keep up with demand

The findings are important as many guidelines recommend multidisciplinary teams (MDTs) for all ASD diagnostic assessment. However, the resources for this model can’t meet the demand of children needing a diagnosis and can lead to long waits for ASD therapies.

In Canada, the researchers note, the average wait time from referral to receipt of ASD diagnosis has been reported as 7 months and “has likely lengthened since the COVID-19 pandemic.”

Jennifer Gerdts, PhD, an attending psychologist at the Seattle Children’s Autism Center, said in an interview that the wait there for diagnosis in children older than 4 is “multiple years,” a length of time that’s common across the United States. Meanwhile, in many states families can’t access services without a diagnosis.

Expanding capacity with diagnoses by general pediatricians may improve access, but the diagnostic accuracy is critical.

Dr. Gerdts, who was not part of the study, said this research is “hugely important in the work that is under way to build community capacity for diagnostic evaluation.”

She said this study shows that not all diagnoses need the resources of a multiple-disciplinary team and that “pediatricians can do it, too, and they can do it pretty accurately.” Dr. Gerdts evaluates children for autism and helps train pediatricians to make diagnoses.
 

Pediatricians, specialist team completed blinded assessments

The 17 pediatricians in the study and the specialist team independently completed blinded assessment and each recorded a decision on whether the child had ASD. The prospective diagnostic study was conducted in a specialist assessment center in Toronto and in general pediatrician practices in Ontario from June 2016 to March 2020.

Children were younger than 5.5 years, did not have an ASD diagnosis and were referred because there was a development concern. The pediatricians referred 106 children (75% boys; average age, 3.5 years). More than half (57%) of the participating children were from minority racial and ethnic groups.

The children were randomly assigned to two groups: One included children who had their MDT visits before their pediatrician assessment and the other group included those who had their MDT visits after their pediatrician assessment.

The MDT diagnosed more than two-thirds of the children (68%) with ASD.

Sensitivity and specificity of the pediatrician assessments, compared with that of the specialist team, were 0.75 (95% confidence interval, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively.
 

A look at pediatricians’ accuracy

Pediatricians reported the decisions they would have made had the child not been in the study.

• In 69% of the true-positive cases, pediatricians would have given an ASD diagnosis.
• In 44% of true-negative cases, they would have told the family the child did not have autism; in 30% of those case, they would give alternative diagnoses (most commonly ADHD and language delay).
• The pediatrician would have diagnosed ASD in only one of the seven false-positive cases and would refer those patients to a subspecialist 71% of the time.
• In false-negative cases, the pediatrician would incorrectly tell the family the child does not have autism 44% of the time.

Regarding the false-negative cases, the authors wrote, “more caution is needed for pediatricians when definitively ruling out ASD, which might result in diagnostic delays.”
 

Confidence is key

Physician confidence was also correlated with accuracy.

The authors wrote: “Among true-positive cases (MDT and pediatrician agree the child has ASD), the pediatrician was certain or very certain 80% of the time (43 cases) and the MDT was certain or very certain 96% of the time (52 cases). As such, if pediatricians conferred ASD diagnoses when feeling certain or very certain, they would make 46 correct diagnoses and 2 incorrect diagnoses.”

The high accuracy of diagnosis when physicians are confident suggests “listening to that sense of certainty is important,” Dr. Gerdts said. Conversely, these numbers show when a physician is uncertain about diagnosing ASD, they should listen to that instinct, too, and refer.

The results of the study support having general pediatricians diagnose and move forward with their patients when the signs of ASD are more definitive, saving the less-certain cases for the more resource-intensive teams to diagnose. Many states are moving toward that “tiered” system, Dr. Gerdts said.

“For many, and in fact most children, general pediatricians are pretty accurate when making an autism diagnosis,” she said.

“Let’s get [general pediatricians] confident in recognizing when this is outside their skill and ability level,” she said. “If you’re not sure, it is better to refer them on than to misdiagnose them.”

The important missing piece she said is how to support them “so they don’t feel pressure to make that call,” Dr. Gerdts said.

This project was funded by a grant from the Bloorview Research Institute, a grant from the Canadian Institutes of Health Research and a grant from the Canadian Institutes of Health. Three coauthors consult for and receive grants from several pharmaceutical companies and other organizations. Dr. Gerdts declared no relevant financial relationships.

General pediatricians and a multidisciplinary team of specialists agreed most of the time on which children should be diagnosed with autism spectrum disorder (ASD), data from a new study suggest.

But when it came to ruling out ASD, the agreement rate was much lower.

The study by Melanie Penner, MSc, MD, with the Autism Research Centre at Bloorview Research Institute, Toronto, and colleagues found that 89% of the time when a physician determined a child had ASD, the multidisciplinary team agreed. But when a pediatrician thought a child did not have ASD, the multidisciplinary team agreed only 60% of the time. The study was published in JAMA Network Open.

Multidisciplinary team model can’t keep up with demand

The findings are important as many guidelines recommend multidisciplinary teams (MDTs) for all ASD diagnostic assessment. However, the resources for this model can’t meet the demand of children needing a diagnosis and can lead to long waits for ASD therapies.

In Canada, the researchers note, the average wait time from referral to receipt of ASD diagnosis has been reported as 7 months and “has likely lengthened since the COVID-19 pandemic.”

Jennifer Gerdts, PhD, an attending psychologist at the Seattle Children’s Autism Center, said in an interview that the wait there for diagnosis in children older than 4 is “multiple years,” a length of time that’s common across the United States. Meanwhile, in many states families can’t access services without a diagnosis.

Expanding capacity with diagnoses by general pediatricians may improve access, but the diagnostic accuracy is critical.

Dr. Gerdts, who was not part of the study, said this research is “hugely important in the work that is under way to build community capacity for diagnostic evaluation.”

She said this study shows that not all diagnoses need the resources of a multiple-disciplinary team and that “pediatricians can do it, too, and they can do it pretty accurately.” Dr. Gerdts evaluates children for autism and helps train pediatricians to make diagnoses.
 

Pediatricians, specialist team completed blinded assessments

The 17 pediatricians in the study and the specialist team independently completed blinded assessment and each recorded a decision on whether the child had ASD. The prospective diagnostic study was conducted in a specialist assessment center in Toronto and in general pediatrician practices in Ontario from June 2016 to March 2020.

Children were younger than 5.5 years, did not have an ASD diagnosis and were referred because there was a development concern. The pediatricians referred 106 children (75% boys; average age, 3.5 years). More than half (57%) of the participating children were from minority racial and ethnic groups.

The children were randomly assigned to two groups: One included children who had their MDT visits before their pediatrician assessment and the other group included those who had their MDT visits after their pediatrician assessment.

The MDT diagnosed more than two-thirds of the children (68%) with ASD.

Sensitivity and specificity of the pediatrician assessments, compared with that of the specialist team, were 0.75 (95% confidence interval, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively.
 

A look at pediatricians’ accuracy

Pediatricians reported the decisions they would have made had the child not been in the study.

• In 69% of the true-positive cases, pediatricians would have given an ASD diagnosis.
• In 44% of true-negative cases, they would have told the family the child did not have autism; in 30% of those case, they would give alternative diagnoses (most commonly ADHD and language delay).
• The pediatrician would have diagnosed ASD in only one of the seven false-positive cases and would refer those patients to a subspecialist 71% of the time.
• In false-negative cases, the pediatrician would incorrectly tell the family the child does not have autism 44% of the time.

Regarding the false-negative cases, the authors wrote, “more caution is needed for pediatricians when definitively ruling out ASD, which might result in diagnostic delays.”
 

Confidence is key

Physician confidence was also correlated with accuracy.

The authors wrote: “Among true-positive cases (MDT and pediatrician agree the child has ASD), the pediatrician was certain or very certain 80% of the time (43 cases) and the MDT was certain or very certain 96% of the time (52 cases). As such, if pediatricians conferred ASD diagnoses when feeling certain or very certain, they would make 46 correct diagnoses and 2 incorrect diagnoses.”

The high accuracy of diagnosis when physicians are confident suggests “listening to that sense of certainty is important,” Dr. Gerdts said. Conversely, these numbers show when a physician is uncertain about diagnosing ASD, they should listen to that instinct, too, and refer.

The results of the study support having general pediatricians diagnose and move forward with their patients when the signs of ASD are more definitive, saving the less-certain cases for the more resource-intensive teams to diagnose. Many states are moving toward that “tiered” system, Dr. Gerdts said.

“For many, and in fact most children, general pediatricians are pretty accurate when making an autism diagnosis,” she said.

“Let’s get [general pediatricians] confident in recognizing when this is outside their skill and ability level,” she said. “If you’re not sure, it is better to refer them on than to misdiagnose them.”

The important missing piece she said is how to support them “so they don’t feel pressure to make that call,” Dr. Gerdts said.

This project was funded by a grant from the Bloorview Research Institute, a grant from the Canadian Institutes of Health Research and a grant from the Canadian Institutes of Health. Three coauthors consult for and receive grants from several pharmaceutical companies and other organizations. Dr. Gerdts declared no relevant financial relationships.