On Jan. 6, 2021, Americans and the world witnessed a violent insurrection at the U.S. Capitol inspired by a president and other elected leaders and driven by lies, conspiracy theories, militias, and white supremacy. The violent insurrection was carried out by thousands of citizens, including many with weapons.

MDedge News

Psychiatric organizations condemned the attack and warned about the potential traumatic impact of these events on those directly involved as well as for others in the United States already living under anxiety and fear tied to the surging COVID pandemic.

A major challenge for U.S. society is to prevent other potential future violent attacks. For those who didn’t already know, the Capitol attack made it apparent that the United States faces major problems with white supremacists and domestic terrorism. FBI Director Christopher Wray stipulated that those involved in the Jan. 6 events were violent agitators and extremists.

Addressing the causes and preventing domestic terrorism is also a challenge and opportunity for psychiatry and other mental health professionals. I write as a psychiatrist in academic medicine who has spent more than 10 years advocating for public health approaches to the causes and consequences of violence, especially involving violent extremism. I believe that violence prevention cannot be left exclusively to law enforcement and that psychiatrists have a role to play as part of a whole-of-society coalition with other multidisciplinary practitioners and stakeholders.

Day by day, we learn more and more about those responsible for the insurrection and how to understand their motivations, intentions, and actions. Seditionists incite or commit acts of violence against a lawful authority with the goal of destroying or overthrowing it. Domestic terrorists commit violent, criminal acts to further ideological goals stemming from domestic influences, such as those of a political, religious, social, racial, or environmental nature. The mob that attacked the Capitol contained both. What’s more, the Capitol insurrection might inspire others to take similar actions. The risk for even broader and deeper radicalization to violence is a grave concern.

Aided by more than 100,000 tips, the FBI is conducting a massive nationwide manhunt and thus far, dozens of people have been charged with crimes. Given that the United States has no law that makes domestic terrorism a crime, they are being charged with other crimes. Upholding the rule of law is necessary, but it should not be regarded as sufficient to deal with the white supremacism and domestic terrorism threats.

In many countries all over the world, and to a much lesser extent in the United States, there are successful non–law enforcement programs helping people move away from domestic terrorism and other forms of violence. One example in the United States is Life After Hate, a nongovernmental organization that uses former white supremacist extremists to counsel people to leave the movement. Another example is the Colorado Resilience Collaborative, which takes a socioecological approach to prevent terrorism and targeted violence. At Boston Children’s Hospital, a regional prevention initiative is focused on reducing youth risk for targeted violence and terrorism by reducing mental health problems and increasing social belonging among adolescents. These are but three of several initiatives currently being conducted throughout the United States.

Over the past decade, I have had the opportunity to become familiar with several of these programs domestically and internationally. These include programs aimed at rehabilitating and reintegrating repatriated foreign fighters and their children and other family members all over the world, including in Kazakhstan. I would like to share some of the lessons learned from these programs to aid in preventing domestic terrorism in the United States.

One lesson learned from combating international terrorism is that intelligence and law enforcement strategies (hard counterterrorism) need to be balanced with civil society–led prevention strategies. Overreliance on hard strategies can harm individuals and communities through oversecuritization. Alternatively, we need to build civil society–led initiatives that focus on other levers, such as addressing the underlying conditions, including individual psychosocial and mental health dimensions, or social dimensions (for example, lack of opportunity), that mitigate a person’s involvement in violent extremism.

A second lesson is not to focus exclusively on ideology and deradicalization. Yes, we need to challenge extremist ideology and disinformation, but a wide range of different factors explains involvement in violent extremism and the many pathways into it. Using a socioecological model, we can identify modifiable risk and protective factors that mitigate for or against extremist violence (for example, family support, job prospects, untreated mental health problems). In addition, it is well-established that prevention programs should seek to disengage, not deradicalize, potential violent extremists.

Third, we should leverage existing evidence-based interventions and best practices in mental health and public health, but we should also invest in building and evaluating new models through research approaches, especially for secondary and tertiary prevention. As much as possible, these should be integrated into broader programs to improve individual and community mental health and health.

A fourth lesson is we must vigorously protect the human rights and civil liberties of individuals and communities involved in these programs, and uphold racial equity. We can learn from public health experts about how to engage vulnerable individuals and communities without adding to their stigmatization. One way is to not focus on single communities, and not just on ideologically motivated violence, but to build violence prevention programs that are broad enough to address multiple forms of violence.

Fifth, if we expect community-based organizations to do the work, then they need adequate resources, capacity building, training and supervision, and quality improvement activities to succeed. For example, psychiatrists and other mental health professionals will require additional training to learn how to work effectively and ethically in this space.

MDedge News

Psychiatrists can start by building their knowledge and skills in understanding violent extremism and how it can be assessed and addressed, which is not the same as for suicidality. Psychiatrists can also become involved in established or emerging violence prevention programs, such as threat assessment programs in schools, workplaces, and communities. Across the country, there is a need for building new secondary and tertiary violence prevention initiatives, and they will need psychiatrists to work with them. Academic psychiatrists can become involved in building the models, developing and delivering training, and designing and conducting the program evaluations.

Finally, I suggest that psychiatrists look at domestic terrorism prevention through the lens of public health and not overly “psychiatrize” the issue. A public health approach uses evidence-based programs and policies, addresses underlying causes, and focuses on prevention. Public health builds programs with teams of experts from across disciplines – educators, health care workers, mental health professionals, faith leaders, youth leaders, community advocates, peers, and law enforcement.

As part of a public health–oriented team, psychiatrists can contribute to addressing the grave challenges of domestic terrorism facing our nation today.
 

Dr. Weine is professor of psychiatry, director of global medicine, and director of the Center for Global Health at the University of Illinois at Chicago. He has no conflicts of interest.

On Jan. 6, 2021, Americans and the world witnessed a violent insurrection at the U.S. Capitol inspired by a president and other elected leaders and driven by lies, conspiracy theories, militias, and white supremacy. The violent insurrection was carried out by thousands of citizens, including many with weapons.

MDedge News

Psychiatric organizations condemned the attack and warned about the potential traumatic impact of these events on those directly involved as well as for others in the United States already living under anxiety and fear tied to the surging COVID pandemic.

A major challenge for U.S. society is to prevent other potential future violent attacks. For those who didn’t already know, the Capitol attack made it apparent that the United States faces major problems with white supremacists and domestic terrorism. FBI Director Christopher Wray stipulated that those involved in the Jan. 6 events were violent agitators and extremists.

Addressing the causes and preventing domestic terrorism is also a challenge and opportunity for psychiatry and other mental health professionals. I write as a psychiatrist in academic medicine who has spent more than 10 years advocating for public health approaches to the causes and consequences of violence, especially involving violent extremism. I believe that violence prevention cannot be left exclusively to law enforcement and that psychiatrists have a role to play as part of a whole-of-society coalition with other multidisciplinary practitioners and stakeholders.

Day by day, we learn more and more about those responsible for the insurrection and how to understand their motivations, intentions, and actions. Seditionists incite or commit acts of violence against a lawful authority with the goal of destroying or overthrowing it. Domestic terrorists commit violent, criminal acts to further ideological goals stemming from domestic influences, such as those of a political, religious, social, racial, or environmental nature. The mob that attacked the Capitol contained both. What’s more, the Capitol insurrection might inspire others to take similar actions. The risk for even broader and deeper radicalization to violence is a grave concern.

Aided by more than 100,000 tips, the FBI is conducting a massive nationwide manhunt and thus far, dozens of people have been charged with crimes. Given that the United States has no law that makes domestic terrorism a crime, they are being charged with other crimes. Upholding the rule of law is necessary, but it should not be regarded as sufficient to deal with the white supremacism and domestic terrorism threats.

In many countries all over the world, and to a much lesser extent in the United States, there are successful non–law enforcement programs helping people move away from domestic terrorism and other forms of violence. One example in the United States is Life After Hate, a nongovernmental organization that uses former white supremacist extremists to counsel people to leave the movement. Another example is the Colorado Resilience Collaborative, which takes a socioecological approach to prevent terrorism and targeted violence. At Boston Children’s Hospital, a regional prevention initiative is focused on reducing youth risk for targeted violence and terrorism by reducing mental health problems and increasing social belonging among adolescents. These are but three of several initiatives currently being conducted throughout the United States.

Over the past decade, I have had the opportunity to become familiar with several of these programs domestically and internationally. These include programs aimed at rehabilitating and reintegrating repatriated foreign fighters and their children and other family members all over the world, including in Kazakhstan. I would like to share some of the lessons learned from these programs to aid in preventing domestic terrorism in the United States.

One lesson learned from combating international terrorism is that intelligence and law enforcement strategies (hard counterterrorism) need to be balanced with civil society–led prevention strategies. Overreliance on hard strategies can harm individuals and communities through oversecuritization. Alternatively, we need to build civil society–led initiatives that focus on other levers, such as addressing the underlying conditions, including individual psychosocial and mental health dimensions, or social dimensions (for example, lack of opportunity), that mitigate a person’s involvement in violent extremism.

A second lesson is not to focus exclusively on ideology and deradicalization. Yes, we need to challenge extremist ideology and disinformation, but a wide range of different factors explains involvement in violent extremism and the many pathways into it. Using a socioecological model, we can identify modifiable risk and protective factors that mitigate for or against extremist violence (for example, family support, job prospects, untreated mental health problems). In addition, it is well-established that prevention programs should seek to disengage, not deradicalize, potential violent extremists.

Third, we should leverage existing evidence-based interventions and best practices in mental health and public health, but we should also invest in building and evaluating new models through research approaches, especially for secondary and tertiary prevention. As much as possible, these should be integrated into broader programs to improve individual and community mental health and health.

A fourth lesson is we must vigorously protect the human rights and civil liberties of individuals and communities involved in these programs, and uphold racial equity. We can learn from public health experts about how to engage vulnerable individuals and communities without adding to their stigmatization. One way is to not focus on single communities, and not just on ideologically motivated violence, but to build violence prevention programs that are broad enough to address multiple forms of violence.

Fifth, if we expect community-based organizations to do the work, then they need adequate resources, capacity building, training and supervision, and quality improvement activities to succeed. For example, psychiatrists and other mental health professionals will require additional training to learn how to work effectively and ethically in this space.

MDedge News

Psychiatrists can start by building their knowledge and skills in understanding violent extremism and how it can be assessed and addressed, which is not the same as for suicidality. Psychiatrists can also become involved in established or emerging violence prevention programs, such as threat assessment programs in schools, workplaces, and communities. Across the country, there is a need for building new secondary and tertiary violence prevention initiatives, and they will need psychiatrists to work with them. Academic psychiatrists can become involved in building the models, developing and delivering training, and designing and conducting the program evaluations.

Finally, I suggest that psychiatrists look at domestic terrorism prevention through the lens of public health and not overly “psychiatrize” the issue. A public health approach uses evidence-based programs and policies, addresses underlying causes, and focuses on prevention. Public health builds programs with teams of experts from across disciplines – educators, health care workers, mental health professionals, faith leaders, youth leaders, community advocates, peers, and law enforcement.

As part of a public health–oriented team, psychiatrists can contribute to addressing the grave challenges of domestic terrorism facing our nation today.
 

Dr. Weine is professor of psychiatry, director of global medicine, and director of the Center for Global Health at the University of Illinois at Chicago. He has no conflicts of interest.

On Jan. 6, 2021, Americans and the world witnessed a violent insurrection at the U.S. Capitol inspired by a president and other elected leaders and driven by lies, conspiracy theories, militias, and white supremacy. The violent insurrection was carried out by thousands of citizens, including many with weapons.

MDedge News

Psychiatric organizations condemned the attack and warned about the potential traumatic impact of these events on those directly involved as well as for others in the United States already living under anxiety and fear tied to the surging COVID pandemic.

A major challenge for U.S. society is to prevent other potential future violent attacks. For those who didn’t already know, the Capitol attack made it apparent that the United States faces major problems with white supremacists and domestic terrorism. FBI Director Christopher Wray stipulated that those involved in the Jan. 6 events were violent agitators and extremists.

Addressing the causes and preventing domestic terrorism is also a challenge and opportunity for psychiatry and other mental health professionals. I write as a psychiatrist in academic medicine who has spent more than 10 years advocating for public health approaches to the causes and consequences of violence, especially involving violent extremism. I believe that violence prevention cannot be left exclusively to law enforcement and that psychiatrists have a role to play as part of a whole-of-society coalition with other multidisciplinary practitioners and stakeholders.

Day by day, we learn more and more about those responsible for the insurrection and how to understand their motivations, intentions, and actions. Seditionists incite or commit acts of violence against a lawful authority with the goal of destroying or overthrowing it. Domestic terrorists commit violent, criminal acts to further ideological goals stemming from domestic influences, such as those of a political, religious, social, racial, or environmental nature. The mob that attacked the Capitol contained both. What’s more, the Capitol insurrection might inspire others to take similar actions. The risk for even broader and deeper radicalization to violence is a grave concern.

Aided by more than 100,000 tips, the FBI is conducting a massive nationwide manhunt and thus far, dozens of people have been charged with crimes. Given that the United States has no law that makes domestic terrorism a crime, they are being charged with other crimes. Upholding the rule of law is necessary, but it should not be regarded as sufficient to deal with the white supremacism and domestic terrorism threats.

In many countries all over the world, and to a much lesser extent in the United States, there are successful non–law enforcement programs helping people move away from domestic terrorism and other forms of violence. One example in the United States is Life After Hate, a nongovernmental organization that uses former white supremacist extremists to counsel people to leave the movement. Another example is the Colorado Resilience Collaborative, which takes a socioecological approach to prevent terrorism and targeted violence. At Boston Children’s Hospital, a regional prevention initiative is focused on reducing youth risk for targeted violence and terrorism by reducing mental health problems and increasing social belonging among adolescents. These are but three of several initiatives currently being conducted throughout the United States.

Over the past decade, I have had the opportunity to become familiar with several of these programs domestically and internationally. These include programs aimed at rehabilitating and reintegrating repatriated foreign fighters and their children and other family members all over the world, including in Kazakhstan. I would like to share some of the lessons learned from these programs to aid in preventing domestic terrorism in the United States.

One lesson learned from combating international terrorism is that intelligence and law enforcement strategies (hard counterterrorism) need to be balanced with civil society–led prevention strategies. Overreliance on hard strategies can harm individuals and communities through oversecuritization. Alternatively, we need to build civil society–led initiatives that focus on other levers, such as addressing the underlying conditions, including individual psychosocial and mental health dimensions, or social dimensions (for example, lack of opportunity), that mitigate a person’s involvement in violent extremism.

A second lesson is not to focus exclusively on ideology and deradicalization. Yes, we need to challenge extremist ideology and disinformation, but a wide range of different factors explains involvement in violent extremism and the many pathways into it. Using a socioecological model, we can identify modifiable risk and protective factors that mitigate for or against extremist violence (for example, family support, job prospects, untreated mental health problems). In addition, it is well-established that prevention programs should seek to disengage, not deradicalize, potential violent extremists.

Third, we should leverage existing evidence-based interventions and best practices in mental health and public health, but we should also invest in building and evaluating new models through research approaches, especially for secondary and tertiary prevention. As much as possible, these should be integrated into broader programs to improve individual and community mental health and health.

A fourth lesson is we must vigorously protect the human rights and civil liberties of individuals and communities involved in these programs, and uphold racial equity. We can learn from public health experts about how to engage vulnerable individuals and communities without adding to their stigmatization. One way is to not focus on single communities, and not just on ideologically motivated violence, but to build violence prevention programs that are broad enough to address multiple forms of violence.

Fifth, if we expect community-based organizations to do the work, then they need adequate resources, capacity building, training and supervision, and quality improvement activities to succeed. For example, psychiatrists and other mental health professionals will require additional training to learn how to work effectively and ethically in this space.

MDedge News

Psychiatrists can start by building their knowledge and skills in understanding violent extremism and how it can be assessed and addressed, which is not the same as for suicidality. Psychiatrists can also become involved in established or emerging violence prevention programs, such as threat assessment programs in schools, workplaces, and communities. Across the country, there is a need for building new secondary and tertiary violence prevention initiatives, and they will need psychiatrists to work with them. Academic psychiatrists can become involved in building the models, developing and delivering training, and designing and conducting the program evaluations.

Finally, I suggest that psychiatrists look at domestic terrorism prevention through the lens of public health and not overly “psychiatrize” the issue. A public health approach uses evidence-based programs and policies, addresses underlying causes, and focuses on prevention. Public health builds programs with teams of experts from across disciplines – educators, health care workers, mental health professionals, faith leaders, youth leaders, community advocates, peers, and law enforcement.

As part of a public health–oriented team, psychiatrists can contribute to addressing the grave challenges of domestic terrorism facing our nation today.
 

Dr. Weine is professor of psychiatry, director of global medicine, and director of the Center for Global Health at the University of Illinois at Chicago. He has no conflicts of interest.

Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during acute COVID-19 illness raises the risk for euglycemic diabetic ketoacidosis (euDKA), a new case series suggests.

Five patients with type 2 diabetes who were taking SGLT2 inhibitors presented in DKA despite having glucose levels below 300 mg/dL. The report was published online last month in AACE Clinical Case Reports by Rebecca J. Vitale, MD, and colleagues at Brigham and Women’s Hospital, Boston.

“A cluster of euglycemic DKA cases at our hospital during the first wave of the pandemic suggests that patients with diabetes taking SGLT2 inhibitors may be at enhanced risk for euDKA when they contract COVID-19,” senior author Naomi D.L. Fisher, MD, said in an interview.

Dr. Fisher, an endocrinologist, added: “This complication is preventable with the simple measure of holding the drug. We are hopeful that widespread patient and physician education will prevent future cases of euDKA as COVID-19 infections continue to surge.”

These cases underscore recommendations published early in the COVID-19 pandemic by an international panel, she noted.

“Patients who are acutely ill with nausea, vomiting, abdominal pain, or diarrhea, or who are experiencing loss of appetite with reduced food and fluid intake, should be advised to hold their SGLT2 inhibitor. This medication should not be resumed until patients are feeling better and eating and drinking normally.”  

On the other hand, “If patients with asymptomatic or mild COVID-19 infection are otherwise well, and are eating and drinking normally, there is no evidence that SGLT2 inhibitors need to be stopped. These patients should monitor [themselves] closely for worsening symptoms, especially resulting in poor hydration and nutrition, which would be reason to discontinue their medication.” 
 

Pay special attention to the elderly, those with complications

However, special consideration should be given to elderly patients and those with medical conditions known to increase the likelihood of severe infection, like heart failure and chronic obstructive pulmonary disease, Dr. Fisher added.

The SGLT2 inhibitor class of drugs causes significant urinary glucose excretion, and they are also diuretics. A decrease in available glucose and volume depletion are probably both important contributors to euDKA, she explained.

With COVID-19 infection the euDKA risk is compounded by several mechanisms. Most cases of euDKA are associated with an underlying state of starvation that can be triggered by vomiting, diarrhea, loss of appetite, and poor oral intake.

In addition – although not yet known for certain – SARS-CoV-2 may also be toxic to pancreatic beta cells and thus reduce insulin secretion. The maladaptive inflammatory response seen with COVID-19 may also contribute, she said.  

The patients in the current case series were three men and two women seen between March and May 2020. They ranged in age from 52 to 79 years.

None had a prior history of DKA or any known diabetes complications. In all of them, antihyperglycemic medications, including SGLT2 inhibitors, were stopped on hospital admission. The patients were initially treated with intravenous insulin, and then subcutaneous insulin after the DKA diagnosis.

Three of the patients were discharged to rehabilitation facilities on hospital days 28-47 and one (age 53 years) was discharged home on day 11. The other patient also had hypertension and nonalcoholic steatohepatitis.

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

Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during acute COVID-19 illness raises the risk for euglycemic diabetic ketoacidosis (euDKA), a new case series suggests.

Five patients with type 2 diabetes who were taking SGLT2 inhibitors presented in DKA despite having glucose levels below 300 mg/dL. The report was published online last month in AACE Clinical Case Reports by Rebecca J. Vitale, MD, and colleagues at Brigham and Women’s Hospital, Boston.

“A cluster of euglycemic DKA cases at our hospital during the first wave of the pandemic suggests that patients with diabetes taking SGLT2 inhibitors may be at enhanced risk for euDKA when they contract COVID-19,” senior author Naomi D.L. Fisher, MD, said in an interview.

Dr. Fisher, an endocrinologist, added: “This complication is preventable with the simple measure of holding the drug. We are hopeful that widespread patient and physician education will prevent future cases of euDKA as COVID-19 infections continue to surge.”

These cases underscore recommendations published early in the COVID-19 pandemic by an international panel, she noted.

“Patients who are acutely ill with nausea, vomiting, abdominal pain, or diarrhea, or who are experiencing loss of appetite with reduced food and fluid intake, should be advised to hold their SGLT2 inhibitor. This medication should not be resumed until patients are feeling better and eating and drinking normally.”  

On the other hand, “If patients with asymptomatic or mild COVID-19 infection are otherwise well, and are eating and drinking normally, there is no evidence that SGLT2 inhibitors need to be stopped. These patients should monitor [themselves] closely for worsening symptoms, especially resulting in poor hydration and nutrition, which would be reason to discontinue their medication.” 
 

Pay special attention to the elderly, those with complications

However, special consideration should be given to elderly patients and those with medical conditions known to increase the likelihood of severe infection, like heart failure and chronic obstructive pulmonary disease, Dr. Fisher added.

The SGLT2 inhibitor class of drugs causes significant urinary glucose excretion, and they are also diuretics. A decrease in available glucose and volume depletion are probably both important contributors to euDKA, she explained.

With COVID-19 infection the euDKA risk is compounded by several mechanisms. Most cases of euDKA are associated with an underlying state of starvation that can be triggered by vomiting, diarrhea, loss of appetite, and poor oral intake.

In addition – although not yet known for certain – SARS-CoV-2 may also be toxic to pancreatic beta cells and thus reduce insulin secretion. The maladaptive inflammatory response seen with COVID-19 may also contribute, she said.  

The patients in the current case series were three men and two women seen between March and May 2020. They ranged in age from 52 to 79 years.

None had a prior history of DKA or any known diabetes complications. In all of them, antihyperglycemic medications, including SGLT2 inhibitors, were stopped on hospital admission. The patients were initially treated with intravenous insulin, and then subcutaneous insulin after the DKA diagnosis.

Three of the patients were discharged to rehabilitation facilities on hospital days 28-47 and one (age 53 years) was discharged home on day 11. The other patient also had hypertension and nonalcoholic steatohepatitis.

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

Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during acute COVID-19 illness raises the risk for euglycemic diabetic ketoacidosis (euDKA), a new case series suggests.

Five patients with type 2 diabetes who were taking SGLT2 inhibitors presented in DKA despite having glucose levels below 300 mg/dL. The report was published online last month in AACE Clinical Case Reports by Rebecca J. Vitale, MD, and colleagues at Brigham and Women’s Hospital, Boston.

“A cluster of euglycemic DKA cases at our hospital during the first wave of the pandemic suggests that patients with diabetes taking SGLT2 inhibitors may be at enhanced risk for euDKA when they contract COVID-19,” senior author Naomi D.L. Fisher, MD, said in an interview.

Dr. Fisher, an endocrinologist, added: “This complication is preventable with the simple measure of holding the drug. We are hopeful that widespread patient and physician education will prevent future cases of euDKA as COVID-19 infections continue to surge.”

These cases underscore recommendations published early in the COVID-19 pandemic by an international panel, she noted.

“Patients who are acutely ill with nausea, vomiting, abdominal pain, or diarrhea, or who are experiencing loss of appetite with reduced food and fluid intake, should be advised to hold their SGLT2 inhibitor. This medication should not be resumed until patients are feeling better and eating and drinking normally.”  

On the other hand, “If patients with asymptomatic or mild COVID-19 infection are otherwise well, and are eating and drinking normally, there is no evidence that SGLT2 inhibitors need to be stopped. These patients should monitor [themselves] closely for worsening symptoms, especially resulting in poor hydration and nutrition, which would be reason to discontinue their medication.” 
 

Pay special attention to the elderly, those with complications

However, special consideration should be given to elderly patients and those with medical conditions known to increase the likelihood of severe infection, like heart failure and chronic obstructive pulmonary disease, Dr. Fisher added.

The SGLT2 inhibitor class of drugs causes significant urinary glucose excretion, and they are also diuretics. A decrease in available glucose and volume depletion are probably both important contributors to euDKA, she explained.

With COVID-19 infection the euDKA risk is compounded by several mechanisms. Most cases of euDKA are associated with an underlying state of starvation that can be triggered by vomiting, diarrhea, loss of appetite, and poor oral intake.

In addition – although not yet known for certain – SARS-CoV-2 may also be toxic to pancreatic beta cells and thus reduce insulin secretion. The maladaptive inflammatory response seen with COVID-19 may also contribute, she said.  

The patients in the current case series were three men and two women seen between March and May 2020. They ranged in age from 52 to 79 years.

None had a prior history of DKA or any known diabetes complications. In all of them, antihyperglycemic medications, including SGLT2 inhibitors, were stopped on hospital admission. The patients were initially treated with intravenous insulin, and then subcutaneous insulin after the DKA diagnosis.

Three of the patients were discharged to rehabilitation facilities on hospital days 28-47 and one (age 53 years) was discharged home on day 11. The other patient also had hypertension and nonalcoholic steatohepatitis.

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

A new recommendation for the treatment of patients with gastric cancer has been proposed on the basis of final results from the phase 3 trial GC-07, which showed survival benefit. The trial was conducted by the Japan Clinical Cancer Research Organization.

Adjuvant treatment with S-1 plus docetaxel is now recommended for patients with pathologic stage III gastric cancer who have undergone D2 gastrectomy and who have not received neoadjuvant chemotherapy, say the researchers.

The 3-year relapse-free survival (RFS) and 3-year overall survival rates were significantly superior among patients treated with S-1/docetaxel, compared with those treated with S-1 alone, commented lead study author Kazuhiro Yoshida, PhD, MD, director of Gifu University Hospital and professor and chairman of the department of surgical oncology, Gifu (Japan) University.

“The study met its primary endpoint and improved the RFS [recurrence-free survival],” he said. “Postoperative S-1 plus docetaxel was safe and manageable.”

Dr. Yoshida presented the updated findings of the GC-07 trial at the Gastrointestinal Cancers Symposium (GICS) 2021, which was held online this year.
 

S-1 widely used in Asia

S-1 is a novel oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine. The drug, which is a biochemical modulation of 5-fluorouracil, comprises tegafur and two types of enzyme inhibitor. It is widely used to treat various solid tumors in Asia.

“S1 is a standard postoperative adjuvant chemotherapy for patients with p-stage II/III gastric cancer in Asia,” said Dr. Yoshida, but the “outcome in p-stage III is unsatisfactory,” he added.

The GC-07 trial set out to further investigate the use of this drug in this patient population. Dr. Yoshida and colleagues included 915 patients with stage III gastric cancer who had undergone R0 resection and D2 lymphadenectomy and who tested negative on peritoneal-washing cytology. The patients were randomly assigned to receive either S-1 plus docetaxel or S-1 alone for up to 1 year in the postoperative setting.

The data presented at the meeting are the final results from GC-07. They confirm earlier data.

Previously, a second interim analysis showed that the trial had met its primary endpoint. As a result of that analysis, the study was terminated.

That interim analysis showed that the 3-year RFS of the S-1/docetaxel arm was significantly superior to that of the S-1 arm (65.9% vs. 49.6%; hazard ratio, 0.632; P = .0007).

Now, the final results, at a median follow-up of 48.2 months, show that there were 400 recurrences and 324 deaths. The 3-year RFS was 67.7% in the S-1/docetaxel group, which was significantly superior to the 57.4% reported in the S-1 group (HR, 0.715; P = .0008). Similarly, 3-year overall survival was 77.7% in the S-1/docetaxel group, vs. 71.2% in the S-1 group (HR, 0.742; P = .0076).

At 12 months, 62.7% of patients in the S-1 group had experienced treatment failure, compared with 56.2% in the combination-therapy group.

In addition to reducing overall relapse, treatment with combination therapy also decreased the incidence of relapse at specific sites, compared with S-1 alone. These included reductions in lymphatic recurrence (6.4% vs. 15.0%), hematogenous recurrence (9.7% vs. 15.5%), local recurrence (2.9% vs. 4.4%), and peritoneal recurrence (18.8% vs. 21.4%).

No new safety signals were observed, Dr. Yoshida commented. Grade 3/4 adverse events that occurred more frequently with S-1/docetaxel than with S-1 alone included neutropenia (39.2% vs. 16.4%), leukopenia (22.4% vs. 2.7%), and febrile neutropenia (5.7% vs. 0.4%).

However, the authors noted that, in a subgroup analysis, patients with stage IIIB disease did not derive the same benefit in RFS and overall survival with combination therapy as the patients with stage IIIA or IIIC disease.

The discussant for this paper, Rutika Mehta, MD, MPH, of the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla., highlighted differences in benefit among the subgroups, as well as the finding that patients with stage IIIB appeared to benefit less.

However, she noted that the seventh edition of the American Joint Committee on Cancer TNM classification, which distinguishes patients on the basis of prognostic subgroups, is inaccurate for stage III disease, and this might have affected the study results. Dr. Mehta pointed to a previous analysis in which more than 33% of individuals with stage IIIB disease, determined in accordance with the seventh edition of the AJCC staging system, were reclassified as having stage IIIC disease, as determined using the more recent eighth edition.

“There were also few T2, N0, and N1 patients, making meaningful deductions in these subgroups not possible,” she said.

She said that despite these limitations, these “results are meaningful and impactful, and the combination of docetaxel and S-1 showed better RFS and overall survival than S-1 alone.

“These results do favor a new recommendation for the use of docetaxel plus S-1 for stage III gastric cancer patients after D2 lymphadenectomy,” she concluded.

The study was funded by the Japan Clinical Cancer Research Organization. Dr. Yoshida has received honoraria and research funding from many pharmaceutical companies, as listed in the abstract.

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

A new recommendation for the treatment of patients with gastric cancer has been proposed on the basis of final results from the phase 3 trial GC-07, which showed survival benefit. The trial was conducted by the Japan Clinical Cancer Research Organization.

Adjuvant treatment with S-1 plus docetaxel is now recommended for patients with pathologic stage III gastric cancer who have undergone D2 gastrectomy and who have not received neoadjuvant chemotherapy, say the researchers.

The 3-year relapse-free survival (RFS) and 3-year overall survival rates were significantly superior among patients treated with S-1/docetaxel, compared with those treated with S-1 alone, commented lead study author Kazuhiro Yoshida, PhD, MD, director of Gifu University Hospital and professor and chairman of the department of surgical oncology, Gifu (Japan) University.

“The study met its primary endpoint and improved the RFS [recurrence-free survival],” he said. “Postoperative S-1 plus docetaxel was safe and manageable.”

Dr. Yoshida presented the updated findings of the GC-07 trial at the Gastrointestinal Cancers Symposium (GICS) 2021, which was held online this year.
 

S-1 widely used in Asia

S-1 is a novel oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine. The drug, which is a biochemical modulation of 5-fluorouracil, comprises tegafur and two types of enzyme inhibitor. It is widely used to treat various solid tumors in Asia.

“S1 is a standard postoperative adjuvant chemotherapy for patients with p-stage II/III gastric cancer in Asia,” said Dr. Yoshida, but the “outcome in p-stage III is unsatisfactory,” he added.

The GC-07 trial set out to further investigate the use of this drug in this patient population. Dr. Yoshida and colleagues included 915 patients with stage III gastric cancer who had undergone R0 resection and D2 lymphadenectomy and who tested negative on peritoneal-washing cytology. The patients were randomly assigned to receive either S-1 plus docetaxel or S-1 alone for up to 1 year in the postoperative setting.

The data presented at the meeting are the final results from GC-07. They confirm earlier data.

Previously, a second interim analysis showed that the trial had met its primary endpoint. As a result of that analysis, the study was terminated.

That interim analysis showed that the 3-year RFS of the S-1/docetaxel arm was significantly superior to that of the S-1 arm (65.9% vs. 49.6%; hazard ratio, 0.632; P = .0007).

Now, the final results, at a median follow-up of 48.2 months, show that there were 400 recurrences and 324 deaths. The 3-year RFS was 67.7% in the S-1/docetaxel group, which was significantly superior to the 57.4% reported in the S-1 group (HR, 0.715; P = .0008). Similarly, 3-year overall survival was 77.7% in the S-1/docetaxel group, vs. 71.2% in the S-1 group (HR, 0.742; P = .0076).

At 12 months, 62.7% of patients in the S-1 group had experienced treatment failure, compared with 56.2% in the combination-therapy group.

In addition to reducing overall relapse, treatment with combination therapy also decreased the incidence of relapse at specific sites, compared with S-1 alone. These included reductions in lymphatic recurrence (6.4% vs. 15.0%), hematogenous recurrence (9.7% vs. 15.5%), local recurrence (2.9% vs. 4.4%), and peritoneal recurrence (18.8% vs. 21.4%).

No new safety signals were observed, Dr. Yoshida commented. Grade 3/4 adverse events that occurred more frequently with S-1/docetaxel than with S-1 alone included neutropenia (39.2% vs. 16.4%), leukopenia (22.4% vs. 2.7%), and febrile neutropenia (5.7% vs. 0.4%).

However, the authors noted that, in a subgroup analysis, patients with stage IIIB disease did not derive the same benefit in RFS and overall survival with combination therapy as the patients with stage IIIA or IIIC disease.

The discussant for this paper, Rutika Mehta, MD, MPH, of the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla., highlighted differences in benefit among the subgroups, as well as the finding that patients with stage IIIB appeared to benefit less.

However, she noted that the seventh edition of the American Joint Committee on Cancer TNM classification, which distinguishes patients on the basis of prognostic subgroups, is inaccurate for stage III disease, and this might have affected the study results. Dr. Mehta pointed to a previous analysis in which more than 33% of individuals with stage IIIB disease, determined in accordance with the seventh edition of the AJCC staging system, were reclassified as having stage IIIC disease, as determined using the more recent eighth edition.

“There were also few T2, N0, and N1 patients, making meaningful deductions in these subgroups not possible,” she said.

She said that despite these limitations, these “results are meaningful and impactful, and the combination of docetaxel and S-1 showed better RFS and overall survival than S-1 alone.

“These results do favor a new recommendation for the use of docetaxel plus S-1 for stage III gastric cancer patients after D2 lymphadenectomy,” she concluded.

The study was funded by the Japan Clinical Cancer Research Organization. Dr. Yoshida has received honoraria and research funding from many pharmaceutical companies, as listed in the abstract.

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

A new recommendation for the treatment of patients with gastric cancer has been proposed on the basis of final results from the phase 3 trial GC-07, which showed survival benefit. The trial was conducted by the Japan Clinical Cancer Research Organization.

Adjuvant treatment with S-1 plus docetaxel is now recommended for patients with pathologic stage III gastric cancer who have undergone D2 gastrectomy and who have not received neoadjuvant chemotherapy, say the researchers.

The 3-year relapse-free survival (RFS) and 3-year overall survival rates were significantly superior among patients treated with S-1/docetaxel, compared with those treated with S-1 alone, commented lead study author Kazuhiro Yoshida, PhD, MD, director of Gifu University Hospital and professor and chairman of the department of surgical oncology, Gifu (Japan) University.

“The study met its primary endpoint and improved the RFS [recurrence-free survival],” he said. “Postoperative S-1 plus docetaxel was safe and manageable.”

Dr. Yoshida presented the updated findings of the GC-07 trial at the Gastrointestinal Cancers Symposium (GICS) 2021, which was held online this year.
 

S-1 widely used in Asia

S-1 is a novel oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine. The drug, which is a biochemical modulation of 5-fluorouracil, comprises tegafur and two types of enzyme inhibitor. It is widely used to treat various solid tumors in Asia.

“S1 is a standard postoperative adjuvant chemotherapy for patients with p-stage II/III gastric cancer in Asia,” said Dr. Yoshida, but the “outcome in p-stage III is unsatisfactory,” he added.

The GC-07 trial set out to further investigate the use of this drug in this patient population. Dr. Yoshida and colleagues included 915 patients with stage III gastric cancer who had undergone R0 resection and D2 lymphadenectomy and who tested negative on peritoneal-washing cytology. The patients were randomly assigned to receive either S-1 plus docetaxel or S-1 alone for up to 1 year in the postoperative setting.

The data presented at the meeting are the final results from GC-07. They confirm earlier data.

Previously, a second interim analysis showed that the trial had met its primary endpoint. As a result of that analysis, the study was terminated.

That interim analysis showed that the 3-year RFS of the S-1/docetaxel arm was significantly superior to that of the S-1 arm (65.9% vs. 49.6%; hazard ratio, 0.632; P = .0007).

Now, the final results, at a median follow-up of 48.2 months, show that there were 400 recurrences and 324 deaths. The 3-year RFS was 67.7% in the S-1/docetaxel group, which was significantly superior to the 57.4% reported in the S-1 group (HR, 0.715; P = .0008). Similarly, 3-year overall survival was 77.7% in the S-1/docetaxel group, vs. 71.2% in the S-1 group (HR, 0.742; P = .0076).

At 12 months, 62.7% of patients in the S-1 group had experienced treatment failure, compared with 56.2% in the combination-therapy group.

In addition to reducing overall relapse, treatment with combination therapy also decreased the incidence of relapse at specific sites, compared with S-1 alone. These included reductions in lymphatic recurrence (6.4% vs. 15.0%), hematogenous recurrence (9.7% vs. 15.5%), local recurrence (2.9% vs. 4.4%), and peritoneal recurrence (18.8% vs. 21.4%).

No new safety signals were observed, Dr. Yoshida commented. Grade 3/4 adverse events that occurred more frequently with S-1/docetaxel than with S-1 alone included neutropenia (39.2% vs. 16.4%), leukopenia (22.4% vs. 2.7%), and febrile neutropenia (5.7% vs. 0.4%).

However, the authors noted that, in a subgroup analysis, patients with stage IIIB disease did not derive the same benefit in RFS and overall survival with combination therapy as the patients with stage IIIA or IIIC disease.

The discussant for this paper, Rutika Mehta, MD, MPH, of the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla., highlighted differences in benefit among the subgroups, as well as the finding that patients with stage IIIB appeared to benefit less.

However, she noted that the seventh edition of the American Joint Committee on Cancer TNM classification, which distinguishes patients on the basis of prognostic subgroups, is inaccurate for stage III disease, and this might have affected the study results. Dr. Mehta pointed to a previous analysis in which more than 33% of individuals with stage IIIB disease, determined in accordance with the seventh edition of the AJCC staging system, were reclassified as having stage IIIC disease, as determined using the more recent eighth edition.

“There were also few T2, N0, and N1 patients, making meaningful deductions in these subgroups not possible,” she said.

She said that despite these limitations, these “results are meaningful and impactful, and the combination of docetaxel and S-1 showed better RFS and overall survival than S-1 alone.

“These results do favor a new recommendation for the use of docetaxel plus S-1 for stage III gastric cancer patients after D2 lymphadenectomy,” she concluded.

The study was funded by the Japan Clinical Cancer Research Organization. Dr. Yoshida has received honoraria and research funding from many pharmaceutical companies, as listed in the abstract.

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

Daily life is now a juggling act for Misty Richards, MD, MS. As the program director of a rigorous child psychiatry fellowship, a psychiatrist caring for women with perinatal psychiatric disorders, and the mother of three young children, Dr. Richards tries to view these tasks as an opportunity for growth. But some days it feels as if she’s navigating a storm in the middle of the ocean without a life jacket.

In the age of COVID, “the wave of demands has morphed into one giant tidal wave of desperate need,” Dr. Richards, of the department of psychiatry & biobehavioral sciences, University of California, Los Angeles, Semel Institute of Neuroscience & Human Behavior, said in an interview. “The painfully loud and clear message is that our patients need us, and our children – who have been stripped from healthy routines and peer interactions that nourish social-emotional development – rely on us. We cannot turn our backs for even a moment, or else they will suffer.”

Tasked with caring for a much sicker and distressed population, navigating home duties such as child care, online school, and taking care of certain family members, women psychiatrists are feeling the impact of COVID-19.

Many have seamlessly transferred their practices online, maintaining a lifeline with their patients through telehealth visits. Even with this convenience, the emotional labor of being a psychiatrist is still very stressful, Pooja Lakshmin, MD, of the department of psychiatry and behavioral sciences at George Washington University, Washington, said in an interview. Because the nature of work has changed, and many are doing things virtually at home, separating home from work life can be a challenge. “It’s harder to disconnect,” admitted Dr. Lakshmin. “Even my patients tell me that they have no time to themselves anymore.”

The pandemic demands that women in the profession “white-knuckle” their way to the finish line – a moving target that remains nowhere in sight, Dr. Richards said. “In this process, we are expected to fill the emotional cups of a broken nation, to provide answers that do not exist, and to do so with never-ending gratitude for a demanding system that has no ‘off’ switch,” she noted.
 

‘In two places at once’

COVID-19’s physical and emotional toll has swept across the various subspecialties of clinical psychiatry. As some navigate outpatient/telehealth work, inpatient psychiatrists directly interact with COVID patients.

“Our inpatient psychiatry unit regularly takes care of COVID patients, including perinatal patients who are COVID positive,” Samantha Meltzer-Brody, MD, MPH, distinguished professor and chair, University of North Carolina, Chapel Hill, department of psychiatry and director of medical school’s Center for Women’s Mood Disorders, said in an interview. A psychiatry consultation-liaison service also provides psychiatry care to medical and surgical patients, including medically ill COVID patients across the hospital.

“We are on the front lines in the sense that we are dealing with the trauma of the general population and having to be present for that emotional distress,” Dr. Meltzer-Brody said.

The struggle to balance rising caseloads and home responsibilities makes things difficult, she continued. “There’s a never-ending onslaught of patient referrals,” reflecting the anxiety and depression issues people are experiencing in the wake of a global pandemic, frenetic political situation in the United States, and job uncertainty.

Child care and elder care responsibilities affect both men and women, yet research shows that caregiving demands disproportionately affect women, observed Dr. Meltzer-Brody.

Overall, the stress of caregiving and parenting responsibilities for men and women has been markedly higher during the pandemic. Most clinical psychiatrists “have been extraordinarily busy for a very long time,” she added.

Tiffani L. Bell, MD, a psychiatrist in Winston-Salem, N.C., has seen an increase in anxiety and depression in people with no previous history of diagnosed mental illness. “The impact of the pandemic has truly been multifaceted. People are struggling with loss of jobs, loss of wages, and loss of loved ones, along with grieving the loss of the usual way of life,” she said in an interview.

Many of her colleagues report feeling overburdened at work with increased admissions and patient loads, decreased time to see each patient, and the feeling of “needing to be in two places at once.”

“As a female psychiatrist, I do believe that we can sometimes have an increased mental burden due to the emotional and physical burnout that can occur when our routines are shaken,” added Dr. Bell, who specializes in adult, child, and adolescent psychiatry, and obesity and lifestyle medicine. Even in the early months of the pandemic, Dr. Bell said she heard people joke that “they don’t know if they are working from home or living at work.”

Physicians aren’t the only ones who are overwhelmed. “We’re also hearing stories from our patients – those at risk for partner violence, dealing with kids out of school, working full time while providing support at home,” Ludmila De Faria, MD, chair of the American Psychiatric Association’s Committee on Women’s Mental Health, said in an interview.

American mothers in particular spend nearly twice as much time caring for their children and cooking than their spouses, said Dr. Bell, citing recent studies. “Even if one is not a mom, if you couple the increased housework at baseline with the added responsibilities of working as a front-line physician and/or working from home while managing a household, it can lead to increased stress for all involved.”
 

Women leaving the workforce

Nationally, a growing number of women are either reducing their hours or leaving the workforce in response to the pandemic. Fidelity Investments, which surveyed 1,902 U.S. adults in mid-2020 projected that 4 in 10 women were mulling such options. Among 951 women surveyed, 42% were considering stepping back from their jobs because of their children’s homeschooling needs, and 27% cited difficulties of balancing home and job responsibilities.

Interruptions caused by child care affect women more than men, according to a report from the Century Foundation and the Center for American Progress. “Study after study has shown that, in response to school, child care, and camp closings, as well as reduced hours and reduced class sizes, significantly more women than men have reduced their work hours, left work to care for children, and spent more time on education and household tasks,” the authors noted.

They estimated that the American economy could incur $64.5 billion per year in lost wages and economic activity from the fallout of these trends. In September 2020, four times as many women as men left the workforce, nearly 865,000 women in comparison to 216,000 men.

Many women psychiatrists have been forced to choose between their careers or child care duties – decisions they don’t want to make, but that may be necessary during these unprecedented circumstances. They may be reducing their work hours to assist at home. Others are leaving their jobs, “a terrible situation given the enormous mental health needs of the pandemic” and the fact that so many areas of the United States already suffer from a shortage of clinical psychiatrists, said Dr. Meltzer-Brody.

She has personally seen the effects of this in the large academic department she supervises. “I’m seeing women reducing their work hours or leave positions,” she continued. In addition to child care needs, these women are tending to aging parents affected by COVID-19 or other illnesses, or dealing with the fact that options for elder care aren’t available.

“I have multiple faculty contending with that situation,” added Dr. Meltzer-Brody. As a result, productivity is going down. “These women are trying to keep all of the balls in the air but find they can’t.”

Dr. Richards believes some changes are in order to take the disproportionate burden off of women in psychiatry, and the workforce as a whole. The health care system “places too much pressure on individuals to compensate for its deficiencies. Those individuals who often step up to the plate are women, and this is not their sole burden to carry.”

A move toward telehealth in clinical psychiatry has made it possible for patients and physicians to meet virtually in their respective homes and discuss treatment options. “Even while this is both a blessing and privilege, it comes with the unique challenges of having to manage Zoom calls, child care, meals, distance learning, cleaning, and work responsibilities, while previously there was a clearer delineation to the day for many,” Dr. Bell said.

Clinical psychiatrists educating the public about the mental stressors of COVID-19 face their own unique challenges.

Dr. Lakshmin, who makes appearances in various media and social media outlets, said this adds more pressure to the job. “One of the challenges for me is to figure out how much outward facing I do. That’s hard when you’re navigating working and living through a pandemic. This is something I do because I enjoy doing it. But it’s still a type of work. And it’s certainly increased because the media has been paying more attention to mental health” since the pandemic started, she added.
 

The dual stress of COVID and social justice

Some women psychiatrists of color are dealing with social justice issues on top of other COVID stressors, Dr. De Faria said. The focus on addressing institutionalized racism means that minority women are taking on extra work to advocate for their peers.

Michelle Jacobs-Elliott, MD, of the department of psychiatry and assistant dean of the Office of Diversity and Health Equity at the University of Florida, Gainesville, knows of such responsibilities. “I have been in many discussions either with my coworkers in my department or others who work for the University of Florida” on systemic racism, she said in an interview.

Dr. Jacobs-Elliott became a trainer for Bias Reduction in Internal Medicine, a workshop aimed at reducing bias, and prior to 2020 participated in a social justice summit at the University of Florida. “Talking with my medical as well as undergraduate students about their experiences both here in Gainesville and elsewhere, they are all feeling the hurt, disappointment, and disbelief that we are still fighting battles that our grandparents fought in health care, housing, and employment. This adds an extra layer of stress to everyone’s life.”

The tense social climate has made the apparent racial inequalities in COVID-19 deaths and severity of disease hard to ignore, Dr. Bell noted. “It is my sincere hope that the availability of COVID-19 vaccines will help decrease the number of people affected by this horrible disease. The added burden of racism on top of the stressors of this pandemic can feel insurmountable. I hope 2021 will provide a way forward for us all.”
 

Taking time for self-care

Amid the endless referrals and increasing demands at home, women psychiatrists often don’t have the time to do normal activities, Dr. Meltzer-Brody observed. Like most people, COVID restrictions prevent them from traveling or going to the gym or restaurants. Dr. De Faria has not been able to visit family in Latin America, a trip she used to make twice a year. “That was once my de-stress time. But now, I can’t connect with my roots. My father is elderly and very much at risk.”

This is the time to get creative and resourceful – to make time for self-care, several sources said.

“We need to realize that we cannot be all things to all people, at the same time,” noted Dr. Bell. It’s important to prioritize what’s most important – and keep assessing your priorities. There’s no shame in tending to your own needs. Dr. Bell recommended that women in her profession should pick 1 day a week, put it in their calendar, and stick to this goal of self-care.

“Even if it’s only 15 minutes, it is important to put time aside. Some quick, cheap ideas are to do a quick meditation session, read a chapter in a book, listen to an audiobook, journal, go for a walk and get fresh air. Eat a healthy meal. Even 10 minutes helps,” she urged.

COVID-19 has pushed society to find new ways to do things, Dr. Bell continued. Women psychiatrists, in assessing their work-life balance, may need to reassess their goals. Consider work schedules and see if there’s a place to scale back a task. Delegate tasks at home to family members, if necessary. Most importantly, exercise self-compassion, she stressed. “During this pandemic, I believe it is vital to keep our cups filled so we can pour into others.”

Dr. Lakshmin said she has benefited greatly from having a therapist during the pandemic. “It has been so instrumental in forcing me to take that time for myself, to give me a space to take care of me, and remember it’s okay to take care of me. It’s so important for us as psychiatrists to have that for ourselves. It’s not just for our patients – we need it, too.”

The APA has resources and numerous support groups that meet regularly to address and discuss the stressors of the pandemic. Its College Mental Health Caucus, for example, holds a monthly, hour-long Zoom meeting. Not surprisingly, women comprise the majority of attendees, Dr. De Faria said. “Most women in academic psychiatry are working from home and using telehealth, which isolates people a lot.” Maureen Sayres Van Niel, MD, who is head of the APA’s Women’s Caucus, sends out a regular newsletter that advises on self-care. Women psychiatrists should also contact their local psychiatric organizations to get support from their professional peers.

Sometimes it’s wise to leave work behind and engage with friends. Dr. De Faria regularly Zooms with a group of friends outside of her profession to de-stress and reconnect. “At least I can talk to them about things other than psychiatry.”

Mentally and physically exhausted, Dr. Jacobs-Elliott said she looks forward to the day when society can return to meeting with friends and family “without being afraid that we are an asymptomatic carrier who is infecting our loved ones.”

Daily life is now a juggling act for Misty Richards, MD, MS. As the program director of a rigorous child psychiatry fellowship, a psychiatrist caring for women with perinatal psychiatric disorders, and the mother of three young children, Dr. Richards tries to view these tasks as an opportunity for growth. But some days it feels as if she’s navigating a storm in the middle of the ocean without a life jacket.

In the age of COVID, “the wave of demands has morphed into one giant tidal wave of desperate need,” Dr. Richards, of the department of psychiatry & biobehavioral sciences, University of California, Los Angeles, Semel Institute of Neuroscience & Human Behavior, said in an interview. “The painfully loud and clear message is that our patients need us, and our children – who have been stripped from healthy routines and peer interactions that nourish social-emotional development – rely on us. We cannot turn our backs for even a moment, or else they will suffer.”

Tasked with caring for a much sicker and distressed population, navigating home duties such as child care, online school, and taking care of certain family members, women psychiatrists are feeling the impact of COVID-19.

Many have seamlessly transferred their practices online, maintaining a lifeline with their patients through telehealth visits. Even with this convenience, the emotional labor of being a psychiatrist is still very stressful, Pooja Lakshmin, MD, of the department of psychiatry and behavioral sciences at George Washington University, Washington, said in an interview. Because the nature of work has changed, and many are doing things virtually at home, separating home from work life can be a challenge. “It’s harder to disconnect,” admitted Dr. Lakshmin. “Even my patients tell me that they have no time to themselves anymore.”

The pandemic demands that women in the profession “white-knuckle” their way to the finish line – a moving target that remains nowhere in sight, Dr. Richards said. “In this process, we are expected to fill the emotional cups of a broken nation, to provide answers that do not exist, and to do so with never-ending gratitude for a demanding system that has no ‘off’ switch,” she noted.
 

‘In two places at once’

COVID-19’s physical and emotional toll has swept across the various subspecialties of clinical psychiatry. As some navigate outpatient/telehealth work, inpatient psychiatrists directly interact with COVID patients.

“Our inpatient psychiatry unit regularly takes care of COVID patients, including perinatal patients who are COVID positive,” Samantha Meltzer-Brody, MD, MPH, distinguished professor and chair, University of North Carolina, Chapel Hill, department of psychiatry and director of medical school’s Center for Women’s Mood Disorders, said in an interview. A psychiatry consultation-liaison service also provides psychiatry care to medical and surgical patients, including medically ill COVID patients across the hospital.

“We are on the front lines in the sense that we are dealing with the trauma of the general population and having to be present for that emotional distress,” Dr. Meltzer-Brody said.

The struggle to balance rising caseloads and home responsibilities makes things difficult, she continued. “There’s a never-ending onslaught of patient referrals,” reflecting the anxiety and depression issues people are experiencing in the wake of a global pandemic, frenetic political situation in the United States, and job uncertainty.

Child care and elder care responsibilities affect both men and women, yet research shows that caregiving demands disproportionately affect women, observed Dr. Meltzer-Brody.

Overall, the stress of caregiving and parenting responsibilities for men and women has been markedly higher during the pandemic. Most clinical psychiatrists “have been extraordinarily busy for a very long time,” she added.

Tiffani L. Bell, MD, a psychiatrist in Winston-Salem, N.C., has seen an increase in anxiety and depression in people with no previous history of diagnosed mental illness. “The impact of the pandemic has truly been multifaceted. People are struggling with loss of jobs, loss of wages, and loss of loved ones, along with grieving the loss of the usual way of life,” she said in an interview.

Many of her colleagues report feeling overburdened at work with increased admissions and patient loads, decreased time to see each patient, and the feeling of “needing to be in two places at once.”

“As a female psychiatrist, I do believe that we can sometimes have an increased mental burden due to the emotional and physical burnout that can occur when our routines are shaken,” added Dr. Bell, who specializes in adult, child, and adolescent psychiatry, and obesity and lifestyle medicine. Even in the early months of the pandemic, Dr. Bell said she heard people joke that “they don’t know if they are working from home or living at work.”

Physicians aren’t the only ones who are overwhelmed. “We’re also hearing stories from our patients – those at risk for partner violence, dealing with kids out of school, working full time while providing support at home,” Ludmila De Faria, MD, chair of the American Psychiatric Association’s Committee on Women’s Mental Health, said in an interview.

American mothers in particular spend nearly twice as much time caring for their children and cooking than their spouses, said Dr. Bell, citing recent studies. “Even if one is not a mom, if you couple the increased housework at baseline with the added responsibilities of working as a front-line physician and/or working from home while managing a household, it can lead to increased stress for all involved.”
 

Women leaving the workforce

Nationally, a growing number of women are either reducing their hours or leaving the workforce in response to the pandemic. Fidelity Investments, which surveyed 1,902 U.S. adults in mid-2020 projected that 4 in 10 women were mulling such options. Among 951 women surveyed, 42% were considering stepping back from their jobs because of their children’s homeschooling needs, and 27% cited difficulties of balancing home and job responsibilities.

Interruptions caused by child care affect women more than men, according to a report from the Century Foundation and the Center for American Progress. “Study after study has shown that, in response to school, child care, and camp closings, as well as reduced hours and reduced class sizes, significantly more women than men have reduced their work hours, left work to care for children, and spent more time on education and household tasks,” the authors noted.

They estimated that the American economy could incur $64.5 billion per year in lost wages and economic activity from the fallout of these trends. In September 2020, four times as many women as men left the workforce, nearly 865,000 women in comparison to 216,000 men.

Many women psychiatrists have been forced to choose between their careers or child care duties – decisions they don’t want to make, but that may be necessary during these unprecedented circumstances. They may be reducing their work hours to assist at home. Others are leaving their jobs, “a terrible situation given the enormous mental health needs of the pandemic” and the fact that so many areas of the United States already suffer from a shortage of clinical psychiatrists, said Dr. Meltzer-Brody.

She has personally seen the effects of this in the large academic department she supervises. “I’m seeing women reducing their work hours or leave positions,” she continued. In addition to child care needs, these women are tending to aging parents affected by COVID-19 or other illnesses, or dealing with the fact that options for elder care aren’t available.

“I have multiple faculty contending with that situation,” added Dr. Meltzer-Brody. As a result, productivity is going down. “These women are trying to keep all of the balls in the air but find they can’t.”

Dr. Richards believes some changes are in order to take the disproportionate burden off of women in psychiatry, and the workforce as a whole. The health care system “places too much pressure on individuals to compensate for its deficiencies. Those individuals who often step up to the plate are women, and this is not their sole burden to carry.”

A move toward telehealth in clinical psychiatry has made it possible for patients and physicians to meet virtually in their respective homes and discuss treatment options. “Even while this is both a blessing and privilege, it comes with the unique challenges of having to manage Zoom calls, child care, meals, distance learning, cleaning, and work responsibilities, while previously there was a clearer delineation to the day for many,” Dr. Bell said.

Clinical psychiatrists educating the public about the mental stressors of COVID-19 face their own unique challenges.

Dr. Lakshmin, who makes appearances in various media and social media outlets, said this adds more pressure to the job. “One of the challenges for me is to figure out how much outward facing I do. That’s hard when you’re navigating working and living through a pandemic. This is something I do because I enjoy doing it. But it’s still a type of work. And it’s certainly increased because the media has been paying more attention to mental health” since the pandemic started, she added.
 

The dual stress of COVID and social justice

Some women psychiatrists of color are dealing with social justice issues on top of other COVID stressors, Dr. De Faria said. The focus on addressing institutionalized racism means that minority women are taking on extra work to advocate for their peers.

Michelle Jacobs-Elliott, MD, of the department of psychiatry and assistant dean of the Office of Diversity and Health Equity at the University of Florida, Gainesville, knows of such responsibilities. “I have been in many discussions either with my coworkers in my department or others who work for the University of Florida” on systemic racism, she said in an interview.

Dr. Jacobs-Elliott became a trainer for Bias Reduction in Internal Medicine, a workshop aimed at reducing bias, and prior to 2020 participated in a social justice summit at the University of Florida. “Talking with my medical as well as undergraduate students about their experiences both here in Gainesville and elsewhere, they are all feeling the hurt, disappointment, and disbelief that we are still fighting battles that our grandparents fought in health care, housing, and employment. This adds an extra layer of stress to everyone’s life.”

The tense social climate has made the apparent racial inequalities in COVID-19 deaths and severity of disease hard to ignore, Dr. Bell noted. “It is my sincere hope that the availability of COVID-19 vaccines will help decrease the number of people affected by this horrible disease. The added burden of racism on top of the stressors of this pandemic can feel insurmountable. I hope 2021 will provide a way forward for us all.”
 

Taking time for self-care

Amid the endless referrals and increasing demands at home, women psychiatrists often don’t have the time to do normal activities, Dr. Meltzer-Brody observed. Like most people, COVID restrictions prevent them from traveling or going to the gym or restaurants. Dr. De Faria has not been able to visit family in Latin America, a trip she used to make twice a year. “That was once my de-stress time. But now, I can’t connect with my roots. My father is elderly and very much at risk.”

This is the time to get creative and resourceful – to make time for self-care, several sources said.

“We need to realize that we cannot be all things to all people, at the same time,” noted Dr. Bell. It’s important to prioritize what’s most important – and keep assessing your priorities. There’s no shame in tending to your own needs. Dr. Bell recommended that women in her profession should pick 1 day a week, put it in their calendar, and stick to this goal of self-care.

“Even if it’s only 15 minutes, it is important to put time aside. Some quick, cheap ideas are to do a quick meditation session, read a chapter in a book, listen to an audiobook, journal, go for a walk and get fresh air. Eat a healthy meal. Even 10 minutes helps,” she urged.

COVID-19 has pushed society to find new ways to do things, Dr. Bell continued. Women psychiatrists, in assessing their work-life balance, may need to reassess their goals. Consider work schedules and see if there’s a place to scale back a task. Delegate tasks at home to family members, if necessary. Most importantly, exercise self-compassion, she stressed. “During this pandemic, I believe it is vital to keep our cups filled so we can pour into others.”

Dr. Lakshmin said she has benefited greatly from having a therapist during the pandemic. “It has been so instrumental in forcing me to take that time for myself, to give me a space to take care of me, and remember it’s okay to take care of me. It’s so important for us as psychiatrists to have that for ourselves. It’s not just for our patients – we need it, too.”

The APA has resources and numerous support groups that meet regularly to address and discuss the stressors of the pandemic. Its College Mental Health Caucus, for example, holds a monthly, hour-long Zoom meeting. Not surprisingly, women comprise the majority of attendees, Dr. De Faria said. “Most women in academic psychiatry are working from home and using telehealth, which isolates people a lot.” Maureen Sayres Van Niel, MD, who is head of the APA’s Women’s Caucus, sends out a regular newsletter that advises on self-care. Women psychiatrists should also contact their local psychiatric organizations to get support from their professional peers.

Sometimes it’s wise to leave work behind and engage with friends. Dr. De Faria regularly Zooms with a group of friends outside of her profession to de-stress and reconnect. “At least I can talk to them about things other than psychiatry.”

Mentally and physically exhausted, Dr. Jacobs-Elliott said she looks forward to the day when society can return to meeting with friends and family “without being afraid that we are an asymptomatic carrier who is infecting our loved ones.”

Daily life is now a juggling act for Misty Richards, MD, MS. As the program director of a rigorous child psychiatry fellowship, a psychiatrist caring for women with perinatal psychiatric disorders, and the mother of three young children, Dr. Richards tries to view these tasks as an opportunity for growth. But some days it feels as if she’s navigating a storm in the middle of the ocean without a life jacket.

In the age of COVID, “the wave of demands has morphed into one giant tidal wave of desperate need,” Dr. Richards, of the department of psychiatry & biobehavioral sciences, University of California, Los Angeles, Semel Institute of Neuroscience & Human Behavior, said in an interview. “The painfully loud and clear message is that our patients need us, and our children – who have been stripped from healthy routines and peer interactions that nourish social-emotional development – rely on us. We cannot turn our backs for even a moment, or else they will suffer.”

Tasked with caring for a much sicker and distressed population, navigating home duties such as child care, online school, and taking care of certain family members, women psychiatrists are feeling the impact of COVID-19.

Many have seamlessly transferred their practices online, maintaining a lifeline with their patients through telehealth visits. Even with this convenience, the emotional labor of being a psychiatrist is still very stressful, Pooja Lakshmin, MD, of the department of psychiatry and behavioral sciences at George Washington University, Washington, said in an interview. Because the nature of work has changed, and many are doing things virtually at home, separating home from work life can be a challenge. “It’s harder to disconnect,” admitted Dr. Lakshmin. “Even my patients tell me that they have no time to themselves anymore.”

The pandemic demands that women in the profession “white-knuckle” their way to the finish line – a moving target that remains nowhere in sight, Dr. Richards said. “In this process, we are expected to fill the emotional cups of a broken nation, to provide answers that do not exist, and to do so with never-ending gratitude for a demanding system that has no ‘off’ switch,” she noted.
 

‘In two places at once’

COVID-19’s physical and emotional toll has swept across the various subspecialties of clinical psychiatry. As some navigate outpatient/telehealth work, inpatient psychiatrists directly interact with COVID patients.

“Our inpatient psychiatry unit regularly takes care of COVID patients, including perinatal patients who are COVID positive,” Samantha Meltzer-Brody, MD, MPH, distinguished professor and chair, University of North Carolina, Chapel Hill, department of psychiatry and director of medical school’s Center for Women’s Mood Disorders, said in an interview. A psychiatry consultation-liaison service also provides psychiatry care to medical and surgical patients, including medically ill COVID patients across the hospital.

“We are on the front lines in the sense that we are dealing with the trauma of the general population and having to be present for that emotional distress,” Dr. Meltzer-Brody said.

The struggle to balance rising caseloads and home responsibilities makes things difficult, she continued. “There’s a never-ending onslaught of patient referrals,” reflecting the anxiety and depression issues people are experiencing in the wake of a global pandemic, frenetic political situation in the United States, and job uncertainty.

Child care and elder care responsibilities affect both men and women, yet research shows that caregiving demands disproportionately affect women, observed Dr. Meltzer-Brody.

Overall, the stress of caregiving and parenting responsibilities for men and women has been markedly higher during the pandemic. Most clinical psychiatrists “have been extraordinarily busy for a very long time,” she added.

Tiffani L. Bell, MD, a psychiatrist in Winston-Salem, N.C., has seen an increase in anxiety and depression in people with no previous history of diagnosed mental illness. “The impact of the pandemic has truly been multifaceted. People are struggling with loss of jobs, loss of wages, and loss of loved ones, along with grieving the loss of the usual way of life,” she said in an interview.

Many of her colleagues report feeling overburdened at work with increased admissions and patient loads, decreased time to see each patient, and the feeling of “needing to be in two places at once.”

“As a female psychiatrist, I do believe that we can sometimes have an increased mental burden due to the emotional and physical burnout that can occur when our routines are shaken,” added Dr. Bell, who specializes in adult, child, and adolescent psychiatry, and obesity and lifestyle medicine. Even in the early months of the pandemic, Dr. Bell said she heard people joke that “they don’t know if they are working from home or living at work.”

Physicians aren’t the only ones who are overwhelmed. “We’re also hearing stories from our patients – those at risk for partner violence, dealing with kids out of school, working full time while providing support at home,” Ludmila De Faria, MD, chair of the American Psychiatric Association’s Committee on Women’s Mental Health, said in an interview.

American mothers in particular spend nearly twice as much time caring for their children and cooking than their spouses, said Dr. Bell, citing recent studies. “Even if one is not a mom, if you couple the increased housework at baseline with the added responsibilities of working as a front-line physician and/or working from home while managing a household, it can lead to increased stress for all involved.”
 

Women leaving the workforce

Nationally, a growing number of women are either reducing their hours or leaving the workforce in response to the pandemic. Fidelity Investments, which surveyed 1,902 U.S. adults in mid-2020 projected that 4 in 10 women were mulling such options. Among 951 women surveyed, 42% were considering stepping back from their jobs because of their children’s homeschooling needs, and 27% cited difficulties of balancing home and job responsibilities.

Interruptions caused by child care affect women more than men, according to a report from the Century Foundation and the Center for American Progress. “Study after study has shown that, in response to school, child care, and camp closings, as well as reduced hours and reduced class sizes, significantly more women than men have reduced their work hours, left work to care for children, and spent more time on education and household tasks,” the authors noted.

They estimated that the American economy could incur $64.5 billion per year in lost wages and economic activity from the fallout of these trends. In September 2020, four times as many women as men left the workforce, nearly 865,000 women in comparison to 216,000 men.

Many women psychiatrists have been forced to choose between their careers or child care duties – decisions they don’t want to make, but that may be necessary during these unprecedented circumstances. They may be reducing their work hours to assist at home. Others are leaving their jobs, “a terrible situation given the enormous mental health needs of the pandemic” and the fact that so many areas of the United States already suffer from a shortage of clinical psychiatrists, said Dr. Meltzer-Brody.

She has personally seen the effects of this in the large academic department she supervises. “I’m seeing women reducing their work hours or leave positions,” she continued. In addition to child care needs, these women are tending to aging parents affected by COVID-19 or other illnesses, or dealing with the fact that options for elder care aren’t available.

“I have multiple faculty contending with that situation,” added Dr. Meltzer-Brody. As a result, productivity is going down. “These women are trying to keep all of the balls in the air but find they can’t.”

Dr. Richards believes some changes are in order to take the disproportionate burden off of women in psychiatry, and the workforce as a whole. The health care system “places too much pressure on individuals to compensate for its deficiencies. Those individuals who often step up to the plate are women, and this is not their sole burden to carry.”

A move toward telehealth in clinical psychiatry has made it possible for patients and physicians to meet virtually in their respective homes and discuss treatment options. “Even while this is both a blessing and privilege, it comes with the unique challenges of having to manage Zoom calls, child care, meals, distance learning, cleaning, and work responsibilities, while previously there was a clearer delineation to the day for many,” Dr. Bell said.

Clinical psychiatrists educating the public about the mental stressors of COVID-19 face their own unique challenges.

Dr. Lakshmin, who makes appearances in various media and social media outlets, said this adds more pressure to the job. “One of the challenges for me is to figure out how much outward facing I do. That’s hard when you’re navigating working and living through a pandemic. This is something I do because I enjoy doing it. But it’s still a type of work. And it’s certainly increased because the media has been paying more attention to mental health” since the pandemic started, she added.
 

The dual stress of COVID and social justice

Some women psychiatrists of color are dealing with social justice issues on top of other COVID stressors, Dr. De Faria said. The focus on addressing institutionalized racism means that minority women are taking on extra work to advocate for their peers.

Michelle Jacobs-Elliott, MD, of the department of psychiatry and assistant dean of the Office of Diversity and Health Equity at the University of Florida, Gainesville, knows of such responsibilities. “I have been in many discussions either with my coworkers in my department or others who work for the University of Florida” on systemic racism, she said in an interview.

Dr. Jacobs-Elliott became a trainer for Bias Reduction in Internal Medicine, a workshop aimed at reducing bias, and prior to 2020 participated in a social justice summit at the University of Florida. “Talking with my medical as well as undergraduate students about their experiences both here in Gainesville and elsewhere, they are all feeling the hurt, disappointment, and disbelief that we are still fighting battles that our grandparents fought in health care, housing, and employment. This adds an extra layer of stress to everyone’s life.”

The tense social climate has made the apparent racial inequalities in COVID-19 deaths and severity of disease hard to ignore, Dr. Bell noted. “It is my sincere hope that the availability of COVID-19 vaccines will help decrease the number of people affected by this horrible disease. The added burden of racism on top of the stressors of this pandemic can feel insurmountable. I hope 2021 will provide a way forward for us all.”
 

Taking time for self-care

Amid the endless referrals and increasing demands at home, women psychiatrists often don’t have the time to do normal activities, Dr. Meltzer-Brody observed. Like most people, COVID restrictions prevent them from traveling or going to the gym or restaurants. Dr. De Faria has not been able to visit family in Latin America, a trip she used to make twice a year. “That was once my de-stress time. But now, I can’t connect with my roots. My father is elderly and very much at risk.”

This is the time to get creative and resourceful – to make time for self-care, several sources said.

“We need to realize that we cannot be all things to all people, at the same time,” noted Dr. Bell. It’s important to prioritize what’s most important – and keep assessing your priorities. There’s no shame in tending to your own needs. Dr. Bell recommended that women in her profession should pick 1 day a week, put it in their calendar, and stick to this goal of self-care.

“Even if it’s only 15 minutes, it is important to put time aside. Some quick, cheap ideas are to do a quick meditation session, read a chapter in a book, listen to an audiobook, journal, go for a walk and get fresh air. Eat a healthy meal. Even 10 minutes helps,” she urged.

COVID-19 has pushed society to find new ways to do things, Dr. Bell continued. Women psychiatrists, in assessing their work-life balance, may need to reassess their goals. Consider work schedules and see if there’s a place to scale back a task. Delegate tasks at home to family members, if necessary. Most importantly, exercise self-compassion, she stressed. “During this pandemic, I believe it is vital to keep our cups filled so we can pour into others.”

Dr. Lakshmin said she has benefited greatly from having a therapist during the pandemic. “It has been so instrumental in forcing me to take that time for myself, to give me a space to take care of me, and remember it’s okay to take care of me. It’s so important for us as psychiatrists to have that for ourselves. It’s not just for our patients – we need it, too.”

The APA has resources and numerous support groups that meet regularly to address and discuss the stressors of the pandemic. Its College Mental Health Caucus, for example, holds a monthly, hour-long Zoom meeting. Not surprisingly, women comprise the majority of attendees, Dr. De Faria said. “Most women in academic psychiatry are working from home and using telehealth, which isolates people a lot.” Maureen Sayres Van Niel, MD, who is head of the APA’s Women’s Caucus, sends out a regular newsletter that advises on self-care. Women psychiatrists should also contact their local psychiatric organizations to get support from their professional peers.

Sometimes it’s wise to leave work behind and engage with friends. Dr. De Faria regularly Zooms with a group of friends outside of her profession to de-stress and reconnect. “At least I can talk to them about things other than psychiatry.”

Mentally and physically exhausted, Dr. Jacobs-Elliott said she looks forward to the day when society can return to meeting with friends and family “without being afraid that we are an asymptomatic carrier who is infecting our loved ones.”

After bariatric surgery, patients have a “much higher” risk of unhealthy alcohol use—even if they had no documented unhealthy drinking at baseline, according to researchers from the Durham Veteran Affairs (VA) Medical Center in North Carolina.

Based on their findings, the researchers estimate that for every 21 patients who undergo laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB), on average one from each group will develop unhealthy alcohol use.

The researchers collected electronic health record (EHR) data from 2,608 veterans who underwent LSG or RYGB at any bariatric center in the VA health system between 2008 and 2016, and compared that group with a nonsurgical control group.

Nearly all the patients screened negative for unhealthy alcohol use in the 2-year baseline period; however, their mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after surgery when compared with the control group. Eight years after an LSG, the probability was 3.4% higher (7.9% vs 4.5%). Eight years after an RYGB, the probability was 9.2% vs 4.4%, a difference of 4.8%.

The estimated prevalence of unhealthy alcohol use 8 years after bariatric surgery was higher for patients with unhealthy drinking at baseline (30  40%) than it was for those without baseline unhealthy drinking (5 - 10%). However, the probability was significantly higher for patients who had an RYGB than it was for nonsurgical control patients after 8 years, which might reflect alcohol pharmacokinetics changes, the researchers say.

Not drinking alcohol is the safest option after bariatric surgery, the researchers say, given that blood alcohol concentration peaks at higher levels after the operation. They advise monitoring patients long-term, using the three-item AUDIT-C scale. And, importantly, they advise cautioning patients undergoing bariatric surgery that drinking alcohol can escalate, even if they have had no history of drinking above recommended limits.

After bariatric surgery, patients have a “much higher” risk of unhealthy alcohol use—even if they had no documented unhealthy drinking at baseline, according to researchers from the Durham Veteran Affairs (VA) Medical Center in North Carolina.

Based on their findings, the researchers estimate that for every 21 patients who undergo laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB), on average one from each group will develop unhealthy alcohol use.

The researchers collected electronic health record (EHR) data from 2,608 veterans who underwent LSG or RYGB at any bariatric center in the VA health system between 2008 and 2016, and compared that group with a nonsurgical control group.

Nearly all the patients screened negative for unhealthy alcohol use in the 2-year baseline period; however, their mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after surgery when compared with the control group. Eight years after an LSG, the probability was 3.4% higher (7.9% vs 4.5%). Eight years after an RYGB, the probability was 9.2% vs 4.4%, a difference of 4.8%.

The estimated prevalence of unhealthy alcohol use 8 years after bariatric surgery was higher for patients with unhealthy drinking at baseline (30  40%) than it was for those without baseline unhealthy drinking (5 - 10%). However, the probability was significantly higher for patients who had an RYGB than it was for nonsurgical control patients after 8 years, which might reflect alcohol pharmacokinetics changes, the researchers say.

Not drinking alcohol is the safest option after bariatric surgery, the researchers say, given that blood alcohol concentration peaks at higher levels after the operation. They advise monitoring patients long-term, using the three-item AUDIT-C scale. And, importantly, they advise cautioning patients undergoing bariatric surgery that drinking alcohol can escalate, even if they have had no history of drinking above recommended limits.

After bariatric surgery, patients have a “much higher” risk of unhealthy alcohol use—even if they had no documented unhealthy drinking at baseline, according to researchers from the Durham Veteran Affairs (VA) Medical Center in North Carolina.

Based on their findings, the researchers estimate that for every 21 patients who undergo laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB), on average one from each group will develop unhealthy alcohol use.

The researchers collected electronic health record (EHR) data from 2,608 veterans who underwent LSG or RYGB at any bariatric center in the VA health system between 2008 and 2016, and compared that group with a nonsurgical control group.

Nearly all the patients screened negative for unhealthy alcohol use in the 2-year baseline period; however, their mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after surgery when compared with the control group. Eight years after an LSG, the probability was 3.4% higher (7.9% vs 4.5%). Eight years after an RYGB, the probability was 9.2% vs 4.4%, a difference of 4.8%.

The estimated prevalence of unhealthy alcohol use 8 years after bariatric surgery was higher for patients with unhealthy drinking at baseline (30  40%) than it was for those without baseline unhealthy drinking (5 - 10%). However, the probability was significantly higher for patients who had an RYGB than it was for nonsurgical control patients after 8 years, which might reflect alcohol pharmacokinetics changes, the researchers say.

Not drinking alcohol is the safest option after bariatric surgery, the researchers say, given that blood alcohol concentration peaks at higher levels after the operation. They advise monitoring patients long-term, using the three-item AUDIT-C scale. And, importantly, they advise cautioning patients undergoing bariatric surgery that drinking alcohol can escalate, even if they have had no history of drinking above recommended limits.

The United States set a new weekly high for COVID-19 cases in children, surpassing 200,000 for the first time since the pandemic began, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

There were 211,466 new cases reported in children during the week of Jan. 8-14, topping the previous high (Dec. 11-17) by almost 30,000. Those new cases bring the total for the pandemic to over 2.5 million children infected with the coronavirus, which represents 12.6% of all reported cases, the AAP and the CHA said Jan. 19 in their weekly COVID-19 report.

The rise in cases also brought an increase in the proportion reported among children. The week before (Jan. 1-7), cases in children were 12.9% of all cases reported, but the most recent week saw that number rise to 14.5% of all cases, the highest it’s been since early October, based on data collected from the health department websites of 49 states (excluding New York), the District of Columbia, New York City, Puerto Rio, and Guam.

The corresponding figures for severe illness continue to be low: Children represent 1.8% of all hospitalizations from COVID-19 in 24 states and New York City and 0.06% of all deaths in 43 states and New York City. Three deaths were reported for the week of Jan. 8-14, making for a total of 191 since the pandemic started, the AAP and CHA said in their report.

Among the states, California has the most overall cases at just over 350,000, Wyoming has the highest proportion of cases in children (20.3%), and North Dakota has the highest rate of infection (over 8,100 per 100,000 children). The infection rate for the nation is now above 3,300 per 100,000 children, and 11 states reported rates over 5,000, according to the AAP and the CHA.

rfranki@mdedge.com

The United States set a new weekly high for COVID-19 cases in children, surpassing 200,000 for the first time since the pandemic began, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

There were 211,466 new cases reported in children during the week of Jan. 8-14, topping the previous high (Dec. 11-17) by almost 30,000. Those new cases bring the total for the pandemic to over 2.5 million children infected with the coronavirus, which represents 12.6% of all reported cases, the AAP and the CHA said Jan. 19 in their weekly COVID-19 report.

The rise in cases also brought an increase in the proportion reported among children. The week before (Jan. 1-7), cases in children were 12.9% of all cases reported, but the most recent week saw that number rise to 14.5% of all cases, the highest it’s been since early October, based on data collected from the health department websites of 49 states (excluding New York), the District of Columbia, New York City, Puerto Rio, and Guam.

The corresponding figures for severe illness continue to be low: Children represent 1.8% of all hospitalizations from COVID-19 in 24 states and New York City and 0.06% of all deaths in 43 states and New York City. Three deaths were reported for the week of Jan. 8-14, making for a total of 191 since the pandemic started, the AAP and CHA said in their report.

Among the states, California has the most overall cases at just over 350,000, Wyoming has the highest proportion of cases in children (20.3%), and North Dakota has the highest rate of infection (over 8,100 per 100,000 children). The infection rate for the nation is now above 3,300 per 100,000 children, and 11 states reported rates over 5,000, according to the AAP and the CHA.

rfranki@mdedge.com

The United States set a new weekly high for COVID-19 cases in children, surpassing 200,000 for the first time since the pandemic began, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

There were 211,466 new cases reported in children during the week of Jan. 8-14, topping the previous high (Dec. 11-17) by almost 30,000. Those new cases bring the total for the pandemic to over 2.5 million children infected with the coronavirus, which represents 12.6% of all reported cases, the AAP and the CHA said Jan. 19 in their weekly COVID-19 report.

The rise in cases also brought an increase in the proportion reported among children. The week before (Jan. 1-7), cases in children were 12.9% of all cases reported, but the most recent week saw that number rise to 14.5% of all cases, the highest it’s been since early October, based on data collected from the health department websites of 49 states (excluding New York), the District of Columbia, New York City, Puerto Rio, and Guam.

The corresponding figures for severe illness continue to be low: Children represent 1.8% of all hospitalizations from COVID-19 in 24 states and New York City and 0.06% of all deaths in 43 states and New York City. Three deaths were reported for the week of Jan. 8-14, making for a total of 191 since the pandemic started, the AAP and CHA said in their report.

Among the states, California has the most overall cases at just over 350,000, Wyoming has the highest proportion of cases in children (20.3%), and North Dakota has the highest rate of infection (over 8,100 per 100,000 children). The infection rate for the nation is now above 3,300 per 100,000 children, and 11 states reported rates over 5,000, according to the AAP and the CHA.

rfranki@mdedge.com

Preliminary data suggest that a certain pattern of gut microbes may be useful in predicting which patients with advanced gastric cancer are likely to benefit from treatment with the immunotherapy nivolumab.

Researchers have demonstrated bacterial invasion of the epithelial cell pathway in the gut microbiome and suggest that this could potentially become a novel biomarker.

“In addition, we found gastric cancer–specific gut microbiome predictive of responses to immune checkpoint inhibitors,” said study author Yu Sunakawa, MD, PhD, an associate professor in the department of clinical oncology at St. Marianna University, Kawasaki, Japan.

Dr. Sunakawa presented the study’s results at the 2021 Gastrointestinal Cancers Symposium.

The gut microbiome holds great interest as a potential biomarker for response. Previous studies suggested that it may hold the key to immunotherapy responses. The concept has been demonstrated in several studies involving patients with melanoma, but this is the first study in patients with gastric cancer.

Nivolumab monotherapy has been shown to provide a survival benefit with a manageable safety profile in previously treated patients with gastric cancer or gastroesophageal junction (GEJ) cancer, Dr. Sunakawa noted. However, fewer than half of patients responded to therapy.

“The disease control rate was about 40%, and many patients did not experience any tumor degradation,” he said. “About 60% of the patients did not respond to nivolumab as a late-line therapy.”

In the observational/translational DELIVER trial, investigators enrolled 501 patients with recurrent or metastatic adenocarcinoma of the stomach or GEJ. The patients were recruited from 50 sites in Japan.

The primary endpoint was the relationship between the genomic pathway in the gut microbiome and efficacy of nivolumab and whether there was progressive disease or not at the first evaluation, as determined in accordance with Response Evaluation Criteria in Solid Tumors criteria.

Genomic data were measured by genome shotgun sequence at a central laboratory. Biomarkers were analyzed by Wilcoxon rank sum test in the first 200 patients, who constituted the training cohort. The top 30 biomarker candidates were validated in the last 300 patients (the validation cohort) using the Bonferroni method.

Clinical and genomic data were available for 437 patients (87%). Of this group, 180 constituted the training cohort, and 257, the validation cohort.

The phylogenetic composition of common bacterial taxa was similar for both cohorts.

In the training cohort, 62.2% of patients had progressive disease, as did 53.2% in the validation cohort. The microbiome was more diverse among the patients who did not have progressive disease than among those who did have progressive disease.

The authors noted that, although there was no statistically significant pathway to be validated for a primary endpoint using the Bonferroni method, bacterial invasion of epithelial cells in the KEGG pathway was associated with clinical outcomes in both the training cohort (P = .057) and the validation cohort (P = .014). However, these pathways were not significantly associated with progressive disease after Bonferroni correction, a conservative test that adjusts for multiple comparisons.

An exploratory analysis of genus showed that Odoribacter and Veillonella species were associated with tumor response to nivolumab in both cohorts.

Dr. Sunakawa noted that biomarker analyses are ongoing. The researchers are investigating the relationships between microbiome and survival times, as well as other endpoints.
 

Still some gaps

In a discussion of the study, Jonathan Yeung, MD, PhD, of Princess Margaret Cancer Center, Toronto, congratulated the investigators on their study, noting that “the logistical hurdles must have been tremendous to obtain these data.”

However, Dr. Yeung pointed out some limitations and gaps in the data that were presented. For example, he found that the ratio of the training set to the validation set was unusual. “The training set is usually larger and usually an 80/20 ratio,” he said. “In their design, the validation set is larger, and I’m quite curious about their rationale.

“The conclusion of the study is that a more diverse microbiome was observed in patients with a tumor response than in those without a response,” he continued, “but they don’t actually show the statistical test used to make this conclusion. There is considerable overlap between the groups, and more compelling data are needed to make that conclusion.”

Another limitation was the marked imbalance in the number of patients whose condition responded to nivolumab in comparison with those whose condition did not (20 vs. 417 patients). This could have affected the statistical power of the study.

But overall, Dr. Yeung congratulated the authors for presenting a very impressive dataset. “The preliminary data are very interesting, and I look forward to the final results,” he said.

The study was funded by Ono Pharmaceutical and Bristol-Myers Squibb, which markets nivolumab. Dr. Sunakawa has received honoraria from Bayer Yakuhin, Bristol-Myers Squibb Japan, Chugai, Kyowa Hakko Kirin, Lilly Japan, Nippon Kayaku, Sanofi, Taiho, Takeda, and Yakult Honsha. He has held a consulting or advisory role for Bristol-Myers Squibb Japan, Daiichi Sankyo, and Takeda and has received research funding from Chugai Pharma, Daiichi Sankyo, Lilly Japan, Sanofi, Taiho Pharmaceutical, and Takeda. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

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

Preliminary data suggest that a certain pattern of gut microbes may be useful in predicting which patients with advanced gastric cancer are likely to benefit from treatment with the immunotherapy nivolumab.

Researchers have demonstrated bacterial invasion of the epithelial cell pathway in the gut microbiome and suggest that this could potentially become a novel biomarker.

“In addition, we found gastric cancer–specific gut microbiome predictive of responses to immune checkpoint inhibitors,” said study author Yu Sunakawa, MD, PhD, an associate professor in the department of clinical oncology at St. Marianna University, Kawasaki, Japan.

Dr. Sunakawa presented the study’s results at the 2021 Gastrointestinal Cancers Symposium.

The gut microbiome holds great interest as a potential biomarker for response. Previous studies suggested that it may hold the key to immunotherapy responses. The concept has been demonstrated in several studies involving patients with melanoma, but this is the first study in patients with gastric cancer.

Nivolumab monotherapy has been shown to provide a survival benefit with a manageable safety profile in previously treated patients with gastric cancer or gastroesophageal junction (GEJ) cancer, Dr. Sunakawa noted. However, fewer than half of patients responded to therapy.

“The disease control rate was about 40%, and many patients did not experience any tumor degradation,” he said. “About 60% of the patients did not respond to nivolumab as a late-line therapy.”

In the observational/translational DELIVER trial, investigators enrolled 501 patients with recurrent or metastatic adenocarcinoma of the stomach or GEJ. The patients were recruited from 50 sites in Japan.

The primary endpoint was the relationship between the genomic pathway in the gut microbiome and efficacy of nivolumab and whether there was progressive disease or not at the first evaluation, as determined in accordance with Response Evaluation Criteria in Solid Tumors criteria.

Genomic data were measured by genome shotgun sequence at a central laboratory. Biomarkers were analyzed by Wilcoxon rank sum test in the first 200 patients, who constituted the training cohort. The top 30 biomarker candidates were validated in the last 300 patients (the validation cohort) using the Bonferroni method.

Clinical and genomic data were available for 437 patients (87%). Of this group, 180 constituted the training cohort, and 257, the validation cohort.

The phylogenetic composition of common bacterial taxa was similar for both cohorts.

In the training cohort, 62.2% of patients had progressive disease, as did 53.2% in the validation cohort. The microbiome was more diverse among the patients who did not have progressive disease than among those who did have progressive disease.

The authors noted that, although there was no statistically significant pathway to be validated for a primary endpoint using the Bonferroni method, bacterial invasion of epithelial cells in the KEGG pathway was associated with clinical outcomes in both the training cohort (P = .057) and the validation cohort (P = .014). However, these pathways were not significantly associated with progressive disease after Bonferroni correction, a conservative test that adjusts for multiple comparisons.

An exploratory analysis of genus showed that Odoribacter and Veillonella species were associated with tumor response to nivolumab in both cohorts.

Dr. Sunakawa noted that biomarker analyses are ongoing. The researchers are investigating the relationships between microbiome and survival times, as well as other endpoints.
 

Still some gaps

In a discussion of the study, Jonathan Yeung, MD, PhD, of Princess Margaret Cancer Center, Toronto, congratulated the investigators on their study, noting that “the logistical hurdles must have been tremendous to obtain these data.”

However, Dr. Yeung pointed out some limitations and gaps in the data that were presented. For example, he found that the ratio of the training set to the validation set was unusual. “The training set is usually larger and usually an 80/20 ratio,” he said. “In their design, the validation set is larger, and I’m quite curious about their rationale.

“The conclusion of the study is that a more diverse microbiome was observed in patients with a tumor response than in those without a response,” he continued, “but they don’t actually show the statistical test used to make this conclusion. There is considerable overlap between the groups, and more compelling data are needed to make that conclusion.”

Another limitation was the marked imbalance in the number of patients whose condition responded to nivolumab in comparison with those whose condition did not (20 vs. 417 patients). This could have affected the statistical power of the study.

But overall, Dr. Yeung congratulated the authors for presenting a very impressive dataset. “The preliminary data are very interesting, and I look forward to the final results,” he said.

The study was funded by Ono Pharmaceutical and Bristol-Myers Squibb, which markets nivolumab. Dr. Sunakawa has received honoraria from Bayer Yakuhin, Bristol-Myers Squibb Japan, Chugai, Kyowa Hakko Kirin, Lilly Japan, Nippon Kayaku, Sanofi, Taiho, Takeda, and Yakult Honsha. He has held a consulting or advisory role for Bristol-Myers Squibb Japan, Daiichi Sankyo, and Takeda and has received research funding from Chugai Pharma, Daiichi Sankyo, Lilly Japan, Sanofi, Taiho Pharmaceutical, and Takeda. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

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

Preliminary data suggest that a certain pattern of gut microbes may be useful in predicting which patients with advanced gastric cancer are likely to benefit from treatment with the immunotherapy nivolumab.

Researchers have demonstrated bacterial invasion of the epithelial cell pathway in the gut microbiome and suggest that this could potentially become a novel biomarker.

“In addition, we found gastric cancer–specific gut microbiome predictive of responses to immune checkpoint inhibitors,” said study author Yu Sunakawa, MD, PhD, an associate professor in the department of clinical oncology at St. Marianna University, Kawasaki, Japan.

Dr. Sunakawa presented the study’s results at the 2021 Gastrointestinal Cancers Symposium.

The gut microbiome holds great interest as a potential biomarker for response. Previous studies suggested that it may hold the key to immunotherapy responses. The concept has been demonstrated in several studies involving patients with melanoma, but this is the first study in patients with gastric cancer.

Nivolumab monotherapy has been shown to provide a survival benefit with a manageable safety profile in previously treated patients with gastric cancer or gastroesophageal junction (GEJ) cancer, Dr. Sunakawa noted. However, fewer than half of patients responded to therapy.

“The disease control rate was about 40%, and many patients did not experience any tumor degradation,” he said. “About 60% of the patients did not respond to nivolumab as a late-line therapy.”

In the observational/translational DELIVER trial, investigators enrolled 501 patients with recurrent or metastatic adenocarcinoma of the stomach or GEJ. The patients were recruited from 50 sites in Japan.

The primary endpoint was the relationship between the genomic pathway in the gut microbiome and efficacy of nivolumab and whether there was progressive disease or not at the first evaluation, as determined in accordance with Response Evaluation Criteria in Solid Tumors criteria.

Genomic data were measured by genome shotgun sequence at a central laboratory. Biomarkers were analyzed by Wilcoxon rank sum test in the first 200 patients, who constituted the training cohort. The top 30 biomarker candidates were validated in the last 300 patients (the validation cohort) using the Bonferroni method.

Clinical and genomic data were available for 437 patients (87%). Of this group, 180 constituted the training cohort, and 257, the validation cohort.

The phylogenetic composition of common bacterial taxa was similar for both cohorts.

In the training cohort, 62.2% of patients had progressive disease, as did 53.2% in the validation cohort. The microbiome was more diverse among the patients who did not have progressive disease than among those who did have progressive disease.

The authors noted that, although there was no statistically significant pathway to be validated for a primary endpoint using the Bonferroni method, bacterial invasion of epithelial cells in the KEGG pathway was associated with clinical outcomes in both the training cohort (P = .057) and the validation cohort (P = .014). However, these pathways were not significantly associated with progressive disease after Bonferroni correction, a conservative test that adjusts for multiple comparisons.

An exploratory analysis of genus showed that Odoribacter and Veillonella species were associated with tumor response to nivolumab in both cohorts.

Dr. Sunakawa noted that biomarker analyses are ongoing. The researchers are investigating the relationships between microbiome and survival times, as well as other endpoints.
 

Still some gaps

In a discussion of the study, Jonathan Yeung, MD, PhD, of Princess Margaret Cancer Center, Toronto, congratulated the investigators on their study, noting that “the logistical hurdles must have been tremendous to obtain these data.”

However, Dr. Yeung pointed out some limitations and gaps in the data that were presented. For example, he found that the ratio of the training set to the validation set was unusual. “The training set is usually larger and usually an 80/20 ratio,” he said. “In their design, the validation set is larger, and I’m quite curious about their rationale.

“The conclusion of the study is that a more diverse microbiome was observed in patients with a tumor response than in those without a response,” he continued, “but they don’t actually show the statistical test used to make this conclusion. There is considerable overlap between the groups, and more compelling data are needed to make that conclusion.”

Another limitation was the marked imbalance in the number of patients whose condition responded to nivolumab in comparison with those whose condition did not (20 vs. 417 patients). This could have affected the statistical power of the study.

But overall, Dr. Yeung congratulated the authors for presenting a very impressive dataset. “The preliminary data are very interesting, and I look forward to the final results,” he said.

The study was funded by Ono Pharmaceutical and Bristol-Myers Squibb, which markets nivolumab. Dr. Sunakawa has received honoraria from Bayer Yakuhin, Bristol-Myers Squibb Japan, Chugai, Kyowa Hakko Kirin, Lilly Japan, Nippon Kayaku, Sanofi, Taiho, Takeda, and Yakult Honsha. He has held a consulting or advisory role for Bristol-Myers Squibb Japan, Daiichi Sankyo, and Takeda and has received research funding from Chugai Pharma, Daiichi Sankyo, Lilly Japan, Sanofi, Taiho Pharmaceutical, and Takeda. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

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

New guidelines issued jointly by four major international hematology groups focus on the management of patients with von Willebrand disease (VWD), the most common bleeding disorder in the world.

The evidence-based guidelines, published in Blood Advances, were developed in collaboration by the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis, the National Hemophilia Foundation, and the World Federation of Hemophilia. They outline key recommendations spanning the care of patients with a broad range of therapeutic needs.

“We addressed some of the questions that were most important to the community, but certainly there are a lot of areas that we couldn’t cover” said coauthor Veronica H. Flood, MD, of the Medical College of Wisconsin in Milwaukee.

The guidelines process began with a survey sent to the von Willebrand disease community, including patients, caregivers, nurses, physicians, and scientists. The respondents were asked to prioritize issues that they felt should be addressed in the guidelines.

“Interestingly, some of the issues were the same between patients and caregivers and physicians, and some were different, but there were obviously some areas that we just couldn’t cover,” she said in an interview.

One of the areas of greatest concern for respondents was bleeding in women, and many of the recommendations include specific considerations for management of gynecologic and obstetric patients, Dr. Flood said.

“We also tried to make the questions applicable to as many patients with von Willebrand disease as possible,” she added.

Some of the questions, such as recommendation 1, regarding prophylaxis, are geared toward management of patients with severe disease, while others, such as recommendations for treatment of menstrual bleeding, are more suited for patients with milder VWD.

All of the recommendations in the guidelines are “conditional” (suggested), due to very low certainty in the evidence of effects, the authors noted.
 

Prophylaxis

The guidelines suggest long-term prophylaxis for patients with a history of severe and frequent bleeds, with periodic assessment of the need for prophylaxis.

Desmopressin

For those patients who may benefit from the use of desmopressin, primarily those with type 1 VWD, and who have a baseline von Willebrand factor (VWF) level below 0.30 IU/mL, the panel issued a conditional recommendation for a desmopressin trial with treatment based on the patient’s results compared with not performing a trial and treating with tranexamic acid or factor concentrate. The guidelines also advise against treating with desmopressin in the absence of a trial. In a section of “good practice statements,” the guidelines indicate that using desmopressin in patients with type 2B VWD is generally contraindicated, because of the risk of thrombocytopenia as a result of increased platelet binding. In addition, desmopressin is generally contraindicated in patients with active cardiovascular disease, patients with seizure disorders, patients less than 2 years old, and patients with type 1C VWD in the setting of surgery.

Antithrombotic therapy

The guideline panelists conditionally recommend antithrombotic therapy with either antiplatelet agents or anticoagulants, with an emphasis on reassessing bleeding risk throughout the course of treatment.

An accompanying good practice statement calls for individualized assessments of risks and benefits of specific antithrombotic therapies by a multidisciplinary team including hematologists, cardiovascular specialists, and the patient.
 

Major surgery

This section includes a recommendation for targeting both factor VIII and VWF activity levels to a minimum of 50 IU/mL for at least 3 days after surgery, and a suggestion against using factor VIII target levels alone.

Minor surgery/invasive procedures

The panelists suggest increasing VWF activity levels to a minimum of 0.50 IU/mL with desmopressin or factor concentrate with the addition of tranexamic acid over raising VWF levels to at least 0.50 IU/mL with desmopressin or factor concentrate alone.

In addition, the panelists suggest “giving tranexamic acid alone over increasing VWF activity levels to a minimum threshold of 0.50 IU/mL with any intervention in patients with type 1 VWD with baseline VWF activity levels of 0.30 IU/mL and a mild bleeding phenotype undergoing minor mucosal procedures.”
 

Heavy menstrual bleeding

In women with heavy menstrual bleeding who do not plan to conceive, the panel suggests either combined hormonal therapy or levonorgestrel-releasing intrauterine system, or tranexamic acid over desmopressin.

In women who wish to conceive, the panel suggests using tranexamic acid over desmopressin.
 

Neuraxial anesthesia during labor

For women in labor for whom neuraxial anesthesia is considered, the guidelines suggest targeting a VWF activity level from 0.50 to 1.50 IU/mL over targeting a level above 1.50 IU/mL.

Postpartum management

“The guideline panel suggests the use of tranexamic acid over not using it in women with type 1 VWD or low VWF levels (and this may also apply to types 2 and 3 VWD) during the postpartum period,” the guidelines say.

An accompanying good practice statement says that tranexamic acid can be provided orally or intravenously. The oral dose is 25 mg/kg three times daily for 10-14 days, or longer if blood loss remains heavy.

Dr. Flood said that the guidelines were developed under the assumption that they would apply to care of patients in regions with a high or moderately high degree of clinical resources.

“We recognize that this eliminates a great deal of the globe, and our hope is that ASH and the other sponsoring organizations are going to let us revise this and do a version for lower-resourced settings,” she said.

New guidelines issued jointly by four major international hematology groups focus on the management of patients with von Willebrand disease (VWD), the most common bleeding disorder in the world.

The evidence-based guidelines, published in Blood Advances, were developed in collaboration by the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis, the National Hemophilia Foundation, and the World Federation of Hemophilia. They outline key recommendations spanning the care of patients with a broad range of therapeutic needs.

“We addressed some of the questions that were most important to the community, but certainly there are a lot of areas that we couldn’t cover” said coauthor Veronica H. Flood, MD, of the Medical College of Wisconsin in Milwaukee.

The guidelines process began with a survey sent to the von Willebrand disease community, including patients, caregivers, nurses, physicians, and scientists. The respondents were asked to prioritize issues that they felt should be addressed in the guidelines.

“Interestingly, some of the issues were the same between patients and caregivers and physicians, and some were different, but there were obviously some areas that we just couldn’t cover,” she said in an interview.

One of the areas of greatest concern for respondents was bleeding in women, and many of the recommendations include specific considerations for management of gynecologic and obstetric patients, Dr. Flood said.

“We also tried to make the questions applicable to as many patients with von Willebrand disease as possible,” she added.

Some of the questions, such as recommendation 1, regarding prophylaxis, are geared toward management of patients with severe disease, while others, such as recommendations for treatment of menstrual bleeding, are more suited for patients with milder VWD.

All of the recommendations in the guidelines are “conditional” (suggested), due to very low certainty in the evidence of effects, the authors noted.
 

Prophylaxis

The guidelines suggest long-term prophylaxis for patients with a history of severe and frequent bleeds, with periodic assessment of the need for prophylaxis.

Desmopressin

For those patients who may benefit from the use of desmopressin, primarily those with type 1 VWD, and who have a baseline von Willebrand factor (VWF) level below 0.30 IU/mL, the panel issued a conditional recommendation for a desmopressin trial with treatment based on the patient’s results compared with not performing a trial and treating with tranexamic acid or factor concentrate. The guidelines also advise against treating with desmopressin in the absence of a trial. In a section of “good practice statements,” the guidelines indicate that using desmopressin in patients with type 2B VWD is generally contraindicated, because of the risk of thrombocytopenia as a result of increased platelet binding. In addition, desmopressin is generally contraindicated in patients with active cardiovascular disease, patients with seizure disorders, patients less than 2 years old, and patients with type 1C VWD in the setting of surgery.

Antithrombotic therapy

The guideline panelists conditionally recommend antithrombotic therapy with either antiplatelet agents or anticoagulants, with an emphasis on reassessing bleeding risk throughout the course of treatment.

An accompanying good practice statement calls for individualized assessments of risks and benefits of specific antithrombotic therapies by a multidisciplinary team including hematologists, cardiovascular specialists, and the patient.
 

Major surgery

This section includes a recommendation for targeting both factor VIII and VWF activity levels to a minimum of 50 IU/mL for at least 3 days after surgery, and a suggestion against using factor VIII target levels alone.

Minor surgery/invasive procedures

The panelists suggest increasing VWF activity levels to a minimum of 0.50 IU/mL with desmopressin or factor concentrate with the addition of tranexamic acid over raising VWF levels to at least 0.50 IU/mL with desmopressin or factor concentrate alone.

In addition, the panelists suggest “giving tranexamic acid alone over increasing VWF activity levels to a minimum threshold of 0.50 IU/mL with any intervention in patients with type 1 VWD with baseline VWF activity levels of 0.30 IU/mL and a mild bleeding phenotype undergoing minor mucosal procedures.”
 

Heavy menstrual bleeding

In women with heavy menstrual bleeding who do not plan to conceive, the panel suggests either combined hormonal therapy or levonorgestrel-releasing intrauterine system, or tranexamic acid over desmopressin.

In women who wish to conceive, the panel suggests using tranexamic acid over desmopressin.
 

Neuraxial anesthesia during labor

For women in labor for whom neuraxial anesthesia is considered, the guidelines suggest targeting a VWF activity level from 0.50 to 1.50 IU/mL over targeting a level above 1.50 IU/mL.

Postpartum management

“The guideline panel suggests the use of tranexamic acid over not using it in women with type 1 VWD or low VWF levels (and this may also apply to types 2 and 3 VWD) during the postpartum period,” the guidelines say.

An accompanying good practice statement says that tranexamic acid can be provided orally or intravenously. The oral dose is 25 mg/kg three times daily for 10-14 days, or longer if blood loss remains heavy.

Dr. Flood said that the guidelines were developed under the assumption that they would apply to care of patients in regions with a high or moderately high degree of clinical resources.

“We recognize that this eliminates a great deal of the globe, and our hope is that ASH and the other sponsoring organizations are going to let us revise this and do a version for lower-resourced settings,” she said.

New guidelines issued jointly by four major international hematology groups focus on the management of patients with von Willebrand disease (VWD), the most common bleeding disorder in the world.

The evidence-based guidelines, published in Blood Advances, were developed in collaboration by the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis, the National Hemophilia Foundation, and the World Federation of Hemophilia. They outline key recommendations spanning the care of patients with a broad range of therapeutic needs.

“We addressed some of the questions that were most important to the community, but certainly there are a lot of areas that we couldn’t cover” said coauthor Veronica H. Flood, MD, of the Medical College of Wisconsin in Milwaukee.

The guidelines process began with a survey sent to the von Willebrand disease community, including patients, caregivers, nurses, physicians, and scientists. The respondents were asked to prioritize issues that they felt should be addressed in the guidelines.

“Interestingly, some of the issues were the same between patients and caregivers and physicians, and some were different, but there were obviously some areas that we just couldn’t cover,” she said in an interview.

One of the areas of greatest concern for respondents was bleeding in women, and many of the recommendations include specific considerations for management of gynecologic and obstetric patients, Dr. Flood said.

“We also tried to make the questions applicable to as many patients with von Willebrand disease as possible,” she added.

Some of the questions, such as recommendation 1, regarding prophylaxis, are geared toward management of patients with severe disease, while others, such as recommendations for treatment of menstrual bleeding, are more suited for patients with milder VWD.

All of the recommendations in the guidelines are “conditional” (suggested), due to very low certainty in the evidence of effects, the authors noted.
 

Prophylaxis

The guidelines suggest long-term prophylaxis for patients with a history of severe and frequent bleeds, with periodic assessment of the need for prophylaxis.

Desmopressin

For those patients who may benefit from the use of desmopressin, primarily those with type 1 VWD, and who have a baseline von Willebrand factor (VWF) level below 0.30 IU/mL, the panel issued a conditional recommendation for a desmopressin trial with treatment based on the patient’s results compared with not performing a trial and treating with tranexamic acid or factor concentrate. The guidelines also advise against treating with desmopressin in the absence of a trial. In a section of “good practice statements,” the guidelines indicate that using desmopressin in patients with type 2B VWD is generally contraindicated, because of the risk of thrombocytopenia as a result of increased platelet binding. In addition, desmopressin is generally contraindicated in patients with active cardiovascular disease, patients with seizure disorders, patients less than 2 years old, and patients with type 1C VWD in the setting of surgery.

Antithrombotic therapy

The guideline panelists conditionally recommend antithrombotic therapy with either antiplatelet agents or anticoagulants, with an emphasis on reassessing bleeding risk throughout the course of treatment.

An accompanying good practice statement calls for individualized assessments of risks and benefits of specific antithrombotic therapies by a multidisciplinary team including hematologists, cardiovascular specialists, and the patient.
 

Major surgery

This section includes a recommendation for targeting both factor VIII and VWF activity levels to a minimum of 50 IU/mL for at least 3 days after surgery, and a suggestion against using factor VIII target levels alone.

Minor surgery/invasive procedures

The panelists suggest increasing VWF activity levels to a minimum of 0.50 IU/mL with desmopressin or factor concentrate with the addition of tranexamic acid over raising VWF levels to at least 0.50 IU/mL with desmopressin or factor concentrate alone.

In addition, the panelists suggest “giving tranexamic acid alone over increasing VWF activity levels to a minimum threshold of 0.50 IU/mL with any intervention in patients with type 1 VWD with baseline VWF activity levels of 0.30 IU/mL and a mild bleeding phenotype undergoing minor mucosal procedures.”
 

Heavy menstrual bleeding

In women with heavy menstrual bleeding who do not plan to conceive, the panel suggests either combined hormonal therapy or levonorgestrel-releasing intrauterine system, or tranexamic acid over desmopressin.

In women who wish to conceive, the panel suggests using tranexamic acid over desmopressin.
 

Neuraxial anesthesia during labor

For women in labor for whom neuraxial anesthesia is considered, the guidelines suggest targeting a VWF activity level from 0.50 to 1.50 IU/mL over targeting a level above 1.50 IU/mL.

Postpartum management

“The guideline panel suggests the use of tranexamic acid over not using it in women with type 1 VWD or low VWF levels (and this may also apply to types 2 and 3 VWD) during the postpartum period,” the guidelines say.

An accompanying good practice statement says that tranexamic acid can be provided orally or intravenously. The oral dose is 25 mg/kg three times daily for 10-14 days, or longer if blood loss remains heavy.

Dr. Flood said that the guidelines were developed under the assumption that they would apply to care of patients in regions with a high or moderately high degree of clinical resources.

“We recognize that this eliminates a great deal of the globe, and our hope is that ASH and the other sponsoring organizations are going to let us revise this and do a version for lower-resourced settings,” she said.

By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.

By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.¹ In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”

With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.

Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.

A potentially more efficacious way to deliver topical tranexamic acid for treating melasma and

pigmentation is with laser-assisted delivery. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.

Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.

In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.² Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.

In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.³ At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.

No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

References

1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.

2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.

3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.

By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.

By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.¹ In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”

With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.

Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.

A potentially more efficacious way to deliver topical tranexamic acid for treating melasma and

pigmentation is with laser-assisted delivery. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.

Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.

In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.² Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.

In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.³ At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.

No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

References

1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.

2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.

3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.

By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.

By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.¹ In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”

With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.

Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.

A potentially more efficacious way to deliver topical tranexamic acid for treating melasma and

pigmentation is with laser-assisted delivery. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.

Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.

In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.² Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.

In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.³ At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.

No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

References

1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.

2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.

3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.