Jill Murphy, Associate Editor

Study authors of a recent study published in 

 explained that they observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes following COVID-19 infection. Although long-term health issues from COVID-19 are a major public health concern, evidence on post-acute COVID-19 syndrome, or post-COVID-19, is still limited, specifically among children and adolescents.

During the study, the researchers used comprehensive health care data on approximately 46% of the German population and analyzed post-COVID-19-associated morbidity among 2 groups—children/adolescents and adults. The study authors noted that routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020 were used for their analysis, with the base population including all individuals insured for at least 1 day in 2020. The team then identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020.

The researchers then assigned a control cohort using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. Further, the date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.

In all, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical, mental, and physical/mental overlap). The researchers then used Poisson regression to estimate incidence rate ratios with 95% confidence intervals.

The population of participants included 11,950 children/adolescents between age 0 and 11 years and 145,184 adults between age 18 and 49 years. The mean follow-up time was 236 days in children/adolescents and 254 days in adults, and the COVID-19 and control cohorts were well balanced regarding covariates.

In at least 1/100 person-years in the COVID-19 cohort in children and adolescents, the specific outcomes with the highest incidence rate ratios (IRR) and an incidence rate (IRs) were malaise/fatigue/exhaustion, cough, and throat/chest pain.

In adults, this included disturbances of smell and taste, fever, and dyspnea. For health outcomes combined, IRs per 1000 person-years in the COVID-19 cohort were significantly higher than those in the control in both children/adolescents and adults. The magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain.

In the COVID-19 cohort, IRs were higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. The IRR estimates were similar for age groups 0 to 11 and 12 to 17, and IRs in children/adolescents were consistently lower than those in adults.

Additionally, the study authors noted that there were study limitations, such as potentially unmeasured confounding and detection bias. However, the study authors also explained that these findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults.

Roessler M, Tesch F, Batram M, et al. Post-COVID-19-associated morbidity in children, adolescents, and adults: A matched cohort study including more than 157,000 individuals with COVID-19 in Germany. PLOS Medicine. November 10, 2022. Accessed November 18, 2022. 

https://doi.org/10.1371/journal.pmed.1004122

Articles

Although long-term health issues from COVID-19 are a major public health concern, evidence on post-COVID-19 symptoms are still limited, specifically among children and adolescents. 

Data Analysis Shows Significant New Onset Morbidity Post-COVID-19 in Children, Adolescents, Adults

A guided mindfulness-based stress reduction program may be as effective as escitalopram for patients with anxiety disorders, according to the authors of a study published in 

. The data were released shortly after the United States Preventive Services Task Force recommended screening for anxiety disorders due to their high prevalence.

“Our study provides evidence for clinicians, insurers and health care systems to recommend, include and provide reimbursement for mindfulness-based stress reduction as an effective treatment for anxiety disorders because mindfulness meditation currently is reimbursed by very few providers,” said first study author Elizabeth Hoge, MD, director of the Anxiety Disorders Research Program and associate professor of psychiatry at Georgetown, in a press release. “A big advantage of mindfulness meditation is that it doesn’t require a clinical degree to train someone to become a mindfulness facilitator. Additionally, sessions can be done outside of a medical setting, such as at a school or community center.”

Anxiety disorders include generalized anxiety, social anxiety, panic disorder, and fear of certain places or situations, including crowds and public transportation. These disorders contribute to an increased risk of suicide, disability, and distress, and are commonly treated in psychiatric clinics.

Currently prescribed medications for anxiety disorders can be very effective; however, many patients have difficulty gaining access to these drugs, do not respond to them, or find adverse effects to be a barrier to adherence. Standardized mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR), can lower feelings of anxiety; however, previous studies have not compared these interventions with effective anti-anxiety drugs.

The clinicians recruited 276 patients between June 2018 and February 2020 from 3 hospitals in Boston, New York City, and Washington, DC, and randomly assigned them to either MBSR or escitalopram. MBSR was offered weekly for 8 weeks via 2 and a half-hour in-person classes, a daylong retreat weekend class during the fifth or sixth week, and 45-minute daily home practice exercises.

Symptoms of anxiety were assessed at enrollment and at completion of the intervention at 8 weeks, along with post-treatment assessments at 12 and 24 weeks after enrollment. For the blinded assessments, trained clinical evaluators did not know whether the patients they were measuring received the drug or MBSR.

By the end of the study, 102 patients had completed MBSR and 106 had completed their medication course. The patients were relatively young, with a mean of 33 years, and included 156 women, who represented 75% of the enrollees.

Using validated assessments, the researchers measured the severity of symptoms of anxiety across all the disorders using a scale of 1 to 7, with 7 being severe anxiety. Both groups experienced decreased anxiety symptoms, dropping from a mean of about 4.5 for both, which translates to an approximately 30% reduction in the severity of peoples’ anxiety.

After participating in a previous study and again in the current study, enrollee Olga Cannistraro said she learned 2 key MBSR techniques.

“It gave me the tools to spy on myself. Once you have awareness of an anxious reaction, then you can make a choice for how to deal with it. It’s not like a magic cure, but it was a lifelong kind of training. Instead of my anxiety progressing, it went in the other direction, and I’m very grateful for that,” Cannistraro said in a press release.

Hoge said it is important to highlight that although mindfulness meditation works, not everyone is willing to invest the time and effort to successfully complete all of the necessary sessions and do regular home practice, which enhances the effect.

“Also, virtual delivery via videoconference is likely to be effective, so long as the ‘live’ components are retained, such as question-and-answer periods and group discussion,” Hoge said in a press release.

Hoge added that there are phone apps available that offer guided meditation, but the researchers do not know how the apps compared with the full in-person, weekly group class experience.

Most enrollees completed their 8-week course of treatment before the COVID-19 pandemic started. Further, the research team conducted a second phase of the study during the pandemic that involved reorganizing the treatments to an online video conference, which will continue to be analyzed in future analyses. The effects of MBSR on sleep and depression will also be analyzed in future studies.

Mindfulness-Based Stress Reduction is as Effective as an Antidepressant Drug for Treating Anxiety Disorders. Georgetown University Medical Center. November 9, 2022. Accessed November 10, 2022. 

https://gumc.georgetown.edu/news-release/mindfulness-based-stress-reduction-is-as-effective-as-an-antidepressant-drug-for-treating-anxiety-disorders/

Patients with anxiety disorders were found to be able to use mindfulness techniques to manage generalized anxiety, social anxiety, panic disorder, and fear of certain places or situations, including crowds and public transportation.

Study: Mindfulness Can Effectively Reduce Stress for Patients With Anxiety Disorders

A recent study discovered the first evidence in humans that short-term lifestyle changes can disrupt the response to insulin of blood vessels and the first analysis showing men and women reacting differently to these changes, according to the authors of a study conducted at the University of Missouri School of Medicine.

Previous studies had analyzed the topic of sugary diets, with researchers suggesting that the consumption of sugary drinks is associated with higher cancer risk and the risk of obesity.

 A feature of obesity and type 2 diabetes is vascular insulin, which contributes to vascular disease.

During this trial, the researchers examined vascular insulin resistance in 36 young and healthy men and women by exposing them to 10 days of reduced physical activity and cutting their step count from 10,000 to 5,000 steps per day. The participants also increased their sugary beverage intake to 6 cans of soda per day.

“We know that incidence of insulin resistance and cardiovascular disease is lower in premenopausal women compared to men, but we wanted to see how men and women reacted to reduced physical activity and increased sugar in their diet over a short period of time,” said Camila Manrique-Acevedo, MD, associate professor of medicine, in a press release.

The results highlighted that only in men did the sedentary lifestyle and high sugar intake cause decreased insulin-stimulated leg blood flow and a drop in a protein, called adropin, which regulates insulin sensitivity and is an important biomarker for cardiovascular disease.

“These findings underscore a sex-related difference in the development of vascular insulin resistance induced by adopting a lifestyle high in sugar and low on exercise,” Manrique-Acevedo said in a press release. “To our knowledge, this is the first evidence in humans that vascular insulin resistance can be provoked by short-term adverse lifestyle changes, and it’s the first documentation of sex-related differences in the development of vascular insulin resistance in association with changes in adropin levels.”

Manrique-Acevedo added that she would like to analyze how long it takes to reverse these vascular and metabolic changes and more fully assess the impact of the role of sex in the development of vascular insulin resistance.

Sedentary Lifestyle and Sugary Diet More Detrimental to Men. University of Missouri School of Medicine. October 27, 2022. Accessed November 2, 2022. 

https://medicine.missouri.edu/news/sedentary-lifestyle-and-sugary-diet-more-detrimental-men

Antrim A. Sugary Drinks Consumption Associated with Higher Cancer Risk. 

. July 17, 2019. Accessed November 2, 2022. 

https://www.contemporaryclinic.com/view/sugary-drinks-consumption-associated-with-higher-cancer-risk

A feature of obesity and type 2 diabetes is vascular insulin, which contributes to vascular disease.

Study: Sedentary Lifestyle, Sugary Diet More Detrimental to Men

A greater percentage of participants who worked many hours in a stressful job had scores that would qualify them for a diagnosis of moderate to severe depression compared with those working fewer hours, according to data presented in a recent study. Using advanced statistical methods, the research team created a clinical trial that accounts for multiple other factors in doctors’ personal and professional lives.

A “dose response” effect was found between hours worked and depression symptoms, with an average symptom increase of 1.8 points on a standard scale for those working 40 to 45 hours, ranging up to 5.2 points for those working more than 90 hours. The study authors concluded that among all stressors affecting physicians, working a lot of hours is a major contributor to depression.

The findings were based off studying 11 years’ worth of data on more than 17,000 first-year medical residents who were training in hundreds of hospitals across the United States. The Intern Health Study, based at the Michigan Neuroscience Institute and the Eisenberg Family Depression Center, recruits new medical school graduates each year to take part in a year of tracking their depressive symptoms, work hours, sleep, and more while completing their first year of residency, or their intern year.

The interns in the study reported a wide range of previous-week work hours, with the most common work hour levels between 65 to 80 hours per week. The Accreditation Council for Graduate Medical Education (ACGME), which sets national standards for residency programs, currently sets an 80-hour limit on residents’ work weeks, but that can be averaged over 4 weeks with possible exceptions.

Additionally, AGCME limits the length of a single shift and the number of days in a row that residents can work. The studies have shown mixed results about the impact these limits have had on resident wellness and patient safety risks.

The study authors noted that their findings point to a clear need to further reduce the number of hours residents work each week on average.

"This analysis suggests strongly that reducing the average number of work hours would make a difference in the degree to which interns' depressive symptoms increase over time, and reduce the number who develop diagnosable depression," said study senior author Amy Bohnert, PhD, a professor at the U-M Medical School, in a press release. "The key thing is to have people work fewer hours; you can more effectively deal with the stresses or frustrations of your job when you have more time to recover."

The recent study uses a design called an emulated clinical trial, which mimics a randomized clinical trial in scenarios where conducting a real randomized trial is not feasible. Due to the nature of all interns nationwide beginning at the same time of year and being subject to varying work schedules set by their programs, analyzing people going through this stage of medical trial is crucial for the clinical trial.

The study authors suggest that studies parallel to this work on physicians should be conducted in other high-stress and high-work-hour jobs.

"We would expect that the negative effect of long work hours on physician mental health would be present in other professions," Srijan Sen, MD, PhD, founder of the Intern Health Study, said in a press release.

The average age of physicians in the study was 27 years; additionally, 1 in 5 were training in surgical disciplines and 18% were from racial or ethnic groups traditionally underrepresented in the medical profession.

Furthermore, less than 1 in 20 met the criteria for moderate to severe depression at the start of the intern year. In total, 46% had a stressful life event such as family death or birth, or getting married, during their intern year. Moreover, 37% stated they had been involved in at least 1 medical error during the year.

The researchers noted that while analyzing the results, they adjusted for gender, neuroticism, pre-internship history of depression, early family environment, age, year they began internship, marital status, whether they had children, and stressful life events and medical errors during the intern year.

"National initiatives on clinician wellbeing have put increasing emphasis on the complex set of factors that affect clinician well-being, including the electronic health record, regulatory burden, resilience, workplace violence and culture," Sen said in a press release. "I think this emphasis has inadvertently led to the feeling that the problem is infinitely complicated and making real progress is hopeless. This paper demonstrates how big of an impact that the single factor of work hours has on clinician depression and wellbeing."

In stressful jobs, depression risk rises with hours worked, study in new doctors finds. ScienceDaily. October 19, 2022. Accessed October 25, 2022. 

https://www.sciencedaily.com/releases/2022/10/221019172305.htm

Data from a recent study show a clear need to further reduce the number of hours residents work each week on average to decrease the occurrence of depression.

Study: Depression Risk Rises With Hours Worked in Stressful Jobs

Exposure to fluoridated water among young children did not show signs of a negative association with child emotional and behavioral development and executive functioning in their adolescence, according to the authors of a follow-up study conducted by the University of Queensland Faculty of Health and Behavioral Sciences School of Dentistry in Australia. During the study, the investigators examined the impact of early childhood exposure to water fluoridation on measures of school-age executive functioning and emotional and behavioral development in a population-based sample.

This follow-up study used information from Australia’s National Child Oral Health Study of 2012 to 2014, and then contacted the children who were between 5 to 10 years of age at baseline during the original study after 7 to 8 years. However, the investigators ensured they contacted the children for the follow up before they had turned 18 years of age.

Using residential history and postcode-level fluoride levels in public tap water, the investigators were able to calculate the percent lifetime exposed to fluoridated water (LEFW) from birth to age of 5 years. The measures of children’s emotional and behavioral development were assessed by the Strength and Difficulties Questionnaire (SDQ), and executive functioning was measured by the Behavior Inventory of Executive Functioning (BRIEF).

The multivariable regression models were created to compare the associations between the exposure and the primary outcomes, which were controlled for covariates. Further, an equivalence test was conducted to compare the primary outcomes of those who had 100%LEFW compared to those with 0%LEFW.

Additionally, a sensitivity analysis was conducted in which a total of 2682 children completed SDQ and BRIEF with mean scores of 7.0 and 45.3, respectively. Those with a lower percentage of LEFW were seen to have poorer scores on the SDQ and BRIEF. Further, multivariable regression models reported no association between exposure to fluoridated water and the SDQ and BRIEF scores. Some factors associated with poorer SDQ/BRIEF scores included low household income, indigenous identity, and having a neurodevelopment diagnosis.

Due to these results, the study authors concluded that exposure to fluoridated water during the first 5 years of life was not demonstrated to be associated with an impact on child emotional and behavioral development and executive functioning. Additionally, children who had been exposed to fluoridated water for their early childhood had their measures of emotional, behavioral development, and executive functioning at least equivalent to that of children who did not have the exposure to fluoridated water.

“Water fluoridation is unquestionably effective in preventing dental caries, and this study is an important addition to the body of literature documenting the safety of water fluoridation,” said International Association for Dental Research (IADR) president Brian O’Connell, Dean of the Faculty of Health Sciences at Trinity College Dublin in Ireland, in a press release. “The IADR recently reaffirmed its support for water fluoridation as this public health measure has a high benefit/cost ratio and benefits deprived communities the most, thus reducing health inequalities.”

Study Finds No Adverse Effects of Early Fluoride Exposure on Childhood Development. IADR. October 10, 2022. Accessed October 18, 2022. 

https://www.iadr.org/about/news-reports/press-releases/study-finds-no-adverse-effects-early-fluoride-exposure-childhood

The measures of children’s emotional and behavioral development were assessed by the Strength and Difficulties Questionnaire (SDQ), and executive functioning was measured by the Behavior Inventory of Executive Functioning (BRIEF).

Study: Early Fluoride Exposure Not Found to Have Impact on Childhood Development  

Psychotic disorders may have a stronger link with dementia than other mental health disorders, such as depression or anxiety, according to the authors of a recently published systematic review. The analysis is the first to assess a range of psychotic disorders and their association with dementia risk. Psychotic disorders, such as schizophrenia, are severe illnesses that involve symptoms such as hallucinations and delusions and social withdrawal, as well as impairments in cognitive and functional skills.

"We found that having a diagnosis of a psychotic disorder is linked to a much higher risk of developing dementia later in life,” said senior author Jean Stafford, MD, in a press release. "Our findings add to evidence that protecting people's mental health throughout life could help to prevent dementia."

The researchers analyzed evidence from 11 studies conducted in 9 countries on 4 continents, which included approximately 13 million participants. During their assessment of the data, the team observed a higher risk of dementia later in life across multiple psychotic disorders, regardless of the age of the mental illness was first developed. In some studies, there were participants who were diagnosed with psychotic disorders while young adults, with follow-up periods of multiple decades.

Additionally, the investigators observed that patients who have had a psychotic disorder tend to be younger than average at dementia diagnosis, with 2 studies finding that people with psychotic disorders were more likely to be diagnosed while still in their 60s.

Previous studies found that 4 in 10 cases of patients with dementia could be prevented or delayed by targeting risk factors from across their lifespans. In this study, the authors also found that experiencing post-traumatic stress disorder during a patient’s lifespan can increase the likelihood of dementia. However, the investigators observed that the strongest association with dementia risk was with psychotic disorders.

Furthermore, during the study the research team was still not able to confirm the cause of the association between dementia risk and psychotic disorders. Specifically, they were unable to determine whether the association is due to the psychotic disorder itself or due to these disorders potential for increasing the likelihood of conditions that increase the dementia risk.

"People with psychotic disorders are more likely to have other health conditions such as cardiovascular disease or obesity, which can increase the risk of dementia, while they are also more likely to have a poor diet, smoke or use drugs, which may harm their health in ways that could increase their likelihood of developing dementia,” Orgeta said in the press release.

The researchers were also not able to determine whether effective treatment for psychotic disorders could lessen the risk of dementia, or whether antipsychotic medication could be a factor due to limited and conflicting evidence.

"As people with psychotic disorders face a higher risk of numerous other health conditions, managing their overall physical and mental health is very important, and here we found that health professionals working with them should also be watchful for any signs of cognitive decline,” said lead study author Sara El Miniawi in a press release.

Schizophrenia may increase dementia risk by 2.5 times. ScienceDaily. October 6, 2022. Accessed October 12, 2022. 

https://www.sciencedaily.com/releases/2022/10/221006092313.htm

The researchers analyzed evidence from 11 studies conducted in 9 countries on 4 continents, which included approximately 13 million participants. 