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New study documents increasing frequency, cost, and severity of gunshot wounds

The rise in firearm violence has coincided with an increase in the severity of injuries firearms inflict as well as the cost of operations to treat those injuries; policy makers must be more aggressive in addressing violence to curb these trends, researchers report in a large national study of gunshot wounds that appears as an “article in press” on the Journal of the American College of Surgeons website ahead of print.

“Taken together, our findings suggest that gun violence has increased in numbers, at least for the sector that meets surgical criteria, and that these injuries result in a substantial financial burden in addition to the obvious psychosocial burden and other downstream effects,” said lead study author Peyman Benharash, MD, MS, with the Cardiovascular Outcomes Research Laboratories and an associate professor-in-residence of surgery and bioengineering at the David Geffen School of Medicine at the University of California Los Angeles. “We hope that our findings are able to better inform policy in terms of violence prevention as well as reimbursement to hospitals, which are often in underserved regions, that care for these patients.”

The study authors note that gun violence overall carries an annual cost to the U.S. health care system of $170 billion, with $16 billion for operations alone. The researchers used the National Inpatient Sample (NIS) to identify all hospital admissions for gunshot wounds (GSW) from 2005 through 2016. The researchers did not look at all adult GSW victims admitted to the hospital, estimated at 322,599, but only at the 262,098 victims who required at least one major operation.

Dr. Benharash explained the rationale for the study. “We’re now seeing a lot more on the impact of gun violence,” he said. “In the past, gun violence was never really discussed in the open; it was thought to only affect a certain population. However, now we know that it affects everyone. In the hopes of trying to reduce it at a systemic level from top to bottom, we’re reporting, as surgeons, how gun violence in the patients that we treat has changed over the last decade.”

The costs for hospitalizations, measured as median costs adjusted for gross domestic product, increased more than 27 percent over the 12-year study period, from $15,100 to $19,200 (p<0.001). The amount of time these patients spent in the hospital—a major cost driver—also increased from an average of 7.1 days to 12.6 days (p<0.001). The percentage of fatalities declined, from 8.6 percent in 2005 to 7.6 percent in 2016, despite an annual increase in overall admissions for GSW-related operations, from 19,832 in 2005 to 23,480 in 2016. The severity of these injuries, based on billing codes, increased slightly over that period, with predicted survival decreasing from 81 to 79 percent (P<0.001). The authors used a non-parametric test for trends to judge the significance of temporal changes in their analysis.

The cost analysis categorized operations by type and three different cost ranges: low, medium and high, with average costs of $7,400, $17,200, and $58,800, respectively. “We found that compared with those who were not operated on, patients having head-neck, vascular, and gastrointestinal operations had increased odds of being in the high-cost tertile,” Dr. Benharash said. “Being in the Western United States was also a predictor [of being in the high-cost tertile], as was being of Black race and having insurance by Medicaid. So there are certainly disparities that are socioeconomic in origin as well.”

For example, the study found that while 3.4 percent of all patients had operations for head and neck injuries, these operations were disproportionately represented in the low- and high-cost ranges, accounting for only 0.81 percent of the former but 7.1 percent of the latter. “Gunshot wounds to the neck, for example, can be very costly because they can affect many delicate structures as compared with lower extremities, and these patients often require extensive hospitalization and a greater number of procedures,” Dr. Benharash said.

The finding that costs in the West were higher is also important, Dr. Benharash noted, because it’s in line with what other studies have reported with other specialties. “It’s very important for policy makers and health services researchers to evaluate the disparities in cost,” he said.

The improved survival of GSW patients is a function of improvements in trauma transport from the field, better prehospital resuscitation, and improved techniques, patient management and adjunct therapies once they get to the hospital, Dr. Benharash said. “It appears that patients are reaching surgery more often because of reduced mortality before they get to the hospital,” he said.

The study also attributed these improvements in survival to efforts by the American College of Surgeon’s Committee on Trauma, including the Advanced Trauma Life Support curriculum and Stop the Bleed campaign. The latter trains the public in techniques to stop life-threatening bleeding in everyday emergencies.

But those improvements don’t obviate the need for addressing the underlying problem, Dr. Benharash noted. “It’s very important to put it in perspective that this entity is quite economically burdensome,” he said. “If you’re looking at prevention vs. treating a gunshot wound from an economic standpoint, it would make sense to invest in anti-violence interventions that can reduce assaults that are often preventable.”

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Immunization programs yield high ‘return on investment,’ saving hundreds of billions of dollars

Immunization programs offered in low- and middle-income countries provide a high “return on investment” in terms of the economic costs of diseases that are prevented and the values of lives that would have been lost, according to a new study led by scientists at the International Vaccine Access Center based at Johns Hopkins Bloomberg School of Public Health.

The researchers, who report their findings in the August issue of Health Affairs, analyzed recent data on immunization programs aimed at preventing 10 infectious diseases in 94 low- and middle-income countries. The research team generated estimates for the economic cost of illnesses and broader losses due to disability and premature death that would occur without the programs, comparing those costs to the costs of the programs themselves.

Using a model that factors in treatment costs, lost wages, and productivity losses, the researchers estimate that the costs averted by implementing these immunization programs will amount to $681.9 billion for 2011-20 and $828.5 billion for the next decade. This estimated net benefit is about 26 times the immunization programs’ costs during 2011-20, and about 20 times their costs for the next ten years, 2021-30.

A second analysis based on the imputed monetary values of lives that will be saved by the immunization programs suggested net-benefit vs. cost ratios for the two decades of more than 50 to 1.

“This analysis shows that immunization programs now have and will continue to have a high return on investment,” says study senior author Bryan Patenaude, ScD, an assistant professor in the Bloomberg School’s Department of International Health. “It also helps put immunization program investments in perspective alongside investments such as education programs and infrastructure investments that might not otherwise seem comparable.”

The new study was conducted under the auspices the Decade of Vaccine Economics project based at the Bloomberg School’s International Vaccine Access Center. DOVE’s research provides economic evidence on vaccines that can be used by organizations such as Gavi, the international public health organization that sponsors immunization programs in low- and middle-income countries worldwide.

“The goal here was to show the return on ‘investment’ in economic or monetary terms, not just in terms of health impact,” says Patenaude. “Framing health investments in economic terms can help organizations and governments compare them to other social investments in an explicit and concrete way.”

For their analysis, the researchers analyzed Gavi’s data and other available data on the costs of immunization programs in 94 low- and middle-income countries against the meningitis-causing Haemophilus influenzae type b and Neisseria meningitidis serotype A; the pneumonia-causing Streptococcus pneumoniae; hepatitis B virus; human papillomavirus; Japanese encephalitis virus; measles virus; rotavirus; rubella virus (German measles); and yellow fever virus.

In the analysis, the costs of these programs will amount to an estimated $25.2 billion for 2011-20 and $39.9 billion in 2021-30 for the 94 low- and middle-income countries. Gavi hosts immunization programs, or has done so in the recent past, in most of the countries covered by the analysis.

The researchers compared these estimated costs to the estimated economic costs of illnesses in the scenario in which there were no immunizations against these pathogens. To do this they used two models. The first was a Cost of Illness model with estimates for cost items such as treatment of disease, lost caregiver wages, and productivity loss due to disability or premature death. The COI model yielded the estimated averted costs of $681.9 billion for 2011-20 and $828.5 billion for the following decade.

The second model, a Value of Statistical Life (VSL) model, was based on the estimated value of a saved life—a calculation derived from estimates of people’s willingness to spend money to reduce their risk of death. Based on this model the averted costs will be $1.31 trillion and $2.1 trillion for the two decades, respectively.

The estimated return on investment, the ratio between the net savings obtained by the programs and their cost, was therefore, for the 2011-20 decade, 26.1 using the COI model and 51.0 using the VSL model. For the 2021-30 decade, those figures were 19.8 and 52.2, respectively.

“Obviously, regardless of the approach you take to estimate benefits, immunization programs are a great value in terms of return on investment and have significant benefits over time,” says Patenaude.

The researchers bundled the estimates for the 10 pathogens together because Gavi typically offers programs with similarly bundled immunizations. But the investigators noted that measles virus was the largest driver of estimated disease-related costs.

“With some countries transitioning away from donor support, these findings can be used to advocate for sustained immunization financing,” says Elizabeth Watts, research associate at the International Vaccine Access Center and co-first author of the study.

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Less than half of people in England understand current lockdown rules

Under half (45%) of people in England report having a “broad understanding” of the current lockdown rules, compared to 90% across the UK during the strict lockdown period, finds UCL’s COVID-19 Social Study.

Levels in Scotland and Wales have also fallen but are higher than those in England, with reported levels of understanding at 75% and 61% respectively. Complete understanding has fallen even further, with only 14% of adults in England reporting understanding the rules completely as lockdown eased, compared to 18% in Wales and 27% in Scotland.

Launched in the week before lockdown started, this ongoing study is funded by the Nuffield Foundation with additional support from Wellcome and UK Research and Innovation (UKRI). It is the UK’s largest study into how adults are feeling about the lockdown, government advice and overall wellbeing and mental health with over 70,000 participants who have been followed across the last 19 weeks.

Access to healthcare has also fallen during the lockdown, with one in 10 people across the UK reporting being unable to see or speak with a GP about their physical health, one in 20 unable to speak to a professional about their mental health, and one in five not telling a GP about symptoms of an illness when they usually would have done (even when appointments to see GPs were available). Groups who faced the most barriers included younger adults, women, individuals from BAME backgrounds, and people with physical and mental health conditions.

People with a diagnosed mental health condition were significantly more likely to have not spoken to a mental health professional when they usually would have done, with a fifth reported not being able to access professional mental health support during lockdown.

Lead author, Dr. Daisy Fancourt (UCL Epidemiology & Health Care) said: “Our study shows that as lockdown measures have eased at different rates in each nation of the UK, levels of understanding around what is and isn’t permissible have dropped, especially amongst younger adults. This could possibly reflect difficulties in applying the rules to more complex life scenarios amongst younger adults, or may be reflective of the different amounts of time spent following the news on COVID-19 amongst different age groups. The general drop-off in understanding could be due to unclear messaging from the government, or a reduction in interest and engagement from people, especially with the cessation of the daily Downing Street coronavirus briefing in late June.”

Depression and anxiety levels, life satisfaction, and happiness have all shown improvements across every socio-demographic subgroup examined, and loneliness levels have also decreased further, showing the first clear pattern of decrease in 19 weeks. However there has been little change in people reporting major or minor stress due to catching COVID-19, unemployment, finance, or getting food.

Cheryl Lloyd, education program head at the Nuffield Foundation said: “With concerns growing over a second wave of COVID-19 it is concerning that many people in England report not understanding the current government guidance. As another Nuffield-funded study by the Reuters Institute has shown, people are less likely to access news about COVID-19 on a daily basis now that lockdown has eased. With the rules changing regularly, this may be a factor in the public not understanding the government guidance.”

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New motion capture screening technology could slow progression of arthritis

Most people don’t think about their thumbs very often. But for people living with advancing arthritis, the simplest thumb movements—from grasping a cup to sending a text message—can be painful and incredibly challenging.

That’s why Michigan State University researchers set out to see if they could use motion capture technology to screen for differences between healthy hand movements and those in patients with osteoarthritis, or OA. This method could potentially detect arthritis earlier, possibly delaying and preventing the loss of thumb function. In turn, that could save arthritis patients from surgery and even being forced into assisted living.

The team’s research is published in Clinical Biomechanics.

“Our work suggests that three-dimensional motion tasks may be able to identify OA-associated motion deficits earlier than the two-dimensional motion tasks typically used in a clinical setting,” said Amber Vocelle, co-author on the research and a DO/Ph.D. student in the College of Osteopathic Medicine. “By identifying the disease earlier, we can treat OA earlier in the disease process.”

According to Vocelle, therapists and clinicians traditionally use goniometers, simple two-dimensional measurement tools, along with basic movements to screen for reduced hand function due to OA. But the results can vary depending on who’s doing the measuring, making it hard to track reliably over time.

“There are pieces of information that aren’t being gathered right now that could be useful for early prediction of OA of the thumb, or setting up thresholds to define when people should consider doing therapy before they’re in severe pain,” said Tamara Reid Bush, an associate professor of mechanical engineering in the College of Engineering who also worked on the research.

In contrast, motion capture technology records precise, objective measurements in three dimensions.

Both Bush and Vocelle, along with Gail Shafer, an assistant professor in the College of Human Medicine, put markers on participants’ hands, which were then monitored by motion capture technology as they went through a series of three-dimensional thumb movements. Differences between healthy and OA-diagnosed patients were observed.

The thumb isn’t usually looked at in isolation with reference to OA, but this research may be changing that.

“Thumbs aren’t just important for people playing the piano or knitting for fun. Almost everything you do on a daily basis involves the thumb in some way, shape or form,” Bush added.

Forthcoming research from the trio will look at how a six-week thumb exercise protocol impacted the ability to generate forces with the thumb. The researchers observed an increase in thumb strength in just two weeks.

So where could this go next? One avenue would be to develop tools for conducting these three-dimensional measurements in-clinic without the need for laboratory-grade motion capture devices. That would give therapists the ability to not only evaluate more complex movement patterns for earlier diagnosis, but also measure the impact of treatment for better outcomes.

This type of collaboration between research specialties can be difficult to pull off, but Vocelle’s rotations as part of her DO/Ph.D. program presented a meaningful opportunity for integration. The three combined Vocelle’s clinical knowledge, Shafer’s rehabilitation expertise, and Bush’s deep understanding of biomechanics to offer a fresh perspective on a long-standing clinical problem.

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Ever heard of a surgical assistant? Meet a new boost to your medical bills

Izzy Benasso was playing a casual game of tennis with her father on a summer Saturday when she felt her knee pop. She had torn a meniscus, one of the friction-reducing pads in the knee, locking it in place at a 45-degree angle.

Although she suspected she had torn something, the 21-year-old senior at the University of Colorado in Boulder had to endure an anxious weekend in July 2019 until she could get an MRI that Monday.

“It was kind of emotional for her,” said her father, Steve Benasso. “Just sitting there thinking about all the things she wasn’t going to be able to do.”

At the UCHealth Steadman Hawkins Clinic Denver, the MRI confirmed the tear, and she was scheduled for surgery on Thursday. Her father, who works in human resources, told her exactly what to ask the clinic regarding her insurance coverage.

Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and Genuario’s clinic were in her Cigna health plan’s network.

“We were pretty conscious going into it,” he said.

Isabel met with Genuario’s physician assistant on Wednesday, and the following day underwent a successful meniscus repair operation.

“I had already gotten a ski pass at that point,” she said. “So that was depressing.” But she was heartened to hear that with time and rehab she would get back to her active lifestyle.

Then the letter arrived, portending of bills to come.

The Patient: Izzy Benasso, a 21-year-old college student covered by her mother’s Cigna health plan.

The Total Bill: $96,377 for the surgery was billed by the hospital, Sky Ridge Medical Center in Lone Tree, Colorado, part of HealthONE, a division of the for-profit hospital chain HCA. It accepted a $3,216.60 payment from the insurance company, as well as $357.40 from the Benassos, as payment in full. The surgical assistant billed separately for $1,167.

Service Provider: Eric Griffith, a surgical assistant who works as an independent contractor.

Medical Service: Outpatient arthroscopic meniscus repair surgery.

What Gives: The Benassos had stumbled into a growing trend in health care: third-party surgical assistants who aren’t part of a hospital staff or a surgeon’s practice. They tend to stay out-of-network with health plans, either accepting what a health plan will pay them or billing the patient directly. That, in turn, is leading to many surprise bills.

Even before any other medical bills showed up, Izzy received a notice from someone whose name she didn’t recognize.

“I’m writing this letter as a courtesy to remind you of my presence during your surgery,” the letter read.

It came from Eric Griffith, a Denver-based surgical assistant. He went on to write that he had submitted a claim to her health plan requesting payment for his services, but that it was too early to know whether the plan would cover his fee. It didn’t talk dollars and cents.

Steve Benasso said he was perplexed by the letter’s meaning, adding: “We had never read or heard of anything like that before.”

Surgical assistants serve as an extra set of hands for surgeons, allowing them to concentrate on the technical aspects of the surgery. Oftentimes other surgeons or physician assistants—or, in teaching hospitals, medical residents or surgical fellows—fill that role at no extra charge. But some doctors rely on certified surgical assistants, who generally have an undergraduate science degree, complete a 12- to 24-month training program, and then pass a certification exam.

Surgeons generally decide when they need surgical assistants, although the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.

A Sky Ridge spokesperson said that it is the responsibility of the surgeon to preauthorize the use and payment of a surgical assistant during outpatient surgery, and that HealthOne hospitals do not hire surgical assistants. Neither the assistant nor the surgeon works directly for the hospital. UC School of Medicine, the surgeon’s employer, declined requests for comment from Genuario.

Karen Ludwig, executive director of the Association of Surgical Assistants, estimates that 75% of certified surgical assistants are employed by hospitals, while the rest are independent contractors or work for surgical assistant groups.

“We’re seeing more of the third parties,” said Dr. Karan Chhabra, a surgeon and health policy researcher at the University of Michigan Medical School. “This is an emerging area of business.”

And it can be lucrative: Some of the larger surgical assistant companies are backed by private equity investment. Private equity firms often target segments of the health care system where patients have little choice in who provides their care. Indeed, under anesthesia for surgery, patients are often unaware the assistants are in the operating room. The private equity business models include keeping such helpers out-of-network so they can bill patients for larger amounts than they could negotiate from insurance companies.

Surgical assistants counter that many insurance plans are unwilling to contract with them.

“They’re not interested,” said Luis Aragon, a Chicago-area surgical assistant and managing director of American Surgical Professionals, a private equity-backed group in Houston.

Chhabra and his colleagues at the University of Michigan recently found that 1 in 5 privately insured patients undergoing surgery by in-network doctors at in-network facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical assistants, tied with anesthesiologists as the most frequent offenders. The researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at an average of $1,591 per bill.

Colorado has surprise billing protections for consumers like the Benassos who have state-regulated health plans. But state protections don’t apply to the 61% of American workers who have self-funded employer plans. Colorado Consumer Health Initiative, which helps consumers dispute surprise bills, has seen a lot of cases involving surgical assistants, said Adam Fox, director of strategic engagement.

Resolution: Initially, the Benassos ignored the missive. Izzy didn’t recall meeting Griffith or being told a surgical assistant would be involved in her case.

But a month and a half later, when Steve logged on to check his daughter’s explanation of benefits, he saw that Griffith had billed the plan for $1,167. Cigna had not paid any of it.

Realizing then that the assistant was likely out-of-network, Steve sent him a letter saying “we had no intention of paying.”

Griffith declined to comment on the specifics of the Benasso case but said he sends letters to every patient so no one is surprised when he submits a claim.

“With all the different people talking to you in pre-op, and the stress of surgery, even if we do meet, they may forget who I was or that I was even there,” he said. “So the intention of the letter is just to say, ‘Hey, I was part of your surgery.'”

After KHN inquired, Cigna officials reviewed the case and Genuario’s operative report, determined that the services of an assistant surgeon were appropriate for the procedure and approved Griffith’s claim. Because Griffith was an out-of-network provider, Cigna applied his fee to Benasso’s $2,000 outpatient deductible. The Benassos have not received a bill for that fee.

Griffith says insurers often require more information before determining whether to pay for a surgical assistant’s services. If the plan pays anything, he accepts that as payment in full. If the plan pays nothing, Griffith usually bills the patient.

The Takeaway: As hospitals across the country restart elective surgeries, patients should be aware of this common pitfall.

Chhabra said he’s hearing more anecdotal reports about insurance plans simply not paying for surgical assistants, which leaves the patient stuck with the bill.

Chhabra said patients should ask their surgeons before surgery whether an assistant will be involved and whether that assistant is in-network.

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The good, the bad, and the ugly of coming off antidepressants

The world has changed a lot in the three and a half years since I started taking antidepressants. I’ve changed a lot, too.

Like most people who are prescribed medication to manage their mood, taking selective serotonin reuptake inhibitors (SSRIs) — a type of antidepressant — was never really my Plan A. Nor was it my plan B, or even C. it was more like a Plan Z — after all other options had been exhausted.

And I was exhausted, too. Crippled by acute anxiety, sleeplessness, intense panic attacks, and unable to cope with even the most basic of my day-to-day responsibilities, SSRIs looked like a raft to safety. 

But like many other people I feared that once I began taking them I’d never be able to stop – that I’d become dependent. That I wouldn’t be able to function without them. It is only now that I feel ready to confront that fear head on – so this month I decided to finish my prescription for the last time. 

My life has changed so dramatically and in such a positive way since I began taking them that I had started to wonder. Had I really changed all that much? What was down to me and what was down to the drugs? 

What started as a small curiosity soon felt much more like a burning question. Added to that was the side effects of the drugs, which though not life-altering, I’d prefer not to experience if I don’t need to. These included lethargy, weight gain, jaw grinding and issues reaching orgasm. 

They were tolerable, and small sacrifices for being able to live a full and healthy life — but I wanted to feel energised again.

While SSRIs protected me from the intensity of the shocks and blows of life, they also had the same blunting effect on the highs. After meeting someone during lockdown (I know) and suddenly being in the throes of a new romance, I felt ready to be more present with my feelings. I wanted to make sure I experienced them in all of their colour, depth and intensity.

When I began taking antidepressants, there was no doubt that I needed help. After being sent home from work after a particularly dramatic panic attack that caused me to collapse in the middle of my office — I was no longer able to pretend. 

‘You can continue battling this yourself and be patient,’ my GP said to me, ‘and you will feel better eventually…. or you can take these pills and within six weeks things are likely to feel much, much more manageable.’

I was under pressure to return to work and in my desperation, lacking the requisite confidence to even believe I could get better alone — this felt like a glimmer of hope, some relative certainty onto which I could cling. 

And so I took the drugs. I surrendered to the help offered, went back to work alongside regular therapy, and quietly waited to feel the effects.

Things really did get better — not because the pills somehow removed my sadness or anxiety, but because I was finally strong enough to be able to do the work

A lot of people assume that taking antidepressants will make you happy. That you’ll wake up one day and everything will be great without you having had to work for it. It would be nice, wouldn’t it? I didn’t know what to expect, but reasoned that anything would be better than the tortuous panic that had taken over my life.

I can’t speak for everyone, but for me the road to recovery was much, much messier. One of the side-effects that’s less well known to those without personal experience is that in the first six weeks or so of beginning treatment, your symptoms can actually get worse. 

Eventually though, things did get easier. The weight of panic began to lift a little from my chest — although it never truly disappeared. I was able to laugh for the first time in months, to concentrate for long enough that I could begin to vaguely follow the plot of TV shows (although only ones I’d seen before).

I could engage in conversation and hear about other people and challenging things that were going on with them, without then fearing that the same thing would happen to me. But my brain was still alert – like fly paper where new ideas of things to worry about could get stuck and cause me to overthink.

Eventually, CBT – a therapeutic process that helps you to challenge negative thinking patterns and therefore change your emotional responses and behaviour – helped me to get to a place where I could recognise that what was going on with me was more than just a spell of difficult mental health.

This allowed me to feel comfortable enough to get a formal psychiatric assessment, where I was diagnosed with post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD) — the latter of which had become a coping mechanism to deal with the former.

My meds were increased and things really did start getting better — but not because the pills somehow removed my sadness or anxiety. It’s because I was finally strong and stable enough to be able to do the work involved to feel better.

They cushioned the blows, but didn’t eliminate them altogether. And staying healthy was – and still is – a lot of work.

I’m being explicit here because – despite progress in our general understanding of mental health as a society – there is still so much misinformation, particularly when it comes to medical intervention and prescription drugs.

Popular culture and mass media have done a lot of damage to the common perception of antidepressants as ‘happy pills’ – and I therefore bear a large amount of responsibility for correcting this, one column at a time.

There’s never a good time to come off antidepressants, but there definitely is a bad time. Many mental health professionals would advise you not to come off them in the winter (particularly in the northern hemisphere), because Vitamin D plays such a huge part in boosting your mood.

You will also be advised to titrate as you come off – which means to slowly reduce your dose over a long period of time to avoid any extreme fluctuations in mood.

There have been three times over the past three years when my plans to come off the meds have been interrupted by stressful life events, either in my personal life  or, most recently, by  the Covid-19 pandemic. 

It’s not that I needed to come off them – many people stay on them forever, and that is up to them and their own needs. It’s an incredibly personal thing and everyone feels different. There’s no ‘one size fits all’.

But there was one morning about a month or so ago, after numerous conversations with my best mate, my doctor and my therapist about whether or not it was the right time, when I suddenly felt ready. And so instead of taking the full dose with my breakfast as usual, I snapped the pill in two and only took half.

I made sure to tell those closest to me so that they could keep an eye on me over the next few weeks as things were likely to get pretty bumpy emotionally.

A month has passed and I feel OK. I don’t feel catatonic, nor jubilant. Just OK.

I’ve felt the return of some intense feelings, for better or worse. I’ve had moments when my emotions feel a lot like looking out the window of an accelerating car as the outside world starts to blur into a mess of indistinguishable colours and shapes. I’ve had moments of crying where I can’t imagine ever feeling less sad. 

I’ve felt the return of some obsessive thinking and been crippled by indecision on a number of occasions. But in each and every such moment, I have used the tools and experience learned over the past few years to steady myself until things begin to feel more solid again.

I don’t know what the future holds, but I do know I’d never rule out going back on antidepressants.

And while I’m excited to close the door on what was an incredibly challenging period of my life and move forward with more awareness and healthier habits – there’s comfort in knowing those little pills would be there if ever I needed a helping hand again. 

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Measuring the complexity of the aging brain

An international collaboration between the Center for Healthy Brain Aging (CHeBA) and Beihang University in China has researched differential longitudinal changes in structural complexity and volumetric measures in community-dwelling older individuals.

The research analyzed the brain scans of community-dwelling older individuals aged 70-90 without dementia, using data from CHeBA’s Sydney Memory & Aging Study.

The findings, published in Neurobiology of Aging discovered that a measure of “complexity” of the brain is more sensitive to brain changes over time than more conventional measures such as cortical thickness or cortical volumes.

To understand the concept, Group Leader of CHeBA’s Neuroimaging Group and co-author on the research, Associate Professor Wei Wen asks us to consider how we measure and compare the geometric complexity of two objects.

“There are many ways, depending on what you want to measure,” says Associate Professor Wen. “Natural and biological morphologies are irregular.”

“Compared with Euclidean geometry, a term used to denote standard geometry such as width, length or volume and thickness, mother nature exhibits not simply just a higher degree but entirely a different level of complexity.”

An example, according to Associate Professor Wen, is if you zoom in from a satellite image of the coastline of Australia, you will see increasing amount of detail altering from a simple curve to a clear representation of bays, inlets and lagoons.

“Such ‘zooming-in’ can be infinite and the complexity of the coastline will continue to increase so long as our satellite has such spatial resolution,” he says.

Fractal analysis is one of the methods in describing and quantifying the morphological complexity in magnetic resonance imaging (MRI).

“To investigate the relationship between the complexity measure, which is indexed as fractal dimensionality (FD), and the traditional Euclidean metric, such as volume and thickness, of the brain in older age, we analyzed MRI scans of 161 community-dwelling, non-demented individuals aged 70-90 years at baseline and at their 2-year and 6-year follow-ups,” said Associate Professor Wen.

“We quantified changes of neuroimaging metrics in cortical lobes and subcortical structures, and investigated the age, sex, hemisphere and education effects on FD.”

FD showed significant age-related decline in all brain structures, and its trajectory was best modeled quadratically, i.e. it accelerated in later years, in bilateral frontal, parietal, and occipital lobes, as well as in bilateral subcortical structures such as hippocampus.

According to Professor Wei Wen the findings suggest that FD is reliable yet shows a different pattern of decline compared to volumetric measures.

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Ethical recommendations for triage of COVID-19 patients

An international expert group led by Mathias Wirth, professor of systematic theology and ethics at the University of Bern, has developed recommendations for avoiding triage of COVID-19 patients in extreme situations. The recommendations should support medical personnel in difficult decisions during a second wave of the infection and ensure better patient care.

“A lack of intensive care ventilation units owing to rapidly increasing infection rates numbers among the most significant nightmare scenarios of the corona pandemic,” says Mathias Wirth, head of the Ethics Department in the Faculty of Theology at the University of Bern, because: “Shortages of supply can result in triage of patients suffering from severe cases of COVID-19 and thus force a life or death decision.” Here, triage means favoring some COVID-19 patients over others depending on urgency and prognosis. Together with experts from Yale University, King’s College London, Charité Berlin and Essen University Hospital, medical ethicist Mathias Wirth has prepared a statement on these difficult decisions. The statement was published in the American Journal of Bioethics (AJOB), the most frequently cited scientific journal in the entire field of ethics.

Triage is only ethically justifiable under very specific circumstances

The experts warn against the possibility of prematurely implementing triage; even though triage allows for decisions based on fairness in extreme situations, it leads to significant strain on the affected parties, relatives and medical personnel. In order to avoid it, every effort must be made to transfer seriously ill patients to other hospitals without shortages of supply—across country borders in case of emergency, according to the authors.

In concrete terms, Mathias Wirth’s team of researchers recommend increased regional, national and even international collaboration in intensive care for COVID-19 patients in preparation for future waves of infection. “Just because triage is correct under some circumstances does not mean that it is correct under all circumstances,” says Wirth. “There is no real and legitimate triage situation as long as treatment spaces are available elsewhere.”

Negative decision requires special care

Secondly, a negative triage decision for individual people should not under any circumstances mean that their medical and psychological care is neglected. Quite the opposite: If they are deprived of a ventilator, maximum effort is required for their care and treatment, both for them and for their relatives.

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Gigi Hadid Reveals a Bit of Her Bump & Why You Won't See More

During her pregnancy, Gigi Hadid is learning one of the first harsh rules about motherhood: Some people will care more about your child more than they do about all the other amazing things you create. Case in point, in preparing to promote Gigi Journal Part II, an art book she created with V Magazine, she wound up receiving tons of fan questions about showing off her baby bump, yet again.

“I’m so grateful for the positive comments and the questions and wanting just to know that we’re all good and safe and everything’s going great and I love you guys,” Hadid said on Wednesday in a long Instagram Live post to unveil the book.

“Obviously, I think a lot of people are confused why I’m not sharing more, but I’m pregnant through a pandemic,” she explained. “Obviously, my pregnancy is not the most important thing going on in the world. That’s a reason that I felt that it’s not really something that I need to share apart from with my family and friends. Obviously, a lot of people have lost lives due to coronavirus that was in the beginning of quarantine and still happening. And then we moved obviously into the reemergence of the [Black Lives Matter] movement, and I thought that our presence on social media should be used for that.”

This is a very mature, selfless way of explaining Hadid’s lack of pregnancy updates. Mine would have been more like, “I’ll post if I want to, so mind your own business,” only with more expletives. (Reason #798 Hadid is a social media star and I am not.)

But beyond the fact that the world is on fire and there are more important things to discuss than the shape of one model’s belly, Hadid also does want to maintain a bit of privacy during this very special time.

“I have been taking a lot of pictures of my bump and sending it to friends and family,” she said. “And it’s been really cute and exciting, and I’m trying to document it well because I’ve heard a lot of people say, make sure you don’t miss it. And I will be sharing stuff like that in the future. I just am not rushed to do it, and I feel like right now, I just want to experience it.”

Hadid spends her entire life presenting an image of herself for public consumption, so it’s pretty understanding if she wants a break from all that.

“I just don’t want to worry about waking up every day during my pregnancy and worry about having to like look cute or post something,” she went on.

We’ll always have the Bella twins for pregnancy bump pics.

Still, she made one tiny concession for curious fans who just want to see evidence of the life growing inside her. After she had previously explained about not looking pregnant on Instagram videos taking from the front, she discussed her love of loose, linen clothing, particularly the set from Holiday she was wearing. Then she unbuttoned the bottom of her shirt.

“OK, there’s my belly, y’all,” she said, revealing the top of her bump and leaving the rest out of view of the camera. “It’s there. It’s just that from the front, it’s different. … I’m taking my time with sharing my pregnancy, and you guys will see it when you see it.”

With that, she continued on with her original purpose, to show off Gigi’s Journal. Because, for real, can we please let a mom-to-be also have her career?

If Gigi and Zayn don’t have a name picked out yet, maybe they can get inspo from these wacky celebrity baby names.

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Scientists evaluate the perspectives of zinc intake for COVID-19 prevention

Researchers from Sechenov University in collaboration with colleagues from Germany, Greece and Russia, have reviewed scientific articles on the role of zinc in the prevention and treatment of viral infections and pneumonia, with projections on those caused by SARS-CoV-2. The results were published in the International Journal of Molecular Medicine.

Zinc is necessary for normal metabolism and functioning of the reproductive, cardiovascular and nervous systems, but it is also important for the immune system, in particular for the proliferation and maturation of white blood cells (some of them are able to capture and digest microorganisms, and others to produce antibodies). In addition, zinc is involved in the regulation of inflammation. Thus, normal levels of zinc support human resistance to inflammatory and infectious diseases.

“According to the current estimates, the risk of zinc deficiency is observed in more than 1.5 billion people in the world. In Russia, deficiency of this element occurs in 20-40% of the population; in some regions it reaches 60%. Given the crucial role of zinc in regulation of immunity, one can propose that its insufficiency may be considered as a risk factor for infectious diseases,” said the research leader, head of the Laboratory of Molecular Dietetics at Sechenov University, Professor Anatoly Skalny.

The scientists reviewed the results of studies on the use of zinc-containing drugs for increasing immunity and preventing viral infections, including SARS-CoV-2. Previous studies showed that zinc and its binding substances can slow down the work of RNA polymerase (an enzyme that synthesizes viral RNA molecules) of coronaviruses and suppress their spread in the body. One of the substances that stimulates cellular zinc uptake, chloroquine, has already been tested on patients with SARS-CoV-2, but its strong side effects make it necessary to look for other compounds with a similar effect or use zinc separately. However, both options have not been sufficiently studied or tested yet.

Observations of the development of other viruses, such as rhinoviruses (this family includes pathogens of acute respiratory diseases), show that an increase in the level of zinc in cells suppresses replication of the virus and stimulates production of interferon alpha, which has an antiviral activity.

In addition, zinc deficiency is considered as one of the risk factors for the development of pneumonia: it increases the susceptibility to infectious agents and the disease duration. Several studies show the effectiveness of zinc-containing drugs in decreasing severity and duration of symptoms and reducing the prevalence of pneumonia. However, in general, data on the use of zinc as a therapy, rather than prevention, are contradictory.

Another possible application of zinc is modulation of inflammation. Existing data show that zinc ions have an anti-inflammatory effect, reducing damage to lung tissue in pneumonia. Zinc also helps the body resist bacteria, and bacterial pneumonia frequently occurs in patients with secondary viral infections.

“A recent study conducted by scientists from the U.S. confirmed our assumptions, demonstrating the effect of zinc intake on the risk of a severe course and the need for artificial ventilation in patients with COVID-19,” said Alexey Tinkov, coauthor of the article, a leading researcher at the Laboratory of Molecular Dietetics at Sechenov University.

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