At a recent visit to the Veterans Affairs clinic in the Bronx, Barry, a decorated Vietnam veteran, learned that he belonged to a very exclusive club. According to a new AI-assisted algorithm, he was one of several hundred VA patients nationwide, of 6 million total, deemed at imminent risk of suicide.The bbgoex鑫航國際 did not take him entirely off guard. Barry, 69, who was badly wounded in the 1968 Tet offensive, had already made two previous attempts on his life. "I don't like this idea of a list, to tell you the truth -- a computer telling me something like this," Barry, a retired postal worker, said in a phone interview. He asked that his surname be omitted for privacy.Sign up for The Morning bbgoex鑫航國際letter from the New York Times"But I thought about it," Barry said. "I decided, you know, OK -- if it's going to get me more support that I need, then I'm OK with it."For more than a decade, health officials have watched in vain as suicide rates climbed steadily -- by 30% nationally since 2000 -- and rates in the VA system have been higher than in the general population. The trends have defied easy explanation and driven investment in blind analysis: machine learning, or AI-assisted algorithms that search medical and other records for patterns historically associated with suicides or attempts in large clinical populations.Doctors have traditionally gauged patients' risks by looking at past mental health diagnoses and incidents of substance abuse, and by drawing on experience and medical instinct. But these evaluations fall well short of predictive, and the artificially intelligent programs explore many more factors, like employment and marital status, physical ailments, prescription history and hospital visits. These algorithms are black boxes: They flag a person as at high risk of suicide, without providing any rationale.But human intelligence isn't necessarily better at the task. "The fact is, we can't rely on trained medical experts to identify people who are truly at high risk," said Dr. Marianne S. Goodman, a psychiatrist at the Veterans Integrated Service Network in the Bronx, and a clinical professor of medicine at the Icahn School of Medicine at Mount Sinai. "We're no good at it."Deploying AI in this way is not new; researchers have been gathering data on suicides through the National Health Service in Britain since 1996. The U.S. Army, Kaiser Permanente and Massachusetts General Hospital each has separately developed an algorithm intended to predict suicide risk. But the VA's program, called Reach Vet, which identified Barry as at high risk, is the first of the new U.S. systems to be used in daily clinical practice, and it is being watched closely. How these systems perform -- whether they save lives and at what cost, socially and financially -- will help determine if digital medicine can deliver on its promise."It is a critical test for these big-data systems," said Alex John London, the director of the Center for Ethics and Policy at Carnegie Mellon University in Pittsburgh. "If these things have a high rate of false positives, for instance, that marks a lot of people at high risk who are not -- and the stigma associated with that could be harmful indeed downstream. We need to be sure these risk flags lead to people getting better or more help, not somehow being punished."The VA's algorithm updates continually, generating a new list of high-risk veterans each month. Some names stay on the list for months, others fall off. When a person is flagged, his or her name shows up on the computer dashboard of the local clinic's Reach Vet coordinator, who calls to arrange an appointment. The veteran's doctor explains what the high-risk designation means -- it is a warning sign, not a prognosis -- and makes sure the person has a suicide safety plan: that any guns and ammunition are stored separately; that photos of loved ones are visible; and that phone numbers of friends, social workers and suicide hotlines are on hand.Doctors who have worked with Reach Vet say that the system produces unexpected results, both in whom it flags and whom it does not.To some of his therapists, Chris, 36, who deployed to Iraq and Afghanistan, looked very much like someone who should be on the radar. He had been a Marine rifleman and saw combat in three of his four tours, taking and returning heavy fire in multiple skirmishes. In 2008, a roadside bomb injured several of his friends but left him unscathed. After the attack he had persistent nightmares about it and received a diagnosis of post-traumatic stress. In 2016, he had a suicidal episode; he asked that his last name be omitted to protect his privacy."I remember going to the shower, coming out and grabbing my gun," he said in an interview at his home near New York City. "I had a Glock 9-millimeter. For me, I love guns, they're like a safety blanket. Next thing I know, I'm waking up in cold water, sitting in the tub, the gun is sitting right there, out of the holster. I blacked out. I mean, I have no idea what happened. There were no bullets in the gun, it turned out."The strongest risk factor for suicide is a previous attempt, especially one with a gun. Yet Chris' name has not turned up on the high-risk list compiled by AI, and he does not think it ever will."At the time, in 2016, I was going to school for a master's, working full time," he said. "Our two kids were toddlers; I was sleeping no more than a few hours a night, if that. It was too much. I was sleep-deprived all the time. I had never been suicidal, never had suicidal thoughts; it was a totally impulsive thing."The AI behind Reach Vet seems to home in on other risk factors, Goodman said: "The things this program picks up wouldn't necessarily be the ones I thought about. The analytics are beginning to change our understanding of who's at greatest risk."The algorithm is built on an analysis of thousands of previous suicides in the VA's database, dating to 2008. The computer mixes and shuffles scores of facts from the medical records -- age, marital status, diagnoses, prescriptions -- and settles on the factors that together are most strongly associated with suicide risk.The VA model integrates 61 factors in all, including some that are not obvious, like arthritis and statin use, and produces a composite score for each person. Those who score at the very top of the range -- the top 0.1% -- are flagged as high risk."The risk concentration for people in the top 0.1% on this score was about 40 times," said John McCarthy, the director of data and surveillance, in Suicide Prevention in the VA Office of Mental Health and Suicide Prevention. "That is, they were 40 times more likely to die of suicide" than the average person.Bridget Matarazzo, the director of clinical services at the Rocky Mountain Mental Illness Research Education and Clinical Center for Veteran Suicide Prevention, said of Reach Vet, "My impression is that it's identifying some folks who were previously on providers' radar, but also others who were not."Late in 2018, a VA team led by McCarthy presented the first results of the Reach Vet system. Over a six-month period, with Reach Vet in place, high-risk veterans more than doubled their use of VA services. By contrast, in a comparison group tracked for six months before Reach Vet was installed, the use of VA services stayed roughly the same.The Reach Vet group also had a lower mortality rate over that time -- although it was an overall rate, including any cause of death. The analysis did not detect a difference in suicides, at least up to that stage. "It's encouraging, but we've got much more to do to see if we're having the impact we want," McCarthy said.Ronald Kessler, a professor of health care and policy at Harvard Medical School, said: "Right now, this and other models predict who's at highest risk. What they don't tell you is who is most likely to profit from an intervention. If you don't know that, you don't know where to put your resources."For doctors using the system, however, it has already prompted some rethinking of how to assess risk. "You end up with a lot of older men who are really struggling with medical problems," Goodman said. "They're quietly miserable, in pain, often alone, with financial problems, and you don't see them because they're not coming in."And for those whose names have popped up on Reach Vet's list, the experience of being identified and contacted is not something they can easily forget.Barry, the Vietnam veteran, said that he was in a relatively good place, for now. He is close to his two grown children, and he receives regular care at the Bronx VA, including both individual and group therapy, and medication for recurrent psychotic episodes. But he is also aware of how quickly things can turn dark."Look, I know I sometimes talk to myself at night, and I hear voices," he said. "The meds work fine, but once in a while they don't, and that angers them, the voices. And that is not good for me."----If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.This article originally appeared in The New York Times.(C) 2020 The New York Times Company
While most of us strive to avoid inhaling aerosols that could harbor a deadly virus, millions of teens and young adults are deliberately bathing their lungs in aerosols rich in chemicals with known or suspected health hazards.I'm referring to vaping (or "juuling"): the use of electronic cigarettes that is hooking young people on a highly addictive drug -- nicotine -- and will be likely to keep them hooked for decades. Meanwhile, e-cigarettes and other vaping devices are legally sold with few restrictions while producers and sellers reap the monetary rewards. Although many states prohibit e-cigarette sales to persons younger than 18 or 21, youngsters have little trouble accessing the products online or from friends and relatives.In just one year, from 2017 to 2018, vaping by high school seniors increased more than "for any substance we've ever monitored in 45 years, and the next year it rose again almost as much," said Richard Miech, principal investigator for the national survey Monitoring the Future.Sign up for The Morning bbgoex鑫航國際letter from the New York TimesBy 2019, one-quarter of 12th graders were vaping nicotine, nearly half of them daily. Daily vaping rose in all three grades surveyed -- eighth, 10th and 12th -- "with accompanying increases in the proportions of youth who are physically addicted to nicotine," Miech and colleagues reported in The New England Journal of Medicine last year.Although self-reported use of e-cigarettes by high school and middle school students decreased over the past year, Dr. Robert R. Redfield, director of the Centers for Disease Control and Prevention, cautioned, "Youth e-cigarette use remains an epidemic.""We're stepping backward from all the advances we've made in tobacco control," Miech, professor at the Institute for Social Research at the University of Michigan, said in an interview. "I'm worried that we will eventually return to the tobacco situation of yore. There's evidence that kids who vape are four to five times more likely the next year to experiment with cigarettes for the first time."As someone who witnessed the persuasive tactics the tobacco industry used to get nearly half of American adults hooked on regular cigarettes in the 1950s, I see similar efforts being used today to promote these new delivery systems for nicotine: sex, glamour, endorsements by celebrities and doctors, and sponsorship of popular sports and musical events. Only now there are even more pervasive avenues of influence through websites and social media.In 2016, ads for e-cigarettes reached nearly 4 in 5 middle and high school students in the United States, Dr. Ellen S. Rome said.As in decades past, the nation's regulatory agencies have been slow -- some say negligent -- to recognize this fast-growing threat to the health and development of young Americans. Rome, a pediatrician who heads the Center for Adolescent Medicine at the Cleveland Clinic, explained that nicotine forms addictive pathways in the brain that can increase a youngster's susceptibility to addiction throughout life. The adolescent brain is still developing, she told me, and e-cigarette use is often a gateway to vaping of marijuana, which can affect the brain centers responsible for attention, memory, learning, cognition, self-control and decision-making.In a review published last December in the Cleveland Clinic Journal of Medicine, Rome and her co-author, Perry Dinardo, challenged the public perception that vaping is harmless, or "at least less harmful than cigarette smoking."While it's likely to be true that vaping may be less hazardous than tobacco cigarettes, since the vaped aerosols that reach the lungs are devoid of the thousands of tobacco-derived toxic and carcinogenic substances inhaled by cigarette smokers, vaping still introduces a fair share of potentially harmful chemicals. In addition to nicotine, some of the chemicals, like the carcinogen formaldehyde, are created when the nicotine-rich liquid in some vaping devices is heated to high temperatures."E-cigarettes might have their own unique health effects we haven't discovered yet," said Theodore L. Wagener, director of the Center for Tobacco Research at Ohio State University. "Although compared to tobacco cigarettes, e-cigarettes without a doubt expose users to much lower levels of harmful chemicals, we still don't know how the body handles them and what their long-term effects might be."Remember, it took many decades of smoking by tens of millions of people before the deadly hazards of tobacco cigarettes were recognized.The surge in the use of electronic cigarettes was tied to a game-changing product, Juul, a cartridge device introduced in 2017 in a slew of enticing flavors. Flavors especially attractive to youngsters are now banned from use in closed-system devices like Juul, which now is sold only in tobacco and menthol flavors, but can still be used in the open-system products sold in vape shops. And now, taking advantage of a loophole in regulations, a disposable product called Puff Bar, which comes in more than 20 flavors, has replaced Juul as the vape of choice among young people.Concerns about vaping grew after a 2019 outbreak of severe lung injuries, which were subsequently linked to vitamin E acetate, an additive found in some vaping devices that deliver THC, the psychoactive ingredient in marijuana. Juul pods are not designed to be refillable with substances like THC or other chemicals.Producers of Juul introduced changes that enhanced the palatability and safety of vaping, but at the same time "made it easier for kids to start using nicotine," Wagener said. Instead of freebase nicotine that is very harsh to inhale, Juul contains a nicotine salt, "a very palatable form of nicotine that makes inhaling high doses of nicotine easy," he explained. And Juul doesn't require the high temperatures that produce toxic substances like formaldehyde. A single pod contains the nicotine equivalent of a pack of conventional cigarettes."Juul made it cool, and young people who had never smoked cigarettes are becoming addicted to nicotine," said Erika R. Cheng, a public health researcher at Indiana University School of Medicine. In addition to nicotine, Juul pods contain a mix of glycerol, propylene glycol, benzoic acid and flavoring agents, the long-term health effects of which have yet to be determined, she said."E-cigarettes were initially advertised as a means to help people transition from harmful tobacco smoking," Cheng said. "A lot of early users didn't even know they contained nicotine." Although a small minority of smokers have used e-cigarettes to help them quit or reduce their dependence on tobacco, most who use the devices vape to get their nicotine fix when they can't smoke regular cigarettes.Although there have been calls for bans on e-cigarettes, Abigail S. Friedman, a health economist at Yale University School of Public Health, cautioned that "bans can push people into the black market looking for something that can be acutely dangerous."Friedman said that rather than outright bans that can have unanticipated costs, she favors better regulations. Currently, other than flavors, what is inhaled from e-cigarettes is unregulated. Still, she and other experts are very concerned about the explosive uptake of vaping by young people. In the 2019 Youth Risk Behavior Survey of 4.9 million high school students, she said, 6% reported smoking conventional cigarettes while 33% puffed e-cigarettes in the past 30 days. In December 2018, the U.S. Surgeon General, Dr. Jerome Adams, declared e-cigarette use by youth an epidemic.This article originally appeared in The New York Times.(C) 2020 The New York Times Company
Pfizer, Moderna and AstraZeneca are producing the leading COVID-19 vaccine candidates. How effective are they in helping end the pandemic?
The "safest bet" for some families will be not to have family gatherings this Christmas in order to stop the spread of the coronavirus, Maria Van Kerkhove, the World Health Organization's technical lead for COVID-19, said on Monday. "In some situations, the difficult decision not to have a family gathering is the safest bet," she told a virtual briefing in Geneva.
“Donald Trump defeated Donald Trump.”
“The victory was a vindication of a style of American politics that many feared was gone forever.”
“Mr. Biden’s victory — and Mr. Trump’s defeat — is a testament to the resilience of American democracy.”
“Trump’s 2020 reelection bid was doomed by his boorish behavior. Time and again, he refused to act like a president.”
“Biden took the opportunity to unite the Democratic Party.”