Texas, Ohio top courts allow abortion bans to take effect

 

The top courts in Texas and Ohio allowed the Republican-led states to enforce restrictions and bans on abortions after the U.S. Supreme Court last week overturned the nationwide constitutional right to abortion.

The Texas Supreme Court late on Friday allowed a nearly century-old ban to take effect, reversing a temporary restraining order a judge issued Tuesday that allowed the procedure to resume in the state up to the already-restricted six weeks of pregnancy.

The order, which allows the law to be enforced civilly but not criminally, came the same day the Ohio Supreme Court gave the state the go-ahead to enforce a 2019 ban on abortions at six weeks of pregnancy.

The dual orders came one week after the conservative-majority U.S. Supreme Court restored states' authority to ban abortions, triggering a flurry of lawsuits seeking to preserve the ability of women to terminate their own pregnancies.

Lawyers for the abortion clinics who challenged the 1925 ban vowed to continue fighting.

Since the Supreme Court erased the nearly 50-year precedent, abortion rights groups have challenged anti-abortion laws in 11 states, and judges in Florida, Louisiana, Kentucky, and Utah have prevented restrictions or bans from being enforced.

Friday's orders came as two Democratic-controlled states, New York and New Jersey, moved to bolster abortion rights within their borders.

In New Jersey, Governor Phil Murphy signed legislation designed to allow women who venture to the state seeking abortions to do so without fear of prosecution or civil litigation from their home states.

The New York Senate passed an amendment to the state constitution to codify the right to an abortion, as well as the right to contraception.

https://www.marketscreener.com/news/latest/Texas-Ohio-top-courts-allow-abortion-bans-to-take-effect--40886649/

Hyloris' Post-Op Pain Treatment Stalled by CRL

 Hyloris Pharmaceuticals has received a complete response letter from the U.S. Food and Drug Administration, seeking clarification on one topic related to its registration of Maxigesic IV. 

Hyloris did not provide details on the FDA's concern but said that it will fully comply with whatever is necessary to move the product forward. Maxigesic IV is a combination of 1000 mg paracetamol and 300 mg ibuprofen to be given intravenously to treat post-operative pain. It is administered as a 15-minute IV infusion in adults experiencing mild to moderate pain and to reduce fever.

"We believe, along with our partners at AFT, that generating the additional information that FDA requires to support the NDA submission of Maxigesic IV will allow the product to fulfill its full commercial potential in the US and not affect the Company's other existing development programs," Stijn Van Rompay, CEO of Hyloris, said in a press release.

"The additional work required by FDA falls well within the parameters of our normal operational budget and will be completed expeditiously," he added. 

The drug is already licensed in over 100 countries for the same indication. It is also registered in 39 countries, including Germany, Korea and Australia. It also has several patents in force and more pending patent applications. 

This is not the first time Hyloris and partner AFT Pharmaceuticals received a CRL for Maxigesic. In September 2020, the FDA issued a CRL concerning its application for the tablet version of the drug, citing the delay in the inspection of the product's production facilities. The inspection was held back due to COVID-19-related restrictions. The FDA has also requested minor changes to the oral version's label and requested an update on its global safety information. 

Hyloris had responded positively to the regulator's requests.

"This is a very pleasing result. The letter shows a prescription version of Maxigesic is approvable in the US and that AFT is well on the way to approval of its patented medicine in the US market," AFT managing director Dr. Hartley Atkinson said in an earlier statement. 

The FDA accepted the New Drug Application for Maxigesic IV in November 2021. At the same time, the U.S. Patent and Trademark Office issued a Notice of Allowance and enabled the process and formulation of patents for the drug in the U.S. Maxigesic IV will be commercialized when approved by Hikma Pharmaceuticals, Hyloris and AFT's partner supplier in the country. 

The distribution of novel pain medications like Maxigesic IV offers hope to the millions of surgeries performed in the U.S. each year that have insufficient post-operative pain solutions. It could also help curb synthetic opioid misuse, leading to staggering death numbers through the years. According to the Centers for Disease Control and Prevention, 62% of the total number of drug overdose fatalities in the country in 2020 were due to the abuse of pain meds. 

https://www.biospace.com/article/fda-issues-crl-to-paracetamol-ibuprofen-combo-drug-maker/

COVID-19 viral load in lungs supports prognosis in severely ill patients

 The coronavirus SARS-CoV-2 can infect various body tissues. While the detection of the virus in the nasopharynx is established as a diagnostic method, the amount of virus found there does not allow a prognosis of the course of the disease. In a recent study, a research team from the Helmholtz Center for Infection Research (HZI) in cooperation with the University of Rijeka, Croatia, investigated the correlation between the viral load in different tissues and the mortality of patients with a severe course of COVID-19.

The researchers show for the first time that viral load can contribute to clinical prognosis, as a higher viral load in the lungs at the time of ventilation correlates with an increased risk of death. In this interview, first author Henrike Maaß and study leader Prof Luka Cicin-Sain, head of the department "Viral Immunology" at HZI, talk about the research results that were published in the journal Viruses.

You studied the viral load in different clinical samples from ventilated COVID-19 patients. What does viral load reveal about the clinical prognosis of patients? For which group of people does this apply?

Henrike Maaß: Unfortunately, a clear clinical prognosis is not possible based on the viral load alone. Especially in serum samples, the viral load can only be detected in particularly severely ill patients, as the virus first replicates in the upper and lower respiratory tract. Nevertheless, our data show that viral load can be used to identify which patients are likely to have a severe course of the disease and therefore need additional treatment.

Luka Cicin-Sain: We have seen this correlation in patients with severe disease, where lung sampling has not been an additional burden for the patient. Due to ethical considerations and patient care, we could not obtain such samples from the lungs in people with a milder course of the disease and then also not evaluate them. In these patients, the viral load can still be measured in the blood serum. As a rule of thumb, the patients with a very severe course showed a detectable viral titer in the bloodstream.

What kind of samples did you examine in the study? Are there any special aspects to be taken into account?

HM: In the study, on the one hand, we examined serum samples and, on the other hand, samples from the broncho-alveolar lavage (BAL). The special thing about BAL samples is that they come directly from the lungs. The lungs are rinsed with saline solution and the fluid is then aspirated. Since this procedure is much more complicated and elaborate than that for serum samples, this type of sample is not used very often. Fortunately for us, in Croatia these samples are used as a diagnostic tool to identify infections with bacterial lung pathogens, which allowed us to use these samples for our study. Another point is that since BAL fluids come directly from the lungs—the compartment where the virus replicates—they are highly infectious, unlike blood. To analyze this material, we worked in the S3 laboratory at HZI. This laboratory meets the high safety standards for working with such infectious samples.

The clinical samples were taken in the second and third corona waves in Croatia. Which virus variants were predominant at the time and were there differences between the variants?

HM: At the time of the second wave, there were mainly SARS-CoV-2 variants now called pre-alpha. At the time of the third wave, the virus variant alpha was dominant. In most of our analyses, we combined the two cohorts. However, in a separate analysis, we found that alpha-infected patients had a higher viral load, both in serum and in BAL samples. In the near future, we will do further studies with delta-infected patient samples and then see how this variant compares to the previous ones. Preliminary results from these patients also show that the viral load in patients who died from the infection is higher than that of survivors.

How could these study results improve the treatment of COVID-19?

LCS: In this study, we showed for the first time that viral load in the lungs has a significant correlation with the severity of the disease. This is important because previous studies could not find a correlation, but viral load was measured in the upper airways because it is easier to do. However, the viral load in the lungs is more important for the course of the disease and our results have confirmed this. Thus, our data suggest once again that treatment with antiviral drugs after hospitalization and before admission to the intensive care unit is definitely useful in order to reduce the virus load in the lung. Our study also provides further evidence that patients die because of their SARS-CoV-2 infection and not "with corona." Animal experiments have already shown that a higher viral load in the lungs also causes higher mortality. Our data show that this correlation also exists in humans.

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Explore further

Vaccination greatly reduces infectious viral load in COVID-19

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More information: Mario Ynga-Durand et al, SARS-CoV-2 Viral Load in the Pulmonary Compartment of Critically Ill COVID-19 Patients Correlates with Viral Serum Load and Fatal Outcomes, Viruses (2022). DOI: 10.3390/v14061292

https://medicalxpress.com/news/2022-06-covid-viral-lungs-prognosis-severely.html

'Soft' CRISPR may offer a new fix for genetic defects

 Curing debilitating genetic diseases is one of the great challenges of modern medicine. During the past decade, development of CRISPR technologies and advancements in genetics research brought new hope for patients and their families, although the safety of these new methods is still of significant concern.

Publishing July 1 in the journal Science Advances, a team of biologists at the University of California San Diego that includes postdoctoral scholar Sitara Roy, specialist Annabel Guichard and Professor Ethan Bier describes a new, safer approach that may correct genetic defects in the future. Their strategy, which makes use of natural DNA repair machinery, provides a foundation for novel gene therapy strategies with the potential to cure a large spectrum of genetic diseases.

In many cases, those suffering from genetic disorders carry distinct mutations in the two copies of genes inherited from their parents. This means that often, a mutation on one chromosome will have a functional sequence counterpart on the other chromosome. The researchers employed CRISPR genetic editing tools to exploit this fact.

“The healthy variant can be used by the cell’s repair machinery to correct the defective mutation after cutting the mutant DNA,” said Guichard, the senior author of the study, “Remarkably, this can be achieved even more efficiently by a simple harmless nick.”

Working in fruit flies, the researchers designed mutants permitting visualization of such “homologous chromosome-templated repair,” or HTR, by the production of pigments in their eyes. Such mutants initially featured entirely white eyes. But when the same flies expressed CRISPR components (a guide RNA plus Cas9), they displayed large red patches across their eyes, a sign that the cell’s DNA repair machinery had succeeded in reversing the mutation using the functional DNA from the other chromosome.

They then tested their new system with Cas9 variants known as “nickases” that targeted just one strand of DNA instead of both. Surprisingly, the authors found that such nicks also gave rise to high-level restoration of red eye color nearly on par with normal (non-mutated) healthy flies. They found a 50-70% repair success rate with the nickase compared with just 20-30% in dual-strand cutting Cas9, which also generates frequent mutations and targets other sites throughout the genome (so-called off-target mutations). “I could not believe how well the nickase worked—it was completely unanticipated,” said Roy, the lead author of the study. The versatility of the new system could serve as a model for fixing genetic mutations in mammals, the researchers noted.

“We don’t know yet how this process will translate to human cells and if we can apply it to any gene,” said Guichard. “Some adjustment may be needed to obtain efficient HTR for disease-causing mutations carried by human chromosomes.”

The new research extends the group’s previous achievements in precision-editing with “allelic-drives,” which expand on principles of gene-drives with a guide RNA that directs the CRISPR system to cut undesired variants of a gene and replace them with a preferred version of the gene.

A key feature of the team’s research is that their nickase-based system causes far fewer on- and off-target mutations, as is known to happen with more traditional Cas9-based CRISPR edits. They also say a slow, continuous delivery of nickase components across several days may prove more beneficial than one-time deliveries.

“Another notable advantage of this approach is its simplicity,” said Bier. “It relies on very few components and DNA nicks are ‘soft,’ unlike Cas9, which produces full DNA breaks often accompanied by mutations.”

“If the frequency of such events could be increased either by promoting interhomolog pairing or by optimizing nick-specific repair processes, such strategies could be harnessed to correct numerous dominant or trans-heterozygous disease-causing mutations,” said Roy.

The Science Advances paper’s complete author list: Sitara Roy, Sara Sanz Juste, Marketta Sneider, Ankush Auradkar, Carissa Klanseck, Zhiqian Li, Alison Henrique Ferreira Julio, Victor Lopez del Amo, Ethan Bier and Annabel Guichard.

Support for the research was provided by the National Institutes of Health (grant R01 GM117321), a Paul G. Allen Frontiers Group Distinguished Investigators Award and a gift from the Tata Trusts in India to the Tata Institute for Genetics and Society (TIGS)-UC San Diego and TIGS India.

Competing interest note: Bier has equity interest in two companies he co-founded: Synbal Inc. and Agragene, Inc., which may potentially benefit from the research results. He also serves on Synbal’s board of directors and the scientific advisory board for both companies.

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JOURNAL

Science Advances

DOI

10.1126/sciadv.abo0721 

METHOD OF RESEARCH

Experimental study

SUBJECT OF RESEARCH

Animals

ARTICLE TITLE

Cas9/Nickase-induced allelic conversion by homologous chromosome-templated repair in Drosophila somatic cells

ARTICLE PUBLICATION DATE

1-Jul-2022

COI STATEMENT

Ethan Bier has equity interest in two companies he co-founded: Synbal Inc. and Agragene, Inc., which may potentially benefit from the research results. He also serves on Synbal’s board of directors and the scientific advisory board for both companies.

https://www.eurekalert.org/news-releases/956960

How Much Health Insurers Pay for Almost Everything Is About to Go Public

 Consumers, employers, and just about everyone else interested in health care prices will soon get an unprecedented look at what insurers pay for care, perhaps helping answer a question that has long dogged those who buy insurance: Are we getting the best deal we can?

As of July 1, health insurers and self-insured employers must post on websites just about every price they've negotiated with providers for health care services, item by item. About the only thing excluded are the prices paid for prescription drugs, except those administered in hospitals or doctors' offices.

The federally required data release could affect future prices or even how employers contract for health care. Many will see for the first time how well their insurers are doing compared with others.

The new rules are far broader than those that went into effect last year requiring hospitals to post their negotiated rates for the public to see. Now insurers must post the amounts paid for "every physician in network, every hospital, every surgery center, every nursing facility," said Jeffrey Leibach, a partner at the consulting firm Guidehouse.

"When you start doing the math, you're talking trillions of records," he said. The fines the federal government could impose for noncompliance are also heftier than the penalties that hospitals face.

Federal officials learned from the hospital experience and gave insurers more direction on what was expected, said Leibach. Insurers or self-insured employers could be fined as much as $100 a day for each violation, for each affected enrollee if they fail to provide the data.

"Get your calculator out: All of a sudden you are in the millions pretty fast," Leibach said.

Determined consumers, especially those with high-deductible health plans, may try to dig in right away and use the data to try comparing what they will have to pay at different hospitals, clinics, or doctor offices for specific services.

But each database's enormous size may mean that most people "will find it very hard to use the data in a nuanced way," said Katherine Baicker, dean of the University of Chicago Harris School of Public Policy.

At least at first.

Entrepreneurs are expected to quickly translate the information into more user-friendly formats so it can be incorporated into new or existing services that estimate costs for patients. And starting Jan. 1, the rules require insurers to provide online tools that will help people get upfront cost estimates for about 500 so-called "shoppable" services, meaning medical care they can schedule ahead of time.

Once those things happen, "you'll at least have the options in front of you," said Chris Severn, CEO of Turquoise Health, an online company that has posted price information made available under the rules for hospitals, although many hospitals have yet to comply.

With the addition of the insurers' data, sites like his will be able to drill down further into cost variation from one place to another or among insurers.

"If you're going to get an X-ray, you will be able to see that you can do it for $250 at this hospital, $75 at the imaging center down the road, or your specialist can do it in office for $25," he said.

Everyone will know everyone else's business: for example, how much insurers Aetna and Humana pay the same surgery center for a knee replacement.

The requirements stem from the Affordable Care Act and a 2019 executive order by then-President Donald Trump.

"These plans are supposed to be acting on behalf of employers in negotiating good rates, and the little insight we have on that shows it has not happened," said Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, an affiliation of employers who offer job-based health benefits to workers. "I do believe the dynamics are going to change."

Other observers are more circumspect.

"Maybe at best this will reduce the wide variance of prices out there," said Zack Cooper, director of health policy at the Yale University Institution for Social and Policy Studies. "But it won't be unleashing a consumer revolution."

Still, the biggest value of the July data release may well be to shed light on how successful insurers have been at negotiating prices. It comes on the heels of research that has shown tremendous variation in what is paid for health care. A recent study by the Rand Corp., for example, shows that employers that offer job-based insurance plans paid, on average, 224% more than Medicare for the same services.

Tens of thousands of employers who buy insurance coverage for their workers will get this more-complete pricing picture — and may not like what they see.

"What we're learning from the hospital data is that insurers are really bad at negotiating," said Gerard Anderson, a professor in the department of health policy at the Johns Hopkins Bloomberg School of Public Health, citing research that found that negotiated rates for hospital care can be higher than what the facilities accept from patients who are not using insurance and are paying cash.

That could add to the frustration that Mitchell and others say employers have with the current health insurance system. More might try to contract with providers directly, only using insurance companies for claims processing.

Other employers may bring their insurers back to the bargaining table.

"For the first time, an employer will be able to go to an insurance company and say, 'You have not negotiated a good-enough deal, and we know that because we can see the same provider has negotiated a better deal with another company,'" said James Gelfand, president of the ERISA Industry Committee, a trade group of self-insured employers.

If that happens, he added, "patients will be able to save money."

That's not necessarily a given, however.

Because this kind of public release of pricing data hasn't been tried widely in health care before, how it will affect future spending remains uncertain. If insurers are pushed back to the bargaining table or providers see where they stand relative to their peers, prices could drop. However, some providers could raise their prices if they see they are charging less than their peers.

"Downward pressure may not be a given," said Kelley Schultz, vice president of commercial policy for AHIP, the industry's trade lobby.

Baicker, of the University of Chicago, said that even after the data is out, rates will continue to be heavily influenced by local conditions, such as the size of an insurer or employer — providers often give bigger discounts, for example, to the insurers or self-insured employers that can send them the most patients. The number of hospitals in a region also matters — if an area has only one, for instance, that usually means the facility can demand higher rates.

Another unknown: Will insurers meet the deadline and provide usable data?

Schultz, at AHIP, said the industry is well on the way, partly because the original deadline was extended by six months. She expects insurers to do better than the hospital industry. "We saw a lot of hospitals that just decided not to post files or make them difficult to find," she said.

So far, more than 300 noncompliant hospitals received warning letters from the government. But they could face $300-a-day fines for failing to comply, which is less than what insurers potentially face, although the federal government has recently upped the ante to up to $5,500 a day for the largest facilities.

Even after the pricing data is public, "I don't think things will change overnight," said Leibach. "Patients are still going to make care decisions based on their doctors and referrals, a lot of reasons other than price."

https://www.medscape.com/viewarticle/976521

'Not Their Fault': Obesity Warrants Long-term Management

 I think it's important to remember and to think about the first time when patients with obesity come to see us: What have they faced? What have been their struggles? What shame and blame and bias have they faced?

One of the first things that I do when a patient comes to see me is I invite them to share their weight journey with me. I invite them to tell me about their struggles, about what's worked and what hasn't worked, what they would like, and what their health goals are.

As they share their stories, I look for the opportunity to share with them that obesity is not their fault, but that it's biology driving their body to carry extra weight and their body is super smart. Neither their body nor their brain want them to starve.

Our bodies evolved during a time where there was food scarcity and the potential of famine. We have a complex system that was designed to make sure that we always held on to extra weight, specifically extra fat, because that's how we store energy. In the current obesogenic environment, what happens is our bodies carry extra weight, or specifically, extra fat.

Again, I say to them, this is biology. Your body's doing exactly what it was designed to do. Your body's very smart, but now we have to figure out how to help your body want to carry less fat because it is impacting your health. This is not your fault. Having obesity is not your fault any more than having diabetes or hypertension is anyone's fault. Now it's time for all of us to use highly effective tools that target the pathophysiology of obesity.

When a patient comes to me for weight management or to help them treat their obesity, I listen to them and I look for clues as to what might help that specific patient. Every patient deserves to have individualized treatment. One medicine may be right for one person, another medicine may be right for another, and surgery may be right for another patient. I really try to listen and hear what that patient is telling me.

What we as providers really need is tools — different options — to be able to provide for our patients and basically present them with different options, and then guide them toward the best therapy for them. Whether it's semaglutide or tirzepatide potentially in the future, these types of medications are excellent options for our patients. They're highly effective tools with safe profiles.

A question that I often get from providers or patients is, "Well, Doctor, I've lost the weight now. How long should I take this medicine? Can I stop it now? I've lost the weight."

Then, we have a conversation, and we actually usually have this conversation even before we start the medicine. Basically, we talk about the fact that obesity is a chronic disease. There's no cure for obesity. Because it's a chronic disease, we need to treat it like we would treat any other chronic disease.

The example that I often use is, if you have a patient who has hypertension and you start them on an antihypertensive medication, what happens? Their blood pressure goes down. It improves. Now, if their blood pressure is improved with a specific antihypertensive, would you stop that medicine? What would happen if you stopped that antihypertensive? Well, their blood pressure would go up, and we wouldn't be surprised.

In the same way, if you have a patient who has obesity and you start that patient on an anti-obesity medication, and their weight decreases and their body fat mass at that point decreases, what would happen if you stop that medicine? They lost the weight, but you stop the medicine. Well, their weight gain comes back. They regain the weight.

We should not be surprised that weight gain occurs when we stop the treatment. That really underscores the fact that treatment needs to be continued. If a patient is started on an anti-obesity medication and they lose weight, that medication needs to be continued to maintain that weight loss.

Basically, we eat food and our body responds by releasing these hormones. The hormones are made in our gut and in our pancreas and these hormones inform our brain. Are we hungry? Are we full? Where are we with our homeostatic set point of fat mass? Based on that, our brain is like the sensor or the thermostat.

Obesity is a chronic, treatable disease. We should treat obesity as we treat any other chronic disease, with effective and safe approaches that target underlying disease mechanisms. These results in the SURMOUNT-1 trial underscore that tirzepatide may be doing just that. Remarkably, 9 in 10 individuals with obesity lost weight while taking tirzepatide. These results are impressive. They're an important step forward in potentially expanding effective therapeutic options for people with obesity.

Ania Jastreboff, MD, PhD is Associate Professor of Medicine and Pediatrics (Endocrinology and Metabolism and Pediatric Endocrinology), Yale University School of Medicine; Director of Weight Management and Obesity Prevention, Yale Stress Center; Co-Director of the Yale Center for Weight Management, Yale New Haven Hospital, New Haven, Connecticut

Disclosure: Ania Jastreboff, MD, PhD, has disclosed the following relevant financial relationship:
Conducts multicenter trials with: Eli Lilly; Novo Nordisk; Rhythm Pharmaceuticals
Serves on scientific advisory boards for: Eli Lilly; Intellihealth; Novo Nordisk; Pfizer; Rhythm Pharmaceuticals; and WW (formerly WeightWatchers)
Consults for: Boehringer Ingelheim; Scholar Rock

https://www.medscape.com/viewarticle/975213

Do Social Networks Really Threaten Adolescents' Mental Health?

 When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics (SFP), based on an increasing amount of scientific literature on the subject.

In 2021, 4.2 billion people, or more than half the world's population, used social networks, and 80.3% of French citizens had a social network account.

"Facebook Depression"

Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?

Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.

"Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: 'Facebook Depression,' " commented Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.

"But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use."

Teens' Fantasy Life

There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.

This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.

However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. "Thus, it isn't the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme," summed up Morgiève.

The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by "FOMO," or fear of missing out.

Hence the idea of defining a specific entity called "social network addiction," which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).

"Substitutive" use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.

Language of Distress

Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.

The very structure of the language (more words, more use of "I," more references to death, and fewer verbs) correlated with users in distress.

According to the authors, the typical social network practice of vaguebooking — writing a post that may incite worry, such as "better days are coming" — is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists — for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.

Internet Risks and Dangers

Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to "hang yourself."

Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.

Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.

Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.

A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.

The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.

"People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments)," explained Morgiève.

But in these communities, emotionally charged information that spreads rapidly and repetitively could promote co-rumination, hence the concept of "suicidocosme [suicide world]", developed in 2017 by Charles-Edouard Notredame, MD, of the Child and Adolescent Psychiatry Department at Lille University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.

Just one of many examples is Marilyn Monroe's suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).

Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae's TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.

Support on Social Networks?

Social networks can increase connectedness, i.e., the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.

The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users' social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.

Taking Facebook and its "anniversary" feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.

"Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it," stated Morgiève.

They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support."

An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group."

Promoting Access to Care

In Morgiève's opinion, "access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.

"There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame."

These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.

On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people's lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.

The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.

Morgiève summed it up by saying, "While offline life is silent because young people don't talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they're not doing in real life."

Professionals Go Digital

France records one suicide every hour (8885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance (PADS) programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc, have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 — with professionals who are available to listen 24 hours a day, 7 days a week — was launched by the Ministry of Health and Prevention last October.

Its values and principles include confidentiality, proactivity, concern and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400 to 500 calls a day. The dedicated chat application was co-designed with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word "suicide."

Morgiève states that she has no conflicts of interest regarding the subject presented.

https://www.medscape.com/viewarticle/976522