Tag Archives: Hospitalized

Roche arthritis drug cuts deaths in hospitalized COVID-19 patients, study suggests

Roche’s arthritis drug tocilizumab cuts the risk of death among patients hospitalized with severe COVID-19, also shortening the time to recovery and reducing the need for mechanical ventilation, results of a large trial showed on Thursday.

The findings — from the U.K.-based RECOVERY trial, which has been testing a range of potential treatments for COVID-19 since March 2020 — should help clear up confusion about whether tocilizumab has any benefit for COVID-19 patients after a slew of recent mixed trial results.

“We now know that the benefits of tocilizumab extend to all COVID patients with low oxygen levels and significant inflammation,” said Peter Horby, a professor of emerging infectious diseases at Oxford University and the joint lead investigator on the RECOVERY trial.

In June last year, the RECOVERY trial found that the cheap and widely available steroid dexamethasone reduced death rates by around a third among the most severely ill COVID-19 patients. That drug has since rapidly became part of standard-of-care recommended for severe patients.

Tocilizumab, sold under the brand name Actemra, is an intravenous anti-inflammatory monoclonal antibody drug used to treat rheumatoid arthritis. It was added to the trial in April 2020 for patients with COVID-19 who required oxygen and had evidence of inflammation.

The study included from 2,022 COVID-19 patients who were randomly allocated to receive tocilizumab by intravenous infusion, and who were compared with 2,094 patients randomly allocated to usual care alone. Researchers said 82 per cent of all patients were taking a systemic steroid such as dexamethasone.

Results showed that treatment with tocilizumab significantly reduced deaths — with 596 (29 per cent) of the patients in the tocilizumab group dying within 28 days, compared with 694 (33 per cent) patients in the usual care group.

This translates to an absolute difference of four per cent. It also means that for every 25 patients treated with tocilizumab, one additional life would be saved, Horby and his co-lead investigator Martin Landray said.

They added that benefits of tocilizumab were clearly seen to be in addition to those of steroids.

WATCH | Progress and setbacks in treating COVID-19:

While vaccines can prevent recipients from getting sick, finding and approving treatments for the virus has been difficult. 2:06

“Used in combination, the impact is substantial,” said Landray, who is also an Oxford professor of medicine and epidemiology.

Roche’s drug division chief Bill Anderson said last week that previous mixed results were likely due to differences in the type of patients studied, when they were treated, and the endpoint — the juncture at which success or failure is measured.

“We think we’re sort of zooming in on both the most relevant endpoints and relevant patient population,” Anderson said. “It seems like the ideal candidates are patients who are really in that acute phase of inflammatory attack.”

Drug used for some patients with COVID-19 in Canada

Actemra, along with Sanofi’s similar drug Kevzara, was authorized by Britain’s NHS in early January for COVID-19 patients in intensive care units after preliminary data from a smaller study called REMAP-CAP indicated it could reduce hospital stays by about 10 days.

The researchers said preliminary results will be made available on the medRxiv preprint server shortly and submitted to a peer-reviewed medical journal.

Dr. Niall Ferguson, head of critical care at Toronto’s University Health Network and Sinai Health System, sees potential in early data for tocilizumab, which is approved for use in Canada to treat rheumatoid arthritis.

Although evolving data has been mixed and is still emerging, Ferguson noted last week that the monoclonal antibody is already being used off-label for some severe patients in Toronto.

“It’s happening on a bit of an ad hoc basis when patients are caught at the right time and look like they may have a bit of
additional inflammation going on that could be set aside with this drug,” said Ferguson, who looks after the most severe COVID-19 cases at Toronto General Hospital.

Stephen Evans, a professor of pharmacoepidemiology at the London School of Hygiene & Tropical Medicine who was not directly involved in the U.K. trial, said its results were important.
 
“It is a large trial and the benefits were seen both on earlier discharge from hospital and mortality,” he said. “The 
magnitude of benefit is not startling but is clinically important, with a reduction in deaths from 33 per cent to 29 per cent.” 
 

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Former CNN talk show host Larry King hospitalized with COVID-19, network says

Former CNN talk show host Larry King has been hospitalized with COVID-19 for more than a week, the news channel reported Saturday.

Citing an unidentified person close to the family, CNN said the 87-year-old King is undergoing treatment at Cedars-Sinai Medical Center in Los Angeles.

Hospital protocols have kept King’s family members from visiting him.

The Peabody Award-winning broadcaster was among the United States’ most prominent interviewers of celebrities, presidents and other newsmakers during a half-century career that included 25 years with a nightly show on CNN.

He has had medical issues in recent decades, including heart attacks and diagnoses of diabetes and lung cancer.

Last year, King lost two of his five children within weeks of each other. Son Andy King died of a heart attack at 65 in August, and daughter Chaia King died from lung cancer at 51 in July, Larry King said then in a statement.

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Mystery illness in India has killed 1, hospitalized hundreds

At least one person has died and 200 others have been hospitalized due to an unidentified illness in the southern Indian state of Andhra Pradesh, reports said Monday.

The illness was detected Saturday evening in Eluru, an ancient city famous for its hand-woven products. Since then, patients have experienced symptoms ranging from nausea and anxiety to loss of consciousness, doctors said.

A 45-year-old man who was hospitalized with nausea and symptoms similar to epilepsy died Sunday evening, the Press Trust of India news agency reported.

Officials are trying to determine the cause of the illness. So far, water samples from impacted areas haven’t shown any signs of contamination, and the chief minister’s office said people not linked to the municipal water supply have also fallen ill.

The patients are of different ages and have tested negative for COVID-19 and other viral diseases such as dengue, chikungunya or herpes.

An expert team delegated by the federal government reached the city to investigate the sudden illness Monday.

State chief minister Y.S. Jagan Mohan Reddy visited a government hospital and met patients who were ill.

Opposition leader N. Chandrababu Naidu demanded on Twitter an “impartial, full-fledged inquiry into the incident.”

Andhra Pradesh state is among those worst hit by COVID-19, with more than 800,000 detected cases. The health system in the state, like the rest of India, has been frayed by the virus.

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WHO advises against treating hospitalized COVID-19 patients with remdesivir

Gilead’s remdesivir is not recommended for patients hospitalized with COVID-19, regardless of how ill they are, as there is no evidence the drug improves survival or reduces the need for ventilation, a World Health Organization panel said on Friday.

The panel found “a lack of evidence that remdesivir improved outcomes that matter to patients,” the guideline said.

“Especially given the costs and resource implications associated with remdesivir … the panel felt the responsibility should be on demonstrating evidence of efficacy, which is not established by the currently available data.”

The WHO said it has suspended remdesivir from its so-called prequalification list, an official list of medicines used as a benchmark for procurement by developing countries, after issuing the guidance.

“Yes we have suspended it from the PQ [prequalification list],” Tarik Jasarevic said in an emailed response to Reuters. “The suspension is a signal to countries that WHO, in compliance with the treatment guidelines, does not recommend countries procure the drug for COVID.”

The advice is another setback for the drug, which grabbed worldwide attention as a potentially effective treatment for COVID-19 in the summer after early trials showed some promise.

The antiviral, known by the brand name Veklury, is one of only two medicines currently authorized to treat COVID-19 patients across the world. But a large WHO-led trial known as the Solidarity Trial showed last month that it had little or no effect on 28-day mortality or length of hospital stays for COVID-19 patients.

The medication was one of the drugs used to treat U.S. President Donald Trump’s coronavirus infection, and had been shown in previous studies to have cut time to recovery. It is authorized or approved for use as a COVID-19 treatment in more than 50 countries. That includes Canada, where a limited number of patients have been treated with the drug under Health Canada’s Special Access Program.

Gilead has questioned the Solidarity Trial’s results and said in a statement on Friday it was “disappointed” at the new WHO guideline.

“Veklury is recognized as a standard of care for the treatment of hospitalized patients with COVID-19 in guidelines from numerous credible national organizations,” it said.

“The WHO guidelines appear to ignore this evidence at a time when cases are dramatically increasing around the world and doctors are relying on Veklury as the first and only approved antiviral treatment for patients with COVID-19.”

The WHO advice raises questions about whether the European Union will need the 500,000 courses of the antiviral, worth 1 billion euros ($ 1.86 billion Cdn), it ordered last month.

Italy’s drugs regulator, AIFA, said it had been “stressing for weeks the modest effectiveness of remdesivir.”

“In practice we have been saying for some time that it is not use for much,” the regulator said.

Expensive, no noticed impact on death rates

The WHO’s Guideline Development Group (GDG) panel said its recommendation was based on an evidence review that included data from four international randomized trials involving more than 7,000 patients hospitalized with COVID-19.

After reviewing the evidence, the panel said it concluded that remdesivir, which has to be given intravenously and is therefore costly and complex to administer, has no meaningful effect on death rates or other important outcomes for patients.

Peter Horby, a professor of emerging infectious diseases at Britain’s Oxford University, said the WHO’s new advice should prompt “a rethink about the place of remdesivir in COVID-19.”

“Remdesivir is an expensive drug that must be given intravenously for five to 10 days, so this recommendation will save money and other health-care resources,” he said.

At the end of October, Gilead cut its 2020 revenue forecast, citing lower-than-expected demand and difficulty in predicting sales of remdesivir.

The fresh advice also comes after one of the world’s top bodies representing intensive care doctors said remdesivir should not be used for COVID-19 patients in critical care.

The recommendation, which is not binding, is part of its so-called “living guidelines” project, designed to offer ongoing guidance for doctors. The panel said that it supported continued enrolment into clinical trials evaluating remdesivir in patients with COVID-19, which it said should “provide higher certainty of evidence for specific groups of patients.”

The European Commission on Friday said there had been no change in the authorized uses of remdesivir.

“We take note that the WHO has now updated its guidelines on the use of remdesivir,” a Commission spokesperson said in an email.

The European drugs regulator has requested full data from the WHO-led Solidarity trial into the drug and will assess the evidence, together with other available data, to see if any changes are needed to its market authorization, he said.

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Former U.S. presidential candidate Herman Cain dead after being hospitalized for coronavirus

Herman Cain, a Republican candidate for president in 2012, has died after being hospitalized with the coronavirus, according to a statement on his website and social media pages.

He was 74.

“We’re heartbroken, and the world is poorer: Herman Cain has gone to be with the Lord,” posts on his social media accounts said.

It’s not clear when or where Cain was infected, but he was hospitalized less than two weeks after attending U.S. President Donald Trump’s campaign rally on June 20 in Tulsa, Okla. Cain, not seen wearing a mask in available pictures of the event, did not meet with Trump there.

Cain had entered an Atlanta-area hospital for treatment on July 1.

“We knew when he was first hospitalized with COVID-19 that this was going to be a rough fight,” read an article posted on his Twitter account. “He had trouble breathing and was taken to the hospital by ambulance. We all prayed that the initial meds they gave him would get his breathing back to normal, but it became clear pretty quickly that he was in for a battle.”


In a condolence tweet Thursday, Trump described Cain as “a Powerful Voice of Freedom and all that is good.”

“Herman had an incredible career and was adored by everyone that ever met him, especially me,” Trump wrote. “He was a very special man, an American Patriot, and great friend.”

Surprise candidate

Cain briefly rose to the top of polls during the 2012 race for the Republican presidential nomination despite never having held political office by stressing the need to simplify the tax code with what he called the 9-9-9 plan.

On the campaign trail, he spoke about being diagnosed in 2006 with Stage 4 liver cancer and his doctors giving him slim hope for long-term survival. 

The Georgian eventually faded in the polls, with allegations of sexual harassment and an extramarital affair soon surfacing. He also stumbled on some debate answers when tested on his knowledge of U.S. foreign policy.

Mitt Romney, who emerged as the Republican nominee in that contest and now serves as Utah senator, helped lead the tributes to Cain on social media, calling him a “formidable champion of business, politics and policy.”

WATCH | Mitt Romney pays tribute to Herman Cain:

Cain ran against the Republican senator from Utah during the 2012 U.S. presidential race. 0:29

Democrat Ted Deutch of Florida said he was “shaken by Mr. Cain’s passing.”

“Like so many of the 150,000+ COVID-19 deaths in America, Herman Cain’s death was preventable, heartbreaking, senseless, and enraging,” said Deutch.

White House press secretary Kaleigh McEnany expressed her condolences, saying Cain “embodied the American Dream and represented the very best of the American spirit.”

Trump posited putting up Cain for a spot on the Federal Reserve Board in 2019 but after opposition arose, he was not put forth as a nominee. He had served as chair of the Federal Reserve Bank of Kansas City decades earlier.


Herman Cain shakes hands with Mitt Romney after a June 2011 debate in Manchester, N.H., as fellow candidates Ron Paul, second from left, and Tim Pawlenty look on. (Joel Page/Reuters)

Trump faced criticism for holding the big-arena event despite warnings from public health experts that it is not yet safe to hold mass gatherings.

More than 6,000 people attended the rally at the BOK Center. At least six campaign staffers and two members of the Secret Service working in advance of the Tulsa rally tested positive for coronavirus.

Cain kept involved in conservative politics recently as a commentator on Newsmax, which was the first media outlet to report his death on Thursday.

He is survived by his wife of 52 years, Gloria Etchison, and their children and grandchildren.

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U.S. Supreme Court Justice Ruth Bader Ginsburg hospitalized with possible infection

U.S. Supreme Court Justice Ruth Bader Ginsburg was being treated for a possible infection and was expected to stay in the hospital for a few days following a medical procedure, the court said in a statement Tuesday.

The court said that the 87-year-old Ginsburg went to a hospital in Washington on Monday evening after experiencing fever and chills. She then underwent a procedure at Johns Hopkins Hospital in Baltimore on Tuesday afternoon to clean out a bile duct stent that was placed last August, when she was treated for a cancerous tumour on her pancreas.

The statement said the justice “is resting comfortably and will stay in the hospital for a few days to receive intravenous antibiotic treatment.”

Ginsburg spent a night in the hospital in May with an infection caused by a gallstone. While in the hospital, she participated in arguments the court heard by telephone because of the coronavirus pandemic.

Ginsburg, who was appointed by former president Bill Clinton and joined the court in 1993, has been treated four times for cancer. In addition to the tumour on her pancreas last year, she was previously treated for colorectal cancer in 1999 and pancreatic cancer in 2009. She had lung surgery to remove cancerous growths in December 2018.

Speaking at a news conference in the Rose Garden on Tuesday evening, U.S. President Donald Trump was asked about Ginsburg. He said he hadn’t heard she had been hospitalized.

“I wish her the best. I hope she’s better,” Trump said.

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U.S. Supreme Court says Justice Ruth Bader Ginsburg hospitalized with infection

Justice Ruth Bader Ginsburg was hospitalized Tuesday with an infection caused by a gallstone, but plans to take part in the court’s arguments by telephone Wednesday, the U.S. Supreme Court said.

The 87-year-old justice underwent non-surgical treatment for what the court described as acute cholecystitis, a benign gall bladder condition, at Johns Hopkins Hospital in Baltimore, Md.

She is resting comfortably and expects to be in the hospital for a day or two, the court said.

Ginsburg took part in the court’s telephone arguments Monday and Tuesday. She initially sought medical care Monday, when the gallstone was first diagnosed.

She has been treated four times for cancer, most recently in August, when she underwent radiation for a tumour on her pancreas.

Her most recent hospital stay was in November, when she spent two nights at Johns Hopkins with a likely infection after suffering from chills and fever.

The frail-looking liberal icon also bounced back from lung surgery to remove cancerous growths in December 2018. Her recovery from that surgery forced her to miss court arguments for the first time since she became a justice in 1993, appointed by President Bill Clinton.

She has been doing her usual workout with a personal trainer at the court, even as the justices have cancelled courtroom arguments in favour of telephone sessions because of the coronavirus pandemic.

Ginsburg has said she would like to serve until she’s 90, if her health allows.

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Ryan Newman hospitalized after fiery crash at Daytona 500

Ryan Newman flipped across the finish line, his Ford planted upside down and engulfed in flames, a grim reminder of a sport steeped in danger that has stretched nearly two decades without a fatality.

At the finish line, Denny Hamlin made history with a second straight Daytona 500 victory in an an overtime photo-finish over Ryan Blaney, a celebration that quickly became muted as word of Newman’s wreck spread.

“I think we take for granted sometimes how safe the cars are,” Hamlin said. “But number one, we are praying for Ryan.”

Roughly two hours after the crash, NASCAR read a statement from Roush Fenway Racing that said Newman is in “serious condition, but doctors have indicated his injuries are not life threatening.”

WATCH | Ryan Newman involved in terrifying crash at Daytona 500:

Ryan Newman was leading the race when he was involved in a crash that sent his car spinning before it caught on fire. 2:08

NASCAR scrapped the traditional victory lane party for Hamlin’s third Daytona 500 victory, rocked by Newman’s accident 19 years after Dale Earnhardt was killed on the last lap of the 2001 Daytona 500. Earnhardt was the last driver killed in a NASCAR Cup Series race.

Newman had surged into the lead on the final lap when Blaney’s bumper caught the back of his Ford and sent Newman hard right into the wall. His car flipped, rolled, was hit on the driver’s side by another car, and finally skidded across the finish line in flames.

It took several minutes for his car to be rolled back onto its wheels. The 2008 Daytona 500 winner was placed in a waiting ambulance and taken directly to a hospital, and the damage to his Mustang was extensive. It appeared the entire roll cage designed to protect his head had caved.


Drivers were stricken with concern, including a rattled Corey LaJoie, the driver who hit Newman’s car as it was flipping.

“Dang, I hope Newman is ok,” he posted on Twitter. “That is [the] worst case scenario and I had nowhere to go but [into the] smoke.”

Hamlin is the first driver since Sterling Marlin in 1995 to win consecutive Daytona 500s, but his celebration in victory lane was subdued.

Hamlin said he was unaware of Newman’s situation when he initially began his celebration. It wasn’t until Fox Sports told him they would not interview him on the frontstretch after his burnouts that Hamlin learned Newman’s incident was bad.

“It’s a weird balance of excitement and happiness for yourself, but someone’s health and their family is bigger than any win in any sport,” he said. “We are just hoping for the best.”

Team owner Joe Gibbs apologized after the race for the winning team celebration.

“We didn’t know until victory lane,” Gibbs said. “I know that for a lot of us, participating in sports and being in things where there are some risks, in a way, that’s what they get excited about. Racing, we know what can happen, we just dream it doesn’t happen. We are all just praying now for the outcome on this.”

Runner-up Blaney said the way the final lap shook out, with Newman surging ahead of Hamlin, that Blaney got a push from Hamlin that locked him in behind Newman in a move of brand alliance for Ford.

“We pushed Newman there to the lead and then we got a push from the 11 … I was committed to just pushing him to the win and having a Ford win it and got the bumpers hooked up wrong,” he said. “It looked bad.”


Track workers attend to Ryan Newman, driver of the #6 Koch Industries Ford, following a crash during the NASCAR Cup Series 62nd Annual Daytona 500. (Mike Ehrmann/Getty Images)

Hamlin had eight Ford drivers lined up behind him as the leader on the second overtime shootout without a single fellow Toyota driver in the vicinity to help him. It allowed Newman to get past him for the lead, but the bumping in the pack led to Newman’s hard turn right into the wall, followed by multiple rolls and a long skid across the finish line.

Hamlin’s win last year was a 1-2-3 sweep for Joe Gibbs Racing and kicked off a yearlong company celebration in which Gibbs drivers won a record 19 races and the Cup championship. Now his third Daytona 500 win puts him alongside six Hall of Fame drivers as winners of three or more Daytona 500s. He tied Dale Jarrett — who gave JGR its first Daytona 500 win in 1993 — Jeff Gordon and Bobby Allison. Hamlin trails Cale Yarborough’s four wins and the record seven by Richard Petty.

This victory came after just the second rain postponement in 62 years, a visit from President Donald Trump, a pair of red flag stoppages and two overtimes. The 0.014 margin of victory was the second closest in race history, and Hamlin’s win over Martin Truex Jr. in 2016 was the closest finish in race history.

That margin of victory was 0.01 seconds. The win in “The Great American Race” is the third for Toyota, all won by Hamlin. Gibbs has four Daytona 500 victories as an owner.

“I just feel like I’m a student to the game. I never stop learning and trying to figure out where I need to put myself at the right time,” Hamlin said. “It doesn’t always work. We’ve defied odds here in the last eight years or so in the Daytona 500, but just trust my instincts, and so far they’ve been good for me.”

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Prince Philip hospitalized in London as ‘precautionary measure’

Prince Philip, the 98-year-old husband of Queen Elizabeth, was taken to a hospital in London on Friday as a “precautionary measure” for treatment for a pre-existing condition, Buckingham Palace said on Friday.

“The Duke of Edinburgh travelled from Norfolk this morning to the King Edward VII Hospital in London for observation and treatment in relation to a pre-existing condition,” the palace said in a statement.

“The admission is a precautionary measure, on the advice of his royal highness’s doctor.”

Philip, who has been at his wife’s side throughout her record 67 years on the throne, retired from public life in August 2017, although he has occasionally appeared at official engagements.

He has not been seen in public since the wedding of Elizabeth’s first cousin once removed, Gabriella Windsor, in May at Windsor Castle, local media reported.

72nd anniversary last month

The Queen, 93, carried out the official opening of Parliament on Thursday and Philip’s illness did not disrupt her plans. She was pictured arriving in Norfolk on Friday before heading to Sandringham, where the Royal Family traditionally gathers for Christmas.

Philip spent Christmas in 2011 in hospital after an operation to clear a blocked artery in his heart and missed the end of celebrations to mark his wife’s 60th year on the throne in 2012 after being hospitalized with a bladder infection.

Last year, he spent 10 days in hospital following hip replacement surgery.

In January this year, he escaped unhurt when his Land Rover car flipped over after a collision with another car close to the royals’ Sandringham estate in Norfolk.

Buckingham Palace said soon after that the duke had voluntarily surrendered his licence “after careful consideration.”

Elizabeth has described Philip — they married at London’s Westminster Abbey in 1947 — as her “strength and stay” during her long reign. They celebrated their 72nd wedding anniversary in November.

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Thousands of young people hospitalized due to cannabis and other substance use, report reveals

About 65 young people in Canada per day land in hospital because of harm caused by cannabis, alcohol, opioids and other substances, according to a new report.

Clinicians and a former user say the findings from the Canadian Institute for Health Information (CIHI) highlight the desperate need for more community supports to help those with mental health concerns.

The institute released the report, titled “Hospital stays for harm caused by substance use among youth age 10 to 24,” on Thursday. The figures present a snapshot of the hospital stays in those age groups in 2017-2018, before the legalization of cannabis.

Last year, more than 23,500 youth were hospitalized for harm from substance use, the report says. In comparison, about 8,000 were hospitalized for illnesses related to the appendix. 

The findings highlight the need to focus attention on youth who experience harm caused by substance use and have mental health conditions occurring at the same time, as well as those who live in lower-income or rural and remote areas, the report’s authors said.

Cannabis accounted for nearly 40 per cent of those hospital stays among youth, followed by alcohol-related hospitalizations at about 26 per cent.

Missed opportunities

Dr. Joanna Henderson, a psychologist and senior scientist at the Centre for Addiction and Mental Health in Toronto, says the report shows perspectives on substance abuse need to expand, especially when nearly 70 per cent of the hospitalizations for harm caused by substance use involve mental health conditions, as well.

That’s nearly double the proportion among those aged 25 and older.

“We need adequate services in the hospital but we also need to be thinking about how are we intervening sooner,” said Henderson, who was not involved in the research.

“We are missing opportunities like schools, local malls … where young people are.”

Young people need places in communities that are one-stop shops to connect them with employment, education, housing and health services, including mental health and substance use, she said.

‘You’re not alone’

Lucas Wade, 31, first started smoking cannabis at 17 “out of peer pressure,” he said.  At age 20, he was toking daily for pleasure along with boozing. 

“I was admitted to hospital after my roommate found me after trying to suicide because I couldn’t stop smoking pot, no matter what,” Wade said. “I couldn’t keep living that way.”

Wade ended up homeless when a landlord evicted him for smoking indoors after signing a contract saying he wouldn’t.

Wade studied social work and now works as a support counselor in Toronto, where he sees many youth with underlining mental health issues using substances as a coping mechanism.

The first step is to talk to someone close to you, such as a best friend, parent or sibling, Wade said.


(CIHI)

“If you’re the youth, find a safe space or people where you can share and talk about this stuff because it is so hard. When you’re in the throes of it, you feel so alone. You’re not alone.”

Previous research suggests young people with pre-existing mental health concerns can be at higher risk for problematic substance use and it occur in the other direction as well, Henderson said.

It’s important not only to collect consistent data across Canada regularly to find any changes but to speak to young people about their experience with how services are delivered, she added.

About 17 per cent of the youth were hospitalized more than once in the same fiscal year, according to CIHI. That’s another red flag for the need for better community supports, clinicians say.

Hospitalization rates varied by province and territory. The hospital stays are “the tip of the iceberg when it comes to estimating harm caused by substance use,” CIHI said, and doesn’t include fatal overdoses in the community.

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