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MidMichigan Health Foundation recently received a $10,000 funding commitment from the cialis online us John A. And Audrey Brown Memorial Endowment Fund cialis online us housed at Clare County Community Foundation to fund an educational program.Students in sixth grade grade at Clare Public Schools will receive education on nutrition and physical activity to empower them to make informed, science-based decisions on lifestyle choices from a young age. The program’s goal is to provide healthy lifestyle knowledge that reduces risks for development of obesity, type 2 diabetes, hypertension and some other cardiac cialis online us diseases.Obesity is directly linked with type 2 diabetes and adult hypertension and heart disease.

According to the State of Childhood Obesity, the national average obesity rate among kids aged 10 to 17 is 15.5 percent, and Michigan’s rate is 17.3 percent, ranking Michigan 12 out of 50 states and Washington, D.C.Jeri Brown, R.N., C.D.C.E.S., diabetes educator, MidMichigan Medical Center- Clare, is looking forward to getting back to in-person education sessions in the fall of 2021 cialis online us. €œOur Clare cialis online us County students enjoy this program,” she said. €œWe want to make sure they are equipped with the proper information so they are able to build lifelong healthy habits.”The program provides information to students in a fun, hands-on way by demonstrating portion sizes, and helps them to create their own healthy snacks using guidelines for things like calories and fat.About Clare County Community FoundationThe Clare County Community Foundation strengthens our community by providing leadership, fostering collaboration on local needs and cialis online us issues, and encouraging a legacy of giving through grants, scholarships and events.Adam Heinemann, D.O., has been named medical director for the Wound Treatment and Hyperbaric Medicine Center at MidMichigan Medical Center – Alpena.Adam Heinemann, D.O., has been named medical director for the Wound Treatment and Hyperbaric Medicine Center at MidMichigan Medical Center – Alpena.Dr.

Heinemann has been caring for patients in the Medical Center’s Emergency Department for more than two years and cialis online us will continue in that role in addition to seeing patients in the Wound Treatment and Hyperbaric Medicine Center. Dr. Heinemann earned a doctor of medicine degree at Michigan State University College of Osteopathic Medicine and completed his residency in emergency medicine at Ohio Valley Medical Center in Wheeling, West Virginia.

He has completed intensive training in wound treatment and recently received his certification to supervise hyperbaric medicine.“My interest in wound care began in 2009 when I was fortunate to shadow Dr. Kevin Florek, the director of the wound care center at Crittenton Hospital in Rochester, Michigan,” said Dr. Heinemann.

€œThis experience allowed me a glimpse of life changing treatments administered in the office where both an immediate and long term difference can be seen.”Dr. Heinemann joins full-time provider, Jacob Straley, A.G.A.C.N.P.-B.C., M.S.N., who specializes in wound treatment and hyperbaric medicine and is board certified in gerontology.The Wound Treatment Center focuses on treating chronic wounds that have not healed within 30 days of conventional treatment. It follows clinically proven protocols that have led to 98.76 percent patient satisfaction and a median time to heal of 28 days.

Treatment options include hyperbaric oxygen therapy, debridement, dressings, medications, patient education and other advanced applications. A multidisciplinary team coordinates care for any underlying conditions such as diabetes or vascular disease that may impact healing. The Center has a partnership with Healogics, the nation’s leading wound care management company, which provides consulting services to more than 500 hospitals across the United States.The Center also provides hyperbaric oxygen (HBO) treatment for emergency conditions, such as carbon monoxide poisoning or decompression sickness.

It is one of only three facilities in Michigan and the only one in Northern Michigan designated for emergent HBO therapy.Those who would like more information may call (989) 356-8075 or visit www.midmichigan.org/wound..

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Police have recovered the body of a missing Hudson Valley man.The 32-year-old Orange County buy cialis through paypal resident cialis precio walmart went missing around 7 p.m. On Sunday, June 27 in Port Jervis, in the cialis precio walmart area of Laurel Grove Cemetery at a popular swimming hold called "Goose Rock." When officers responded, witnesses reported that the swimmer was last seen floating towards the middle of the river towards the I-84 Bridge when he submerged underwater and never resurfaced, said Port Jervis Police Chief William. Worden.Fire Department divers from multiple agencies were deployed and conducted a search of the river for the man.The search was suspended prior to darkness on Sunday, and fire department divers resumed searching for the victim on Monday, June 28, with the aid of search dogs.At approximately 11:45 a.m., Monday, cialis precio walmart June 28, divers located the man approximately 60 feet from shore in a depth of around 12 feet of water. Police and fire officials are withholding the name of the decedent until family members are notified cialis precio walmart.

An investigation into the incident is cialis precio walmart ongoing by Port Jervis City Police Detectives with the assistance of the Orange County Medical Examiner’s OfficeAnyone with information can contact the Port Jervis City Police Detective unit at 845-858-4003. Click here to sign up for Daily Voice's free daily emails and news alerts..

Police have recovered the body of a missing cialis online us Hudson Valley man.The 32-year-old Orange County resident went missing around 7 p.m. On Sunday, June 27 in Port Jervis, in the area of Laurel Grove Cemetery at a popular swimming hold called "Goose Rock." When officers responded, witnesses reported that the swimmer was cialis online us last seen floating towards the middle of the river towards the I-84 Bridge when he submerged underwater and never resurfaced, said Port Jervis Police Chief William. Worden.Fire Department divers from multiple agencies were deployed and conducted a search of the river for the man.The search was suspended prior to darkness on Sunday, and fire department divers resumed searching for the victim on Monday, June 28, with the aid of search dogs.At approximately 11:45 cialis online us a.m., Monday, June 28, divers located the man approximately 60 feet from shore in a depth of around 12 feet of water. Police and fire officials are withholding the name of the decedent cialis online us until family members are notified. An investigation cialis online us into the incident is ongoing by Port Jervis City Police Detectives with the assistance of the Orange County Medical Examiner’s OfficeAnyone with information can contact the Port Jervis City Police Detective unit at 845-858-4003.

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People in Aboriginal communities across NSW will have access to expanded suicide prevention support thanks to an investment of $7.7 cialis and skin cancer million from the NSW Government.Minister for Mental Health http://bretmwebb.com/?p=53 Bronnie Taylor said the funding would enable 12 community organisations to deliver culturally appropriate suicide prevention activities. €œIn Aboriginal communities, there is a growing body of evidence around the healing power of culture when it comes to mental health issues and suicide prevention,” Mrs Taylor said. €œThis funding will support community-led and culturally appropriate initiatives to tackle these important issues.“These new programs will involve Elders and focus on building identity and connection, as well as helping Aboriginal cialis and skin cancer people access mental health services.” The funding has been allocated to 12 Aboriginal Community Controlled Health Organisations (ACCHOs) which can use the funds flexibly for a combination of grassroots community activities and clinical services. Suicide is the fourth leading cause of death for Indigenous Australians living in NSW, compared to 17th for non-Indigenous Australians. Minister for Aboriginal Affairs Don Harwin praised cialis and skin cancer the initiative and echoed the importance of targeted efforts to address the issue within Aboriginal communities.

€œToo many Aboriginal families in NSW are sadly impacted by suicide,” Mr Harwin said. €œI’m heartened that as part of the NSW Government’s Towards Zero Suicides strategy, this important investment will enable Aboriginal Community Controlled Health Organisations to deliver services to support the mental health and social and emotional wellbeing of our Aboriginal people and communities across the State.” Tharawal Aboriginal Medical Services in Campbelltown is one of the ACCHOs to receive funding and CEO Darryl Wright said he wants to see the next generation flourish. €œThis funding will go towards reducing cialis and skin cancer the intergenerational grief and trauma that still impacts our youth today. For every family that we can help heal and nourish, our community will grow stronger and our futures glow brighter," Mr Wright said. Building on Resilience in Aboriginal Communities is part of Towards Zero Suicides, a NSW Premier’s Priority and NSW Government investment of $87 million over three years in new and exisiting cialis and skin cancer suicide prevention initiatives.

If you, or someone you know, is thinking about suicide or experiencing a personal crisis or distress, please seek help immediately by calling 000 or one of these services. Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental Health Line 1800 011 511 ​​.

People in Aboriginal communities across NSW will have access to expanded suicide prevention support thanks to an best price cialis 20mg investment of $7.7 cialis online us million from the NSW Government.Minister for Mental Health Bronnie Taylor said the funding would enable 12 community organisations to deliver culturally appropriate suicide prevention activities. €œIn Aboriginal communities, there is a growing body of evidence around the healing power of culture when it comes to mental health issues and suicide prevention,” Mrs Taylor said. €œThis funding will support community-led and culturally appropriate initiatives to tackle these important issues.“These new programs will involve Elders and focus on building identity and connection, as well as helping Aboriginal people access mental health services.” The funding has been allocated cialis online us to 12 Aboriginal Community Controlled Health Organisations (ACCHOs) which can use the funds flexibly for a combination of grassroots community activities and clinical services. Suicide is the fourth leading cause of death for Indigenous Australians living in NSW, compared to 17th for non-Indigenous Australians.

Minister for cialis online us Aboriginal Affairs Don Harwin praised the initiative and echoed the importance of targeted efforts to address the issue within Aboriginal communities. €œToo many Aboriginal families in NSW are sadly impacted by suicide,” Mr Harwin said. €œI’m heartened that as part of the NSW Government’s Towards Zero Suicides strategy, this important investment will enable Aboriginal Community Controlled Health Organisations to deliver services to support the mental health and social and emotional wellbeing of our Aboriginal people and communities across buy cialis online the State.” Tharawal Aboriginal Medical Services in Campbelltown is one of the ACCHOs to receive funding and CEO Darryl Wright said he wants to see the next generation flourish. €œThis funding will go towards reducing the intergenerational grief and trauma that still impacts cialis online us our youth today.

For every family that we can help heal and nourish, our community will grow stronger and our futures glow brighter," Mr Wright said. Building on Resilience in Aboriginal Communities is part of Towards Zero Suicides, a NSW Premier’s Priority and cialis online us NSW Government investment of $87 million over three years in new and exisiting suicide prevention initiatives. If you, or someone you know, is thinking about suicide or experiencing a personal crisis or distress, please seek help immediately by calling 000 or one of these services. Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental Health Line 1800 011 511 ​​.

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IntroductionIn recent years, many studies have been published buy cialis 10mg uk on new diagnostic possibilities and management approaches in cohorts of patients suspected to have a disorder/difference of sex development (DSD).1–13 Based on these studies, it has become clear that services and institutions still differ how long does cialis work in the composition of the multidisciplinary teams that provide care for patients who have a DSD.11 14 Several projects have now worked to resolve this variability in care. The European Cooperation in Science and Technology (EU COST) action BM1303 ‘A systematic elucidation of differences of sex development’ has been a platform to achieve European agreement on harmonisation of clinical management and laboratory practices.15–17 Another such initiative involved an update of the 2006 DSD consensus document by an international group of professionals and patient representatives.18 These initiatives have highlighted how cultural and financial aspects and the availability of resources differ significantly between countries and societies, a situation that hampers supranational agreement on common diagnostic protocols. As only a few national guidelines have been published in international journals, comparison of these guidelines is difficult even though such a comparison is necessary to capture the differences and initiate actions to overcome them how long does cialis work. Nonetheless, four DSD (expert) centres located in the Netherlands and Flanders (the Dutch-speaking Northern part of Belgium) have collaborated to produce a detailed guideline on diagnostics in DSD.19 This shows that a supranational guideline can be a reasonable approach for countries with similarly structured healthcare systems and similar resources. Within the guideline there is agreement that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only how long does cialis work a few centres and by centralising pathological review of gonadal tissues.

International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which DSD is embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical aspect of the genitalia indicating a possible DSD is becoming increasingly common, and we discuss appropriate how long does cialis work counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 Furthermore, informing patients and/or their parents about atypical sex development and why this may warrant referral to a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers. Moreover, this enables DSD specialists to refer to the guideline when how long does cialis work advising a referral. Transition from the prenatal to the postnatal team and from the paediatric to the adult team requires optimal communication between the specialists involved.

Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and classification of removed gonadal tissue is challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an interdisciplinary multicentre group was formed with all members responsible for updating the literature for a how long does cialis work specific part of the guideline. Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line with the Clinical Practice how long does cialis work Advisory Document method described by Burke et al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper.

Abstracts had to be written in English and were identified using a broad range of Medical how long does cialis work Subject Headings terms (eg, DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, 46,XY DSD, guideline, multidisciplinary care). Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports were excluded, as were how long does cialis work articles that were not open access or retrievable through institutional access. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft was discussed by the writing committee how long does cialis work and, after having obtained agreement on remaining points of discussion, revised into a final draft.

This version was sent to a broad group of professionals from academic centres and DSD teams whose members had volunteered to review the draft guideline. After receiving and incorporating their input, the final version was presented to the paediatric and genetic associations for approval. After approval by the members of the paediatric (NVK), clinical genetic (VKGN) and genetic laboratory (VKGL) associations, the guideline was published on their respective websites.19 Although Turner syndrome and Klinefelter syndrome are considered to be how long does cialis work part of the DSD spectrum, they are not extensively discussed in this diagnostic guideline as guidelines dedicated to these syndromes already exist.25 26 However, some individuals with Turner syndrome or Klinefelter syndrome may present with ambiguous or atypical genitalia and may therefore initially follow the DSD diagnostic process.Guideline highlightsPrenatal settingPresentationThe most frequent prenatal presentation of a DSD condition is atypical genitalia found on prenatal ultrasound as an isolated finding or in combination with other structural anomalies. This usually occurs after the 20-week routine medical ultrasound for screening of congenital anomalies, but may also occur earlier, for example, when a commercial ultrasound is performed at the request of the parents.Another way DSD can be diagnosed before birth is when invasive prenatal genetic testing carried out for a different reason, for example, due to suspicion of other structural anomalies, reveals a discrepancy between the genotypic sex and the phenotypic sex seen by ultrasound. In certified laboratories, the possibility of a how long does cialis work sample switch is extremely low but should be ruled out immediately.

More often, the discrepancy will be due to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive prenatal testing (NIPT), which is now available to high-risk pregnant women in the Netherlands and to all pregnant women in Belgium, and later ultrasound findings. NIPT screens for CNVs in how long does cialis work the fetus. However, depending on legal restrictions and/or ethical considerations, the X and Y chromosomes are not always included in NIPT analysis and reports. If the X and Y chromosomes are included, it is important to realise that the presence of a Y-chromosome does how long does cialis work not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague prenatal specialists working with or in a DSD team.

After confirming an atypical genital on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To enable the parents to make a how long does cialis work well-informed decision, prenatal counselling should, in our opinion, include. Information on the ultrasound findings and the limitations of this technique. The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the how long does cialis work type of information genetic testing can and cannot provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved.

The clinical geneticist should be experienced in prenatal counselling and well informed about the diagnostic possibilities given the limited time span in which how long does cialis work test results need to be available to allow parents to make a well-informed decision about whether or not to continue the pregnancy. Termination of pregnancy can be considered, for instance, in a syndromic form of DSD with multiple malformations, but when the DSD occurs as an apparently isolated condition, expecting parents may also consider termination of pregnancy, which, although considered controversial by some, is legal in Belgium and the Netherlands. The psychologist of the DSD team can support parents during and after pregnancy and help how long does cialis work them cope with feelings of uncertainty and eventual considerations of a termination of pregnancy, as well as with practical issues, for example, how to inform others. The stress of not knowing exactly what the child’s genitalia will look like and uncertainty about the diagnosis, treatment and prognosis cannot be avoided completely. Parents are informed that if the postnatal phenotype is different from what was prenatally expected, the advice how long does cialis work given about diagnostic testing can be adjusted accordingly, for example, if a hypospadias is milder than was expected based on prenatal ultrasound images.

In our experience, parents appreciate having already spoken to some members of the DSD team during pregnancy and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, umbilical cord blood is how long does cialis work a good source for (molecular) karyotyping and storage of DNA and can be obtained by the obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 23 and midwives and staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array. It was recently estimated that >30% of individuals who have a DSD have additional structural anomalies, with cardiac how long does cialis work and neurological anomalies and fetal growth restriction being particularly common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS.

NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and we propose completing the analysis well before the how long does cialis work expected delivery.Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 1 Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing.First contact by a professional less experienced in DSDWhereas most current guidelines start from the point when an individual has been referred to the DSD team,1 15 the Dutch-Flemish guideline dedicates a chapter to healthcare professionals less experienced in DSD as they are often the first to suspect or identify such a condition. Apart from the paper of Indyk,7 little guidance is available for these professionals about how to act in such a situation. The chapter in the Dutch-Flemish guideline summarises the various clinical presentations that a DSD can have and provides information on how to communicate with parents and/or patients about the findings of the physical examination, the first-line investigations and the need for prompt referral to a specialised centre for further evaluation. Clinical examples are offered to illustrate some of these recurring situations.

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline. Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively.

Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing.

CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone." data-icon-position data-hide-link-title="0">Figure 2 46,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia.

AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 3 46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing.Very recently, a European position paper has been published focusing on the genetic workup of DSD.16 It highlights the limitations and drawbacks of NGS-based tests, which include the chance of missing subtle structural variants such as CNVs and mosaicism and the fact that NGS cannot detect methylation defects or other epigenetic changes.16 28 31 Targeted DNA analysis is preferred in cases where hormonal investigations suggest a block in steroidogenesis (eg, 11-β-hydroxylase deficiency, 21-hydroxylase deficiency), or in the context of a specific clinical constellation such as the often coincidental finding of Müllerian structures in a boy with normal external genitalia or cryptorchidism, that is, persistent Müllerian duct syndrome.33 34 Alternative tests should also be considered depending on the available information. Sometimes, a simple mouth swab for FISH analysis can detect mosaic XY/X in a male with hypospadias or asymmetric gonadal development or in a female with little or no Turner syndrome stigmata and a normal male molecular karyotyping profile or peripheral blood karyotype. Such targeted testing avoids incidental findings and is cheaper and faster than analysis of a large NGS-based panel, although the cost difference is rapidly declining.However, due to the genetic and phenotypic heterogeneity of DSD conditions, the most cost-effective next steps in the majority of cases are whole exome sequencing followed by panel analysis of genes involved in genital development and function or trio-analysis of a large gene panel (such as a Mendeliome).16 35–38 Pretest genetic counselling involves discussing what kind of information will be reported to patients or parents and the chance of detecting VUS, and the small risk of incidental findings when analysing a DSD panel should be mentioned. Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences.

If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing. Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites.

Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another. This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

How should we deal with the frequent findings of mainly unique VUS or class 3 variants (ACMG recommendation) in the many different DSD-related genes in the diagnostic setting?. Reporting VUS can be a source of uncertainty for parents, but not reporting these variants precludes further investigations to determine their possible pathogenicity. It can also be difficult to prove variant pathogenicity, both on gene-level and variant-level.39 Moreover, given the gonad-specific expression of some genes and the variable phenotypic spectrum and reduced penetrance, segregation analysis is not always informative. A class 3 variant that does not fit the clinical presentation may be unrelated to the observed phenotype, but it could also represent a newly emerging phenotype. This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD.

In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring. This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise.

For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time. Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres.

Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions. One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

This will enable highly individualised holistic care tailored to the patient’s needs and expectations. Once they are well-informed of all available options, parents and/or patients can choose what they consider the optimal care for their children or themselves.15 16ConclusionThe Dutch-Flemish guideline uniquely addresses some topics that are under-represented in the literature, thus adding some key aspects to those addressed in recent consensus papers and guidelines.15–17 33 47As more children with a DSD are now being identified prenatally, and the literature on prenatal diagnosis of DSD remains scarce,20 21 we propose a prenatal diagnostic algorithm and emphasise the importance of having a prenatal specialist involved in or collaborating with DSD (expert) centres.We also stress that good communication between all involved parties is essential. Professionals should be well informed about protocols and communication. Collaboration between centres is necessary to optimise aspects of care such as uniform interpretation of gonadal pathology and functional testing of class 3 variants found by genetic testing. Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline.

Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543..

IntroductionIn recent years, many studies have been published on new diagnostic possibilities and management approaches in cohorts of patients suspected to have a disorder/difference of sex development (DSD).1–13 Based on these studies, cialis online us it has become clear that services and institutions still differ in the composition of the multidisciplinary teams that provide care for patients who have a DSD.11 14 Several projects have now worked to resolve this variability in care. The European Cooperation in Science and Technology (EU COST) action BM1303 ‘A systematic elucidation of differences of sex development’ has been a platform to achieve European agreement on harmonisation of clinical management and laboratory practices.15–17 Another such initiative involved an update of the 2006 DSD consensus document by an international group of professionals and patient representatives.18 These initiatives have highlighted how cultural and financial aspects and the availability of resources differ significantly between countries and societies, a situation that hampers supranational agreement on common diagnostic protocols. As only a few national guidelines have cialis online us been published in international journals, comparison of these guidelines is difficult even though such a comparison is necessary to capture the differences and initiate actions to overcome them. Nonetheless, four DSD (expert) centres located in the Netherlands and Flanders (the Dutch-speaking Northern part of Belgium) have collaborated to produce a detailed guideline on diagnostics in DSD.19 This shows that a supranational guideline can be a reasonable approach for countries with similarly structured healthcare systems and similar resources. Within the guideline there is agreement that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only a few centres and by centralising cialis online us pathological review of gonadal tissues.

International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which DSD is embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical cialis online us aspect of the genitalia indicating a possible DSD is becoming increasingly common, and we discuss appropriate counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 Furthermore, informing patients and/or their parents about atypical sex development and why this may warrant referral to a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers. Moreover, this enables DSD specialists to refer cialis online us to the guideline when advising a referral. Transition from the prenatal to the postnatal team and from the paediatric to the adult team requires optimal communication between the specialists involved.

Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and cialis online us classification of removed gonadal tissue is challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an interdisciplinary multicentre group was formed with all members responsible for updating the literature for a specific part of the guideline. Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line with the Clinical Practice Advisory Document method described by Burke et al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with cialis online us sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper.

Abstracts had to be written in English and were identified using a broad range of Medical Subject cialis online us Headings terms (eg, DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, 46,XY DSD, guideline, multidisciplinary care). Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports cialis online us were excluded, as were articles that were not open access or retrievable through institutional access. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft was discussed by the writing committee and, after having obtained agreement on remaining points of discussion, revised into a final draft cialis online us.

This version was sent to a broad group of professionals from academic centres and DSD teams whose members had volunteered to review the draft guideline. After receiving and incorporating their input, the final version was presented to the paediatric and genetic associations for approval. After approval by the members of the paediatric (NVK), clinical genetic (VKGN) and genetic laboratory (VKGL) associations, the guideline was published on their respective websites.19 Although Turner syndrome and Klinefelter syndrome are considered to be part of the DSD spectrum, they are not extensively discussed in this diagnostic guideline as guidelines dedicated to cialis online us these syndromes already exist.25 26 However, some individuals with Turner syndrome or Klinefelter syndrome may present with ambiguous or atypical genitalia and may therefore initially follow the DSD diagnostic process.Guideline highlightsPrenatal settingPresentationThe most frequent prenatal presentation of a DSD condition is atypical genitalia found on prenatal ultrasound as an isolated finding or in combination with other structural anomalies. This usually occurs after the 20-week routine medical ultrasound for screening of congenital anomalies, but may also occur earlier, for example, when a commercial ultrasound is performed at the request of the parents.Another way DSD can be diagnosed before birth is when invasive prenatal genetic testing carried out for a different reason, for example, due to suspicion of other structural anomalies, reveals a discrepancy between the genotypic sex and the phenotypic sex seen by ultrasound. In certified laboratories, the possibility of a sample switch is extremely low but should be cialis online us ruled out immediately.

More often, the discrepancy will be due to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive prenatal testing (NIPT), which is now available to high-risk pregnant women in the Netherlands and to all pregnant women in Belgium, and later ultrasound findings. NIPT screens for cialis online us CNVs in the fetus. However, depending on legal restrictions and/or ethical considerations, the X and Y chromosomes are not always included in NIPT analysis and reports. If the X and Y chromosomes are included, it is important to realise that the presence of a cialis online us Y-chromosome does not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague prenatal specialists working with or in a DSD team.

After confirming an atypical genital cialis online us on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To enable the parents to make a well-informed decision, prenatal counselling should, in our opinion, include. Information on the ultrasound findings and the limitations of this technique. The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the type of information genetic testing can and cannot cialis online us provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved.

The clinical geneticist should be experienced in prenatal counselling and well informed about the diagnostic possibilities given the limited time span cialis online us in which test results need to be available to allow parents to make a well-informed decision about whether or not to continue the pregnancy. Termination of pregnancy can be considered, for instance, in a syndromic form of DSD with multiple malformations, but when the DSD occurs as an apparently isolated condition, expecting parents may also consider termination of pregnancy, which, although considered controversial by some, is legal in Belgium and the Netherlands. The psychologist of the DSD team can support parents during and cialis online us after pregnancy and help them cope with feelings of uncertainty and eventual considerations of a termination of pregnancy, as well as with practical issues, for example, how to inform others. The stress of not knowing exactly what the child’s genitalia will look like and uncertainty about the diagnosis, treatment and prognosis cannot be avoided completely. Parents are informed that if the postnatal phenotype is different from what was prenatally expected, the advice given about diagnostic testing can be adjusted accordingly, for example, if a hypospadias is milder than cialis online us was expected based on prenatal ultrasound images.

In our experience, parents appreciate having already spoken to some members of the DSD team during pregnancy and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, cialis online us umbilical cord blood is a good source for (molecular) karyotyping and storage of DNA and can be obtained by the obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 23 and midwives and staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array. It was recently estimated that >30% of individuals who have a DSD have additional structural anomalies, with cardiac cialis online us and neurological anomalies and fetal growth restriction being particularly common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS.

NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and cialis online us we propose completing the analysis well before the expected delivery.Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 1 Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing.First contact by a professional less experienced in DSDWhereas most current guidelines start from the point when an individual has been referred to the DSD team,1 15 the Dutch-Flemish guideline dedicates a chapter to healthcare professionals less experienced in DSD as they are often the first to suspect or identify such a condition. Apart from the paper of Indyk,7 little guidance is available for these professionals about how to act in such a situation. The chapter in the Dutch-Flemish guideline summarises the various clinical presentations that a DSD can have and provides information on how to communicate with parents and/or patients about the findings of the physical examination, the first-line investigations and the need for prompt referral to a specialised centre for further evaluation. Clinical examples are offered to illustrate some of these recurring situations.

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline. Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively.

Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing.

CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone." data-icon-position data-hide-link-title="0">Figure 2 46,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia.

AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 3 46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing.Very recently, a European position paper has been published focusing on the genetic workup of DSD.16 It highlights the limitations and drawbacks of NGS-based tests, which include the chance of missing subtle structural variants such as CNVs and mosaicism and the fact that NGS cannot detect methylation defects or other epigenetic changes.16 28 31 Targeted DNA analysis is preferred in cases where hormonal investigations suggest a block in steroidogenesis (eg, 11-β-hydroxylase deficiency, 21-hydroxylase deficiency), or in the context of a specific clinical constellation such as the often coincidental finding of Müllerian structures in a boy with normal external genitalia or cryptorchidism, that is, persistent Müllerian duct syndrome.33 34 Alternative tests should also be considered depending on the available information. Sometimes, a simple mouth swab for FISH analysis can detect mosaic XY/X in a male with hypospadias or asymmetric gonadal development or in a female with little or no Turner syndrome stigmata and a normal male molecular karyotyping profile or peripheral blood karyotype. Such targeted testing avoids incidental findings and is cheaper and faster than analysis of a large NGS-based panel, although the cost difference is rapidly declining.However, due to the genetic and phenotypic heterogeneity of DSD conditions, the most cost-effective next steps in the majority of cases are whole exome sequencing followed by panel analysis of genes involved in genital development and function or trio-analysis of a large gene panel (such as a Mendeliome).16 35–38 Pretest genetic counselling involves discussing what kind of information will be reported to patients or parents and the chance of detecting VUS, and the small risk of incidental findings when analysing a DSD panel should be mentioned. Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences.

If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing. Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites.

Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another. This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

How should we deal with the frequent findings of mainly unique VUS or class 3 variants (ACMG recommendation) in the many different DSD-related genes in the diagnostic setting?. Reporting VUS can be a source of uncertainty for parents, but not reporting these variants precludes further investigations to determine their possible pathogenicity. It can also be difficult to prove variant pathogenicity, both on gene-level and variant-level.39 Moreover, given the gonad-specific expression of some genes and the variable phenotypic spectrum and reduced penetrance, segregation analysis is not always informative. A class 3 variant that does not fit the clinical presentation may be unrelated to the observed phenotype, but it could also represent a newly emerging phenotype. This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD.

In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring. This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise.

For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time. Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres.

Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions. One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

This will enable highly individualised holistic care tailored to the patient’s needs and expectations. Once they are well-informed of all available options, parents and/or patients can choose what they consider the optimal care for their children or themselves.15 16ConclusionThe Dutch-Flemish guideline uniquely addresses some topics that are under-represented in the literature, thus adding some key aspects to those addressed in recent consensus papers and guidelines.15–17 33 47As more children with a DSD are now being identified prenatally, and the literature on prenatal diagnosis of DSD remains scarce,20 21 we propose a prenatal diagnostic algorithm and emphasise the importance of having a prenatal specialist involved in or collaborating with DSD (expert) centres.We also stress that good communication between all involved parties is essential. Professionals should be well informed about protocols and communication. Collaboration between centres is necessary to optimise aspects of care such as uniform interpretation of gonadal pathology and functional testing of class 3 variants found by genetic testing. Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline.

Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543..

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Para frustración de quienes estudian el tema, los datos sobre cuántas personas son hospitalizadas cialis over the counter usa de manera involuntaria, y cuánto How to get diflucan online les cuesta, son escasos. De lo que se puede recopilar, aproximadamente 2 millones de pacientes psiquiátricos son hospitalizados cada año en los Estados Unidos, casi la mitad contra su voluntad. Un estudio descubrió que una cuarta parte de estas internaciones están cubiertas por un seguro de salud privado, que a menudo tiene copagos elevados, y el 10% eran pacientes a los que se factura pero no pueden pagar.

Soy psiquiatra en la cialis over the counter usa ciudad de Nueva York y he atendido a cientos de pacientes hospitalizados involuntariamente. Casi nunca se habla del costo. Muchos pacientes con enfermedades mentales graves tienen ingresos bajos, a diferencia de Britney Spears.

En una encuesta informal cialis over the counter usa a mis colegas sobre el tema, la respuesta más común es. €œSí, está mal, pero ¿qué más podemos hacer?. €.

Cuando los pacientes presentan un riesgo muy alto de daño para cialis over the counter usa ellos mismos o para los demás, los psiquiatras están obligados a ordenar la internación en contra de su voluntad, incluso si esto pudiera generar una tensión financiera a largo plazo. Si bien los hospitales a veces absorben el costo, los pacientes pueden enfrentar créditos destruidos, llamadas de agencias de cobro interminables y una desconfianza adicional en el sistema de atención de salud mental. En los casos en que un hospital opta por demandar, los pacientes incluso pueden ir presos por no presentarse ante el tribunal.

Las facturas impagas también podrían incentivar aún más a cialis over the counter usa un hospital a cerrar las camas psiquiátricas en favor de servicios médicos más lucrativos, como cirugías para pacientes ambulatorios, con mejores reembolsos de los seguros. Rebecca Lewis, residente de Ohio de 27 años, se ha enfrentado a este problema desde que es paciente psiquiátrica. A los 24 años, comenzó a experimentar alucinaciones auditivas de personas que la llamaban por su nombre, seguidas de creencias delirantes sobre criaturas mitológicas.

Si bien estas experiencias le parecían muy reales, sabía que cialis over the counter usa algo andaba mal. Sin saber a dónde acudir, Lewis llamó a una línea de crisis, en donde le dijeron que fuera a un centro de evaluación en Columbus. Cuando condujo hasta allí, encontró una ambulancia esperándola.

€œMe dijeron que entrara en la ambulancia”, cialis over the counter usa dijo, “y dijeron que sería peor si corría”. Lewis, a quien finalmente se le diagnosticó esquizofrenia, fue hospitalizada durante dos días en contra de su voluntad. Se negó a firmar el papeleo reconociendo la responsabilidad de los cargos.

El hospital intentó obtener la tarjeta de crédito de su madre, que le habían dado a Lewis en caso de emergencia, pero se negó a cialis over the counter usa entregarla. Más tarde recibió una factura de $1,700 por correo. No se puso en contacto con el hospital para negociar la cuenta porque, dijo, “no tenía la energía emocional para esa batalla”.

Hasta el día de hoy, Lewis recibe llamadas y cialis over the counter usa cartas reclamando el pago de la deuda. Cuando las atiende, explica que no tiene intención de pagar porque la forzaron a recibir esos servicios. Su crédito está dañado, pero se considera afortunada porque pudo comprarle una casa a un familiar, dado lo difícil que habría sido conseguir una hipoteca.

La deuda impacta cialis over the counter usa en su psiquis. €œNo es divertido saber que hay algo que tal vez nunca pueda arreglar. Siento que tengo que tener mucho cuidado, siempre, para siempre, porque habrá una deuda”, dijo.

Lewis recibe atención psiquiátrica ambulatoria que la ha estabilizado cialis over the counter usa y ayudado a prevenir más hospitalizaciones, pero aún mira hacia atrás, a su primera y única internación con desdén. €œSe aprovecharon de mi desesperación”, dijo. Si bien es probable que muchos miles de estadounidenses compartan la experiencia de Lewis, no tenemos datos confiables sobre las deudas contraídas por atención psiquiátrica involuntaria.

Según el doctor Nathaniel Morris, profesor asistente de psiquiatría en la cialis over the counter usa Universidad de California-San Francisco, no sabemos con qué frecuencia se les cobra a los pacientes por atención involuntaria o cuánto terminan pagando. Incluso los datos sobre la frecuencia con la que las personas son hospitalizadas en contra de su voluntad son limitados. Morris es uno de los pocos investigadores que se ha centrado en este tema.

Se interesó después de que cialis over the counter usa sus pacientes le dijeran que se les facturaba después de una hospitalización involuntaria, y le sorprendió el dilema ético que representan estas facturas. €œHe tenido pacientes que me preguntan cuánto va a costar su atención y una de las cosas más horribles es que, como médico, a menudo no puedo decírselo porque nuestros sistemas de facturación médica son muy complejos”, dijo. €œEntonces, cuando se agrega el factor psiquiátrico involuntario, simplemente el problema alcanza otro nivel”.

Asimismo, las sentencias legales sobre el tema cialis over the counter usa son escasas. €œSolo he visto un puñado de decisiones a lo largo de los años”, dijo Ira Burnim, director legal del Bazelon Center for Mental Health Law. €œNo sé si hay consenso”.

Las personas que han sido internadas en contra de su voluntad rara vez buscan un abogado, dijo Burnim, pero cuando lo hacen, las agencias de cobro de deudas a menudo abandonan el caso en lugar de enfrentar una cialis over the counter usa costosa batalla legal. Los medios estarán obsesionados con las apariciones de Britney Spears en la corte. Es probable que se describan más detalles de su tutela que resaltarán la difícil situación de las personas que son forzadas a recibir atención.

Otras personas no recibirán cialis over the counter usa la atención mediática. Como dijo Rebecca Lewis, reflexionando sobre su decisión de no desafiar las facturas que enfrenta. €œEllos son Goliat y yo soy el pequeño David”.

El doctor Christopher Magoon cialis over the counter usa es médico residente en el Departamento de Psiquiatría de la Universidad de Columbia en la ciudad de Nueva York. Related Topics Contact Us Submit a Story TipThe approval of a controversial new drug for Alzheimer’s disease, Aduhelm, is shining a spotlight on mild cognitive impairment — problems with memory, attention, language or other cognitive tasks that exceed changes expected with normal aging. After initially indicating that Aduhelm could be prescribed to anyone with dementia, the Food and Drug Administration now specifies that the prescription drug be given to individuals with mild cognitive impairment or early-stage Alzheimer’s, the groups in which the medication was studied.

Yet this narrower cialis over the counter usa recommendation raises questions. What does a diagnosis of mild cognitive impairment mean?. Is Aduhelm appropriate for all people with mild cognitive impairment, or only some?.

And who should decide which cialis over the counter usa patients qualify for treatment. Dementia specialists or primary care physicians?. Controversy surrounds Aduhelm because its effectiveness hasn’t been proved, its cost is high (an estimated $56,000 a year, not including expenses for imaging and monthly infusions), and its potential side effects are significant (41% of patients in the drug’s clinical trials experienced brain swelling and bleeding).

Furthermore, an FDA advisory committee strongly recommended against Aduhelm’s approval, and Congress is cialis over the counter usa investigating the process leading to the FDA’s decision. Medicare is studying whether it should cover the medication, and the Department of Veterans Affairs has declined to do so under most circumstances. Clinical trials for Aduhelm excluded people over age 85.

Those taking blood thinners cialis over the counter usa. Those who had experienced a stroke. And those with cardiovascular disease or impaired kidney or liver function, among other conditions.

If those criteria were broadly applied, 85% of people with mild cognitive impairment would not qualify to take the medication, according to a new cialis over the counter usa research letter in the Journal of the American Medical Association. Given these considerations, carefully selecting patients with mild cognitive impairment who might respond to Aduhelm is “becoming a priority,” said Dr. Kenneth Langa, a professor of medicine, health management and policy at the University of Michigan.

Dr. Ronald Petersen, who directs the Mayo Clinic’s Alzheimer’s Disease Research Center, said, “One of the biggest issues we’re dealing with since Aduhelm’s approval is, ‘Are appropriate patients going to be given this drug?. €™â€ Here’s what people should know about mild cognitive impairment based on a review of research studies and conversations with leading experts.

Basics. Mild cognitive impairment is often referred to as a borderline state between normal cognition and dementia. But this can be misleading.

Although a significant number of people with mild cognitive impairment eventually develop dementia — usually Alzheimer’s disease — many do not. Cognitive symptoms — for instance, difficulties with short-term memory or planning — are often subtle but they persist and represent a decline from previous functioning. Yet a person with the condition may still be working or driving and appear entirely normal.

By definition, mild cognitive impairment leaves intact a person’s ability to perform daily activities independently. According to an American Academy of Neurology review of dozens of studies, published in 2018, mild cognitive impairment affects nearly 7% of people ages 60 to 64, 10% of those 70 to 74 and 25% of 80- to 84-year-olds. Causes.

Mild cognitive impairment can be caused by biological processes (the accumulation of amyloid beta and tau proteins and changes in the brain’s structure) linked to Alzheimer’s disease. Between 40% and 60% of people with mild cognitive impairment have evidence of Alzheimer’s-related brain pathology, according to a 2019 review. But cognitive symptoms can also be caused by other factors, including small strokes.

Poorly managed conditions such as diabetes, depression and sleep apnea. Responses to medications. Thyroid disease.

And unrecognized hearing loss. When these issues are treated, normal cognition may be restored or further decline forestalled. Subtypes.

During the past decade, experts have identified four subtypes of mild cognitive impairment. Each subtype appears to carry a different risk of progressing to Alzheimer’s disease, but precise estimates haven’t been established. People with memory problems and multiple medical issues who are found to have changes in their brain through imaging tests are thought to be at greatest risk.

€œIf biomarker tests converge and show abnormalities in amyloid, tau and neurodegeneration, you can be pretty certain a person with MCI has the beginnings of Alzheimer’s in their brain and that disease will continue to evolve,” said Dr. Howard Chertkow, chairperson for cognitive neurology and innovation at Baycrest, an academic health sciences center in Toronto that specializes in care for older adults. Diagnosis.

Usually, this process begins when older adults tell their doctors that “something isn’t right with my memory or my thinking” — a so-called subjective cognitive complaint. Short cognitive tests can confirm whether objective evidence of impairment exists. Other tests can determine whether a person is still able to perform daily activities successfully.

More sophisticated neuropsychological tests can be helpful if there is uncertainty about findings or a need to better assess the extent of impairment. But “there is a shortage of physicians with expertise in dementia — neurologists, geriatricians, geriatric psychiatrists” — who can undertake comprehensive evaluations, said Kathryn Phillips, director of health services research and health economics at the University of California-San Francisco School of Pharmacy. The most important step is taking a careful medical history that documents whether a decline in functioning from an individual’s baseline has occurred and investigating possible causes such as sleep patterns, mental health concerns and inadequate management of chronic conditions that need attention.

Mild cognitive impairment “isn’t necessarily straightforward to recognize, because people’s thinking and memory changes over time [with advancing age] and the question becomes ‘Is this something more than that?. €™â€ said Dr. Zoe Arvanitakis, a neurologist and director of Rush University’s Rush Memory Clinic in Chicago.

More than one set of tests is needed to rule out the possibility that someone performed poorly because they were nervous or sleep-deprived or had a bad day. €œAdministering tests to people over time can do a pretty good job of identifying who’s actually declining and who’s not,” Langa said. Progression.

Mild cognitive impairment doesn’t always progress to dementia, nor does it usually do so quickly. But this isn’t well understood. And estimates of progression vary, based on whether patients are seen in specialty dementia clinics or in community medical clinics and how long patients are followed.

A review of 41 studies found that 5% of patients treated in community settings each year went on to develop dementia. For those seen in dementia clinics — typically, patients with more serious symptoms — the rate was 10%. The American Academy of Neurology’s review found that after two years 15% of patients were observed to have dementia.

Progression to dementia isn’t the only path people follow. A sizable portion of patients with mild cognitive impairment — from 14% to 38% — are discovered to have normal cognition upon further testing. Another portion remains stable over time.

(In both cases, this may be because underlying risk factors — poor sleep, for instance, or poorly controlled diabetes or thyroid disease — have been addressed.) Still another group of patients fluctuate, sometimes improving and sometimes declining, with periods of stability in between. €œYou really need to follow people over time — for up to 10 years — to have an idea of what is going on with them,” said Dr. Oscar Lopez, director of the Alzheimer’s Disease Research Center at the University of Pittsburgh.

Specialists versus generalists. Only people with mild cognitive impairment associated with Alzheimer’s should be considered for treatment with Aduhelm, experts agreed. €œThe question you want to ask your doctor is, ‘Do I have MCI [mild cognitive impairment] due to Alzheimer’s disease?.

€™â€ Chertkow said. Because this medication targets amyloid, a sticky protein that is a hallmark of Alzheimer’s, confirmation of amyloid accumulation through a PET scan or spinal tap should be a prerequisite. But the presence of amyloid isn’t determinative.

One-third of older adults with normal cognition have been found to have amyloid deposits in their brains. Because of these complexities, “I think, for the early rollout of a complex drug like this, treatment should be overseen by specialists, at least initially,” said Petersen of the Mayo Clinic. Arvanitakis of Rush University agreed.

€œIf someone is really and truly interested in trying this medication, at this point I would recommend it be done under the care of a psychiatrist or neurologist or someone who really specializes in cognition,” she said. We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Judith Graham. khn.navigatingaging@gmail.com, @judith_graham Related Topics Contact Us Submit a Story TipWhen Britney Spears last went before a judge, in June, she bristled as she told of being forced into psychiatric care that cost her $60,000 a month. Though the pop star’s circumstances in a financial conservatorship are unusual, every year hundreds of thousands of other psychiatric patients also receive involuntary care, and many are stuck with the bill.

Few have Spears’ resources to pay for it, which can have devastating consequences. To the frustration of those who study the issue, data on how many people are involuntarily hospitalized and how much they pay is sparse. From what can be gathered, approximately 2 million psychiatric patients are hospitalized each year in the United States, nearly half involuntarily.

One study found that a quarter of these hospitalizations are covered by private insurance, which often has high copays, and 10% were “self-pay/no charge,” where patients are often billed but cannot pay. I am a psychiatrist in New York City, and I have cared for hundreds of involuntarily hospitalized patients. Cost is almost never discussed.

Many patients with serious mental illness have low incomes, unlike Britney Spears. In an informal survey of my colleagues on the issue, the most common response is, “Yeah, that feels wrong, but what else can we do?. € When patients pose an acutely high risk of harm to themselves or others, psychiatrists are obligated to hospitalize them against their will, even if it could lead to long-term financial strain.

While hospitals sometimes absorb the cost, patients can be left with ruined credit, endless collection calls and additional mistrust of the mental health care system. In cases in which a hospital chooses to sue, patients can even be incarcerated for not showing up in court. On the hospital side, unpaid bills might further incentivize a hospital to close psych beds in favor of more lucrative medical services, such as outpatient surgeries, with better insurance reimbursement.

Rebecca Lewis, a 27-year-old Ohioan, has confronted this problem for as long as she has been a psychiatric patient. At 24, she began experiencing auditory hallucinations of people calling her name, followed by delusional beliefs about mythological creatures. While these experiences felt very real to her, she nevertheless knew something was off.

Not knowing where to turn, Lewis called a crisis line, which told her to go to an evaluation center in Columbus. When she drove herself there, she found an ambulance waiting for her. €œThey told me to get into the ambulance,” she said, “and they said it would be worse if I ran.” Lewis, who was ultimately diagnosed with schizophrenia, was hospitalized for two days against her will.

She refused to sign paperwork acknowledging responsibility for charges. The hospital attempted to obtain her mother’s credit card, which Lewis had been given in case of emergencies, but she refused to hand it over. She later got a $1,700 bill in the mail.

She did not contact the hospital to negotiate the bill because, she said, “I did not have the emotional energy to return to that battle.” To this day, Lewis gets debt collection calls and letters. When she picks up the calls, she explains she has no intention of paying because the services were forced on her. Her credit is damaged, but she considers herself lucky because she was able to buy a house from a family member, given how challenging it would have been to secure a mortgage.

The debt looms over her psyche. €œIt’s not fun to know that there’s this thing out there that I don’t feel that I can ever fix. I feel like I have to be extra careful — always, forever — because there’s going to be this debt,” she said.

Lewis receives outpatient psychiatric care that has stabilized her and prevented further hospitalizations, but she still looks back on her first and only hospitalization with scorn. €œThey preyed on my desperation,” she said. While it is likely that many thousands of Americans share Lewis’ experience, we lack reliable data on debt incurred for involuntary psychiatric care.

According to Dr. Nathaniel Morris, an assistant professor of psychiatry at the University of California-San Francisco, we don’t know how often patients are charged for involuntary care or how much they end up paying. Even data on how often people are hospitalized against their wishes is limited.

Morris is one of the few researchers who have focused on this issue. He got interested after his patients told him about being billed after involuntary hospitalization, and he was struck by the ethical dilemma these bills represent. €œI’ve had patients ask me how much their care is going to cost, and one of the most horrible things is, as a physician, I often can’t tell them because our medical billing systems are so complex,” he said.

€œThen, when you add on the involuntary psychiatric factor, it just takes it to another level.” Similarly, legal rulings on the issue are sparse. €œI’ve only seen a handful of decisions over the years,” said Ira Burnim, legal director of the Bazelon Center for Mental Health Law. €œI don’t know that there is a consensus.” People who have been involuntarily hospitalized rarely seek a lawyer, Burnim said, but when they do, the debt collection agencies will often drop the case rather than face a costly legal battle.

The media will be obsessed with Britney Spears’ next day in court, expected to be Sept. 29. She will likely describe further details of her conservatorship that will highlight the plight of many forced into care.

Others won’t get that kind of attention. As Rebecca Lewis put it, reflecting on her decision not to challenge the bills she faces. €œThey’re Goliath and I’m little David.” Dr.

Christopher Magoon is a resident physician at the Columbia University Department of Psychiatry in New York City. Related Topics Contact Us Submit a Story TipThe fierce wildfires that broke out across much of the western United States this summer, spreading smoke across hundreds of miles, continue to pose a serious health hazard to millions. More are expected this fall.

That’s a major health concern because microscopic particles in wildfire smoke, carried by the wind, can penetrate deep into your lungs and travel into your bloodstream. One study linked wildfire smoke exposure to a twofold increase in the rate of asthma and a 40% rise in strokes and heart attacks. Other research tied smoke to hospital admissions, ER visits and premature deaths.

The standard advice is to stay inside when heavy smoke is in the air. But the smoke can get into your house or apartment. So you might want to consider investing in equipment to clean the air inside your home, especially with climate change likely to continue escalating the scope and intensity of the fires.

€œI think we have fires enough now that people should think of this as something they want to buy,” says Deborah Bennett, a professor of public health at the University of California-Davis. €œEven if they only turn it on during the fires, there’s going to be plenty of times when they’re going to have it turned on.” There are many options for cleaning the air in your home, depending on your circumstances and — of course — your budget. If you have an HVAC system, it likely recirculates air that’s inside the house rather than drawing in air from outside.

But if you have an air conditioner with a “fresh air” system that brings in outside air, you should turn off the fresh air setting on heavy smoke days. If you don’t know how, seek professional advice. And be sure to close all doors and windows.

Otherwise, your efforts will be in vain. You can convert your HVAC unit or furnace into a better air-cleaning system by installing a higher-efficiency filter capable of catching a large proportion — though it won’t get 100% — of the tiny smoke particles. To cope with wildfire smoke, many public health and air quality experts recommend what’s known as a MERV 13 filter.

MERV, or “minimum efficiency reporting value,” is a scale from 1 to 20 that rates a filter’s ability to capture particles. MERV 1 is the lowest rating, indicating the least impact on air quality, while filters rated MERV 17 or higher are used in hospital operating rooms and clean rooms. You can buy MERV 13 filters at large stores such as Costco, the Home Depot and Lowe’s or online from multiple vendors.

A MERV 13 should cost around $20, or substantially less if you buy packages of them. Before you install a new filter, check first with an HVAC professional to make sure your system can accommodate it. The more efficient the filter, the more it reduces airflow, diminishing the cooling capacity of an air conditioner and requiring more energy to run the heater.

If you don’t have central air, or you have it and want to augment your system’s ability to clear the air, consider buying a portable air cleaner with a high-efficiency particulate air, or HEPA, filter, which can remove almost all particles of the tiny size found in smoke. You can put it in the room you use most during the day, then move it to your bedroom at night. If the smoke gets really bad, put it in the room of your choice and stay there as much as possible.

€œIf you have an appropriately sized air cleaner with a true HEPA filter and you put it in a room and close the doors and windows, you have clean air really fast,” says Sarah Coefield, an air quality specialist with the Missoula City-County Health Department in Montana, which has had its share of wildfire smoke in recent years. If you have kids, or share the home with other people, you should ideally have one air cleaner for each bedroom. Alternatively, you may need to put everyone in one room at night during a smoke emergency.

Portable HEPA air cleaners cost anywhere from under $100 to over $1,000, depending in part on the number of square feet they can clean effectively. To clean a room, you can get a perfectly good one for under $200. All air cleaning devices sold in California must be certified by the California Air Resources Board, which posts a list of air cleaners it has certified.

You might also want to look at Consumer Reports’ list of best and worst air cleaners and at a review of those selected by The New York Times’ product review website, Wirecutter. Public health experts warn that you should avoid devices that are sold as air cleaners but actually emit ozone, the main component of smog. The air resources board also publishes a list of ozone-emitting devices.

Gina Spadafori, a resident of West Sacramento, has both a central HVAC system with an extra-thick filter and a portable HEPA air cleaner she keeps in her bedroom. Spadafori, 63, has serious asthma and has long been concerned about the air quality in her house. In recent years, she has endured numerous days of hazardous wildfire smoke and that has changed the way she uses her HVAC.

€œI probably use the fan-only setting more than I have in the past to just filter the air rather than heating or cooling it,” she says. On bad air days, she turns the portable air cleaner on an hour before she goes to bed and closes the door so it will “super-clean that air” and she’ll get a good night’s sleep. €œIt’s just sort of a second line of defense,” she says.

There is a lower-cost option. Make your own air purifier by attaching a high-efficiency filter to an electric box fan. You can get a suitable fan for around $30 and the filters for around $20 — or cheaper in bulk.

The website montanawildfiresmoke.org publishes a how-to guide for building such a contraption. The Environmental Protection Agency has an FAQ on box fan air cleaners with instructions for building them. The EPA recommends using only box fans built in 2012 or later, because earlier models could overheat and cause a fire.

Lab testing has clearly shown such do-it-yourself devices are safe, though they may heat up the room and produce more noise than a portable HEPA cleaner, according to the EPA. For those who can’t even afford to make an air cleaner from a house fan, nonprofits and local government agencies have provided help. People who don’t have a lot of money are likely to live in older, leakier housing that lets more smoke in.

They are also more likely to have chronic illness and thus be in greater need of clean air — yet less able to afford it. Climate Smart Missoula, a Montana nonprofit, has distributed around 500 air cleaners to low-income and homebound people in recent years, said Amy Cilimburg, its executive director. In California, the Bay Area Air Quality Management District is providing 3,000 air fiation devices to low-income people with respiratory conditions in nine counties.

The American Lung Association has also donated air cleaners to people in need. But these efforts are tiny compared with the gaping need, said Cilimburg, who thinks the federal and state governments, hospitals and insurers should step in. She envisions a day when medical staffers at a clinic will tell a patient, “‘Oh, look, given x, y or z, you should just take one of these HEPA filters home with you.’” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Bernard J. Wolfson. bwolfson@kff.org, @bjwolfson Related Topics Contact Us Submit a Story TipThe advertisement opens with a doctor sitting across from his patient and holding a prescription drug pill bottle.

€œYou want to continue with this medication?. € the doctor asks while an older patient nods. The doctor then explains that he can no longer provide the medicine to her because insurance companies and Washington bureaucrats “are working together to swipe $500 billion from Medicare to pay for [House Speaker Nancy] Pelosi and [Senate Majority Leader Chuck] Schumer’s out-of-control spending spree.” “They’re calling it Medicare negotiation, but, really, it’s just a way to cut your benefits and no longer pay for lifesaving medicines,” the doctor says.

Medicare negotiation refers to the federal government bargaining directly with pharmaceutical companies on the price of prescription drugs. Currently, Medicare is prohibited from using its vast market-share muscle to set prices. But supporters of Medicare drug negotiations eye the Democratic-backed budget reconciliation bill now being discussed in Congress as a means to reverse the policy.

This ad, seen on television and online, is part of a multiplatform campaign by the 60 Plus American Association of Senior Citizens, a conservative group that lobbies on senior issues and brands itself as the “right alternative to AARP.” It’s one example of a swath of ads that have popped up in the past month about Medicare drug price negotiations. Since drug pricing is a hot topic and a critical piece of the broad, politically charged debate in Congress, we thought it was important to dig into the ad’s messages. The $500 Billion Number First, the ad claims that Medicare drug price negotiation will take “$500 billion from Medicare.” All five of the Medicare and drug pricing experts we consulted said that was a misleading way to frame this policy.

The reference to $500 billion most likely comes from a Congressional Budget Office estimate of a provision in H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act.

It’s an estimate of how much the government would save over 10 years if drug price negotiations were enacted. That is, the government would be paying pharmaceutical companies $500 billion less for prescription drugs. And, in that bill, $300 billion to $400 billion of the savings were to be used to expand benefits to include dental, hearing and vision coverage, said Juliette Cubanski, deputy director of the program on Medicare policy at KFF.

Right now, Medicare doesn’t provide that coverage to seniors. If this policy were to make it into the pending budget reconciliation, some of the savings would also likely address other Democratic health care priorities, such as permanently closing the Medicaid coverage gap and improving Affordable Care Act coverage and subsidies. So the ad’s charged language — that Pelosi and Schumer are planning to “swipe” this money from Medicare — is incorrect.

That $500 billion in savings would be slated for reinvestment in the program. And some experts said the changes to drug pricing could also translate into lower premiums and out-of-pocket costs for seniors. The point of negotiations is “to spend less on the drugs we’re already buying and put the money back into the health system,” said Rachel Sachs, a law professor and expert on drug policy at Washington University in St.

Louis. But what about the ad’s other main point — that Medicare negotiation will result in seniors no longer being able to get their medications?. Since 60 Plus did not return requests for comment, it’s hard to know exactly what it is asserting will come between seniors and their medication.

It’s possible the ad is implying that drugmakers may walk away from the negotiating table if they don’t like the prices the government promotes. But experts said it’s likely a financial penalty would be in place to motivate the companies to work with the government. H.R.

3 proposed an escalating excise tax. The U.S. Has the world’s largest prescription market, so it seems unlikely companies would stop selling drugs here completely, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University.

And the number of drugs subject to negotiation would probably be a small subset of all drugs on the market, based on the negotiation method that was proposed in H.R. 3. In real life, the scenario shown in the ad is unlikely to happen, said Joseph Antos, senior fellow in health care policy at the American Enterprise Institute.

€œThe question of whether a drug would be taken off the market — it’s always a little hard to say and, clearly, that is a possibility,” said Antos. €œBut it’s much more plausible to say this is the kind of policy that would lead to some new drugs not coming out to the market.” That’s an argument often wielded by the pharmaceutical industry. Evidence suggests there’s a grain of truth in the assessment that lower industry profits results in less research and development, said Paul Van de Water, a senior fellow in health care policy at the Center on Budget and Policy Priorities.

But only a grain. For the most part, the drug industry overstates the effect of lost profits. €œA lot of these drugs are what’s known as ‘me-too’ medicines, which means the drugmakers are making small innovations on existing drugs,” said Van de Water.

€œThe loss to Medicare beneficiaries of those types of drugs would be relatively small.” In a separate analysis, the CBO examined to what extent negotiated drug prices could squeeze the pharmaceutical industry’s R&D capacity. The agency, using a 30-year window, estimated that 59 drugs wouldn’t come to market. That’s against a baseline of about 900 drugs being released per year, said Sachs, which means it would stymie only a tiny fraction of otherwise expected drugs.

Still, some experts say the CBO report can’t precisely predict the future and a loss in profits would have a larger effect on smaller, start-up pharmaceutical companies. €œAt the small operations, a scientist thinks they have an insight into some biological process and they attract venture capitalists to develop a drug,” said Antos. €œBut drug development is a complicated business, and the drug might not make it to market.

With less funds for that type of research, that is the part of the drug business most directly affected by the drug pricing policy.” Why It Matters The political stakes surrounding the Medicare drug price negotiations are high. Currently, the idea is seen as a way to help pay for the Democratic-backed health initiatives being discussed as part of the reconciliation bill. And, a recent poll from KFF shows that almost 90% of the public supports the government’s ability to negotiate for lower drug prices.

But allowing Medicare to bargain on drugs is controversial, even among Democrats, some of whom say they don’t want to stifle drug companies’ innovation, especially if it’s a big industry in the area of the country they represent. Meanwhile, PhRMA, the powerful pharmaceutical industry trade group, announced Sept. 15 it would be launching a seven-figure ad campaign against the drug pricing proposals, according to The Hill.

Our Rating The 60 Plus Association ran an advertisement that claimed Medicare drug price negotiations were “swiping” $500 billion from Medicare and going to be used as a way to “cut benefits and no longer pay for lifesaving medicines.” While the $500 billion number is based on facts, everything else this ad says is misleading. If Congress approves a plan to let Medicare negotiate drug prices, Democrats are calling for most of the savings to be funneled directly back into the Medicare program to provide vision, dental and hearing benefits. So, it’s not true that the plan for the money is to steal from Medicare.

Experts also agreed it is specious to say seniors could no longer get the medications they’re currently taking. We rate this claim False. Sources60 Plus American Association of Senior Citizens, “Our Mission,” accessed Sept.

22, 202160 Plus American Association of Senior Citizens, “Protecting Medicare,” accessed Sept. 22, 2021Center on Budget and Policy Priorities, Build Back Better Legislation Would Close the Medicaid Coverage Gap, Sept. 13, 2021Congressional Budget Office, CBO’s Simulation Model of New Drug Development, August 2021Congressional Budget Office, H.R.

3, Elijah E. Cummings Lower Drug Costs Now Act Cost Estimate, Dec. 10, 2019Congress.gov, H.R.3 — Elijah E.

Cummings Lower Drug Costs Now Act — 116th Congress (2019-2020), accessed Sept. 22, 2021Email interview with Stacie Dusetzina, associate professor of health policy at Vanderbilt University, Sept. 21, 2021Fierce Pharma, “Advocates Roll Pricey Ad Campaigns as Biden, Congress Push for Medicare Drug Negotiations,” Aug.

17, 2021The Hill, “PhRMA Launches 7-Figure Ad Campaign Against Democrats’ Drug Pricing Measures,” Sept. 15, 2021KFF, What’s the Latest on Medicare Drug Price Negotiations?. , July 23, 2021KFF, Public Opinion on Prescription Drugs and Their Prices, June 15, 2021KHN/PolitiFact, “Pharma’s Take on the Pelosi Drug-Pricing Bill.

Fair Warning or Fearmongering?. € Dec. 5, 2019KHN/PolitiFact, “Biden Promise Tracker — Promise.

Lower Cost of Prescription Drugs,” updated July 15, 2021Open Secrets, “Pharmaceutical Industry Backs Democratic Holdouts on Drug Pricing Plan,” Sept. 17, 2021Politico, “House Leadership Looks to Jam Holdouts on Drug Pricing,” Sept. 21, 2021Phone interview with Juliette Cubanski, deputy director of the program on Medicare policy at KFF, Sept.

21, 2021Phone interview with Joseph Antos, senior fellow and Wilson H. Taylor Scholar in health care and retirement policy at the American Enterprise Institute, Sept. 21, 2021Phone interview with Paul N.

Van de Water, senior fellow at the Center on Budget and Policy Priorities, Sept. 21, 2021Phone interview with Rachel Sachs, Treiman professor of law at Washington University in St. Louis School of Law, Sept.

21, 2021The Washington Post, “Three Democrats Say They’ll Oppose Party’s Drug-Price Plan, Creating Roadblock for Larger Package,” Sept. 14, 2021YouTube, 60 Plus Association Official Account, “Doctor’s Visit,” Sept. 10, 2021 Victoria Knight.

vknight@kff.org, @victoriaregisk Related Topics Contact Us Submit a Story Tip.

Para frustración de quienes estudian el tema, los datos sobre http://unitedpunjabisofamerica.org/how-to-get-diflucan-online cuántas personas son hospitalizadas de manera involuntaria, cialis online us y cuánto les cuesta, son escasos. De lo que se puede recopilar, aproximadamente 2 millones de pacientes psiquiátricos son hospitalizados cada año en los Estados Unidos, casi la mitad contra su voluntad. Un estudio descubrió que una cuarta parte de estas internaciones están cubiertas por un seguro de salud privado, que a menudo tiene copagos elevados, y el 10% eran pacientes a los que se factura pero no pueden pagar. Soy psiquiatra en cialis online us la ciudad de Nueva York y he atendido a cientos de pacientes hospitalizados involuntariamente. Casi nunca se habla del costo.

Muchos pacientes con enfermedades mentales graves tienen ingresos bajos, a diferencia de Britney Spears. En una encuesta informal a mis colegas sobre el tema, la respuesta más cialis online us común es. €œSí, está mal, pero ¿qué más podemos hacer?. €. Cuando los pacientes presentan un riesgo muy alto de daño para ellos mismos o cialis online us para los demás, los psiquiatras están obligados a ordenar la internación en contra de su voluntad, incluso si esto pudiera generar una tensión financiera a largo plazo.

Si bien los hospitales a veces absorben el costo, los pacientes pueden enfrentar créditos destruidos, llamadas de agencias de cobro interminables y una desconfianza adicional en el sistema de atención de salud mental. En los casos en que un hospital opta por demandar, los pacientes incluso pueden ir presos por no presentarse ante el tribunal. Las facturas impagas también cialis online us podrían incentivar aún más a un hospital a cerrar las camas psiquiátricas en favor de servicios médicos más lucrativos, como cirugías para pacientes ambulatorios, con mejores reembolsos de los seguros. Rebecca Lewis, residente de Ohio de 27 años, se ha enfrentado a este problema desde que es paciente psiquiátrica. A los 24 años, comenzó a experimentar alucinaciones auditivas de personas que la llamaban por su nombre, seguidas de creencias delirantes sobre criaturas mitológicas.

Si bien estas experiencias cialis online us le parecían muy reales, sabía que algo andaba mal. Sin saber a dónde acudir, Lewis llamó a una línea de crisis, en donde le dijeron que fuera a un centro de evaluación en Columbus. Cuando condujo hasta allí, encontró una ambulancia esperándola. €œMe dijeron que entrara en la ambulancia”, dijo, “y dijeron que sería peor si corría” cialis online us. Lewis, a quien finalmente se le diagnosticó esquizofrenia, fue hospitalizada durante dos días en contra de su voluntad.

Se negó a firmar el papeleo reconociendo la responsabilidad de los cargos. El hospital intentó obtener la tarjeta de crédito de su madre, cialis online us que le habían dado a Lewis en caso de emergencia, pero se negó a entregarla. Más tarde recibió una factura de $1,700 por correo. No se puso en contacto con el hospital para negociar la cuenta porque, dijo, “no tenía la energía emocional para esa batalla”. Hasta el día de hoy, Lewis recibe llamadas y cartas reclamando el cialis online us pago de la deuda.

Cuando las atiende, explica que no tiene intención de pagar porque la forzaron a recibir esos servicios. Su crédito está dañado, pero se considera afortunada porque pudo comprarle una casa a un familiar, dado lo difícil que habría sido conseguir una hipoteca. La deuda impacta cialis online us en su psiquis. €œNo es divertido saber que hay algo que tal vez nunca pueda arreglar. Siento que tengo que tener mucho cuidado, siempre, para siempre, porque habrá una deuda”, dijo.

Lewis recibe atención psiquiátrica ambulatoria que la ha estabilizado y ayudado a prevenir más hospitalizaciones, pero aún mira hacia atrás, a su primera cialis online us y única internación con desdén. €œSe aprovecharon de mi desesperación”, dijo. Si bien es probable que muchos miles de estadounidenses compartan la experiencia de Lewis, no tenemos datos confiables sobre las deudas contraídas por atención psiquiátrica involuntaria. Según el doctor Nathaniel Morris, cialis online us profesor asistente de psiquiatría en la Universidad de California-San Francisco, no sabemos con qué frecuencia se les cobra a los pacientes por atención involuntaria o cuánto terminan pagando. Incluso los datos sobre la frecuencia con la que las personas son hospitalizadas en contra de su voluntad son limitados.

Morris es uno de los pocos investigadores que se ha centrado en este tema. Se interesó después de que sus pacientes le dijeran que se les facturaba después de una hospitalización involuntaria, cialis online us y le sorprendió el dilema ético que representan estas facturas. €œHe tenido pacientes que me preguntan cuánto va a costar su atención y una de las cosas más horribles es que, como médico, a menudo no puedo decírselo porque nuestros sistemas de facturación médica son muy complejos”, dijo. €œEntonces, cuando se agrega el factor psiquiátrico involuntario, simplemente el problema alcanza otro nivel”. Asimismo, las sentencias legales sobre el tema son cialis online us escasas.

€œSolo he visto un puñado de decisiones a lo largo de los años”, dijo Ira Burnim, director legal del Bazelon Center for Mental Health Law. €œNo sé si hay consenso”. Las personas que han sido internadas en contra de su voluntad rara vez buscan un abogado, dijo Burnim, pero cuando lo hacen, las agencias de cobro de deudas a menudo abandonan el caso en lugar de enfrentar una costosa cialis online us batalla legal. Los medios estarán obsesionados con las apariciones de Britney Spears en la corte. Es probable que se describan más detalles de su tutela que resaltarán la difícil situación de las personas que son forzadas a recibir atención.

Otras personas no recibirán la atención mediática cialis online us. Como dijo Rebecca Lewis, reflexionando sobre su decisión de no desafiar las facturas que enfrenta. €œEllos son Goliat y yo soy el pequeño David”. El doctor Christopher Magoon es médico residente cialis online us en el Departamento de Psiquiatría de la Universidad de Columbia en la ciudad de Nueva York. Related Topics Contact Us Submit a Story TipThe approval of a controversial new drug for Alzheimer’s disease, Aduhelm, is shining a spotlight on mild cognitive impairment — problems with memory, attention, language or other cognitive tasks that exceed changes expected with normal aging.

After initially indicating that Aduhelm could be prescribed to anyone with dementia, the Food and Drug Administration now specifies that the prescription drug be given to individuals with mild cognitive impairment or early-stage Alzheimer’s, the groups in which the medication was studied. Yet this narrower cialis online us recommendation raises questions. What does a diagnosis of mild cognitive impairment mean?. Is Aduhelm appropriate for all people with mild cognitive impairment, or only some?. And who should cialis online us decide which patients qualify for treatment.

Dementia specialists or primary care physicians?. Controversy surrounds Aduhelm because its effectiveness hasn’t been proved, its cost is high (an estimated $56,000 a year, not including expenses for imaging and monthly infusions), and its potential side effects are significant (41% of patients in the drug’s clinical trials experienced brain swelling and bleeding). Furthermore, an FDA advisory committee strongly cialis online us recommended against Aduhelm’s approval, and Congress is investigating the process leading to the FDA’s decision. Medicare is studying whether it should cover the medication, and the Department of Veterans Affairs has declined to do so under most circumstances. Clinical trials for Aduhelm excluded people over age 85.

Those taking blood cialis online us thinners. Those who had experienced a stroke. And those with cardiovascular disease or impaired kidney or liver function, among other conditions. If those criteria were broadly applied, 85% of people with mild cognitive impairment cialis online us would not qualify to take the medication, according to a new research letter in the Journal of the American Medical Association. Given these considerations, carefully selecting patients with mild cognitive impairment who might respond to Aduhelm is “becoming a priority,” said Dr.

Kenneth Langa, a professor of medicine, health management and policy at the University of Michigan. Dr. Ronald Petersen, who directs the Mayo Clinic’s Alzheimer’s Disease Research Center, said, “One of the biggest issues we’re dealing with since Aduhelm’s approval is, ‘Are appropriate patients going to be given this drug?. €™â€ Here’s what people should know about mild cognitive impairment based on a review of research studies and conversations with leading experts. Basics.

Mild cognitive impairment is often referred to as a borderline state between normal cognition and dementia. But this can be misleading. Although a significant number of people with mild cognitive impairment eventually develop dementia — usually Alzheimer’s disease — many do not. Cognitive symptoms — for instance, difficulties with short-term memory or planning — are often subtle but they persist and represent a decline from previous functioning. Yet a person with the condition may still be working or driving and appear entirely normal.

By definition, mild cognitive impairment leaves intact a person’s ability to perform daily activities independently. According to an American Academy of Neurology review of dozens of studies, published in 2018, mild cognitive impairment affects nearly 7% of people ages 60 to 64, 10% of those 70 to 74 and 25% of 80- to 84-year-olds. Causes. Mild cognitive impairment can be caused by biological processes (the accumulation of amyloid beta and tau proteins and changes in the brain’s structure) linked to Alzheimer’s disease. Between 40% and 60% of people with mild cognitive impairment have evidence of Alzheimer’s-related brain pathology, according to a 2019 review.

But cognitive symptoms can also be caused by other factors, including small strokes. Poorly managed conditions such as diabetes, depression and sleep apnea. Responses to medications. Thyroid disease. And unrecognized hearing loss.

When these issues are treated, normal cognition may be restored or further decline forestalled. Subtypes. During the past decade, experts have identified four subtypes of mild cognitive impairment. Each subtype appears to carry a different risk of progressing to Alzheimer’s disease, but precise estimates haven’t been established. People with memory problems and multiple medical issues who are found to have changes in their brain through imaging tests are thought to be at greatest risk.

€œIf biomarker tests converge and show abnormalities in amyloid, tau and neurodegeneration, you can be pretty certain a person with MCI has the beginnings of Alzheimer’s in their brain and that disease will continue to evolve,” said Dr. Howard Chertkow, chairperson for cognitive neurology and innovation at Baycrest, an academic health sciences center in Toronto that specializes in care for older adults. Diagnosis. Usually, this process begins when older adults tell their doctors that “something isn’t right with my memory or my thinking” — a so-called subjective cognitive complaint. Short cognitive tests can confirm whether objective evidence of impairment exists.

Other tests can determine whether a person is still able to perform daily activities successfully. More sophisticated neuropsychological tests can be helpful if there is uncertainty about findings or a need to better assess the extent of impairment. But “there is a shortage of physicians with expertise in dementia — neurologists, geriatricians, geriatric psychiatrists” — who can undertake comprehensive evaluations, said Kathryn Phillips, director of health services research and health economics at the University of California-San Francisco School of Pharmacy. The most important step is taking a careful medical history that documents whether a decline in functioning from an individual’s baseline has occurred and investigating possible causes such as sleep patterns, mental health concerns and inadequate management of chronic conditions that need attention. Mild cognitive impairment “isn’t necessarily straightforward to recognize, because people’s thinking and memory changes over time [with advancing age] and the question becomes ‘Is this something more than that?.

€™â€ said Dr. Zoe Arvanitakis, a neurologist and director of Rush University’s Rush Memory Clinic in Chicago. More than one set of tests is needed to rule out the possibility that someone performed poorly because they were nervous or sleep-deprived or had a bad day. €œAdministering tests to people over time can do a pretty good job of identifying who’s actually declining and who’s not,” Langa said. Progression.

Mild cognitive impairment doesn’t always progress to dementia, nor does it usually do so quickly. But this isn’t well understood. And estimates of progression vary, based on whether patients are seen in specialty dementia clinics or in community medical clinics and how long patients are followed. A review of 41 studies found that 5% of patients treated in community settings each year went on to develop dementia. For those seen in dementia clinics — typically, patients with more serious symptoms — the rate was 10%.

The American Academy of Neurology’s review found that after two years 15% of patients were observed to have dementia. Progression to dementia isn’t the only path people follow. A sizable portion of patients with mild cognitive impairment — from 14% to 38% — are discovered to have normal cognition upon further testing. Another portion remains stable over time. (In both cases, this may be because underlying risk factors — poor sleep, for instance, or poorly controlled diabetes or thyroid disease — have been addressed.) Still another group of patients fluctuate, sometimes improving and sometimes declining, with periods of stability in between.

€œYou really need to follow people over time — for up to 10 years — to have an idea of what is going on with them,” said Dr. Oscar Lopez, director of the Alzheimer’s Disease Research Center at the University of Pittsburgh. Specialists versus generalists. Only people with mild cognitive impairment associated with Alzheimer’s should be considered for treatment with Aduhelm, experts agreed. €œThe question you want to ask your doctor is, ‘Do I have MCI [mild cognitive impairment] due to Alzheimer’s disease?.

€™â€ Chertkow said. Because this medication targets amyloid, a sticky protein that is a hallmark of Alzheimer’s, confirmation of amyloid accumulation through a PET scan or spinal tap should be a prerequisite. But the presence of amyloid isn’t determinative. One-third of older adults with normal cognition have been found to have amyloid deposits in their brains. Because of these complexities, “I think, for the early rollout of a complex drug like this, treatment should be overseen by specialists, at least initially,” said Petersen of the Mayo Clinic.

Arvanitakis of Rush University agreed. €œIf someone is really and truly interested in trying this medication, at this point I would recommend it be done under the care of a psychiatrist or neurologist or someone who really specializes in cognition,” she said. We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips. Judith Graham.

khn.navigatingaging@gmail.com, @judith_graham Related Topics Contact Us Submit a Story TipWhen Britney Spears last went before a judge, in June, she bristled as she told of being forced into psychiatric care that cost her $60,000 a month. Though the pop star’s circumstances in a financial conservatorship are unusual, every year hundreds of thousands of other psychiatric patients also receive involuntary care, and many are stuck with the bill. Few have Spears’ resources to pay for it, which can have devastating consequences. To the frustration of those who study the issue, data on how many people are involuntarily hospitalized and how much they pay is sparse. From what can be gathered, approximately 2 million psychiatric patients are hospitalized each year in the United States, nearly half involuntarily.

One study found that a quarter of these hospitalizations are covered by private insurance, which often has high copays, and 10% were “self-pay/no charge,” where patients are often billed but cannot pay. I am a psychiatrist in New York City, and I have cared for hundreds of involuntarily hospitalized patients. Cost is almost never discussed. Many patients with serious mental illness have low incomes, unlike Britney Spears. In an informal survey of my colleagues on the issue, the most common response is, “Yeah, that feels wrong, but what else can we do?.

€ When patients pose an acutely high risk of harm to themselves or others, psychiatrists are obligated to hospitalize them against their will, even if it could lead to long-term financial strain. While hospitals sometimes absorb the cost, patients can be left with ruined credit, endless collection calls and additional mistrust of the mental health care system. In cases in which a hospital chooses to sue, patients can even be incarcerated for not showing up in court. On the hospital side, unpaid bills might further incentivize a hospital to close psych beds in favor of more lucrative medical services, such as outpatient surgeries, with better insurance reimbursement. Rebecca Lewis, a 27-year-old Ohioan, has confronted this problem for as long as she has been a psychiatric patient.

At 24, she began experiencing auditory hallucinations of people calling her name, followed by delusional beliefs about mythological creatures. While these experiences felt very real to her, she nevertheless knew something was off. Not knowing where to turn, Lewis called a crisis line, which told her to go to an evaluation center in Columbus. When she drove herself there, she found an ambulance waiting for her. €œThey told me to get into the ambulance,” she said, “and they said it would be worse if I ran.” Lewis, who was ultimately diagnosed with schizophrenia, was hospitalized for two days against her will.

She refused to sign paperwork acknowledging responsibility for charges. The hospital attempted to obtain her mother’s credit card, which Lewis had been given in case of emergencies, but she refused to hand it over. She later got a $1,700 bill in the mail. She did not contact the hospital to negotiate the bill because, she said, “I did not have the emotional energy to return to that battle.” To this day, Lewis gets debt collection calls and letters. When she picks up the calls, she explains she has no intention of paying because the services were forced on her.

Her credit is damaged, but she considers herself lucky because she was able to buy a house from a family member, given how challenging it would have been to secure a mortgage. The debt looms over her psyche. €œIt’s not fun to know that there’s this thing out there that I don’t feel that I can ever fix. I feel like I have to be extra careful — always, forever — because there’s going to be this debt,” she said. Lewis receives outpatient psychiatric care that has stabilized her and prevented further hospitalizations, but she still looks back on her first and only hospitalization with scorn.

€œThey preyed on my desperation,” she said. While it is likely that many thousands of Americans share Lewis’ experience, we lack reliable data on debt incurred for involuntary psychiatric care. According to Dr. Nathaniel Morris, an assistant professor of psychiatry at the University of California-San Francisco, we don’t know how often patients are charged for involuntary care or how much they end up paying. Even data on how often people are hospitalized against their wishes is limited.

Morris is one of the few researchers who have focused on this issue. He got interested after his patients told him about being billed after involuntary hospitalization, and he was struck by the ethical dilemma these bills represent. €œI’ve had patients ask me how much their care is going to cost, and one of the most horrible things is, as a physician, I often can’t tell them because our medical billing systems are so complex,” he said. €œThen, when you add on the involuntary psychiatric factor, it just takes it to another level.” Similarly, legal rulings on the issue are sparse. €œI’ve only seen a handful of decisions over the years,” said Ira Burnim, legal director of the Bazelon Center for Mental Health Law.

€œI don’t know that there is a consensus.” People who have been involuntarily hospitalized rarely seek a lawyer, Burnim said, but when they do, the debt collection agencies will often drop the case rather than face a costly legal battle. The media will be obsessed with Britney Spears’ next day in court, expected to be Sept. 29. She will likely describe further details of her conservatorship that will highlight the plight of many forced into care. Others won’t get that kind of attention.

As Rebecca Lewis put it, reflecting on her decision not to challenge the bills she faces. €œThey’re Goliath and I’m little David.” Dr. Christopher Magoon is a resident physician at the Columbia University Department of Psychiatry in New York City. Related Topics Contact Us Submit a Story TipThe fierce wildfires that broke out across much of the western United States this summer, spreading smoke across hundreds of miles, continue to pose a serious health hazard to millions. More are expected this fall.

That’s a major health concern because microscopic particles in wildfire smoke, carried by the wind, can penetrate deep into your lungs and travel into your bloodstream. One study linked wildfire smoke exposure to a twofold increase in the rate of asthma and a 40% rise in strokes and heart attacks. Other research tied smoke to hospital admissions, ER visits and premature deaths. The standard advice is to stay inside when heavy smoke is in the air. But the smoke can get into your house or apartment.

So you might want to consider investing in equipment to clean the air inside your home, especially with climate change likely to continue escalating the scope and intensity of the fires. €œI think we have fires enough now that people should think of this as something they want to buy,” says Deborah Bennett, a professor of public health at the University of California-Davis. €œEven if they only turn it on during the fires, there’s going to be plenty of times when they’re going to have it turned on.” There are many options for cleaning the air in your home, depending on your circumstances and — of course — your budget. If you have an HVAC system, it likely recirculates air that’s inside the house rather than drawing in air from outside. But if you have an air conditioner with a “fresh air” system that brings in outside air, you should turn off the fresh air setting on heavy smoke days.

If you don’t know how, seek professional advice. And be sure to close all doors and windows. Otherwise, your efforts will be in vain. You can convert your HVAC unit or furnace into a better air-cleaning system by installing a higher-efficiency filter capable of catching a large proportion — though it won’t get 100% — of the tiny smoke particles. To cope with wildfire smoke, many public health and air quality experts recommend what’s known as a MERV 13 filter.

MERV, or “minimum efficiency reporting value,” is a scale from 1 to 20 that rates a filter’s ability to capture particles. MERV 1 is the lowest rating, indicating the least impact on air quality, while filters rated MERV 17 or higher are used in hospital operating rooms and clean rooms. You can buy MERV 13 filters at large stores such as Costco, the Home Depot and Lowe’s or online from multiple vendors. A MERV 13 should cost around $20, or substantially less if you buy packages of them. Before you install a new filter, check first with an HVAC professional to make sure your system can accommodate it.

The more efficient the filter, the more it reduces airflow, diminishing the cooling capacity of an air conditioner and requiring more energy to run the heater. If you don’t have central air, or you have it and want to augment your system’s ability to clear the air, consider buying a portable air cleaner with a high-efficiency particulate air, or HEPA, filter, which can remove almost all particles of the tiny size found in smoke. You can put it in the room you use most during the day, then move it to your bedroom at night. If the smoke gets really bad, put it in the room of your choice and stay there as much as possible. €œIf you have an appropriately sized air cleaner with a true HEPA filter and you put it in a room and close the doors and windows, you have clean air really fast,” says Sarah Coefield, an air quality specialist with the Missoula City-County Health Department in Montana, which has had its share of wildfire smoke in recent years.

If you have kids, or share the home with other people, you should ideally have one air cleaner for each bedroom. Alternatively, you may need to put everyone in one room at night during a smoke emergency. Portable HEPA air cleaners cost anywhere from under $100 to over $1,000, depending in part on the number of square feet they can clean effectively. To clean a room, you can get a perfectly good one for under $200. All air cleaning devices sold in California must be certified by the California Air Resources Board, which posts a list of air cleaners it has certified.

You might also want to look at Consumer Reports’ list of best and worst air cleaners and at a review of those selected by The New York Times’ product review website, Wirecutter. Public health experts warn that you should avoid devices that are sold as air cleaners but actually emit ozone, the main component of smog. The air resources board also publishes a list of ozone-emitting devices. Gina Spadafori, a resident of West Sacramento, has both a central HVAC system with an extra-thick filter and a portable HEPA air cleaner she keeps in her bedroom. Spadafori, 63, has serious asthma and has long been concerned about the air quality in her house.

In recent years, she has endured numerous days of hazardous wildfire smoke and that has changed the way she uses her HVAC. €œI probably use the fan-only setting more than I have in the past to just filter the air rather than heating or cooling it,” she says. On bad air days, she turns the portable air cleaner on an hour before she goes to bed and closes the door so it will “super-clean that air” and she’ll get a good night’s sleep. €œIt’s just sort of a second line of defense,” she says. There is a lower-cost option.

Make your own air purifier by attaching a high-efficiency filter to an electric box fan. You can get a suitable fan for around $30 and the filters for around $20 — or cheaper in bulk. The website montanawildfiresmoke.org publishes a how-to guide for building such a contraption. The Environmental Protection Agency has an FAQ on box fan air cleaners with instructions for building them. The EPA recommends using only box fans built in 2012 or later, because earlier models could overheat and cause a fire.

Lab testing has clearly shown such do-it-yourself devices are safe, though they may heat up the room and produce more noise than a portable HEPA cleaner, according to the EPA. For those who can’t even afford to make an air cleaner from a house fan, nonprofits and local government agencies have provided help. People who don’t have a lot of money are likely to live in older, leakier housing that lets more smoke in. They are also more likely to have chronic illness and thus be in greater need of clean air — yet less able to afford it. Climate Smart Missoula, a Montana nonprofit, has distributed around 500 air cleaners to low-income and homebound people in recent years, said Amy Cilimburg, its executive director.

In California, the Bay Area Air Quality Management District is providing 3,000 air fiation devices to low-income people with respiratory conditions in nine counties. The American Lung Association has also donated air cleaners to people in need. But these efforts are tiny compared with the gaping need, said Cilimburg, who thinks the federal and state governments, hospitals and insurers should step in. She envisions a day when medical staffers at a clinic will tell a patient, “‘Oh, look, given x, y or z, you should just take one of these HEPA filters home with you.’” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Bernard J.

Wolfson. bwolfson@kff.org, @bjwolfson Related Topics Contact Us Submit a Story TipThe advertisement opens with a doctor sitting across from his patient and holding a prescription drug pill bottle. €œYou want to continue with this medication?. € the doctor asks while an older patient nods. The doctor then explains that he can no longer provide the medicine to her because insurance companies and Washington bureaucrats “are working together to swipe $500 billion from Medicare to pay for [House Speaker Nancy] Pelosi and [Senate Majority Leader Chuck] Schumer’s out-of-control spending spree.” “They’re calling it Medicare negotiation, but, really, it’s just a way to cut your benefits and no longer pay for lifesaving medicines,” the doctor says.

Medicare negotiation refers to the federal government bargaining directly with pharmaceutical companies on the price of prescription drugs. Currently, Medicare is prohibited from using its vast market-share muscle to set prices. But supporters of Medicare drug negotiations eye the Democratic-backed budget reconciliation bill now being discussed in Congress as a means to reverse the policy. This ad, seen on television and online, is part of a multiplatform campaign by the 60 Plus American Association of Senior Citizens, a conservative group that lobbies on senior issues and brands itself as the “right alternative to AARP.” It’s one example of a swath of ads that have popped up in the past month about Medicare drug price negotiations. Since drug pricing is a hot topic and a critical piece of the broad, politically charged debate in Congress, we thought it was important to dig into the ad’s messages.

The $500 Billion Number First, the ad claims that Medicare drug price negotiation will take “$500 billion from Medicare.” All five of the Medicare and drug pricing experts we consulted said that was a misleading way to frame this policy. The reference to $500 billion most likely comes from a Congressional Budget Office estimate of a provision in H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act. It’s an estimate of how much the government would save over 10 years if drug price negotiations were enacted.

That is, the government would be paying pharmaceutical companies $500 billion less for prescription drugs. And, in that bill, $300 billion to $400 billion of the savings were to be used to expand benefits to include dental, hearing and vision coverage, said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. Right now, Medicare doesn’t provide that coverage to seniors. If this policy were to make it into the pending budget reconciliation, some of the savings would also likely address other Democratic health care priorities, such as permanently closing the Medicaid coverage gap and improving Affordable Care Act coverage and subsidies. So the ad’s charged language — that Pelosi and Schumer are planning to “swipe” this money from Medicare — is incorrect.

That $500 billion in savings would be slated for reinvestment in the program. And some experts said the changes to drug pricing could also translate into lower premiums and out-of-pocket costs for seniors. The point of negotiations is “to spend less on the drugs we’re already buying and put the money back into the health system,” said Rachel Sachs, a law professor and expert on drug policy at Washington University in St. Louis. But what about the ad’s other main point — that Medicare negotiation will result in seniors no longer being able to get their medications?.

Since 60 Plus did not return requests for comment, it’s hard to know exactly what it is asserting will come between seniors and their medication. It’s possible the ad is implying that drugmakers may walk away from the negotiating table if they don’t like the prices the government promotes. But experts said it’s likely a financial penalty would be in place to motivate the companies to work with the government. H.R. 3 proposed an escalating excise tax.

The U.S. Has the world’s largest prescription market, so it seems unlikely companies would stop selling drugs here completely, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. And the number of drugs subject to negotiation would probably be a small subset of all drugs on the market, based on the negotiation method that was proposed in H.R. 3. In real life, the scenario shown in the ad is unlikely to happen, said Joseph Antos, senior fellow in health care policy at the American Enterprise Institute.

€œThe question of whether a drug would be taken off the market — it’s always a little hard to say and, clearly, that is a possibility,” said Antos. €œBut it’s much more plausible to say this is the kind of policy that would lead to some new drugs not coming out to the market.” That’s an argument often wielded by the pharmaceutical industry. Evidence suggests there’s a grain of truth in the assessment that lower industry profits results in less research and development, said Paul Van de Water, a senior fellow in health care policy at the Center on Budget and Policy Priorities. But only a grain. For the most part, the drug industry overstates the effect of lost profits.

€œA lot of these drugs are what’s known as ‘me-too’ medicines, which means the drugmakers are making small innovations on existing drugs,” said Van de Water. €œThe loss to Medicare beneficiaries of those types of drugs would be relatively small.” In a separate analysis, the CBO examined to what extent negotiated drug prices could squeeze the pharmaceutical industry’s R&D capacity. The agency, using a 30-year window, estimated that 59 drugs wouldn’t come to market. That’s against a baseline of about 900 drugs being released per year, said Sachs, which means it would stymie only a tiny fraction of otherwise expected drugs. Still, some experts say the CBO report can’t precisely predict the future and a loss in profits would have a larger effect on smaller, start-up pharmaceutical companies.

€œAt the small operations, a scientist thinks they have an insight into some biological process and they attract venture capitalists to develop a drug,” said Antos. €œBut drug development is a complicated business, and the drug might not make it to market. With less funds for that type of research, that is the part of the drug business most directly affected by the drug pricing policy.” Why It Matters The political stakes surrounding the Medicare drug price negotiations are high. Currently, the idea is seen as a way to help pay for the Democratic-backed health initiatives being discussed as part of the reconciliation bill. And, a recent poll from KFF shows that almost 90% of the public supports the government’s ability to negotiate for lower drug prices.

But allowing Medicare to bargain on drugs is controversial, even among Democrats, some of whom say they don’t want to stifle drug companies’ innovation, especially if it’s a big industry in the area of the country they represent. Meanwhile, PhRMA, the powerful pharmaceutical industry trade group, announced Sept. 15 it would be launching a seven-figure ad campaign against the drug pricing proposals, according to The Hill. Our Rating The 60 Plus Association ran an advertisement that claimed Medicare drug price negotiations were “swiping” $500 billion from Medicare and going to be used as a way to “cut benefits and no longer pay for lifesaving medicines.” While the $500 billion number is based on facts, everything else this ad says is misleading. If Congress approves a plan to let Medicare negotiate drug prices, Democrats are calling for most of the savings to be funneled directly back into the Medicare program to provide vision, dental and hearing benefits.

So, it’s not true that the plan for the money is to steal from Medicare. Experts also agreed it is specious to say seniors could no longer get the medications they’re currently taking. We rate this claim False. Sources60 Plus American Association of Senior Citizens, “Our Mission,” accessed Sept. 22, 202160 Plus American Association of Senior Citizens, “Protecting Medicare,” accessed Sept.

22, 2021Center on Budget and Policy Priorities, Build Back Better Legislation Would Close the Medicaid Coverage Gap, Sept. 13, 2021Congressional Budget Office, CBO’s Simulation Model of New Drug Development, August 2021Congressional Budget Office, H.R. 3, Elijah E. Cummings Lower Drug Costs Now Act Cost Estimate, Dec. 10, 2019Congress.gov, H.R.3 — Elijah E.

Cummings Lower Drug Costs Now Act — 116th Congress (2019-2020), accessed Sept. 22, 2021Email interview with Stacie Dusetzina, associate professor of health policy at Vanderbilt University, Sept. 21, 2021Fierce Pharma, “Advocates Roll Pricey Ad Campaigns as Biden, Congress Push for Medicare Drug Negotiations,” Aug. 17, 2021The Hill, “PhRMA Launches 7-Figure Ad Campaign Against Democrats’ Drug Pricing Measures,” Sept. 15, 2021KFF, What’s the Latest on Medicare Drug Price Negotiations?.

, July 23, 2021KFF, Public Opinion on Prescription Drugs and Their Prices, June 15, 2021KHN/PolitiFact, “Pharma’s Take on the Pelosi Drug-Pricing Bill. Fair Warning or Fearmongering?. € Dec. 5, 2019KHN/PolitiFact, “Biden Promise Tracker — Promise. Lower Cost of Prescription Drugs,” updated July 15, 2021Open Secrets, “Pharmaceutical Industry Backs Democratic Holdouts on Drug Pricing Plan,” Sept.

17, 2021Politico, “House Leadership Looks to Jam Holdouts on Drug Pricing,” Sept. 21, 2021Phone interview with Juliette Cubanski, deputy director of the program on Medicare policy at KFF, Sept. 21, 2021Phone interview with Joseph Antos, senior fellow and Wilson H. Taylor Scholar in health care and retirement policy at the American Enterprise Institute, Sept. 21, 2021Phone interview with Paul N.

Van de Water, senior fellow at the Center on Budget and Policy Priorities, Sept. 21, 2021Phone interview with Rachel Sachs, Treiman professor of law at Washington University in St. Louis School of Law, Sept. 21, 2021The Washington Post, “Three Democrats Say They’ll Oppose Party’s Drug-Price Plan, Creating Roadblock for Larger Package,” Sept. 14, 2021YouTube, 60 Plus Association Official Account, “Doctor’s Visit,” Sept.

10, 2021 Victoria Knight. vknight@kff.org, @victoriaregisk Related Topics Contact Us Submit a Story Tip.