Generic levitra price

Covid-19 has created a crisis throughout the generic levitra price world. This crisis has produced a test of leadership generic levitra price. With no good options to combat a novel pathogen, countries were forced to make hard choices about how generic levitra price to respond. Here in the generic levitra price United States, our leaders have failed that test.

They have taken a crisis and turned it into generic levitra price a tragedy.The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double generic levitra price that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. Covid-19 is an overwhelming challenge, and many generic levitra price factors contribute to its severity.

But the one we can control is how we generic levitra price behave. And in the generic levitra price United States we have consistently behaved poorly.We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, generic levitra price as compared with more than 500 per million in the United States.

Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, generic levitra price along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used generic levitra price these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by generic levitra price orders of magnitude.Why has the United States handled this pandemic so badly?. We have failed at almost every step.

We had ample warning, but generic levitra price when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be generic levitra price way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and generic levitra price Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.2 Moreover, a lack of emphasis on developing capacity has meant that U.S. Test results are often long delayed, rendering the results generic levitra price useless for disease control.Although we tend to focus on technology, most of the interventions that have large effects are not complicated.

The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing generic levitra price have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people generic levitra price simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures. The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust.The generic levitra price United States came into this crisis with enormous advantages.

Along with tremendous manufacturing capacity, we have a generic levitra price biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much generic levitra price of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and generic levitra price even denigrate experts.The response of our nation’s leaders has been consistently inadequate.

The federal government has generic levitra price largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by generic levitra price competence. But whatever their competence, governors do not have the tools that Washington controls. Instead of using those tools, the federal government has generic levitra price undermined them.

The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has suffered generic levitra price dramatic testing and policy failures. The National Institutes of Health have generic levitra price played a key role in vaccine development but have been excluded from much crucial government decision making. And the Food and Drug Administration has been shamefully politicized,3 appearing to respond to pressure from the administration generic levitra price rather than scientific evidence. Our current leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them.

Instead of relying on expertise, the administration generic levitra price has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.Let’s be clear about the cost of not taking even simple measures. An outbreak that has disproportionately affected communities of generic levitra price color has exacerbated the tensions associated with inequality. Many of our children are missing school at critical generic levitra price times in their social and intellectual development. The hard work of health care professionals, who have put their lives on the line, has generic levitra price not been used wisely.

Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have died generic levitra price. Some deaths generic levitra price from Covid-19 were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands generic levitra price in a pandemic that has already killed more Americans than any conflict since World War II.Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences.

Our leaders have largely generic levitra price claimed immunity for their actions. But this election gives us the power to render judgment. Reasonable people will certainly disagree generic levitra price about the many political positions taken by candidates. But truth is neither liberal nor conservative generic levitra price.

When it comes to the response to the largest public health crisis of our time, our current generic levitra price political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable generic levitra price the deaths of thousands more Americans by allowing them to keep their jobs.Patients Figure 1. Figure 1. Enrollment and generic levitra price Randomization.

Of the 1114 patients who were assessed for eligibility, 1062 underwent randomization generic levitra price. 541 were assigned to the remdesivir group and 521 to the generic levitra price placebo group (intention-to-treat population) (Figure 1). 159 (15.0%) generic levitra price were categorized as having mild-to-moderate disease, and 903 (85.0%) were in the severe disease stratum. Of those assigned to receive remdesivir, 531 patients (98.2%) received the treatment as assigned.

Fifty-two patients had remdesivir treatment discontinued before day 10 because of an adverse event or a serious generic levitra price adverse event other than death and 10 withdrew consent. Of those assigned to receive generic levitra price placebo, 517 patients (99.2%) received placebo as assigned. Seventy patients discontinued placebo before day 10 because of an adverse event or a serious adverse event other than death generic levitra price and 14 withdrew consent. A total of 517 patients in the remdesivir group and 508 in the placebo group completed the generic levitra price trial through day 29, recovered, or died.

Fourteen patients who received remdesivir and 9 who received placebo terminated their participation in the trial before day 29. A total of 54 of the patients who were in the mild-to-moderate stratum at randomization were subsequently determined to meet generic levitra price the criteria for severe disease, resulting in 105 patients in the mild-to-moderate disease stratum and 957 in the severe stratum. The as-treated population included 1048 patients who received the assigned treatment (532 in the remdesivir group, including one patient who had been randomly generic levitra price assigned to placebo and received remdesivir, and 516 in the placebo group). Table 1 generic levitra price.

Table 1 generic levitra price. Demographic and Clinical Characteristics of the Patients at Baseline. The mean age of the patients was 58.9 years, and 64.4% were generic levitra price male (Table 1). On the basis of the evolving epidemiology of Covid-19 during the trial, generic levitra price 79.8% of patients were enrolled at sites in North America, 15.3% in Europe, and 4.9% in Asia (Table S1 in the Supplementary Appendix).

Overall, 53.3% of the patients were White, 21.3% were Black, 12.7% were Asian, and 12.7% were designated as other or generic levitra price not reported. 250 (23.5%) were Hispanic or generic levitra price Latino. Most patients had either one (25.9%) or two or more (54.5%) of the prespecified coexisting conditions at enrollment, most commonly hypertension (50.2%), obesity (44.8%), and type 2 diabetes mellitus (30.3%). The median number of days between symptom onset and randomization was 9 (interquartile generic levitra price range, 6 to 12) (Table S2).

A total of 957 patients (90.1%) had generic levitra price severe disease at enrollment. 285 patients (26.8%) met category 7 criteria on the ordinal scale, generic levitra price 193 (18.2%) category 6, 435 (41.0%) category 5, and 138 (13.0%) category 4. Eleven patients (1.0%) had missing ordinal scale data at enrollment generic levitra price. All these patients discontinued the study before treatment.

During the study, 373 patients (35.6% of the 1048 patients in the as-treated population) received hydroxychloroquine generic levitra price and 241 (23.0%) received a glucocorticoid (Table S3). Primary Outcome Figure 2 generic levitra price. Figure 2 generic levitra price. Kaplan–Meier Estimates generic levitra price of Cumulative Recoveries.

Cumulative recovery estimates are shown in the overall population (Panel A), in patients with a baseline score of 4 generic levitra price on the ordinal scale (not receiving oxygen. Panel B), in those with a baseline score of 5 (receiving oxygen. Panel C), in those with a baseline score of 6 (receiving high-flow generic levitra price oxygen or noninvasive mechanical ventilation. Panel D), and in those with a baseline score of 7 generic levitra price (receiving mechanical ventilation or extracorporeal membrane oxygenation [ECMO].

Panel E).Table generic levitra price 2. Table 2 generic levitra price. Outcomes Overall and According to Score on the Ordinal Scale in the Intention-to-Treat Population. Figure 3 generic levitra price.

Figure 3 generic levitra price. Time to generic levitra price Recovery According to Subgroup. The widths of the confidence intervals have not been adjusted for multiplicity and generic levitra price therefore cannot be used to infer treatment effects. Race and ethnic group were reported by the patients.Patients in the remdesivir group had a shorter time to recovery than patients in the placebo group (median, 10 days, as compared with 15 days.

Rate ratio for recovery, generic levitra price 1.29. 95% confidence interval generic levitra price [CI], 1.12 to 1.49. P<0.001) (Figure generic levitra price 2 and Table 2). In the severe disease stratum (957 patients) the median time to recovery was 11 days, as compared with 18 days (rate ratio for recovery, 1.31 generic levitra price.

95% CI, 1.12 to 1.52) (Table S4). The rate ratio for generic levitra price recovery was largest among patients with a baseline ordinal score of 5 (rate ratio for recovery, 1.45. 95% CI, 1.18 to 1.79) generic levitra price. Among patients with a baseline score of 4 and those with a baseline score of 6, the generic levitra price rate ratio estimates for recovery were 1.29 (95% CI, 0.91 to 1.83) and 1.09 (95% CI, 0.76 to 1.57), respectively.

For those receiving mechanical ventilation or ECMO at enrollment (baseline ordinal score of 7), the rate ratio for recovery was 0.98 generic levitra price (95% CI, 0.70 to 1.36). Information on interactions of treatment with baseline ordinal score as a continuous variable is provided in Table S11. An analysis adjusting for baseline ordinal score as a covariate was conducted to evaluate the overall effect (of the percentage of patients in each ordinal generic levitra price score category at baseline) on the primary outcome. This adjusted analysis produced a similar treatment-effect generic levitra price estimate (rate ratio for recovery, 1.26.

95% CI, 1.09 generic levitra price to 1.46). Patients who underwent randomization generic levitra price during the first 10 days after the onset of symptoms had a rate ratio for recovery of 1.37 (95% CI, 1.14 to 1.64), whereas patients who underwent randomization more than 10 days after the onset of symptoms had a rate ratio for recovery of 1.20 (95% CI, 0.94 to 1.52) (Figure 3). The benefit of remdesivir was larger when given earlier in the illness, though the benefit persisted in most analyses of duration of symptoms (Table S6). Sensitivity analyses in which data were censored at earliest reported use generic levitra price of glucocorticoids or hydroxychloroquine still showed efficacy of remdesivir (9.0 days to recovery with remdesivir vs.

14.0 days generic levitra price to recovery with placebo. Rate ratio, 1.28 generic levitra price. 95% CI, 1.09 to 1.50, and 10.0 vs generic levitra price. 16.0 days to recovery.

Rate ratio, 1.32 generic levitra price. 95% CI, 1.11 to 1.58, respectively) generic levitra price (Table S8). Key Secondary Outcome The odds of improvement in the ordinal scale score were higher in the remdesivir group, as determined by a proportional odds generic levitra price model at the day 15 visit, than in the placebo group (odds ratio for improvement, 1.5. 95% CI, 1.2 to 1.9, adjusted for disease severity) generic levitra price (Table 2 and Fig.

S7). Mortality Kaplan–Meier estimates of mortality by day 15 were 6.7% in the remdesivir group generic levitra price and 11.9% in the placebo group (hazard ratio, 0.55. 95% CI, 0.36 to 0.83) generic levitra price. The estimates by day 29 were 11.4% generic levitra price and 15.2% in two groups, respectively (hazard ratio, 0.73.

95% CI, generic levitra price 0.52 to 1.03). The between-group differences in mortality varied considerably according to baseline severity (Table 2), with the largest difference seen among patients with a baseline ordinal score of 5 (hazard ratio, 0.30. 95% CI, 0.14 generic levitra price to 0.64). Information on interactions of treatment with baseline ordinal score with respect to mortality generic levitra price is provided in Table S11.

Additional Secondary generic levitra price Outcomes Table 3. Table 3 generic levitra price. Additional Secondary Outcomes. Patients in the remdesivir group had a shorter time to improvement of one or of two categories on the ordinal scale from generic levitra price baseline than patients in the placebo group (one-category improvement.

Median, 7 generic levitra price vs. 9 days generic levitra price. Rate ratio generic levitra price for recovery, 1.23. 95% CI, 1.08 to 1.41.

Two-category improvement generic levitra price. Median, 11 vs generic levitra price. 14 days generic levitra price. Rate ratio, 1.29 generic levitra price.

95% CI, 1.12 to 1.48) (Table 3). Patients in the remdesivir group had a shorter time to discharge or to a National Early Warning Score of 2 or lower than those generic levitra price in the placebo group (median, 8 days vs. 12 days generic levitra price. Hazard ratio, 1.27 generic levitra price.

95% CI, 1.10 generic levitra price to 1.46). The initial length of hospital stay was shorter in the remdesivir group than in the placebo group (median, 12 days vs. 17 days) generic levitra price. 5% of patients in the generic levitra price remdesivir group were readmitted to the hospital, as compared with 3% in the placebo group.

Among the 913 patients receiving oxygen at enrollment, those in the remdesivir group continued to receive oxygen generic levitra price for fewer days than patients in the placebo group (median, 13 days vs. 21 days), and the incidence of new oxygen use among patients who were not receiving oxygen at enrollment was lower in the remdesivir group than generic levitra price in the placebo group (incidence, 36% [95% CI, 26 to 47] vs. 44% [95% CI, 33 to 57]). For the 193 patients receiving noninvasive ventilation or high-flow oxygen at enrollment, the median duration generic levitra price of use of these interventions was 6 days in both the remdesivir and placebo groups.

Among the 573 patients who were not receiving noninvasive ventilation, high-flow oxygen, invasive ventilation, generic levitra price or ECMO at baseline, the incidence of new noninvasive ventilation or high-flow oxygen use was lower in the remdesivir group than in the placebo group (17% [95% CI, 13 to 22] vs. 24% [95% CI, 19 generic levitra price to 30]). Among the 285 patients who were receiving generic levitra price mechanical ventilation or ECMO at enrollment, patients in the remdesivir group received these interventions for fewer subsequent days than those in the placebo group (median, 17 days vs. 20 days), and the incidence of new mechanical ventilation or ECMO use among the 766 patients who were not receiving these interventions at enrollment was lower in the remdesivir group than in the placebo group (13% [95% CI, 10 to 17] vs.

23% [95% generic levitra price CI, 19 to 27]) (Table 3). Safety Outcomes In the as-treated population, serious generic levitra price adverse events occurred in 131 of 532 patients (24.6%) in the remdesivir group and in 163 of 516 patients (31.6%) in the placebo group (Table S17). There were 47 serious respiratory failure adverse events in the remdesivir group (8.8% of patients), including acute respiratory failure and the need for endotracheal intubation, and 80 in the placebo group (15.5% generic levitra price of patients) (Table S19). No deaths were considered by the investigators to generic levitra price be related to treatment assignment.

Grade 3 generic levitra price or 4 adverse events occurred on or before day 29 in 273 patients (51.3%) in the remdesivir group and in 295 (57.2%) in the placebo group (Table S18). 41 events were judged by the investigators to be related to remdesivir and 47 events to placebo (Table S17). The most common nonserious adverse events occurring in at least 5% of generic levitra price all patients included decreased glomerular filtration rate, decreased hemoglobin level, decreased lymphocyte count, respiratory failure, anemia, pyrexia, hyperglycemia, increased blood creatinine level, and increased blood glucose level (Table S20). The incidence of these adverse events was generally similar in the remdesivir and generic levitra price placebo groups.

Crossover After the data and safety monitoring board recommended that the preliminary primary analysis report be provided to the sponsor, data on a generic levitra price total of 51 patients (4.8% of the total study enrollment) — 16 (3.0%) in the remdesivir group and 35 (6.7%) in the placebo group — were unblinded. 26 (74.3%) of those in the placebo group whose data were unblinded were given remdesivir generic levitra price. Sensitivity analyses evaluating the unblinding (patients whose treatment assignments were unblinded had their data censored at the time of unblinding) and crossover (patients in the placebo group treated with remdesivir had their data censored at the initiation of remdesivir treatment) produced results similar to those of the primary analysis (Table S9).Trial Objectives, Participants, and Oversight We assessed the safety and immunogenicity of three dose levels of BNT162b1 and BNT162b2. Healthy adults 18 to 55 years of age or 65 to 85 years of age were eligible for generic levitra price inclusion.

Key exclusion criteria were known infection with human generic levitra price immunodeficiency virus, hepatitis C virus, or hepatitis B virus. An immunocompromised generic levitra price condition. A history generic levitra price of autoimmune disease. A previous clinical or microbiologic diagnosis of Covid-19.

The receipt generic levitra price of medications intended to prevent Covid-19. Any previous coronavirus vaccination generic levitra price. Positive test generic levitra price for SARS-CoV-2 IgM or IgG at the screening visit. And positive nasal-swab results on a SARS-CoV-2 nucleic acid amplification test within 24 hours before the receipt of trial vaccine generic levitra price or placebo.

BioNTech was the regulatory sponsor of the trial. Pfizer was responsible generic levitra price for the trial design. For the collection, analysis, and interpretation of the data generic levitra price. And for the writing of generic levitra price the report.

The corresponding generic levitra price author had full access to all the data in the trial and had final responsibility for the decision to submit the manuscript for publication. All the trial data were available to all the authors. Trial Procedures Using an interactive Web-based response technology system, we randomly assigned trial participants to groups defined generic levitra price according to the vaccine candidate, dose level, and age range. Groups of participants 18 to generic levitra price 55 years of age and 65 to 85 years of age were to receive doses of 10 μg, 20 μg, or 30 μg of BNT162b1 or BNT162b2 (or placebo) on a two-dose schedule.

One group of participants 18 to generic levitra price 55 years of age was assigned to receive 100-μg doses of BNT162b1 or placebo. All the participants were assigned to receive two 0.5-ml injections of active vaccine (BNT162b1 or BNT162b2) or placebo into the deltoid, generic levitra price administered 21 days apart. The first five participants in each new dose level or age group (with a randomization ratio of 4:1 for active vaccine:placebo) were observed for 4 hours after the injection to identify immediate adverse events. All the other participants were observed for generic levitra price 30 minutes.

Blood samples were obtained for safety and immunogenicity assessments generic levitra price. Safety The primary end points in phase 1 of this trial were solicited local reactions (i.e., specific local generic levitra price reactions as prompted by and recorded in an electronic diary), systemic events, and use of antipyretic or pain medication within 7 days after the receipt of vaccine or placebo, as prompted by and recorded in an electronic diary. Unsolicited adverse events and serious adverse events (i.e., those reported by the participants, without electronic-diary prompts), assessed from the receipt of the first dose through 1 month and 6 months, respectively, after the receipt of the second generic levitra price dose. Clinical laboratory abnormalities, assessed 1 day and 7 days after the receipt of vaccine or placebo.

And grading shifts in laboratory assessments between baseline and 1 day and 7 days after the first generic levitra price dose and between 2 days and 7 days after the second dose. Protocol-specified safety stopping rules were in effect for all the generic levitra price participants in the phase 1 portion of the trial. The full protocol, including the statistical analysis plan, is available with the full text of this article at NEJM.org generic levitra price. An internal review committee and an external data and safety monitoring committee reviewed generic levitra price all safety data.

Immunogenicity Immunogenicity assessments (SARS-CoV-2 serum neutralization assay and receptor-binding domain [RBD]–binding or S1-binding IgG direct Luminex immunoassays) were conducted before the administration of vaccine or placebo, at 7 days and 21 days after the first dose, and at 7 days (i.e., day 28) and 14 days (i.e., day 35) after the second dose. The neutralization assay, which also generated previously described virus-neutralization data from trials of the BNT162 candidates,2,5 used a previously described strain of SARS-CoV-2 (USA_WA1/2020) that had been generated by reverse generic levitra price genetics and engineered by the insertion of an mNeonGreen gene into open reading frame 7 of the viral genome.11,12 The 50% neutralization titers and 90% neutralization titers were reported as the interpolated reciprocal of the dilutions yielding 50% and 90% reductions, respectively, in fluorescent viral foci. Any serologic values below the lower limit of quantitation were set generic levitra price to 0.5 times the lower limit of quantitation. Available serologic results were included in the generic levitra price analysis.

Immunogenicity data from a human convalescent serum panel were generic levitra price included as a benchmark. A total of 38 serum samples were obtained from donors 18 to 83 years of age (median age, 42.5 years) who had recovered from SARS-CoV-2 infection or Covid-19. Samples were obtained at least 14 days generic levitra price after a polymerase chain reaction–confirmed diagnosis and after symptom resolution. Neutralizing geometric mean titers generic levitra price (GMTs) in subgroups of the donors were as follows.

90, among 35 donors with generic levitra price symptomatic infections. 156, among 3 generic levitra price donors with asymptomatic infection. And 618, in 1 donor who was hospitalized. Each serum sample in the panel was from a generic levitra price different donor.

Thus, most of the serum samples generic levitra price were obtained from persons with moderate Covid-19 who had not been hospitalized. The serum samples were obtained from Sanguine Biosciences, the MT Group, generic levitra price and Pfizer Occupational Health and Wellness. Statistical Analysis We report descriptive results of safety and immunogenicity analyses, and the sample size was not based on generic levitra price statistical hypothesis testing. Results of the safety analyses are presented as counts, percentages, and associated Clopper–Pearson 95% confidence intervals for local reactions, systemic events, and any adverse events after the administration of vaccine or placebo, according to terms in the Medical Dictionary for Regulatory Activities, version 23.0, for each vaccine group.

Summary statistics are provided generic levitra price for abnormal laboratory values and grading shifts. Given the small number of participants in each group, the trial was not powered for formal statistical generic levitra price comparisons between dose levels or between age groups. Immunogenicity analyses of SARS-CoV-2 serum neutralizing titers, S1-binding IgG and RBD-binding IgG concentrations, GMTs, and geometric mean concentrations (GMCs) were generic levitra price computed along with associated 95% confidence intervals. The GMTs and GMCs were calculated as the mean of the generic levitra price assay results after the logarithmic transformation was made.

We then exponentiated the mean to express results on the original scale. Two-sided 95% confidence intervals were obtained by performing logarithmic transformations of titers or concentrations, calculating the 95% confidence interval with reference to Student’s t-distribution, and then exponentiating the limits of the confidence intervals.Trial Design generic levitra price and Oversight The RECOVERY trial is an investigator-initiated platform trial to evaluate the effects of potential treatments in patients hospitalized with Covid-19. The trial is being conducted generic levitra price at 176 hospitals in the United Kingdom. (Details are provided in the Supplementary Appendix, available with the full text of this article at NEJM.org.) The investigators were assisted by the National Institute for Health Research Clinical Research Network, and generic levitra price the trial is coordinated by the Nuffield Department of Population Health at the University of Oxford, the trial sponsor.

Although patients are no longer being enrolled in the generic levitra price hydroxychloroquine, dexamethasone, and lopinavir–ritonavir groups, the trial continues to study the effects of azithromycin, tocilizumab, convalescent plasma, and REGN-COV2 (a combination of two monoclonal antibodies directed against the SARS-CoV-2 spike protein). Other treatments may be studied in the future. The hydroxychloroquine that was used in this phase of generic levitra price the trial was supplied by the U.K. National Health Service (NHS) generic levitra price.

Hospitalized patients generic levitra price were eligible for the trial if they had clinically-suspected or laboratory-confirmed SARS-CoV-2 infection and no medical history that might, in the opinion of the attending clinician, put patients at substantial risk if they were to participate in the trial. Initially, recruitment was limited to generic levitra price patients who were at least 18 years of age, but the age limit was removed as of May 9, 2020. Written informed consent was obtained from all the patients or from a legal representative if they were too unwell or unable to provide consent. The trial was conducted in accordance with Good Clinical Practice guidelines of the International Conference on Harmonisation and was approved generic levitra price by the U.K.

Medicines and Healthcare Products Regulatory Agency generic levitra price (MHRA) and the Cambridge East Research Ethics Committee. The protocol with its generic levitra price statistical analysis plan are available at NEJM.org, with additional information in the Supplementary Appendix and on the trial website at www.recoverytrial.net. The initial version of the manuscript was drafted by the first and last generic levitra price authors, developed by the writing committee, and approved by all members of the trial steering committee. The funders had no role in the analysis of the data, in the preparation or approval of the manuscript, or in the decision to submit the generic levitra price manuscript for publication.

The first and last members of the writing committee vouch for the completeness and accuracy of the data and for the fidelity of the trial to the protocol and statistical analysis plan. Randomization and Treatment We collected generic levitra price baseline data using a Web-based case-report form that included demographic data, level of respiratory support, major coexisting illnesses, the suitability of the trial treatment for a particular patient, and treatment availability at the trial site. Using a Web-based unstratified randomization method with the concealment of generic levitra price trial group, we assigned patients to receive either the usual standard of care or the usual standard of care plus hydroxychloroquine or one of the other available treatments that were being evaluated. The number of patients who were assigned to receive usual care was twice the number who generic levitra price were assigned to any of the active treatments for which the patient was eligible (e.g., 2:1 ratio in favor of usual care if the patient was eligible for only one active treatment group, 2:1:1 if the patient was eligible for two active treatments, etc.).

For some patients, hydroxychloroquine was unavailable at the hospital at the time of enrollment or was considered by the managing generic levitra price physician to be either definitely indicated or definitely contraindicated. Patients with a known prolonged corrected QT interval on electrocardiography were ineligible to receive hydroxychloroquine. (Coadministration with medications generic levitra price that prolong the QT interval was not an absolute contraindication, but attending clinicians were advised to check the QT interval by performing electrocardiography.) These patients were excluded from entry in the randomized comparison between hydroxychloroquine and usual care. In the hydroxychloroquine group, patients received hydroxychloroquine sulfate (in the form of a 200-mg tablet containing a 155-mg base equivalent) in a loading dose of four tablets (total dose, 800 mg) at baseline and at 6 hours, which was followed by two tablets (total dose, 400 mg) starting at 12 hours after the initial dose and then every 12 hours for the next 9 days or until discharge, whichever occurred earlier (see the Supplementary Appendix).15 The assigned treatment generic levitra price was prescribed by the attending clinician.

The patients generic levitra price and local trial staff members were aware of the assigned trial groups. Procedures A single online follow-up form was to be completed by the local generic levitra price trial staff members when each trial patient was discharged, at 28 days after randomization, or at the time of death, whichever occurred first. Information was recorded regarding the adherence to the assigned treatment, receipt of other treatments for Covid-19, duration of admission, receipt of respiratory support (with duration and type), receipt of renal dialysis or hemofiltration, and vital status (including cause of death). Starting on May 12, 2020, extra information was recorded on generic levitra price the occurrence of new major cardiac arrhythmia.

In addition, we obtained routine health care and registry data that generic levitra price included information on vital status (with date and cause of death) and discharge from the hospital. Outcome Measures generic levitra price The primary outcome was all-cause mortality within 28 days after randomization. Further analyses were specified at 6 generic levitra price months. Secondary outcomes were the time until discharge from the hospital and a composite of the initiation of invasive mechanical ventilation including extracorporeal membrane oxygenation or death among patients who were not receiving invasive mechanical ventilation at the time of randomization.

Decisions to generic levitra price initiate invasive mechanical ventilation were made by the attending clinicians, who were informed by guidance from NHS England and the National Institute for Health and Care Excellence. Subsidiary clinical outcomes included cause-specific mortality (which was recorded in all patients) and major cardiac arrhythmia (which was recorded in a subgroup of generic levitra price patients). All information generic levitra price presented in this report is based on a data cutoff of September 21, 2020. Information regarding the primary outcome is complete for all generic levitra price the trial patients.

Statistical Analysis For the primary outcome of 28-day mortality, we used the log-rank observed-minus-expected statistic and its variance both to test the null hypothesis of equal survival curves and to calculate the one-step estimate of the average mortality rate ratio in the comparison between the hydroxychloroquine group and the usual-care group. Kaplan–Meier survival curves were constructed to show cumulative mortality generic levitra price over the 28-day period. The same methods were used to analyze the time until hospital discharge, with censoring of data on day 29 generic levitra price for patients who had died in the hospital. We used the Kaplan–Meier generic levitra price estimates to calculate the median time until hospital discharge.

For the generic levitra price prespecified composite secondary outcome of invasive mechanical ventilation or death within 28 days (among patients who had not been receiving invasive mechanical ventilation at randomization), the precise date of the initiation of invasive mechanical ventilation was not available, so the risk ratio was estimated instead. Estimates of the between-group difference in absolute risk were also calculated. All the analyses were generic levitra price performed according to the intention-to-treat principle. Prespecified analyses of the primary outcome were performed in generic levitra price six subgroups, as defined by characteristics at randomization.

Age, sex, race, level of respiratory support, days since symptom generic levitra price onset, and predicted 28-day risk of death. (Details are provided in the Supplementary generic levitra price Appendix.) Estimates of rate and risk ratios are shown with 95% confidence intervals without adjustment for multiple testing. The P value for the assessment of the primary outcome is two-sided. The full database is held by the trial team, which collected the data from the trial sites and generic levitra price performed the analyses, at the Nuffield Department of Population Health at the University of Oxford.

The independent data monitoring committee was asked to review unblinded analyses of the trial data and any other information that was considered to generic levitra price be relevant at intervals of approximately 2 weeks. The committee was then charged generic levitra price with determining whether the randomized comparisons in the trial provided evidence with respect to mortality that was strong enough (with a range of uncertainty around the results that was narrow enough) to affect national and global treatment strategies. In such a circumstance, the committee would inform the members of the trial steering committee, who would make the results available to the public and amend the generic levitra price trial accordingly. Unless that happened, the steering committee, investigators, and all others involved in the trial would remain unaware of the interim results until 28 days after the last patient had been randomly assigned to a particular treatment group.

On June 4, 2020, in response to a request from the MHRA, the independent data monitoring committee conducted a review of the data and recommended that the chief investigators review the unblinded generic levitra price data for the hydroxychloroquine group. The chief investigators and steering committee members concluded that the data showed generic levitra price no beneficial effect of hydroxychloroquine in patients hospitalized with Covid-19. Therefore, the enrollment of patients in the hydroxychloroquine group was closed on June 5, 2020, and the preliminary result for the generic levitra price primary outcome was made public. Investigators were advised that any patients who were receiving hydroxychloroquine as part of the trial should discontinue the treatment.Supported by a philanthropic donation from Stein Erik Hagen and Canica generic levitra price.

By a grant from the Deutsche Forschungsgemeinschaft Cluster of Excellence “Precision Medicine in Chronic Inflammation” (EXC2167). By a Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Covid-19 Biobank generic levitra price grant (to Dr. Valenti). By grants from the Italian Ministry of Health (RF-2016-02364358, to Dr.

Valenti) and Ministero dell’Istruzione, dell’Università e della Ricerca project “Dipartimenti di Eccellenza 2018–2022” (D15D18000410001 to the Department of Medical Sciences, University of Turin. By a grant from the Spanish Ministry of Science and Innovation JdC fellowship (IJC2018-035131-I, to Dr. Acosta-Herrera). And by the GCAT Cession Research Project PI-2020-01.

HLA typing was performed and supported by the Stefan-Morsch-Stiftung. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. Dr. Ellinghaus and Ms.

Degenhardt and Drs. Valenti, Franke, and Karlsen contributed equally to this article.The members of the writing committee (David Ellinghaus, Ph.D., Frauke Degenhardt, M.Sc., Luis Bujanda, M.D., Ph.D., Maria Buti, M.D., Ph.D., Agustín Albillos, M.D., Ph.D., Pietro Invernizzi, M.D., Ph.D., Javier Fernández, M.D., Ph.D., Daniele Prati, M.D., Guido Baselli, Ph.D., Rosanna Asselta, Ph.D., Marit M. Grimsrud, M.D., Chiara Milani, Ph.D., Fátima Aziz, B.S., Jan Kässens, Ph.D., Sandra May, Ph.D., Mareike Wendorff, M.Sc., Lars Wienbrandt, Ph.D., Florian Uellendahl-Werth, M.Sc., Tenghao Zheng, M.D., Ph.D., Xiaoli Yi, Raúl de Pablo, M.D., Ph.D., Adolfo G. Chercoles, B.S., Adriana Palom, M.S., B.S., Alba-Estela Garcia-Fernandez, B.S., Francisco Rodriguez-Frias, M.S., Ph.D., Alberto Zanella, M.D., Alessandra Bandera, M.D., Ph.D., Alessandro Protti, M.D., Alessio Aghemo, M.D., Ph.D., Ana Lleo, M.D., Ph.D., Andrea Biondi, M.D., Andrea Caballero-Garralda, M.S., Ph.D., Andrea Gori, M.D., Anja Tanck, Anna Carreras Nolla, B.S., Anna Latiano, Ph.D., Anna Ludovica Fracanzani, M.D., Anna Peschuck, Antonio Julià, Ph.D., Antonio Pesenti, M.D., Antonio Voza, M.D., David Jiménez, M.D., Ph.D., Beatriz Mateos, M.D., Ph.D., Beatriz Nafria Jimenez, B.S., Carmen Quereda, M.D., Ph.D., Cinzia Paccapelo, M.Sc., Christoph Gassner, Ph.D., Claudio Angelini, M.D., Cristina Cea, B.S., Aurora Solier, M.D., David Pestaña, M.D., Ph.D., Eduardo Muñiz-Diaz, M.D., Ph.D., Elena Sandoval, M.D., Elvezia M.

Paraboschi, Ph.D., Enrique Navas, M.D., Ph.D., Félix García Sánchez, Ph.D., Ferruccio Ceriotti, M.D., Filippo Martinelli-Boneschi, M.D., Ph.D., Flora Peyvandi, M.D., Ph.D., Francesco Blasi, M.D., Ph.D., Luis Téllez, M.D., Ph.D., Albert Blanco-Grau, B.S., M.S., Georg Hemmrich-Stanisak, Ph.D., Giacomo Grasselli, M.D., Giorgio Costantino, M.D., Giulia Cardamone, Ph.D., Giuseppe Foti, M.D., Serena Aneli, Ph.D., Hayato Kurihara, M.D., Hesham ElAbd, M.Sc., Ilaria My, M.D., Iván Galván-Femenia, M.Sc., Javier Martín, M.D., Ph.D., Jeanette Erdmann, Ph.D., Jose Ferrusquía-Acosta, M.D., Koldo Garcia-Etxebarria, Ph.D., Laura Izquierdo-Sanchez, B.S., Laura R. Bettini, M.D., Lauro Sumoy, Ph.D., Leonardo Terranova, Ph.D., Leticia Moreira, M.D., Ph.D., Luigi Santoro, M.S., Luigia Scudeller, M.D., Francisco Mesonero, M.D., Luisa Roade, M.D., Malte C. Rühlemann, Ph.D., Marco Schaefer, Ph.D., Maria Carrabba, M.D., Ph.D., Mar Riveiro-Barciela, M.D., Ph.D., Maria E. Figuera Basso, Maria G.

Valsecchi, Ph.D., María Hernandez-Tejero, M.D., Marialbert Acosta-Herrera, Ph.D., Mariella D’Angiò, M.D., Marina Baldini, M.D., Marina Cazzaniga, M.D., Martin Schulzky, M.A., Maurizio Cecconi, M.D., Ph.D., Michael Wittig, M.Sc., Michele Ciccarelli, M.D., Miguel Rodríguez-Gandía, M.D., Monica Bocciolone, M.D., Monica Miozzo, Ph.D., Nicola Montano, M.D., Ph.D., Nicole Braun, Nicoletta Sacchi, Ph.D., Nilda Martínez, M.D., Onur Özer, M.Sc., Orazio Palmieri, Ph.D., Paola Faverio, M.D., Paoletta Preatoni, M.D., Paolo Bonfanti, M.D., Paolo Omodei, M.D., Paolo Tentorio, M.S., Pedro Castro, M.D., Ph.D., Pedro M. Rodrigues, Ph.D., Aaron Blandino Ortiz, M.D., Rafael de Cid, Ph.D., Ricard Ferrer, M.D., Roberta Gualtierotti, M.D., Rosa Nieto, M.D., Siegfried Goerg, M.D., Salvatore Badalamenti, M.D., Ph.D., Sara Marsal, Ph.D., Giuseppe Matullo, Ph.D., Serena Pelusi, M.D., Simonas Juzenas, Ph.D., Stefano Aliberti, M.D., Valter Monzani, M.D., Victor Moreno, Ph.D., Tanja Wesse, Tobias L. Lenz, Ph.D., Tomas Pumarola, M.D., Ph.D., Valeria Rimoldi, Ph.D., Silvano Bosari, M.D., Wolfgang Albrecht, Wolfgang Peter, Ph.D., Manuel Romero-Gómez, M.D., Ph.D., Mauro D’Amato, Ph.D., Stefano Duga, Ph.D., Jesus M. Banales, Ph.D., Johannes R Hov, M.D., Ph.D., Trine Folseraas, M.D., Ph.D., Luca Valenti, M.D., Andre Franke, Ph.D., and Prof.

Tom H. Karlsen, M.D., Ph.D.) assume responsibility for the overall content and integrity of this article.This article was published on June 17, 2020, at NEJM.org.We thank all the patients who consented to participate in this study, and we express our condolences to the families of patients who died from Covid-19. We also thank the entire clinical staff during the outbreak situation at the different centers who were able to work on this scientific study in parallel with their clinical duties. All the members of the Humanitas Covid-19 Task Force for contributions to the recruitment of patients (see the Supplementary Notes section in Supplementary Appendix 1).

Sören Brunak and Karina Banasik for discussions on the ABO association. Goncalo Abecasis and his team for providing the Michigan imputation server. Fabrizio Bossa and Francesca Tavano for contributions to control-sample acquisition. Maria Reig for help in the case-sample acquisition.

The staff of the Basque Biobank in Spain for assistance in the acquisition of samples. The staff of GCAT|Genomes for Life, a cohort study of the Genomes of Catalonia, Institute for Health Science Research Germans Trias i Pujol, for data contribution. Alexander Eck, Jenspeter Horst, and Jens Scholz for supporting the HLA typing in the project. And the members of the ethics commissions, review boards, and consortia who fast-track reviewed our applications and enabled this rapid genetic discovery study..

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People tried to escape a heat wave baking the West by heading to Castaic Lake in California on Saturday.Credit...Marcio http://cz.keimfarben.de/buy-generic-levitra-uk/ Jose Sanchez/Associated PressFor many Americans, Labor Day is a goodbye to summer before viagra oder cialis oder levitra children go back to school and cold weather arrives. But public health experts are worried that in the midst of a pandemic, the traditional last blast of summer could translate into disaster this fall.After the Memorial Day and Fourth of July weekends, cases of Covid-19 surged around the country after people held family gatherings or congregated in large groups. Dr.

Anthony S. Fauci, the country’s top infectious disease expert, said he wanted people to enjoy Labor Day weekend but urged them to take precautions to avoid a post-holiday spike in cases. Take the fun outdoors.

Avoid crowds, keep gatherings to 10 people or fewer. And even outdoors, where transmission risk is much lower, you still need to wear a mask and practice physical distancing if you’re spending time with people outside your household.“We’ve been through this before,” Dr. Fauci said.

€œWe see what happens over holiday weekends, and we want to make sure we don’t have an uptick. What I have been saying is kind of a plea to the American public, and to the younger people, that they can enjoy themselves over Labor Day weekend, but please be aware of and adhere to public health guidelines.”In terms of daily case counts, the United States over all was in worse shape going into Labor Day weekend than it was for Memorial Day weekend. The nation is now averaging about 40,000 new confirmed cases per day, up from about 22,000 per day ahead of Memorial Day weekend.

Dr. Fauci said that the number of daily cases in the United States was “unacceptably high” and that a spike in Covid-19 infections following Labor Day would make it far tougher to control the spread of the disease in the fall as people head indoors.“We’d like to get a good head start into the fall by getting our daily cases and our test positivity as low as possible,” Dr. Fauci said.

€œIf we get another resurgence of infections after Labor Day, it will make it that much more difficult to get that baseline down and make it much more problematic as we enter the fall season.”Public health experts said it might be even more challenging to persuade people to curtail their Labor Day weekend plans, compared with past holiday weekends, because so many people are suffering from pandemic fatigue after six months of social-distancing restrictions, closures and separation from loved ones.“People are getting tired of taking these precautions and of having their lives upended,” said Eleanor J. Murray, an assistant professor of epidemiology at the Boston University School of Public Health. €œThey’re missing their friends and family, and everyone wishes things were back to normal.

That’s totally understandable, but unfortunately we don’t get a say, really.”Dr. Murray said it was important for people to remember that just one gathering could lead to spikes in cases that would affect many more people. She noted that a wedding in Maine with an estimated 65 guests had resulted in 147 infections, including three deaths among people who didn’t even attend the wedding.Dr.

Murray said that if people decided to ignore public health guidelines this weekend, at the very least they should place themselves in quarantine for two weeks after the event. €œIf those people at the wedding had said, ‘This is a risk I’m personally willing to take,’ but after the wedding they had quarantined, then the maximum number of cases would have been the 65 wedding attendees,” she said.Although it’s safer to gather outside than indoors, the virus can still be transmitted in outdoor spaces when people gather in large groups or stand close to one another for long periods of time. Alcohol can loosen inhibitions, prompting people to forget about social distancing.

Loud music can prompt people to stand closer and speak louder, which can spew more viral particles and put you at risk even if you’re wearing a mask, health experts say.Dr. Murray said that whatever plan you have for the holiday weekend, ask yourself how you can make it safer for everyone.“People need to socialize and to see people who are important to them,” Dr. Murray said.

€œIf you were thinking of being indoors, go outdoors. If you were thinking about being outdoors, spread out further. Wear masks.

Think about what you can do to move down the risk continuum.”While many people feel safer socializing with family members, a number of outbreaks have been traced back to family parties that included relatives from more than one household. In Maryland, 44 percent of the state’s new cases were traced back to family gatherings, compared with 23 percent from house parties and 21 percent to outdoor events, according to a tweet posted by Gov. Larry Hogan.After a family gathering of two dozen people in Catawba County, N.C., 14 people who attended became ill, but it didn’t end there.

€œBefore they started to show symptoms, they continued with their daily lives, such as going to work or taking a beach trip with other families,” Jennifer McCracken, Catawba County’s public health director, wrote in a case study of the event. €œThis set into motion a person-to-person contact chain that to date has spread COVID-19 to 41 people in nine different families and eight different workplaces.”Gregg Gonsalves, an assistant professor of epidemiology at the Yale School of Public Health, said the holiday weekend would multiply the number of family gatherings around the country.“A family gathering one weekend in August that sets off cases in a given county or town is one thing,” Dr. Gonsalves said.

€œOne hundred family gatherings in that county on Labor Day weekend makes it a much larger epidemiological impact.”Dr. Gonsalves said concerns about Labor Day celebrations were being compounded by the fact that there are already large outbreaks on college campuses. €œWe’ve had this gigantic migration event over the past few weeks where students are moving all over the country from homes to universities,” Dr.

Gonsalves said. €œThe relative calm of places like New York and Connecticut has to be now thought of in the context of all this big jumble of people crisscrossing the country to get back to college.”ABC News posted a video on Twitter showing crowds of people gathering at a sports bar near the University of South Carolina. The university has reported more than 1,735 cases since Aug.

1, including 1,461 active cases, according to its Covid-19 dashboard.Brian Pace, a 35-year old psychologist in Phoenix, said he and his friends in Salt Lake City had talked about getting together for a socially distanced outdoor barbecue this weekend. He decided it was smarter to stay home, so he will get takeout from a local barbecue restaurant, JL Smokehouse, instead.“I debated with friends,” Mr. Pace said.

€œBut in the end, my decision boiled down to. Will I look back five years from now and say, ‘That was pretty stupid,’ or regret that I didn’t do it?. It probably would be that it was stupid to do that, so we’re pretty much hunkered down here.

When I go out, I wear a mask, and it’s takeout only.”Dr. Fauci said he didn’t want his words of caution about Labor Day celebrations to stop people from enjoying the holiday. He said he personally planned to spend the weekend with his wife, fishing in the Potomac and having dinner with two friends, for a total of four people, on his backyard deck.“You don’t want to tell people on a holiday weekend that even outdoors is bad — they will get completely discouraged,” Dr.

Fauci said. €œWhat we try to say is enjoy outdoors, but you can do it with safe spacing. You can be on a beach, and you don’t have to be falling all over each other.

You can be six, seven, eight, nine or 10 feet apart. You can go on a hike. You can go on a run.

You can go on a picnic with a few people. You don’t have to be in a crowd with 30, 40 or 50 people all breathing on each other.”The medical mistakes that befell the 87-year-old mother of a North Carolina pharmacist should not happen to anyone, and my hope is that this column will keep you and your loved ones from experiencing similar, all-too-common mishaps.As the pharmacist, Kim H. DeRhodes of Charlotte, N.C., recalled, it all began when her mother went to the emergency room two weeks after a fall because she had lingering pain in her back and buttocks.

Told she had sciatica, the elderly woman was prescribed prednisone and a muscle relaxant. Three days later, she became delirious, returned to the E.R., was admitted to the hospital, and was discharged two days later when her drug-induced delirium resolved.A few weeks later, stomach pain prompted a third trip to the E.R. And a prescription for an antibiotic and proton-pump inhibitor.

Within a month, she developed severe diarrhea lasting several days. Back to the E.R., and this time she was given a prescription for dicyclomine to relieve intestinal spasms, which triggered another bout of delirium and three more days in the hospital. She was discharged after lab tests and imaging studies revealed nothing abnormal.“Review of my mother’s case highlights separate but associated problems.

Likely misdiagnosis and inappropriate prescribing of medications,” Ms. DeRhodes wrote in JAMA Internal Medicine. €œDiagnostic errors led to the use of prescription drugs that were not indicated and caused my mother further harm.

The muscle relaxer and prednisone led to her first incidence of delirium. Prednisone likely led to the gastrointestinal issues, and the antibiotic likely led to the diarrhea, which led to the prescribing of dicyclomine, which led to the second incidence of delirium.”The doctors who wrote the woman’s prescriptions apparently never consulted the Beers Criteria, a list created by the American Geriatrics Society of drugs often unsafe for the elderly.In short, Ms. DeRhodes’s mother was a victim of two medical problems that are too often overlooked by examining doctors and unrecognized by families.

The first is giving an 87-year-old medications known to be unsafe for the elderly. The second is a costly and often frightening medically induced condition called “a prescribing cascade” that starts with drug-induced side effects which are then viewed as a new ailment and treated with yet another drug or drugs that can cause still other side effects.I’d like to think that none of this would have happened if instead of going to the E.R. The older woman had seen her primary care doctor.

But experts told me that no matter where patients are treated, they are not immune to getting caught in a prescribing cascade. The problem also can happen to people who self-treat with over-the-counter or herbal remedies. Nor is it limited to the elderly.

Young people can also become victims of a prescribing cascade, Ms. DeRhodes said.“Doctors are often taught to think of everything as a new problem,” Dr. Timothy Anderson, internist at Beth Israel Deaconess Medical Center in Boston, said.

€œThey have to start thinking about whether the patient is on medication and whether the medication is the problem.”“Doctors are very good at prescribing but not so good at deprescribing,” Ms. DeRhodes said. €œAnd a lot of times patients are given a prescription without first trying something else.”A popular treatment for high blood pressure, which afflicts a huge proportion of older people, is a common precipitant of the prescribing cascade, Dr.

Anderson said.He cited a Canadian study of 41,000 older adults with hypertension who were prescribed drugs called calcium channel blockers. Within a year after treatment began, nearly one person in 10 was given a diuretic to treat leg swelling caused by the first drug. Many were inappropriately prescribed a so-called loop diuretic that Dr.

Anderson said can result in dehydration, kidney problems, lightheadedness and falls.Type 2 diabetes is another common condition in which medications are often improperly prescribed to treat drug-induced side effects, said Lisa M. McCarthy, doctor of pharmacy at the University of Toronto who directed the Canadian study. Recognizing a side effect for what it is can be hampered when the effect doesn’t happen for weeks or even months after a drug is started.

While patients taking opioids for pain may readily recognize constipation as a consequence, Dr. McCarthy said that over time, patients taking metformin for diabetes can develop diarrhea and may self-treat with Lomotil, which in turn can cause dizziness and confusion.Dr. Paula Rochon, geriatrician at Women’s College Hospital in Ontario, said patients taking a drug called a cholinesterase inhibitor to treat early dementia can develop urinary incontinence, which is then treated with another drug that can worsen the patient’s confusion.Complicating matters is the large number of drugs some people take.

€œOlder adults frequently take many medications, with two-fifths taking five or more,” Dr. Anderson wrote in JAMA Internal Medicine. In cases of polypharmacy, as this is called, it can be hard to determine which, if any, of the drugs a person is taking is the cause of the current symptom.Dr.

Rochon emphasized that a prescribing cascade can happen to anybody. She said, “Everyone needs to consider the possibility every time a drug is prescribed.”Before accepting a prescription, she recommended that patients or their caregivers should ask the doctor a series of questions, starting with “Am I experiencing a symptom that could be a side effect of a drug I’m taking?. € Follow-up questions should include:Is this new drug being used to treat a side effect?.

Is there a safer drug available than the one I’m taking?. Could I take a lower dose of the prescribed drug?. Most important, Dr.

Rochon said, patients should ask “Do I need to take this drug at all?. €Patients and doctors alike often overlook or resist alternatives to medication that may be more challenging to adopt than swallowing a pill. For example, among well-established nondrug remedies for hypertension are weight loss, increasing physical activity, consuming less salt and other sources of sodium, and eating more potassium-rich foods like bananas and cantaloupe.For some patients, frequent use of a nonsteroidal anti-inflammatory drug sold over-the-counter, like ibuprofen or naproxen, is responsible for their elevated blood pressure.The risk of getting caught in a prescribing cascade is increased when patients are prescribed medications by more than one provider.

It’s up to patients to be sure every doctor they consult is given an up-to-date list of every drug they take, whether prescription or over-the-counter, as well as nondrug remedies and dietary supplements. Dr. Rochon recommended that patients maintain an up-to-date list of when and why they started every new drug, along with its dose and frequency, and show that list to the doctor as well.At a glance.

Medicare health insurance in Maine Medicare enrollment in Maine346,003 residents were enrolled in Medicare in Maine as of July 2020. That’s nearly 26 percent of the state’s total population filing for Medicare benefits, compared with about 19 percent of the United States population with Medicare coverage enrollment.Maine’s substantial Medicare enrollment is not surprising, given that it has the highest percentage of residents age 65+ in the country. Medicare eligibility is also triggered for younger people who are disabled for at least two years, or diagnosed with ALS or end-stage renal disease.

Nationwide, about 15 percent of Medicare beneficiaries are under the age of 65, but this is also higher in Maine, where 18 percent of Medicare beneficiaries are under 65. Medicare Advantage in Maine30 percent of Medicare beneficiaries in Maine were enrolled in private Medicare Advantage plans in 2018. The remaining 70 percent of Maine’s Medicare beneficiaries had opted instead for coverage under Original Medicare.

As of 2018, Medicare Advantage plans covered 34 percent of all Medicare beneficiaries, so Medicare Advantage enrollment was a little lower in Maine than it was nationwide at that point. But by mid-2020, enrollment in private Medicare plans had grown to 43 percent of Maine’s Medicare population, which was higher than the 40 percent national average at that point.The availability of Medicare Advantage plans varies from one county to another. Across Maine’s 16 counties, Medicare Advantage availability in 2020 ranges from 12 plans in Washington County, to 34 plans in Androscoggin, Cumberland, Kennebec, and Waldo counties.Medicare beneficiaries can switch from Medicare Advantage enrollment to Original Medicare or vice versa, each year during the annual election period in the fall (October 15 through December 7).

There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MaineMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.Medigap plans are standardized under federal rules — plans are designated by letter, from A through N. All Medigap insurers must offer at least Plan A and also offer at least Plan C or Plan F in addition to Plan A (note that under federal rules, Plan C and Plan F cannot be sold to people who weren’t already eligible for Medicare in 2019 or earlier).People are granted a six-month window, when they turn 65 and enroll in Original Medicare, during which coverage is guaranteed issue for Medigap plans. Federal rules do not, however, guarantee access to a Medigap plan if you’re under 65 and eligible for Medicare as a result of a disability.

And after the initial six-month open enrollment period ends, federal rules do not allow enrollees guaranteed-issue access to Medigap plans (including switching from one plan to another) unless they experience one of the limited situations that trigger a guaranteed-issue right.But Maine has much more extensive Medigap regulations, designed to protect consumers and ensure greater access to Medigap. Maine’s rules are explained in the state’s Consumer Guide to Medicare Supplement Plans, and include several provisions:All Medigap insurers in Maine must designate at least one month per year when all applicants will be accepted for enrollment in Medigap Plan A, regardless of their medical history (Plan A offers the least amount of benefits). Insurers can be more lenient than this basic requirement and two insurers (Anthem Blue Cross Blue Shield, and Colonial Penn) offer year-round access to Medigap Plan A.People under age 65 in Maine are granted the same six-month open enrollment period for guaranteed-issue Medigap plans (starting when they’re enrolled in Medicare Part B) as people who are 65 and enrolling in Medicare due to their age.

These enrollees also have access to another six-month open enrollment period — during which they can switch to any Medigap plan on a guaranteed-issue basis — when they turn 65. This is clarified in Maine Rule 275, Section 11, which clarifies that insurers cannot condition eligibility or premiums on a person’s medical history as long as they enroll during their six-month open enrollment window, or in the 60 days preceding it (to ensure that people can have a seamless transition to Medicare, with Medigap coverage effective the same day Medicare begins).After the initial six-month window ends, Medigap enrollees in Maine are allowed to switch to a different plan from their current insurer or a different insurer, as long as they pick a plan with equal or lesser benefits (this chart shows which plans are available, depending on the plan the person already has) and as long as they haven’t had a break of more than 90 days in their Medigap coverage since their initial open enrollment period.Medigap insurers in Maine must allow a Medicare beneficiary to enroll in a Medigap plan if they apply within 90 days of losing coverage under an individual market plan (not counting a short-term health plan or fixed indemnity plan), an employer-sponsored plan, or MaineCare (Medicaid).Maine is one of eight states where Medigap premiums cannot vary based on age, and that provision also includes people under age 65 (some of the states that ban age-based Medigap premiums only apply that requirement to plans sold to people who are at least 65 years old). Medigap premiums in Maine only vary based on tobacco use.Federal law gives people a “trial right” to try Medicare Advantage and then switch to Original Medicare instead, with guaranteed-issue access to Medigap as long as the person makes the switch to Original Medicare within a year.

But Maine law extends that trial right period to three years. If a person in Maine signs up for Medicare Advantage when they’re first eligible for Medicare and then switches to Original Medicare within three years, they have a guaranteed-issue right to buy any Medigap plan available in their area, as long as they purchase it within 90 days of their Medicare Advantage plan ending.Maine residents who have Medigap coverage and terminate it to switch to Medicare Advantage also have a three-year trial period, although it’s a little more restrictive. As long as they switch back to Original Medicare within three years and apply for a Medigap plan within 90 days of the Medicare Advantage plan ending, they have a guaranteed issue right to buy a Medigap plan with benefits that are equal to or less than their original Medigap plan’s benefits (again, this chart shows which plans have equal or lesser benefits).There are 14 insurers in Maine that offer Medigap plans, as well as several association groups that offer Medigap coverage in the state.

The state’s consumer guide shows 2020 Medigap premiums as well as each insurer’s pre-existing condition waiting period (if applicable) for people who didn’t have continuous coverage before enrolling in the Medigap plan. Insurers cannot exclude pre-existing conditions if the applicant had a least six months of creditable coverage prior to enrolling in Medigap (if they had creditable coverage but for a period of less than six months, the insurer can implement a pre-existing condition waiting period of up to six months minus the amount of time the person had creditable coverage in the prior six months). Maine Medicare Part DOriginal Medicare does not cover outpatient prescription drugs.

But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D plan.As of July 2020, there were 125,831 Medicare beneficiaries in Maine enrolled in stand-alone Medicare Part D prescription drug plans. In addition to those with stand-alone Part D plans, more than 140,000 Maine residents had Part D coverage integrated with the Medicare Advantage plans as of mid-2020. As of late 2018, about 43 percent of Maine’s Medicare beneficiaries had been enrolled in stand-alone Medicare Part D plans, but that has dropped as Medicare Advantage enrollment had increased.

By mid-2020, about 36 percent of the Maine Medicare beneficiaries were enrolled in stand-alone Medicare Part D plans.For 2020 coverage, there are 26 stand-alone Medicare Part D plans available in Maine, with premiums ranging from $13 to $84 per month.Medicare Part D enrollment is available when a person is first eligible for Medicare, and there’s also an annual open enrollment period (October 15 – December 7) when beneficiaries can enroll in Part D coverage or switch to a different plan for the coming year.Medicare spending in MaineIn 2018, average spending per beneficiary on Medicare in Maine was $8,841, based on data that were standardized to eliminate regional differences in payment rates. Costs for Medicare Advantage enrollees were not included in the analysis. The national average that year was $10,096 per enrollee, so Medicare spending in Maine was 12 percent lower than the national average.In terms of the extremes on both ends of the spectrum, average per-beneficiary Original Medicare costs in Louisiana were the highest in the nation, at $11,932, while they were lowest in the nation in Hawaii, at $6,971.Medicare in Maine.

Resources for beneficiaries and their caregiversYou can contact the Maine State Health Insurance Assistance Program if you have questions related to Medicare eligibility in Maine or Medicare enrollment in Maine.The Maine Bureau of Insurance also maintains a page of frequently asked questions about Medicare in Maine.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance expertsAt a glance.

Medicare health insurance in Maine Medicare enrollment in Maine346,003 residents were enrolled in Medicare in Maine as of July 2020. That’s nearly 26 percent of the state’s total population filing for Medicare benefits, compared with about 19 percent of the United States population with Medicare coverage enrollment.Maine’s substantial Medicare enrollment is not surprising, given that it has the highest percentage of residents age 65+ in the country. Medicare eligibility is also triggered for younger people who are disabled for at least two years, or diagnosed with ALS or end-stage renal disease.

Nationwide, about 15 percent of Medicare beneficiaries are under the age of 65, but this is also higher in Maine, where 18 percent of Medicare beneficiaries are under 65. Medicare Advantage in Maine30 percent of Medicare beneficiaries in Maine were enrolled in private Medicare Advantage plans in 2018. The remaining 70 percent of Maine’s Medicare beneficiaries had opted instead for coverage under Original Medicare.

As of 2018, Medicare Advantage plans covered 34 percent of all Medicare beneficiaries, so Medicare Advantage enrollment was a little lower in Maine than it was nationwide at that point. But by mid-2020, enrollment in private Medicare plans had grown to 43 percent of Maine’s Medicare population, which was higher than the 40 percent national average at that point.The availability of Medicare Advantage plans varies from one county to another. Across Maine’s 16 counties, Medicare Advantage availability in 2020 ranges from 12 plans in Washington County, to 34 plans in Androscoggin, Cumberland, Kennebec, and Waldo counties.Medicare beneficiaries can switch from Medicare Advantage enrollment to Original Medicare or vice versa, each year during the annual election period in the fall (October 15 through December 7).

There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MaineMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.Medigap plans are standardized under federal rules — plans are designated by letter, from A through N. All Medigap insurers must offer at least Plan A and also offer at least Plan C or Plan F in addition to Plan A (note that under federal rules, Plan C and Plan F cannot be sold to people who weren’t already eligible for Medicare in 2019 or earlier).People are granted a six-month window, when they turn 65 and enroll in Original Medicare, during which coverage is guaranteed issue for Medigap plans. Federal rules do not, however, guarantee access to a Medigap plan if you’re under 65 and eligible for Medicare as a result of a disability.

And after the initial six-month open enrollment period ends, federal rules do not allow enrollees guaranteed-issue access to Medigap plans (including switching from one plan to another) unless they experience one of the limited situations that trigger a guaranteed-issue right.But Maine has much more extensive Medigap regulations, designed to protect consumers and ensure greater access to Medigap. Maine’s rules are explained in the state’s Consumer Guide to Medicare Supplement Plans, and include several provisions:All Medigap insurers in Maine must designate at least one month per year when all applicants will be accepted for enrollment in Medigap Plan A, regardless of their medical history (Plan A offers the least amount of benefits). Insurers can be more lenient than this basic requirement and two insurers (Anthem Blue Cross Blue Shield, and Colonial Penn) offer year-round access to Medigap Plan A.People under age 65 in Maine are granted the same six-month open enrollment period for guaranteed-issue Medigap plans (starting when they’re enrolled in Medicare Part B) as people who are 65 and enrolling in Medicare due to their age.

These enrollees also have access to another six-month open enrollment period — during which they can switch to any Medigap plan on a guaranteed-issue basis — when they turn 65. This is clarified in Maine Rule 275, Section 11, which clarifies that insurers cannot condition eligibility or premiums on a person’s medical history as long as they enroll during their six-month open enrollment window, or in the 60 days preceding it (to ensure that people can have a seamless transition to Medicare, with Medigap coverage effective the same day Medicare begins).After the initial six-month window ends, Medigap enrollees in Maine are allowed to switch to a different plan from their current insurer or a different insurer, as long as they pick a plan with equal or lesser benefits (this chart shows which plans are available, depending on the plan the person already has) and as long as they haven’t had a break of more than 90 days in their Medigap coverage since their initial open enrollment period.Medigap insurers in Maine must allow a Medicare beneficiary to enroll in a Medigap plan if they apply within 90 days of losing coverage under an individual market plan (not counting a short-term health plan or fixed indemnity plan), an employer-sponsored plan, or MaineCare (Medicaid).Maine is one of eight states where Medigap premiums cannot vary based on age, and that provision also includes people under age 65 (some of the states that ban age-based Medigap premiums only apply that requirement to plans sold to people who are at least 65 years old). Medigap premiums in Maine only vary based on tobacco use.Federal law gives people a “trial right” to try Medicare Advantage and then switch to Original Medicare instead, with guaranteed-issue access to Medigap as long as the person makes the switch to Original Medicare within a year.

But Maine law extends that trial right period to three years. If a person in Maine signs up for Medicare Advantage when they’re first eligible for Medicare and then switches to Original Medicare within three years, they have a guaranteed-issue right to buy any Medigap plan available in their area, as long as they purchase it within 90 days of their Medicare Advantage plan ending.Maine residents who have Medigap coverage and terminate it to switch to Medicare Advantage also have a three-year trial period, although it’s a little more restrictive. As long as they switch back to Original Medicare within three years and apply for a Medigap plan within 90 days of the Medicare Advantage plan ending, they have a guaranteed issue right to buy a Medigap plan with benefits that are equal to or less than their original Medigap plan’s benefits (again, this chart shows which plans have equal or lesser benefits).There are 14 insurers in Maine that offer Medigap plans, as well as several association groups that offer Medigap coverage in the state.

The state’s consumer guide shows 2020 Medigap premiums as well as each insurer’s pre-existing condition waiting period (if applicable) for people who didn’t have continuous coverage before enrolling in the Medigap plan. Insurers cannot exclude pre-existing conditions if the applicant had a least six months of creditable coverage prior to enrolling in Medigap (if they had creditable coverage but for a period of less than six months, the insurer can implement a pre-existing condition waiting period of up to six months minus the amount of time the person had creditable coverage in the prior six months). Maine Medicare Part DOriginal Medicare does not cover outpatient prescription drugs.

But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D plan.As of July 2020, there were 125,831 Medicare beneficiaries in Maine enrolled in stand-alone Medicare Part D prescription drug plans. In addition to those with stand-alone Part D plans, more than 140,000 Maine residents had Part D coverage integrated with the Medicare Advantage plans as of mid-2020. As of late 2018, about 43 percent of Maine’s Medicare beneficiaries had been enrolled in stand-alone Medicare Part D plans, but that has dropped as Medicare Advantage enrollment had increased.

By mid-2020, about 36 percent of the Maine Medicare beneficiaries were enrolled in stand-alone Medicare Part D plans.For 2020 coverage, there are 26 stand-alone Medicare Part D plans available in Maine, with premiums ranging from $13 to $84 per month.Medicare Part D enrollment is available when a person is first eligible for Medicare, and there’s also an annual open enrollment period (October 15 – December 7) when beneficiaries can enroll in Part D coverage or switch to a different plan for the coming year.Medicare spending in MaineIn 2018, average spending per beneficiary on Medicare in Maine was $8,841, based on data that were standardized to eliminate regional differences in payment rates. Costs for Medicare Advantage enrollees were not included in the analysis. The national average that year was $10,096 per enrollee, so Medicare spending in Maine was 12 percent lower than the national average.In terms of the extremes on both ends of the spectrum, average per-beneficiary Original Medicare costs in Louisiana were the highest in the nation, at $11,932, while they were lowest in the nation in Hawaii, at $6,971.Medicare in Maine.

Resources for beneficiaries and their caregiversYou can contact the Maine State Health Insurance Assistance Program if you have questions related to Medicare eligibility in Maine or Medicare enrollment in Maine.The Maine Bureau of Insurance also maintains a page of frequently asked questions about Medicare in Maine.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance expertsAt a glance.

Medicare enrollment in WisconsinAbout 1.15 million residents are enrolled in Medicare in Wisconsin. Fifteen percent are under 65 and enrolled due to a disability.More than 40 percent of beneficiaries of Medicare in Wisconsin are enrolled in Medicare Advantage plans.The market for Medicare Advantage in Wisconsin is robust, with between 11 and 47 plans available, depending on the county.At least 32 insurers offer Medigap plans in Wisconsin. The state does its own Medigap plan standardization, so Medigap plans in Wisconsin are different from Medigap plans sold in most states.In 2020, Wisconsin lawmakers considered, but did not pass, legislation that would have allowed Wisconsin Medigap enrollees to switch, without medical underwriting, to a plan with equal or lesser benefits.Wisconsin regulations guarantee access to Medigap Basic plans for disabled enrollees under age 65, but premiums can be considerably higher for under-65 enrollees.There are 30 stand-alone Medicare Part D prescription drug plans available in Wisconsin in 2020, with premiums ranging from about $13 to $124 per month.

About 38% of Wisconsin Medicare beneficiaries have stand-alone Part D prescription drug plans.Per-enrollee spending for Original Medicare in Wisconsin is 13% lower than the national average.How many people are enrolled in Medicare in Wisconsin?. Medicare enrollment in Wisconsin stood at 1,198,428 people as of July 2020, amounting to more than 20 percent of the state’s population. In most cases, filing for Medicare benefits goes along with turning 65.

But Medicare also provides coverage for disabled Americans under age 65, once they have been receiving disability benefits for 24 months, and for people with ALS or end-stage renal disease. Nationwide, 15 percent of Medicare beneficiaries are under age 65. In Wisconsin, it’s 14 percent.

In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.Read about Medicare’s open enrollment period Medicare Advantage in WisconsinMedicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. Medicare Advantage plans are offered by private insurers, so plan availability varies from one area to another. Wisconsin’s Medicare Advantage market is robust.

Medicare Advantage plans are available state-wide, and residents in every county have access to at least 11 Medicare Advantage plans, and in most cases, more than 20. In Waukesha and Brown counties, there are 47 Medicare Advantage plans for sale.Forty percent of beneficiaries of Medicare in Wisconsin had Medicare Advantage enrollment coverage as of 2018, versus about 34 percent nationwide. As of July 2020, there were 556,643 Wisconsin Medicare beneficiaries enrolled in private Medicare coverage (not counting private supplemental coverage like Part D and Medigap).

That’s more than 46 percent of the state’s Medicare population, but some Wisconsin Medicare beneficiaries are enrolled in Medicare Cost plans, which are an earlier form of private Medicare coverage that predates Medicare Advantage plans (three insurers in Wisconsin offer Medicare Cost plans). The other 661,785 Medicare beneficiaries in Wisconsin had coverage under Original Medicare as of mid-2020.The popularity of Medicare Advantage enrollment varies from one state to another. In Minnesota, nearly half of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Medicare Advantage plans (via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).Original Medicare coverage is provided directly by the federal government, and enrollees have access to a nationwide network of providers.

But people with Original Medicare need supplemental coverage (from an employer-sponsored plan, Medicaid, or privately purchased plans) for things like prescription drugs and out-of-pocket costs (out-of-pocket costs are not capped under Original Medicare).Original Medicare includes Medicare Parts A and B. Medicare Advantage includes all of the coverage provided by Medicare Parts A and B, and the plans often include additional benefits, usually including integrated Medicare Part D prescription drug coverage and often including coverage for things like dental and vision care. But Medicare Advantage insurers establish their own provider networks, which are generally localized and more limited than the nationwide network for Original Medicare.

Out-of-pocket costs for Medicare Advantage are often higher than they would be if a beneficiary had Original Medicare plus a Medigap plan. There are pros and cons to either option, and the right solution is different for each person.Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan). And people who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.Medigap in WisconsinOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage.

Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had only Original Medicare.Although Medigap plans are sold by private insurers, the plans in nearly every state are standardized under federal rules. But Wisconsin is one of just three states that have waivers from the federal government allowing the state to conduct its own Medigap standardization.

So Medigap plans in Wisconsin are not the same as they are in most of the rest of the country.Instead of having ten different plan designs available (as is the case in most states), Wisconsin Medigap is structured so that there’s a basic plan, and then enrollees can choose to add riders that make the coverage more comprehensive. So instead of buying “Plan G” (as newly-eligible enrollees in most states would do if they wanted the most comprehensive Medigap plan), Wisconsin Medigap enrollees would buy the basic plan and then add on the optional riders.Wisconsin Medigap insurers have to offer “basic benefits” that include coverage for Part A coinsurance (including the Part A hospice coinsurance and hospital coinsurance), Part B coinsurance, and up to three pints of blood each year. Each Medigap insurer has to offer a “Basic Plan,” which includes the basic benefits in addition to Part A skilled nursing facility coinsurance, additional coverage for home health care and inpatient mental health care (both have limits on the number of days that are covered), outpatient mental health care, and Wisconsin state-mandated benefits.In addition, Wisconsin Medigap insurers can offer up to seven optional riders that enrollees can purchase, with coverage for things like the Part A deductible, additional home health care, the Part B deductible and excess charges, and foreign travel coverage for emergencies abroad (people who are newly eligible for Medicare in 2020 or later are not be able to purchase Medigap coverage for the Part B deductible.

Those who already had this coverage can keep it, and people who became eligible for Medicare prior to 2020 can still purchase it, assuming they can meet the medical underwriting requirements. This applies nationwide, under the terms of the Medicare Access and CHIP Reauthorization Act of 2015).So if a person in Wisconsin wants a Medigap plan that’s comparable to Medigap Plan G sold in other states, they would need to buy the Basic Plan plus riders for the Part A deductible, Part B excess charges, additional home health care benefits, and foreign travel emergency coverage. Medigap coverage similar to the various lettered plans sold in other states can thus be obtained in Wisconsin by layering various riders on top of the Basic Plan.Medigap insurers in Wisconsin can also offer cost-sharing plans that require the member to pay a portion of the out-of-pocket costs until they reach a specified out-of-pocket limit (similar to Medigap plans K and L that are sold in other states), and high-deductible plans that require the member the pay all costs until they meet the deductible for the year (similar to the high-deductible versions of Medigap plans F and G that are sold in other states).There are at least 32 insurers that offer traditional Medigap plans in Wisconsin as of 2020, in addition to four insurers that offer Medicare Select plans (Wisconsin’s Medigap guide notes that there may be other insurers in the state that have chosen not to have their pricing and sales information detailed in the publication).

299,988 Wisconsin Medicare beneficiaries had Medigap coverage as of 2018, according to an AHIP analysis. That was about 45 percent of the state’s Original Medicare enrollees (Medigap coverage cannot be used with Medicare Advantage plans).Medigap insurers in Wisconsin can choose to use attained-age rating (rates increase as an enrollee gets older) or issue-age rating (rates are based on the age the person was when they enrolled).Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue.

This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a Medigap plan).Lawmakers in Wisconsin considered SB615 in 2020 (a 2018 bill that was brought back up for consideration in the 2020 session). The legislation, which did not pass, would have allowed people to switch to equal or lesser Medigap plans without underwriting. That’s fairly rare – very few states have guaranteed-issue rules for Medigap outside of the initial enrollment window.

And although Wisconsin lawmakers considered changing that rule, they did not do so during the 2020 legislative session.People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, and 15 percent of Medicare beneficiaries in Wisconsin are under age 65. Federal rules do not guarantee access to Medigap plans for people who are under 65, but the majority of the states — including Wisconsin — have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans.Medigap insurers in Wisconsin are required to offer coverage to disabled enrollees under age 65, with the same six-month open enrollment period that begins when the person is enrolled in Medicare Part B. But premiums for people under the age of 65 are considerably higher than premiums for people who are 65 and over.

And insurers are only required to offer the Medigap Basic Plan to applicants under the age of 65. There are only a handful of insurers that offer any other plans (the high-deductible option, and the 25 percent and 50 percent cost-sharing options). Humana, Wisconsin Physicians Service Insurance Corporation, Garden State, Physicians Life Insurance Company, United American, and United World.Disabled Medicare beneficiaries also have access to the normal Medigap open enrollment period when they turn 65.

At that point, they can select from among any of the available Medigap plans, with lower premiums that apply to people who are aging onto Medicare when they turn 65.Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (as of 2021, Medicare beneficiaries who have kidney failure will be able to enroll in Medicare Advantage plans). Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But as noted above, Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care, plus the out-of-pocket cost of prescription drugs (the upper limit for out-of-pocket costs, not counting prescription costs, will increase to $7,550 as of 2021).Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those rules don’t apply to Medigap plans.

Medigap insurers can impose a pre-existing condition waiting period of up to six months if you didn’t have at least six months of continuous coverage prior to your enrollment (although many of them choose not to do so). And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the Medigap insurer can consider your medical history in determining whether to accept your application, and at what premium. Wisconsin Medicare Part DOriginal Medicare does not provide coverage for outpatient prescription drugs.

More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.Medicare beneficiaries who do not have Medicaid or employer-sponsored drug coverage need Medicare Part D enrollment in order to have coverage for prescriptions. Medicare Part D was created under the Medicare Modernization Act of 2003, and can be purchased as a stand-alone plan, or obtained as part of a Medicare Advantage with built-in Part D benefits.There are 30 stand-alone Medicare Part D plans for sale in Wisconsin in 2020, with premiums that range from about $13 to $124/month.About 38 percent of Wisconsin’s Medicare beneficiaries (452,969 people) had stand-alone Medicare Part D plans as of mid-2020. Another 441,044 Wisconsin Medicare beneficiaries had Medicare Part D prescription coverage integrated with their Medicare Advantage plans.Medicare Part D enrollment is available during a beneficiary’s initial enrollment period (when they turn 65 or become eligible for Medicare due to a disability), and there is also an annual open enrollment period each fall.

During this window, beneficiaries can switch to a different Medicare Part D plan or enroll for the first time (with a late enrollment penalty, depending on the circumstances), with coverage effective the following January. Per-beneficiary spending for Medicare in WisconsinPer-beneficiary spending for Original Medicare in Wisconsin was 13 percent lower than the national average in 2018, at $8,763. Only ten states had lower average per-beneficiary Original Medicare spending.

The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage. Nationwide, average per-beneficiary Original Medicare spending stood at $10,096.Per-beneficiary Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in Wisconsin. Resources for beneficiaries and their caregiversNeed help with Medicare enrollment in Wisconsin?.

You can contact the Wisconsin State Health Insurance Information Program with questions related to Medicare coverage in Wisconsin or Medicare eligibility in Wisconsin.The Wisconsin Department of Health Services also has a comprehensive list of resources related to Medicare coverage in Wisconsin.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

People tried to escape a heat wave baking the West by heading to Castaic Lake in California on Saturday.Credit...Marcio Jose Sanchez/Associated PressFor levitra prix en pharmacie many Americans, Labor Day generic levitra price is a goodbye to summer before children go back to school and cold weather arrives. But public health experts are worried that in the midst of a pandemic, the traditional last blast of summer could translate into disaster this fall.After the Memorial Day and Fourth of July weekends, cases of Covid-19 surged around the country after people held family gatherings or congregated in large groups. Dr. Anthony S. Fauci, the country’s top infectious disease expert, said he wanted people to enjoy Labor Day weekend but urged them to take precautions to avoid a post-holiday spike in cases.

Take the fun outdoors. Avoid crowds, keep gatherings to 10 people or fewer. And even outdoors, where transmission risk is much lower, you still need to wear a mask and practice physical distancing if you’re spending time with people outside your household.“We’ve been through this before,” Dr. Fauci said. €œWe see what happens over holiday weekends, and we want to make sure we don’t have an uptick.

What I have been saying is kind of a plea to the American public, and to the younger people, that they can enjoy themselves over Labor Day weekend, but please be aware of and adhere to public health guidelines.”In terms of daily case counts, the United States over all was in worse shape going into Labor Day weekend than it was for Memorial Day weekend. The nation is now averaging about 40,000 new confirmed cases per day, up from about 22,000 per day ahead of Memorial Day weekend. Dr. Fauci said that the number of daily cases in the United States was “unacceptably high” and that a spike in Covid-19 infections following Labor Day would make it far tougher to control the spread of the disease in the fall as people head indoors.“We’d like to get a good head start into the fall by getting our daily cases and our test positivity as low as possible,” Dr. Fauci said.

€œIf we get another resurgence of infections after Labor Day, it will make it that much more difficult to get that baseline down and make it much more problematic as we enter the fall season.”Public health experts said it might be even more challenging to persuade people to curtail their Labor Day weekend plans, compared with past holiday weekends, because so many people are suffering from pandemic fatigue after six months of social-distancing restrictions, closures and separation from loved ones.“People are getting tired of taking these precautions and of having their lives upended,” said Eleanor J. Murray, an assistant professor of epidemiology at the Boston University School of Public Health. €œThey’re missing their friends and family, and everyone wishes things were back to normal. That’s totally understandable, but unfortunately we don’t get a say, really.”Dr. Murray said it was important for people to remember that just one gathering could lead to spikes in cases that would affect many more people.

She noted that a wedding in Maine with an estimated 65 guests had resulted in 147 infections, including three deaths among people who didn’t even attend the wedding.Dr. Murray said that if people decided to ignore public health guidelines this weekend, at the very least they should place themselves in quarantine for two weeks after the event. €œIf those people at the wedding had said, ‘This is a risk I’m personally willing to take,’ but after the wedding they had quarantined, then the maximum number of cases would have been the 65 wedding attendees,” she said.Although it’s safer to gather outside than indoors, the virus can still be transmitted in outdoor spaces when people gather in large groups or stand close to one another for long periods of time. Alcohol can loosen inhibitions, prompting people to forget about social distancing. Loud music can prompt people to stand closer and speak louder, which can spew more viral particles and put you at risk even if you’re wearing a mask, health experts say.Dr.

Murray said that whatever plan you have for the holiday weekend, ask yourself how you can make it safer for everyone.“People need to socialize and to see people who are important to them,” Dr. Murray said. €œIf you were thinking of being indoors, go outdoors. If you were thinking about being outdoors, spread out further. Wear masks.

Think about what you can do to move down the risk continuum.”While many people feel safer socializing with family members, a number of outbreaks have been traced back to family parties that included relatives from more than one household. In Maryland, 44 percent of the state’s new cases were traced back to family gatherings, compared with 23 percent from house parties and 21 percent to outdoor events, according to a tweet posted by Gov. Larry Hogan.After a family gathering of two dozen people in Catawba County, N.C., 14 people who attended became ill, but it didn’t end there. €œBefore they started to show symptoms, they continued with their daily lives, such as going to work or taking a beach trip with other families,” Jennifer McCracken, Catawba County’s public health director, wrote in a case study of the event. €œThis set into motion a person-to-person contact chain that to date has spread COVID-19 to 41 people in nine different families and eight different workplaces.”Gregg Gonsalves, an assistant professor of epidemiology at the Yale School of Public Health, said the holiday weekend would multiply the number of family gatherings around the country.“A family gathering one weekend in August that sets off cases in a given county or town is one thing,” Dr.

Gonsalves said. €œOne hundred family gatherings in that county on Labor Day weekend makes it a much larger epidemiological impact.”Dr. Gonsalves said concerns about Labor Day celebrations were being compounded by the fact that there are already large outbreaks on college campuses. €œWe’ve had this gigantic migration event over the past few weeks where students are moving all over the country from homes to universities,” Dr. Gonsalves said.

€œThe relative calm of places like New York and Connecticut has to be now thought of in the context of all this big jumble of people crisscrossing the country to get back to college.”ABC News posted a video on Twitter showing crowds of people gathering at a sports bar near the University of South Carolina. The university has reported more than 1,735 cases since Aug. 1, including 1,461 active cases, according to its Covid-19 dashboard.Brian Pace, a 35-year old psychologist in Phoenix, said he and his friends in Salt Lake City had talked about getting together for a socially distanced outdoor barbecue this weekend. He decided it was smarter to stay home, so he will get takeout from a local barbecue restaurant, JL Smokehouse, instead.“I debated with friends,” Mr. Pace said.

€œBut in the end, my decision boiled down to. Will I look back five years from now and say, ‘That was pretty stupid,’ or regret that I didn’t do it?. It probably would be that it was stupid to do that, so we’re pretty much hunkered down here. When I go out, I wear a mask, and it’s takeout only.”Dr. Fauci said he didn’t want his words of caution about Labor Day celebrations to stop people from enjoying the holiday.

He said he personally planned to spend the weekend with his wife, fishing in the Potomac and having dinner with two friends, for a total of four people, on his backyard deck.“You don’t want to tell people on a holiday weekend that even outdoors is bad — they will get completely discouraged,” Dr. Fauci said. €œWhat we try to say is enjoy outdoors, but you can do it with safe spacing. You can be on a beach, and you don’t have to be falling all over each other. You can be six, seven, eight, nine or 10 feet apart.

You can go on a hike. You can go on a run. You can go on a picnic with a few people. You don’t have to be in a crowd with 30, 40 or 50 people all breathing on each other.”The medical mistakes that befell the 87-year-old mother of a North Carolina pharmacist should not happen to anyone, and my hope is that this column will keep you and your loved ones from experiencing similar, all-too-common mishaps.As the pharmacist, Kim H. DeRhodes of Charlotte, N.C., recalled, it all began when her mother went to the emergency room two weeks after a fall because she had lingering pain in her back and buttocks.

Told she had sciatica, the elderly woman was prescribed prednisone and a muscle relaxant. Three days later, she became delirious, returned to the E.R., was admitted to the hospital, and was discharged two days later when her drug-induced delirium resolved.A few weeks later, stomach pain prompted a third trip to the E.R. And a prescription for an antibiotic and proton-pump inhibitor. Within a month, she developed severe diarrhea lasting several days. Back to the E.R., and this time she was given a prescription for dicyclomine to relieve intestinal spasms, which triggered another bout of delirium and three more days in the hospital.

She was discharged after lab tests and imaging studies revealed nothing abnormal.“Review of my mother’s case highlights separate but associated problems. Likely misdiagnosis and inappropriate prescribing of medications,” Ms. DeRhodes wrote in JAMA Internal Medicine. €œDiagnostic errors led to the use of prescription drugs that were not indicated and caused my mother further harm. The muscle relaxer and prednisone led to her first incidence of delirium.

Prednisone likely led to the gastrointestinal issues, and the antibiotic likely led to the diarrhea, which led to the prescribing of dicyclomine, which led to the second incidence of delirium.”The doctors who wrote the woman’s prescriptions apparently never consulted the Beers Criteria, a list created by the American Geriatrics Society of drugs often unsafe for the elderly.In short, Ms. DeRhodes’s mother was a victim of two medical problems that are too often overlooked by examining doctors and unrecognized by families. The first is giving an 87-year-old medications known to be unsafe for the elderly. The second is a costly and often frightening medically induced condition called “a prescribing cascade” that starts with drug-induced side effects which are then viewed as a new ailment and treated with yet another drug or drugs that can cause still other side effects.I’d like to think that none of this would have happened if instead of going to the E.R. The older woman had seen her primary care doctor.

But experts told me that no matter where patients are treated, they are not immune to getting caught in a prescribing cascade. The problem also can happen to people who self-treat with over-the-counter or herbal remedies. Nor is it limited to the elderly. Young people can also become victims of a prescribing cascade, Ms. DeRhodes said.“Doctors are often taught to think of everything as a new problem,” Dr.

Timothy Anderson, internist at Beth Israel Deaconess Medical Center in Boston, said. €œThey have to start thinking about whether the patient is on medication and whether the medication is the problem.”“Doctors are very good at prescribing but not so good at deprescribing,” Ms. DeRhodes said. €œAnd a lot of times patients are given a prescription without first trying something else.”A popular treatment for high blood pressure, which afflicts a huge proportion of older people, is a common precipitant of the prescribing cascade, Dr. Anderson said.He cited a Canadian study of 41,000 older adults with hypertension who were prescribed drugs called calcium channel blockers.

Within a year after treatment began, nearly one person in 10 was given a diuretic to treat leg swelling caused by the first drug. Many were inappropriately prescribed a so-called loop diuretic that Dr. Anderson said can result in dehydration, kidney problems, lightheadedness and falls.Type 2 diabetes is another common condition in which medications are often improperly prescribed to treat drug-induced side effects, said Lisa M. McCarthy, doctor of pharmacy at the University of Toronto who directed the Canadian study. Recognizing a side effect for what it is can be hampered when the effect doesn’t happen for weeks or even months after a drug is started.

While patients taking opioids for pain may readily recognize constipation as a consequence, Dr. McCarthy said that over time, patients taking metformin for diabetes can develop diarrhea and may self-treat with Lomotil, which in turn can cause dizziness and confusion.Dr. Paula Rochon, geriatrician at Women’s College Hospital in Ontario, said patients taking a drug called a cholinesterase inhibitor to treat early dementia can develop urinary incontinence, which is then treated with another drug that can worsen the patient’s confusion.Complicating matters is the large number of drugs some people take. €œOlder adults frequently take many medications, with two-fifths taking five or more,” Dr. Anderson wrote in JAMA Internal Medicine.

In cases of polypharmacy, as this is called, it can be hard to determine which, if any, of the drugs a person is taking is the cause of the current symptom.Dr. Rochon emphasized that a prescribing cascade can happen to anybody. She said, “Everyone needs to consider the possibility every time a drug is prescribed.”Before accepting a prescription, she recommended that patients or their caregivers should ask the doctor a series of questions, starting with “Am I experiencing a symptom that could be a side effect of a drug I’m taking?. € Follow-up questions should include:Is this new drug being used to treat a side effect?. Is there a safer drug available than the one I’m taking?.

Could I take a lower dose of the prescribed drug?. Most important, Dr. Rochon said, patients should ask “Do I need to take this drug at all?. €Patients and doctors alike often overlook or resist alternatives to medication that may be more challenging to adopt than swallowing a pill. For example, among well-established nondrug remedies for hypertension are weight loss, increasing physical activity, consuming less salt and other sources of sodium, and eating more potassium-rich foods like bananas and cantaloupe.For some patients, frequent use of a nonsteroidal anti-inflammatory drug sold over-the-counter, like ibuprofen or naproxen, is responsible for their elevated blood pressure.The risk of getting caught in a prescribing cascade is increased when patients are prescribed medications by more than one provider.

It’s up to patients to be sure every doctor they consult is given an up-to-date list of every drug they take, whether prescription or over-the-counter, as well as nondrug remedies and dietary supplements. Dr. Rochon recommended that patients maintain an up-to-date list of when and why they started every new drug, along with its dose and frequency, and show that list to the doctor as well.At a glance. Medicare health insurance in Maine Medicare enrollment in Maine346,003 residents were enrolled in Medicare in Maine as of July 2020. That’s nearly 26 percent of the state’s total population filing for Medicare benefits, compared with about 19 percent of the United States population with Medicare coverage enrollment.Maine’s substantial Medicare enrollment is not surprising, given that it has the highest percentage of residents age 65+ in the country.

Medicare eligibility is also triggered for younger people who are disabled for at least two years, or diagnosed with ALS or end-stage renal disease. Nationwide, about 15 percent of Medicare beneficiaries are under the age of 65, but this is also higher in Maine, where 18 percent of Medicare beneficiaries are under 65. Medicare Advantage in Maine30 percent of Medicare beneficiaries in Maine were enrolled in private Medicare Advantage plans in 2018. The remaining 70 percent of Maine’s Medicare beneficiaries had opted instead for coverage under Original Medicare. As of 2018, Medicare Advantage plans covered 34 percent of all Medicare beneficiaries, so Medicare Advantage enrollment was a little lower in Maine than it was nationwide at that point.

But by mid-2020, enrollment in private Medicare plans had grown to 43 percent of Maine’s Medicare population, which was higher than the 40 percent national average at that point.The availability of Medicare Advantage plans varies from one county to another. Across Maine’s 16 counties, Medicare Advantage availability in 2020 ranges from 12 plans in Washington County, to 34 plans in Androscoggin, Cumberland, Kennebec, and Waldo counties.Medicare beneficiaries can switch from Medicare Advantage enrollment to Original Medicare or vice versa, each year during the annual election period in the fall (October 15 through December 7). There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MaineMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.Medigap plans are standardized under federal rules — plans are designated by letter, from A through N. All Medigap insurers must offer at least Plan A and also offer at least Plan C or Plan F in addition to Plan A (note that under federal rules, Plan C and Plan F cannot be sold to people who weren’t already eligible for Medicare in 2019 or earlier).People are granted a six-month window, when they turn 65 and enroll in Original Medicare, during which coverage is guaranteed issue for Medigap plans. Federal rules do not, however, guarantee access to a Medigap plan if you’re under 65 and eligible for Medicare as a result of a disability.

And after the initial six-month open enrollment period ends, federal rules do not allow enrollees guaranteed-issue access to Medigap plans (including switching from one plan to another) unless they experience one of the limited situations that trigger a guaranteed-issue right.But Maine has much more extensive Medigap regulations, designed to protect consumers and ensure greater access to Medigap. Maine’s rules are explained in the state’s Consumer Guide to Medicare Supplement Plans, and include several provisions:All Medigap insurers in Maine must designate at least one month per year when all applicants will be accepted for enrollment in Medigap Plan A, regardless of their medical history (Plan A offers the least amount of benefits). Insurers can be more lenient than this basic requirement and two insurers (Anthem Blue Cross Blue Shield, and Colonial Penn) offer year-round access to Medigap Plan A.People under age 65 in Maine are granted the same six-month open enrollment period for guaranteed-issue Medigap plans (starting when they’re enrolled in Medicare Part B) as people who are 65 and enrolling in Medicare due to their age. These enrollees also have access to another six-month open enrollment period — during which they can switch to any Medigap plan on a guaranteed-issue basis — when they turn 65. This is clarified in Maine Rule 275, Section 11, which clarifies that insurers cannot condition eligibility or premiums on a person’s medical history as long as they enroll during their six-month open enrollment window, or in the 60 days preceding it (to ensure that people can have a seamless transition to Medicare, with Medigap coverage effective the same day Medicare begins).After the initial six-month window ends, Medigap enrollees in Maine are allowed to switch to a different plan from their current insurer or a different insurer, as long as they pick a plan with equal or lesser benefits (this chart shows which plans are available, depending on the plan the person already has) and as long as they haven’t had a break of more than 90 days in their Medigap coverage since their initial open enrollment period.Medigap insurers in Maine must allow a Medicare beneficiary to enroll in a Medigap plan if they apply within 90 days of losing coverage under an individual market plan (not counting a short-term health plan or fixed indemnity plan), an employer-sponsored plan, or MaineCare (Medicaid).Maine is one of eight states where Medigap premiums cannot vary based on age, and that provision also includes people under age 65 (some of the states that ban age-based Medigap premiums only apply that requirement to plans sold to people who are at least 65 years old).

Medigap premiums in Maine only vary based on tobacco use.Federal law gives people a “trial right” to try Medicare Advantage and then switch to Original Medicare instead, with guaranteed-issue access to Medigap as long as the person makes the switch to Original Medicare within a year. But Maine law extends that trial right period to three years. If a person in Maine signs up for Medicare Advantage when they’re first eligible for Medicare and then switches to Original Medicare within three years, they have a guaranteed-issue right to buy any Medigap plan available in their area, as long as they purchase it within 90 days of their Medicare Advantage plan ending.Maine residents who have Medigap coverage and terminate it to switch to Medicare Advantage also have a three-year trial period, although it’s a little more restrictive. As long as they switch back to Original Medicare within three years and apply for a Medigap plan within 90 days of the Medicare Advantage plan ending, they have a guaranteed issue right to buy a Medigap plan with benefits that are equal to or less than their original Medigap plan’s benefits (again, this chart shows which plans have equal or lesser benefits).There are 14 insurers in Maine that offer Medigap plans, as well as several association groups that offer Medigap coverage in the state. The state’s consumer guide shows 2020 Medigap premiums as well as each insurer’s pre-existing condition waiting period (if applicable) for people who didn’t have continuous coverage before enrolling in the Medigap plan.

Insurers cannot exclude pre-existing conditions if the applicant had a least six months of creditable coverage prior to enrolling in Medigap (if they had creditable coverage but for a period of less than six months, the insurer can implement a pre-existing condition waiting period of up to six months minus the amount of time the person had creditable coverage in the prior six months). Maine Medicare Part DOriginal Medicare does not cover outpatient prescription drugs. But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D plan.As of July 2020, there were 125,831 Medicare beneficiaries in Maine enrolled in stand-alone Medicare Part D prescription drug plans. In addition to those with stand-alone Part D plans, more than 140,000 Maine residents had Part D coverage integrated with the Medicare Advantage plans as of mid-2020. As of late 2018, about 43 percent of Maine’s Medicare beneficiaries had been enrolled in stand-alone Medicare Part D plans, but that has dropped as Medicare Advantage enrollment had increased.

By mid-2020, about 36 percent of the Maine Medicare beneficiaries were enrolled in stand-alone Medicare Part D plans.For 2020 coverage, there are 26 stand-alone Medicare Part D plans available in Maine, with premiums ranging from $13 to $84 per month.Medicare Part D enrollment is available when a person is first eligible for Medicare, and there’s also an annual open enrollment period (October 15 – December 7) when beneficiaries can enroll in Part D coverage or switch to a different plan for the coming year.Medicare spending in MaineIn 2018, average spending per beneficiary on Medicare in Maine was $8,841, based on data that were standardized to eliminate regional differences in payment rates. Costs for Medicare Advantage enrollees were not included in the analysis. The national average that year was $10,096 per enrollee, so Medicare spending in Maine was 12 percent lower than the national average.In terms of the extremes on both ends of the spectrum, average per-beneficiary Original Medicare costs in Louisiana were the highest in the nation, at $11,932, while they were lowest in the nation in Hawaii, at $6,971.Medicare in Maine. Resources for beneficiaries and their caregiversYou can contact the Maine State Health Insurance Assistance Program if you have questions related to Medicare eligibility in Maine or Medicare enrollment in Maine.The Maine Bureau of Insurance also maintains a page of frequently asked questions about Medicare in Maine.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance expertsAt a glance. Medicare health insurance in Maine Medicare enrollment in Maine346,003 residents were enrolled in Medicare in Maine as of July 2020. That’s nearly 26 percent of the state’s total population filing for Medicare benefits, compared with about 19 percent of the United States population with Medicare coverage enrollment.Maine’s substantial Medicare enrollment is not surprising, given that it has the highest percentage of residents age 65+ in the country. Medicare eligibility is also triggered for younger people who are disabled for at least two years, or diagnosed with ALS or end-stage renal disease. Nationwide, about 15 percent of Medicare beneficiaries are under the age of 65, but this is also higher in Maine, where 18 percent of Medicare beneficiaries are under 65.

Medicare Advantage in Maine30 percent of Medicare beneficiaries in Maine were enrolled in private Medicare Advantage plans in 2018. The remaining 70 percent of Maine’s Medicare beneficiaries had opted instead for coverage under Original Medicare. As of 2018, Medicare Advantage plans covered 34 percent of all Medicare beneficiaries, so Medicare Advantage enrollment was a little lower in Maine than it was nationwide at that point. But by mid-2020, enrollment in private Medicare plans had grown to 43 percent of Maine’s Medicare population, which was higher than the 40 percent national average at that point.The availability of Medicare Advantage plans varies from one county to another. Across Maine’s 16 counties, Medicare Advantage availability in 2020 ranges from 12 plans in Washington County, to 34 plans in Androscoggin, Cumberland, Kennebec, and Waldo counties.Medicare beneficiaries can switch from Medicare Advantage enrollment to Original Medicare or vice versa, each year during the annual election period in the fall (October 15 through December 7).

There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MaineMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.Medigap plans are standardized under federal rules — plans are designated by letter, from A through N. All Medigap insurers must offer at least Plan A and also offer at least Plan C or Plan F in addition to Plan A (note that under federal rules, Plan C and Plan F cannot be sold to people who weren’t already eligible for Medicare in 2019 or earlier).People are granted a six-month window, when they turn 65 and enroll in Original Medicare, during which coverage is guaranteed issue for Medigap plans. Federal rules do not, however, guarantee access to a Medigap plan if you’re under 65 and eligible for Medicare as a result of a disability. And after the initial six-month open enrollment period ends, federal rules do not allow enrollees guaranteed-issue access to Medigap plans (including switching from one plan to another) unless they experience one of the limited situations that trigger a guaranteed-issue right.But Maine has much more extensive Medigap regulations, designed to protect consumers and ensure greater access to Medigap. Maine’s rules are explained in the state’s Consumer Guide to Medicare Supplement Plans, and include several provisions:All Medigap insurers in Maine must designate at least one month per year when all applicants will be accepted for enrollment in Medigap Plan A, regardless of their medical history (Plan A offers the least amount of benefits).

Insurers can be more lenient than this basic requirement and two insurers (Anthem Blue Cross Blue Shield, and Colonial Penn) offer year-round access to Medigap Plan A.People under age 65 in Maine are granted the same six-month open enrollment period for guaranteed-issue Medigap plans (starting when they’re enrolled in Medicare Part B) as people who are 65 and enrolling in Medicare due to their age. These enrollees also have access to another six-month open enrollment period — during which they can switch to any Medigap plan on a guaranteed-issue basis — when they turn 65. This is clarified in Maine Rule 275, Section 11, which clarifies that insurers cannot condition eligibility or premiums on a person’s medical history as long as they enroll during their six-month open enrollment window, or in the 60 days preceding it (to ensure that people can have a seamless transition to Medicare, with Medigap coverage effective the same day Medicare begins).After the initial six-month window ends, Medigap enrollees in Maine are allowed to switch to a different plan from their current insurer or a different insurer, as long as they pick a plan with equal or lesser benefits (this chart shows which plans are available, depending on the plan the person already has) and as long as they haven’t had a break of more than 90 days in their Medigap coverage since their initial open enrollment period.Medigap insurers in Maine must allow a Medicare beneficiary to enroll in a Medigap plan if they apply within 90 days of losing coverage under an individual market plan (not counting a short-term health plan or fixed indemnity plan), an employer-sponsored plan, or MaineCare (Medicaid).Maine is one of eight states where Medigap premiums cannot vary based on age, and that provision also includes people under age 65 (some of the states that ban age-based Medigap premiums only apply that requirement to plans sold to people who are at least 65 years old). Medigap premiums in Maine only vary based on tobacco use.Federal law gives people a “trial right” to try Medicare Advantage and then switch to Original Medicare instead, with guaranteed-issue access to Medigap as long as the person makes the switch to Original Medicare within a year. But Maine law extends that trial right period to three years.

If a person in Maine signs up for Medicare Advantage when they’re first eligible for Medicare and then switches to Original Medicare within three years, they have a guaranteed-issue right to buy any Medigap plan available in their area, as long as they purchase it within 90 days of their Medicare Advantage plan ending.Maine residents who have Medigap coverage and terminate it to switch to Medicare Advantage also have a three-year trial period, although it’s a little more restrictive. As long as they switch back to Original Medicare within three years and apply for a Medigap plan within 90 days of the Medicare Advantage plan ending, they have a guaranteed issue right to buy a Medigap plan with benefits that are equal to or less than their original Medigap plan’s benefits (again, this chart shows which plans have equal or lesser benefits).There are 14 insurers in Maine that offer Medigap plans, as well as several association groups that offer Medigap coverage in the state. The state’s consumer guide shows 2020 Medigap premiums as well as each insurer’s pre-existing condition waiting period (if applicable) for people who didn’t have continuous coverage before enrolling in the Medigap plan. Insurers cannot exclude pre-existing conditions if the applicant had a least six months of creditable coverage prior to enrolling in Medigap (if they had creditable coverage but for a period of less than six months, the insurer can implement a pre-existing condition waiting period of up to six months minus the amount of time the person had creditable coverage in the prior six months). Maine Medicare Part DOriginal Medicare does not cover outpatient prescription drugs.

But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D plan.As of July 2020, there were 125,831 Medicare beneficiaries in Maine enrolled in stand-alone Medicare Part D prescription drug plans. In addition to those with stand-alone Part D plans, more than 140,000 Maine residents had Part D coverage integrated with the Medicare Advantage plans as of mid-2020. As of late 2018, about 43 percent of Maine’s Medicare beneficiaries had been enrolled in stand-alone Medicare Part D plans, but that has dropped as Medicare Advantage enrollment had increased. By mid-2020, about 36 percent of the Maine Medicare beneficiaries were enrolled in stand-alone Medicare Part D plans.For 2020 coverage, there are 26 stand-alone Medicare Part D plans available in Maine, with premiums ranging from $13 to $84 per month.Medicare Part D enrollment is available when a person is first eligible for Medicare, and there’s also an annual open enrollment period (October 15 – December 7) when beneficiaries can enroll in Part D coverage or switch to a different plan for the coming year.Medicare spending in MaineIn 2018, average spending per beneficiary on Medicare in Maine was $8,841, based on data that were standardized to eliminate regional differences in payment rates. Costs for Medicare Advantage enrollees were not included in the analysis.

The national average that year was $10,096 per enrollee, so Medicare spending in Maine was 12 percent lower than the national average.In terms of the extremes on both ends of the spectrum, average per-beneficiary Original Medicare costs in Louisiana were the highest in the nation, at $11,932, while they were lowest in the nation in Hawaii, at $6,971.Medicare in Maine. Resources for beneficiaries and their caregiversYou can contact the Maine State Health Insurance Assistance Program if you have questions related to Medicare eligibility in Maine or Medicare enrollment in Maine.The Maine Bureau of Insurance also maintains a page of frequently asked questions about Medicare in Maine.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance expertsAt a glance. Medicare enrollment in WisconsinAbout 1.15 million residents are enrolled in Medicare in Wisconsin.

Fifteen percent are under 65 and enrolled due to a disability.More than 40 percent of beneficiaries of Medicare in Wisconsin are enrolled in Medicare Advantage plans.The market for Medicare Advantage in Wisconsin is robust, with between 11 and 47 plans available, depending on the county.At least 32 insurers offer Medigap plans in Wisconsin. The state does its own Medigap plan standardization, so Medigap plans in Wisconsin are different from Medigap plans sold in most states.In 2020, Wisconsin lawmakers considered, but did not pass, legislation that would have allowed Wisconsin Medigap enrollees to switch, without medical underwriting, to a plan with equal or lesser benefits.Wisconsin regulations guarantee access to Medigap Basic plans for disabled enrollees under age 65, but premiums can be considerably higher for under-65 enrollees.There are 30 stand-alone Medicare Part D prescription drug plans available in Wisconsin in 2020, with premiums ranging from about $13 to $124 per month. About 38% of Wisconsin Medicare beneficiaries have stand-alone Part D prescription drug plans.Per-enrollee spending for Original Medicare in Wisconsin is 13% lower than the national average.How many people are enrolled in Medicare in Wisconsin?. Medicare enrollment in Wisconsin stood at 1,198,428 people as of July 2020, amounting to more than 20 percent of the state’s population. In most cases, filing for Medicare benefits goes along with turning 65.

But Medicare also provides coverage for disabled Americans under age 65, once they have been receiving disability benefits for 24 months, and for people with ALS or end-stage renal disease. Nationwide, 15 percent of Medicare beneficiaries are under age 65. In Wisconsin, it’s 14 percent. In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.Read about Medicare’s open enrollment period Medicare Advantage in WisconsinMedicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. Medicare Advantage plans are offered by private insurers, so plan availability varies from one area to another.

Wisconsin’s Medicare Advantage market is robust. Medicare Advantage plans are available state-wide, and residents in every county have access to at least 11 Medicare Advantage plans, and in most cases, more than 20. In Waukesha and Brown counties, there are 47 Medicare Advantage plans for sale.Forty percent of beneficiaries of Medicare in Wisconsin had Medicare Advantage enrollment coverage as of 2018, versus about 34 percent nationwide. As of July 2020, there were 556,643 Wisconsin Medicare beneficiaries enrolled in private Medicare coverage (not counting private supplemental coverage like Part D and Medigap). That’s more than 46 percent of the state’s Medicare population, but some Wisconsin Medicare beneficiaries are enrolled in Medicare Cost plans, which are an earlier form of private Medicare coverage that predates Medicare Advantage plans (three insurers in Wisconsin offer Medicare Cost plans).

The other 661,785 Medicare beneficiaries in Wisconsin had coverage under Original Medicare as of mid-2020.The popularity of Medicare Advantage enrollment varies from one state to another. In Minnesota, nearly half of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Medicare Advantage plans (via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).Original Medicare coverage is provided directly by the federal government, and enrollees have access to a nationwide network of providers. But people with Original Medicare need supplemental coverage (from an employer-sponsored plan, Medicaid, or privately purchased plans) for things like prescription drugs and out-of-pocket costs (out-of-pocket costs are not capped under Original Medicare).Original Medicare includes Medicare Parts A and B. Medicare Advantage includes all of the coverage provided by Medicare Parts A and B, and the plans often include additional benefits, usually including integrated Medicare Part D prescription drug coverage and often including coverage for things like dental and vision care. But Medicare Advantage insurers establish their own provider networks, which are generally localized and more limited than the nationwide network for Original Medicare.

Out-of-pocket costs for Medicare Advantage are often higher than they would be if a beneficiary had Original Medicare plus a Medigap plan. There are pros and cons to either option, and the right solution is different for each person.Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan). And people who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.Medigap in WisconsinOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had only Original Medicare.Although Medigap plans are sold by private insurers, the plans in nearly every state are standardized under federal rules.

But Wisconsin is one of just three states that have waivers from the federal government allowing the state to conduct its own Medigap standardization. So Medigap plans in Wisconsin are not the same as they are in most of the rest of the country.Instead of having ten different plan designs available (as is the case in most states), Wisconsin Medigap is structured so that there’s a basic plan, and then enrollees can choose to add riders that make the coverage more comprehensive. So instead of buying “Plan G” (as newly-eligible enrollees in most states would do if they wanted the most comprehensive Medigap plan), Wisconsin Medigap enrollees would buy the basic plan and then add on the optional riders.Wisconsin Medigap insurers have to offer “basic benefits” that include coverage for Part A coinsurance (including the Part A hospice coinsurance and hospital coinsurance), Part B coinsurance, and up to three pints of blood each year. Each Medigap insurer has to offer a “Basic Plan,” which includes the basic benefits in addition to Part A skilled nursing facility coinsurance, additional coverage for home health care and inpatient mental health care (both have limits on the number of days that are covered), outpatient mental health care, and Wisconsin state-mandated benefits.In addition, Wisconsin Medigap insurers can offer up to seven optional riders that enrollees can purchase, with coverage for things like the Part A deductible, additional home health care, the Part B deductible and excess charges, and foreign travel coverage for emergencies abroad (people who are newly eligible for Medicare in 2020 or later are not be able to purchase Medigap coverage for the Part B deductible. Those who already had this coverage can keep it, and people who became eligible for Medicare prior to 2020 can still purchase it, assuming they can meet the medical underwriting requirements.

This applies nationwide, under the terms of the Medicare Access and CHIP Reauthorization Act of 2015).So if a person in Wisconsin wants a Medigap plan that’s comparable to Medigap Plan G sold in other states, they would need to buy the Basic Plan plus riders for the Part A deductible, Part B excess charges, additional home health care benefits, and foreign travel emergency coverage. Medigap coverage similar to the various lettered plans sold in other states can thus be obtained in Wisconsin by layering various riders on top of the Basic Plan.Medigap insurers in Wisconsin can also offer cost-sharing plans that require the member to pay a portion of the out-of-pocket costs until they reach a specified out-of-pocket limit (similar to Medigap plans K and L that are sold in other states), and high-deductible plans that require the member the pay all costs until they meet the deductible for the year (similar to the high-deductible versions of Medigap plans F and G that are sold in other states).There are at least 32 insurers that offer traditional Medigap plans in Wisconsin as of 2020, in addition to four insurers that offer Medicare Select plans (Wisconsin’s Medigap guide notes that there may be other insurers in the state that have chosen not to have their pricing and sales information detailed in the publication). 299,988 Wisconsin Medicare beneficiaries had Medigap coverage as of 2018, according to an AHIP analysis. That was about 45 percent of the state’s Original Medicare enrollees (Medigap coverage cannot be used with Medicare Advantage plans).Medigap insurers in Wisconsin can choose to use attained-age rating (rates increase as an enrollee gets older) or issue-age rating (rates are based on the age the person was when they enrolled).Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue.

This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a Medigap plan).Lawmakers in Wisconsin considered SB615 in 2020 (a 2018 bill that was brought back up for consideration in the 2020 session). The legislation, which did not pass, would have allowed people to switch to equal or lesser Medigap plans without underwriting. That’s fairly rare – very few states have guaranteed-issue rules for Medigap outside of the initial enrollment window. And although Wisconsin lawmakers considered changing that rule, they did not do so during the 2020 legislative session.People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, and 15 percent of Medicare beneficiaries in Wisconsin are under age 65. Federal rules do not guarantee access to Medigap plans for people who are under 65, but the majority of the states — including Wisconsin — have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans.Medigap insurers in Wisconsin are required to offer coverage to disabled enrollees under age 65, with the same six-month open enrollment period that begins when the person is enrolled in Medicare Part B.

But premiums for people under the age of 65 are considerably higher than premiums for people who are 65 and over. And insurers are only required to offer the Medigap Basic Plan to applicants under the age of 65. There are only a handful of insurers that offer any other plans (the high-deductible option, and the 25 percent and 50 percent cost-sharing options). Humana, Wisconsin Physicians Service Insurance Corporation, Garden State, Physicians Life Insurance Company, United American, and United World.Disabled Medicare beneficiaries also have access to the normal Medigap open enrollment period when they turn 65. At that point, they can select from among any of the available Medigap plans, with lower premiums that apply to people who are aging onto Medicare when they turn 65.Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (as of 2021, Medicare beneficiaries who have kidney failure will be able to enroll in Medicare Advantage plans).

Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But as noted above, Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care, plus the out-of-pocket cost of prescription drugs (the upper limit for out-of-pocket costs, not counting prescription costs, will increase to $7,550 as of 2021).Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those rules don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months if you didn’t have at least six months of continuous coverage prior to your enrollment (although many of them choose not to do so). And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the Medigap insurer can consider your medical history in determining whether to accept your application, and at what premium. Wisconsin Medicare Part DOriginal Medicare does not provide coverage for outpatient prescription drugs.

More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.Medicare beneficiaries who do not have Medicaid or employer-sponsored drug coverage need Medicare Part D enrollment in order to have coverage for prescriptions. Medicare Part D was created under the Medicare Modernization Act of 2003, and can be purchased as a stand-alone plan, or obtained as part of a Medicare Advantage with built-in Part D benefits.There are 30 stand-alone Medicare Part D plans for sale in Wisconsin in 2020, with premiums that range from about $13 to $124/month.About 38 percent of Wisconsin’s Medicare beneficiaries (452,969 people) had stand-alone Medicare Part D plans as of mid-2020. Another 441,044 Wisconsin Medicare beneficiaries had Medicare Part D prescription coverage integrated with their Medicare Advantage plans.Medicare Part D enrollment is available during a beneficiary’s initial enrollment period (when they turn 65 or become eligible for Medicare due to a disability), and there is also an annual open enrollment period each fall. During this window, beneficiaries can switch to a different Medicare Part D plan or enroll for the first time (with a late enrollment penalty, depending on the circumstances), with coverage effective the following January. Per-beneficiary spending for Medicare in WisconsinPer-beneficiary spending for Original Medicare in Wisconsin was 13 percent lower than the national average in 2018, at $8,763.

Only ten states had lower average per-beneficiary Original Medicare spending. The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage. Nationwide, average per-beneficiary Original Medicare spending stood at $10,096.Per-beneficiary Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in Wisconsin. Resources for beneficiaries and their caregiversNeed help with Medicare enrollment in Wisconsin?. You can contact the Wisconsin State Health Insurance Information Program with questions related to Medicare coverage in Wisconsin or Medicare eligibility in Wisconsin.The Wisconsin Department of Health Services also has a comprehensive list of resources related to Medicare coverage in Wisconsin.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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How to cite this article:Singh levitra 5mg review O P Going Here. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one of the levitra 5mg review highly publicized events in our country. Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide.

As expected, the media went into a frenzy as newspapers, news channels, and social media were full of stories levitra 5mg review providing minute details of the suicidal act. Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor. All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the actor were besmirched and their private levitra 5mg review and personal details were freely and blatantly broadcast and discussed on electronic, print, and social media.

We understand that media houses have their own need and duty to report and sensationalize news for increasing their visibility (aka TRP), but such reporting has huge impacts on the mental health of the vulnerable population.The impact of this was soon realized when many incidents of copycat suicide were reported from all over the country within a few days of the incident. Psychiatrists suddenly levitra 5mg review started getting distress calls from their patients in despair with increased suicidal ideation. This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of photograph levitra 5mg review of mentally ill person without his consent.[1] The Press Council of India has adopted the guidelines of World Health Organization report on Preventing Suicide.

A resource for media professionals, which came out with an advisory to be followed by media in reporting cases of suicide. It includes points forbidding them from putting stories in prominent positions and unduly repeating them, explicitly describing the method used, providing details about the site/location, using sensational headlines, or using photographs and video footage of the incident.[2] Unfortunately, the advisory seems to have little effect in the aftermath of celebrity suicides. Channels were full of levitra 5mg review speculations about the person's mental condition and illness and also his relationships and finances. Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him.

The Indian Psychiatric Society has written to the Press Council of India underlining this concern and asking for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide levitra 5mg review reporting on the lives of many vulnerable persons, there is even a more urgent need for training of psychiatrists regarding the proper way of interaction with media. This has been amply brought out in the aftermath of this incident. Many psychiatrists and mental health professionals were called by media houses to comment on the episode levitra 5mg review. Many psychiatrists were quoted, or “misquoted,” or “quoted out of context,” commenting on the life of a person whom they had never examined and had no “professional authority” to do so.

There were even stories with byline of a psychiatrist where the content provided was not only unscientific but also way beyond the expertise of a psychiatrist. These types of viewpoints perpetuate stigma, myths, and “misleading concepts” about psychiatry and are detrimental to the image of psychiatry in addition to doing harm and injustice to levitra 5mg review our patients. Hence, the need to formulate a guideline for interaction of psychiatrists with the media is imperative.In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinion about the fitness of Barry Goldwater for presidential candidature. Out of 2417 respondents, 1189 psychiatrists reported him to be mentally unfit while none had actually examined him.[3] This led to the formulation of “The Goldwater Rule” by the American Psychiatric Association in 1973,[4] but we have witnessed the same phenomenon at the time of presidential candidature of Donald Trump.Psychiatrists should be encouraged to interact levitra 5mg review with media to provide scientific information about mental illnesses and reduction of stigma, but “statements to the media” can be a double-edged sword, and we should know about the rules of engagements and boundaries of interactions.

Methods and principles of interaction with media should form a part of our training curriculum. Many professional societies have guidelines and resource books for interacting with media, and psychiatrists should familiarize themselves with these documents levitra 5mg review. The Press Council guideline is likely to prompt reporters to seek psychiatrists for their expert opinion. It is useful for them to have a template ready with suicide rates, emphasizing multicausality of suicide, role of mental disorders, as well as help available.[5]It is about time that the Indian Psychiatric Society formulated its own guidelines laying down the broad principles and boundaries governing the interaction of Indian psychiatrists with the media.

Till then, it is desirable to be guided by the following broad principles:It should be assumed that no statement goes “off the record” as the media person is most likely recording the interview, and we should also record any such conversation from our endIt should be clarified in which capacity comments are being made – professional, personal, or as a representative of an organizationOne should not comment on any person whom he has not examinedPsychiatrists should take any such opportunity to educate the public about mental health issuesThe comments should be justified and limited by the boundaries of scientific knowledge available at the levitra 5mg review moment. References Correspondence Address:Dr. O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata levitra 5mg review - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment. The dangerousness of ECT has been mainly attributed to its claimed ability to cause brain damage.

This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this question specifically. Thus, even though there are newer technological tools and innovations, any review attempting to answer this question would have to take recourse to indirect methods.

These include structural, functional, and metabolic neuroimaging. Body fluid biochemical marker studies. And follow-up studies of cognitive impairment and incidence of dementia in people who have received ECT among others. The review of literature and present evidence suggests that ECT has a demonstrable impact on the structure and function of the brain.

However, there is a lack of evidence at present to suggest that ECT causes brain damage.Keywords. Adverse effect, brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update.

Indian J Psychiatry 2020;62:339-53 Introduction Electroconvulsive therapy (ECT) as a modality of treatment for psychiatric disorders has existed at least since 1938.[1] ECT is an effective modality of treatment for various psychiatric disorders. However, from the very beginning, the practice of ECT has also faced resistance from various groups who claim that it is coercive and harmful.[2] While the ethical aspects of the practice of ECT have been dealt with elsewhere, the question of harmfulness or brain damage consequent upon the passage of electric current needs to be examined afresh in light of technological advances and new knowledge.[3]The question whether ECT causes brain damage was reviewed in a holistic fashion by Devanand et al. In the mid-1990s.[4],[5] The authors had attempted to answer this question by reviewing the effect of ECT on the brain in various areas – cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epileptic patients, and finally animal ECS studies. The authors had concluded that ECT does not produce brain damage.This narrative review aims to update the evidence with regard to whether ECT causes brain damage by reviewing relevant literature from 1994 to the present time.

Framing the Question The Oxford Dictionary defines damage as physical harm that impairs the value, usefulness, or normal function of something.[6] Among medical dictionaries, the Peter Collins Dictionary defines damage as harm done to things (noun) or to harm something (verb).[7] Brain damage is defined by the British Medical Association Medical Dictionary as degeneration or death of nerve cells and tracts within the brain that may be localized to a particular area of the brain or diffuse.[8] Going by such a definition, brain damage in the context of ECT should refer to death or degeneration of brain tissue, which results in the impairment of functioning of the brain. The importance of precisely defining brain damage shall become evident subsequently in this review.There are now many more tools available to investigate the structure and function of brain in health and illness. However, there are obvious ethical issues in designing human studies that are designed to answer this specific question. Therefore, one must necessarily take recourse to indirect evidences available through studies that have been designed to answer other research questions.

These studies have employed the following methods:Structural neuroimaging studiesFunctional neuroimaging studiesMetabolic neuroimaging studiesBody fluid biochemical marker studiesCognitive impairment studies.While the early studies tended to focus more on establishing the safety of ECT and finding out whether ECT causes gross microscopic brain damage, the later studies especially since the advent of advanced neuroimaging techniques have been focusing more on a mechanistic understanding of ECT. Hence, the primary objective of the later neuroimaging studies has been to look for structural and functional brain changes which might explain how ECT acts rather than evidence of gross structural damage per se. However, put together, all these studies would enable us to answer our titular question to some satisfaction. [Table 1] and [Table 2] provide an overview of the evidence base in this area.

Structural and Functional Neuroimaging Studies Devanand et al. Reviewed 16 structural neuroimaging studies on the effect of ECT on the brain.[4] Of these, two were pneumoencephalography studies, nine were computed tomography (CT) scan studies, and five were magnetic resonance imaging (MRI) studies. However, most of these studies were retrospective in design, with neuroimaging being done in patients who had received ECT in the past. In the absence of baseline neuroimaging, it would be very difficult to attribute any structural brain changes to ECT.

In addition, pneumoencephalography, CT scan, and even early 0.3 T MRI provided images with much lower spatial resolution than what is available today. The authors concluded that there was no evidence to show that ECT caused any structural damage to the brain.[4] Since then, at least twenty more MRI-based structural neuroimaging studies have studied the effect of ECT on the brain. The earliest MRI studies in the early 1990s focused on detecting structural damage following ECT. All of these studies were prospective in design, with the first MRI scan done at baseline and a second MRI scan performed post ECT.[9],[11],[12],[13],[41] While most of the studies imaged the patient once around 24 h after receiving ECT, some studies performed multiple post ECT neuroimaging in the first 24 h after ECT to better capture the acute changes.

A single study by Coffey et al. Followed up the patients for a duration of 6 months and repeated neuroimaging again at 6 months in order to capture any long-term changes following ECT.[10]The most important conclusion which emerged from this early series of studies was that there was no evidence of cortical atrophy, change in ventricle size, or increase in white matter hyperintensities.[4] The next major conclusion was that there appeared to be an increase in the T1 and T2 relaxation time immediately following ECT, which returned to normal within 24 h. This supported the theory that immediately following ECT, there appears to be a temporary breakdown of the blood–brain barrier, leading to water influx into the brain tissue.[11] The last significant observation by Coffey et al. In 1991 was that there was no significant temporal changes in the total volumes of the frontal lobes, temporal lobes, or amygdala–hippocampal complex.[10] This was, however, something which would later be refuted by high-resolution MRI studies.

Nonetheless, one inescapable conclusion of these early studies was that there was no evidence of any gross structural brain changes following administration of ECT. Much later in 2007, Szabo et al. Used diffusion-weighted MRI to image patients in the immediate post ECT period and failed to observe any obvious brain tissue changes following ECT.[17]The next major breakthrough came in 2010 when Nordanskog et al. Demonstrated that there was a significant increase in the volume of the hippocampus bilaterally following a course of ECT in a cohort of patients with depressive illness.[18] This contradicted the earlier observations by Coffey et al.

That there was no volume increase in any part of the brain following ECT.[10] This was quite an exciting finding and was followed by several similar studies. However, the perspective of these studies was quite different from the early studies. In contrast to the early studies looking for the evidence of ECT-related brain damage, the newer studies were focused more on elucidating the mechanism of action of ECT. Further on in 2014, Nordanskog et al.

In a follow-up study showed that though there was a significant increase in the volume of the hippocampus 1 week after a course of ECT, the hippocampal volume returned to the baseline after 6 months.[19] Two other studies in 2013 showed that in addition to the hippocampus, the amygdala also showed significant volume increase following ECT.[20],[21] A series of structural neuroimaging studies after that have expanded on these findings and as of now, gray matter volume increase following ECT has been demonstrated in the hippocampus, amygdala, anterior temporal pole, subgenual cortex,[21] right caudate nucleus, and the whole of the medial temporal lobe (MTL) consisting of the hippocampus, amygdala, insula, and the posterosuperior temporal cortex,[24] para hippocampi, right subgenual anterior cingulate gyrus, and right anterior cingulate gyrus,[25] left cerebellar area VIIa crus I,[29] putamen, caudate nucleus, and nucleus acumbens [31] and clusters of increased cortical thickness involving the temporal pole, middle and superior temporal cortex, insula, and inferior temporal cortex.[27] However, the most consistently reported and replicated finding has been the bilateral increase in the volume of the hippocampus and amygdala. In light of these findings, it has been tentatively suggested that ECT acts by inducing neuronal regeneration in the hippocampus – amygdala complex.[42],[43] However, there are certain inconsistencies to this hypothesis. Till date, only one study – Nordanskog et al., 2014 – has followed study patients for a long term – 6 months in their case. And significantly, the authors found out that after increasing immediately following ECT, the hippocampal volume returns back to baseline by 6 months.[19] This, however, was not associated with the relapse of depressive symptoms.

Another area of significant confusion has been the correlation of hippocampal volume increase with improvement of depressive symptoms. Though almost all studies demonstrate a significant increase in hippocampal volume following ECT, a majority of studies failed to demonstrate a correlation between symptom improvement and hippocampal volume increase.[19],[20],[22],[24],[28] However, a significant minority of volumetric studies have demonstrated correlation between increase in hippocampal and/or amygdala volume and improvement of symptoms.[21],[25],[30]Another set of studies have used diffusion tensor imaging, functional MRI (fMRI), anatomical connectome, and structural network analysis to study the effect of ECT on the brain. The first of these studies by Abbott et al. In 2014 demonstrated that on fMRI, the connectivity between right and left hippocampus was significantly reduced in patients with severe depression.

It was also shown that the connectivity was normalized following ECT, and symptom improvement was correlated with an increase in connectivity.[22] In a first of its kind DTI study, Lyden et al. In 2014 demonstrated that fractional anisotropy which is a measure of white matter tract or fiber density is increased post ECT in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left superior longitudinal fasciculus. The authors suggested that ECT acts to normalize major depressive disorder-related abnormalities in the structural connectivity of the dorsal fronto-limbic pathways.[23] Another DTI study in 2015 constructed large-scale anatomical networks of the human brain – connectomes, based on white matter fiber tractography. The authors found significant reorganization in the anatomical connections involving the limbic structure, temporal lobe, and frontal lobe.

It was also found that connection changes between amygdala and para hippocampus correlated with reduction in depressive symptoms.[26] In 2016, Wolf et al. Used a source-based morphometry approach to study the structural networks in patients with depression and schizophrenia and the effect of ECT on the same. It was found that the medial prefrontal cortex/anterior cingulate cortex (ACC/MPFC) network, MTL network, bilateral thalamus, and left cerebellar regions/precuneus exhibited significant difference between healthy controls and the patient population. It was also demonstrated that administration of ECT leads to significant increase in the network strength of the ACC/MPFC network and the MTL network though the increase in network strength and symptom amelioration were not correlated.[32]Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of brain volume changes – focusing on hippocampal volume increase following ECT in patients with major depressive disorder and bipolar disorder.

The authors initially selected 32 original articles from which six articles met the criteria for quantitative synthesis. The results showed significant increase in the volume of the right and left hippocampus following ECT. For the rest of the brain regions, the heterogeneity in protocols and imaging techniques did not permit a quantitative analysis, and the authors have resorted to a narrative review similar to the present one with similar conclusions.[44] Focusing exclusively on hippocampal volume change in ECT, Oltedal et al. In 2018 conducted a mega-analysis of 281 patients with major depressive disorder treated with ECT enrolled at ten different global sites of the Global ECT-MRI Research Collaboration.[45] Similar to previous studies, there was a significant increase in hippocampal volume bilaterally with a dose–response relationship with the number of ECTs administered.

Furthermore, bilateral (B/L) ECT was associated with an equal increase in volume in both right and left hippocampus, whereas right unilateral ECT was associated with greater volume increase in the right hippocampus. Finally, contrary to expectation, clinical improvement was found to be negatively correlated with hippocampal volume.Thus, a review of the current evidence amply demonstrates that from looking for ECT-related brain damage – and finding none, we have now moved ahead to looking for a mechanistic understanding of the effect of ECT. In this regard, it has been found that ECT does induce structural changes in the brain – a fact which has been seized upon by some to claim that ECT causes brain damage.[46] Such statements should, however, be weighed against the definition of damage as understood by the scientific medical community and patient population. Neuroanatomical changes associated with effective ECT can be better described as ECT-induced brain neuroplasticity or ECT-induced brain neuromodulation rather than ECT-induced brain damage.

Metabolic Neuroimaging Studies. Magnetic Resonance Spectroscopic Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase-encoding procedure to map the spatial distribution of magnetic resonance (MR) signals of different molecules. The crucial difference, however, is that while MRI maps the MR signals of water molecules, MRSI maps the MR signals generated by different metabolites – such as N-acetyl aspartate (NAA) and choline-containing compounds. However, the concentration of these metabolites is at least 10,000 times lower than water molecules and hence the signal strength generated would also be correspondingly lower.

However, MRSI offers us the unique advantage of studying in vivo the change in the concentration of brain metabolites, which has been of great significance in fields such as psychiatry, neurology, and basic neuroscience research.[47]MRSI studies on ECT in patients with depression have focused largely on four metabolites in the human brain – NAA, choline-containing compounds (Cho) which include majorly cell membrane compounds such as glycerophosphocholine, phosphocholine and a miniscule contribution from acetylcholine, creatinine (Cr) and glutamine and glutamate together (Glx). NAA is located exclusively in the neurons, and is suggested to be a marker of neuronal viability and functionality.[48] Choline-containing compounds (Cho) mainly include the membrane compounds, and an increase in Cho would be suggestive of increased membrane turnover. Cr serves as a marker of cellular energy metabolism, and its levels are usually expected to remain stable. The regions which have been most widely studied in MRSI studies include the bilateral hippocampus and amygdala, dorsolateral prefrontal cortex (DLPFC), and ACC.Till date, five MRSI studies have measured NAA concentration in the hippocampus before and after ECT.

Of these, three studies showed that there is no significant change in the NAA concentration in the hippocampus following ECT.[33],[38],[49] On the other hand, two recent studies have demonstrated a statistically significant reduction in NAA concentration in the hippocampus following ECT.[39],[40] The implications of these results are of significant interest to us in answering our titular question. A normal level of NAA following ECT could signify that there is no significant neuronal death or damage following ECT, while a reduction would signal the opposite. However, a direct comparison between these studies is complicated chiefly due to the different ECT protocols, which has been used in these studies. It must, however, be acknowledged that the three older studies used 1.5 T MRI, whereas the two newer studies used a higher 3 T MRI which offers betters signal-to-noise ratio and hence lesser risk of errors in the measurement of metabolite concentrations.

The authors of a study by Njau et al.[39] argue that a change in NAA levels might reflect reversible changes in neural metabolism rather than a permanent change in the number or density of neurons and also that reduced NAA might point to a change in the ratio of mature to immature neurons, which, in fact, might reflect enhanced adult neurogenesis. Thus, the authors warn that to conclude whether a reduction in NAA concentration is beneficial or harmful would take a simultaneous measurement of cognitive functioning, which was lacking in their study. In 2017, Cano et al. Also demonstrated a significant reduction in NAA/Cr ratio in the hippocampus post ECT.

More significantly, the authors also showed a significant increase in Glx levels in the hippocampus following ECT, which was also associated with an increase in hippocampal volume.[40] To explain these three findings, the authors proposed that ECT produces a neuroinflammatory response in the hippocampus – likely mediated by Glx, which has been known to cause inflammation at higher concentrations, thereby accounting for the increase in hippocampal volume with a reduction in NAA concentration. The cause for the volume increase remains unclear – with the authors speculating that it might be due to neuronal swelling or due to angiogenesis. However, the same study and multiple other past studies [21],[25],[30] have demonstrated that hippocampal volume increase was correlated with clinical improvement following ECT. Thus, we are led to the hypothesis that the same mechanism which drives clinical improvement with ECT is also responsible for the cognitive impairment following ECT.

Whether this is a purely neuroinflammatory response or a neuroplastic response or a neuroinflammatory response leading to some form of neuroplasticity is a critical question, which remains to be answered.[40]Studies which have analyzed NAA concentration change in other brain areas have also produced conflicting results. The ACC is another area which has been studied in some detail utilizing the MRSI technique. In 2003, Pfleiderer et al. Demonstrated that there was no significant change in the NAA and Cho levels in the ACC following ECT.

This would seem to suggest that there was no neurogenesis or membrane turnover in the ACC post ECT.[36] However, this finding was contested by Merkl et al. In 2011, who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and that these levels were significantly elevated following ECT.[37] This again is contested by Njau et al. Who showed that NAA levels are significantly reduced following ECT in the left dorsal ACC.[39] A direct comparison of these three studies is complicated by the different ECT and imaging parameters used and hence, no firm conclusion can be made on this point at this stage. In addition to this, one study had demonstrated increased NAA levels in the amygdala following administration of ECT,[34] with a trend level increase in Cho levels, which again is suggestive of neurogenesis and/or neuroplasticity.

A review of studies on the DLPFC reveals a similarly confusing picture with one study, each showing no change, reduction, and elevation of concentration of NAA following ECT.[35],[37],[39] Here, again, a direct comparison of the three studies is made difficult by the heterogeneous imaging and ECT protocols followed by them.A total of five studies have analyzed the concentration of choline-containing compounds (Cho) in patients undergoing ECT. Conceptually, an increase in Cho signals is indicative of increased membrane turnover, which is postulated to be associated with synaptogenesis, neurogenesis, and maturation of neurons.[31] Of these, two studies measured Cho concentration in the B/L hippocampus, with contrasting results. Ende et al. In 2000 demonstrated a significant elevation in Cho levels in B/L hippocampus after ECT, while Jorgensen et al.

In 2015 failed to replicate the same finding.[33],[38] Cho levels have also been studied in the amygdala, ACC, and the DLPFC. However, none of these studies showed a significant increase or decrease in Cho levels before and after ECT in the respective brain regions studied. In addition, no significant difference was seen in the pre-ECT Cho levels of patients compared to healthy controls.[34],[36],[37]In review, we must admit that MRSI studies are still at a preliminary stage with significant heterogeneity in ECT protocols, patient population, and regions of the brain studied. At this stage, it is difficult to draw any firm conclusions except to acknowledge the fact that the more recent studies – Njau et al., 2017, Cano, 2017, and Jorgensen et al., 2015 – have shown decrease in NAA concentration and no increase in Cho levels [38],[39],[40] – as opposed to the earlier studies by Ende et al.[33] The view offered by the more recent studies is one of a neuroinflammatory models of action of ECT, probably driving neuroplasticity in the hippocampus.

This would offer a mechanistic understanding of both clinical response and the phenomenon of cognitive impairment associated with ECT. However, this conclusion is based on conjecture, and more work needs to be done in this area. Body Fluid Biochemical Marker Studies Another line of evidence for analyzing the effect of ECT on the human brain is the study of concentration of neurotrophins in the plasma or serum. Neurotrophins are small protein molecules which mediate neuronal survival and development.

The most prominent among these is brain-derived neurotrophic factor (BDNF) which plays an important role in neuronal survival, plasticity, and migration.[50] A neurotrophic theory of mood disorders was suggested which hypothesized that depressive disorders are associated with a decreased expression of BDNF in the limbic structures, resulting in the atrophy of these structures.[51] It was also postulated that antidepressant treatment has a neurotrophic effect which reverses the neuronal cell loss, thereby producing a therapeutic effect. It has been well established that BDNF is decreased in mood disorders.[52] It has also been shown that clinical improvement of depression is associated with increase in BDNF levels.[53] Thus, serum BDNF levels have been tentatively proposed as a biomarker for treatment response in depression. Recent meta-analytic evidence has shown that ECT is associated with significant increase in serum BDNF levels in patients with major depressive disorder.[54] Considering that BDNF is a potent stimulator of neurogenesis, the elevation of serum BDNF levels following ECT lends further credence to the theory that ECT leads to neurogenesis in the hippocampus and other limbic structures, which, in turn, mediates the therapeutic action of ECT. Cognitive Impairment Studies Cognitive impairment has always been the single-most important side effect associated with ECT.[55] Concerns regarding long-term cognitive impairment surfaced soon after the introduction of ECT and since then has grown to become one of the most controversial aspects of ECT.[56] Anti-ECT groups have frequently pointed out to cognitive impairment following ECT as evidence of ECT causing brain damage.[56] A meta-analysis by Semkovska and McLoughlin in 2010 is one of the most detailed studies which had attempted to settle this long-standing debate.[57] The authors reviewed 84 studies (2981 participants), which had used a combined total of 22 standardized neuropsychological tests assessing various cognitive functions before and after ECT in patients diagnosed with major depressive disorder.

The different cognitive domains reviewed included processing speed, attention/working memory, verbal episodic memory, visual episodic memory, spatial problem-solving, executive functioning, and intellectual ability. The authors concluded that administration of ECT for depression is associated with significant cognitive impairment in the first few days after ECT administration. However, it was also seen that impairment in cognitive functioning resolved within a span of 2 weeks and thereafter, a majority of cognitive domains even showed mild improvement compared to the baseline performance. It was also demonstrated that not a single cognitive domain showed persistence of impairment beyond 15 days after ECT.Memory impairment following ECT can be analyzed broadly under two conceptual schemes – one that classifies memory impairment as objective memory impairment and subjective memory impairment and the other that classifies it as impairment in anterograde memory versus impairment in retrograde memory.

Objective memory can be roughly defined as the ability to retrieve stored information and can be measured by various standardized neuropsychological tests. Subjective memory or meta-memory, on the other hand, refers to the ability to make judgments about one's ability to retrieve stored information.[58] As described previously, it has been conclusively demonstrated that anterograde memory impairment does not persist beyond 2 weeks after ECT.[57] However, one of the major limitations of this meta-analysis was the lack of evidence on retrograde amnesia following ECT. This is particularly unfortunate considering that it is memory impairment – particularly retrograde amnesia which has received the most attention.[59] In addition, reports of catastrophic retrograde amnesia have been repeatedly held up as sensational evidence of the lasting brain damage produced by ECT.[59] Admittedly, studies on retrograde amnesia are fewer and less conclusive than on anterograde amnesia.[60],[61] At present, the results are conflicting, with some studies finding some impairment in retrograde memory – particularly autobiographical retrograde memory up to 6 months after ECT.[62],[63],[64],[65] However, more recent studies have failed to support this finding.[66],[67] While they do demonstrate an impairment in retrograde memory immediately after ECT, it was seen that this deficit returned to pre-ECT levels within a span of 1–2 months and improved beyond baseline performance at 6 months post ECT.[66] Adding to the confusion are numerous factors which confound the assessment of retrograde amnesia. It has been shown that depressive symptoms can produce significant impairment of retrograde memory.[68],[69] It has also been demonstrated that sine-wave ECT produces significantly more impairment of retrograde memory as compared to brief-pulse ECT.[70] However, from the 1990s onward, sine-wave ECT has been completely replaced by brief-pulse ECT, and it is unclear as to the implications of cognitive impairment from the sine-wave era in contemporary ECT practice.Another area of concern are reports of subjective memory impairment following ECT.

One of the pioneers of research into subjective memory impairment were Squire and Chace who published a series of studies in the 1970s demonstrating the adverse effect of bilateral ECT on subjective assessment of memory.[62],[63],[64],[65] However, most of the studies conducted post 1980 – from when sine-wave ECT was replaced by brief-pulse ECT report a general improvement in subjective memory assessments following ECT.[71] In addition, most of the recent studies have failed to find a significant association between measures of subjective and objective memory.[63],[66],[70],[72],[73],[74] It has also been shown that subjective memory impairment is strongly associated with the severity of depressive symptoms.[75] In light of these facts, the validity and value of measures of subjective memory impairment as a marker of cognitive impairment and brain damage following ECT have been questioned. However, concerns regarding subjective memory impairment and catastrophic retrograde amnesia continue to persist, with significant dissonance between the findings of different research groups and patient self-reports in various media.[57]Some studies reported the possibility of ECT being associated with the development of subsequent dementia.[76],[77] However, a recent large, well-controlled prospective Danish study found that the use of ECT was not associated with elevated incidence of dementia.[78] Conclusion Our titular question is whether ECT leads to brain damage, where damage indicates destruction or degeneration of nerves or nerve tracts in the brain, which leads to loss of function. This issue was last addressed by Devanand et al. In 1994 since which time our understanding of ECT has grown substantially, helped particularly by the advent of modern-day neuroimaging techniques which we have reviewed in detail.

And, what these studies reveal is rather than damaging the brain, ECT has a neuromodulatory effect on the brain. The various lines of evidence – structural neuroimaging studies, functional neuroimaging studies, neurochemical and metabolic studies, and serum BDNF studies all point toward this. These neuromodulatory changes have been localized to the hippocampus, amygdala, and certain other parts of the limbic system. How exactly these changes mediate the improvement of depressive symptoms is a question that remains unanswered.

However, there is little by way of evidence from neuroimaging studies which indicates that ECT causes destruction or degeneration of neurons. Though cognitive impairment studies do show that there is objective impairment of certain functions – particularly memory immediately after ECT, these impairments are transient with full recovery within a span of 2 weeks. Perhaps, the single-most important unaddressed concern is retrograde amnesia, which has been shown to persist for up to 2 months post ECT. In this regard, the recent neurometabolic studies have offered a tentative mechanism of action of ECT, producing a transient inflammation in the limbic cortex, which, in turn, drives neurogenesis, thereby exerting a neuromodulatory effect.

This hypothesis would explain both the cognitive adverse effects of ECT – due to the transient inflammation – and the long-term improvement in mood – neurogenesis in the hippocampus. Although unproven at present, such a hypothesis would imply that cognitive impairment is tied in with the mechanism of action of ECT and not an indicator of damage to the brain produced by ECT.The review of literature suggests that ECT does cause at least structural and functional changes in the brain, and these are in all probability related to the effects of the ECT. However, these cannot be construed as brain damage as is usually understood. Due to the relative scarcity of data that directly examines the question of whether ECT causes brain damage, it is not possible to conclusively answer this question.

However, in light of enduring ECT survivor accounts, there is a need to design studies that specifically answer this question.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Payne NA, Prudic J. Electroconvulsive therapy. Part I.

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77.Brodaty H, Hickie I, Mason C, Prenter L. A prospective follow-up study of ECT outcome in older depressed patients. J Affect Disord 2000;60:101-11. 78.Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB.

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Shubh Mohan SinghDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_239_19 Tables [Table 1], [Table 2].

How to cite this article:Singh levitra online prices O generic levitra price P. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity generic levitra price suicide is one of the highly publicized events in our country.

Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide. As expected, generic levitra price the media went into a frenzy as newspapers, news channels, and social media were full of stories providing minute details of the suicidal act. Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor.

All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the generic levitra price process, reputations of many people associated with the actor were besmirched and their private and personal details were freely and blatantly broadcast and discussed on electronic, print, and social media. We understand that media houses have their own need and duty to report and sensationalize news for increasing their visibility (aka TRP), but such reporting has huge impacts on the mental health of the vulnerable population.The impact of this was soon realized when many incidents of copycat suicide were reported from all over the country within a few days of the incident.

Psychiatrists suddenly started getting distress calls from generic levitra price their patients in despair with increased suicidal ideation. This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of photograph of mentally ill person without his consent.[1] The Press Council of India has adopted the guidelines of World Health Organization generic levitra price report on Preventing Suicide.

A resource for media professionals, which came out with an advisory to be followed by media in reporting cases of suicide. It includes points forbidding them from putting stories in prominent positions and unduly repeating them, explicitly describing the method used, providing details about the site/location, using sensational headlines, or using photographs and video footage of the incident.[2] Unfortunately, the advisory seems to have little effect in the aftermath of celebrity suicides. Channels were full of speculations about generic levitra price the person's mental condition and illness and also his relationships and finances.

Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him. The Indian Psychiatric generic levitra price Society has written to the Press Council of India underlining this concern and asking for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more urgent need for training of psychiatrists regarding the proper way of interaction with media. This has been amply brought out in the aftermath of this incident.

Many psychiatrists and mental health professionals were called by media houses to comment generic levitra price on the episode. Many psychiatrists were quoted, or “misquoted,” or “quoted out of context,” commenting on the life of a person whom they had never examined and had no “professional authority” to do so. There were even stories with byline of a psychiatrist where the content provided was not only unscientific but also way beyond the expertise of a psychiatrist.

These types of viewpoints perpetuate stigma, myths, and “misleading concepts” about generic levitra price psychiatry and are detrimental to the image of psychiatry in addition to doing harm and injustice to our patients. Hence, the need to formulate a guideline for interaction of psychiatrists with the media is imperative.In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinion about the fitness of Barry Goldwater for presidential candidature. Out of 2417 respondents, 1189 psychiatrists reported him to be mentally unfit while none had actually examined him.[3] This led to the formulation of “The Goldwater Rule” by the American Psychiatric Association in 1973,[4] but we have witnessed the same phenomenon at the time of presidential candidature of Donald Trump.Psychiatrists should be encouraged to interact with media to provide scientific information about mental illnesses and reduction of stigma, but “statements to the media” can be a double-edged sword, and we should know about the rules of engagements generic levitra price and boundaries of interactions.

Methods and principles of interaction with media should form a part of our training curriculum. Many professional societies have guidelines and resource books for interacting with media, generic levitra price and psychiatrists should familiarize themselves with these documents. The Press Council guideline is likely to prompt reporters to seek psychiatrists for their expert opinion.

It is useful for them to have a template ready with suicide rates, emphasizing multicausality of suicide, role of mental disorders, as well as help available.[5]It is about time that the Indian Psychiatric Society formulated its own guidelines laying down the broad principles and boundaries governing the interaction of Indian psychiatrists with the media. Till then, it is desirable to be guided by the following broad principles:It should be assumed that no statement goes “off the record” as the media person is most likely recording the interview, and we should also record any such conversation from our endIt should be clarified in which capacity comments are being made – professional, personal, or as a representative of an organizationOne should not comment on any person whom he has not examinedPsychiatrists should take any such opportunity to educate the generic levitra price public about mental health issuesThe comments should be justified and limited by the boundaries of scientific knowledge available at the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, generic levitra price Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment. The dangerousness of ECT has been mainly attributed to its claimed ability to cause brain damage.

This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this question specifically.

Thus, even though there are newer technological tools and innovations, any review attempting to answer this question would have to take recourse to indirect methods. These include structural, functional, and metabolic neuroimaging. Body fluid biochemical marker studies.

And follow-up studies of cognitive impairment and incidence of dementia in people who have received ECT among others. The review of literature and present evidence suggests that ECT has a demonstrable impact on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.Keywords.

Adverse effect, brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update.

Indian J Psychiatry 2020;62:339-53 Introduction Electroconvulsive therapy (ECT) as a modality of treatment for psychiatric disorders has existed at least since 1938.[1] ECT is an effective modality of treatment for various psychiatric disorders. However, from the very beginning, the practice of ECT has also faced resistance from various groups who claim that it is coercive and harmful.[2] While the ethical aspects of the practice of ECT have been dealt with elsewhere, the question of harmfulness or brain damage consequent upon the passage of electric current needs to be examined afresh in light of technological advances and new knowledge.[3]The question whether ECT causes brain damage was reviewed in a holistic fashion by Devanand et al. In the mid-1990s.[4],[5] The authors had attempted to answer this question by reviewing the effect of ECT on the brain in various areas – cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epileptic patients, and finally animal ECS studies.

The authors had concluded that ECT does not produce brain damage.This narrative review aims to update the evidence with regard to whether ECT causes brain damage by reviewing relevant literature from 1994 to the present time. Framing the Question The Oxford Dictionary defines damage as physical harm that impairs the value, usefulness, or normal function of something.[6] Among medical dictionaries, the Peter Collins Dictionary defines damage as harm done to things (noun) or to harm something (verb).[7] Brain damage is defined by the British Medical Association Medical Dictionary as degeneration or death of nerve cells and tracts within the brain that may be localized to a particular area of the brain or diffuse.[8] Going by such a definition, brain damage in the context of ECT should refer to death or degeneration of brain tissue, which results in the impairment of functioning of the brain. The importance of precisely defining brain damage shall become evident subsequently in this review.There are now many more tools available to investigate the structure and function of brain in health and illness.

However, there are obvious ethical issues in designing human studies that are designed to answer this specific question. Therefore, one must necessarily take recourse to indirect evidences available through studies that have been designed to answer other research questions. These studies have employed the following methods:Structural neuroimaging studiesFunctional neuroimaging studiesMetabolic neuroimaging studiesBody fluid biochemical marker studiesCognitive impairment studies.While the early studies tended to focus more on establishing the safety of ECT and finding out whether ECT causes gross microscopic brain damage, the later studies especially since the advent of advanced neuroimaging techniques have been focusing more on a mechanistic understanding of ECT.

Hence, the primary objective of the later neuroimaging studies has been to look for structural and functional brain changes which might explain how ECT acts rather than evidence of gross structural damage per se. However, put together, all these studies would enable us to answer our titular question to some satisfaction. [Table 1] and [Table 2] provide an overview of the evidence base in this area.

Structural and Functional Neuroimaging Studies Devanand et al. Reviewed 16 structural neuroimaging studies on the effect of ECT on the brain.[4] Of these, two were pneumoencephalography studies, nine were computed tomography (CT) scan studies, and five were magnetic resonance imaging (MRI) studies. However, most of these studies were retrospective in design, with neuroimaging being done in patients who had received ECT in the past.

In the absence of baseline neuroimaging, it would be very difficult to attribute any structural brain changes to ECT. In addition, pneumoencephalography, CT scan, and even early 0.3 T MRI provided images with much lower spatial resolution than what is available today. The authors concluded that there was no evidence to show that ECT caused any structural damage to the brain.[4] Since then, at least twenty more MRI-based structural neuroimaging studies have studied the effect of ECT on the brain.

The earliest MRI studies in the early 1990s focused on detecting structural damage following ECT. All of these studies were prospective in design, with the first MRI scan done at baseline and a second MRI scan performed post ECT.[9],[11],[12],[13],[41] While most of the studies imaged the patient once around 24 h after receiving ECT, some studies performed multiple post ECT neuroimaging in the first 24 h after ECT to better capture the acute changes. A single study by Coffey et al.

Followed up the patients for a duration of 6 months and repeated neuroimaging again at 6 months in order to capture any long-term changes following ECT.[10]The most important conclusion which emerged from this early series of studies was that there was no evidence of cortical atrophy, change in ventricle size, or increase in white matter hyperintensities.[4] The next major conclusion was that there appeared to be an increase in the T1 and T2 relaxation time immediately following ECT, which returned to normal within 24 h. This supported the theory that immediately following ECT, there appears to be a temporary breakdown of the blood–brain barrier, leading to water influx into the brain tissue.[11] The last significant observation by Coffey et al. In 1991 was that there was no significant temporal changes in the total volumes of the frontal lobes, temporal lobes, or amygdala–hippocampal complex.[10] This was, however, something which would later be refuted by high-resolution MRI studies.

Nonetheless, one inescapable conclusion of these early studies was that there was no evidence of any gross structural brain changes following administration of ECT. Much later in 2007, Szabo et al. Used diffusion-weighted MRI to image patients in the immediate post ECT period and failed to observe any obvious brain tissue changes following ECT.[17]The next major breakthrough came in 2010 when Nordanskog et al.

Demonstrated that there was a significant increase in the volume of the hippocampus bilaterally following a course of ECT in a cohort of patients with depressive illness.[18] This contradicted the earlier observations by Coffey et al. That there was no volume increase in any part of the brain following ECT.[10] This was quite an exciting finding and was followed by several similar studies. However, the perspective of these studies was quite different from the early studies.

In contrast to the early studies looking for the evidence of ECT-related brain damage, the newer studies were focused more on elucidating the mechanism of action of ECT. Further on in 2014, Nordanskog et al. In a follow-up study showed that though there was a significant increase in the volume of the hippocampus 1 week after a course of ECT, the hippocampal volume returned to the baseline after 6 months.[19] Two other studies in 2013 showed that in addition to the hippocampus, the amygdala also showed significant volume increase following ECT.[20],[21] A series of structural neuroimaging studies after that have expanded on these findings and as of now, gray matter volume increase following ECT has been demonstrated in the hippocampus, amygdala, anterior temporal pole, subgenual cortex,[21] right caudate nucleus, and the whole of the medial temporal lobe (MTL) consisting of the hippocampus, amygdala, insula, and the posterosuperior temporal cortex,[24] para hippocampi, right subgenual anterior cingulate gyrus, and right anterior cingulate gyrus,[25] left cerebellar area VIIa crus I,[29] putamen, caudate nucleus, and nucleus acumbens [31] and clusters of increased cortical thickness involving the temporal pole, middle and superior temporal cortex, insula, and inferior temporal cortex.[27] However, the most consistently reported and replicated finding has been the bilateral increase in the volume of the hippocampus and amygdala.

In light of these findings, it has been tentatively suggested that ECT acts by inducing neuronal regeneration in the hippocampus – amygdala complex.[42],[43] However, there are certain inconsistencies to this hypothesis. Till date, only one study – Nordanskog et al., 2014 – has followed study patients for a long term – 6 months in their case. And significantly, the authors found out that after increasing immediately following ECT, the hippocampal volume returns back to baseline by 6 months.[19] This, however, was not associated with the relapse of depressive symptoms.

Another area of significant confusion has been the correlation of hippocampal volume increase with improvement of depressive symptoms. Though almost all studies demonstrate a significant increase in hippocampal volume following ECT, a majority of studies failed to demonstrate a correlation between symptom improvement and hippocampal volume increase.[19],[20],[22],[24],[28] However, a significant minority of volumetric studies have demonstrated correlation between increase in hippocampal and/or amygdala volume and improvement of symptoms.[21],[25],[30]Another set of studies have used diffusion tensor imaging, functional MRI (fMRI), anatomical connectome, and structural network analysis to study the effect of ECT on the brain. The first of these studies by Abbott et al.

In 2014 demonstrated that on fMRI, the connectivity between right and left hippocampus was significantly reduced in patients with severe depression. It was also shown that the connectivity was normalized following ECT, and symptom improvement was correlated with an increase in connectivity.[22] In a first of its kind DTI study, Lyden et al. In 2014 demonstrated that fractional anisotropy which is a measure of white matter tract or fiber density is increased post ECT in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left superior longitudinal fasciculus.

The authors suggested that ECT acts to normalize major depressive disorder-related abnormalities in the structural connectivity of the dorsal fronto-limbic pathways.[23] Another DTI study in 2015 constructed large-scale anatomical networks of the human brain – connectomes, based on white matter fiber tractography. The authors found significant reorganization in the anatomical connections involving the limbic structure, temporal lobe, and frontal lobe. It was also found that connection changes between amygdala and para hippocampus correlated with reduction in depressive symptoms.[26] In 2016, Wolf et al.

Used a source-based morphometry approach to study the structural networks in patients with depression and schizophrenia and the effect of ECT on the same. It was found that the medial prefrontal cortex/anterior cingulate cortex (ACC/MPFC) network, MTL network, bilateral thalamus, and left cerebellar regions/precuneus exhibited significant difference between healthy controls and the patient population. It was also demonstrated that administration of ECT leads to significant increase in the network strength of the ACC/MPFC network and the MTL network though the increase in network strength and symptom amelioration were not correlated.[32]Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of brain volume changes – focusing on hippocampal volume increase following ECT in patients with major depressive disorder and bipolar disorder.

The authors initially selected 32 original articles from which six articles met the criteria for quantitative synthesis. The results showed significant increase in the volume of the right and left hippocampus following ECT. For the rest of the brain regions, the heterogeneity in protocols and imaging techniques did not permit a quantitative analysis, and the authors have resorted to a narrative review similar to the present one with similar conclusions.[44] Focusing exclusively on hippocampal volume change in ECT, Oltedal et al.

In 2018 conducted a mega-analysis of 281 patients with major depressive disorder treated with ECT enrolled at ten different global sites of the Global ECT-MRI Research Collaboration.[45] Similar to previous studies, there was a significant increase in hippocampal volume bilaterally with a dose–response relationship with the number of ECTs administered. Furthermore, bilateral (B/L) ECT was associated with an equal increase in volume in both right and left hippocampus, whereas right unilateral ECT was associated with greater volume increase in the right hippocampus. Finally, contrary to expectation, clinical improvement was found to be negatively correlated with hippocampal volume.Thus, a review of the current evidence amply demonstrates that from looking for ECT-related brain damage – and finding none, we have now moved ahead to looking for a mechanistic understanding of the effect of ECT.

In this regard, it has been found that ECT does induce structural changes in the brain – a fact which has been seized upon by some to claim that ECT causes brain damage.[46] Such statements should, however, be weighed against the definition of damage as understood by the scientific medical community and patient population. Neuroanatomical changes associated with effective ECT can be better described as ECT-induced brain neuroplasticity or ECT-induced brain neuromodulation rather than ECT-induced brain damage. Metabolic Neuroimaging Studies.

Magnetic Resonance Spectroscopic Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase-encoding procedure to map the spatial distribution of magnetic resonance (MR) signals of different molecules. The crucial difference, however, is that while MRI maps the MR signals of water molecules, MRSI maps the MR signals generated by different metabolites – such as N-acetyl aspartate (NAA) and choline-containing compounds. However, the concentration of these metabolites is at least 10,000 times lower than water molecules and hence the signal strength generated would also be correspondingly lower.

However, MRSI offers us the unique advantage of studying in vivo the change in the concentration of brain metabolites, which has been of great significance in fields such as psychiatry, neurology, and basic neuroscience research.[47]MRSI studies on ECT in patients with depression have focused largely on four metabolites in the human brain – NAA, choline-containing compounds (Cho) which include majorly cell membrane compounds such as glycerophosphocholine, phosphocholine and a miniscule contribution from acetylcholine, creatinine (Cr) and glutamine and glutamate together (Glx). NAA is located exclusively in the neurons, and is suggested to be a marker of neuronal viability and functionality.[48] Choline-containing compounds (Cho) mainly include the membrane compounds, and an increase in Cho would be suggestive of increased membrane turnover. Cr serves as a marker of cellular energy metabolism, and its levels are usually expected to remain stable.

The regions which have been most widely studied in MRSI studies include the bilateral hippocampus and amygdala, dorsolateral prefrontal cortex (DLPFC), and ACC.Till date, five MRSI studies have measured NAA concentration in the hippocampus before and after ECT. Of these, three studies showed that there is no significant change in the NAA concentration in the hippocampus following ECT.[33],[38],[49] On the other hand, two recent studies have demonstrated a statistically significant reduction in NAA concentration in the hippocampus following ECT.[39],[40] The implications of these results are of significant interest to us in answering our titular question. A normal level of NAA following ECT could signify that there is no significant neuronal death or damage following ECT, while a reduction would signal the opposite.

However, a direct comparison between these studies is complicated chiefly due to the different ECT protocols, which has been used in these studies. It must, however, be acknowledged that the three older studies used 1.5 T MRI, whereas the two newer studies used a higher 3 T MRI which offers betters signal-to-noise ratio and hence lesser risk of errors in the measurement of metabolite concentrations. The authors of a study by Njau et al.[39] argue that a change in NAA levels might reflect reversible changes in neural metabolism rather than a permanent change in the number or density of neurons and also that reduced NAA might point to a change in the ratio of mature to immature neurons, which, in fact, might reflect enhanced adult neurogenesis.

Thus, the authors warn that to conclude whether a reduction in NAA concentration is beneficial or harmful would take a simultaneous measurement of cognitive functioning, which was lacking in their study. In 2017, Cano et al. Also demonstrated a significant reduction in NAA/Cr ratio in the hippocampus post ECT.

More significantly, the authors also showed a significant increase in Glx levels in the hippocampus following ECT, which was also associated with an increase in hippocampal volume.[40] To explain these three findings, the authors proposed that ECT produces a neuroinflammatory response in the hippocampus – likely mediated by Glx, which has been known to cause inflammation at higher concentrations, thereby accounting for the increase in hippocampal volume with a reduction in NAA concentration. The cause for the volume increase remains unclear – with the authors speculating that it might be due to neuronal swelling or due to angiogenesis. However, the same study and multiple other past studies [21],[25],[30] have demonstrated that hippocampal volume increase was correlated with clinical improvement following ECT.

Thus, we are led to the hypothesis that the same mechanism which drives clinical improvement with ECT is also responsible for the cognitive impairment following ECT. Whether this is a purely neuroinflammatory response or a neuroplastic response or a neuroinflammatory response leading to some form of neuroplasticity is a critical question, which remains to be answered.[40]Studies which have analyzed NAA concentration change in other brain areas have also produced conflicting results. The ACC is another area which has been studied in some detail utilizing the MRSI technique.

In 2003, Pfleiderer et al. Demonstrated that there was no significant change in the NAA and Cho levels in the ACC following ECT. This would seem to suggest that there was no neurogenesis or membrane turnover in the ACC post ECT.[36] However, this finding was contested by Merkl et al.

In 2011, who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and that these levels were significantly elevated following ECT.[37] This again is contested by Njau et al. Who showed that NAA levels are significantly reduced following ECT in the left dorsal ACC.[39] A direct comparison of these three studies is complicated by the different ECT and imaging parameters used and hence, no firm conclusion can be made on this point at this stage. In addition to this, one study had demonstrated increased NAA levels in the amygdala following administration of ECT,[34] with a trend level increase in Cho levels, which again is suggestive of neurogenesis and/or neuroplasticity.

A review of studies on the DLPFC reveals a similarly confusing picture with one study, each showing no change, reduction, and elevation of concentration of NAA following ECT.[35],[37],[39] Here, again, a direct comparison of the three studies is made difficult by the heterogeneous imaging and ECT protocols followed by them.A total of five studies have analyzed the concentration of choline-containing compounds (Cho) in patients undergoing ECT. Conceptually, an increase in Cho signals is indicative of increased membrane turnover, which is postulated to be associated with synaptogenesis, neurogenesis, and maturation of neurons.[31] Of these, two studies measured Cho concentration in the B/L hippocampus, with contrasting results. Ende et al.

In 2000 demonstrated a significant elevation in Cho levels in B/L hippocampus after ECT, while Jorgensen et al. In 2015 failed to replicate the same finding.[33],[38] Cho levels have also been studied in the amygdala, ACC, and the DLPFC. However, none of these studies showed a significant increase or decrease in Cho levels before and after ECT in the respective brain regions studied.

In addition, no significant difference was seen in the pre-ECT Cho levels of patients compared to healthy controls.[34],[36],[37]In review, we must admit that MRSI studies are still at a preliminary stage with significant heterogeneity in ECT protocols, patient population, and regions of the brain studied. At this stage, it is difficult to draw any firm conclusions except to acknowledge the fact that the more recent studies – Njau et al., 2017, Cano, 2017, and Jorgensen et al., 2015 – have shown decrease in NAA concentration and no increase in Cho levels [38],[39],[40] – as opposed to the earlier studies by Ende et al.[33] The view offered by the more recent studies is one of a neuroinflammatory models of action of ECT, probably driving neuroplasticity in the hippocampus. This would offer a mechanistic understanding of both clinical response and the phenomenon of cognitive impairment associated with ECT.

However, this conclusion is based on conjecture, and more work needs to be done in this area. Body Fluid Biochemical Marker Studies Another line of evidence for analyzing the effect of ECT on the human brain is the study of concentration of neurotrophins in the plasma or serum. Neurotrophins are small protein molecules which mediate neuronal survival and development.

The most prominent among these is brain-derived neurotrophic factor (BDNF) which plays an important role in neuronal survival, plasticity, and migration.[50] A neurotrophic theory of mood disorders was suggested which hypothesized that depressive disorders are associated with a decreased expression of BDNF in the limbic structures, resulting in the atrophy of these structures.[51] It was also postulated that antidepressant treatment has a neurotrophic effect which reverses the neuronal cell loss, thereby producing a therapeutic effect. It has been well established that BDNF is decreased in mood disorders.[52] It has also been shown that clinical improvement of depression is associated with increase in BDNF levels.[53] Thus, serum BDNF levels have been tentatively proposed as a biomarker for treatment response in depression. Recent meta-analytic evidence has shown that ECT is associated with significant increase in serum BDNF levels in patients with major depressive disorder.[54] Considering that BDNF is a potent stimulator of neurogenesis, the elevation of serum BDNF levels following ECT lends further credence to the theory that ECT leads to neurogenesis in the hippocampus and other limbic structures, which, in turn, mediates the therapeutic action of ECT.

Cognitive Impairment Studies Cognitive impairment has always been the single-most important side effect associated with ECT.[55] Concerns regarding long-term cognitive impairment surfaced soon after the introduction of ECT and since then has grown to become one of the most controversial aspects of ECT.[56] Anti-ECT groups have frequently pointed out to cognitive impairment following ECT as evidence of ECT causing brain damage.[56] A meta-analysis by Semkovska and McLoughlin in 2010 is one of the most detailed studies which had attempted to settle this long-standing debate.[57] The authors reviewed 84 studies (2981 participants), which had used a combined total of 22 standardized neuropsychological tests assessing various cognitive functions before and after ECT in patients diagnosed with major depressive disorder. The different cognitive domains reviewed included processing speed, attention/working memory, verbal episodic memory, visual episodic memory, spatial problem-solving, executive functioning, and intellectual ability. The authors concluded that administration of ECT for depression is associated with significant cognitive impairment in the first few days after ECT administration.

However, it was also seen that impairment in cognitive functioning resolved within a span of 2 weeks and thereafter, a majority of cognitive domains even showed mild improvement compared to the baseline performance. It was also demonstrated that not a single cognitive domain showed persistence of impairment beyond 15 days after ECT.Memory impairment following ECT can be analyzed broadly under two conceptual schemes – one that classifies memory impairment as objective memory impairment and subjective memory impairment and the other that classifies it as impairment in anterograde memory versus impairment in retrograde memory. Objective memory can be roughly defined as the ability to retrieve stored information and can be measured by various standardized neuropsychological tests.

Subjective memory or meta-memory, on the other hand, refers to the ability to make judgments about one's ability to retrieve stored information.[58] As described previously, it has been conclusively demonstrated that anterograde memory impairment does not persist beyond 2 weeks after ECT.[57] However, one of the major limitations of this meta-analysis was the lack of evidence on retrograde amnesia following ECT. This is particularly unfortunate considering that it is memory impairment – particularly retrograde amnesia which has received the most attention.[59] In addition, reports of catastrophic retrograde amnesia have been repeatedly held up as sensational evidence of the lasting brain damage produced by ECT.[59] Admittedly, studies on retrograde amnesia are fewer and less conclusive than on anterograde amnesia.[60],[61] At present, the results are conflicting, with some studies finding some impairment in retrograde memory – particularly autobiographical retrograde memory up to 6 months after ECT.[62],[63],[64],[65] However, more recent studies have failed to support this finding.[66],[67] While they do demonstrate an impairment in retrograde memory immediately after ECT, it was seen that this deficit returned to pre-ECT levels within a span of 1–2 months and improved beyond baseline performance at 6 months post ECT.[66] Adding to the confusion are numerous factors which confound the assessment of retrograde amnesia. It has been shown that depressive symptoms can produce significant impairment of retrograde memory.[68],[69] It has also been demonstrated that sine-wave ECT produces significantly more impairment of retrograde memory as compared to brief-pulse ECT.[70] However, from the 1990s onward, sine-wave ECT has been completely replaced by brief-pulse ECT, and it is unclear as to the implications of cognitive impairment from the sine-wave era in contemporary ECT practice.Another area of concern are reports of subjective memory impairment following ECT.

One of the pioneers of research into subjective memory impairment were Squire and Chace who published a series of studies in the 1970s demonstrating the adverse effect of bilateral ECT on subjective assessment of memory.[62],[63],[64],[65] However, most of the studies conducted post 1980 – from when sine-wave ECT was replaced by brief-pulse ECT report a general improvement in subjective memory assessments following ECT.[71] In addition, most of the recent studies have failed to find a significant association between measures of subjective and objective memory.[63],[66],[70],[72],[73],[74] It has also been shown that subjective memory impairment is strongly associated with the severity of depressive symptoms.[75] In light of these facts, the validity and value of measures of subjective memory impairment as a marker of cognitive impairment and brain damage following ECT have been questioned. However, concerns regarding subjective memory impairment and catastrophic retrograde amnesia continue to persist, with significant dissonance between the findings of different research groups and patient self-reports in various media.[57]Some studies reported the possibility of ECT being associated with the development of subsequent dementia.[76],[77] However, a recent large, well-controlled prospective Danish study found that the use of ECT was not associated with elevated incidence of dementia.[78] Conclusion Our titular question is whether ECT leads to brain damage, where damage indicates destruction or degeneration of nerves or nerve tracts in the brain, which leads to loss of function. This issue was last addressed by Devanand et al.

In 1994 since which time our understanding of ECT has grown substantially, helped particularly by the advent of modern-day neuroimaging techniques which we have reviewed in detail. And, what these studies reveal is rather than damaging the brain, ECT has a neuromodulatory effect on the brain. The various lines of evidence – structural neuroimaging studies, functional neuroimaging studies, neurochemical and metabolic studies, and serum BDNF studies all point toward this.

These neuromodulatory changes have been localized to the hippocampus, amygdala, and certain other parts of the limbic system. How exactly these changes mediate the improvement of depressive symptoms is a question that remains unanswered. However, there is little by way of evidence from neuroimaging studies which indicates that ECT causes destruction or degeneration of neurons.

Though cognitive impairment studies do show that there is objective impairment of certain functions – particularly memory immediately after ECT, these impairments are transient with full recovery within a span of 2 weeks. Perhaps, the single-most important unaddressed concern is retrograde amnesia, which has been shown to persist for up to 2 months post ECT. In this regard, the recent neurometabolic studies have offered a tentative mechanism of action of ECT, producing a transient inflammation in the limbic cortex, which, in turn, drives neurogenesis, thereby exerting a neuromodulatory effect.

This hypothesis would explain both the cognitive adverse effects of ECT – due to the transient inflammation – and the long-term improvement in mood – neurogenesis in the hippocampus. Although unproven at present, such a hypothesis would imply that cognitive impairment is tied in with the mechanism of action of ECT and not an indicator of damage to the brain produced by ECT.The review of literature suggests that ECT does cause at least structural and functional changes in the brain, and these are in all probability related to the effects of the ECT. However, these cannot be construed as brain damage as is usually understood.

Due to the relative scarcity of data that directly examines the question of whether ECT causes brain damage, it is not possible to conclusively answer this question. However, in light of enduring ECT survivor accounts, there is a need to design studies that specifically answer this question.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Payne NA, Prudic J.

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Neurotrophic effects of electroconvulsive therapy. A proton magnetic resonance study of the left amygdalar region in patients with treatment-resistant depression. Neuropsychopharmacology 2003;28:720-5.

36.Pfleiderer B, Michael N, Erfurth A, Ohrmann P, Hohmann U, Wolgast M, et al. Effective electroconvulsive therapy reverses glutamate/glutamine deficit in the left anterior cingulum of unipolar depressed patients. Psychiatry Res 2003;122:185-92.

37.Merkl A, Schubert F, Quante A, Luborzewski A, Brakemeier EL, Grimm S, et al. Abnormal cingulate and prefrontal cortical neurochemistry in major depression after electroconvulsive therapy. Biol Psychiatry 2011;69:772-9.

38.Jorgensen A, Magnusson P, Hanson LG, Kirkegaard T, Benveniste H, Lee H, et al. Regional brain volumes, diffusivity, and metabolite changes after electroconvulsive therapy for severe depression. Acta Psychiatr Scand 2016;133:154-64.

39.Njau S, Joshi SH, Espinoza R, Leaver AM, Vasavada M, Marquina A, et al. Neurochemical correlates of rapid treatment response to electroconvulsive therapy in patients with major depression. J Psychiatry Neurosci 2017;42:6-16.

40.Cano M, Martínez-Zalacaín I, Bernabéu-Sanz Á, Contreras-Rodríguez O, Hernández-Ribas R, Via E, et al. Brain volumetric and metabolic correlates of electroconvulsive therapy for treatment-resistant depression. A longitudinal neuroimaging study.

Transl Psychiatry 2017;7:e1023. 41.Figiel GS, Krishnan KR, Doraiswamy PM. Subcortical structural changes in ECT-induced delirium.

J Geriatr Psychiatry Neurol 1990;3:172-6. 42.Rotheneichner P, Lange S, O'Sullivan A, Marschallinger J, Zaunmair P, Geretsegger C, et al. Hippocampal neurogenesis and antidepressive therapy.

Shocking relations. Neural Plast 2014;2014:723915. 43.Singh A, Kar SK.

How electroconvulsive therapy works?. Understanding the neurobiological mechanisms. Clin Psychopharmacol Neurosci 2017;15:210-21.

44.Gbyl K, Videbech P. Electroconvulsive therapy increases brain volume in major depression. A systematic review and meta-analysis.

Acta Psychiatr Scand 2018;138:180-95. 45.Oltedal L, Narr KL, Abbott C, Anand A, Argyelan M, Bartsch H, et al. Volume of the human hippocampus and clinical response following electroconvulsive therapy.

Biol Psychiatry 2018;84:574-81. 46.Breggin PR. Brain-Disabling Treatments in Psychiatry.

Drugs, Electroshock, and the Role of the FDA. New York. Springer Pub.

Co.. 1997. 47.Posse S, Otazo R, Dager SR, Alger J.

MR spectroscopic imaging. Principles and recent advances. J Magn Reson Imaging 2013;37:1301-25.

48.Simmons ML, Frondoza CG, Coyle JT. Immunocytochemical localization of N-acetyl-aspartate with monoclonal antibodies. Neuroscience 1991;45:37-45.

49.Obergriesser T, Ende G, Braus DF, Henn FA. Long-term follow-up of magnetic resonance-detectable choline signal changes in the hippocampus of patients treated with electroconvulsive therapy. J Clin Psychiatry 2003;64:775-80.

50.Bramham CR, Messaoudi E. BDNF function in adult synaptic plasticity. The synaptic consolidation hypothesis.

Prog Neurobiol 2005;76:99-125. 51.Duman RS, Monteggia LM. A neurotrophic model for stress-related mood disorders.

Biol Psychiatry 2006;59:1116-27. 52.Bocchio-Chiavetto L, Bagnardi V, Zanardini R, Molteni R, Nielsen MG, Placentino A, et al. Serum and plasma BDNF levels in major depression.

A replication study and meta-analyses. World J Biol Psychiatry 2010;11:763-73. 53.Brunoni AR, Lopes M, Fregni F.

A systematic review and meta-analysis of clinical studies on major depression and BDNF levels. Implications for the role of neuroplasticity in depression. Int J Neuropsychopharmacol 2008;11:1169-80.

54.Rocha RB, Dondossola ER, Grande AJ, Colonetti T, Ceretta LB, Passos IC, et al. Increased BDNF levels after electroconvulsive therapy in patients with major depressive disorder. A meta-analysis study.

J Psychiatr Res 2016;83:47-53. 55.UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders.

A systematic review and meta-analysis. Lancet 2003;361:799-808. 56.57.Semkovska M, McLoughlin DM.

Objective cognitive performance associated with electroconvulsive therapy for depression. A systematic review and meta-analysis. Biol Psychiatry 2010;68:568-77.

58.Tulving E, Madigan SA. Memory and verbal learning. Annu Rev Psychol 1970;21:437-84.

59.Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy. Systematic review.

BMJ 2003;326:1363. 60.Semkovska M, McLoughlin DM. Measuring retrograde autobiographical amnesia following electroconvulsive therapy.

Historical perspective and current issues. J ECT 2013;29:127-33. 61.Fraser LM, O'Carroll RE, Ebmeier KP.

The effect of electroconvulsive therapy on autobiographical memory. A systematic review. J ECT 2008;24:10-7.

62.Squire LR, Chace PM. Memory functions six to nine months after electroconvulsive therapy. Arch Gen Psychiatry 1975;32:1557-64.

63.Squire LR, Slater PC. Electroconvulsive therapy and complaints of memory dysfunction. A prospective three-year follow-up study.

Br J Psychiatry 1983;142:1-8. 64.Squire LR, Slater PC, Miller PL. Retrograde amnesia and bilateral electroconvulsive therapy.

Long-term follow-up. Arch Gen Psychiatry 1981;38:89-95. 65.Squire LR, Wetzel CD, Slater PC.

Memory complaint after electroconvulsive therapy. Assessment with a new self-rating instrument. Biol Psychiatry 1979;14:791-801.

66.Calev A, Nigal D, Shapira B, Tubi N, Chazan S, Ben-Yehuda Y, et al. Early and long-term effects of electroconvulsive therapy and depression on memory and other cognitive functions. J Nerv Ment Dis 1991;179:526-33.

67.Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000;57:425-34.

68.Abrams R. Does brief-pulse ECT cause persistent or permanent memory impairment?. J ECT 2002;18:71-3.

69.Peretti CS, Danion JM, Grangé D, Mobarek N. Bilateral ECT and autobiographical memory of subjective experiences related to melancholia. A pilot study.

J Affect Disord 1996;41:9-15. 70.Weiner RD, Rogers HJ, Davidson JR, Squire LR. Effects of stimulus parameters on cognitive side effects.

Ann N Y Acad Sci 1986;462:315-25. 71.Prudic J, Peyser S, Sackeim HA. Subjective memory complaints.

A review of patient self-assessment of memory after electroconvulsive therapy. J ECT 2000;16:121-32. 72.Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, et al.

Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993;328:839-46. 73.Frith CD, Stevens M, Johnstone EC, Deakin JF, Lawler P, Crow TJ.

Effects of ECT and depression on various aspects of memory. Br J Psychiatry 1983;142:610-7. 74.Ng C, Schweitzer I, Alexopoulos P, Celi E, Wong L, Tuckwell V, et al.

Efficacy and cognitive effects of right unilateral electroconvulsive therapy. J ECT 2000;16:370-9. 75.Coleman EA, Sackeim HA, Prudic J, Devanand DP, McElhiney MC, Moody BJ.

Subjective memory complaints prior to and following electroconvulsive therapy. Biol Psychiatry 1996;39:346-56. 76.Berggren Š, Gustafson L, Höglund P, Johanson A.

A long-term longitudinal follow-up of depressed patients treated with ECT with special focus on development of dementia. J Affect Disord 2016;200:15-24. 77.Brodaty H, Hickie I, Mason C, Prenter L.

A prospective follow-up study of ECT outcome in older depressed patients. J Affect Disord 2000;60:101-11. 78.Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB.

Electroconvulsive therapy and risk of dementia in patients with affective disorders. A cohort study. Lancet Psychiatry 2018;5:348-56.

Correspondence Address:Dr. Shubh Mohan SinghDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_239_19 Tables [Table 1], [Table 2].

Can levitra be cut in half

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Sport is predicated on the idea of victors emerging from a level playing can levitra be cut in half field. All ethically informed evaluate practices are like this. They require an equality of respect, consideration, and opportunity, while trying can levitra be cut in half to achieve substantively unequal outcomes. For instance. Limited resources mean that physicians must treat some patients and not others, while still treating them with equal respect.

Examiners must pass some students and can levitra be cut in half not others, while still giving their work equal consideration. Employers may only be able to hire one applicant, while still being required to treat all applicants fairly, and so on. The 800 m is meant to be one of these practices can levitra be cut in half. A level and equidistance running track from which one victor is intended to emerge. The case of Caster Semenya raises challenging questions about what makes level-playing-fields level, questions that extend beyond any given playing field.In the Feature Article for this issue Loland provides us with new and engaging reasons to support of the Court of Arbitration for Sport (CAS) decision in the Casta Semenya case.

The impact of the can levitra be cut in half CAS decision requires Casta Semenya to supress her naturally occurring testosterone if she is to compete in an international athletics events. The Semenya case is described by Loland as creating a ‘dilemma of rights’.i The dilemma lies in the choice between ‘the right of Semenya to compete in sport according to her legal sex and gender identity’ and ‘the right of other athletes within the average female testosterone range to compete under fair conditions’ (see footnote i).No one denies the importance of Semenya’s right. As Carpenter explains, ‘even where inconvenient, sex assigned at birth should always be respected unless an individual seeks otherwise’.2 Loland’s conclusions, Carpenter argues, ‘support a convenience-based approach to classification of sex where choices about the status of people with intersex variations can levitra be cut in half are made by others according to their interests at that time’ (see footnote ii). Carpenter then further explains how the CAS decision is representative of ‘systemic forms of discrimination and human rights violations’ and provides no assistance in ‘how we make the world more hospitable and more accepting of difference’ (see footnote ii).What is therefore at issue is the existence of the second right. Let me explain how Loland constructs it.

The background principle is the principle of fair equality of opportunity, which requires that ‘individuals with similar endowments and talents and similar ambitions should be given similar opportunities and roughly equivalent prospects for competitive success’(see footnote can levitra be cut in half i). This principle reflects, according to Loland, a deeper deontological right of respect and fair treatment. As we can appreciate, when it comes to the principle of fair equality of opportunity, a lot turns on what counts as ‘similar’ (or sufficiently different) endowments and talents and what counts as ‘similar’ (or sufficiently different) opportunities and prospects for success.For Loland, ‘dynamic inequalities’ concern differences in capabilities (such as strength, speed, and endurance, and in technical and tactical skills) that can be ‘cultivated by hard work and effort’ (see footnote i). These are capabilities that are ‘relevant’ and therefore permit a range differences between otherwise ‘similar’ can levitra be cut in half athletes. €˜Stable inequalities’ are characterises (such as in age, sex, body size, and disability/ability) are ‘not-relevant’ and therefore require classification to ensure that ‘similar’ athletes are given ‘roughly equivalent prospects for success’.

It follows for Loland that can levitra be cut in half athletes with ‘46 XY DSD conditions (and not for individuals with normal female XX chromosones), with testosterone levels above five nanomoles per litre blood (nmol/L), and who experience a ‘material androgenizing effect’’ benefit from a stable inequality (see footnote i). Hence, the ‘other athletes within the average female testosterone range’ therefore have a right not to compete under conditions of stable inequality. The solution, according to Knox and Anderson, lies in more nuance classifications. Commenting in (qualified) support of Loland, they suggest that ‘classification according to sex alone is no longer adequate’.3 Instead, ‘all athletes would be categorised, making classification the norm’ (see footnote can levitra be cut in half iii).However, as we have just seen, Loland’s distinction between stable and dynamic inequalities depends on their ‘relevance’, and ‘relevance’ is a term that does not travel alone. Something is relevant (or irrelevant) only in relation to the value, purpose, or aim, of some practice.

One interpretation (which I take Loland to be saying) is that strength, speed, and endurance (and so on) are ‘relevant’ to can levitra be cut in half ‘performance outcomes’. This can be misleading. Both dynamic and stable inequalities are relevant to (ie, can have an impact on) an athletic performance. Is a question can levitra be cut in half of whether we ought to permit them to have an impact. The temptation is then to say that dynamic inequalities are relevant (and stable inequalities are irrelevant) where the aim is ‘respect and fair treatment’.

But here the snake begins to eat its tail (the principle of fair treatment requires sufficiently similar prospects for success >similar prospects for success require only dynamic inequalities>dynamic inequalities are capabilities that are permitted by the principle of fair treatment).In order to determine questions of relevance, we need to identify the value, purpose, or aim, of the social practice in question. If the aim of an athletic event is to have a victor emerge from a completely level playing field, then, as Chambers notes, socioeconomic inequalities are a larger affront to fair treatment than can levitra be cut in half athletes with 46 XY DSD conditions.4 If the aim is to have a victor emerge from completely level hormonal playing field then ‘a man with low testosterone levels is unfairly disadvantaged against a man whose natural levels are higher, and so men’s competitions are unfair’ (see footnote iv). Or, at least very high testosterone males should be on hormone suppressants in order to give the ‘average’ competitor a ‘roughly equivalent prospect for competitive success’.The problem is that we are not interested in the average competitor. We are interested in can levitra be cut in half the exceptional among us. Unless, it is for light relief.

In every Olympiad there is the observation that, in every Olympic event, one average person should be included in the competition for the spectators’ reference. The humour lies in the can levitra be cut in half absurd scenarios that would follow, whether it be the 100 m sprint, high jump, or synchronised swimming. Great chasms of natural ability would be laid bare, the results of a lifetime of training and dedication would be even clearer to see, and the last place result would be entirely predictable. But note how can levitra be cut in half these are different attributes. While we may admire Olympians, it is unclear whether it is because of their God-given ability, their grit and determination, or their role in the unpredictable theatre of sport.

If sport is a worthwhile social practice, we need to start spelling out its worth. Without doing can levitra be cut in half so, we are unable to identify what capabilities are ‘relevant’ or ‘irrelevant’ to its aims, purpose or value. And until we can explain why one naturally occurring capability is ‘irrelevant’ to the aims, purposes, or values, of sport, while the remainder of them are relevant, I can only identify one right in play in the Semenya case.IntroductionSince the start of the COVID-19 pandemic, many medical systems have needed to divert routine services in order to support the large number of patients with acute COVID-19 disease. For example, in the National Health Service can levitra be cut in half (NHS) almost all elective surgery has been postponed1 and outpatient clinics have been cancelled or conducted on-line treatment regimens for many forms of cancer have changed2. This diversion inevitably reduces availability of routine treatments for non-COVID-19-related illness.

Even urgent treatments have needed to be modified. Patients with acute surgical emergencies such as appendicitis still present for care, cancers continue to be discovered in patients, and may require urgent management can levitra be cut in half. Health systems are focused on making sure that these urgent needs are met. However, to achieve this goal, many patients are offered treatments that deviate from standard, non-pandemic management.Deviations from standard management are required for multiple factors such as:Limited resources (staff and equipment reallocated).Risk of nosocomial acquired infection in high-risk patients.Increased risk for medical staff to deliver treatments due to aerosolisation1.Treatments requiring intensive care therapy that is in limited availability.Operative procedures that are long and difficult or that are technically challenging if conducted in personal protective equipment. The outcomes from such procedures may be worse than in normal circumstances.Treatments that render patients more susceptible to COVID-19 disease, for example chemotherapy.There are many instances of compromise, but some examples that we are aware of include open appendectomy rather than laparoscopy to reduce risk of aerosolisation3 can levitra be cut in half and offering a percutaneousCoronary intervention (PCI) rather than coronary artery bypass grafting (CABG) for coronary artery disease, to reduce need for intensive care.

Surgery for cancers ordinarily operated on urgently maybe deferred for up to 3 months4 and surgery might be conducted under local anaesthesia that would typically have merited a general anaesthetic (both to reduce the aerosol risk of General anaesthesia, and because of relative lack of anaesthetists).The current emergency offers a unique difficulty. A significant number of treatments with proven benefit might be unavailable to patients while those alternatives that are available are not usually considered best practice and can levitra be cut in half might be actually inferior. In usual circumstances, where two treatment options for a particular problem are considered appropriate, the decision of which option to pursue would often depend on the personal preference of the patient.But during the pandemic what is ethically and legally required of the doctor or medical professional informing patients about treatment and seeking their consent?. In particular, do health professionals need to make patients aware of the usual forms of treatment that they are not being offered in the current setting?. We consider two theoretical case examples:Case 1Jenny2 is a can levitra be cut in half model in her mid-20s who presents to hospital at the peak of the COVID-19 pandemic with acute appendicitis.

Her surgeon, Miss Schmidt, approaches Jenny to obtain consent for an open appendectomy. Miss Schmidt explains the risks can levitra be cut in half of the operative procedure, and the alternative of conservative management (with intravenous antibiotics). Jenny consents to the procedure. However, she develops a postoperative wound infection and an unsightly scar. She does some research and can levitra be cut in half discovers that a laparoscopic procedure would ordinarily have been performed and would have had a lower chance of wound infection.

She sues Miss Schmidt and the hospital trust where she was treated.Case 2June2s a retired teacher in her early 70s who has well-controlled diabetes and hypertension. She is active and runs a local food bank. Immediately prior to the pandemic lockdown in can levitra be cut in half the UK June had an episode of severe chest pain and investigations revealed that she has had a non-ST elevation myocardial infarction. The cardiothoracic surgical team recommends that June undergo a PCI although normally her pattern of coronary artery disease would be treated by CABG. When the cardiologist explains that surgery would be normally offered in this situation, and is theoretically superior to PCI, June’s husband becomes angry and demands that June is listed for surgery.In favour of non-disclosureIt might appear at first glance that doctors should obviously inform Jenny and June about the usual standard of care can levitra be cut in half.

After all, consent cannot be informed if crucial information is lacking. However, one reason that this may be called into question is that it is not immediately clear how it benefits a patient to be informed about alternatives that are not actually available?. In usual circumstances, doctors are not can levitra be cut in half obliged to inform patients about treatments that are performed overseas but not in the UK. In the UK, for example, there is a rigorous process for assessment of new treatments (not including experimental therapies). Some treatments that are available in other jurisdictions have not been deemed by can levitra be cut in half the National Institute for Health and Care Excellence (NICE) to be sufficiently beneficial and cost-effective to be offered by the NHS.

It is hard to imagine that a health professional would be found negligent for not discussing with a patient a treatment that NICE has explicitly rejected. The same might apply for novel therapies that are currently unfunded pending formal evaluation by NICE.Of course, the difference is that the treatments we are discussing have been proven (or are believed) to be beneficial and would normally be provided. The Montgomery Ruling of 2015 in the can levitra be cut in half UK established that patients must be informed of material risks of treatment and reasonable alternatives to treatment. The Bayley –v- George Eliot Hospital NHS Trust5case established that those reasonable alternative treatments must be ‘appropriate treatment’ not just a ‘possible treatment’6. In the current crisis, many previously standard treatments are no longer appropriate given can levitra be cut in half the restrictions outlined.

In other circumstances they are appropriate. During a pandemic they are no longer appropriate, even if they become appropriate again at some unknown time in the future.In both ethical and legal terms, it is widely accepted that, for consent to be valid, if must be given voluntarily by a person who has capacity to consent and who understands the nature and risks of the treatment. A failure can levitra be cut in half to obtain valid consent, or performing interventions in the absence of consent, could result in criminal proceedings for assault. Failing to provide adequate information in the consent process could support a claim of negligence. Ethically, adequate information about treatments is essential for the patient to enable them to weigh up options and decide which treatments they wish to undertake.

However, information about unavailable treatments arguably does not help can levitra be cut in half the patient make an informed decision because it does not give them information that is relevant to consenting or to refusal of treatment that is actually available. If Miss Schmidt had given Jenny information about the relative benefits of laparoscopic appendectomy, that could not have helped Jenny’s decision to proceed with surgery. Her available choices were open appendectomy or no surgery can levitra be cut in half. Moreover, as the case of June highlights, providing information about alternatives may lead them to desire or even demand those alternative options. This could cause distress both to the patient and the health professional (who is unable to acquiesce).Consideration might also be paid to the effect on patients of disclosure.

How would it affect a patient with newly diagnosed cancer to tell them that an alternative, perhaps better therapy, might be routinely available in usual circumstances but is not available now? can levitra be cut in half. There is provision in the Montgomery Ruling, in rare circumstances, for therapeutic exception. That is, if can levitra be cut in half information is significantly detrimental to the health of a patient it might be omitted. We could imagine a version of the case where Jenny was so intensely anxious about the proposed surgery that her surgeon comes to a sincere belief that discussion of the laparoscopic alternative would be extremely distressing or might even lead her to refuse surgery. In most cases, though, it would be hard to be sure that the risks of disclosing alternative (non-available) treatments would be so great that non-disclosure would be justified.In favour of disclosureIn the UK, professional guidance issued by the GMC (General Medical Council) requires doctors to take a personalised approach to information sharing about treatments by sharing ‘with patients the information they want or need in order to make decisions’.

The Montgomery can levitra be cut in half judgement of 20157 broadly endorsed the position of the GMC, requiring patients to be told about any material risks and reasonable alternatives relevant to the decision at hand. The Supreme Court clarifies that materiality here should be judged by reference to a new two-limbed test founded on the notions of the ‘reasonable person in the patient’s position’ and the ‘particular patient’. One practical test might be for the clinician to ask themselves whether patients in general, or this particular patient might wish to know about alternative forms of treatment that would usually be offered.The GMC has recently produced pandemic-specific guidance8 on consent and decision-making, but this guidance is focused on managing consent in COVID-19-related interventions. While the GMC can levitra be cut in half takes the view that its consent guidelines continue to apply as far as is practical, it also notes that the patient is enabled to consider the ‘reasonable alternatives’, and that the doctor is ‘open and honest with patients about the decision-making process and the criteria for setting priorities in individual cases’.In some situations, there might be the option of delaying treatment until later. When other surgical procedures are possible.

In that setting, it would be important can levitra be cut in half to ensure that the patient is aware of those future options (including the risks of delay). For example, if Jenny had symptomatic gallstones, her surgeons might be offering an open cholecystectomy now or the possibility of a laparoscopic surgery at some later point. Understanding the full options open to her now and in the future may have considerable influence on Jenny’s decision. Likewise, if June is aware that she is not being offered standard treatment she may can levitra be cut in half wish to delay treatment of her atherosclerosis until a later date. Of course, such a delay might lead to greater harm overall.

However, it would be ethically permissible to delay treatment if that was the patient’s informed choice (just as it would be permissible for the patient to refuse treatment altogether).In the appendicitis case, Jenny does not have the option for delaying her treatment, but the choice for June is more complicated, between immediate PCI which is a second-best treatment can levitra be cut in half versus waiting for standard therapy. Immediate surgery also raises a risk of acquiring nosocomial COVID-19 infection and June is in an age group and has comorbidities that put her at risk of severe COVID-19 disease. Waiting for surgery leaves June at risk of sudden death. For an active and otherwise well patient with coronary disease like June, PCI procedure can levitra be cut in half is not as good a treatment as CABG and June might legitimately wish to take her chances and wait for the standard treatment. The decision to operate or wait is a balance of risks that only June is fully able to make.

Patients in this can levitra be cut in half scenario will take different approaches. Patients will need different amounts of information to form their decisions, many patients will need as much information as is available including information about procedures not currently available to make up their mind.June’s husband insists that she should receive the best treatment, and that she should therefore be listed for CABG. Although this treatment would appear to be in June’s best interests, and would respect her autonomy, those ethical considerations are potentially outweighed by distributive justice. The COVID-19 can levitra be cut in half pandemic of 2020 is being characterised by limitations. Liberties curtailed and choices restricted, this is justified by a need to protect healthcare systems from demand exceeding availability.

While resource allocation is always a relevant ethical concern in publicly funded healthcare systems, it is a dominant concern in a setting where there is a high demand for medical care and scare resources.It is well established that competent adult patients can consent to or refuse medical treatment but they cannot demand that health professionals provide treatments that are contrary to their professional judgement or (even more importantly) would consume scarce healthcare resources. In June’s case, agreeing to perform CABG at a time when large numbers of patients are critically ill with COVID-19 might mean that another patient is denied access to can levitra be cut in half intensive care (and even dies as a result). Of course, it may be that there are actually available beds in intensive care, and June’s operation would not directly lead to denial of treatment for another patient. However, that does not automatically mean that surgery can levitra be cut in half must proceed. The hospital may have been justified in making a decision to suspend some forms of cardiac surgery.

That could be on the basis of the need to use the dedicated space, staff and equipment of the cardiothoracic critical care unit for patients with COVID-19. Even if all that physical space is not currently can levitra be cut in half occupied if may not be feasible or practical to try to simultaneously accommodate some non-COVID-19 patients. (There would be a risk that June would contract COVID-19 postoperatively and end up considerably worse off than she would have been if she had instead received PCI.) Moreover, it seems problematic for individual patients to be able to circumvent policies about allocation of resources purely on the basis that they stand to be disadvantaged by the policy.Perhaps the most significant benefit of disclosure of non-options is transparency and honesty. We suggest that can levitra be cut in half the main reason why Miss Schmidt ought to have included discussion of the laparoscopic alternative is so that Jenny understands the reasoning behind the decision. If Miss Schmidt had explained to Jenny that in the current circumstances laparoscopic surgery has been stopped, that might have helped her to appreciate that she was being offered the best available management.

It might have enabled a frank discussion about the challenges faced by health professionals in the context of the pandemic and the inevitable need for compromise. It may have avoided awkward discussions later after Jenny developed her complication.Transparent disclosure should not mean can levitra be cut in half that patients can demand treatment. But it might mean that patients could appeal against a particular policy if they feel that it has been reached unfairly, or applied unfairly. For example, if June became aware that some patients were still being offered CABG, she might (or might not) be justified in appealing against the decision not to offer it to her. Obviously such an appeal would only be possible if the patient were aware of the alternatives that they were being denied.For can levitra be cut in half patients faced by decisions such as that faced by June, balancing risks of either option is highly personal.

Individuals need to weigh up these decisions for them and require all of the information available to do so. Some information can levitra be cut in half is readily available, for example, the rate of infection for Jenny and the risk of death without treatment for June. But other risks are unknown, such as the risk of acquiring nosocomial infection with COVID-19. Doctors might feel discomfort talking about unquantifiable risks, but we argue that it is important that the patient has all available information to weigh up options for them, including information that is unknown.ConclusionIn a pandemic, as in other times, doctors should ensure that they offer appropriate medical treatment, based on the needs of an individual. They should aim to provide available treatment that is beneficial and can levitra be cut in half should not offer treatment that is unavailable or contrary to the patient best interests.

It is ethical. Indeed it is vital within a public can levitra be cut in half healthcare system, to consider distributive justice in the allocation of treatment. Where treatment is scarce, it may not be possible or appropriate to offer to patients some treatments that would be beneficial and desired by them.Informed consent needs to be individualised. Doctors are obliged to tailor their information to the needs of an individual. We suggest that in the current climate this should include, for can levitra be cut in half most patients, a nuanced open discussion about alternative treatments that would have been available to them in usual circumstances.

That will sometimes be a difficult conversation, and require clinicians to be frank about limited resources and necessary rationing. However, transparency and honesty will usually be the best policy..

Sport is http://cz.keimfarben.de/cheapest-place-to-buy-levitra/ predicated on the idea of victors emerging from a level generic levitra price playing field. All ethically informed evaluate practices are like this. They require an equality of respect, consideration, generic levitra price and opportunity, while trying to achieve substantively unequal outcomes. For instance.

Limited resources mean that physicians must treat some patients and not others, while still treating them with equal respect. Examiners must pass some students and not generic levitra price others, while still giving their work equal consideration. Employers may only be able to hire one applicant, while still being required to treat all applicants fairly, and so on. The 800 m is meant to be one of these practices generic levitra price.

A level and equidistance running track from which one victor is intended to emerge. The case of Caster Semenya raises challenging questions about what makes level-playing-fields level, questions that extend beyond any given playing field.In the Feature Article for this issue Loland provides us with new and engaging reasons to support of the Court of Arbitration for Sport (CAS) decision in the Casta Semenya case. The impact of the CAS decision requires Casta Semenya to supress her naturally occurring testosterone if she generic levitra price is to compete in an international athletics events. The Semenya case is described by Loland as creating a ‘dilemma of rights’.i The dilemma lies in the choice between ‘the right of Semenya to compete in sport according to her legal sex and gender identity’ and ‘the right of other athletes within the average female testosterone range to compete under fair conditions’ (see footnote i).No one denies the importance of Semenya’s right.

As Carpenter explains, ‘even where inconvenient, sex generic levitra price assigned at birth should always be respected unless an individual seeks otherwise’.2 Loland’s conclusions, Carpenter argues, ‘support a convenience-based approach to classification of sex where choices about the status of people with intersex variations are made by others according to their interests at that time’ (see footnote ii). Carpenter then further explains how the CAS decision is representative of ‘systemic forms of discrimination and human rights violations’ and provides no assistance in ‘how we make the world more hospitable and more accepting of difference’ (see footnote ii).What is therefore at issue is the existence of the second right. Let me explain how Loland constructs it. The background principle is the principle of fair equality of opportunity, generic levitra price which requires that ‘individuals with similar endowments and talents and similar ambitions should be given similar opportunities and roughly equivalent prospects for competitive success’(see footnote i).

This principle reflects, according to Loland, a deeper deontological right of respect and fair treatment. As we can appreciate, when it comes to the principle of fair equality of opportunity, a lot turns on what counts as ‘similar’ (or sufficiently different) endowments and talents and what counts as ‘similar’ (or sufficiently different) opportunities and prospects for success.For Loland, ‘dynamic inequalities’ concern differences in capabilities (such as strength, speed, and endurance, and in technical and tactical skills) that can be ‘cultivated by hard work and effort’ (see footnote i). These are capabilities that are ‘relevant’ and generic levitra price therefore permit a range differences between otherwise ‘similar’ athletes. €˜Stable inequalities’ are characterises (such as in age, sex, body size, and disability/ability) are ‘not-relevant’ and therefore require classification to ensure that ‘similar’ athletes are given ‘roughly equivalent prospects for success’.

It follows for Loland that athletes with ‘46 XY DSD conditions (and not for individuals with normal female XX chromosones), with testosterone levels above five generic levitra price nanomoles per litre blood (nmol/L), and who experience a ‘material androgenizing effect’’ benefit from a stable inequality (see footnote i). Hence, the ‘other athletes within the average female testosterone range’ therefore have a right not to compete under conditions of stable inequality. The solution, according to Knox and Anderson, lies in more nuance classifications. Commenting in (qualified) support of Loland, they suggest that ‘classification according to sex alone generic levitra price is no longer adequate’.3 Instead, ‘all athletes would be categorised, making classification the norm’ (see footnote iii).However, as we have just seen, Loland’s distinction between stable and dynamic inequalities depends on their ‘relevance’, and ‘relevance’ is a term that does not travel alone.

Something is relevant (or irrelevant) only in relation to the value, purpose, or aim, of some practice. One interpretation (which I take Loland to be saying) is that strength, speed, and endurance (and so on) are ‘relevant’ to generic levitra price ‘performance outcomes’. This can be misleading. Both dynamic and stable inequalities are relevant to (ie, can have an impact on) an athletic performance.

Is a question of whether we generic levitra price ought to permit them to have an impact. The temptation is then to say that dynamic inequalities are relevant (and stable inequalities are irrelevant) where the aim is ‘respect and fair treatment’. But here the snake begins to eat its tail (the principle of fair treatment requires sufficiently similar prospects for success >similar prospects for success require only dynamic inequalities>dynamic inequalities are capabilities that are permitted by the principle of fair treatment).In order to determine questions of relevance, we need to identify the value, purpose, or aim, of the social practice in question. If the aim of an athletic event is to have a victor emerge from a completely level playing field, then, as Chambers notes, socioeconomic inequalities are a larger affront to fair treatment than athletes with 46 XY DSD conditions.4 If the aim is to have a victor emerge from completely level hormonal playing field then ‘a generic levitra price man with low testosterone levels is unfairly disadvantaged against a man whose natural levels are higher, and so men’s competitions are unfair’ (see footnote iv).

Or, at least very high testosterone males should be on hormone suppressants in order to give the ‘average’ competitor a ‘roughly equivalent prospect for competitive success’.The problem is that we are not interested in the average competitor. We are interested in the exceptional among generic levitra price us. Unless, it is for light relief. In every Olympiad there is the observation that, in every Olympic event, one average person should be included in the competition for the spectators’ reference.

The humour lies in the generic levitra price absurd scenarios that would follow, whether it be the 100 m sprint, high jump, or synchronised swimming. Great chasms of natural ability would be laid bare, the results of a lifetime of training and dedication would be even clearer to see, and the last place result would be entirely predictable. But note how these generic levitra price are different attributes. While we may admire Olympians, it is unclear whether it is because of their God-given ability, their grit and determination, or their role in the unpredictable theatre of sport.

If sport is a worthwhile social practice, we need to start spelling out its worth. Without doing so, we are unable to identify what capabilities generic levitra price are ‘relevant’ or ‘irrelevant’ to its aims, purpose or value. And until we can explain why one naturally occurring capability is ‘irrelevant’ to the aims, purposes, or values, of sport, while the remainder of them are relevant, I can only identify one right in play in the Semenya case.IntroductionSince the start of the COVID-19 pandemic, many medical systems have needed to divert routine services in order to support the large number of patients with acute COVID-19 disease. For example, generic levitra price in the National Health Service (NHS) almost all elective surgery has been postponed1 and outpatient clinics have been cancelled or conducted on-line treatment regimens for many forms of cancer have changed2.

This diversion inevitably reduces availability of routine treatments for non-COVID-19-related illness. Even urgent treatments have needed to be modified. Patients with acute surgical emergencies such as appendicitis still present for care, cancers continue to be discovered in patients, and may require generic levitra price urgent management. Health systems are focused on making sure that these urgent needs are met.

However, to achieve this goal, many patients are offered treatments that deviate from standard, non-pandemic management.Deviations from standard management are required for multiple factors such as:Limited resources (staff and equipment reallocated).Risk of nosocomial acquired infection in high-risk patients.Increased risk for medical staff to deliver treatments due to aerosolisation1.Treatments requiring intensive care therapy that is in limited availability.Operative procedures that are long and difficult or that are technically challenging if conducted in personal protective equipment. The outcomes from such procedures may be worse than in normal circumstances.Treatments that render patients more susceptible to COVID-19 disease, for example chemotherapy.There are many instances of compromise, but some examples that we are aware of include open appendectomy rather than laparoscopy to reduce risk of aerosolisation3 and offering a percutaneousCoronary intervention (PCI) rather than coronary artery bypass grafting (CABG) for coronary generic levitra price artery disease, to reduce need for intensive care. Surgery for cancers ordinarily operated on urgently maybe deferred for up to 3 months4 and surgery might be conducted under local anaesthesia that would typically have merited a general anaesthetic (both to reduce the aerosol risk of General anaesthesia, and because of relative lack of anaesthetists).The current emergency offers a unique difficulty. A significant number of treatments with proven benefit might be generic levitra price unavailable to patients while those alternatives that are available are not usually considered best practice and might be actually inferior.

In usual circumstances, where two treatment options for a particular problem are considered appropriate, the decision of which option to pursue would often depend on the personal preference of the patient.But during the pandemic what is ethically and legally required of the doctor or medical professional informing patients about treatment and seeking their consent?. In particular, do health professionals need to make patients aware of the usual forms of treatment that they are not being offered in the current setting?. We consider two theoretical case examples:Case 1Jenny2 is a model in her generic levitra price mid-20s who presents to hospital at the peak of the COVID-19 pandemic with acute appendicitis. Her surgeon, Miss Schmidt, approaches Jenny to obtain consent for an open appendectomy.

Miss Schmidt explains the risks of the operative procedure, and the alternative of conservative management generic levitra price (with intravenous antibiotics). Jenny consents to the procedure. However, she develops a postoperative wound infection and an unsightly scar. She does some research and discovers that a laparoscopic procedure would ordinarily have been performed and would have had a lower chance of wound infection generic levitra price.

She sues Miss Schmidt and the hospital trust where she was treated.Case 2June2s a retired teacher in her early 70s who has well-controlled diabetes and hypertension. She is active and runs a local food bank. Immediately prior to the pandemic lockdown in the UK June had an episode of severe chest pain generic levitra price and investigations revealed that she has had a non-ST elevation myocardial infarction. The cardiothoracic surgical team recommends that June undergo a PCI although normally her pattern of coronary artery disease would be treated by CABG.

When the cardiologist generic levitra price explains that surgery would be normally offered in this situation, and is theoretically superior to PCI, June’s husband becomes angry and demands that June is listed for surgery.In favour of non-disclosureIt might appear at first glance that doctors should obviously inform Jenny and June about the usual standard of care. After all, consent cannot be informed if crucial information is lacking. However, one reason that this may be called into question is that it is not immediately clear how it benefits a patient to be informed about alternatives that are not actually available?. In usual generic levitra price circumstances, doctors are not obliged to inform patients about treatments that are performed overseas but not in the UK.

In the UK, for example, there is a rigorous process for assessment of new treatments (not http://cz.keimfarben.de/what-i-should-buy-with-levitra/ including experimental therapies). Some treatments that are available in other jurisdictions have not been deemed by the National Institute for Health and Care Excellence (NICE) to be sufficiently beneficial and cost-effective to generic levitra price be offered by the NHS. It is hard to imagine that a health professional would be found negligent for not discussing with a patient a treatment that NICE has explicitly rejected. The same might apply for novel therapies that are currently unfunded pending formal evaluation by NICE.Of course, the difference is that the treatments we are discussing have been proven (or are believed) to be beneficial and would normally be provided.

The Montgomery Ruling of 2015 in the UK established generic levitra price that patients must be informed of material risks of treatment and reasonable alternatives to treatment. The Bayley –v- George Eliot Hospital NHS Trust5case established that those reasonable alternative treatments must be ‘appropriate treatment’ not just a ‘possible treatment’6. In the current crisis, generic levitra price many previously standard treatments are no longer appropriate given the restrictions outlined. In other circumstances they are appropriate.

During a pandemic they are no longer appropriate, even if they become appropriate again at some unknown time in the future.In both ethical and legal terms, it is widely accepted that, for consent to be valid, if must be given voluntarily by a person who has capacity to consent and who understands the nature and risks of the treatment. A failure to obtain valid consent, generic levitra price or performing interventions in the absence of consent, could result in criminal proceedings for assault. Failing to provide adequate information in the consent process could support a claim of negligence. Ethically, adequate information about treatments is essential for the patient to enable them to weigh up options and decide which treatments they wish to undertake.

However, information about unavailable treatments arguably does not help the patient make an informed decision because it does not give them information that is relevant to consenting or to refusal of treatment that generic levitra price is actually available. If Miss Schmidt had given Jenny information about the relative benefits of laparoscopic appendectomy, that could not have helped Jenny’s decision to proceed with surgery. Her available generic levitra price choices were open appendectomy or no surgery. Moreover, as the case of June highlights, providing information about alternatives may lead them to desire or even demand those alternative options.

This could cause distress both to the patient and the health professional (who is unable to acquiesce).Consideration might also be paid to the effect on patients of disclosure. How would it affect generic levitra price a patient with newly diagnosed cancer to tell them that an alternative, perhaps better therapy, might be routinely available in usual circumstances but is not available now?. There is provision in the Montgomery Ruling, in rare circumstances, for therapeutic exception. That is, generic levitra price if information is significantly detrimental to the health of a patient it might be omitted.

We could imagine a version of the case where Jenny was so intensely anxious about the proposed surgery that her surgeon comes to a sincere belief that discussion of the laparoscopic alternative would be extremely distressing or might even lead her to refuse surgery. In most cases, though, it would be hard to be sure that the risks of disclosing alternative (non-available) treatments would be so great that non-disclosure would be justified.In favour of disclosureIn the UK, professional guidance issued by the GMC (General Medical Council) requires doctors to take a personalised approach to information sharing about treatments by sharing ‘with patients the information they want or need in order to make decisions’. The Montgomery judgement of 20157 broadly endorsed the position of the GMC, generic levitra price requiring patients to be told about any material risks and reasonable alternatives relevant to the decision at hand. The Supreme Court clarifies that materiality here should be judged by reference to a new two-limbed test founded on the notions of the ‘reasonable person in the patient’s position’ and the ‘particular patient’.

One practical test might be for the clinician to ask themselves whether patients in general, or this particular patient might wish to know about alternative forms of treatment that would usually be offered.The GMC has recently produced pandemic-specific guidance8 on consent and decision-making, but this guidance is focused on managing consent in COVID-19-related interventions. While the GMC takes the view that its consent guidelines continue to apply as far as is practical, it also notes that the patient is enabled to consider the ‘reasonable alternatives’, and that the doctor generic levitra price is ‘open and honest with patients about the decision-making process and the criteria for setting priorities in individual cases’.In some situations, there might be the option of delaying treatment until later. When other surgical procedures are possible. In that generic levitra price setting, it would be important to ensure that the patient is aware of those future options (including the risks of delay).

For example, if Jenny had symptomatic gallstones, her surgeons might be offering an open cholecystectomy now or the possibility of a laparoscopic surgery at some later point. Understanding the full options open to her now and in the future may have considerable influence on Jenny’s decision. Likewise, if June is aware that she is not being offered standard treatment she may wish to delay treatment of her atherosclerosis generic levitra price until a later date. Of course, such a delay might lead to greater harm overall.

However, it would be ethically permissible to delay treatment if that was the patient’s informed choice (just as it would be permissible for the patient to refuse treatment altogether).In the appendicitis case, Jenny does not have the option for delaying her treatment, but the choice for June is generic levitra price more complicated, between immediate PCI which is a second-best treatment versus waiting for standard therapy. Immediate surgery also raises a risk of acquiring nosocomial COVID-19 infection and June is in an age group and has comorbidities that put her at risk of severe COVID-19 disease. Waiting for surgery leaves June at risk of sudden death. For an active and otherwise well patient with coronary disease like June, PCI procedure is not as good a treatment as CABG and June might legitimately wish to take her chances and wait for the standard generic levitra price treatment.

The decision to operate or wait is a balance of risks that only June is fully able to make. Patients in this scenario will generic levitra price take different approaches. Patients will need different amounts of information to form their decisions, many patients will need as much information as is available including information about procedures not currently available to make up their mind.June’s husband insists that she should receive the best treatment, and that she should therefore be listed for CABG. Although this treatment would appear to be in June’s best interests, and would respect her autonomy, those ethical considerations are potentially outweighed by distributive justice.

The COVID-19 pandemic of 2020 is generic levitra price being characterised by limitations. Liberties curtailed and choices restricted, this is justified by a need to protect healthcare systems from demand exceeding availability. While resource allocation is always a relevant ethical concern in publicly funded healthcare systems, it is a dominant concern in a setting where there is a high demand for medical care and scare resources.It is well established that competent adult patients can consent to or refuse medical treatment but they cannot demand that health professionals provide treatments that are contrary to their professional judgement or (even more importantly) would consume scarce healthcare resources. In June’s case, agreeing to perform CABG at a time when large numbers of patients are critically ill with COVID-19 might mean that another generic levitra price patient is denied access to intensive care (and even dies as a result).

Of course, it may be that there are actually available beds in intensive care, and June’s operation would not directly lead to denial of treatment for another patient. However, that does not automatically mean that surgery must generic levitra price proceed. The hospital may have been justified in making a decision to suspend some forms of cardiac surgery. That could be on the basis of the need to use the dedicated space, staff and equipment of the cardiothoracic critical care unit for patients with COVID-19.

Even if all that physical space is not currently occupied if may not be feasible or practical to try to generic levitra price simultaneously accommodate some non-COVID-19 patients. (There would be a risk that June would contract COVID-19 postoperatively and end up considerably worse off than she would have been if she had instead received PCI.) Moreover, it seems problematic for individual patients to be able to circumvent policies about allocation of resources purely on the basis that they stand to be disadvantaged by the policy.Perhaps the most significant benefit of disclosure of non-options is transparency and honesty. We suggest that the generic levitra price main reason why Miss Schmidt ought to have included discussion of the laparoscopic alternative is so that Jenny understands the reasoning behind the decision. If Miss Schmidt had explained to Jenny that in the current circumstances laparoscopic surgery has been stopped, that might have helped her to appreciate that she was being offered the best available management.

It might have enabled a frank discussion about the challenges faced by health professionals in the context of the pandemic and the inevitable need for compromise. It may have avoided awkward discussions later generic levitra price after Jenny developed her complication.Transparent disclosure should not mean that patients can demand treatment. But it might mean that patients could appeal against a particular policy if they feel that it has been reached unfairly, or applied unfairly. For example, if June became aware that some patients were still being offered CABG, she might (or might not) be justified in appealing against the decision not to offer it to her.

Obviously such an appeal would only be possible if the patient were aware of the alternatives that they were being denied.For patients faced by decisions such as that faced by June, balancing generic levitra price risks of either option is highly personal. Individuals need to weigh up these decisions for them and require all of the information available to do so. Some information generic levitra price is readily available, for example, the rate of infection for Jenny and the risk of death without treatment for June. But other risks are unknown, such as the risk of acquiring nosocomial infection with COVID-19.

Doctors might feel discomfort talking about unquantifiable risks, but we argue that it is important that the patient has all available information to weigh up options for them, including information that is unknown.ConclusionIn a pandemic, as in other times, doctors should ensure that they offer appropriate medical treatment, based on the needs of an individual. They should aim to provide generic levitra price available treatment that is beneficial and should not offer treatment that is unavailable or contrary to the patient best interests. It is ethical. Indeed it is generic levitra price vital within a public healthcare system, to consider distributive justice in the allocation of treatment.

Where treatment is scarce, it may not be possible or appropriate to offer to patients some treatments that would be beneficial and desired by them.Informed consent needs to be individualised. Doctors are obliged to tailor their information to the needs of an individual. We suggest that in the current climate this should include, for most patients, a generic levitra price nuanced open discussion about alternative treatments that would have been available to them in usual circumstances. That will sometimes be a difficult conversation, and require clinicians to be frank about limited resources and necessary rationing.

However, transparency and honesty will usually be the best policy..

Canada levitra online pharmacy

NONE

At a canada levitra online pharmacy glance. Medicare health insurance in North Carolina Medicare enrollment in North CarolinaAs of July 2020, there were 2,025,301 residents with Medicare in North Carolina. For most canada levitra online pharmacy of them, Medicare coverage enrollment was triggered by turning 65. But 17 percent of North Carolina Medicare beneficiaries — about 340,000 people — were under age 65 as of 2017.

Nationwide, there are nearly 10 million people under the age of 65 who are covered by Medicare, accounting for about 15 percent of canada levitra online pharmacy all Medicare beneficiaries. This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or ALS.In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are disabled and under age 65. At the other end of the spectrum, just canada levitra online pharmacy 9 percent of Hawaii’s Medicare beneficiaries are under 65.Read about Medicare’s open enrollment period. Medicare Advantage in North CarolinaMedicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare.

There are pros and cons to either option, and the right solution depends on each enrollee’s circumstances canada levitra online pharmacy and preferences.Since Medicare Advantage plans are offered by private insurers, plan availability varies from one area to another. There are Medicare Advantage plans for sale in all 100 counties in North Carolina in 2020, but plan availability ranges from just four plan options in Craven, Dare, Lenoir, and Onslow counties, to 38 plan options in Mecklenburg County.As of 2018, a little more than a third of all Medicare beneficiaries nationwide were enrolled in Medicare Advantage plans, and North Carolina’s Medicare Advantage enrollment was very much in line with the national average, with 33 percent of the state’s Medicare beneficiaries covered by Advantage plans. But as of mid-2020, total private Medicare enrollment in North Carolina (not counting people with private supplemental coverage like Part canada levitra online pharmacy D and Medigap) had grown to nearly 41 percent of the state’s Medicare population, with 823,992 people enrolled in private plans. The other 1,201,309 Medicare beneficiaries had Original Medicare coverage as of mid-2020.Medicare Advantage enrollment is an option when people are first eligible for Medicare, and Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan).

The Medicare Advantage open enrollment period, which runs from January 1 to March 31, gives people who are already enrolled in Medicare Advantage plans an opportunity to switch to canada levitra online pharmacy a different Advantage plan or switch to Original Medicare.Medigap in North CarolinaOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or canada levitra online pharmacy all of the out-of-pocket costs they would otherwise have to pay if they had Original Medicare on its own.As of 2018, according to an AHIP analysis, there were 505,388 North Carolina Medicare beneficiaries enrolled in Medigap plans as of 2018. That’s about 40 percent of the state’s Original Medicare beneficiaries (Medigap coverage cannot be used with Medicare Advantage plans).Medigap plans are sold by private insurers, but they’re standardized under federal rules and regulated by state laws and insurance commissioners.

There are 52 insurers that offer Medigap plans in North canada levitra online pharmacy Carolina as of 2020. The state’s plan comparison tool displays the plans based on how much they cost, to make it easy to compare the various options. Since the plan benefits are standardized (ie, Plan G has the same benefits regardless of which insurer sells it), consumers can make their plan selection canada levitra online pharmacy based on premiums and less tangible factors like customer service. North Carolina’s Medigap shopping guide is a useful resource for consumers.North Carolina allows Medigap insurers to pick their own rating approach, so nearly all of the plans for sale in the state use attained-age rating, which means that an enrollee’s premiums will increase as they get older, regardless of how old they were when they first enrolled.

The other two approaches to Medigap premiums are issue-age rating, in which premiums are based on the age the person was when they enrolled, and canada levitra online pharmacy community rating (sometimes called “no age” rating), which means premiums don’t vary base on age. Some states require one of these approaches, but North Carolina does not. Only four Medigap insurers in North Carolina are using issue-age rating as of 2020, and just one — UnitedHealthcare-AARP — is using community rating.Federal rules require Medigap insurers to offer plans on a guaranteed-issue basis during canada levitra online pharmacy an enrollee’s open enrollment period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and Part A. You have to be enrolled in both to obtain Medigap).

But federal rules do not guarantee access to Medigap plans for people under age canada levitra online pharmacy 65. But North Carolina is among the majority of the states that have enacted rules to ensure access to Medigap plans for disabled enrollees under age 65.North Carolina law (see North Carolina statute § 58-54-45) requires all Medigap insurers in the state to offer at least Plan A to people under age 65 who are enrolled in Medicare due to a disability. And if the insurer also offers either Plan C or Plan F to people who are 65+, they must also make that plan available to beneficiaries under age 65 who were eligible for Medicare prior canada levitra online pharmacy to 2020. If the insurer offers either Plan D or Plan G to people who are 65+, they must also offer that plan to people who are under 65 and eligible for Medicare (under federal rules, as a result of MACRA, Medigap Plans C and F cannot be sold to people who become eligible for Medicare in 2020 or later).North Carolina Medicare beneficiaries under age 65 are granted a one-time six-month open enrollment period that begins when they’re enrolled in Medicare Part B (or when they find out they’ve been retroactively enrolled in Part B).

So they essentially have the same enrollment period as people who are turning 65, but it applies regardless of age, and it only guarantees access to Plan A and, in some cases, Plan C and Plan F.But while state law in North Carolina guarantees access to Medigap plans for disabled beneficiaries under age 65, canada levitra online pharmacy the insurers charge significantly higher premiums for these enrollees. Medigap Plan A rates in 2020 for a person age 55 range from $260 per month to $1,157 per month. In comparison, the same Plan A for a person age 65 ranges in price from $97 per month to $525 per month. And for canada levitra online pharmacy Plan G, premiums for a 55-year-old range from $386 per month to $735 per month, whereas a 65-year-old would pay between $107 and $541 per month for the same plans.Disabled Medicare beneficiaries have access to the Medigap open enrollment period when they turn 65.

At that point, they have access to any of the available Medigap plans, at the standard age-65 rates.Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (note that as of 2021, people with kidney failure will no longer be barred from joining Medicare Advantage plans). Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those canada levitra online pharmacy under 65. But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care (increasing to $7,550 in 2021), plus the out-of-pocket cost of prescription drugs. North CarolinAt a glance canada levitra online pharmacy.

Medicare health insurance in North Carolina Medicare enrollment in North CarolinaAs of July 2020, there were 2,025,301 residents with Medicare in North Carolina. For most of them, canada levitra online pharmacy Medicare coverage enrollment was triggered by turning 65. But 17 percent of North Carolina Medicare beneficiaries — about 340,000 people — were under age 65 as of 2017. Nationwide, there canada levitra online pharmacy are nearly 10 million people under the age of 65 who are covered by Medicare, accounting for about 15 percent of all Medicare beneficiaries.

This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or ALS.In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are disabled and under age 65. At the other end canada levitra online pharmacy of the spectrum, just 9 percent of Hawaii’s Medicare beneficiaries are under 65.Read about Medicare’s open enrollment period. Medicare Advantage in North CarolinaMedicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. There are pros and cons canada levitra online pharmacy to either option, and the right solution depends on each enrollee’s circumstances and preferences.Since Medicare Advantage plans are offered by private insurers, plan availability varies from one area to another.

There are Medicare Advantage plans for sale in all 100 counties in North Carolina in 2020, but plan availability ranges from just four plan options in Craven, Dare, Lenoir, and Onslow counties, to 38 plan options in Mecklenburg County.As of 2018, a little more than a third of all Medicare beneficiaries nationwide were enrolled in Medicare Advantage plans, and North Carolina’s Medicare Advantage enrollment was very much in line with the national average, with 33 percent of the state’s Medicare beneficiaries covered by Advantage plans. But as of canada levitra online pharmacy mid-2020, total private Medicare enrollment in North Carolina (not counting people with private supplemental coverage like Part D and Medigap) had grown to nearly 41 percent of the state’s Medicare population, with 823,992 people enrolled in private plans. The other 1,201,309 Medicare beneficiaries had Original Medicare coverage as of mid-2020.Medicare Advantage enrollment is an option when people are first eligible for Medicare, and Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan). The Medicare canada levitra online pharmacy Advantage open enrollment period, which runs from January 1 to March 31, gives people who are already enrolled in Medicare Advantage plans an opportunity to switch to a different Advantage plan or switch to Original Medicare.Medigap in North CarolinaOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage.

Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had canada levitra online pharmacy Original Medicare on its own.As of 2018, according to an AHIP analysis, there were 505,388 North Carolina Medicare beneficiaries enrolled in Medigap plans as of 2018. That’s about 40 percent of the state’s Original Medicare beneficiaries (Medigap coverage cannot be used with Medicare Advantage plans).Medigap plans are sold by private insurers, but they’re standardized under federal rules and regulated by state laws and insurance commissioners. There are 52 insurers that offer Medigap plans in North canada levitra online pharmacy Carolina as of 2020.

The state’s plan comparison tool displays the plans based on how much they cost, to make it easy to compare the various options. Since the plan benefits are standardized (ie, Plan G has the same canada levitra online pharmacy benefits regardless of which insurer sells it), consumers can make their plan selection based on premiums and less tangible factors like customer service. North Carolina’s Medigap shopping guide is a useful resource for consumers.North Carolina allows Medigap insurers to pick their own rating approach, so nearly all of the plans for sale in the state use attained-age rating, which means that an enrollee’s premiums will increase as they get older, regardless of how old they were when they first enrolled. The other canada levitra online pharmacy two approaches to Medigap premiums are issue-age rating, in which premiums are based on the age the person was when they enrolled, and community rating (sometimes called “no age” rating), which means premiums don’t vary base on age.

Some states require one of these approaches, but North Carolina does not. Only four Medigap insurers in North Carolina are using issue-age rating as of 2020, and just one — UnitedHealthcare-AARP — is using community rating.Federal rules require Medigap insurers to offer plans on a guaranteed-issue basis during an enrollee’s open enrollment period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and canada levitra online pharmacy Part A. You have to be enrolled in both to obtain Medigap). But federal rules do not guarantee access to Medigap plans for people under age 65.

But North Carolina is among the majority of the states that have enacted rules to ensure access to Medigap plans for disabled canada levitra online pharmacy enrollees under age 65.North Carolina law (see North Carolina statute § 58-54-45) requires all Medigap insurers in the state to offer at least Plan A to people under age 65 who are enrolled in Medicare due to a disability. And if the insurer also offers either Plan C or Plan F to people who are 65+, they must also make that plan available to beneficiaries under age 65 who were eligible for Medicare prior to 2020. If the insurer offers either Plan D or Plan G to people who are 65+, they must also offer that plan to people who are under 65 and eligible for Medicare (under federal rules, as a result of MACRA, Medigap Plans C and F cannot be sold canada levitra online pharmacy to people who become eligible for Medicare in 2020 or later).North Carolina Medicare beneficiaries under age 65 are granted a one-time six-month open enrollment period that begins when they’re enrolled in Medicare Part B (or when they find out they’ve been retroactively enrolled in Part B). So they essentially have the same enrollment period as people who are turning 65, but it applies regardless of age, and it only guarantees access to Plan A and, in some cases, Plan C and Plan F.But while state law in North Carolina guarantees access to Medigap plans for disabled beneficiaries under age 65, the insurers charge significantly higher premiums for these enrollees.

Medigap Plan A rates in 2020 for a person age canada levitra online pharmacy 55 range from $260 per month to $1,157 per month. In comparison, the same Plan A for a person age 65 ranges in price from $97 per month to $525 per month. And for Plan G, premiums for a 55-year-old range from $386 per month to $735 per month, whereas a 65-year-old would pay between $107 and $541 per month for canada levitra online pharmacy the same plans.Disabled Medicare beneficiaries have access to the Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans, at the standard age-65 rates.Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (note that as of 2021, people with kidney failure will no longer be barred from joining Medicare Advantage plans).

Medicare Advantage plans are otherwise available to anyone canada levitra online pharmacy who is eligible for Medicare, and the premiums are not higher for those under 65. But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care (increasing to $7,550 in 2021), plus the out-of-pocket cost of prescription drugs. North Carolina Medicare Part DOriginal Medicare does not provide coverage for canada levitra online pharmacy outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.But Medicare Part D, created under the Medicare Modernization Act of 2003, provides drug coverage for Medicare beneficiaries who do not have another source of coverage for prescription costs.

Medicare beneficiaries can buy Medicare Part D plans on a stand-alone basis, or obtain Part D coverage integrated with a Medicare Advantage plan (not canada levitra online pharmacy all Advantage plans include Part D benefits, but most do).There are 28 stand-alone Medicare Part D plans for sale in North Carolina in 2020, with premiums that range from about $13 to $121/month.781,274 North Carolina beneficiaries had Medicare Part D enrollment plans as of July 2020, and another 772,179 had Medicare Advantage plans that included integrated Part D coverage. Together, that’s nearly three-quarters of the state’s Medicare beneficiaries with Part D coverage.Medicare Part D enrollment is available when a person is first eligible for Medicare, and also during the annual open enrollment period that runs from October 15 to December 7. Medicare spending in North CarolinaAverage per-beneficiary spending for Medicare canada levitra online pharmacy in North Carolina was about 5 percent lower than the national average in 2018, at $9,564 (nationwide, the average was $10,096). The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.Average per-beneficiary Original Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in North Carolina.

Resources for canada levitra online pharmacy Medicare beneficiaries and their caregiversNeed help filing for Medicare benefits in North Carolina, or understanding Medicare eligibility in North Carolina?. You can contact SHIIP, North Carolina’s Seniors’ Health Insurance Information Program, with questions related to Medicare enrollment in North Carolina.North Carolina’s Senior Medicare Patrol Program (NCSMP) strives to “reduce Medicare error, fraud, and abuse” by educating Medicare beneficiaries and their caregivers about Medicare benefits, statements, explanations of benefits, etc.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org canada levitra online pharmacy. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.a Medicare Part DOriginal Medicare does not provide coverage for outpatient prescription drugs.

More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.But Medicare Part D, created under the Medicare Modernization Act of 2003, provides drug coverage for Medicare beneficiaries who do not have another source of coverage for prescription canada levitra online pharmacy costs. Medicare beneficiaries can buy Medicare Part D plans on a stand-alone basis, or obtain Part D coverage integrated with a Medicare Advantage plan (not all Advantage plans include Part D benefits, but most do).There are 28 stand-alone Medicare Part D plans for sale in North Carolina in 2020, with premiums that range from about $13 to $121/month.781,274 North Carolina beneficiaries had Medicare Part D enrollment plans as of July 2020, and another 772,179 had Medicare Advantage plans that included integrated Part D coverage. Together, that’s nearly three-quarters of the state’s Medicare beneficiaries with Part D coverage.Medicare Part D enrollment is canada levitra online pharmacy available when a person is first eligible for Medicare, and also during the annual open enrollment period that runs from October 15 to December 7. Medicare spending in North CarolinaAverage per-beneficiary spending for Medicare in North Carolina was about 5 percent lower than the national average in 2018, at $9,564 (nationwide, the average was $10,096).

The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.Average per-beneficiary Original canada levitra online pharmacy Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in North Carolina. Resources for Medicare beneficiaries and their caregiversNeed help filing for Medicare benefits in North Carolina, or understanding Medicare eligibility in North Carolina?. You can contact SHIIP, North Carolina’s Seniors’ Health Insurance Information Program, with questions related to Medicare enrollment in North Carolina.North Carolina’s Senior Medicare Patrol Program (NCSMP) strives to “reduce Medicare error, fraud, and abuse” by educating Medicare beneficiaries and canada levitra online pharmacy their caregivers about Medicare benefits, statements, explanations of benefits, etc.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

At a generic levitra price browse around this site glance. Medicare health insurance in North Carolina Medicare enrollment in North CarolinaAs of July 2020, there were 2,025,301 residents with Medicare in North Carolina. For most of them, Medicare generic levitra price coverage enrollment was triggered by turning 65. But 17 percent of North Carolina Medicare beneficiaries — about 340,000 people — were under age 65 as of 2017.

Nationwide, there are nearly 10 million people under the age of 65 generic levitra price who are covered by Medicare, accounting for about 15 percent of all Medicare beneficiaries. This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or ALS.In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are disabled and under age 65. At the generic levitra price other end of the spectrum, just 9 percent of Hawaii’s Medicare beneficiaries are under 65.Read about Medicare’s open enrollment period. Medicare Advantage in North CarolinaMedicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare.

There are pros and cons to either option, and the right solution depends on each generic levitra price enrollee’s circumstances and preferences.Since Medicare Advantage plans are offered by private insurers, plan availability varies from one area to another. There are Medicare Advantage plans for sale in all 100 counties in North Carolina in 2020, but plan availability ranges from just four plan options in Craven, Dare, Lenoir, and Onslow counties, to 38 plan options in Mecklenburg County.As of 2018, a little more than a third of all Medicare beneficiaries nationwide were enrolled in Medicare Advantage plans, and North Carolina’s Medicare Advantage enrollment was very much in line with the national average, with 33 percent of the state’s Medicare beneficiaries covered by Advantage plans. But as of mid-2020, total private Medicare enrollment generic levitra price in North Carolina (not counting people with private supplemental coverage like Part D and Medigap) had grown to nearly 41 percent of the state’s Medicare population, with 823,992 people enrolled in private plans. The other 1,201,309 Medicare beneficiaries had Original Medicare coverage as of mid-2020.Medicare Advantage enrollment is an option when people are first eligible for Medicare, and Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan).

The Medicare Advantage open enrollment period, which runs from January 1 to March 31, gives people who are already enrolled in Medicare Advantage plans an opportunity to switch to a generic levitra price different Advantage plan or switch to Original Medicare.Medigap in North CarolinaOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had Original generic levitra price Medicare on its own.As of 2018, according to an AHIP analysis, there were 505,388 North Carolina Medicare beneficiaries enrolled in Medigap plans as of 2018. That’s about 40 percent of the state’s Original Medicare beneficiaries (Medigap coverage cannot be used with Medicare Advantage plans).Medigap plans are sold by private insurers, but they’re standardized under federal rules and regulated by state laws and insurance commissioners.

There are 52 insurers that offer Medigap plans generic levitra price in North Carolina as of 2020. The state’s plan comparison tool displays the plans based on how much they cost, to make it easy to compare the various options. Since the plan benefits are standardized (ie, Plan G has the same benefits regardless of which insurer sells it), generic levitra price consumers can make their plan selection based on premiums and less tangible factors like customer service. North Carolina’s Medigap shopping guide is a useful resource for consumers.North Carolina allows Medigap insurers to pick their own rating approach, so nearly all of the plans for sale in the state use attained-age rating, which means that an enrollee’s premiums will increase as they get older, regardless of how old they were when they first enrolled.

The other two approaches to Medigap premiums are issue-age rating, in which premiums are based on the age the person was when they enrolled, and community rating (sometimes called “no age” generic levitra price rating), which means premiums don’t vary base on age. Some states require one of these approaches, but North Carolina does not. Only four Medigap insurers in North Carolina are using issue-age rating as of 2020, and just one — UnitedHealthcare-AARP — is using community rating.Federal rules require Medigap insurers to offer plans on a generic levitra price guaranteed-issue basis during an enrollee’s open enrollment period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and Part A. You have to be enrolled in both to obtain Medigap).

But federal rules do not guarantee access to Medigap plans for people generic levitra price under age 65. But North Carolina is among the majority of the states that have enacted rules to ensure access to Medigap plans for disabled enrollees under age 65.North Carolina law (see North Carolina statute § 58-54-45) requires all Medigap insurers in the state to offer at least Plan A to people under age 65 who are enrolled in Medicare due to a disability. And if the insurer also offers either Plan C or Plan F to people who are 65+, they must also make that plan available to beneficiaries under age 65 who were eligible for Medicare generic levitra price prior to 2020. If the insurer offers either Plan D or Plan G to people who are 65+, they must also offer that plan to people who are under 65 and eligible for Medicare (under federal rules, as a result of MACRA, Medigap Plans C and F cannot be sold to people who become eligible for Medicare in 2020 or later).North Carolina Medicare beneficiaries under age 65 are granted a one-time six-month open enrollment period that begins when they’re enrolled in Medicare Part B (or when they find out they’ve been retroactively enrolled in Part B).

So they essentially have the same enrollment period as people who are turning 65, but it applies generic levitra price regardless of age, and it only guarantees access to Plan A and, in some cases, Plan C and Plan F.But while state law in North Carolina guarantees access to Medigap plans for disabled beneficiaries under age 65, the insurers charge significantly higher premiums for these enrollees. Medigap Plan A rates in 2020 for a person age 55 range from $260 per month to $1,157 per month. In comparison, the same Plan A for a person age 65 ranges in price from $97 per month to $525 per month. And for Plan G, premiums for a 55-year-old range from $386 per month to $735 per month, whereas a 65-year-old would pay between $107 and $541 per month for the same plans.Disabled Medicare beneficiaries have access generic levitra price to the Medigap open enrollment period when they turn 65.

At that point, they have access to any of the available Medigap plans, at the standard age-65 rates.Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (note that as of 2021, people with kidney failure will no longer be barred from joining Medicare Advantage plans). Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not generic levitra price higher for those under 65. But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care (increasing to $7,550 in 2021), plus the out-of-pocket cost of prescription drugs. North CarolinAt generic levitra price a glance.

Medicare health insurance in North Carolina Medicare enrollment in North CarolinaAs of July 2020, there were 2,025,301 residents with Medicare in North Carolina. For most of them, Medicare coverage enrollment was triggered generic levitra price by turning 65. But 17 percent of North Carolina Medicare beneficiaries — about 340,000 people — were under age 65 as of 2017. Nationwide, there are nearly 10 million generic levitra price people under the age of 65 who are covered by Medicare, accounting for about 15 percent of all Medicare beneficiaries.

This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or ALS.In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are disabled and under age 65. At the other end of the spectrum, just 9 percent of Hawaii’s Medicare generic levitra price beneficiaries are under 65.Read about Medicare’s open enrollment period. Medicare Advantage in North CarolinaMedicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. There are pros and cons to either option, and the right solution depends on each enrollee’s circumstances and preferences.Since Medicare Advantage plans generic levitra price are offered by private insurers, plan availability varies from one area to another.

There are Medicare Advantage plans for sale in all 100 counties in North Carolina in 2020, but plan availability ranges from just four plan options in Craven, Dare, Lenoir, and Onslow counties, to 38 plan options in Mecklenburg County.As of 2018, a little more than a third of all Medicare beneficiaries nationwide were enrolled in Medicare Advantage plans, and North Carolina’s Medicare Advantage enrollment was very much in line with the national average, with 33 percent of the state’s Medicare beneficiaries covered by Advantage plans. But as of mid-2020, total private Medicare enrollment in North Carolina (not counting people with private generic levitra price supplemental coverage like Part D and Medigap) had grown to nearly 41 percent of the state’s Medicare population, with 823,992 people enrolled in private plans. The other 1,201,309 Medicare beneficiaries had Original Medicare coverage as of mid-2020.Medicare Advantage enrollment is an option when people are first eligible for Medicare, and Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan). The Medicare Advantage open enrollment period, generic levitra price which runs from January 1 to March 31, gives people who are already enrolled in Medicare Advantage plans an opportunity to switch to a different Advantage plan or switch to Original Medicare.Medigap in North CarolinaOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage.

Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have generic levitra price to pay if they had Original Medicare on its own.As of 2018, according to an AHIP analysis, there were 505,388 North Carolina Medicare beneficiaries enrolled in Medigap plans as of 2018. That’s about 40 percent of the state’s Original Medicare beneficiaries (Medigap coverage cannot be used with Medicare Advantage plans).Medigap plans are sold by private insurers, but they’re standardized under federal rules and regulated by state laws and insurance commissioners. There are 52 generic levitra price insurers that offer Medigap plans in North Carolina as of 2020.

The state’s plan comparison tool displays the plans based on how much they cost, to make it easy to compare the various options. Since the plan benefits are standardized (ie, Plan G has the same benefits regardless of which insurer sells it), consumers can make their plan generic levitra price selection based on premiums and less tangible factors like customer service. North Carolina’s Medigap shopping guide is a useful resource for consumers.North Carolina allows Medigap insurers to pick their own rating approach, so nearly all of the plans for sale in the state use attained-age rating, which means that an enrollee’s premiums will increase as they get older, regardless of how old they were when they first enrolled. The other two approaches to Medigap premiums are issue-age rating, in which premiums are generic levitra price based on the age the person was when they enrolled, and community rating (sometimes called “no age” rating), which means premiums don’t vary base on age.

Some states require one of these approaches, but North Carolina does not. Only four Medigap insurers in North Carolina are using issue-age rating as of 2020, and just one — UnitedHealthcare-AARP — is using community rating.Federal rules require Medigap generic levitra price insurers to offer plans on a guaranteed-issue basis during an enrollee’s open enrollment period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and Part A. You have to be enrolled in both to obtain Medigap). But federal rules do not guarantee access to Medigap plans for people under age 65.

But North Carolina is among the majority of the states that have enacted rules generic levitra price to ensure access to Medigap plans for disabled enrollees under age 65.North Carolina law (see North Carolina statute § 58-54-45) requires all Medigap insurers in the state to offer at least Plan A to people under age 65 who are enrolled in Medicare due to a disability. And if the insurer also offers either Plan C or Plan F to people who are 65+, they must also make that plan available to beneficiaries under age 65 who were eligible for Medicare prior to 2020. If the insurer offers either Plan D or Plan G to people who are 65+, they must also offer that plan to people who are under 65 and eligible for Medicare (under federal rules, as a result of MACRA, Medigap Plans C and F cannot be sold to people who become eligible for Medicare in 2020 or later).North Carolina Medicare beneficiaries under age 65 are granted a one-time six-month open enrollment generic levitra price period that begins when they’re enrolled in Medicare Part B (or when they find out they’ve been retroactively enrolled in Part B). So they essentially have the same enrollment period as people who are turning 65, but it applies regardless of age, and it only guarantees access to Plan A and, in some cases, Plan C and Plan F.But while state law in North Carolina guarantees access to Medigap plans for disabled beneficiaries under age 65, the insurers charge significantly higher premiums for these enrollees.

Medigap Plan A rates generic levitra price in 2020 for a person age 55 range from $260 per month to $1,157 per month. In comparison, the same Plan A for a person age 65 ranges in price from $97 per month to $525 per month. And for Plan G, premiums for a 55-year-old range from $386 per month to $735 per month, whereas a 65-year-old would pay between $107 and $541 per month for the same plans.Disabled Medicare beneficiaries have generic levitra price access to the Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans, at the standard age-65 rates.Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (note that as of 2021, people with kidney failure will no longer be barred from joining Medicare Advantage plans).

Medicare Advantage plans are otherwise available to anyone who is eligible for generic levitra price Medicare, and the premiums are not higher for those under 65. But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care (increasing to $7,550 in 2021), plus the out-of-pocket cost of prescription drugs. North Carolina Medicare Part DOriginal Medicare does generic levitra price not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.But Medicare Part D, created under the Medicare Modernization Act of 2003, provides drug coverage for Medicare beneficiaries who do not have another source of coverage for prescription costs.

Medicare beneficiaries can buy Medicare Part D plans on a generic levitra price stand-alone basis, or obtain Part D coverage integrated with a Medicare Advantage plan (not all Advantage plans include Part D benefits, but most do).There are 28 stand-alone Medicare Part D plans for sale in North Carolina in 2020, with premiums that range from about $13 to $121/month.781,274 North Carolina beneficiaries had Medicare Part D enrollment plans as of July 2020, and another 772,179 had Medicare Advantage plans that included integrated Part D coverage. Together, that’s nearly three-quarters of the state’s Medicare beneficiaries with Part D coverage.Medicare Part D enrollment is available when a person is first eligible for Medicare, and also during the annual open enrollment period that runs from October 15 to December 7. Medicare spending generic levitra price in North CarolinaAverage per-beneficiary spending for Medicare in North Carolina was about 5 percent lower than the national average in 2018, at $9,564 (nationwide, the average was $10,096). The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.Average per-beneficiary Original Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in North Carolina.

Resources for Medicare beneficiaries and their generic levitra price caregiversNeed help filing for Medicare benefits in North Carolina, or understanding Medicare eligibility in North Carolina?. You can contact SHIIP, North Carolina’s Seniors’ Health Insurance Information Program, with questions related to Medicare enrollment in North Carolina.North Carolina’s Senior Medicare Patrol Program (NCSMP) strives to “reduce Medicare error, fraud, and abuse” by educating Medicare beneficiaries and their caregivers about Medicare benefits, statements, explanations of benefits, etc.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about generic levitra price the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.a Medicare Part DOriginal Medicare does not provide coverage for outpatient prescription drugs.

More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.But Medicare Part D, created under the Medicare Modernization Act of 2003, provides drug coverage for Medicare beneficiaries who do not generic levitra price have another source of coverage for prescription costs. Medicare beneficiaries can buy Medicare Part D plans on a stand-alone basis, or obtain Part D coverage integrated with a Medicare Advantage plan (not all Advantage plans include Part D benefits, but most do).There are 28 stand-alone Medicare Part D plans for sale in North Carolina in 2020, with premiums that range from about $13 to $121/month.781,274 North Carolina beneficiaries had Medicare Part D enrollment plans as of July 2020, and another 772,179 had Medicare Advantage plans that included integrated Part D coverage. Together, that’s nearly three-quarters of the state’s generic levitra price Medicare beneficiaries with Part D coverage.Medicare Part D enrollment is available when a person is first eligible for Medicare, and also during the annual open enrollment period that runs from October 15 to December 7. Medicare spending in North CarolinaAverage per-beneficiary spending for Medicare in North Carolina was about 5 percent lower than the national average in 2018, at $9,564 (nationwide, the average was $10,096).

The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.Average per-beneficiary Original Medicare spending was generic levitra price highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in North Carolina. Resources for Medicare beneficiaries and their caregiversNeed help filing for Medicare benefits in North Carolina, or understanding Medicare eligibility in North Carolina?. You can contact SHIIP, North Carolina’s Seniors’ Health Insurance Information Program, with questions related to Medicare enrollment in North Carolina.North Carolina’s Senior Medicare Patrol Program (NCSMP) strives to “reduce Medicare generic levitra price error, fraud, and abuse” by educating Medicare beneficiaries and their caregivers about Medicare benefits, statements, explanations of benefits, etc.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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Copper was one of the first metals http://cz.keimfarben.de/cheapest-place-to-buy-levitra/ to be buy levitra online in usa worked by humankind. Because it is highly malleable, copper could be used for toolmaking and ornamentation even by people whose everyday implements were of flint and bone. A copper pendant unearthed buy levitra online in usa in what is today northern Iraq has been dated to 8,700 B.C.

€” the Neolithic period. Although people have adorned themselves with copper since prehistory, the marketing of copper bracelets as a treatment for arthritis pain appears to date back only to the 1970s. Miner Pain Relief Proponents of copper bracelets often cite the research of Werner Hangarter (1904–1982), a German buy levitra online in usa doctor of internal medicine.

Hangarter evangelized for copper’s therapeutic possibilities after hearing that copper miners in Finland seldom developed rheumatism while laboring in the copper-rich environment of the mines. In the 1950s, he began treating patients suffering from buy levitra online in usa a variety of rheumatic ailments — including rheumatoid arthritis (RA) — with injections of copper in a salicylic acid solution. The results were dramatic.

Patients showed “rapid and persistent remission of fever, alleviation of pain, [and] increased mobility.” Hangarter published several papers on his work, and the alternative-medicine movement popularized his ideas. By the mid-1970s, copper jewelry was being touted as a natural, noninvasive remedy for buy levitra online in usa the pain and inflammation of arthritis. The market now encompasses copper-infused topical creams, insoles for foot pain and compression sleeves with copper fibers for stiff joints.

But is there anything buy levitra online in usa to it?. Health Benefits of Copper Copper does play an important role in individual health. Like many other minerals, copper is an essential micronutrient, a key player in the formation of red blood cells.

The most common symptom of a copper deficiency buy levitra online in usa is anemia. It is found in many common foods, but shellfish, nuts and chocolate are the richest dietary sources. Copper helps with formation of connective tissue, so it’s possible that a copper deficiency could worsen the symptoms of arthritis.

It does not buy levitra online in usa necessarily follow, though, that boosting copper levels can mitigate RA. Testing the Claims Hindsight reveals several problems in Hangarter’s research. Based on inference and anecdote, buy levitra online in usa he assumed a chain of causation — that exposure to environmental copper helped miners ward off RA — where the reverse is actually far more likely.

No active miners had RA because individuals who developed the condition quit the profession. His use of copper salicylate solution also raises more questions than it answers. Salicylic acid is the active ingredient buy levitra online in usa in plain old aspirin, and the effects that Hangarter describes — pain relief and fever reduction — could easily be attributable to aspirin alone.

So even the effects of copper in solution are ambiguous. What about topical copper? buy levitra online in usa. The effectiveness of wearing copper, rather than ingesting it, is based on the idea that trace amounts of the metal can be effectively absorbed through the skin.

But there’s little evidence for this claim, and in any case the occasional peanut-butter sandwich or chocolate bar would be a more efficient way to get the stuff into your system than a $25 bangle. For buy levitra online in usa the same reason, the superiority of copper-infused insoles or compression sleeves over some other material is unlikely. As for those creams, they’re made with a salicylic acid base — aspirin again, which as it turns out is easily absorbed through the skin.

In all these cases, the product may ease discomfort from RA, but the addition of copper doesn’t make them any more (or any less) effective. A 2013 study of 70 buy levitra online in usa rheumatoid arthritis patients provides the most thorough debunking yet. Under double-blind conditions, patients who wore copper bracelets for five weeks saw no statistically significant reduction in pain or inflammation when compared to those who wore lookalike placebo bracelets.

The rigor of the experimental design — inflammation was measured using a protein reactive blood test — provides convincing evidence that if you’re thinking of shelling out for buy levitra online in usa an allegedly therapeutic copper bracelet, you’re better off saving your pennies.After watching a parent succumb to the deleterious effects of Alzheimer's disease, it's only natural to wonder if you might be doomed to the same fate. The good news?. That's not necessarily the case.

The bad news, however, is that the disease is so prevalent your overall buy levitra online in usa risk is still relatively high — especially as you age. At 65, you have a roughly 3 percent chance of contracting Alzheimer's disease each year. This bumps up to a 17 percent chance after your 75th buy levitra online in usa birthday, and increases to a roughly one in three chance you'll develop Alzheimer's after the age of 85.

Experts agree that family history elevates the risk, particularly if you have more than one parent or sibling with the disease, but they disagree on how much. Some studies indicate the risk hovers at around 30 percent, while others estimate an up to two or four times increased risk. Early onset Alzheimer's — which typically strikes individuals between the ages of 40 and 65 — has a more easily understood genetic link, with a 50 percent chance the child of an buy levitra online in usa Alzheimer's patient will also be diagnosed with the disease.

Read More:Why Do Women Get Alzheimer’s More Than Men?. How Did Alzheimer's Disease Get Its Name?. Are We Close to buy levitra online in usa Curing Alzheimer’s Disease?.

However, a combination of genetic and environmental factors come into play for the more common late-onset variation, says Rita Guerreiro, a neurogeneticist at the Van Andel Institute. Which makes things even more difficult buy levitra online in usa to predict. €œMany people who have relatives with [Alzheimer's] never develop the disease, and many without a family history of the disease do develop it,” says Guerreiro.Interested in tipping the odds in your favor?.

Some scientists think keeping your mind active, consuming a diet low in red meat and sugar and exercising regularly could help keep the memory-zapping disease at bay.Late fall and early winter typically mean a flurry of holiday travel and get-togethers for a lot of people. But this year will buy levitra online in usa be anything but normal. Making plans is more than a matter of shopping around for flight prices or car rental fees.

Many of us buy levitra online in usa are probably also asking ourselves whether to stay home or see loved ones, and how to stay safe at holiday gatherings. For the lowest risk of spreading or becoming sick with COVID-19, not traveling is the way to go. However, there might be loved ones who desperately need companionship in the coming months.

€œThere are situations where people will choose, and choose correctly, to go and support those family members,” says Lin buy levitra online in usa H. Chen, director of the Travel Medicine Center at Mount Auburn Hospital and president of the International Society of Travel Medicine. No matter buy levitra online in usa if you’re going cross-country to see siblings or staying at home with your dog, experts say, remember two things.

Plan ahead and stay flexible.Tackle Logistics FirstFor those interested in interstate travel, first assess whether or not those plans are feasible. The states you’re going to (and coming back to) might have rules about isolating yourself for two weeks once you arrive. If you live in one of those states but a two-week isolation period isn’t feasible — because buy levitra online in usa you have to go to work or send kids to school, for example — then traveling for the holidays won’t work for you, says Gabriela Andujar Vazquez, an infectious disease doctor at Tufts Medical Center.

Some states say that isolation requirements don’t apply if you get a negative COVID test. But testing you or your whole family may lie outside your budget if the exams aren’t covered by insurance, Andujar Vazquez says. Factor those financial decisions into your travel plans, too.If you do decide to travel, choose driving over flying buy levitra online in usa if you can.

Busy rest stops might mean confronting crowds of other highway travelers, Chen says. However, compared to the entire process of flying — getting to an airport and waiting in lines repeatedly — buy levitra online in usa driving likely means fewer crowds overall. €œThink about precautions through this journey,” Chen says, “not just on the plane, train, bus or car.”Airplanes themselves receive a lot of attention as potential virus spreaders.

But Chen says there are three instances of infected individuals spreading the disease to two or more people on a flight. Those transmissions happened before any airline required buy levitra online in usa passengers to wear masks. Since then, other interventions like leaving seats open, disinfecting often and updated air filtration have been introduced on airplanes, too.

Though there’s no data yet on how effective these combined intervention strategies are, “the fact that we haven’t heard about masked transmission on recent buy levitra online in usa flights is also reassuring,” Chen says. On the Big DayOdds are you’re debating travel plans for the sake of a big family meal. Or even if you’re staying local, you might try and work something out with friends and relatives nearby.

Both Chen and Andujar Vazquez emphasize that no matter buy levitra online in usa which you choose, keep up the COVID-19 precautions once you’re all together. Generally, the smaller the gathering (and the fewer number of households), the better. Keep activities outdoors if you can, seat groups apart, and keep masks on while not eating.

You might also consider new ways to keep buy levitra online in usa everyone fed. The typical buffet serving style can mean a lot of utensil sharing, so maybe opt for single-serving portioning or have everyone wash or sanitize hands before and after touching communal dishes. And as fun as it buy levitra online in usa might be to play bartender, maybe choose a BYOB policy as well.

Oh, and “no one should be coming sick,” Andujar Vazquez says. €œYou cannot say that enough.”These might sound like a lot of holiday modifications, which is why it’s important to discuss what the situation will look like before coming together. €œPeople have to feel comfortable talking about these things, because it’s part of buy levitra online in usa our daily life now,” Andujar Vazquez says.

€œHave that conversation before the event happens so people don’t have unexpected surprises or feel unsafe with some sort of behavior.”At the same time, acknowledge that even the most careful planning might fall apart. Your destination might become a COVID-19 hotspot days before you’re set to arrive, or you or someone in your gathering might start feeling unwell ahead buy levitra online in usa of time. Though it’s easier said than done, accept that plans will change whether you want them to or not — and that celebrations in the coming months will look different than they used to.

€œRealistically, this holiday season is going to be difficult for a lot of people,” says Jonathan Kanter, psychologist and director of the Center for the Science of Social Connection at the University of Washington. In individuals coping with significant life changes, buy levitra online in usa one of the best predictors of depression is whether or not people can leave former goals behind and adopt new ones, Kanter says. Letting go of old expectations — like how you normally gather with family, for example — can involve a kind of grieving process.

But recalibrating what you want to get out of a situation is an essential coping skill. €œYou won’t be able to get there unless you breathe buy levitra online in usa and accept that you’re in a new context,” Kanter says. €œWith that acceptance, hopefully there's a lot of creativity and innovation and grace about how to make it as successful as possible.” The prospect of not seeing loved ones in the coming months might make some people nervous, for themselves and for others.

What's important to remember is that it's possible to make it through — and that future holidays will get better.As flu season creeps up buy levitra online in usa on the Northern Hemisphere, cold and flu relief medications will inevitably fly off store shelves. A natural remedy that shoppers might reach for is elderberry, a small, blackish-purple fruit that companies turn into syrups, lozenges and gummies. Though therapeutic uses of the berry date back centuries, Michael Macknin, a pediatrician at the Cleveland Clinic, hadn’t heard of using elderberry to treat the flu until a patient’s mother asked him about it.

Some industry-sponsored research claims that the herbal buy levitra online in usa remedy could cut the length of the symptoms by up to four days. For a comparison, Tamiflu, an FDA-approved treatment, only reduces flu duration by about a single day. €œI said, 'Gee, if that’s really true [about elderberry], it would buy levitra online in usa be a huge benefit,'” Macknin says.

But the effectiveness and safety of elderberry is still fairly unclear. Unlike the over-the-counter medicines at your local pharmacy, elderberry hasn't been through rigorous FDA testing and approval. However, Macknin and his team recently published a study in the Journal of General Internal Medicine, which found that elderberry treatments did nothing for flu patients buy levitra online in usa.

This prompts a need for further studies into the remedy — work that unfortunately stands a low chance of happening in the future, Macknin says. Looking For ProofElderberries are full of chemicals that could buy levitra online in usa be good for your health. Like similar fruits, the berries contain high levels of antioxidants, compounds that shut down reactions in our bodies that damage cells.

But whether or not elderberry's properties also help immune systems fend off a virus is murky. There are buy levitra online in usa only a handful of studies that have examined if elderberries reduced the severity or duration of the flu. And though some of the work prior to Macknin’s was well-designed and supported this herbal remedy as a helpful flu aid, at least some — and potentially all — of those studies were funded by elderberry treatment manufacturers.Macknin says an elderberry supplement company provided his team with their products and a placebo version for free, but that the company wasn’t involved in the research beyond that.

Macknin's study is the largest one conducted on elderberry to date, with 87 influenza patients completing the entire treatment course. Participants in the study were also welcome to take Tamiflu, for ethical reasons, as the team didn’t want to buy levitra online in usa exclude anyone from taking a proven flu therapy. Additionally, each participant took home either a bottle of elderberry syrup or the placebo with instructions on when and how to take it.

The research team called participants every day for a symptom check and to remind them to take their medication.By chance, it turned out that a higher percentage of the patients given buy levitra online in usa elderberry syrup had gotten their flu shot and also chose to take Tamiflu. Since the vaccination can reduce the severity of infection in recipients who still come down with the flu, the study coincidentally operated in favor of those who took the herbal remedy, Macknin says. Those patients could have dealt with a shorter, less-intense illness because of the Tamiflu and vaccination.

€œEverything was stacked to have it turn out better [for the elderberry group],” Macknin says, “and it turned out the same.” The buy levitra online in usa researchers found no difference in illness duration or severity between the elderberry and placebo groups. While analyzing the data, the team also found that those on the herbal treatment might have actually fared worse than those on the placebo. The potential for this intervention to actually harm instead buy levitra online in usa of help influenza patients explains why Macknin thinks the therapy needs further research.But, don't expect that work to happen any time soon.

Researchers are faced with a number of challenges when it comes to studying the efficacy of herbal remedies. For starters, there's little financial incentive to investigate if they actually work. Plant products are challenging to patent, making them less lucrative prospects for pharmaceutical companies or research organizations to investigate buy levitra online in usa.

Additionally, investigations that try and prove a proposed therapy as an effective drug — like the one Macknin and his team accomplished — are expensive, Macknin says. Those projects need FDA oversight and additional paperwork, components that drive up study costs. €œIt’s extraordinarily expensive and there’s no money in it for anybody,” Macknin says.Talk To Your DoctorUltimately, research on elderberry therapies for flu patients is a mixed bag, and deserves more attention buy levitra online in usa from scientists.

However, if you still want to discuss elderberry treatments for the flu with your doctor, that’s a conversation you should feel comfortable having, says Erica McIntyre, an expert focused on health and environmental psychology in the School of Public Health at the University of Technology Sydney. Navigating what buy levitra online in usa research says about a particular herbal medicine is challenging for patients and health practitioners alike. The process is made more complex by the range of similar-sounding products on the market that lack standardized ingredients, McIntyre says.

But when doctors judge or shame patients for asking about non-conventional healthcare interventions, the response can distance people and push them closer to potentially unproven treatments. Even worse, those individuals might start to keep buy levitra online in usa their herbal remedies a secret. €œIt is that fear about being judged for use of that medication,” McIntyre says, that drives up to 50 percent of people taking herbal treatments to withhold that information from healthcare practitioners.

That’s a dangerous choice, as some herbal and traditional medications can interact and cause health problems.If a physician shames someone for buy levitra online in usa asking about alternative medicines, it’s likely time to find a new doctor, McIntyre says. Look for someone who will listen to your concerns — whether it's that you feel traditional treatments haven’t worked for you, or that you didn’t like the side effects, the two common reasons people pursue herbal treatments in the first place. €œYou’re not necessarily looking for a doctor that will let you do whatever you want,” McIntyre says, “but that they actually consider you as a patient, your treatment choices and your treatment priorities, and communicate in a way that’s supportive.” And if a doctor suggests that you avoid a treatment you’re interested in, ask why.

They generally have a good reason, McIntyre says.For now, know that even if your doctor doesn’t support you buy levitra online in usa taking elderberry, there are other proven preventative measures that are worth your while — like the flu shot. Anyone six months or older should get it, Macknin says, and stick to the protocols we’re used to following to prevent COVID-19 infections, like social distancing, mask-wearing and hand-washing. Those measures also help prevent flu transmission, too — something, so far, no elderberry supplement package can claim.The yearly influenza season threatens to make the COVID-19 pandemic doubly deadly, but I believe that this isn’t inevitable.There are two commonly given vaccines – the pneumococcal vaccine and the Hib vaccine – that protect against bacterial pneumonias.

These bacteria complicate both influenza and COVID-19, often buy levitra online in usa leading to death. My examination of disease trends and vaccination rates leads me to believe that broader use of the pneumococcal and Hib vaccines could guard against the worst effects of a COVID-19 illness.I am an immunologist and physiologist interested in the effects of combined infections on immunity. I have reached my insight by buy levitra online in usa juxtaposing two seemingly unrelated puzzles.

Infants and children get SARS-CoV-2, the virus that causes COVID-19, but very rarely become hospitalized or die. And case numbers and death rates from COVID-19 began varying greatly from nation to nation and city to city even before lockdowns began. I wondered why.One night I woke buy levitra online in usa up with a possible answer.

Vaccination rates. Most children, buy levitra online in usa beginning at age two months, are vaccinated against numerous diseases. Adults less so.

And, both infant and adult vaccination rates vary widely across the world. Could differences in the rates of vaccination buy levitra online in usa against one or more diseases account for differences in COVID-19 risks?. As someone who had previously investigated other pandemics such as the Great Flu Pandemic of 1918-19 and AIDS, and who has worked with vaccines, I had a strong background for tracking down the relevant data to test my hypothesis.Pneumococcal Vaccination Rates Correlate With Lower COVID-19 Cases and DeathsI gathered national and some local data on vaccination rates against influenza, polio, measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), tuberculosis (BCG), pneumococci and Haemophilus influenzae type B (Hib).

I correlated them with COVID-19 case buy levitra online in usa rates and death rates for 24 nations that had experienced their COVID-19 outbreaks at about the same time. I controlled for factors such as percentage of the population who were obese, diabetic or elderly.I found that only pneumococcal vaccines afforded statistically significant protection against COVID-19. Nations such as Spain, Italy, Belgium, Brazil, Peru and Chile that have the highest COVID-19 rates per million have the poorest pneumococcal vaccination rates among both infants and adults.

Nations with the lowest rates of COVID-19 – Japan, Korea, Denmark, Australia and New Zealand – have the highest rates of pneumococcal vaccination among both infants and adults.A recent preprint study buy levitra online in usa (not yet peer-reviewed) from researchers at the Mayo Clinic has also reported very strong associations between pneumococcal vaccination and protection against COVID-19. This is especially true among minority patients who are bearing the brunt of the coronavirus pandemic. The report also suggests that other vaccines, or combinations of vaccines, such as Hib and MMR may also provide protection.These results are important because in the U.S., childhood vaccination against pneumococci – which protects against Streptococcus pneumoniae bacteria – varies by state from 74% to 92%.

Although the CDC recommends that all adults 18-64 in high buy levitra online in usa risk groups for COVID-19 and all adults over the age of 65 get a pneumococcal vaccination, only 23% of high-risk adults and 64% of those over the age of 65 do so.Similarly, although the CDC recommends at all infants and some high-risk adults be vaccinated against Haemophilus influenzae type B (Hib), only 80.7% of children in the U.S. And a handful of immunologically compromised adults have been. Pneumococcal and Hib vaccination rates are significantly lower in buy levitra online in usa minority populations in the U.S.

And in countries that have been hit harder by COVID-19 than the U.S.Based on these data, I advocate universal pneumococcal and Hib vaccination among children, at-risk adults and all adults over 65 to prevent serious COVID-19 disease.Left. Combined rates of childhood and adult (over 65) pneumococcal vaccination (out of a possible 200). Right.

Cases (per million) population of COVID-19 at about 90 days into the pandemic for 24 nations. Nations with high pneumococcal vaccination rates have low COVID-19 case rates. (Credit.

CC BY-SA)How Pneumococcal Vaccination Protects Against COVID-19Protection against serious COVID-19 disease by pneumococcal and Hib vaccines makes sense for several reasons. First, recent studies reveal that the majority of hospitalized COVID-19 patients, and in some studies nearly all, are infected with streptococci, which causes pneumococcal pneumonias, Hib or other pneumonia-causing bacteria. Pneumococcal and Hib vaccinations should protect coronavirus patients from these infections and thus significantly cut the risk of serious pneumonia.I also found that pneumococcal, Hib and possibly rubella vaccines may confer specific protection against the SARS-CoV-2 virus that causes COVID-19 by means of “molecular mimicry.”Molecular mimicry occurs when the immune system thinks one microbe looks like another.

In this case, proteins found in pneumococcal vaccines and, to a lesser degree, ones found in Hib and rubella vaccines as well look like several proteins produced by the SARS-CoV-2 virus.Two of these proteins found in pneumococcal vaccines mimic the spike and membrane proteins that permit the virus to infect cells. This suggests pneumococcal vaccination may prevent SARS-CoV-2 infection. Two other mimics are the nucleoprotein and replicase that control virus replication.

These proteins are made after viral infection, in which case pneumococcal vaccination may control, but not prevent, SARS-CoV-2 replication.Either way, these vaccines may provide proxy protection against SARS-CoV-2 infection that we can implement right now, even before we have a specific virus vaccine. Such protection may not be complete. People might still suffer a weakened version of COVID-19 but, like most infants and children, be protected against the worst effects of the infection.Fighting Influenza-related Pneumonias During the COVID-19 PandemicWhile the specific protection these other vaccines confer against COVID-19 has not yet been tested in a clinical trial, I advocate broader implementation of pneumococcal and Hib vaccination for one additional, well-validated reason.Pneumococcal and Hib pneumonias – both caused by bacteria – are the major causes of death following viral influenza.

The influenza virus rarely causes death directly. Most often, the virus makes the lungs more susceptible to bacterial pneumonias, which are deadly. Dozens of studies around the world have demonstrated that increasing rates of pneumococcal and Hib vaccination dramatically lowers influenza-related pneumonias.Similar studies demonstrate that the price of using these vaccines is balanced by savings due to lower rates of influenza-related hospitalizations, intensive care unit admissions and deaths.

In the context of COVID-19, lowering rates of influenza-related hospitalizations and ICU admissions would free up resources to fight the coronavirus, independent of any effect these vaccines might have on SARS-CoV-2 itself. In my opinion, that is a winning scenario.In short, we need not wait for a SARS-CoV-2 vaccine to slow down COVID-19.I believe that we can and should act now by fighting the coronavirus with all the tools at our disposal, including influenza, Hib, pneumococcal and perhaps rubella vaccinations.Preventing pneumococcal and Hib complications of influenza and COVID-19, and perhaps proxy-vaccinating against SARS-CoV-2 itself, helps everyone. Administering these already available and well-tested pneumococcal and Hib vaccines to people will save money by freeing up hospital beds and ICUs.

It will also improve public health by reducing the spread of multiple infections and boost the economy by nurturing a healthier population.Robert Root-Bernstein is a Professor of Physiology at Michigan State University. This article was originally published on The Conversation under a Creative Commons liscense Read the original here..

Copper was one generic levitra price of the first metals to be worked http://cz.keimfarben.de/genuine-levitra-online/ by humankind. Because it is highly malleable, copper could be used for toolmaking and ornamentation even by people whose everyday implements were of flint and bone. A copper pendant unearthed in what is today northern Iraq has been dated to 8,700 B.C generic levitra price. €” the Neolithic period. Although people have adorned themselves with copper since prehistory, the marketing of copper bracelets as a treatment for arthritis pain appears to date back only to the 1970s.

Miner Pain Relief Proponents of copper bracelets often generic levitra price cite the research of Werner Hangarter (1904–1982), a German doctor of internal medicine. Hangarter evangelized for copper’s therapeutic possibilities after hearing that copper miners in Finland seldom developed rheumatism while laboring in the copper-rich environment of the mines. In the 1950s, he began treating patients suffering from a variety of rheumatic ailments — including rheumatoid arthritis (RA) — with generic levitra price injections of copper in a salicylic acid solution. The results were dramatic. Patients showed “rapid and persistent remission of fever, alleviation of pain, [and] increased mobility.” Hangarter published several papers on his work, and the alternative-medicine movement popularized his ideas.

By the mid-1970s, copper jewelry was generic levitra price being touted as a natural, noninvasive remedy for the pain and inflammation of arthritis. The market now encompasses copper-infused topical creams, insoles for foot pain and compression sleeves with copper fibers for stiff joints. But is there anything generic levitra price to it?. Health Benefits of Copper Copper does play an important role in individual health. Like many other minerals, copper is an essential micronutrient, a key player in the formation of red blood cells.

The most common symptom of a copper deficiency generic levitra price is anemia. It is found in many common foods, but shellfish, nuts and chocolate are the richest dietary sources. Copper helps with formation of connective tissue, so it’s possible that a copper deficiency could worsen the symptoms of arthritis. It does not necessarily follow, though, that boosting generic levitra price copper levels can mitigate RA. Testing the Claims Hindsight reveals several problems in Hangarter’s research.

Based on inference and anecdote, he assumed generic levitra price a chain of causation — that exposure to environmental copper helped miners ward off RA — where the reverse is actually far more likely. No active miners had RA because individuals who developed the condition quit the profession. His use of copper salicylate solution also raises more questions than it answers. Salicylic acid is the active ingredient in plain old aspirin, and the effects that Hangarter describes — pain relief and fever reduction — could generic levitra price easily be attributable to aspirin alone. So even the effects of copper in solution are ambiguous.

What about topical generic levitra price copper?. The effectiveness of wearing copper, rather than ingesting it, is based on the idea that trace amounts of the metal can be effectively absorbed through the skin. But there’s little evidence for this claim, and in any case the occasional peanut-butter sandwich or chocolate bar would be a more efficient way to get the stuff into your system than a $25 bangle. For the same reason, the superiority of generic levitra price copper-infused insoles or compression sleeves over some other material is unlikely. As for those creams, they’re made with a salicylic acid base — aspirin again, which as it turns out is easily absorbed through the skin.

In all these cases, the product may ease discomfort from RA, but the addition of copper doesn’t make them any more (or any less) effective. A 2013 study of 70 rheumatoid arthritis patients provides the most generic levitra price thorough debunking yet. Under double-blind conditions, patients who wore copper bracelets for five weeks saw no statistically significant reduction in pain or inflammation when compared to those who wore lookalike placebo bracelets. The rigor of the experimental design — inflammation was measured using a protein reactive blood test — provides convincing evidence that if you’re thinking of shelling out for an allegedly therapeutic copper bracelet, you’re better off saving your pennies.After watching a parent succumb to the deleterious effects of Alzheimer's disease, it's only natural to wonder if you might be generic levitra price doomed to the same fate. The good news?.

That's not necessarily the case. The bad news, however, is that the disease is so prevalent your overall risk is still relatively high — especially as generic levitra price you age. At 65, you have a roughly 3 percent chance of contracting Alzheimer's disease each year. This bumps generic levitra price up to a 17 percent chance after your 75th birthday, and increases to a roughly one in three chance you'll develop Alzheimer's after the age of 85. Experts agree that family history elevates the risk, particularly if you have more than one parent or sibling with the disease, but they disagree on how much.

Some studies indicate the risk hovers at around 30 percent, while others estimate an up to two or four times increased risk. Early onset Alzheimer's — which typically strikes individuals between the ages of 40 and 65 — has a more easily understood genetic link, generic levitra price with a 50 percent chance the child of an Alzheimer's patient will also be diagnosed with the disease. Read More:Why Do Women Get Alzheimer’s More Than Men?. How Did Alzheimer's Disease Get Its Name?. Are We Close to Curing generic levitra price Alzheimer’s Disease?.

However, a combination of genetic and environmental factors come into play for the more common late-onset variation, says Rita Guerreiro, a neurogeneticist at the Van Andel Institute. Which makes things even more difficult to predict generic levitra price. €œMany people who have relatives with [Alzheimer's] never develop the disease, and many without a family history of the disease do develop it,” says Guerreiro.Interested in tipping the odds in your favor?. Some scientists think keeping your mind active, consuming a diet low in red meat and sugar and exercising regularly could help keep the memory-zapping disease at bay.Late fall and early winter typically mean a flurry of holiday travel and get-togethers for a lot of people. But this year will be anything but normal generic levitra price.

Making plans is more than a matter of shopping around for flight prices or car rental fees. Many of us are probably also asking ourselves whether to stay home or generic levitra price see loved ones, and how to stay safe at holiday gatherings. For the lowest risk of spreading or becoming sick with COVID-19, not traveling is the way to go. However, there might be loved ones who desperately need companionship in the coming months. €œThere are situations where people generic levitra price will choose, and choose correctly, to go and support those family members,” says Lin H.

Chen, director of the Travel Medicine Center at Mount Auburn Hospital and president of the International Society of Travel Medicine. No matter if you’re going cross-country to see siblings or staying at generic levitra price home with your dog, experts say, remember two things. Plan ahead and stay flexible.Tackle Logistics FirstFor those interested in interstate travel, first assess whether or not those plans are feasible. The states you’re going to (and coming back to) might have rules about isolating yourself for two weeks once you arrive. If you live in one of those states but a two-week isolation period isn’t feasible — because you have to go to work or send kids to school, for example — then traveling for the holidays won’t generic levitra price work for you, says Gabriela Andujar Vazquez, an infectious disease doctor at Tufts Medical Center.

Some states say that isolation requirements don’t apply if you get a negative COVID test. But testing you or your whole family may lie outside your budget if the exams aren’t covered by insurance, Andujar Vazquez says. Factor those financial decisions into your travel plans, too.If you do decide to travel, choose driving over flying if you can generic levitra price. Busy rest stops might mean confronting crowds of other highway travelers, Chen says. However, compared to the entire process of flying — generic levitra price getting to an airport and waiting in lines repeatedly — driving likely means fewer crowds overall.

€œThink about precautions through this journey,” Chen says, “not just on the plane, train, bus or car.”Airplanes themselves receive a lot of attention as potential virus spreaders. But Chen says there are three instances of infected individuals spreading the disease to two or more people on a flight. Those transmissions happened before generic levitra price any airline required passengers to wear masks. Since then, other interventions like leaving seats open, disinfecting often and updated air filtration have been introduced on airplanes, too. Though there’s no data yet on how effective generic levitra price these combined intervention strategies are, “the fact that we haven’t heard about masked transmission on recent flights is also reassuring,” Chen says.

On the Big DayOdds are you’re debating travel plans for the sake of a big family meal. Or even if you’re staying local, you might try and work something out with friends and relatives nearby. Both Chen and Andujar Vazquez emphasize that no matter which you generic levitra price choose, keep up the COVID-19 precautions once you’re all together. Generally, the smaller the gathering (and the fewer number of households), the better. Keep activities outdoors if you can, seat groups apart, and keep masks on while not eating.

You might also consider new generic levitra price ways to keep everyone fed. The typical buffet serving style can mean a lot of utensil sharing, so maybe opt for single-serving portioning or have everyone wash or sanitize hands before and after touching communal dishes. And as generic levitra price fun as it might be to play bartender, maybe choose a BYOB policy as well. Oh, and “no one should be coming sick,” Andujar Vazquez says. €œYou cannot say that enough.”These might sound like a lot of holiday modifications, which is why it’s important to discuss what the situation will look like before coming together.

€œPeople have to feel generic levitra price comfortable talking about these things, because it’s part of our daily life now,” Andujar Vazquez says. €œHave that conversation before the event happens so people don’t have unexpected surprises or feel unsafe with some sort of behavior.”At the same time, acknowledge that even the most careful planning might fall apart. Your destination might become a COVID-19 hotspot days before you’re set to arrive, generic levitra price or you or someone in your gathering might start feeling unwell ahead of time. Though it’s easier said than done, accept that plans will change whether you want them to or not — and that celebrations in the coming months will look different than they used to. €œRealistically, this holiday season is going to be difficult for a lot of people,” says Jonathan Kanter, psychologist and director of the Center for the Science of Social Connection at the University of Washington.

In individuals coping with significant life changes, one of the best predictors of depression is whether or not people generic levitra price can leave former goals behind and adopt new ones, Kanter says. Letting go of old expectations — like how you normally gather with family, for example — can involve a kind of grieving process. But recalibrating what you want to get out of a situation is an essential coping skill. €œYou won’t be able to get there unless you breathe and accept that generic levitra price you’re in a new context,” Kanter says. €œWith that acceptance, hopefully there's a lot of creativity and innovation and grace about how to make it as successful as possible.” The prospect of not seeing loved ones in the coming months might make some people nervous, for themselves and for others.

What's important to remember is that it's possible to make it through — and that future holidays will get better.As flu season creeps up on the Northern Hemisphere, cold and generic levitra price flu relief medications will inevitably fly off store shelves. A natural remedy that shoppers might reach for is elderberry, a small, blackish-purple fruit that companies turn into syrups, lozenges and gummies. Though therapeutic uses of the berry date back centuries, Michael Macknin, a pediatrician at the Cleveland Clinic, hadn’t heard of using elderberry to treat the flu until a patient’s mother asked him about it. Some industry-sponsored generic levitra price research claims that the herbal remedy could cut the length of the symptoms by up to four days. For a comparison, Tamiflu, an FDA-approved treatment, only reduces flu duration by about a single day.

€œI said, 'Gee, if that’s really true generic levitra price [about elderberry], it would be a huge benefit,'” Macknin says. But the effectiveness and safety of elderberry is still fairly unclear. Unlike the over-the-counter medicines at your local pharmacy, elderberry hasn't been through rigorous FDA testing and approval. However, Macknin and his team recently published a generic levitra price study in the Journal of General Internal Medicine, which found that elderberry treatments did nothing for flu patients. This prompts a need for further studies into the remedy — work that unfortunately stands a low chance of happening in the future, Macknin says.

Looking For ProofElderberries are full of chemicals that generic levitra price could be good for your health. Like similar fruits, the berries contain high levels of antioxidants, compounds that shut down reactions in our bodies that damage cells. But whether or not elderberry's properties also help immune systems fend off a virus is murky. There are only a handful of generic levitra price studies that have examined if elderberries reduced the severity or duration of the flu. And though some of the work prior to Macknin’s was well-designed and supported this herbal remedy as a helpful flu aid, at least some — and potentially all — of those studies were funded by elderberry treatment manufacturers.Macknin says an elderberry supplement company provided his team with their products and a placebo version for free, but that the company wasn’t involved in the research beyond that.

Macknin's study is the largest one conducted on elderberry to date, with 87 influenza patients completing the entire treatment course. Participants in the study were also welcome to take Tamiflu, for ethical reasons, as the team didn’t generic levitra price want to exclude anyone from taking a proven flu therapy. Additionally, each participant took home either a bottle of elderberry syrup or the placebo with instructions on when and how to take it. The research team called participants every day for a symptom check and to remind them to take their medication.By chance, it turned out that a higher percentage of the patients given elderberry syrup had gotten their flu shot and generic levitra price also chose to take Tamiflu. Since the vaccination can reduce the severity of infection in recipients who still come down with the flu, the study coincidentally operated in favor of those who took the herbal remedy, Macknin says.

Those patients could have dealt with a shorter, less-intense illness because of the Tamiflu and vaccination. €œEverything was stacked to have it generic levitra price turn out better [for the elderberry group],” Macknin says, “and it turned out the same.” The researchers found no difference in illness duration or severity between the elderberry and placebo groups. While analyzing the data, the team also found that those on the herbal treatment might have actually fared worse than those on the placebo. The potential for this intervention to actually harm instead of help influenza patients explains why Macknin thinks the therapy needs further research.But, generic levitra price don't expect that work to happen any time soon. Researchers are faced with a number of challenges when it comes to studying the efficacy of herbal remedies.

For starters, there's little financial incentive to investigate if they actually work. Plant products are challenging to patent, making them generic levitra price less lucrative prospects for pharmaceutical companies or research organizations to investigate. Additionally, investigations that try and prove a proposed therapy as an effective drug — like the one Macknin and his team accomplished — are expensive, Macknin says. Those projects need FDA oversight and additional paperwork, components that drive up study costs. €œIt’s extraordinarily expensive and there’s no money in it for anybody,” Macknin says.Talk To generic levitra price Your DoctorUltimately, research on elderberry therapies for flu patients is a mixed bag, and deserves more attention from scientists.

However, if you still want to discuss elderberry treatments for the flu with your doctor, that’s a conversation you should feel comfortable having, says Erica McIntyre, an expert focused on health and environmental psychology in the School of Public Health at the University of Technology Sydney. Navigating what research says generic levitra price about a particular herbal medicine is challenging for patients and health practitioners alike. The process is made more complex by the range of similar-sounding products on the market that lack standardized ingredients, McIntyre says. But when doctors judge or shame patients for asking about non-conventional healthcare interventions, the response can distance people and push them closer to potentially unproven treatments. Even worse, generic levitra price those individuals might start to keep their herbal remedies a secret.

€œIt is that fear about being judged for use of that medication,” McIntyre says, that drives up to 50 percent of people taking herbal treatments to withhold that information from healthcare practitioners. That’s a dangerous choice, as some herbal and traditional medications can interact and generic levitra price cause health problems.If a physician shames someone for asking about alternative medicines, it’s likely time to find a new doctor, McIntyre says. Look for someone who will listen to your concerns — whether it's that you feel traditional treatments haven’t worked for you, or that you didn’t like the side effects, the two common reasons people pursue herbal treatments in the first place. €œYou’re not necessarily looking for a doctor that will let you do whatever you want,” McIntyre says, “but that they actually consider you as a patient, your treatment choices and your treatment priorities, and communicate in a way that’s supportive.” And if a doctor suggests that you avoid a treatment you’re interested in, ask why. They generally have a good reason, McIntyre generic levitra price says.For now, know that even if your doctor doesn’t support you taking elderberry, there are other proven preventative measures that are worth your while — like the flu shot.

Anyone six months or older should get it, Macknin says, and stick to the protocols we’re used to following to prevent COVID-19 infections, like social distancing, mask-wearing and hand-washing. Those measures also help prevent flu transmission, too — something, so far, no elderberry supplement package can claim.The yearly influenza season threatens to make the COVID-19 pandemic doubly deadly, but I believe that this isn’t inevitable.There are two commonly given vaccines – the pneumococcal vaccine and the Hib vaccine – that protect against bacterial pneumonias. These bacteria complicate both influenza and COVID-19, often generic levitra price leading to death. My examination of disease trends and vaccination rates leads me to believe that broader use of the pneumococcal and Hib vaccines could guard against the worst effects of a COVID-19 illness.I am an immunologist and physiologist interested in the effects of combined infections on immunity. I have reached my insight by juxtaposing generic levitra price two seemingly unrelated puzzles.

Infants and children get SARS-CoV-2, the virus that causes COVID-19, but very rarely become hospitalized or die. And case numbers and death rates from COVID-19 began varying greatly from nation to nation and city to city even before lockdowns began. I wondered why.One night I woke up with a generic levitra price possible answer. Vaccination rates. Most children, beginning at age generic levitra price two months, are vaccinated against numerous diseases.

Adults less so. And, both infant and adult vaccination rates vary widely across the world. Could differences in the rates of vaccination against one or more generic levitra price diseases account for differences in COVID-19 risks?. As someone who had previously investigated other pandemics such as the Great Flu Pandemic of 1918-19 and AIDS, and who has worked with vaccines, I had a strong background for tracking down the relevant data to test my hypothesis.Pneumococcal Vaccination Rates Correlate With Lower COVID-19 Cases and DeathsI gathered national and some local data on vaccination rates against influenza, polio, measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), tuberculosis (BCG), pneumococci and Haemophilus influenzae type B (Hib). I correlated generic levitra price them with COVID-19 case rates and death rates for 24 nations that had experienced their COVID-19 outbreaks at about the same time.

I controlled for factors such as percentage of the population who were obese, diabetic or elderly.I found that only pneumococcal vaccines afforded statistically significant protection against COVID-19. Nations such as Spain, Italy, Belgium, Brazil, Peru and Chile that have the highest COVID-19 rates per million have the poorest pneumococcal vaccination rates among both infants and adults. Nations with the lowest rates of COVID-19 – Japan, Korea, Denmark, Australia and New Zealand – have the highest rates of pneumococcal vaccination among both infants and adults.A recent preprint study (not yet peer-reviewed) from generic levitra price researchers at the Mayo Clinic has also reported very strong associations between pneumococcal vaccination and protection against COVID-19. This is especially true among minority patients who are bearing the brunt of the coronavirus pandemic. The report also suggests that other vaccines, or combinations of vaccines, such as Hib and MMR may also provide protection.These results are important because in the U.S., childhood vaccination against pneumococci – which protects against Streptococcus pneumoniae bacteria – varies by state from 74% to 92%.

Although the CDC recommends that all adults 18-64 in high risk groups for COVID-19 and all adults over the age of 65 get a pneumococcal vaccination, only 23% of high-risk adults and 64% of those over the age of 65 do so.Similarly, although the CDC recommends at all infants and some high-risk adults be vaccinated against Haemophilus generic levitra price influenzae type B (Hib), only 80.7% of children in the U.S. And a handful of immunologically compromised adults have been. Pneumococcal and Hib vaccination rates are significantly lower generic levitra price in minority populations in the U.S. And in countries that have been hit harder by COVID-19 than the U.S.Based on these data, I advocate universal pneumococcal and Hib vaccination among children, at-risk adults and all adults over 65 to prevent serious COVID-19 disease.Left. Combined rates of childhood and adult (over 65) pneumococcal vaccination (out of a possible 200).

Right. Cases (per million) population of COVID-19 at about 90 days into the pandemic for 24 nations. Nations with high pneumococcal vaccination rates have low COVID-19 case rates. (Credit. CC BY-SA)How Pneumococcal Vaccination Protects Against COVID-19Protection against serious COVID-19 disease by pneumococcal and Hib vaccines makes sense for several reasons.

First, recent studies reveal that the majority of hospitalized COVID-19 patients, and in some studies nearly all, are infected with streptococci, which causes pneumococcal pneumonias, Hib or other pneumonia-causing bacteria. Pneumococcal and Hib vaccinations should protect coronavirus patients from these infections and thus significantly cut the risk of serious pneumonia.I also found that pneumococcal, Hib and possibly rubella vaccines may confer specific protection against the SARS-CoV-2 virus that causes COVID-19 by means of “molecular mimicry.”Molecular mimicry occurs when the immune system thinks one microbe looks like another. In this case, proteins found in pneumococcal vaccines and, to a lesser degree, ones found in Hib and rubella vaccines as well look like several proteins produced by the SARS-CoV-2 virus.Two of these proteins found in pneumococcal vaccines mimic the spike and membrane proteins that permit the virus to infect cells. This suggests pneumococcal vaccination may prevent SARS-CoV-2 infection. Two other mimics are the nucleoprotein and replicase that control virus replication.

These proteins are made after viral infection, in which case pneumococcal vaccination may control, but not prevent, SARS-CoV-2 replication.Either way, these vaccines may provide proxy protection against SARS-CoV-2 infection that we can implement right now, even before we have a specific virus vaccine. Such protection may not be complete. People might still suffer a weakened version of COVID-19 but, like most infants and children, be protected against the worst effects of the infection.Fighting Influenza-related Pneumonias During the COVID-19 PandemicWhile the specific protection these other vaccines confer against COVID-19 has not yet been tested in a clinical trial, I advocate broader implementation of pneumococcal and Hib vaccination for one additional, well-validated reason.Pneumococcal and Hib pneumonias – both caused by bacteria – are the major causes of death following viral influenza. The influenza virus rarely causes death directly. Most often, the virus makes the lungs more susceptible to bacterial pneumonias, which are deadly.

Dozens of studies around the world have demonstrated that increasing rates of pneumococcal and Hib vaccination dramatically lowers influenza-related pneumonias.Similar studies demonstrate that the price of using these vaccines is balanced by savings due to lower rates of influenza-related hospitalizations, intensive care unit admissions and deaths. In the context of COVID-19, lowering rates of influenza-related hospitalizations and ICU admissions would free up resources to fight the coronavirus, independent of any effect these vaccines might have on SARS-CoV-2 itself. In my opinion, that is a winning scenario.In short, we need not wait for a SARS-CoV-2 vaccine to slow down COVID-19.I believe that we can and should act now by fighting the coronavirus with all the tools at our disposal, including influenza, Hib, pneumococcal and perhaps rubella vaccinations.Preventing pneumococcal and Hib complications of influenza and COVID-19, and perhaps proxy-vaccinating against SARS-CoV-2 itself, helps everyone. Administering these already available and well-tested pneumococcal and Hib vaccines to people will save money by freeing up hospital beds and ICUs. It will also improve public health by reducing the spread of multiple infections and boost the economy by nurturing a healthier population.Robert Root-Bernstein is a Professor of Physiology at Michigan State University.

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