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At that time, this drug benefit was "carved into" the Medicaid managed buy furosemide 40mg care benefit package. Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means buy furosemide 40mg that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?.

The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies. Under Medicaid buy furosemide 40mg managed care. Plan formularies will be comparable to but not the same as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan buy furosemide 40mg formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs.

The Pharmacy Benefit will vary by plan. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan buy furosemide 40mg to plan. Prescriber Prevails applies in certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes.

atypical antipsychotics, anti-depressants, buy furosemide 40mg anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics. Prescribers will need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies. The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future buy furosemide 40mg. Standardized Prior Autorization (PA) Form -- The Department of Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care.

The form will be posted on the Pharmacy Information Website in July of 2013. Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy buy furosemide 40mg price. CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this buy furosemide 40mg option only in the limited circumstances during the first year of enrollment in managed care.

Medicaid managed care enrollees can only leave and join another plan within the first 90 days of joining a health plan. After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock buy furosemide 40mg in” period only for good cause. The pharmacy benefit changes are not considered good cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time.

STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or buy furosemide 40mg step therapy or any other utilization control requirements. If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials. Some plans may develop special procedures buy furosemide 40mg for drug denials. Information on these procedures should be provided in member handbooks.

Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called buy furosemide 40mg a 'FInal Adverse Determination" or FAD. See model Denial FAD Notice and FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the buy furosemide 40mg FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals.

The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD buy furosemide 40mg and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care.

Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access buy furosemide 40mg to their medications. Consumers who experience problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers buy furosemide 40mg to obtain prior authorization. These include brand name drugs that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list.

The full Medicaid formulary can be searched on the eMedNY website. Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise buy furosemide 40mg indicated. Prior authorization is required for original prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior buy furosemide 40mg authorization process.

The New York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with buy furosemide 40mg the locations of pharmacies that provide this drug as well as their costs. Click here to view New York State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline.

1-888-614-5400 buy furosemide 40mg NY State Department of Health's Managed Care Hotline. 1-800-206-8125 (Mon. - Fri. 8:30 am - 4:30 pm) NY buy furosemide 40mg State Department of Insurance. 1-800-400-8882 NY State Attorney General's Health Care Bureau.

1-800-771-7755Haitian individuals and immigrants from some other countries who have applied for Temporary Protected Status (TPS) may be eligible for public health insurance in New York State. 2019 updates buy furosemide 40mg - The Trump administration has taken steps to end TPS status. Two courts have temporarily enjoined the termination of TPS, one in New York State in April 2019 and one in California in October 2018. The California case was argued in an appeals court on August 14, 2019, which the LA Times reported looked likely to uphold the federal action ending TPS. See US Immigration Website on TPS buy furosemide 40mg - General TPS website with links to status in all countries, including HAITI.

See also Pew Research March 2019 article. Courts Block Changes in Public charge rule- See updates on the Public Charge rule here, blocked by federal court injunctions in October 2019. Read more about this change buy furosemide 40mg in public charge rules here. What is Temporary Protected Status?. TPS is a temporary immigration status granted to eligible individuals of a certain country designated by the Department of Homeland Security because serious temporary conditions in that country, such as armed conflict or environmental disaster, prevents people from that country to return safely.

On January 21, 2010 the United States determined that individuals buy furosemide 40mg from Haiti warranted TPS because of the devastating earthquake that occurred there on January 12. TPS gives undocumented Haitian residents, who were living in the U.S. On January 12, 2010, protection from forcible deportation and allows them to work legally. It is important buy furosemide 40mg to note that the U.S. Grants TPS to individuals from other countries, as well, including individuals from El Salvador, Honduras, Nicaragua, Somalia and Sudan.

TPS and Public Health Insurance TPS applicants residing in New York are eligible for Medicaid and Family Health Plus as long as they also meet the income requirements for these programs. In New York, applicants for TPS are considered PRUCOL immigrants (Permanently Residing Under Color of Law) for purposes of medical assistance eligibility and thus meet the buy furosemide 40mg immigration status requirements for Medicaid, Family Health Plus, and the Family Planning Benefit Program. Nearly all children in New York remain eligible for Child Health Plus including TPS applicants and children who lack immigration status. For more information on immigrant eligibility for public health insurance in New York see 08 GIS MA/009 and the attached chart. Where to Apply What to BringIndividuals who have applied buy furosemide 40mg for TPS will need to bring several documents to prove their eligibility for public health insurance.

Individuals will need to bring. 1) Proof of identity. 2) Proof of buy furosemide 40mg residence in New York. 3) Proof of income. 4) Proof of application for TPS.

5) buy furosemide 40mg Proof that U.S. Citizenship and Immigration Services (USCIS) has received the application for TPS. Free Communication Assistance All applicants for public health insurance, including Haitian Creole speakers, have a right to get help in a language they can understand. All Medicaid offices and enrollers buy furosemide 40mg are required to offer free translation and interpretation services to anyone who cannot communicate effectively in English. A bilingual worker or an interpreter, whether in-person or over the telephone, must be provided in all interactions with the office.

Important documents, such as Medicaid applications, should be translated either orally or in writing. Interpreter services must be offered free of charge, and applicants requiring interpreter services buy furosemide 40mg must not be made to wait unreasonably longer than English speaking applicants. An applicant must never be asked to bring their own interpreter. Related Resources on TPS and Public Health Insurance o The New York Immigration Coalition (NYIC) has compiled a list of agencies, law firms, and law schools responding to the tragedy in Haiti and the designation of Haiti for Temporary Protected Status. A copy of the list is posted at the NYIC’s website at http://www.thenyic.org.

o USCIS TPS website with links to status in all countries, including HAITI. O For information on eligibility for public health insurance programs call The Legal Aid Society’s Benefits Hotline 1-888-663-6880 Tuesdays, Wednesdays and Thursdays. 9:30 am - 12:30 pm FOR IMMIGRATION HELP. CONTACT THE New York State New Americans Hotline for a referral to an organization to advise you. 212-419-3737 Monday-Friday, from 9:00 a.m.

To 8:00 p.m.Saturday-Sunday, from 9:00 a.m. To 5:00 p.m. Or call toll-free in New York State at 1-800-566-7636 Please see these fact sheets and web sites of national organizations for more information about the new PUBLIC CHARGE rules.

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Lauren Gambill, MDPediatrician, AustinMember, Texas Medical furosemide ped Association (TMA) Committee on Child and Adolescent HealthExecutive Board Member, Texas Pediatric SocietyDoctors are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what is safe, how to protect their families, and furosemide ped the future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net.

The U.S furosemide ped. Census helps determine funding for those resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S. Census. The deadline has been cut short one month and now closes Sept.

30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also have been stretched thin, with teachers scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is vital that all Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example. Federal funds pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% of all births.

The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

Texas also uses this federal funding to study and respond to maternal mortality and perinatal depression.Food and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank saw a 206% rise in clients in March.

Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes during this economic crisis have better hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker.

This stress highlights the desperate need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families. The good news is you still have time to complete the census. Visit 2020census.gov to take it.

It takes less than five minutes to complete. Then talk to your family, neighbors, and colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic. Thank you for helping Texas heal and for supporting these essential safety net programs..

Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child and Adolescent HealthExecutive Board Member, Texas Pediatric SocietyDoctors are community buy furosemide 40mg leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what buy furosemide 40mg is safe, how to protect their families, and the future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net. The U.S buy furosemide 40mg.

Census helps determine funding for those resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S. Census. The deadline has been cut short one month and now closes Sept. 30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more.

Schools also have been stretched thin, with teachers scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago. Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is vital that all Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example.

Federal funds pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% of all births. The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

Texas also uses this federal funding to study and respond to maternal mortality and perinatal depression.Food and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank saw a 206% rise in clients in March. Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census.

Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes during this economic crisis have better hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker. This stress highlights the desperate need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families.

The good news is you still have time to complete the census. Visit 2020census.gov to take it. It takes less than five minutes to complete. Then talk to your family, neighbors, and colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic.

Thank you for helping Texas heal and for supporting these essential safety net programs..

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And so forth—we simply want these scientific findings to become known.
We regularly feature interviews with researchers and activists, and podcasts that explore furosemide price in canada these issues. We launched MIA Reports as a showcase for our print journalism. We have published in-depth articles on promising new initiatives in Europe. Investigative pieces furosemide price in canada on such topics as compulsory outpatient treatment. Coverage of “news” related to mental health policy in the United States.

And occasional reports on how the mainstream media is covering mental health issues. €¨We also furosemide price in canada publish blogs by professionals, academics, people with lived experience, and others with a particular interest in this subject. These blogs and personal stories are meant to help inform society’s “rethinking” of psychiatric care. All of these efforts, I think, fit within the framework of “journalism.” However, I do understand that I am going beyond the boundaries of usual “science journalism” when I publish critiques of the “evidence base” related to psychiatric drugs. I did this in my books Mad in America and Anatomy furosemide price in canada of an Epidemic, as well as a book I co-wrote, Psychiatry Under the Influence.

I have continued to do this with MIA Reports. The usual practice in “science journalism” is to look to the “experts” in the field and report on what they tell about their findings and practices. However, while reporting and writing Mad in America, I came to understand that when “experts” in psychiatry spoke to furosemide price in canada journalists they regularly hewed to a story that they were expected to tell, which was a story of how their field was making great progress in understanding the biology of disorders and of drug treatments that—as I was told over and over when I co-wrote the series for the Boston Globe—fixed chemical imbalances in the brain. But their own science, I discovered, regularly belied the story they were telling to the media. That’s why I turned to focusing on the story that could be dug out from a critical look at their own scientific literature.

So what I do in these critiques—such as suicide in the Prozac era and the impact of antipsychotics on mortality—is furosemide price in canada review the relevant research and put those findings together into a coherent report. I also look at research cited in support of mainstream beliefs and see if the data, in those articles, actually supports the conclusions presented in the abstract. None of this is really that difficult, and yet I know it is unusual for a journalist to challenge conventional “medical wisdom” in this way. Horgan. Anatomy of an Epidemic argues that medications for mental illness, although they give many people short-term reliefs, cause net harm.

Is that a fair summary?. Whitaker. Yes, although my thinking has evolved somewhat since I wrote that book. I am more convinced than ever that psychiatric medications, over the long term, cause net harm. I wish that weren’t the case, but the evidence just keeps mounting that these drugs, on the whole, worsen long-term outcomes.

However, my thinking has evolved in this way. I am not so sure any more that the medications provide a short-term benefit for patient populations as a whole. When you look at the short-term studies of antidepressants and antipsychotics, the evidence of efficacy in reducing symptoms compared to placebo is really pretty marginal, and fails to rise to the level of a “clinically meaningful” benefit. Furthermore, the problem with all of this research is that there is no real placebo group in the studies. The placebo group is composed of patients who have been withdrawn from their psychiatric medications and then randomized to placebo.

Thus, the placebo group is a drug-withdrawal group, and we know that withdrawal from psychiatric drugs can stir myriad negative effects. A medication-naïve placebo group would likely have much better outcomes, and if that were so, how would that placebo response compare to the drug response?. In short, research on the short-term effects of psychiatric drugs is a scientific mess. In fact, a 2017 paper that was designed to defend the long-term use of antipsychotics nevertheless acknowledged, in an off-hand way, that “no placebo-controlled trials have been reported in first-episode psychosis patients.” Antipsychotics were introduced 65 years ago, and we still don’t have good evidence that they work over the short term in first episode patients. Which is rather startling, when you think of it.

Horgan. Have any of your critics—E. Fuller Torrey, for example—made you rethink your thesis?. Whitaker. When the first edition of Anatomy of an Epidemic was published (2010), I knew there would be critics, and I thought, this will be great.

This is just what is needed, a societal discussion about the long-term effects of psychiatric medications. I have to confess that I have been disappointed in the criticism. They mostly have been ad hominem attacks—I cherry-picked the data, or I misunderstood findings, or I am just biased, but the critics don’t then say what data I missed, or point to findings that tell of medications that improve long-term outcomes. I honestly think I could do a much better job of critiquing my own work. You mention E.

Fuller Torrey’s criticism, in which he states that I both misrepresented and misunderstood some of the research I cited. I took this seriously, and answered it at great length. Now if your own “thesis” is indeed flawed, then a critic should be able to point out its flaws while accurately detailing what you wrote. If that is the case, then you have good reason to rethink your beliefs. But if a critique doesn’t meet that standard, but rather relies on misrepresenting what you wrote, then you have reason to conclude that the critic lacks the evidence to make an honest case.

And that is how I see Torrey’s critique. For example, Torrey said that I misunderstood Martin Harrow’s research on long-term outcomes for schizophrenia patients. Harrow reported that the recovery rate was eight times higher for those who got off antipsychotic medication compared to those who stayed on the drugs. However, in his 2007 paper, Harrow stated that the better outcomes for those who got off medication was because they had a better prognosis and not because of negative drug effects. If you read Anatomy of an Epidemic, you’ll see that I present his explanation.

Yet, in my interview with Harrow, I noted that his own data showed that those who were diagnosed with milder psychotic disorders who stayed on antipsychotics fared worse over the long term than schizophrenia patients who stopped taking the medication. This was a comparison that showed the less ill maintained on antipsychotics doing worse than the more severely ill who got off these medications. And I presented that comparison in Anatomy of an Epidemic. By doing that, I was going out on a limb. I was saying that maybe Harrow’s data led to a different conclusion than he had drawn, which was that the antipsychotic medication, over the long-term, had a negative effect.

After Anatomy was published, Harrow and his colleague Thomas Jobe went back to their data and investigated this very possibility. They have subsequently written several papers exploring this theme, citing me in one or two instances for raising the issue, and they found reason to conclude that it might be so. They wrote. €œHow unique among medical treatments is it that the apparent efficacy of antipsychotics could diminish over time or become harmful?. There are many examples for other medications of similar long-term effects, with this often occurring as the body readjusts, biologically, to the medications.” Thus, in this instance, I did the following.

I accurately reported the results of Harrow’s study and his interpretation of his results, and I accurately presented data from his research that told of a possible different interpretation. The authors then revisited their own data to take up this inquiry. And yet Torrey’s critique is that I misrepresented Harrow’s research. This same criticism, by the way, is still being flung at me. Here is a recent article in Vice which, once again, quotes people saying I misrepresent and misunderstand research, with Harrow cited as an example.

I do want to emphasize that critiques of “my thesis” regarding the long-term effects of psychiatric drugs are important and to be welcomed. See two papers in particular that take this on (here and here), and my response in general to such criticisms, and to the second one. Horgan. When I criticize psychiatric drugs, people sometimes tell me that meds saved their lives. You must get this reaction a lot.

How do you respond?. Whitaker. I do hear that, and when I do, I reply, “Great!. I am so glad to know that the medications have worked for you!. € But of course I also hear from many people who say that the drugs ruined their lives.

I do think that the individual’s experience of psychiatric medication, whether good or bad, should be honored as worthy and “valid.” They are witnesses to their own lives, and we should incorporate those voices into our societal thinking about the merits of psychiatric drugs. However, for the longest time, we’ve heard mostly about the “good” outcomes in the mainstream media, while those with “bad” outcomes were resigned to telling their stories on internet forums. What Mad in America has sought to do, in its efforts to serve as a forum for rethinking psychiatry, is provide an outlet for this latter group, so their voices can be heard too. The personal accounts, of course, do not change the bottom-line “evidence” that shows up in outcome studies of larger groups of patients. Unfortunately, that tells of medications that, on the whole, do more harm than good.

As a case in point, in regard to this “saving lives” theme, this benefit does not show up in public health data. The “standard mortality rate” for those with serious mental disorders, compared to the general public, has notably increased in the last 40 years. Horgan. Do you see any promising trends in psychiatry?. Whitaker.

Yes, definitely. You have the spread of Hearing Voices networks, which are composed of people who hear voices and offer support for learning to live with voices as opposed to squashing them, which is what the drugs are supposed to do. These networks are up and running in the U.S., and in many countries worldwide. You have Open Dialogue approaches, which were pioneered in northern Finland and proved successful there, being adopted in the United States and many European countries (and beyond.) This practice puts much less emphasis on treatment with antipsychotics, and much greater emphasis on helping people re-integrate into family and community. You have many alternative programs springing up, even at the governmental level.

Norway, for instance, ordered its hospital districts to offer “medication free” treatment for those who want it, and there is now a private hospital in Norway that is devoted to helping chronic patients taper down from their psychiatric medications. In Israel, you have Soteria houses that have sprung up (sometimes they are called stabilizing houses), where use of antipsychotics is optional, and the environment—a supportive residential environment—is seen as the principal “therapy.” You have the U.N. Special Rapporteur for Health, Dainius Pūras, calling for a “revolution” in mental health, one that would supplant today’s biological paradigm of care with a paradigm that paid more attention to social justice factors—poverty, inequality, etc.—as a source of mental distress. All of those initiatives tell of an effort to find a new way. But perhaps most important, in terms of “positive trends,” the narrative that was told to us starting in the 1980s has collapsed, which is what presents the opportunity for a new paradigm to take hold.

More and more research tells of how the conventional narrative, in all its particulars, has failed to pan out. The diagnoses in the Diagnostic and Statistical Manual (DSM) have not been validated as discrete illnesses. The genetics of mental disorders remain in doubt. MRI scans have not proven to be useful. Long-term outcomes are poor.

And the notion that psychiatric drugs fix chemical imbalances has been abandoned. Ronald Pies, the former editor in chief of Psychiatric Times, has even sought to distance psychiatry, as an institution, from ever having made such a claim. Horgan. Do brain implants or other electrostimulation devices show any therapeutic potential?. Whitaker.

I don’t have a ready answer for this. We have published two articles about the spinning of results from a trial of deep-brain stimulation, and the suffering of some patients so treated over the long-term. Those articles tell of why it may be difficult to answer that question. There are financial influences that push for published results that tell of a therapeutic success, even if the data doesn’t support that finding, and we have a research environment that fails to study long-term outcomes. The history of somatic treatments for mental disorders also provides a reason for caution.

It’s a history of one somatic treatment after another being initially hailed as curative, or extremely helpful, and then failing the test of time. The inventor of frontal lobotomy, Egas Moniz, was awarded a Nobel Prize for inventing that surgery, which today we understand as a mutilation. It’s important to remain open to the possibility that somatic treatments may be helpful, at least for some patients. But there is plenty of reason to be wary of initial claims of success. Horgan.

Should psychedelic drugs be taken seriously as treatments?. Whitaker. I think caution applies here too. Surely there are many risks with psychedelic drugs, and if you were to do a study of first-episode psychosis today, you would find a high percentage of the patients had been using mind-altering drugs before their psychotic break—antidepressants, marijuana, LSD and so forth. At the same time, we’ve published reviews of papers that have reported positive results with use of psychedelics.

What are the benefits versus the risks?. Can possible benefits be realized while risks are minimized?. It is a question worth exploring, but carefully so. Horgan. What about meditation?.

Whitaker. I know that many people find meditation helpful. I also know other people find it difficult—and even threatening—to sit with the silence of their minds. Mad in America has published reviews of research about meditation, we have had a few bloggers write about it, and in our resource section on “non-drug therapies,” we have summarized research findings regarding its use for depression. We concluded that the research on this is not as robust as one would like.

However, I think your question leads to this broader thought. People struggling with their minds and emotions may come up with many different approaches they find helpful. Exercise, diet, meditation, yoga and so forth all represent efforts to change one’s environment, and ultimately, I think that can be very helpful. But the individual has to find his or her way to whatever environmental change that works best for them. Horgan.

Do you see any progress toward understanding the causes of mental illness?. Whitaker. Yes, and that progress might be summed up in this way. Researchers are returning to investigations of how we are impacted by what has “happened to us.” The Adverse Childhood Experiences study provides compelling evidence of how traumas in childhood—divorce, poverty, abuse, bullying and so forth—exact a long-term toll on physical and mental health. Interview any group of women diagnosed with a serious mental disorder, and you’ll regularly find accounts of sexual abuse.

Racism exacts a toll. So too poverty, oppressive working conditions, and so forth. You can go on and on, but all of this is a reminder that we humans are designed to respond to our environment, and it is quite clear that mental distress, in large part, arises from difficult environments and threatening experiences, past and present. And with a focus on life experiences as a source of “mental illness,” a related question is now being asked. What do we all need to be mentally well?.

Shelter, good food, meaning in life, someone to love and so forth—if you look at it from this perspective, you can see why, when those supporting elements begin to disappear, psychiatric difficulties appear. I am not discounting that there may be biological factors that cause “mental illness.” While biological markers that tell of a particular disorder have not been discovered, we are biological creatures, and we do know, for instance, that there are physical illnesses and toxins that can produce psychotic episodes. However, the progress that is being made at the moment is a moving away from the robotic “it’s all about brain chemistry” toward a rediscovery of the importance of our social lives and our experiences. Horgan. Do we still have anything to learn from Sigmund Freud?.

Whitaker. I certainly think so. Freud is a reminder that so much of our mind is hidden from us and that what spills into our consciousness comes from a blend of the many parts of our mind, our emotional centers and our more primal instincts. You can still see merit in Freud’s descriptions of the id, ego and superego as a conceptualization of different parts of the brain. I read Freud when I was in college, and it was a formative experience for me.

Horgan. I fear that American-style capitalism doesn’t produce good health care, including mental-health care. What do you think?. Whitaker. It’s clear that it doesn’t.

First, we have for-profit health-care that is set up to treat “disease.” With mental-health care, that means there is a profit to be made from seeing people as “diseased” and treating them for that “illness.” Take a pill!. In other words, American-style capitalism, which works to create markets for products, provides an incentive to create mental patients, and it has done this to great success over the past 35 years. Second, without a profit to be made, you don’t have as much investment in psychosocial care that can help a person remake his or her life. There is a societal expense, but little corporate profit, in psychosocial care, and American-style capitalism doesn’t lend itself to that equation. Third, with our American-style capitalism (think neoliberalism), it is the individual that is seen as “ill” and needs to be fixed.

Society gets a free pass. This too is a barrier to good “mental health” care, for it prevents us from thinking about what changes we might make to our society that would be more nurturing for us all. With our American-style capitalism, we now have a grossly unequal society, with more and more wealth going to the select few, and more and more people struggling to pay their bills. That is a prescription for psychiatric distress. Good “mental health care” starts with creating a society that is more equal and just.

Horgan. How might the COVID-19 pandemic affect care of the mentally ill?. Whitaker. That is something Mad in America has reported on. The pandemic, of course, can be particularly threatening to people in mental hospitals, or in group homes.

The threat is more than just the exposure to the virus that may come in such settings. People who are struggling in this way often feel terribly isolated, alone, and fearful of being with others. COVID-19 measures, with calls for social distancing, can exacerbate that. I think this puts hospital staff and those who run residential homes into an extraordinarily difficult position—how can they help ease the isolation of patients even as they are being expected to enforce a type of social distancing?. Horgan.

If the next president named you mental health czar, what would be at the top of your To Do list?. Whitaker. Well, I am pretty sure that’s not going to happen, and if it did, I would quickly confess to my being utterly unqualified for the job. But from my perch at Mad in America, here is what I would like to see happen in our society. As you can see from my answers above, I think the fundamental problem is that our society has organized itself around a false narrative, which was sold to us as a narrative of science.

In the early 1980s, we began to hear that psychiatric disorders were discrete brain illnesses, which were caused by chemical imbalances in the brain, and that a new generation of psychiatric drugs fixed those imbalances, like insulin for diabetes. That is a story of an amazing medical breakthrough. Researchers had discovered the very chemicals in our brain that cause madness, depression, anxiety or ADHD, and they had developed drugs that could put brain chemistry back into a normal state. Given the complexity of the human brain, if this were true, it would arguably be the greatest achievement in medical history. And we understood it to be true.

We came to believe that there was a sharp line between the “normal” brain and the “abnormal” brain, and that it was medically helpful to screen for these illnesses, and that psychiatric drugs were very safe and effective, and often needed to be taken for life. But what can be seen clearly today is that this narrative was a marketing story, not a scientific one. It was a story that psychiatry, as an institution, promoted for guild purposes, and it was a story that pharmaceutical companies promoted for commercial reasons. Science actually tells a very different story. The biology of psychiatric disorders remains unknown.

The disorders in the DSM have not been validated as discrete illnesses. The drugs do not fix chemical imbalances but rather perturb normal neurotransmitter functions. And even their short term efficacy is marginal at best. As could be expected, organizing our thinking around a false narrative has been a societal disaster. A sharp rise in the burden of mental illness in our society.

Poor long-term functional outcomes for those who are continuously medicated. The pathologizing of childhood. And so on. What we need now is a new narrative to organize ourselves around, one steeped in history, literature, philosophy, and good science. I think step one is ditching the DSM.

That book presents the most impoverished “philosophy of being” imaginable. Anyone who is too emotional, or struggles with his or her mind, or just doesn’t like being in a boring environment (think ADHD) is a candidate for a diagnosis. We need a narrative that, if truth be told, can be found in literature. Novels, Shakespeare, the Bible—they all tell of how we humans struggle with our minds, our emotions and our behaviors. That is the norm.

It is the human condition. And yet the characters we see in literature, if they were viewed through the DSM lens, would regularly qualify for a diagnosis. At the same time, literature tells of how humans can be so resilient, and that we change as we age and move through different environments. We need that to be part of a new narrative too. Our current disease-model narrative tells of how people are likely going to be chronically ill.

Their brains are defective, and so the therapeutic goal is to manage the symptoms of the “disease.” We need a narrative that replaces that pessimism with hope. If we embraced that literary understanding of what it is to be human, then a “mental health” policy could be forged that would begin with this question. How do we create environments that are more nurturing for us all?. How do we create schools that build on a child’s curiosity?. How do we bring nature back into our lives?.

How do we create a society that helps provide people with meaning, a sense of community, and a sense of civic duty?. How do we create a society that promotes good physical health, and provides access to shelter and medical care?. Furthermore, with this conception in mind, individual therapy would help people change their environments. You could encourage walks in nature. Recommend volunteer work.

Provide settings where people could go and recuperate, and so forth. Most important, in contrast to a “disease-based” paradigm of care, a “wellness-based” paradigm would help people feel hopeful, and help them find a way to create a different future for themselves. This is an approach, by the way, that can be helpful to people who have suffered a psychotic episode. Soteria homes and Open Dialogue are “therapies” that strive to help psychotic patients in this manner. Within this “wellness” paradigm of care, there would still be a place for use of medications that help people feel differently, at least for a time.

Sedatives, tranquilizers, and so forth. And you would still want to fund science that seeks to better understand the many pathways to debilitating mood states and to “psychosis”—trauma, poor physical health, physical disease, lack of sleep, setbacks in life, isolation, loneliness, and yes, whatever biological vulnerabilities that may be present. At the same time, you would want to fund science that seeks to better understand the pillars of “wellness.” Horgan. What’s your utopia?. Whitaker.

My “utopia” would be a world like the one I just described, based on a new narrative about mental illness, rooted in an understanding of how emotional we humans are, of how we struggle with our minds, and of how we are built to be responsive to our environments. And that really is the mission of Mad in America. We want it to be a forum for creating a new societal narrative for “mental health.” Further Reading. Can Psychiatry Heal Itself?. Are Psychiatric Medications Making Us Sicker?.

Meta-Post. Posts on Mental Illness Meta-Post. Posts on Brain Implants Meta-Post. Posts on Psychedelics Meta-Post. Posts on Buddhism and Meditation See also “The Meaning of Madness,” a chapter in my free online book Mind-Body Problems.1970 Sweet Suburbia “Massive movement from central cities to their suburbs, a population boom in the West and Southwest, and a lower rate of population growth in the 1960's than in the 1950's are the findings that stand out in the preliminary results of the 1970 Census as issued by the U.S.

Bureau of the Census. The movement to the suburbs was pervasive. Its extent is indicated by the fact that 13 of the 25 largest cities lost population, whereas 24 of the 25 largest metropolitan areas gained. Washington, D.C., was characteristic. The population of the city changed little between 1960 and 1970, but the metropolitan area grew by 800,000, or more than 38 percent.” 1920 Air Cargo “The proposed machine, known as the ‘Pelican Four-Ton Lorry,' is a colossal cantilever monoplane designed for two 460-horse-power Napier engines.

Its cruising speed is 72 miles per hour. Its total weight is to be 24,100 pounds. The useful load is four tons, with sufficient fuel for the London-Paris journey. Most interesting of all, however, is the novel system of quick loading and unloading which has been planned. This permits handling of shipments with the utmost speed, and is based on a similar practice in the motor truck field.

Idle airplanes mean a large idle capital, hence the designers plan to keep the airplane in the air for the greater part of the time.” Don't Try This Anywhere “Dr. Charles Baskerville points out that while the data thus far obtained on chlorine and influenza do not warrant drawing conclusions, such facts as have been established would indicate to the medical man the advisability of trying experimentally dilute chlorinated air as a prophylactic in such epidemics as so-called influenza. Dr. Baskerville determined to what extent workers in plants where small amounts of chlorine were to be found in the atmosphere were affected seriously by influenza. Many of those from whom information was requested expressed the opinion that chlorine workers are noticeably free from colds and other pneumatic diseases.” 1870 The Rise of Telegraphy “The rapid progress of the telegraph during the last twenty-five years has changed the whole social and commercial systems of the world.

Its advantages and capabilities were so evident that immediately on its introduction, and demonstration of its true character, the most active efforts were made to secure them for every community which desired to keep pace with the advances of modern times. The Morse or signal system seemed for a time to be the perfection of achievement, until Professor Royal E. House astonished the world with his letter printing telegraph. Now, almost every considerable expanse of water is traversed, or soon will be, by the slender cords which bind continents and islands together and practically bring the human race into one great family.” The Transport of Goods 1887. Cargo ship launched as Golconda had room for 6,000 tons of cargo, loaded and unloaded by crane and cargo nets, and 108 passengers.

Credit. Scientific American Supplement, Vol. XXIII, No. 574. January 1, 1887 Oxcarts, railroad cars and freight ships can be loaded and unloaded one item at a time, but it is more efficient to handle cargo packed into “intermodal shipping containers” that are a standardized size and shape.

Our October 1968 issue noted that a “break-bulk” freighter took three days to unload, a container ship less than one (including loading new cargo). Air transport became a link in this complex system, but the concept in the 1920 illustration shown is a little ahead of its time. These days air cargo (and luggage) makes abundant use of “unit load devices,” cargo bins shaped to fit the fuselage of specific aircraft models.The items below are highlights from the free newsletter, “Smart, useful, science stuff about COVID-19.” To receive newsletter issues daily in your inbox, sign-up here. Are you in need of a “dose of optimism” about the pandemic, at least in the U.S.?. Check out this 10/12/20 story at The New York Times by by Donald McNeil Jr., who has covered infectious diseases and epidemics for many years.

McNeil notes the 215,000 people in the U.S. Dead so far from the novel coronavirus, as well as the estimates that the figure could go as high as 400,000 before this era draws to a close. But here is some of the good news that he tallies. 1) mask-wearing by the public is “widely accepted”. 2) the development of vaccines to protect against SARS-CoV-2 and of treatments for COVID-19 are proceeding at record speed.

3) “experts are saying, with genuine confidence, that the pandemic in the United States will be over far sooner than they expected, possibly by the middle of next year”. And 4) fewer infected people die today than did earlier this year, even at nursing homes. About 10 percent of people in the U.S. Have been infected with the virus so far, according to the U.S. Centers for Disease Control, the story states.

€œPandemics don’t end abruptly. They decelerate gradually,” McNeil writes. A 10/14/20 story by Carl Zimmer for The New York Times puts into context three late-stage (Phase 3 safety and effectiveness) COVID-19 experiments that have been paused in recent weeks due to illness among some study participants. Pauses in vaccine studies — in this case Johnson &. Johnson’s vaccine candidate and AstraZeneca’s vaccine candidate — are “not unusual,” the story states, partly because the safety threshold is extremely high for a product that, if approved, could be given to millions or billions of people.

But pauses are rare in treatment studies — in this case Eli Lilly’s monoclonal antibody cocktail drug. Once a drug or treatment experiment (trial) is paused, a safety board determines whether the ill participant was given the new product or a placebo. If it was the placebo, the study can resume. If not, the board looks deeper into the case to determine whether or not the illness is related to the drug or treatment. If a clear connection is discovered, “the trial may have to stop,” Zimmer writes.

Dr. Eric Topol at Scripps Research is quoted in the piece as saying he is “still fairly optimistic” about monoclonal antibody treatments for COVID-19. The safety-related pauses of all three experiments are “an example of how things are supposed to work,” says Dr. Anna Durbin of Johns Hopkins Bloomberg School of Public Health in the story. The top of a story at The Washington Post features an instructive interactive that sketches “Scienceville,” a fictional place where “politicians and public health officials use every tool at their disposal to contain the coronavirus.” It basically shows how genetic analysis and tracing of viral strains found in a frequently and widely tested population could help officials control outbreaks of SARS-CoV-2.

Then the 10/13/20 text story below, by Brady Dennis, Chris Mooney, Sarah Kaplan, and Harry Stevens, focuses on the details of such a “genomic epidemiology” approach and describes some real-life efforts under way, primarily in the UK, to implement the approach. The U.S. Has not been able to effectively use the approach, in part because genetic sequencing of viral strains “has largely been left up to states and individual researchers, rather than being part of a coordinated and well-funded national program,” the story states. The rise in SARS-CoV-2 infections in the U.S. Is now driven by “small gatherings in people’s homes,” according to officials with the U.S.

Centers for Disease Control, reports Carolyn Crist for WebMD (10/14/20). People should continue to wear face masks and to practice social distancing “since most people have still not been exposed to the coronavirus worldwide," the researchers suggest, Crist writes. A newly developed test can detect SARS-CoV-2 in 5 minutes, reports Robert F. Service at Science (10/8/20). The test relies on CRISPR gene-editing technology, for which Jennifer Doudna of the University of California, Berkeley, and Emmanuelle Charpentier of the Max Planck Unit for the Science of Pathogens won the Nobel Prize in Chemistry earlier this month.

Doudna heads up the work that led to this new 5-minute CRISPR test for the coronavirus. By comparison, it can take a day or more to get back standard SARS-CoV-2 test results, the story states. Donald G. McNeil Jr. At The New York Times has written a guide to distinguishing common cold, flu, and COVID-19 symptoms (10/3/20).

A major difference between having a cold and having the flu is that "Flu makes you feel as if you were hit by a truck,” McNeil quotes experts as saying. The symptom that best distinguishes COVID-19 from flu is loss of your sense of smell — strong smells don’t register, he writes. But many flu and COVID-19 symptoms overlap, the story states. The most common symptoms for COVID-19 are a high fever, chills, dry cough and fatigue. For flu, it’s a fever, headaches, body aches, sore throat, runny nose, stuffed sinuses, coughing and sneezing, the story states.

Dr. Anthony Fauci’s three daughters do not plan to visit him for Thanksgiving to avoid potentially transmitting the new coronavirus to their parents, reports Ralph Ellis at WebMD. The story includes holiday traveling and visiting tips from a pulmonary critical care doctor at the University of Washington Medical Center who “believes traveling for the holidays is risky.” The tips include ensuring you have no COVID-19-like symptoms two weeks before traveling, getting tested before traveling, quarantining in a hotel for at least 48 hours before visiting with loved ones, traveling by car, and cutting down on “close contact and talking without a mask” (10/9/20). Adele Chapin has written a guide for reducing kids’ risk of catching and spreading SARS-CoV-2 at the playground. The 10/8/20 piece in The Washington Post makes the usual recommendations for mask-wearing, hand-washing, hand-sanitizer, disinfecting wipes, and distancing.

It quotes a Children’s National Hospital pediatrician advises against gloves, because “people wearing them often touch their faces, which defeats the purpose.” The piece also recommends visiting playgrounds at less busy times and choosing playgrounds with more than one play structure, which makes it easier for kids to distance from one another. A story by Carl Zimmer for The New York Times beautifully describes and illustrates some of the amazing imaging work that scientists have done to study the structure of SARS-CoV-2 and how it infects our cells and multiplies (10/9/20). For starters, check out a mesmerizing video about a quarter of the way down-page that simulates spike proteins (complex molecules) doing a “molecular dance” on the virus membrane. The video (just one of several in this stunning piece) is part of research by a computational biophysicist at the Max Planck Institute of Biophysics and colleagues. The spikes appear to shimmy, which “increases the odds of encountering the protein on the surface of our cells it uses to attach,” the researchers suspect, Zimmer writes.

You might enjoy, “A letter of recommendation in the age of Zoom,” by Matt Cheung, for McSweeney’s (10/14/20).Editor’s Note (10/16/20). This story is being republished in light of the interim results of a large international clinical trial of remdesivir by the World Health Organization. The trial found that the drug, which is widely used to treat COVID patients, failed to prevent deaths. An experimental drug—and one of the world’s best hopes against COVID-19—could shorten the time to recovery from coronavirus infection, according to the largest and most rigorous clinical trial of the compound. The experimental drug, called remdesivir, interferes with replication of some viruses, including the SARS-CoV-2 virus responsible for the current pandemic.

On 29 April, Anthony Fauci, director of the US National Institute of Allergy and Infectious Disease (NIAID), announced that a clinical trial of more than a thousand people showed that people taking remdesivir recovered in 11 days on average, compared to 15 days for those on a placebo. €œAlthough a 31% improvement doesn’t seem like a knockout 100%, it is a very important proof of concept,” Fauci said. €œWhat it has proven is that a drug can block this virus.” Deaths were also lower in trial participants who received the drug, he said, but that trend was not statistically significant. The shortened recovery time, however, was significant, and was enough of a benefit that investigators decided to stop the trial early for ethical reasons, he said, to ensure that those participants who were receiving placebo could now access the drug. Fauci added that remdesivir would become a standard treatment for COVID-19.

The news comes after weeks of data leaks and on a day of mixed results from clinical trials of the drug. In a trial run by the drug’s maker, Gilead Sciences of Foster City, California, more than half of 400 participants with severe COVID-19 recovered from their illness within two weeks of receiving treatment. But the study lacked a placebo controlled arm, making the results difficult to interpret. Another smaller trial run in China found no benefits from remdesivir when compared with a placebo. But the trial was stopped early due to the difficulty in enroling participants as the outbreak subsided in China.

Nevertheless, onlookers are hopeful that the large NIAID trial provides the first glimmer of hope in a race to find a drug that works against the coronavirus, which has infected more than 3 million people worldwide. €œThere is a lot of focus on remdesivir because it’s potentially the best shot we have,” says virologist Stephen Griffin at the University of Leeds in the UK. Small trials The fast-flowing, conflicting information on remdesivir has left people reeling over the past weeks. In the rush to find therapies to combat COVID-19, small, clinical trials without control groups have been common. €œI’m just very annoyed by all of these non-controlled studies,” says Geoffrey Porges, an analyst for the investment bank SVB Leerink in New York City.

€œIt’s reassuring that 50–60% of patients are discharged from the hospital, but this is a disease that mostly gets better anyway.” With so much uncertainty, the remdesivir-watchers were waiting anxiously for final results from the NIAID trial, which were not expected until the end of May. In lieu of a vaccine, which could still be more than a year away, effective therapies are critical to reducing deaths and limiting economic damage from the pandemic. Yet, despite the flood of small clinical trials, no therapy has been convincingly shown to boost survival in people with COVID-19. The NIAID results put a new sheen on remdesivir. €œIt may not be the wonder drug that everyone’s looking for, but if you can stop some patients from becoming critically ill, that’s good enough,” says Griffin.

Fauci said the finding reminded him of the discovery in the 1980s that the drug AZT helped to combat HIV infection. The first randomized, controlled clinical only showed a modest improvement, he said, but researchers continued to build on that success, eventually developing highly effective therapies. For now, he said, remdesivir would become a standard treatment for COVID-19. Remdesivir works by gumming up an enzyme that some viruses, including SARS-CoV-2, use to replicate. In February, researchers showed that the drug reduces viral infection in human cells grown in a laboratory.

Gilead began to ramp up production of remdesivir well before the NIAID results. By the end of March, the company had produced enough to treat 30,000 patients. By streamlining its manufacturing process and finding new sources of raw materials, Gilead announced that it hoped to produce enough remdesivir to treat more than a million people by the end of the year. That calculation was based on the assumption that people would take the drug for 10 days, but the results announced from Gilead’s trial today suggest that a 5-day course of treatment could work just as well. If so, that would effectively double the number of people who could be treated, says Porges.

Many drugs needed In the long term, clinicians will likely want a bevy of anti-viral drugs—with different ways of disabling the virus—in their arsenal, says Timothy Sheahan, a virologist at the University of North Carolina in Chapel Hill, who has teamed up with Gilead researchers to study remdesivir. €œThere is always the potential for antiviral resistance,” he says. €œAnd to hedge against that potential, it’s good to have not only a first-line, but also a second-, third-, fourth-, fifth-line antiviral.” Researchers are furiously testing a wide range of therapies, but early results, while not yet definitive, have not been encouraging. The malaria drugs chloroquine and hydroxychloroquine, both of which also have anti-inflammatory effects, drew so much attention from physicians and the public that some countries have depleted their supplies of the drugs. Yet studies in humans have failed to show a consistent benefit, and some have highlighted the risks posed by side effects of the drugs on the heart.

Early interest in a mix of two HIV drugs called lopinavir and ritonavir flagged when a clinical trial in nearly 200 people did not find any benefit of the mix for those with severe COVID-19. Another promising therapeutic hypothesis—that inhibiting the action of an immune system regulator called IL-6 could reduce the severe inflammation seen in some people with severe COVID-19—has met with mixed results thus far. Still, a host of other therapies are being tested in people, and many researchers are hunting for new drugs at the bench. Sheahan and his colleagues have found a compound that is active against SARS-CoV-2 and other coronaviruses, including a remdesivir-resistant variant of a coronavirus, when tested in laboratory-grown human cells. But much more testing would need to be done before the compound could be tried in people.

€œWhat we’re doing now will hopefully have an impact on the current pandemic,” he says. €œBut maybe more importantly, it could position us to better respond more quickly in the future.” This article is reproduced with permission and was first published on April 29 2020. Read more about the coronavirus outbreak here.During a press conference in early September, President Donald Trump was asked when he thought a vaccine for COVID-19 might become available. His prediction was upbeat. €œWe’re going to have a vaccine very soon,” Trump said.

€œMaybe even before a very special day—you know what day I’m talking about.” Trump was referring, of course, to the presidential election on November 3. But the odds of a vaccine materializing for public use before then appear slim. New drugs and vaccines ordinarily go through a lengthy review process prior to regulatory approval. Vaccines for COVID-19, however, are widely expected to be released under emergency use authorization (EUA) protocols, which allow for the sale of unapproved medical products during national health crises. On October 6 the White House agreed to new EUA guidelines that call on COVID-19 vaccine developers to monitor their phase III clinical trial subjects for at least two months for side effects and severe disease.

The U.S. Food and Drug Administration, which administers EUAs, will host a widely anticipated meeting on October 22 to address standards for efficacy, safety and manufacturing of COVID-19 vaccines. But the FDA’s recommended two-month observation period puts a preelection vaccine approval out of reach. EUAs could, however, make the first successful COVID-19 vaccines available to frontline workers by the start of 2021, although distribution in the general U.S. Population will take longer, starting with elderly and other high-risk groups and then younger, healthier people who may not have access to them until late in the year, according to Paul Offit, a pediatrician and director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

The FDA has already granted hundreds of COVID-related EUAs for products such as diagnostic tests, medical devices and therapies—including for convalescent plasma and hydroxychloroquine (the latter was later revoked). €œAll the COVID-19 vaccine developers are going for an EUA first,” says Eric Topol, a cardiologist and head of the Scripps Research Translational Institute in La Jolla, Calif., who has directed numerous multinational clinical trials (although none for vaccines). €œIt makes no sense to wait for formal licensure.” Defining Success Obtaining an EUA hinges on how independent reviewers judge a vaccine’s performance during periodic readouts of phase III clinical trial data. The trials are each enrolling tens of thousands of people and are also double-blinded—meaning that neither the subjects nor the experimenters know which participants got a vaccine versus a placebo. They were designed to continue until the number of symptomatic infections reaches 150 in the vaccinated and control groups combined.

If a vaccine halves the risk of symptomatic infections among the vaccinated group, it will meet the FDA’s minimum bar for approval. Reviewers examining the interim data readouts will be looking for better protection than that. Pfizer, which began a phase III trial for its vaccine on July 27, plans to conduct its first readout when the number of symptomatic cases reaches 32. The company expects that could happen this month, making it first in line for a potential EUA. Statistical thresholds are set such that if COVID case numbers in the vaccinated group are, at that point, at least five times lower than they are among vaccinated subjects, then reviewers can declare overwhelming efficacy.

In that event, the company will “consult with regulatory authorities about next steps,” which could include an EUA, says a Pfizer spokesperson. In an October 16 open letter, Pfizer chairman and CEO Albert Bourla wrote that if the efficacy data are positive, the company will apply for an EUA in the U.S. €œsoon after the safety milestone is achieved in the third week of November.” The company’s study protocol also includes data readouts at 62, 92 and 120 cases, respectively, although the amount of protection the vaccine has to achieve at each step declines progressively until it reaches the FDA’s minimum target of 50 percent. Other companies racing to develop COVID-19 vaccines are taking a less aggressive approach. Cambridge, Mass.–based Moderna, for instance, plans for a first data readout when it reaches 53 cases among its study subjects and another at 106 cases.

The company anticipates filing for an EUA in late November. Meanwhile Johnson &. Johnson recently paused its clinical trials after a participant got sick. This delay follows a similar pause by AstraZeneca, which has since resumed its trials outside of the U.S. What Happens Postapproval A significant issue is how vaccine developers will continue to assess safety and efficacy after an EUA.

The FDA has said they should include strategies for monitoring a vaccine’s long-term performance in their EUA applications and generate the data needed to support future licensing. The agency has also stressed that companies should continue collecting placebo-controlled trial data for as long as feasible. Yet Pfizer representatives said in an e-mail that if an interim readout shows overwhelming efficacy, they have the option to unblind the data, vaccinate placebo recipients and then follow all the subjects in an unblinded fashion—meaning experimenters and participants would know who got the vaccine. (A Pfizer spokesperson later said the company would only unblind the study with regulatory approval.) The problem with unblinding the data is that a compromised control group “makes it harder to ascertain a vaccine’s risks and benefits and, in particular, how well it protects against severe disease—which isn’t as common as milder infections,” says Peter Gilbert, a biostatistician at the Fred Hutchinson Cancer Research Center in Seattle, who helped design clinical trials for the leading U.S. Candidates.

Topol argues that with a few more weeks, developers could amass the 150 cases that might allow them to more fully assess protection from severe disease, especially in elderly and other vulnerable populations. €œThere shouldn’t be any shortcuts,” he says. €œWe’re talking about giving these vaccines to billions of people. You can’t risk compromising public trust.” Echoing those concerns, Patricia Whitley-Williams, an infectious disease specialist at Rutgers University’s Robert Wood Johnson Medical School, worries that doctors who mainly treat African-Americans and other people of color might be reluctant to recommend vaccines that they believe have not been adequately tested in these populations. Black Americans are hospitalized with COVID-19 at nearly three times the rate white Americans are, so with vaccination, “we need time to look at potential harms in all ethnic, age and gender groups,” she says.

Still, if a vaccine’s interim review shows very high efficacy—say, 90 percent or greater—there will be “appropriate pressure to offer it to control groups immediately,” Gilbert says. These sorts of scenarios are under discussion now, he says, and what is unknown is how many control subjects will opt to be vaccinated if given the opportunity. Gilbert adds that more safety and efficacy data will come from so-called phase IV studies, which monitor immunized people after a vaccine has reached the market.

You’ll find, in the archives of our research reports, a steady parade of findings buy furosemide 40mg that counter the conventional narrative. For instance, there are reports of how the effort to find genes for mental disorders has proven rather fruitless, or of how social inequalities trigger mental distress, or of poor long-term outcomes with our current paradigm of care. And so forth—we simply want these scientific findings to become known.
We regularly feature interviews with researchers and activists, and podcasts that explore these issues. We launched MIA Reports as buy furosemide 40mg a showcase for our print journalism.

We have published in-depth articles on promising new initiatives in Europe. Investigative pieces on such topics as compulsory outpatient treatment. Coverage of “news” related to mental health policy in the United States buy furosemide 40mg. And occasional reports on how the mainstream media is covering mental health issues.

€¨We also publish blogs by professionals, academics, people with lived experience, and others with a particular interest in this subject. These blogs and personal stories are meant to help inform society’s “rethinking” of psychiatric care buy furosemide 40mg. All of these efforts, I think, fit within the framework of “journalism.” However, I do understand that I am going beyond the boundaries of usual “science journalism” when I publish critiques of the “evidence base” related to psychiatric drugs. I did this in my books Mad in America and Anatomy of an Epidemic, as well as a book I co-wrote, Psychiatry Under the Influence.

I have continued to do this with MIA Reports buy furosemide 40mg. The usual practice in “science journalism” is to look to the “experts” in the field and report on what they tell about their findings and practices. However, while reporting and writing Mad in America, I came to understand that when “experts” in psychiatry spoke to journalists they regularly hewed to a story that they were expected to tell, which was a story of how their field was making great progress in understanding the biology of disorders and of drug treatments that—as I was told over and over when I co-wrote the series for the Boston Globe—fixed chemical imbalances in the brain. But their own science, I discovered, regularly belied the story they were telling to the media buy furosemide 40mg.

That’s why I turned to focusing on the story that could be dug out from a critical look at their own scientific literature. So what I do in these critiques—such as suicide in the Prozac era and the impact of antipsychotics on mortality—is review the relevant research and put those findings together into a coherent report. I also buy furosemide 40mg look at research cited in support of mainstream beliefs and see if the data, in those articles, actually supports the conclusions presented in the abstract. None of this is really that difficult, and yet I know it is unusual for a journalist to challenge conventional “medical wisdom” in this way.

Horgan. Anatomy of an Epidemic argues that medications for mental illness, although they give many buy furosemide 40mg people short-term reliefs, cause net harm. Is that a fair summary?. Whitaker.

Yes, although my buy furosemide 40mg thinking has evolved somewhat since I wrote that book. I am more convinced than ever that psychiatric medications, over the long term, cause net harm. I wish that weren’t the case, but the evidence just keeps mounting that these drugs, on the whole, worsen long-term outcomes. However, my buy furosemide 40mg thinking has evolved in this way.

I am not so sure any more that the medications provide a short-term benefit for patient populations as a whole. When you look at the short-term studies of antidepressants and antipsychotics, the evidence of efficacy in reducing symptoms compared to placebo is really pretty marginal, and fails to rise to the level of a “clinically meaningful” benefit. Furthermore, the problem with all of this research buy furosemide 40mg is that there is no real placebo group in the studies. The placebo group is composed of patients who have been withdrawn from their psychiatric medications and then randomized to placebo.

Thus, the placebo group is a drug-withdrawal group, and we know that withdrawal from psychiatric drugs can stir myriad negative effects. A medication-naïve placebo group would likely have much better outcomes, and if that were so, how would that placebo response compare to the drug response? buy furosemide 40mg. In short, research on the short-term effects of psychiatric drugs is a scientific mess. In fact, a 2017 paper that was designed to defend the long-term use of antipsychotics nevertheless acknowledged, in an off-hand way, that “no placebo-controlled trials have been reported in first-episode psychosis patients.” Antipsychotics were introduced 65 years ago, and we still don’t have good evidence that they work over the short term in first episode patients.

Which is rather startling, when you think of buy furosemide 40mg it. Horgan. Have any of your critics—E. Fuller Torrey, for example—made you buy furosemide 40mg rethink your thesis?.

Whitaker. When the first edition of Anatomy of an Epidemic was published (2010), I knew there would be critics, and I thought, this will be great. This is just what is needed, a societal discussion about the long-term effects of psychiatric buy furosemide 40mg medications. I have to confess that I have been disappointed in the criticism.

They mostly have been ad hominem attacks—I cherry-picked the data, or I misunderstood findings, or I am just biased, but the critics don’t then say what data I missed, or point to findings that tell of medications that improve long-term outcomes. I honestly think I could do a much buy furosemide 40mg better job of critiquing my own work. You mention E. Fuller Torrey’s criticism, in which he states that I both misrepresented and misunderstood some of the research I cited.

I took this seriously, buy furosemide 40mg and answered it at great length. Now if your own “thesis” is indeed flawed, then a critic should be able to point out its flaws while accurately detailing what you wrote. If that is the case, then you have good reason to rethink your beliefs. But if a critique buy furosemide 40mg doesn’t meet that standard, but rather relies on misrepresenting what you wrote, then you have reason to conclude that the critic lacks the evidence to make an honest case.

And that is how I see Torrey’s critique. For example, Torrey said that I misunderstood Martin Harrow’s research on long-term outcomes for schizophrenia patients. Harrow reported that the recovery rate was eight times higher for those who got buy furosemide 40mg off antipsychotic medication compared to those who stayed on the drugs. However, in his 2007 paper, Harrow stated that the better outcomes for those who got off medication was because they had a better prognosis and not because of negative drug effects.

If you read Anatomy of an Epidemic, you’ll see that I present his explanation. Yet, in my interview with Harrow, I buy furosemide 40mg noted that his own data showed that those who were diagnosed with milder psychotic disorders who stayed on antipsychotics fared worse over the long term than schizophrenia patients who stopped taking the medication. This was a comparison that showed the less ill maintained on antipsychotics doing worse than the more severely ill who got off these medications. And I presented that comparison in Anatomy of an Epidemic.

By doing that, I was going out on buy furosemide 40mg a limb. I was saying that maybe Harrow’s data led to a different conclusion than he had drawn, which was that the antipsychotic medication, over the long-term, had a negative effect. After Anatomy was published, Harrow and his colleague Thomas Jobe went back to their data and investigated this very possibility. They have subsequently written several papers exploring this theme, citing me in one or two instances buy furosemide 40mg for raising the issue, and they found reason to conclude that it might be so.

They wrote. €œHow unique among medical treatments is it that the apparent efficacy of antipsychotics could diminish over time or become harmful?. There are many examples for other medications of similar long-term effects, with this buy furosemide 40mg often occurring as the body readjusts, biologically, to the medications.” Thus, in this instance, I did the following. I accurately reported the results of Harrow’s study and his interpretation of his results, and I accurately presented data from his research that told of a possible different interpretation.

The authors then revisited their own data to take up this inquiry. And yet Torrey’s critique is that I misrepresented Harrow’s research buy furosemide 40mg. This same criticism, by the way, is still being flung at me. Here is a recent article in Vice which, once again, quotes people saying I misrepresent and misunderstand research, with Harrow cited as an example.

I do want to emphasize that critiques buy furosemide 40mg of “my thesis” regarding the long-term effects of psychiatric drugs are important and to be welcomed. See two papers in particular that take this on (here and here), and my response in general to such criticisms, and to the second one. Horgan. When I criticize psychiatric drugs, buy furosemide 40mg people sometimes tell me that meds saved their lives.

You must get this reaction a lot. How do you respond?. Whitaker buy furosemide 40mg. I do hear that, and when I do, I reply, “Great!.

I am so glad to know that the medications have worked for you!. € But buy furosemide 40mg of course I also hear from many people who say that the drugs ruined their lives. I do think that the individual’s experience of psychiatric medication, whether good or bad, should be honored as worthy and “valid.” They are witnesses to their own lives, and we should incorporate those voices into our societal thinking about the merits of psychiatric drugs. However, for the longest time, we’ve heard mostly about the “good” outcomes in the mainstream media, while those with “bad” outcomes were resigned to telling their stories on internet forums.

What Mad in America has sought to do, in its efforts to serve as a forum for rethinking buy furosemide 40mg psychiatry, is provide an outlet for this latter group, so their voices can be heard too. The personal accounts, of course, do not change the bottom-line “evidence” that shows up in outcome studies of larger groups of patients. Unfortunately, that tells of medications that, on the whole, do more harm than good. As a case in buy furosemide 40mg point, in regard to this “saving lives” theme, this benefit does not show up in public health data.

The “standard mortality rate” for those with serious mental disorders, compared to the general public, has notably increased in the last 40 years. Horgan. Do you see any promising trends buy furosemide 40mg in psychiatry?. Whitaker.

Yes, definitely. You have the spread of Hearing Voices networks, which are composed of people who hear voices and offer support for learning to live with voices as opposed to squashing them, which is what buy furosemide 40mg the drugs are supposed to do. These networks are up and running in the U.S., and in many countries worldwide. You have Open Dialogue approaches, which were pioneered in northern Finland and proved successful there, being adopted in the United States and many European countries (and beyond.) This practice puts much less emphasis on treatment with antipsychotics, and much greater emphasis on helping people re-integrate into family and community.

You have many alternative programs springing up, even at the governmental buy furosemide 40mg level. Norway, for instance, ordered its hospital districts to offer “medication free” treatment for those who want it, and there is now a private hospital in Norway that is devoted to helping chronic patients taper down from their psychiatric medications. In Israel, you have Soteria houses that have sprung up (sometimes they are called stabilizing houses), where use of antipsychotics is optional, and the environment—a supportive residential environment—is seen as the principal “therapy.” You have the U.N. Special Rapporteur for Health, buy furosemide 40mg Dainius Pūras, calling for a “revolution” in mental health, one that would supplant today’s biological paradigm of care with a paradigm that paid more attention to social justice factors—poverty, inequality, etc.—as a source of mental distress.

All of those initiatives tell of an effort to find a new way. But perhaps most important, in terms of “positive trends,” the narrative that was told to us starting in the 1980s has collapsed, which is what presents the opportunity for a new paradigm to take hold. More and more research tells of how the conventional narrative, in all its particulars, has failed to pan out buy furosemide 40mg. The diagnoses in the Diagnostic and Statistical Manual (DSM) have not been validated as discrete illnesses.

The genetics of mental disorders remain in doubt. MRI scans buy furosemide 40mg have not proven to be useful. Long-term outcomes are poor. And the notion that psychiatric drugs fix chemical imbalances has been abandoned.

Ronald Pies, the former editor in chief of Psychiatric Times, has even buy furosemide 40mg sought to distance psychiatry, as an institution, from ever having made such a claim. Horgan. Do brain implants or other electrostimulation devices show any therapeutic potential?. Whitaker buy furosemide 40mg.

I don’t have a ready answer for this. We have published two articles about the spinning of results from a trial of deep-brain stimulation, and the suffering of some patients so treated over the long-term. Those articles tell of why buy furosemide 40mg it may be difficult to answer that question. There are financial influences that push for published results that tell of a therapeutic success, even if the data doesn’t support that finding, and we have a research environment that fails to study long-term outcomes.

The history of somatic treatments for mental disorders also provides a reason for caution. It’s a history of one somatic treatment after another being initially buy furosemide 40mg hailed as curative, or extremely helpful, and then failing the test of time. The inventor of frontal lobotomy, Egas Moniz, was awarded a Nobel Prize for inventing that surgery, which today we understand as a mutilation. It’s important to remain open to the possibility that somatic treatments may be helpful, at least for some patients.

But there is plenty of buy furosemide 40mg reason to be wary of initial claims of success. Horgan. Should psychedelic drugs be taken seriously as treatments?. Whitaker buy furosemide 40mg.

I think caution applies here too. Surely there are many risks with psychedelic drugs, and if you were to do a study of first-episode psychosis today, you would find a high percentage of the patients had been using mind-altering drugs before their psychotic break—antidepressants, marijuana, LSD and so forth. At the same time, we’ve buy furosemide 40mg published reviews of papers that have reported positive results with use of psychedelics. What are the benefits versus the risks?.

Can possible benefits be realized while risks are minimized?. It is a question worth buy furosemide 40mg exploring, but carefully so. Horgan. What about meditation?.

Whitaker buy furosemide 40mg. I know that many people find meditation helpful. I also know other people find it difficult—and even threatening—to sit with the silence of their minds. Mad in America has published reviews of research buy furosemide 40mg about meditation, we have had a few bloggers write about it, and in our resource section on “non-drug therapies,” we have summarized research findings regarding its use for depression.

We concluded that the research on this is not as robust as one would like. However, I think your question leads to this broader thought. People struggling with their minds and buy furosemide 40mg emotions may come up with many different approaches they find helpful. Exercise, diet, meditation, yoga and so forth all represent efforts to change one’s environment, and ultimately, I think that can be very helpful.

But the individual has to find his or her way to whatever environmental change that works best for them. Horgan. Do you see any progress toward understanding the causes of mental illness?. Whitaker.

Yes, and that progress might be summed up in this way. Researchers are returning to investigations of how we are impacted by what has “happened to us.” The Adverse Childhood Experiences study provides compelling evidence of how traumas in childhood—divorce, poverty, abuse, bullying and so forth—exact a long-term toll on physical and mental health. Interview any group of women diagnosed with a serious mental disorder, and you’ll regularly find accounts of sexual abuse. Racism exacts a toll.

So too poverty, oppressive working conditions, and so forth. You can go on and on, but all of this is a reminder that we humans are designed to respond to our environment, and it is quite clear that mental distress, in large part, arises from difficult environments and threatening experiences, past and present. And with a focus on life experiences as a source of “mental illness,” a related question is now being asked. What do we all need to be mentally well?.

Shelter, good food, meaning in life, someone to love and so forth—if you look at it from this perspective, you can see why, when those supporting elements begin to disappear, psychiatric difficulties appear. I am not discounting that there may be biological factors that cause “mental illness.” While biological markers that tell of a particular disorder have not been discovered, we are biological creatures, and we do know, for instance, that there are physical illnesses and toxins that can produce psychotic episodes. However, the progress that is being made at the moment is a moving away from the robotic “it’s all about brain chemistry” toward a rediscovery of the importance of our social lives and our experiences. Horgan.

Do we still have anything to learn from Sigmund Freud?. Whitaker. I certainly think so. Freud is a reminder that so much of our mind is hidden from us and that what spills into our consciousness comes from a blend of the many parts of our mind, our emotional centers and our more primal instincts.

You can still see merit in Freud’s descriptions of the id, ego and superego as a conceptualization of different parts of the brain. I read Freud when I was in college, and it was a formative experience for me. Horgan. I fear that American-style capitalism doesn’t produce good health care, including mental-health care.

What do you think?. Whitaker. It’s clear that it doesn’t. First, we have for-profit health-care that is set up to treat “disease.” With mental-health care, that means there is a profit to be made from seeing people as “diseased” and treating them for that “illness.” Take a pill!.

In other words, American-style capitalism, which works to create markets for products, provides an incentive to create mental patients, and it has done this to great success over the past 35 years. Second, without a profit to be made, you don’t have as much investment in psychosocial care that can help a person remake his or her life. There is a societal expense, but little corporate profit, in psychosocial care, and American-style capitalism doesn’t lend itself to that equation. Third, with our American-style capitalism (think neoliberalism), it is the individual that is seen as “ill” and needs to be fixed.

Society gets a free pass. This too is a barrier to good “mental health” care, for it prevents us from thinking about what changes we might make to our society that would be more nurturing for us all. With our American-style capitalism, we now have a grossly unequal society, with more and more wealth going to the select few, and more and more people struggling to pay their bills. That is a prescription for psychiatric distress.

Good “mental health care” starts with creating a society that is more equal and just. Horgan. How might the COVID-19 pandemic affect care of the mentally ill?. Whitaker.

That is something Mad in America has reported on. The pandemic, of course, can be particularly threatening to people in mental hospitals, or in group homes. The threat is more than just the exposure to the virus that may come in such settings. People who are struggling in this way often feel terribly isolated, alone, and fearful of being with others.

COVID-19 measures, with calls for social distancing, can exacerbate that. I think this puts hospital staff and those who run residential homes into an extraordinarily difficult position—how can they help ease the isolation of patients even as they are being expected to enforce a type of social distancing?. Horgan. If the next president named you mental health czar, what would be at the top of your To Do list?.

Whitaker. Well, I am pretty sure that’s not going to happen, and if it did, I would quickly confess to my being utterly unqualified for the job. But from my perch at Mad in America, here is what I would like to see happen in our society. As you can see from my answers above, I think the fundamental problem is that our society has organized itself around a false narrative, which was sold to us as a narrative of science.

In the early 1980s, we began to hear that psychiatric disorders were discrete brain illnesses, which were caused by chemical imbalances in the brain, and that a new generation of psychiatric drugs fixed those imbalances, like insulin for diabetes. That is a story of an amazing medical breakthrough. Researchers had discovered the very chemicals in our brain that cause madness, depression, anxiety or ADHD, and they had developed drugs that could put brain chemistry back into a normal state. Given the complexity of the human brain, if this were true, it would arguably be the greatest achievement in medical history.

And we understood it to be true. We came to believe that there was a sharp line between the “normal” brain and the “abnormal” brain, and that it was medically helpful to screen for these illnesses, and that psychiatric drugs were very safe and effective, and often needed to be taken for life. But what can be seen clearly today is that this narrative was a marketing story, not a scientific one. It was a story that psychiatry, as an institution, promoted for guild purposes, and it was a story that pharmaceutical companies promoted for commercial reasons.

Science actually tells a very different story. The biology of psychiatric disorders remains unknown. The disorders in the DSM have not been validated as discrete illnesses. The drugs do not fix chemical imbalances but rather perturb normal neurotransmitter functions.

And even their short term efficacy is marginal at best. As could be expected, organizing our thinking around a false narrative has been a societal disaster. A sharp rise in the burden of mental illness in our society. Poor long-term functional outcomes for those who are continuously medicated.

The pathologizing of childhood. And so on. What we need now is a new narrative to organize ourselves around, one steeped in history, literature, philosophy, and good science. I think step one is ditching the DSM.

That book presents the most impoverished “philosophy of being” imaginable. Anyone who is too emotional, or struggles with his or her mind, or just doesn’t like being in a boring environment (think ADHD) is a candidate for a diagnosis. We need a narrative that, if truth be told, can be found in literature. Novels, Shakespeare, the Bible—they all tell of how we humans struggle with our minds, our emotions and our behaviors.

That is the norm. It is the human condition. And yet the characters we see in literature, if they were viewed through the DSM lens, would regularly qualify for a diagnosis. At the same time, literature tells of how humans can be so resilient, and that we change as we age and move through different environments.

We need that to be part of a new narrative too. Our current disease-model narrative tells of how people are likely going to be chronically ill. Their brains are defective, and so the therapeutic goal is to manage the symptoms of the “disease.” We need a narrative that replaces that pessimism with hope. If we embraced that literary understanding of what it is to be human, then a “mental health” policy could be forged that would begin with this question.

How do we create environments that are more nurturing for us all?. How do we create schools that build on a child’s curiosity?. How do we bring nature back into our lives?. How do we create a society that helps provide people with meaning, a sense of community, and a sense of civic duty?.

How do we create a society that promotes good physical health, and provides access to shelter and medical care?. Furthermore, with this conception in mind, individual therapy would help people change their environments. You could encourage walks in nature. Recommend volunteer work.

Provide settings where people could go and recuperate, and so forth. Most important, in contrast to a “disease-based” paradigm of care, a “wellness-based” paradigm would help people feel hopeful, and help them find a way to create a different future for themselves. This is an approach, by the way, that can be helpful to people who have suffered a psychotic episode. Soteria homes and Open Dialogue are “therapies” that strive to help psychotic patients in this manner.

Within this “wellness” paradigm of care, there would still be a place for use of medications that help people feel differently, at least for a time. Sedatives, tranquilizers, and so forth. And you would still want to fund science that seeks to better understand the many pathways to debilitating mood states and to “psychosis”—trauma, poor physical health, physical disease, lack of sleep, setbacks in life, isolation, loneliness, and yes, whatever biological vulnerabilities that may be present. At the same time, you would want to fund science that seeks to better understand the pillars of “wellness.” Horgan.

What’s your utopia?. Whitaker. My “utopia” would be a world like the one I just described, based on a new narrative about mental illness, rooted in an understanding of how emotional we humans are, of how we struggle with our minds, and of how we are built to be responsive to our environments. And that really is the mission of Mad in America.

We want it to be a forum for creating a new societal narrative for “mental health.” Further Reading. Can Psychiatry Heal Itself?. Are Psychiatric Medications Making Us Sicker?. Meta-Post.

Posts on Mental Illness Meta-Post. Posts on Brain Implants Meta-Post. Posts on Psychedelics Meta-Post. Posts on Buddhism and Meditation See also “The Meaning of Madness,” a chapter in my free online book Mind-Body Problems.1970 Sweet Suburbia “Massive movement from central cities to their suburbs, a population boom in the West and Southwest, and a lower rate of population growth in the 1960's than in the 1950's are the findings that stand out in the preliminary results of the 1970 Census as issued by the U.S.

Bureau of the Census. The movement to the suburbs was pervasive. Its extent is indicated by the fact that 13 of the 25 largest cities lost population, whereas 24 of the 25 largest metropolitan areas gained. Washington, D.C., was characteristic.

The population of the city changed little between 1960 and 1970, but the metropolitan area grew by 800,000, or more than 38 percent.” 1920 Air Cargo “The proposed machine, known as the ‘Pelican Four-Ton Lorry,' is a colossal cantilever monoplane designed for two 460-horse-power Napier engines. Its cruising speed is 72 miles per hour. Its total weight is to be 24,100 pounds. The useful load is four tons, with sufficient fuel for the London-Paris journey.

Most interesting of all, however, is the novel system of quick loading and unloading which has been planned. This permits handling of shipments with the utmost speed, and is based on a similar practice in the motor truck field. Idle airplanes mean a large idle capital, hence the designers plan to keep the airplane in the air for the greater part of the time.” Don't Try This Anywhere “Dr. Charles Baskerville points out that while the data thus far obtained on chlorine and influenza do not warrant drawing conclusions, such facts as have been established would indicate to the medical man the advisability of trying experimentally dilute chlorinated air as a prophylactic in such epidemics as so-called influenza.

Dr. Baskerville determined to what extent workers in plants where small amounts of chlorine were to be found in the atmosphere were affected seriously by influenza. Many of those from whom information was requested expressed the opinion that chlorine workers are noticeably free from colds and other pneumatic diseases.” 1870 The Rise of Telegraphy “The rapid progress of the telegraph during the last twenty-five years has changed the whole social and commercial systems of the world. Its advantages and capabilities were so evident that immediately on its introduction, and demonstration of its true character, the most active efforts were made to secure them for every community which desired to keep pace with the advances of modern times.

The Morse or signal system seemed for a time to be the perfection of achievement, until Professor Royal E. House astonished the world with his letter printing telegraph. Now, almost every considerable expanse of water is traversed, or soon will be, by the slender cords which bind continents and islands together and practically bring the human race into one great family.” The Transport of Goods 1887. Cargo ship launched as Golconda had room for 6,000 tons of cargo, loaded and unloaded by crane and cargo nets, and 108 passengers.

Credit. Scientific American Supplement, Vol. XXIII, No. 574.

January 1, 1887 Oxcarts, railroad cars and freight ships can be loaded and unloaded one item at a time, but it is more efficient to handle cargo packed into “intermodal shipping containers” that are a standardized size and shape. Our October 1968 issue noted that a “break-bulk” freighter took three days to unload, a container ship less than one (including loading new cargo). Air transport became a link in this complex system, but the concept in the 1920 illustration shown is a little ahead of its time. These days air cargo (and luggage) makes abundant use of “unit load devices,” cargo bins shaped to fit the fuselage of specific aircraft models.The items below are highlights from the free newsletter, “Smart, useful, science stuff about COVID-19.” To receive newsletter issues daily in your inbox, sign-up here.

Are you in need of a “dose of optimism” about the pandemic, at least in the U.S.?. Check out this 10/12/20 story at The New York Times by by Donald McNeil Jr., who has covered infectious diseases and epidemics for many years. McNeil notes the 215,000 people in the U.S. Dead so far from the novel coronavirus, as well as the estimates that the figure could go as high as 400,000 before this era draws to a close.

But here is some of the good news that he tallies. 1) mask-wearing by the public is “widely accepted”. 2) the development of vaccines to protect against SARS-CoV-2 and of treatments for COVID-19 are proceeding at record speed. 3) “experts are saying, with genuine confidence, that the pandemic in the United States will be over far sooner than they expected, possibly by the middle of next year”.

And 4) fewer infected people die today than did earlier this year, even at nursing homes. About 10 percent of people in the U.S. Have been infected with the virus so far, according to the U.S. Centers for Disease Control, the story states.

€œPandemics don’t end abruptly. They decelerate gradually,” McNeil writes. A 10/14/20 story by Carl Zimmer for The New York Times puts into context three late-stage (Phase 3 safety and effectiveness) COVID-19 experiments that have been paused in recent weeks due to illness among some study participants. Pauses in vaccine studies — in this case Johnson &.

Johnson’s vaccine candidate and AstraZeneca’s vaccine candidate — are “not unusual,” the story states, partly because the safety threshold is extremely high for a product that, if approved, could be given to millions or billions of people. But pauses are rare in treatment studies — in this case Eli Lilly’s monoclonal antibody cocktail drug. Once a drug or treatment experiment (trial) is paused, a safety board determines whether the ill participant was given the new product or a placebo. If it was the placebo, the study can resume.

If not, the board looks deeper into the case to determine whether or not the illness is related to the drug or treatment. If a clear connection is discovered, “the trial may have to stop,” Zimmer writes. Dr. Eric Topol at Scripps Research is quoted in the piece as saying he is “still fairly optimistic” about monoclonal antibody treatments for COVID-19.

The safety-related pauses of all three experiments are “an example of how things are supposed to work,” says Dr. Anna Durbin of Johns Hopkins Bloomberg School of Public Health in the story. The top of a story at The Washington Post features an instructive interactive that sketches “Scienceville,” a fictional place where “politicians and public health officials use every tool at their disposal to contain the coronavirus.” It basically shows how genetic analysis and tracing of viral strains found in a frequently and widely tested population could help officials control outbreaks of SARS-CoV-2. Then the 10/13/20 text story below, by Brady Dennis, Chris Mooney, Sarah Kaplan, and Harry Stevens, focuses on the details of such a “genomic epidemiology” approach and describes some real-life efforts under way, primarily in the UK, to implement the approach.

The U.S. Has not been able to effectively use the approach, in part because genetic sequencing of viral strains “has largely been left up to states and individual researchers, rather than being part of a coordinated and well-funded national program,” the story states. The rise in SARS-CoV-2 infections in the U.S. Is now driven by “small gatherings in people’s homes,” according to officials with the U.S.

Centers for Disease Control, reports Carolyn Crist for WebMD (10/14/20). People should continue to wear face masks and to practice social distancing “since most people have still not been exposed to the coronavirus worldwide," the researchers suggest, Crist writes. A newly developed test can detect SARS-CoV-2 in 5 minutes, reports Robert F. Service at Science (10/8/20).

The test relies on CRISPR gene-editing technology, for which Jennifer Doudna of the University of California, Berkeley, and Emmanuelle Charpentier of the Max Planck Unit for the Science of Pathogens won the Nobel Prize in Chemistry earlier this month. Doudna heads up the work that led to this new 5-minute CRISPR test for the coronavirus. By comparison, it can take a day or more to get back standard SARS-CoV-2 test results, the story states. Donald G.

McNeil Jr. At The New York Times has written a guide to distinguishing common cold, flu, and COVID-19 symptoms (10/3/20). A major difference between having a cold and having the flu is that "Flu makes you feel as if you were hit by a truck,” McNeil quotes experts as saying. The symptom that best distinguishes COVID-19 from flu is loss of your sense of smell — strong smells don’t register, he writes.

But many flu and COVID-19 symptoms overlap, the story states. The most common symptoms for COVID-19 are a high fever, chills, dry cough and fatigue. For flu, it’s a fever, headaches, body aches, sore throat, runny nose, stuffed sinuses, coughing and sneezing, the story states. Dr.

Anthony Fauci’s three daughters do not plan to visit him for Thanksgiving to avoid potentially transmitting the new coronavirus to their parents, reports Ralph Ellis at WebMD. The story includes holiday traveling and visiting tips from a pulmonary critical care doctor at the University of Washington Medical Center who “believes traveling for the holidays is risky.” The tips include ensuring you have no COVID-19-like symptoms two weeks before traveling, getting tested before traveling, quarantining in a hotel for at least 48 hours before visiting with loved ones, traveling by car, and cutting down on “close contact and talking without a mask” (10/9/20). Adele Chapin has written a guide for reducing kids’ risk of catching and spreading SARS-CoV-2 at the playground. The 10/8/20 piece in The Washington Post makes the usual recommendations for mask-wearing, hand-washing, hand-sanitizer, disinfecting wipes, and distancing.

It quotes a Children’s National Hospital pediatrician advises against gloves, because “people wearing them often touch their faces, which defeats the purpose.” The piece also recommends visiting playgrounds at less busy times and choosing playgrounds with more than one play structure, which makes it easier for kids to distance from one another. A story by Carl Zimmer for The New York Times beautifully describes and illustrates some of the amazing imaging work that scientists have done to study the structure of SARS-CoV-2 and how it infects our cells and multiplies (10/9/20). For starters, check out a mesmerizing video about a quarter of the way down-page that simulates spike proteins (complex molecules) doing a “molecular dance” on the virus membrane. The video (just one of several in this stunning piece) is part of research by a computational biophysicist at the Max Planck Institute of Biophysics and colleagues.

The spikes appear to shimmy, which “increases the odds of encountering the protein on the surface of our cells it uses to attach,” the researchers suspect, Zimmer writes. You might enjoy, “A letter of recommendation in the age of Zoom,” by Matt Cheung, for McSweeney’s (10/14/20).Editor’s Note (10/16/20). This story is being republished in light of the interim results of a large international clinical trial of remdesivir by the World Health Organization. The trial found that the drug, which is widely used to treat COVID patients, failed to prevent deaths.

An experimental drug—and one of the world’s best hopes against COVID-19—could shorten the time to recovery from coronavirus infection, according to the largest and most rigorous clinical trial of the compound. The experimental drug, called remdesivir, interferes with replication of some viruses, including the SARS-CoV-2 virus responsible for the current pandemic. On 29 April, Anthony Fauci, director of the US National Institute of Allergy and Infectious Disease (NIAID), announced that a clinical trial of more than a thousand people showed that people taking remdesivir recovered in 11 days on average, compared to 15 days for those on a placebo. €œAlthough a 31% improvement doesn’t seem like a knockout 100%, it is a very important proof of concept,” Fauci said.

€œWhat it has proven is that a drug can block this virus.” Deaths were also lower in trial participants who received the drug, he said, but that trend was not statistically significant. The shortened recovery time, however, was significant, and was enough of a benefit that investigators decided to stop the trial early for ethical reasons, he said, to ensure that those participants who were receiving placebo could now access the drug. Fauci added that remdesivir would become a standard treatment for COVID-19. The news comes after weeks of data leaks and on a day of mixed results from clinical trials of the drug.

In a trial run by the drug’s maker, Gilead Sciences of Foster City, California, more than half of 400 participants with severe COVID-19 recovered from their illness within two weeks of receiving treatment. But the study lacked a placebo controlled arm, making the results difficult to interpret. Another smaller trial run in China found no benefits from remdesivir when compared with a placebo. But the trial was stopped early due to the difficulty in enroling participants as the outbreak subsided in China.

Nevertheless, onlookers are hopeful that the large NIAID trial provides the first glimmer of hope in a race to find a drug that works against the coronavirus, which has infected more than 3 million people worldwide. €œThere is a lot of focus on remdesivir because it’s potentially the best shot we have,” says virologist Stephen Griffin at the University of Leeds in the UK. Small trials The fast-flowing, conflicting information on remdesivir has left people reeling over the past weeks. In the rush to find therapies to combat COVID-19, small, clinical trials without control groups have been common.

€œI’m just very annoyed by all of these non-controlled studies,” says Geoffrey Porges, an analyst for the investment bank SVB Leerink in New York City. €œIt’s reassuring that 50–60% of patients are discharged from the hospital, but this is a disease that mostly gets better anyway.” With so much uncertainty, the remdesivir-watchers were waiting anxiously for final results from the NIAID trial, which were not expected until the end of May. In lieu of a vaccine, which could still be more than a year away, effective therapies are critical to reducing deaths and limiting economic damage from the pandemic. Yet, despite the flood of small clinical trials, no therapy has been convincingly shown to boost survival in people with COVID-19.

The NIAID results put a new sheen on remdesivir. €œIt may not be the wonder drug that everyone’s looking for, but if you can stop some patients from becoming critically ill, that’s good enough,” says Griffin. Fauci said the finding reminded him of the discovery in the 1980s that the drug AZT helped to combat HIV infection. The first randomized, controlled clinical only showed a modest improvement, he said, but researchers continued to build on that success, eventually developing highly effective therapies.

For now, he said, remdesivir would become a standard treatment for COVID-19. Remdesivir works by gumming up an enzyme that some viruses, including SARS-CoV-2, use to replicate. In February, researchers showed that the drug reduces viral infection in human cells grown in a laboratory. Gilead began to ramp up production of remdesivir well before the NIAID results.

By the end of March, the company had produced enough to treat 30,000 patients. By streamlining its manufacturing process and finding new sources of raw materials, Gilead announced that it hoped to produce enough remdesivir to treat more than a million people by the end of the year. That calculation was based on the assumption that people would take the drug for 10 days, but the results announced from Gilead’s trial today suggest that a 5-day course of treatment could work just as well. If so, that would effectively double the number of people who could be treated, says Porges.

Many drugs needed In the long term, clinicians will likely want a bevy of anti-viral drugs—with different ways of disabling the virus—in their arsenal, says Timothy Sheahan, a virologist at the University of North Carolina in Chapel Hill, who has teamed up with Gilead researchers to study remdesivir. €œThere is always the potential for antiviral resistance,” he says. €œAnd to hedge against that potential, it’s good to have not only a first-line, but also a second-, third-, fourth-, fifth-line antiviral.” Researchers are furiously testing a wide range of therapies, but early results, while not yet definitive, have not been encouraging. The malaria drugs chloroquine and hydroxychloroquine, both of which also have anti-inflammatory effects, drew so much attention from physicians and the public that some countries have depleted their supplies of the drugs.

Yet studies in humans have failed to show a consistent benefit, and some have highlighted the risks posed by side effects of the drugs on the heart. Early interest in a mix of two HIV drugs called lopinavir and ritonavir flagged when a clinical trial in nearly 200 people did not find any benefit of the mix for those with severe COVID-19. Another promising therapeutic hypothesis—that inhibiting the action of an immune system regulator called IL-6 could reduce the severe inflammation seen in some people with severe COVID-19—has met with mixed results thus far. Still, a host of other therapies are being tested in people, and many researchers are hunting for new drugs at the bench.

Sheahan and his colleagues have found a compound that is active against SARS-CoV-2 and other coronaviruses, including a remdesivir-resistant variant of a coronavirus, when tested in laboratory-grown human cells. But much more testing would need to be done before the compound could be tried in people. €œWhat we’re doing now will hopefully have an impact on the current pandemic,” he says. €œBut maybe more importantly, it could position us to better respond more quickly in the future.” This article is reproduced with permission and was first published on April 29 2020.

Read more about the coronavirus outbreak here.During a press conference in early September, President Donald Trump was asked when he thought a vaccine for COVID-19 might become available. His prediction was upbeat. €œWe’re going to have a vaccine very soon,” Trump said. €œMaybe even before a very special day—you know what day I’m talking about.” Trump was referring, of course, to the presidential election on November 3.

But the odds of a vaccine materializing for public use before then appear slim. New drugs and vaccines ordinarily go through a lengthy review process prior to regulatory approval. Vaccines for COVID-19, however, are widely expected to be released under emergency use authorization (EUA) protocols, which allow for the sale of unapproved medical products during national health crises. On October 6 the White House agreed to new EUA guidelines that call on COVID-19 vaccine developers to monitor their phase III clinical trial subjects for at least two months for side effects and severe disease.

The U.S. Food and Drug Administration, which administers EUAs, will host a widely anticipated meeting on October 22 to address standards for efficacy, safety and manufacturing of COVID-19 vaccines. But the FDA’s recommended two-month observation period puts a preelection vaccine approval out of reach. EUAs could, however, make the first successful COVID-19 vaccines available to frontline workers by the start of 2021, although distribution in the general U.S.

Population will take longer, starting with elderly and other high-risk groups and then younger, healthier people who may not have access to them until late in the year, according to Paul Offit, a pediatrician and director of the Vaccine Education Center at Children’s Hospital of Philadelphia. The FDA has already granted hundreds of COVID-related EUAs for products such as diagnostic tests, medical devices and therapies—including for convalescent plasma and hydroxychloroquine (the latter was later revoked). €œAll the COVID-19 vaccine developers are going for an EUA first,” says Eric Topol, a cardiologist and head of the Scripps Research Translational Institute in La Jolla, Calif., who has directed numerous multinational clinical trials (although none for vaccines). €œIt makes no sense to wait for formal licensure.” Defining Success Obtaining an EUA hinges on how independent reviewers judge a vaccine’s performance during periodic readouts of phase III clinical trial data.

The trials are each enrolling tens of thousands of people and are also double-blinded—meaning that neither the subjects nor the experimenters know which participants got a vaccine versus a placebo. They were designed to continue until the number of symptomatic infections reaches 150 in the vaccinated and control groups combined. If a vaccine halves the risk of symptomatic infections among the vaccinated group, it will meet the FDA’s minimum bar for approval. Reviewers examining the interim data readouts will be looking for better protection than that.

Pfizer, which began a phase III trial for its vaccine on July 27, plans to conduct its first readout when the number of symptomatic cases reaches 32. The company expects that could happen this month, making it first in line for a potential EUA. Statistical thresholds are set such that if COVID case numbers in the vaccinated group are, at that point, at least five times lower than they are among vaccinated subjects, then reviewers can declare overwhelming efficacy. In that event, the company will “consult with regulatory authorities about next steps,” which could include an EUA, says a Pfizer spokesperson.

In an October 16 open letter, Pfizer chairman and CEO Albert Bourla wrote that if the efficacy data are positive, the company will apply for an EUA in the U.S. €œsoon after the safety milestone is achieved in the third week of November.” The company’s study protocol also includes data readouts at 62, 92 and 120 cases, respectively, although the amount of protection the vaccine has to achieve at each step declines progressively until it reaches the FDA’s minimum target of 50 percent. Other companies racing to develop COVID-19 vaccines are taking a less aggressive approach. Cambridge, Mass.–based Moderna, for instance, plans for a first data readout when it reaches 53 cases among its study subjects and another at 106 cases.

The company anticipates filing for an EUA in late November. Meanwhile Johnson &. Johnson recently paused its clinical trials after a participant got sick. This delay follows a similar pause by AstraZeneca, which has since resumed its trials outside of the U.S.

What Happens Postapproval A significant issue is how vaccine developers will continue to assess safety and efficacy after an EUA. The FDA has said they should include strategies for monitoring a vaccine’s long-term performance in their EUA applications and generate the data needed to support future licensing. The agency has also stressed that companies should continue collecting placebo-controlled trial data for as long as feasible. Yet Pfizer representatives said in an e-mail that if an interim readout shows overwhelming efficacy, they have the option to unblind the data, vaccinate placebo recipients and then follow all the subjects in an unblinded fashion—meaning experimenters and participants would know who got the vaccine.

(A Pfizer spokesperson later said the company would only unblind the study with regulatory approval.) The problem with unblinding the data is that a compromised control group “makes it harder to ascertain a vaccine’s risks and benefits and, in particular, how well it protects against severe disease—which isn’t as common as milder infections,” says Peter Gilbert, a biostatistician at the Fred Hutchinson Cancer Research Center in Seattle, who helped design clinical trials for the leading U.S. Candidates. Topol argues that with a few more weeks, developers could amass the 150 cases that might allow them to more fully assess protection from severe disease, especially in elderly and other vulnerable populations. €œThere shouldn’t be any shortcuts,” he says.

€œWe’re talking about giving these vaccines to billions of people. You can’t risk compromising public trust.” Echoing those concerns, Patricia Whitley-Williams, an infectious disease specialist at Rutgers University’s Robert Wood Johnson Medical School, worries that doctors who mainly treat African-Americans and other people of color might be reluctant to recommend vaccines that they believe have not been adequately tested in these populations. Black Americans are hospitalized with COVID-19 at nearly three times the rate white Americans are, so with vaccination, “we need time to look at potential harms in all ethnic, age and gender groups,” she says. Still, if a vaccine’s interim review shows very high efficacy—say, 90 percent or greater—there will be “appropriate pressure to offer it to control groups immediately,” Gilbert says.

Furosemide alcohol

Can’t see the audio player? furosemide alcohol. Click here to listen on SoundCloud. The death of Supreme Court Justice Ruth Bader Ginsburg — and the insistence of President Donald Trump and furosemide alcohol the GOP-led Senate to fill that vacancy this year — could have major implications for health care. The high court will hear yet another case challenging the constitutionality of the Affordable Care Act the week after the November election, and a long list of cases involving women’s reproductive rights, including both abortion and birth control, are working their way through lower federal courts.Meanwhile, scandals at the Department of Health and Human Services continue to surface, such as the case of a media spokesperson for the National Institutes of Health who criticized his boss’s handling of the pandemic via a conservative website.

And the Centers for Disease Control and Prevention continues to struggle with its credibility, after posting and then taking down another set of guidelines, furosemide alcohol this one concerning whether the COVID-19 virus is spread through aerosol particles.This week’s panelists are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Kimberly Leonard of Business Insider and Mary Ellen McIntire of CQ Roll Call.Among the takeaways from this week’s podcast:The Supreme Court’s upcoming ACA case was brought by Republican state officials seeking to invalidate the law based Congress’ elimination of the penalty for not having insurance, a provision that the court once used to uphold the law because it was considered part of Congress’ right to impose taxes.Many legal experts believe that even if the high court were to decide that the loss of the penalty invalidates the individual mandate to get insurance, other parts of the law should be able to stand. But it’s not clear conservatives on the court will agree.With so much emphasis on the ACA’s insurance marketplace, the expansion of the Medicaid program for low-income people and protections for people with preexisting conditions, many consumers don’t realize that the law touches nearly all aspects of health care, including guarantees of preventive services, insurance practices and even requirements for calorie counts on restaurant menus.Ginsburg’s death could also influence efforts to undermine abortion rights. Two cases are already before the court, one involving the ability of doctors to remotely prescribe drugs that can end a pregnancy and a Mississippi ban on abortions after the 15th week of pregnancy.As the nation marks more than 200,000 deaths from the coronavirus, the “What the Health?. € panel looks at furosemide alcohol problems in the U.S.

Effort to fight COVID-19, including flip-flops on the need for masks, inconsistent messaging from different parts of government and the politicization of science.The Centers for Disease Control and Prevention’s decision to remove guidance on the coronavirus’s ability to spread through the air created more concerns about the politicization of the federal government’s scientific studies. The controversy over the agency’s work is a stark change from the past, when the CDC was considered among the least politicized parts of the government.It may take years after these coronavirus controversies for the CDC to restore its credibility with the public, no matter who is elected president.Trump has touted his efforts to lower prescription drug prices, and last week The New York Times reported that the administration tried unsuccessfully to get drugmakers to send a $100 gift card to all seniors to help cover the costs of their furosemide alcohol medicines. The companies objected because, among other reasons, they were worried the move could be seen as an effort to help the Trump campaign.This week, Rovner also interviews KHN’s Sarah Jane Tribble, whose new podcast, “Where It Hurts,” drops Sept. 29.

The podcast chronicles what happens to a small rural community in Kansas after its local hospital closes.Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:Julie Rovner. KHN’s “Battle Rages Inside Hospitals Over How COVID Strikes and Kills,” by Robert Lewis and Christina JewettAnna Edney. The New Yorker’s “A Young Kennedy, in Kushnerland, Turned Whistle-Blower,” by Jane MayerKimberly Leonard. The Wall Street Journal’s “Medicare Wouldn’t Cover Costs of Administering Coronavirus Vaccine Approved Under Emergency-Use Authorization,” by Stephanie ArmourMary Ellen McIntire.

The New York Times’ “Many Hospitals Charge More Than Twice What Medicare Pays for the Same Care,” by Reed AbelsonOther stories discussed by the panelists this week:The New York Times’ “A Deal on Drug Prices Undone by White House Insistence on ‘Trump Cards,’” by Jonathan Martin and Maggie HabermanThe Daily Beast’s “A Notorious COVID Troll Actually Works for Dr. Fauci’s Agency,” by Lachlan MarkayPolitico’s “Trump Administration Shakes Up HHS Personal Office After Tumultuous Hires,” by Dan DiamondThe Washington Post’s “Pentagon Used Taxpayer Money Meant for Masks and Swabs to Make Jet Engine Parts and Body Armor,” by Aaron Gregg and Yeganeh TorbatiTo hear all our podcasts, click here.And subscribe to What the Health?. on iTunes, Stitcher, Google Play, Spotify or Pocket Casts. Related Topics Courts Elections Health Care Costs Insurance Multimedia Pharmaceuticals The Health Law Abortion CDC COVID-19 Drug Costs HHS KHN's 'What The Health?.

' Podcasts Prescription Drugs Trump Administration.

Can’t see the audio player? buy furosemide 40mg. Click here to listen on SoundCloud. The death of Supreme Court Justice Ruth Bader Ginsburg — and the insistence of buy furosemide 40mg President Donald Trump and the GOP-led Senate to fill that vacancy this year — could have major implications for health care. The high court will hear yet another case challenging the constitutionality of the Affordable Care Act the week after the November election, and a long list of cases involving women’s reproductive rights, including both abortion and birth control, are working their way through lower federal courts.Meanwhile, scandals at the Department of Health and Human Services continue to surface, such as the case of a media spokesperson for the National Institutes of Health who criticized his boss’s handling of the pandemic via a conservative website. And the Centers for Disease Control and Prevention continues to struggle with its credibility, after posting and then taking down another set of guidelines, this one concerning whether the COVID-19 virus is spread through aerosol particles.This week’s panelists are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Kimberly Leonard of Business Insider and Mary Ellen McIntire of CQ Roll Call.Among the takeaways from this week’s podcast:The Supreme Court’s upcoming ACA case was brought by Republican state officials seeking to invalidate the law based Congress’ elimination of the buy furosemide 40mg penalty for not having insurance, a provision that the court once used to uphold the law because it was considered part of Congress’ right to impose taxes.Many legal experts believe that even if the high court were to decide that the loss of the penalty invalidates the individual mandate to get insurance, other parts of the law should be able to stand.

But it’s not clear conservatives on the court will agree.With so much emphasis on the ACA’s insurance marketplace, the expansion of the Medicaid program for low-income people and protections for people with preexisting conditions, many consumers don’t realize that the law touches nearly all aspects of health care, including guarantees of preventive services, insurance practices and even requirements for calorie counts on restaurant menus.Ginsburg’s death could also influence efforts to undermine abortion rights. Two cases are already before the court, one involving the ability of doctors to remotely prescribe drugs that can end a pregnancy and a Mississippi ban on abortions after the 15th week of pregnancy.As the nation marks more than 200,000 deaths from the coronavirus, the “What the Health?. € panel buy furosemide 40mg looks at problems in the U.S. Effort to fight COVID-19, including flip-flops on the need for masks, inconsistent messaging from different parts of government and the politicization of science.The Centers for Disease Control and Prevention’s decision to remove guidance on the coronavirus’s ability to spread through the air created more concerns about the politicization of the federal government’s scientific studies. The controversy over the agency’s work is a stark change from the past, when the CDC was considered among the least politicized parts of the government.It may take years after these coronavirus controversies for the CDC to restore its credibility with the public, no matter who buy furosemide 40mg is elected president.Trump has touted his efforts to lower prescription drug prices, and last week The New York Times reported that the administration tried unsuccessfully to get drugmakers to send a $100 gift card to all seniors to help cover the costs of their medicines.

The companies objected because, among other reasons, they were worried the move could be seen as an effort to help the Trump campaign.This week, Rovner also interviews KHN’s Sarah Jane Tribble, whose new podcast, “Where It Hurts,” drops Sept. 29. The podcast chronicles what happens to a small rural community in Kansas after its local hospital closes.Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:Julie Rovner. KHN’s “Battle Rages Inside Hospitals Over How COVID Strikes and Kills,” by Robert Lewis and Christina JewettAnna Edney. The New Yorker’s “A Young Kennedy, in Kushnerland, Turned Whistle-Blower,” by Jane MayerKimberly Leonard.

The Wall Street Journal’s “Medicare Wouldn’t Cover Costs of Administering Coronavirus Vaccine Approved Under Emergency-Use Authorization,” by Stephanie ArmourMary Ellen McIntire. The New York Times’ “Many Hospitals Charge More Than Twice What Medicare Pays for the Same Care,” by Reed AbelsonOther stories discussed by the panelists this week:The New York Times’ “A Deal on Drug Prices Undone by White House Insistence on ‘Trump Cards,’” by Jonathan Martin and Maggie HabermanThe Daily Beast’s “A Notorious COVID Troll Actually Works for Dr. Fauci’s Agency,” by Lachlan MarkayPolitico’s “Trump Administration Shakes Up HHS Personal Office After Tumultuous Hires,” by Dan DiamondThe Washington Post’s “Pentagon Used Taxpayer Money Meant for Masks and Swabs to Make Jet Engine Parts and Body Armor,” by Aaron Gregg and Yeganeh TorbatiTo hear all our podcasts, click here.And subscribe to What the Health?. on iTunes, Stitcher, Google Play, Spotify or Pocket Casts. Related Topics Courts Elections Health Care Costs Insurance Multimedia Pharmaceuticals The Health Law Abortion CDC COVID-19 Drug Costs HHS KHN's 'What The Health?.

' Podcasts Prescription Drugs Trump Administration.

Furosemide suspension

Rather than treating the mechanical consequences of severe CAVS, identification of causal disease pathways at the tissue level might lead to medical therapies that could actually prevent furosemide suspension or delay the pathological changes in the valve leaflets. Serum levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) activity are associated with the presence of CAVS. However, it has been unclear whether this association is due to a cause–effect relationship. In this issue of Heart, Perrot and colleagues1 used genetic association studies from eight cohorts to show that CAVS was not associated with any of four single nucleotide polymorphisms that are associated furosemide suspension with Lp-PLA2 activity or mass.

These findings suggest that although Lp-PLA2 activity is a biomarker for CAVS unfortunately, it is unlikely to be a therapeutic target (figure 1).Higher Lp-PLA2 activity is significantly associated with the presence of CAVS in patients with heart disease, but variants influencing Lp-PLA2 mass or activity are not associated with CAVS in this large genetic association study. CAVS, calcific aortic valve stenosis. Lp-PLA2, lipoprotein-associated phospholipase A2." data-icon-position data-hide-link-title="0">Figure 1 Higher Lp-PLA2 activity is significantly associated with the presence furosemide suspension of CAVS in patients with heart disease, but variants influencing Lp-PLA2 mass or activity are not associated with CAVS in this large genetic association study. CAVS, calcific aortic valve stenosis.

Lp-PLA2, lipoprotein-associated phospholipase A2.In an editorial, Zheng and Dweck2 discuss this article, summarise current ongoing trials of medical therapy for CAVS (table 1) and comment. €˜Strong evidence points towards elevated Lp(a) levels and its associated oxidised phospholipids (OxPL) as causal risk factors for CAVS, suggesting that furosemide suspension targeting this lipid-driven, inflammatory pathway has a real chance to translate into therapy capable of mitigating disease. The current study suggests that this association is not mediated by Lp-PLA2 and underlines the importance of scrutinising whether biological factors within pathophysiological pathways are merely biomarkers or actually represent a feasible and causal target.’View this table:Table 1 Ongoing randomised clinical trials of medical therapies in aortic stenosisRheumatic heart disease (RHD) remains the primary cause of valve disease worldwide and contributes significantly to maternal and fetal morbidity and mortality. In a study by Baghel and colleagues3 of 681 pregnant women with RHD, adverse cardiovascular evens occurred in about 15% of pregnancies.

Multivariable predictors of adverse outcomes during pregnancy were prior adverse cardiovascular events, lack of appropriate medical therapy, severity of mitral stenosis, valve replacement and pulmonary hypertension furosemide suspension. Based on this analysis, the authors propose a risk score from pregnant women with RHD (table 2).View this table:Table 2 New prognostic score (DEVI’s score) to predict composite adverse cardiac outcome in pregnant women with rheumatic valvular heart diseaseCommenting on this paper, Elkayam and Shmueli4 point out that in about one-fourth of women, the diagnosis of RHD was not known prior to pregnancy and that a late diagnosis often was associated with adverse outcomes. Their editorial provides a concise summary of optimal management of pregnant women with RHD. They conclude ‘With furosemide suspension proper evaluation and risk stratification prior to pregnancy, a close multidisciplinary follow-up during pregnancy, and close monitoring during labour and delivery as well as the early postpartum period most complications can be prevented.’The importance of psychosocial factors in cardiovascular disease (CVD) prevalence and outcomes is increasingly recognised.

Using data from the English Longitudinal Study of Ageing, Bu and colleagues5 found that loneliness was associated with CVD, independent of possible confounders and other risk factors, with a 30% higher risk of a new CVD diagnosis in the most lonely people compared with the least lonely people. As O’Keefe and colleagues6 point out, this data is especially important now in the context of social distancing and stay-at-home recommendations and they offer several approaches to mitigating loneliness during the COVID-19 pandemic.The Education in Heart article7 in this issue focuses on the clinical use and prognostic implications of echocardiographic speckle tracking measurements of global longitudinal strain to detect and quantify early systolic dysfunction of the left ventricle (figure 2).Left ventricular global longitudinal strain to differentiate between mutation-positive sarcomeric hypertrophic cardiomyopathy and cardiac amyloidosis. (A) Apical four-chamber view of a furosemide suspension 66-year-old patient known with mutation-positive hypertrophic cardiomyopathy. The thickness of the septum was 28 mm and the left ventricular ejection fraction was 55%.

(B) The polar map shows markedly impaired longitudinal strain in the septal mid and basal areas and the global longitudinal strain is impaired (−13.6%). (C) Apical four-chamber view of a 75-year-old furosemide suspension patient diagnosed with light chain amyloidosis. There is concentric hypertrophy of the left ventricle and the ejection fraction is 56%. Based on speckle tracking echocardiography analysis, the left ventricular global longitudinal strain is impaired (−12.2%), with typical sparing of the longitudinal strain values in the apical segments (D).

ANT, anterior furosemide suspension. ANT SEPT, anteroseptal. GS, global strain. INF, inferior.

LAT, lateral furosemide suspension. POST, posterior. SEPT, septal." data-icon-position data-hide-link-title="0">Figure 2 Left ventricular global longitudinal strain to differentiate between mutation-positive sarcomeric hypertrophic cardiomyopathy and cardiac amyloidosis. (A) Apical four-chamber view of a furosemide suspension 66-year-old patient known with mutation-positive hypertrophic cardiomyopathy.

The thickness of the septum was 28 mm and the left ventricular ejection fraction was 55%. (B) The polar map shows markedly impaired longitudinal strain in the septal mid and basal areas and the global longitudinal strain is impaired (−13.6%). (C) Apical four-chamber furosemide suspension view of a 75-year-old patient diagnosed with light chain amyloidosis. There is concentric hypertrophy of the left ventricle and the ejection fraction is 56%.

Based on speckle tracking echocardiography analysis, the left ventricular global longitudinal strain is impaired (−12.2%), with typical sparing of the longitudinal strain values in the apical segments (D). ANT, anterior furosemide suspension. ANT SEPT, anteroseptal. GS, global strain.

INF, inferior furosemide suspension. LAT, lateral. POST, posterior. SEPT, septal.Our Cardiology-in-Focus article by Hudson and Pettit8 provides a clear-eyed but brief discussion and outstanding graphic of the challenges in reconciling the varying definitions of the ‘normal’ values for left ventricular ejection fraction, as stated in different guidelines (figure 3).Categories of left furosemide suspension ventricular ejection fraction.

EF, ejection fraction. HF, heart failure. LVEF, left ventricular ejection fraction." data-icon-position data-hide-link-title="0">Figure 3 Categories furosemide suspension of left ventricular ejection fraction. EF, ejection fraction.

HF, heart failure. LVEF, left ventricular ejection fraction.Loneliness is an unpleasant emotional state induced by perceived furosemide suspension isolation. Until about 200 years ago, the English word for being on one’s own was ‘oneliness’, a term that connoted solitude, and was generally considered an essential and positive experience in life. However, solitude and loneliness are not synonymous.

Loneliness is also furosemide suspension described as ‘social pain’ from an unwanted lack of connection and intimacy. Artists have likened loneliness to hunger, not only because we can feel it physically, sometimes described as an ache, a hollowness or a sense of coldness, but also because these physical sensations might be the body’s way of telling us that we are missing something that is important to our survival and flourishing.In this issue of Heart, Bu and colleagues,1 in a prospective observational study that comprised approximately 5000 adults followed for about 10 years, found that individuals reporting high levels of loneliness had 30%–48% increased risks of developing cardiovascular disease (CVD) and CVD-related hospital admission, respectively, even after adjusting for the usual cardiovascular risk factors.1 This major study has three implications. (1) loneliness should be considered among the most dangerous CVD risk factors. (2) feeling lonely is a highly modifiable state that would seemingly respond to lifestyle adjustments as compared with the other foremost psychosocial CVD risk factors—depression and stress/anxiety—which typically require prescription medication or exercise2.

Rather than treating the mechanical consequences of severe CAVS, identification of causal buy furosemide 40mg disease pathways at the tissue level might lead to medical therapies that could actually prevent or delay the pathological changes in the valve leaflets. Serum levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) activity are associated with the presence of CAVS. However, it has been unclear whether this association is due to a cause–effect relationship. In this issue of Heart, Perrot and colleagues1 used genetic association studies from eight cohorts to show that buy furosemide 40mg CAVS was not associated with any of four single nucleotide polymorphisms that are associated with Lp-PLA2 activity or mass.

These findings suggest that although Lp-PLA2 activity is a biomarker for CAVS unfortunately, it is unlikely to be a therapeutic target (figure 1).Higher Lp-PLA2 activity is significantly associated with the presence of CAVS in patients with heart disease, but variants influencing Lp-PLA2 mass or activity are not associated with CAVS in this large genetic association study. CAVS, calcific aortic valve stenosis. Lp-PLA2, lipoprotein-associated phospholipase A2." data-icon-position data-hide-link-title="0">Figure 1 Higher Lp-PLA2 activity is significantly associated with the presence of CAVS in buy furosemide 40mg patients with heart disease, but variants influencing Lp-PLA2 mass or activity are not associated with CAVS in this large genetic association study. CAVS, calcific aortic valve stenosis.

Lp-PLA2, lipoprotein-associated phospholipase A2.In an editorial, Zheng and Dweck2 discuss this article, summarise current ongoing trials of medical therapy for CAVS (table 1) and comment. €˜Strong evidence points towards elevated Lp(a) levels and its associated oxidised phospholipids (OxPL) as causal risk factors for CAVS, suggesting that targeting this lipid-driven, inflammatory pathway has a real chance to translate into therapy capable of mitigating buy furosemide 40mg disease. The current study suggests that this association is not mediated by Lp-PLA2 and underlines the importance of scrutinising whether biological factors within pathophysiological pathways are merely biomarkers or actually represent a feasible and causal target.’View this table:Table 1 Ongoing randomised clinical trials of medical therapies in aortic stenosisRheumatic heart disease (RHD) remains the primary cause of valve disease worldwide and contributes significantly to maternal and fetal morbidity and mortality. In a study by Baghel and colleagues3 of 681 pregnant women with RHD, adverse cardiovascular evens occurred in about 15% of pregnancies.

Multivariable predictors of adverse outcomes during pregnancy were prior adverse cardiovascular events, buy furosemide 40mg lack of appropriate medical therapy, severity of mitral stenosis, valve replacement and pulmonary hypertension. Based on this analysis, the authors propose a risk score from pregnant women with RHD (table 2).View this table:Table 2 New prognostic score (DEVI’s score) to predict composite adverse cardiac outcome in pregnant women with rheumatic valvular heart diseaseCommenting on this paper, Elkayam and Shmueli4 point out that in about one-fourth of women, the diagnosis of RHD was not known prior to pregnancy and that a late diagnosis often was associated with adverse outcomes. Their editorial provides a concise summary of optimal management of pregnant women with RHD. They conclude ‘With proper evaluation and risk stratification prior to pregnancy, a close multidisciplinary follow-up during pregnancy, and close monitoring during labour and delivery as well as the early postpartum period most complications can be buy furosemide 40mg prevented.’The importance of psychosocial factors in cardiovascular disease (CVD) prevalence and outcomes is increasingly recognised.

Using data from the English Longitudinal Study of Ageing, Bu and colleagues5 found that loneliness was associated with CVD, independent of possible confounders and other risk factors, with a 30% higher risk of a new CVD diagnosis in the most lonely people compared with the least lonely people. As O’Keefe and colleagues6 point out, this data is especially important now in the context of social distancing and stay-at-home recommendations and they offer several approaches to mitigating loneliness during the COVID-19 pandemic.The Education in Heart article7 in this issue focuses on the clinical use and prognostic implications of echocardiographic speckle tracking measurements of global longitudinal strain to detect and quantify early systolic dysfunction of the left ventricle (figure 2).Left ventricular global longitudinal strain to differentiate between mutation-positive sarcomeric hypertrophic cardiomyopathy and cardiac amyloidosis. (A) Apical four-chamber view of a 66-year-old patient known with mutation-positive hypertrophic buy furosemide 40mg cardiomyopathy. The thickness of the septum was 28 mm and the left ventricular ejection fraction was 55%.

(B) The polar map shows markedly impaired longitudinal strain in the septal mid and basal areas and the global longitudinal strain is impaired (−13.6%). (C) Apical four-chamber view of a 75-year-old patient diagnosed with light chain amyloidosis buy furosemide 40mg. There is concentric hypertrophy of the left ventricle and the ejection fraction is 56%. Based on speckle tracking echocardiography analysis, the left ventricular global longitudinal strain is impaired (−12.2%), with typical sparing of the longitudinal strain values in the apical segments (D).

ANT, anterior buy furosemide 40mg. ANT SEPT, anteroseptal. GS, global strain. INF, inferior.

LAT, lateral buy furosemide 40mg. POST, posterior. SEPT, septal." data-icon-position data-hide-link-title="0">Figure 2 Left ventricular global longitudinal strain to differentiate between mutation-positive sarcomeric hypertrophic cardiomyopathy and cardiac amyloidosis. (A) Apical four-chamber view of a 66-year-old patient known with mutation-positive buy furosemide 40mg hypertrophic cardiomyopathy.

The thickness of the septum was 28 mm and the left ventricular ejection fraction was 55%. (B) The polar map shows markedly impaired longitudinal strain in the septal mid and basal areas and the global longitudinal strain is impaired (−13.6%). (C) Apical four-chamber view of a 75-year-old patient diagnosed with light buy furosemide 40mg chain amyloidosis. There is concentric hypertrophy of the left ventricle and the ejection fraction is 56%.

Based on speckle tracking echocardiography analysis, the left ventricular global longitudinal strain is impaired (−12.2%), with typical sparing of the longitudinal strain values in the apical segments (D). ANT, anterior buy furosemide 40mg. ANT SEPT, anteroseptal. GS, global strain.

INF, inferior buy furosemide 40mg. LAT, lateral. POST, posterior. SEPT, septal.Our Cardiology-in-Focus article by Hudson and Pettit8 provides a clear-eyed but brief discussion and outstanding graphic of the buy furosemide 40mg challenges in reconciling the varying definitions of the ‘normal’ values for left ventricular ejection fraction, as stated in different guidelines (figure 3).Categories of left ventricular ejection fraction.

EF, ejection fraction. HF, heart failure. LVEF, left ventricular ejection fraction." data-icon-position data-hide-link-title="0">Figure 3 Categories of left ventricular ejection fraction buy furosemide 40mg. EF, ejection fraction.

HF, heart failure. LVEF, left ventricular ejection fraction.Loneliness buy furosemide 40mg is an unpleasant emotional state induced by perceived isolation. Until about 200 years ago, the English word for being on one’s own was ‘oneliness’, a term that connoted solitude, and was generally considered an essential and positive experience in life. However, solitude and loneliness are not synonymous.

Loneliness is also described as ‘social pain’ from an unwanted buy furosemide 40mg lack of connection and intimacy. Artists have likened loneliness to hunger, not only because we can feel it physically, sometimes described as an ache, a hollowness or a sense of coldness, but also because these physical sensations might be the body’s way of telling us that we are missing something that is important to our survival and flourishing.In this issue of Heart, Bu and colleagues,1 in a prospective observational study that comprised approximately 5000 adults followed for about 10 years, found that individuals reporting high levels of loneliness had 30%–48% increased risks of developing cardiovascular disease (CVD) and CVD-related hospital admission, respectively, even after adjusting for the usual cardiovascular risk factors.1 This major study has three implications. (1) loneliness should be considered among the most dangerous CVD risk factors. (2) feeling lonely is a highly modifiable state that would seemingly respond to lifestyle adjustments as compared with the other foremost psychosocial CVD risk factors—depression and stress/anxiety—which typically require prescription medication or exercise2.

Furosemide liquid form

FOUR Special Benefits of MSP furosemide liquid form Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare What furosemide liquid form is Application Process?. 6.

Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing furosemide liquid form Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A furosemide liquid form.

SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A & furosemide liquid form. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

Yes - Benefits begin the month after furosemide liquid form the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA furosemide liquid form 027. Can Enroll in MSP and Medicaid at Same Time?.

YES YES NO!. Must choose between QI-1 furosemide liquid form and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and furosemide liquid form provides different benefits.

The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE furosemide liquid form. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment).

Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in furosemide liquid form any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv.

L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &.

Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind.

(c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO.

18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month.

He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010.

This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a).

(Link is to NYC HRA form, can be adapted for other counties). 3. The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB).

The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year.

(GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both. It is their choice. DOH MRG p.

19. In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit.

People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients.

In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability.

An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life..

Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55.

Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses.

Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections.

Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits.

See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below.

Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B.

Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP.

Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application.

As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare.

If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &.

Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1.

Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district.

The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district.

See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit.

Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE.

Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund.

This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p.

19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6.

Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment.

The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period.

(The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient.

(Note. This process can take awhile!. !. !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS).

​Can the MSP be retroactive like Medicaid, back to 3 months before the application?. ​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year.

No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations.

First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules.

This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay.

Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.

This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them.

These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here. See pp.

53, 86. 1. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance.

2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining.

42 U.S.C. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?.

The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service.

Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200).

See more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible.

If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected.

hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them.

SSL 367-a, subd. 1(d)(iv), added 2016. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules.

The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50.

The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate.

The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No.

Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider.

If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5.

How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here.

They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits.

Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice.

Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26. 2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan.

In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link.

N.Y buy furosemide 40mg. Soc. Serv.

L. § 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1.

No Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &.

Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?. 4.

FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &.

Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7.

What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP.

1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement.

See “Part A Buy-In” YES YES Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application).

See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!.

Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2.

INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below.

NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment).

Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y.

367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include.

(a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS.

* The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind.

(c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher.

The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2.

See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE.

Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work.

Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010.

This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?.

Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties).

3. The Three Medicare Savings Programs - what are they and how are they different?. 1.

Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations.

Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB).

For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3.

Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

They cannot be in both. It is their choice. DOH MRG p.

19. In contrast, one may receive Medicaid and either QMB or SLIMB. 4.

Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable.

They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL.

However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy.

Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients.

In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb.

18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.

If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties...

For life.. Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A.

See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55.

Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.

The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4.

SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down.

Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?.

The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit.

It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website.

Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment.

See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below.

WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B.

Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &.

Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason.

SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note.

The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program.

Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare.

If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid.

See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address.

See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time.

If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program.

In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district.

The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02.

Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals.

Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP.

08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE.

Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016.

Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility.

He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP.

(Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6.

Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium.

See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as.

SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums.

In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7.

What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient.

!. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?.

​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application.

QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year. 7.

QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations.

First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider.

But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM.

Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services.

He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER.

QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.

This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers.

Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article.

CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here.

To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance.

2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid.

Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C.

§ 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3.

For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov.

Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service.

Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down.

For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here.

Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198.

Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov.

Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate.

Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32).

SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case.

This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016.

EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules.

The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016).

Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment.

Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148).

For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. .

4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No.

Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A).

In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at.

CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.

Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5.

How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider.

Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability.

The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays.

Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB.

See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. 6.

If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

Apo furosemide 20mg

Editor’s Note (9/4/20) apo furosemide 20mg. Drugmakers worldwide are working overtime to produce vaccines for COVID-19. If delays emerge, they may apo furosemide 20mg need to rely on costly biotech such as monoclonal antibodies. In this article, Scientific American details another approach making progress in Costa Rica, where inexpensive horse antibodies are being developed against the novel coronavirus. Development of the hundreds of vaccines and therapies for COVID-19 is by no means confined to metro areas surrounding San Francisco, Boston or Washington, D.C.

Borrowing from decades of experience in producing snake antivenoms, scientists, veterinarians and technicians at a scientific and technical institute in Costa Rica have labored nonstop in recent months to produce a therapeutic formulation of equine antibodies against SARS-CoV-2, the coronavirus apo furosemide 20mg that causes COVID-19. Similar efforts are underway in Brazil and Argentina to tide these countries over until the arrival of an effective vaccine. In late March, after the first case of COVID-19 was diagnosed in Costa Rica, Román Macaya—a biochemist and public health expert who heads the Costa Rican Social Security Fund, which runs the nation’s public clinics and hospitals—issued a call for the research community to join the fight against the then nascent pandemic. €œOur response to apo furosemide 20mg COVID-19 could not be only a health care response,” Macaya says. €œIt had to be a scientific response as well.” In making his plea for help, he singled out the antivenom specialists at the University of Costa Rica’s Clodomiro Picado Institute, which is named after a renowned Costa Rican scientist.

€œThe very next day we got a letter from Henning Jensen, then rector of the University of Costa Rica saying, ‘We’re in. Let's get together and work apo furosemide 20mg on this,’” Macaya recalls. The effort’s objective was to harness the technology and experience the Clodomiro Picado Institute has acquired in its work using horse antibodies to fabricate antivenoms for snake bites during the past five decades. Every year, the antivenoms with purified equine antibodies produced at the institute save more than 500 people in Costa Rica and thousands more in other countries around the world. Equine antibodies made at The apo furosemide 20mg Clodomiro Picado Institute’s production plant.

Credit. Jenniffer Jiménez Oficina de Divulgación, Universidad de Costa Rica The Clodomiro Picado Institute has more than 100 horses that have developed strong immunity to snake venoms after being inoculated with small quantities of toxins over a period of weeks to months. Besides their use in antivenoms for snakes, apo furosemide 20mg scorpions and spiders, for decades, pharmaceutical preparations of equine antibodies have been employed worldwide as a treatment for rabies, botulism and diphtheria. Clinical trials of the institute’s antivenoms conducted in Colombia, Nigeria and Papua New Guinea have shown that these antibodies are safe in humans and rarely induce severe adverse reactions. More recently, equine immunoglobulin therapy has emerged as a potential treatment for a range of viruses that have limited therapeutic options.

Among them are the highly pathogenic apo furosemide 20mg avian influenza viruses H5N1 and H7N9 and the coronavirus that causes Middle East Respiratory Syndrome (MERS). €œAll this inspired several research groups to find ways to produce safe and effective COVID-19 equine immunoglobulins,” explains Fan Hui Wen, a researcher and project manager at the Butantan Institute in Brazil, which also has long experience in manufacturing such antibodies. She was not involved with the research at the Clodomiro Picado Institute. The Costa apo furosemide 20mg Rican project has an air of familiarity. €œThe idea behind the antibody therapy for patients with COVID-19 is similar to that of treating patients suffering from snakebite poisoning,” says Alberto Alape Girón, a microbiologist and lead researcher of the COVID-19 project at the Clodomiro Picado Institute.

€œWe want to generate specific antibodies against viral structures in horses, purify the antibodies and give them to patients who are starting to fight the infection but whose immune system still does not produce enough antibodies to clear the viral particles, ” he adds. Private citizens who wanted to help with the apo furosemide 20mg research donated six horses to the institute. The animals were inoculated with engineered proteins of the SARS-CoV-2 virus. Three of apo furosemide 20mg the horses received only S1, a portion of the protein that makes up the protruding spikes that stick out from the pathogen’s surface. The other three animals received a combination of four proteins from the coronavirus, including S1.

After four rounds of inoculations administered every two weeks, the horses produced the desired level of antibodies. At this point, their blood apo furosemide 20mg was extracted, and the red blood cells were separated from the plasma and returned to the horses. €œPlasma is a very complex mixture that has hundreds of proteins,” Alape-Girón says. €œAntibodies are one of the most abundant proteins, but there are others.” At the pharmaceutical plant, researchers used a technology developed by the Clodomiro Picado Institute to separate the antibodies from other proteins in the plasma and then purified them to obtain the therapeutic formulation for human testing. In total, the apo furosemide 20mg plant produced 1,000 10-milliliter vials of purified equine antibodies.

Half of them had antibodies against the S1 protein, and the other half contained the four proteins present in the coronavirus. €œJust one 10-mL vial has about 80 times the quantity of antibodies you can find in 800 mL of convalescent plasma, which is the plasma donated by someone who has overcome an infection of SARS-CoV-2,” Alape-Girón says. To test the efficacy of the equine antibodies, a few vials were shipped to George Mason University’s National Center for Biodefense apo furosemide 20mg and Infectious Diseases (NCBID). €œWe wanted to determine if the SARS-CoV-2 virus could be neutralized by the horse-produced antibodies,” says Charles Bailey, a professor of biology and executive director of the NCBID. €œThe test we performed on the samples is called a plaque reduction neutralization test, PRNTest.

We exposed the antibodies produced in horses, at various dilutions, apo furosemide 20mg to the SARS-CoV-2 virus growing on cell culture. The virus was neutralized.” The results of the research are expected to be published in the near future. The next step—testing the equine antibodies in COVID-19 patients—will begin with an accelerated clinical trial this month. The antibodies’ safety and efficacy will be examined in a group apo furosemide 20mg of 26 patients with COVID-19 who have been hospitalized but not placed in an intensive care unit. The results are expected by the end of September.

If they are positive, the research will then move to a large-scale trial with hundreds of patients. And if the equine antibodies are shown to be effective, the apo furosemide 20mg Clodomiro Picado Institute could immunize more horses to scale up and produce enough of them to cover Costa Rica’s demand—and probably that of its neighbors. It received a $500,000 grant on Aug. 13 from the Central American Bank for Economic Integration to move ahead with equine antibody research. Unlike monoclonal antibodies, which are being developed to target a specific molecular region, or epitope, on the surface of SARS-CoV-2 apo furosemide 20mg to elicit an immune response, horse polyclonal antibodies against SARS-CoV-2 recognize multiple epitopes.

The lower specificity translates into a more inexpensive manufacturing process. Alape-Girón estimates apo furosemide 20mg that a vial of equine antibodies will cost $100 to produce, whereas a treatment with monoclonal antibodies could be 10 times more expensive. €œIt’s not the highest technology,” Macaya says. €œIt’s not a monoclonal antibody, but it allows us the benefit of speed, and it’s a very pragmatic approach.” Further, “if this were a monoclonal antibody, you would need a big factory to produce them,” he adds. €œHere, the horses are the factories—at least apo furosemide 20mg for the production part.

Then comes the purification part, which is an industrial process, but the Clodomiro Picado Institute already has that infrastructure.” Fan says this description mirrors her experience at the Butantan Institute in Brazil. €œPolyclonal antibody products can be made in large quantities, and cost-effectively, to respond to large-scale pandemic situations, such as the infection by SARS-CoV-2”, she says. Currently, the Butantan Institute is preparing horses to be immunized with portions of inactivated SARS-COV-2 virus, which were isolated, cultured and purified, using its expertise in apo furosemide 20mg the production of influenza virus vaccines. Even though the development protocols differ at the Brazilian and Costa Rican institutes, Fan predicts their antibodies “will have equivalent efficiency and safety in the treatment of COVID-19 patients.” Even farther south in South America, scientists in Argentina are also developing a potential therapy for COVID-19 patients using equine antibodies, while other researchers worldwide are exploring antibodies against SARS-CoV-2 from llamas and cows. The objective behind all of these projects is the same.

To save lives apo furosemide 20mg while waiting for a vaccine to become available. Costa Rica has more than 28,000 cases of COVID-19. "We have over 100 patients in the ICU," Macaya says. "And our ICU capacity, as with any country, is limited." His hope is that equine antibodies will prove to be “a very valuable tool in keeping our health care system from apo furosemide 20mg collapsing at the ICU level and, obviously, preventing deaths. That’s the ultimate goal.” Read more about the coronavirus outbreak from Scientific American here.

And read coverage from our international network of magazines here.Editor’s Note (9/4/20). Understanding how the immune system goes awry in COVID-19 may help prevent the most severe and apo furosemide 20mg deadly cases. Earlier this year Scientific American explained how administering an antiviral protein called interferon at just the right time may help. When the immune system fights viruses, timing is key. And this maxim may be especially true for its defense against the deadly severe form of COVID-19 apo furosemide 20mg.

Several new studies of immune response to SARS-CoV-2, the virus that causes the disease, suggest timing could be critical for a class of proteins known as interferons, which are being researched as potential treatments. These immune proteins suppress viral replication early in disease. Yet if they are active later, some scientists think they can exacerbate the harmful inflammation that forces some apo furosemide 20mg COVID-19 patients onto life support. Interferons are “a double-edged sword,” says immunologist Eui-Cheol Shin of the Korea Advanced Institute of Science and Technology. Researchers have been looking at both of that sword’s edges.

About a apo furosemide 20mg decade ago, when Shin was studying the viral disease hepatitis C, interferons were used as a standard treatment. But examinations of some conditions suggested they should not be employed. For example, researchers in Paris found that too much of the proteins apo furosemide 20mg can lead to a diseases known as children’s interferonopathies. In a sense, each of these two perceptions of interferons is correct. And understanding when, and to what extent, using them is warranted could be a critical factor in treating COVID-19.

The researchers in Paris analyzed blood apo furosemide 20mg from 50 people with varying COVID-19 severity and 18 healthy controls. They determined that severely ill patients had lower overall counts of lymphocytes (a type of white blood cell). Using techniques to analyze broad-based gene activity and measure specific proteins, two trends stood out. Compared with patients with milder forms of apo furosemide 20mg the disease, people with severe COVID-19 had an exaggerated inflammatory response, coupled with a marked decrease in interferons. And among severe COVID-19 patients, the interferon deficiency was worse in those who died versus those who stabilized, the team reported on July 13 in Science.

€œWe were surprised,” says Benjamin Terrier, a clinician-researcher at Cochin Hospital in Paris, who was co-senior author of the study. €œIt was not our hypothesis.” An analysis published in the May 28 issue of Cell by researchers apo furosemide 20mg at the Icahn School of Medicine at Mount Sinai turned up a similar dual signature. Low interferon levels and elevated inflammatory proteins. Meanwhile, in another new study, Shin and his colleagues used single-cell RNA sequencing to analyze gene activity in immune cells. They analyzed blood samples from eight patients with mild or severe COVID-19, four healthy donors and five people with apo furosemide 20mg severe influenza—more than 59,000 cells in total.

The researchers employed computer algorithms to compare individual cells’ RNA, and they expected patterns to cluster by cell type. That is, they anticipated that T cells, lymphocytes that coordinate an immune response or kill invading pathogens, would look a lot alike, whether they were taken from patients with COVID-19 or influenza. But that apo furosemide 20mg was not the case. Instead the cellular profiles grouped by disease. For example, T cells from COVID-19 patients did not resemble those from people with influenza.

Rather they looked more like COVID-19 B cells, Shin apo furosemide 20mg says. This curious observation prompted his team to search for molecules that might serve as a common mediator influencing various immune cells. Comparing gene activity profiles, the researchers first noticed a flu-COVID dichotomy. Influenza cells showed apo furosemide 20mg higher activity in genes regulated by interferons, whereas inflammatory genes driven by so-called tumor necrosis factor (TNF) and interleukin-1 beta (IL-1β) predominated in COVID-19. They then compared severe versus mild COVID-19 samples and focused on a specific pool of immune cells called monocytes.

In severe COVID-19 patients, these first-defender cells had increased activity in interferon-stimulated genes in addition to the TNF/IL-1β inflammatory genes. But mild COVID-19 monocytes only had the TNF/IL-1β signature, Shin and his apo furosemide 20mg colleagues reported on July 10 in Science Immunology. At first glance, the recent French and South Korean papers seemed to reach contradictory conclusions—with severely ill COVID-19 patients showing weaker interferon responses in Terrier and his colleagues’ analysis and more interferon activity in Shin and his colleagues’ study. The difference apo furosemide 20mg could come down to technique and timing. The French researchers analyzed RNA in samples containing mixtures of immune cells, whereas the South Korean team sequenced RNA in individual cells and observed interferon differences in monocytes.

But because monocytes make up just a tenth of total make up less than a tenth of white blood cells, an increased signal in this population could be obscured by other cells in the French team’s bulk samples, Shin suggests. There is another side to the apo furosemide 20mg coin, however. Multiple immune cells produce interferons and are presumably influenced by the proteins. Yet the Korean team’s single-cell profiling only looked at interferons’ effect on monocytes. €œWhat is the apo furosemide 20mg impact of a change in one small cell population on the whole system?.

It’s really complicated to interpret,” Terrier says. €œThe interferon response is a little bit tricky,” says Rudragouda Channappanavar, a viral immunologist at the University of Tennessee Health Science Center, who was not involved with the new studies. The response protects the body from apo furosemide 20mg infections by thwarting viral replication. €œThe body needs it, without a doubt,” he says. €œBut viruses are smart.

They have several proteins that can antagonize and suppress early interferon responses.” One apo furosemide 20mg of SARS-CoV-2’s own defenders, a viral protein called Nsp1, can shut down the host cell’s production of immune molecules, including interferons, researchers in Munich reported on July 17 in Science. In earlier studies with Stanley Perlman of the University of Iowa, Channappanavar analyzed mouse models for the coronaviruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Those studies showed that “if the interferon response begins before viral replication peaks, we will have protective immunity,” he says. If the viruses thwart this antiviral defense, however, the delayed interferon response becomes pathogenic—summoning too many monocytes, which secrete inflammatory molecules and cause apo furosemide 20mg tissue damage. €œIt’s the relative timing of interferon with virus replication that’s the key,” Channappanavar says.

Therapeutically, the findings suggest that interferons matter in the initial phase of infection. €œIf you apo furosemide 20mg give interferon early, you can really increase the antiviral response. This is where you gain the most,” says Miriam Merad, who directs the Precision Immunology Institute at the Icahn School of Medicine at Mount Sinai and was not involved with the new research. If a person with COVID-19 has already progressed to having inflammation, “and you go in and give interferon, you are going to make things worse,” she says. In an open-label preprint study in China, interferon nasal drops prevented the disease in at-risk medical apo furosemide 20mg staff who had treated infected individuals.

Early unpublished data from COVID-19 patients hospitalized in the U.K. Suggest that interferons inhaled directly into the lungs shortened hospital stays and increased odds of recovery. And a randomized trial apo furosemide 20mg in Iran is testing whether the proteins can enhance a base therapeutic regimen in moderate to severe COVID-19 patients. Read more about the coronavirus outbreak from Scientific American here. And read coverage from our international network of magazines here..

Editor’s Note (9/4/20) buy furosemide 40mg. Drugmakers worldwide are working overtime to produce vaccines for COVID-19. If delays emerge, they may need to rely on buy furosemide 40mg costly biotech such as monoclonal antibodies.

In this article, Scientific American details another approach making progress in Costa Rica, where inexpensive horse antibodies are being developed against the novel coronavirus. Development of the hundreds of vaccines and therapies for COVID-19 is by no means confined to metro areas surrounding San Francisco, Boston or Washington, D.C. Borrowing from decades of buy furosemide 40mg experience in producing snake antivenoms, scientists, veterinarians and technicians at a scientific and technical institute in Costa Rica have labored nonstop in recent months to produce a therapeutic formulation of equine antibodies against SARS-CoV-2, the coronavirus that causes COVID-19.

Similar efforts are underway in Brazil and Argentina to tide these countries over until the arrival of an effective vaccine. In late March, after the first case of COVID-19 was diagnosed in Costa Rica, Román Macaya—a biochemist and public health expert who heads the Costa Rican Social Security Fund, which runs the nation’s public clinics and hospitals—issued a call for the research community to join the fight against the then nascent pandemic. €œOur response buy furosemide 40mg to COVID-19 could not be only a health care response,” Macaya says.

€œIt had to be a scientific response as well.” In making his plea for help, he singled out the antivenom specialists at the University of Costa Rica’s Clodomiro Picado Institute, which is named after a renowned Costa Rican scientist. €œThe very next day we got a letter from Henning Jensen, then rector of the University of Costa Rica saying, ‘We’re in. Let's get buy furosemide 40mg together and work on this,’” Macaya recalls.

The effort’s objective was to harness the technology and experience the Clodomiro Picado Institute has acquired in its work using horse antibodies to fabricate antivenoms for snake bites during the past five decades. Every year, the antivenoms with purified equine antibodies produced at the institute save more than 500 people in Costa Rica and thousands more in other countries around the world. Equine antibodies made at The Clodomiro Picado buy furosemide 40mg Institute’s production plant.

Credit. Jenniffer Jiménez Oficina de Divulgación, Universidad de Costa Rica The Clodomiro Picado Institute has more than 100 horses that have developed strong immunity to snake venoms after being inoculated with small quantities of toxins over a period of weeks to months. Besides their use in antivenoms for snakes, scorpions and spiders, for decades, pharmaceutical preparations of equine antibodies have been employed worldwide as a treatment for buy furosemide 40mg rabies, botulism and diphtheria.

Clinical trials of the institute’s antivenoms conducted in Colombia, Nigeria and Papua New Guinea have shown that these antibodies are safe in humans and rarely induce severe adverse reactions. More recently, equine immunoglobulin therapy has emerged as a potential treatment for a range of viruses that have limited therapeutic options. Among them are the highly pathogenic avian influenza viruses H5N1 and H7N9 and the coronavirus buy furosemide 40mg that causes Middle East Respiratory Syndrome (MERS).

€œAll this inspired several research groups to find ways to produce safe and effective COVID-19 equine immunoglobulins,” explains Fan Hui Wen, a researcher and project manager at the Butantan Institute in Brazil, which also has long experience in manufacturing such antibodies. She was not involved with the research at the Clodomiro Picado Institute. The Costa Rican project has an air buy furosemide 40mg of familiarity.

€œThe idea behind the antibody therapy for patients with COVID-19 is similar to that of treating patients suffering from snakebite poisoning,” says Alberto Alape Girón, a microbiologist and lead researcher of the COVID-19 project at the Clodomiro Picado Institute. €œWe want to generate specific antibodies against viral structures in horses, purify the antibodies and give them to patients who are starting to fight the infection but whose immune system still does not produce enough antibodies to clear the viral particles, ” he adds. Private citizens who wanted to help with the research donated six horses to the buy furosemide 40mg institute.

The animals were inoculated with engineered proteins of the SARS-CoV-2 virus. Three of the horses buy furosemide 40mg received only S1, a portion of the protein that makes up the protruding spikes that stick out from the pathogen’s surface. The other three animals received a combination of four proteins from the coronavirus, including S1.

After four rounds of inoculations administered every two weeks, the horses produced the desired level of antibodies. At this point, their blood was buy furosemide 40mg extracted, and the red blood cells were separated from the plasma and returned to the horses. €œPlasma is a very complex mixture that has hundreds of proteins,” Alape-Girón says.

€œAntibodies are one of the most abundant proteins, but there are others.” At the pharmaceutical plant, researchers used a technology developed by the Clodomiro Picado Institute to separate the antibodies from other proteins in the plasma and then purified them to obtain the therapeutic formulation for human testing. In total, the plant produced 1,000 10-milliliter vials buy furosemide 40mg of purified equine antibodies. Half of them had antibodies against the S1 protein, and the other half contained the four proteins present in the coronavirus.

€œJust one 10-mL vial has about 80 times the quantity of antibodies you can find in 800 mL of convalescent plasma, which is the plasma donated by someone who has overcome an infection of SARS-CoV-2,” Alape-Girón says. To test the efficacy of the equine antibodies, a few vials were shipped to George Mason University’s National Center for Biodefense and Infectious Diseases buy furosemide 40mg (NCBID). €œWe wanted to determine if the SARS-CoV-2 virus could be neutralized by the horse-produced antibodies,” says Charles Bailey, a professor of biology and executive director of the NCBID.

€œThe test we performed on the samples is called a plaque reduction neutralization test, PRNTest. We exposed the antibodies produced in horses, at various dilutions, to the SARS-CoV-2 virus growing on buy furosemide 40mg cell culture. The virus was neutralized.” The results of the research are expected to be published in the near future.

The next step—testing the equine antibodies in COVID-19 patients—will begin with an accelerated clinical trial this month. The antibodies’ safety and efficacy will be examined in a group of 26 patients with COVID-19 who have buy furosemide 40mg been hospitalized but not placed in an intensive care unit. The results are expected by the end of September.

If they are positive, the research will then move to a large-scale trial with hundreds of patients. And if the equine antibodies are shown to be effective, the Clodomiro Picado Institute could immunize more horses to scale up and produce enough of them to cover Costa Rica’s buy furosemide 40mg demand—and probably that of its neighbors. It received a $500,000 grant on Aug.

13 from the Central American Bank for Economic Integration to move ahead with equine antibody research. Unlike monoclonal antibodies, which are being developed to target a specific buy furosemide 40mg molecular region, or epitope, on the surface of SARS-CoV-2 to elicit an immune response, horse polyclonal antibodies against SARS-CoV-2 recognize multiple epitopes. The lower specificity translates into a more inexpensive manufacturing process.

Alape-Girón estimates that a vial of equine antibodies will cost $100 to produce, whereas a treatment buy furosemide 40mg with monoclonal antibodies could be 10 times more expensive. €œIt’s not the highest technology,” Macaya says. €œIt’s not a monoclonal antibody, but it allows us the benefit of speed, and it’s a very pragmatic approach.” Further, “if this were a monoclonal antibody, you would need a big factory to produce them,” he adds.

€œHere, the horses are the factories—at least for the production part buy furosemide 40mg. Then comes the purification part, which is an industrial process, but the Clodomiro Picado Institute already has that infrastructure.” Fan says this description mirrors her experience at the Butantan Institute in Brazil. €œPolyclonal antibody products can be made in large quantities, and cost-effectively, to respond to large-scale pandemic situations, such as the infection by SARS-CoV-2”, she says.

Currently, the Butantan Institute is preparing horses to be immunized with portions of inactivated buy furosemide 40mg SARS-COV-2 virus, which were isolated, cultured and purified, using its expertise in the production of influenza virus vaccines. Even though the development protocols differ at the Brazilian and Costa Rican institutes, Fan predicts their antibodies “will have equivalent efficiency and safety in the treatment of COVID-19 patients.” Even farther south in South America, scientists in Argentina are also developing a potential therapy for COVID-19 patients using equine antibodies, while other researchers worldwide are exploring antibodies against SARS-CoV-2 from llamas and cows. The objective behind all of these projects is the same.

To save lives while waiting for a vaccine to buy furosemide 40mg become available. Costa Rica has more than 28,000 cases of COVID-19. "We have over 100 patients in the ICU," Macaya says.

"And our ICU capacity, as with any country, is limited." His hope is that equine antibodies will prove to be “a very valuable tool in keeping our health care system from collapsing at the buy furosemide 40mg ICU level and, obviously, preventing deaths. That’s the ultimate goal.” Read more about the coronavirus outbreak from Scientific American here. And read coverage from our international network of magazines here.Editor’s Note (9/4/20).

Understanding how the immune system goes awry in COVID-19 may help buy furosemide 40mg prevent the most severe and deadly cases. Earlier this year Scientific American explained how administering an antiviral protein called interferon at just the right time may help. When the immune system fights viruses, timing is key.

And this maxim may be especially true for buy furosemide 40mg its defense against the deadly severe form of COVID-19. Several new studies of immune response to SARS-CoV-2, the virus that causes the disease, suggest timing could be critical for a class of proteins known as interferons, which are being researched as potential treatments. These immune proteins suppress viral replication early in disease.

Yet if they are active later, some scientists think they can exacerbate the harmful inflammation that forces some COVID-19 patients onto life support buy furosemide 40mg. Interferons are “a double-edged sword,” says immunologist Eui-Cheol Shin of the Korea Advanced Institute of Science and Technology. Researchers have been looking at both of that sword’s edges.

About a decade ago, when Shin was studying the viral buy furosemide 40mg disease hepatitis C, interferons were used as a standard treatment. But examinations of some conditions suggested they should not be employed. For example, researchers in Paris found buy furosemide 40mg that too much of the proteins can lead to a diseases known as children’s interferonopathies.

In a sense, each of these two perceptions of interferons is correct. And understanding when, and to what extent, using them is warranted could be a critical factor in treating COVID-19. The researchers in Paris analyzed blood from 50 people with varying buy furosemide 40mg COVID-19 severity and 18 healthy controls.

They determined that severely ill patients had lower overall counts of lymphocytes (a type of white blood cell). Using techniques to analyze broad-based gene activity and measure specific proteins, two trends stood out. Compared with patients with milder forms of the disease, people with severe COVID-19 had an exaggerated buy furosemide 40mg inflammatory response, coupled with a marked decrease in interferons.

And among severe COVID-19 patients, the interferon deficiency was worse in those who died versus those who stabilized, the team reported on July 13 in Science. €œWe were surprised,” says Benjamin Terrier, a clinician-researcher at Cochin Hospital in Paris, who was co-senior author of the study. €œIt was not our hypothesis.” An analysis published in the May 28 issue of Cell by researchers at the Icahn School of Medicine at Mount Sinai turned up a similar dual signature buy furosemide 40mg.

Low interferon levels and elevated inflammatory proteins. Meanwhile, in another new study, Shin and his colleagues used single-cell RNA sequencing to analyze gene activity in immune cells. They analyzed blood samples from eight patients with mild or buy furosemide 40mg severe COVID-19, four healthy donors and five people with severe influenza—more than 59,000 cells in total.

The researchers employed computer algorithms to compare individual cells’ RNA, and they expected patterns to cluster by cell type. That is, they anticipated that T cells, lymphocytes that coordinate an immune response or kill invading pathogens, would look a lot alike, whether they were taken from patients with COVID-19 or influenza. But that was buy furosemide 40mg not the case.

Instead the cellular profiles grouped by disease. For example, T cells from COVID-19 patients did not resemble those from people with influenza. Rather they looked more like COVID-19 B cells, Shin buy furosemide 40mg says.

This curious observation prompted his team to search for molecules that might serve as a common mediator influencing various immune cells. Comparing gene activity profiles, the researchers first noticed a flu-COVID dichotomy. Influenza cells showed higher activity in genes regulated buy furosemide 40mg by interferons, whereas inflammatory genes driven by so-called tumor necrosis factor (TNF) and interleukin-1 beta (IL-1β) predominated in COVID-19.

They then compared severe versus mild COVID-19 samples and focused on a specific pool of immune cells called monocytes. In severe COVID-19 patients, these first-defender cells had increased activity in interferon-stimulated genes in addition to the TNF/IL-1β inflammatory genes. But mild COVID-19 monocytes only had the TNF/IL-1β signature, Shin and his colleagues buy furosemide 40mg reported on July 10 in Science Immunology.

At first glance, the recent French and South Korean papers seemed to reach contradictory conclusions—with severely ill COVID-19 patients showing weaker interferon responses in Terrier and his colleagues’ analysis and more interferon activity in Shin and his colleagues’ study. The difference buy furosemide 40mg could come down to technique and timing. The French researchers analyzed RNA in samples containing mixtures of immune cells, whereas the South Korean team sequenced RNA in individual cells and observed interferon differences in monocytes.

But because monocytes make up just a tenth of total make up less than a tenth of white blood cells, an increased signal in this population could be obscured by other cells in the French team’s bulk samples, Shin suggests. There is another side to buy furosemide 40mg the coin, however. Multiple immune cells produce interferons and are presumably influenced by the proteins.

Yet the Korean team’s single-cell profiling only looked at interferons’ effect on monocytes. €œWhat is the impact of a change in one small cell population on the buy furosemide 40mg whole system?. It’s really complicated to interpret,” Terrier says.

€œThe interferon response is a little bit tricky,” says Rudragouda Channappanavar, a viral immunologist at the University of Tennessee Health Science Center, who was not involved with the new studies. The response protects the body from infections by buy furosemide 40mg thwarting viral replication. €œThe body needs it, without a doubt,” he says.

€œBut viruses are smart. They have several proteins that can antagonize and suppress early interferon responses.” One of SARS-CoV-2’s own defenders, a viral protein called Nsp1, can shut down the host cell’s production of immune molecules, including interferons, researchers buy furosemide 40mg in Munich reported on July 17 in Science. In earlier studies with Stanley Perlman of the University of Iowa, Channappanavar analyzed mouse models for the coronaviruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).

Those studies showed that “if the interferon response begins before viral replication peaks, we will have protective immunity,” he says. If the viruses buy furosemide 40mg thwart this antiviral defense, however, the delayed interferon response becomes pathogenic—summoning too many monocytes, which secrete inflammatory molecules and cause tissue damage. €œIt’s the relative timing of interferon with virus replication that’s the key,” Channappanavar says.

Therapeutically, the findings suggest that interferons matter in the initial phase of infection. €œIf you give interferon early, you can really buy furosemide 40mg increase the antiviral response. This is where you gain the most,” says Miriam Merad, who directs the Precision Immunology Institute at the Icahn School of Medicine at Mount Sinai and was not involved with the new research.

If a person with COVID-19 has already progressed to having inflammation, “and you go in and give interferon, you are going to make things worse,” she says. In an open-label preprint study in China, interferon nasal drops prevented the disease in at-risk buy furosemide 40mg medical staff who had treated infected individuals. Early unpublished data from COVID-19 patients hospitalized in the U.K.

Suggest that interferons inhaled directly into the lungs shortened hospital stays and increased odds of recovery. And a randomized trial in Iran is testing whether buy furosemide 40mg the proteins can enhance a base therapeutic regimen in moderate to severe COVID-19 patients. Read more about the coronavirus outbreak from Scientific American here.

And read coverage from our international network of magazines here..

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